Every finding on record at Atlas Rehabilitation & Healthcare at West Deptfor

COMPLAINT # 2800691 Based on interview, medical record review, and review of pertinent facility documentation on 8/17/26 and 8/18/26, the facility failed to complete a thorough and accurate discharge summary for Resident #3 when it did not include a post-discharge appointment. The deficient practice was identified for one of two residents (Resident #3) reviewed for discharge and was evidenced by the following:A review of Resident #3's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: displaced intertrochanteric fracture of the left femur (a break in the upper part of the thigh bone between the hip joint and the main shaft), vascular dementia, and chronic diastolic (congestive) heart failure. A review of Resident #3's comprehensive Minimum Data Set (MDS), dated [DATE], an assessment tool reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #3's progress notes revealed a nurse practitioner note dated 2/11/26 at 1:37 PM, which included that the resident was to be discharged and that they were to follow up with an orthopedic surgeon for outpatient services. Further review of the progress notes revealed a physician note dated 2/14/26 at 9:32 PM, which referenced that Resident #3 was discharged on 2/13/26 and noted under the DISCHARGE INSTRUCTIONS section that the resident was to, Follow up with Orthopedic Surgery as scheduled. A review of Resident #3's hospital Discharge summary dated [DATE], revealed that the resident had an orthopedic appointment scheduled for 3/9/26 at 8:30 AM. A review of Resident #3's medical record revealed an Atlas- IDT: Discharge Instructions and Summary - V 2 - V 2 completed by Licensed Practical Nurse (LPN #1) and dated 2/13/26. The form did not include the orthopedic appointment. During an interview on 8/17/26 at 2:40 PM with LPN #1, she stated that due to the resident's cognition, she reviewed all discharge instructions with the resident's family member at the bedside. She stated that the resident was admitted to the facility after having surgery and that the staples were still in place because the resident was supposed to follow-up with the orthopedic surgeon for removal. She stated that it was scheduled but that she could not recall the date. She further stated that she should have included the appointment date in the discharge summary. During a joint interview on 8/18/26 at 4:11 PM with the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS), the DON stated that Resident #3's appointment should have been documented on their discharge summary to ensure continuity of care. A review of the facility's Discharge Summary and Plan policy, revised March 2025, revealed that the discharge summary was to include any current or pending consults, along with that provider's contact information. N.J.A.C. 8:39-5.4(b)

Based on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks and background checks on employees before their start date. The deficient practice was identified for 1 of 151 employees reviewed for background checks (Employee #30) and 57 of 151 employees reviewed for reference checks (Employee #1, Employee #2, Employee#3, Employee #4, Employee #5, Employee #6, Employee #7, Employee #8, Employee #9, Employee #10, Employee #11, Employee #12, Employee #13, Employee #14, Employee #15, Employee #16, Employee #17, Employee #18, Employee #19, Employee #20, Employee #21, Employee #22, Employee #23, Employee #24, Employee #25, Employee #26, Employee #27, Employee #28, Employee #29, Employee #30, Employee #31, Employee #32, Employee #33, Employee #34, Employee #35, Employee #36, Employee #37, Employee #38, Employee #39, Employee #40, Employee #41, Employee #42, Employee #43, Employee #44, Employee #45, Employee #46, Employee #47, Employee #48, Employee #49, Employee #50, Employee #51, Employee #52, Employee #53, Employee #54, Employee #55, Employee #56, and Employee #57) and was evidenced by the following:On 12/4/25 at 10:03 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) the personnel files of all the new employees who were hired since the last standard survey (7/9/2024), whether currently employed or terminated, for review by the survey team. 1.) A review of the employee personnel files revealed the following:For Employee #30, the admission Coordinator with a start date of 2/10/25, there was no evidence of a background check prior to the start of employment. 2.) A review of the employee personnel files revealed the following:For Employee #1, a Certified Nursing Assistant (CNA) with a start date of 10/23/24, there was no evidence of a reference check prior to the start of employment.For Employee #2, a CNA with a start date of 9/25/24, there was no evidence of a reference check prior to the start of employment.For Employee #3, a Nursing Assistant (NA) with a start date of 10/9/24, there was no evidence of a reference check prior to the start of employment.For Employee #4, a CNA with a start date of 11/14/24, there was no evidence of a reference check prior to the start of employment.For Employee #5, a Housekeeper with a start date of 1/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #6, a CNA with a start date of10/9/24, there was no evidence of a reference check prior to the start of employment.For Employee #7, a Dietary Aide with a start date of 9/25/24, there was no evidence of a reference check prior to the start of employment.For Employee #8, Dietary with a start date of 11/20/24, there was no evidence of a reference check prior to the start of employment.For Employee #9, a Dietary [NAME] with a start date of 1/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #10, a Dietary Aide with a start date of 8/28/24, there was no evidence of a reference check prior to the start of employment.For Employee #11, an Activities staff with a start date of 10/9/24, there was no evidence of a reference check prior to the start of employment.For Employee #12, an Activities Aide with a start date of 3/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #13, a NA with a start date of 3/26/25, there was no evidence of a reference check prior to the start of employment.For Employee #14, a CNA with a start date of 2/18/25, there was no evidence of a reference check prior to the start of employment.For Employee #15, an Activities Aide with a start date of 7/31/24, there was no evidence of a reference check prior to the start of employment.For Employee #16, a CNA with a start date of 6/25/24, there was no evidence of a reference check prior to the start of employment.For Employee #17, a Licensed Practical Nurse (LPN) with a start date of 11/19/25, there was no evidence of a reference check prior to the start of employment.For Employee #18, a NA with a start date of 10/7/25, there was no evidence of a reference check prior to the start of employment.For Employee #19, a LPN with a start date of 12/18/24, there was no evidence of a reference check prior to the start of employment.For Employee #20, a LPN with a start date of 11/20/24, there was no evidence of a reference check prior to the start of employment.For Employee #21, a CNA with a start date of 10/9/24, there was no evidence of a reference check prior to the start of employment.For Employee #22, a NA with a start date of 9/11/24, there was no evidence of a reference check prior to the start of employment.For Employee #23, a NA with a start date of 2/18/25, there was no evidence of a reference check prior to the start of employment.For Employee #24, a LPN with a start date of 7/17/24, there was no evidence of a reference check prior to the start of employment.For Employee #25, a LPN with a start date of 11/21/24, there was no evidence of a reference check prior to the start of employment.For Employee #26, a LPN with a start date of 10/9/24, there was no evidence of a reference check prior to the start of employment.For Employee #27, a NA with a start date of 2/18/25, there was no evidence of a reference check prior to the start of employment.For Employee #28, a NA with a start date of 12/4/24, there was no evidence of a reference check prior to the start of employment.For Employee #29, a LPN with a start date of 9/11/24, there was no evidence of a reference check prior to the start of employment.For Employee #30, an admission Coordinator with a start date of 2/10/25, there was no evidence of a reference check prior to the start of employment.For Employee #31, a CNA with a start date of 7/2/24, there was no evidence of a reference check prior to the start of employment.For Employee #32, a Receptionist with a start date of 1/13/25, there was no evidence of a reference check prior to the start of employment.For Employee #33, an Activities staff with a start date of 2/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #34, a LPN with a start date of 11/20/24, there was no evidence of a reference check prior to the start of employment.For Employee #35, a NA with a start date of 7/2/24, there was no evidence of a reference check prior to the start of employment.For Employee #36, a Housekeeper with a start date of 3/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #37, a CNA with a start date of 10/23/24, there was no evidence of a reference check prior to the start of employment.For Employee #38, a LPN with a start date of 3/7/25, there was no evidence of a reference check prior to the start of employment.For Employee #39, a CNA with a start date of 12/4/24, there was no evidence of a reference check prior to the start of employment.For Employee #40, a CNA with a start date of 9/1/24, there was no evidence of a reference check prior to the start of employment.For Employee #41, a CNA with a start date of 2/18/25, there was no evidence of a reference check prior to the start of employment.For Employee #42, a Dietary Aide with a start date of 8/28/25, there was no evidence of a reference check prior to the start of employment.For Employee #43, a CNA with a start date of 1/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #44, a CNA with a start date of 12/21/24, there was no evidence of a reference check prior to the start of employment.For Employee #45, a Registered Nursing (RN) with a start date of 12/18/24, there was no evidence of a reference check prior to the start of employment.For Employee #46, a LPN with a start date of 1/15/25, there was no evidence of a reference check prior to the start of employment.For Employee #47, a Dietary [NAME] with a start date of 2/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #48, a Housekeeper with a start date of 11/25/24, there was no evidence of a reference check prior to the start of employment.For Employee #49, a Housekeeping Aide with a start date of 2/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #50, a Dietary Aide with a start date of 9/25/24, there was no evidence of a reference check prior to the start of employment.For Employee #51, a CNA with a start date of 1/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #52, a Nursing Supervisor with a start date of 1/15/25, there was no evidence of a reference check prior to the start of employment.For Employee #53, a Housekeeper with a start date of 1/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #54, a CNA with a start date of 7/2/24, there was no evidence of a reference check prior to the start of employment.For Employee #55, a Housekeeper with a start date of 3/12/25, there was no evidence of a reference check prior to the start of employment.For Employee #56, a Dietary Aide with a start date of 8/15/24, there was no evidence of a reference check prior to the start of employment.For Employee #57, Dietary with a start date of 7/10/24, there was no evidence of a reference check prior to the start of employment.On 12/9/25 at 10:33 AM, the surveyor interviewed the Human Resource Director (HRD) who stated that a background check would be obtained on every new hired employee. The HRD further stated that that a minimum of two reference checks would be obtained on every new hired employee. The HRD stated that it was important to obtain a background and reference check on every new hired employee to confirm the employee was a good worker, had good attendance, and did not have any abnormalities such as drug issues.On 12/9/25 at 12:45 PM, in the presence of the survey team and the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) acknowledged that background checks should be done prior to hire, and two reference checks should be documented in the employee file. On 12/10/25 at 10:16 AM, in the presence of the survey team, the LNHA, and the DON, the HRD acknowledged that all pre-employment documents, including the background and reference checks, should be kept in the employee personnel files. A review of the facility's Abuse, Neglect and Exploitation policy, revised 7/2024, included: The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Screenings may be conducted by the facility itself, third party agency or academic institution. The facility will maintain documentation of proof that the screening occurred . NJAC 8:39-4.1(a)(5); 9.3(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to adhere to infection control standards and procedures during the provision of wound treatments. This deficient practice was identified for 1 of 1 resident (Resident #13) reviewed for pressure ulcers and was evidenced by the following:On 12/5/25 at 10:43 AM, the surveyor observed Resident #13 lying in bed awake with the head of the bed elevated. The resident did not respond verbally when they were spoken to and was lying on an air mattress. On 12/5/25, the surveyor reviewed the medical record of Resident #13.A review of the admission Record, an admission summary, revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Stage four sacral (a small triangular bone at the base of the spine) pressure ulcer (full-thickness skin loss that extends into underlying muscle, tendon, cartilage, and bone), pressure ulcer of left hip unstageable, pressure ulcer of right buttock unspecified stage, chronic osteomyelitis (inflammation of bone or bone marrow, usually due to an infection), aphasia (loss of ability to understand or express speech) following cerebral infarct (stroke), and protein-calorie malnutrition.A review of the quarterly Minimum Data Set (MDS), an assessment, dated 11/26/25, revealed that the resident had two stage three pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible), and one stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) that was present upon admission to the facility. A review of the resident's Care Plan Report revealed that the resident had a focus area dated 11/12/25, with a focus of on enhanced barrier precautions due to indwelling urinary catheter and wounds. Interventions included: Wash hands appropriately before/after caring for a resident, donning (putting on)/removing personal protective equipment (PPE) to prevent the spread of infection. On 12/9/25 at 9:01 AM, the surveyor met with Licensed Practical Nurse (LPN) #3 to observe the provision of a wound treatment for Resident #13. LPN #4 was also present and stated that he planned to assist with the wound treatment.At 9:04 AM, both LPN #3 and LPN #4 cleaned their hands with alcohol-based hand rub (ABHR) before they both donned a gown and gloves outside of the resident's room prior to entry. At 9:06 AM, LPN #3 then used a sanitizing wipe to clean the table before she immediately placed the wound treatment supplies directly on the over bed table. At 9:07 AM, LPN #4 picked up the trash can with his gloved hands and passed the trash can to LPN #3, who then placed the trash can on the floor with her gloved hands and then used it to discard the soiled dressings. At 9:09 AM, LPN #3 failed to doff (remove) her gloves and perform hand hygiene before she proceeded to open the packaging of the foam dressing and dated it with a permanent marker. LPN #3 then immediately proceeded to remove the resident's soiled sacral dressing. At 9:10 AM, LPN #3 doffed her gloves and used ABHR to sanitize her hands and then donned gloves. A malodorous (foul odor) was noted after the dressing was removed from the sacral wound.At 9:11 AM, LPN #3 proceeded to cleanse the sacral wound with gauze soaked in Vashe (wound cleansing solution) that was placed in a clear, plastic cup by LPN #3. At 9:13 AM, LPN #3 failed to doff her gloves and perform hand hygiene before she proceeded to pour Dakin's solution (diluted bleach solution) into a clear plastic cup and soaked gauze pads in the solution before she packed it into the sacral wound.At 9:14 AM, LPN #3 then proceeded to apply skin prep (a protective barrier) around the outside of the wound edges.At 9:15 AM, the outer packing fell out of the sacral wound onto the resident's incontinence brief. LPN #4 then proceeded to pick up the gauze pad with his gloved hands from the incontinence brief and placed it back into the sacral wound. At 9:16 AM, LPN #3 doffed her gloves and cleaned her hands with ABHR.At 9:17 AM, LPN #3 donned gloves before she proceeded to open the outer foam dressing and dated it in preparation for the wound treatment to be applied to the resident's right ischial (the large bone in the lower part of the hip) wound. At 9:18 AM, LPN #3 cleansed the right ischial wound with three separate gauze pads soaked in Vashe. At 9:20 AM, LPN #3 failed to doff her gloves and perform hand hygiene before she proceeded to soak gauze pads in Dakin's solution and packed it into the resident's right ischial wound. At 9:21 AM, LPN #3 applied skin prep to the outer edges of the wound and covered the wound with a foam dressing. At 9:22 AM, LPN #3 doffed her gloves and performed hand hygiene with ABHR. She then moved the table to the left side of the bed and doffed her gloves and washed her hands for 20 seconds. At 9:27 AM, LPN #3 removed the soiled dressing from the left ischial wound and failed to doff her gloves and perform hand hygiene after. At 9:28 AM, LPN #3 soaked a gauze pad in Vashe and cleansed the left ischial wound. LPN #3 then patted the wound dry with a gauze pad. At 9:29 AM, LPN #3 doffed her gloves and failed to immediately perform hand hygiene after and stated that she needed to get a cotton tipped swab from the wound treatment cart that was in the doorway of the room. LPN #3 then stated that the other resident whose bed was positioned next to the doorway needed to be repositioned as they were too close to the edge of the bed. LPN #3 then placed her bare hands on either side of the resident's shoulders to assist them to sit up straight in their bed without first performing hand hygiene. At 9:30 AM, LPN #3 picked up the cotton tipped swab and placed it on top of the over bed table before she washed her hands for 20 seconds and donned gloves. At 9:32 AM, LPN #3 then opened the cotton tipped applicator and applied Triad (a sterile coating) to the tip of the applicator that was then applied in the resident's left ischial wound. At 9:33 AM, LPN #3 then applied skin prep to the outer perimeter of the wound bed and then placed a foam dressing over the left ischial wound. At 9:34 AM, LPN #3 and LPN #4 repositioned the resident for comfort and LPN #3 doffed her gloves after. LPN #3 failed to perform hand hygiene before she proceeded to pick up a package of gauze pads and secured the package closed with her bare hands. At 9:36 AM, LPN #3 washed her hands for 20 seconds. At 9:37 AM, LPN #3 returned the wound treatment supplies to the wound treatment cart without first cleaning the outside of the bottles of Vashe, Triad, and Dakin's solution. LPN #3 then proceeded to pick up the bag of gauze pads and placed them in the bottom drawer of the treatment cart inside of a box bedside sealed package of 4 x 4 gauze pads. At 9:34 AM, LPN #3 cleaned the over bed table with a sanitizing wipe. When interviewed at that time, LPN #3 was unable to tell the surveyor what the kill time (time needed for the product to contact a surface to kill germs) was for the disinfectant wipes that she used to clean the over bed table both before and after use. At 9:39 AM, when interviewed, LPN #3 stated that there was a potential for the spread of infection if gloves were not doffed and hands sanitized after handling the trash can and prior to handling a wound dressing and removal of the outer dressing. LPN #3 stated she could spread germs if she doffed her gloves without performing hand hygiene and then accessed the treatment cart and assisted another resident to reposition in bed. LPN #3 stated she should have wiped down the resident's supplies before she returned them to the cart. LPN #3 also acknowledged that cross-contamination was a concern when she used the same gloves to clean the wound as she used to pack it.On 12/9/2025 at 9:56 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated there was a risk of contamination if supplies were placed on table before the table dried. The LPN/UM #1 stated that there was also a concern for cross-contamination if gloves were not doffed and hand hygiene were not performed after the trash can was passed between the nurses, the outer treatment was dated, and the soiled sacral dressing was removed.LPN/UM #1 stated that both the field and the wound were contaminated if the nurse did not doff their gloves and perform hand hygiene after the wound was cleansed, and then immediately placed Dakin's-soaked gauze into the wound bed. She stated there was a risk a risk of cross- contamination to both the resident and the treatment cart. At that time, the LPN/UM #1 stated that if LPN #4 placed the Dakin's-soaked gauze that fell on the brief back into the wound bed, he contaminated the wound bed and he should have gotten a new one. On 12/9/25 at 10:08 AM, the surveyor interviewed LPN #4 who stated the whole packing did not fall out, and if the whole packing fell out you could not use it, and that it was an infection control concern. On 12/9/25 at 10:20 AM, the surveyor interviewed the Infection Preventionist (IP) who stated it was an infection control issue if the gloves were not doffed, and the hands were not washed, and clean gloves were put on after the wounds were cleansed and before the wound treatment was administered. The IP further stated, the whole thing is cross-contamination.On 12/9/25 at 10:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated her concern was for cross-contamination if hand hygiene was not performed after the trash can was touched prior to handling dressing packaging and removal of outer sacral dressing. The DON stated it was also a concern for cross-contamination to put a dressing that fell out of the wound back into the wound bed and that he should have discarded it. The DON further stated that the nurse should only have taken what they needed into the room rather than returning the wound treatment supplies to the wound treatment cart. On 12/9/25 at 12:49 PM, the Licensed Nursing Home Administrator (LNHA) was informed of the surveyors concerns with the resident's wound treatment observation. A review of the facility's Wound Care policy, revision date October 2024, included:Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used on the clean field.Wash and dry your hands thoroughly Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard in appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves.Use no-touch technique.Pour liquid solutions directly onto gauze sponges on their papers.Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.Remove dry gauze. Apply treatments as indicated.Dress wound.Pick up sponge with paper and apply directly to the area.Be certain all clean items are on clean field.Discard disposable items in the designated container.Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly.Wipe reusable supplies with alcohol as indicated (i.e., outside of containers that were touched by unclean hands,.etc., Return reusable supplies to resident's drawer in treatment cart. Take only disposable supplies that are necessary for the treatment into the room. Disposable supplies can not be returned to the cart. Wash and dry your hands thoroughly. A review of the facility's Handwashing/Hand Hygiene policy, revision date October 2023, included:The facility considers hand hygiene to be the primary means to prevent the spread of healthcare-associated infections.Indications for Hand Hygiene:Immediately before touching a resident;after contact with blood, body fluids, or contaminated surfaces;after touching a resident;after touching a resident's environment;before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. NJAC 8:39-19.4

Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean, safe, and sanitary manner and b.) maintain nutrition room equipment in 2 of 3 units (East and 2nd) in a clean, safe and sanitary manner as evidenced by the following:On 12/4/25 at 11:02 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen:1. Two (2) of two (2) convention ovens (1-upper and 1-lower unit), had baked on food debris on the two glass doors and on the inside surfaces. The FSD acknowledged that it was not cleaned according to facility policy. 2. One (6 burner) stove top, had all 6 burners with debris on the grates and around the cooker hats. The FSD acknowledged that it was not cleaned according to facility policy. 3. The oven (attached to the 6-burner unit) interior was dirty with a brown, sticky thick substance dripping down from the cooktop area into the interior oven doorframe. The FSD acknowledged that it was not cleaned according to facility policy. On 12/9/25 at 10:48 AM, in the presence of the east wing Licensed Practical Nurse Unit Manager (LPN/UM#2), the surveyor observed the following in the East Nutrition room: 1. 2 of 2 cabinet drawers had multicolored crumb debris loosely among resident snacks (i.e. cookies, crackers). The LPN/UM #2 acknowledged that it was not cleaned according to facility policy and could attract unwanted pest and rodents.2. The refrigerator on the East unit had a cracked and ripped refrigerator door seal with black debris in the track of the seal. The interior of the frost-free freezer had sheets of ice present. The LPN/UM #2 acknowledged that it was not cleaned according to facility policy.3. The microwave had multicolored splatters, and debris were present on the interior ceiling surface. The LPN/UM #2 acknowledged that it was not clean according to facility policy. On 12/9/25 at 11:00 AM, in the presence of the 2nd floor Licensed Practical Nurse Unit Manager (LPN/UM#1) the surveyor observed the following in the 2nd floor Nutrition room:1. The 2 of 2 cabinet drawers had multicolored crumb debris loosely among resident snacks (i.e.cookies, crackers). The LPN/UM #1 acknowledged that it was not cleaned according to facility policy and could attract unwanted pests and rodents.2. The refrigerator on the East unit had a cracked and ripped refrigerator door seal with black debris in the track of the seal. The interior of the frost-free freezer had ice present on the back panel. The LPN/UM #1 acknowledged that it was not cleaned according to facility policy. On 12/9/25 at 11:25 AM, the surveyor interviewed the Environmental Services Director (ESD) who stated the housekeepers process was to surface clean the nutrition rooms daily and deep clean the nutrition room on Wednesdays every week. The surveyor revealed the pictures that were taken in the nutrition rooms. The ESD stated that if there were visible debris, the housekeeping staff was required to wipe and clean the questionable areas daily. The ESD acknowledged the surveyor concerns and agreed it was not clean according to the facility policy. A review of policy, Sanitation, revised in November 2022, revealed, All kitchen areas are kept clean.free of debris and protected from rodents and insects.all kitchen equipment is kept clean, maintained in good repair. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection, for 1 of 4 residents (Resident #162) reviewed for respiratory care.This deficient practice was evidenced by the following:On 12/4/25 at 10:01 AM, the surveyor observed Resident #162 in their room sitting on the bed with oxygen infusing at three liters via a nasal canula (tubing used to deliver oxygen). The surveyor also observed a Bilevel Positive Airway Pressure (BiPAP) machine (a non-invasive breathing device used to treat sleep apnea by delivering pressurized air through a mask) on the resident's nightstand. The mask was uncovered on the nightstand. On 12/4/25 at 1:33 PM, the surveyor reviewed the resident's medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: sleep apnea (a serious sleep disorder where breathing repeatedly stops and starts, most commonly due to airway blockage), chronic respiratory failure with hypoxia (a long term condition where the lungs does not get enough oxygen into the blood), and chronic obstructive pulmonary disease (a progressive lung disease making breathing difficult, characterized by airflow obstruction). A review of the resident's Social Services Assessment and Documentation (a comprehensive assessment), dated 12/1/25, revealed that Resident #162 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/2/25, that the resident had sleep apnea. The interventions included: observe respiratory status, reposition the resident every two to four hours as tolerated, and monitor to for any changes in the mental status. A review of the physician's order, dated 12/3/25 at 3:13 PM, included, place BIPAP at 17/13 with three liters per minute of oxygen at bedtime and to remove in the morning.A review of the December 2025 Treatment Administration Record (TAR) revealed that the resident had used the BiPAP in the night of 12/3/25 and 12/7/25. On 12/8/25 at 11:34 AM, the surveyor conducted a follow-up visit to the resident's room. Resident #162 was lying in bed with oxygen infusing via nasal canula at three liters. The resident's BiPAP mask was uncovered and touching the surface of the nightstand. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) #3 walked up to the resident's room in the surveyor's presence and observed the BiPap mask uncovered and touching the surface of the nightstand. LPN/UM #3 stated the mask should be in a bag to prevent infection and cross contamination.On 12/8/25 at 11:37 AM, the surveyor interviewed LPN/UM #3 who stated that the resident used his/her BiPAP at night. She further stated, that the BiPAP mask should be stored in a bag to prevent bacteria from building up when it was not in use. On 12/8/25 at 1:23 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that BiPAP mask should be in a bag when it was not being used. She further stated that storing it in a bag would reduce the risk of an infection. On 12/8/25 at 1:53 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the BiPAP mask should be kept in a bag when it was not being used for infection control purposes. A review of the facility's BiPAP and CPAP (continuous positive airway pressure) Policy and Procedure policy, undated, included, Store mask in an open bag or container. N.J.A.C. 8:39- 19.4(a)

Based on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 1 resident, (Resident #13) reviewed for pressure ulcers and was evidenced by the following:On 12/5/25 at 10:43 AM, the surveyor observed Resident #13 lying in bed awake with the head of the bed elevated. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 presented to the room and attempted to offer the resident a drink of water. The resident did not respond verbally when they were spoken to. The resident was on an air mattress that was set at 160 pounds (lbs). On 12/5/25, the surveyor reviewed the medical record of Resident #13.A review of the admission Record, an admission summary, revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: Stage four sacral pressure ulcer (full-thickness skin loss that extends into underlying muscle, tendon, cartilage, and bone), pressure ulcer of left hip unstageable, pressure ulcer of right buttock unspecified stage, chronic osteomyelitis (inflammation of bone or bone marrow, usually due to an infection), aphasia (loss of ability to understand or express speech) following cerebral infarct (stroke), and protein-calorie malnutrition.A review of the quarterly Minimum Data Set (MDS), an assessment, dated 11/26/25, revealed that the resident weighed 141 pounds. A further review of the MDS revealed that the resident had two stage three pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible), and one stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) that was present upon admission to the facility. A review of the resident's Care Plan Report revealed that the resident had a focus area dated 8/19/25, which indicated that the resident had a draining wound to the sacrum (a small triangular bone at the base of the spine), and interventions included: low air loss mattress. A review of the resident's Order Summary Report (OSR) dated as of 12/5/25, included the following Physician's Order (PO):-A PO dated 12/5/25, for a Low Air Loss Mattress: Check placement and function every shift.A review of the resident's most recent weight in the electronic medical record (EMR) revealed that on 11/12/25, the resident weighed 140.8 pounds. On 12/8/25 at 10:51 AM, the surveyor observed the resident lying in bed asleep with the head of the bed slightly elevated on an air mattress. The air mattress pump was set at 200 pounds. On 12/8/25 at 10:55 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated that she was working as an aide today. LPN #2 stated the resident had three wounds which included wounds on the left and right ischium, and a sacral wound. LPN #2 stated that the resident had an air mattress that was set according to the resident's weight. LPN #2 stated they did monthly weights, and the nurses were supposed to check to ensure that the air mattress pumps were set to the correct weight setting. LPN #2 then accompanied the surveyor into the resident's room and stated the air mattress pump was set at 200 pounds. LPN #2 then looked up resident weight in the computer and stated that resident weighed 140.8 lbs. as of 11/12/25, and the pump should have been set at 140 lbs. On 12/8/25 at 11:00 AM, LPN #2 returned to resident's room and adjusted the weight on the pump between 120 lbs. and 140 lbs. to achieve the closest weight to the resident's actual weight of 140.8 lbs. LPN #2 stated if the weight was set too high, it would be too firm and could apply too much pressure to the wounds and placed the resident at an increased risk of the wound worsening. On 12/8/25 at 11:08 AM, the surveyor interviewed LPN #1, the resident's assigned nurse, who stated that she had not checked the air mattress pump yet, as the resident was scheduled to be weighed today (12/8/25). On 12/9/25 at 8:53 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurses were responsible to check the low air loss mattress pump settings as it was used for wound prevention and active wounds. LPN/UM #1 further stated that the importance of setting the low air mattress pump at the resident's current weight was to prevent any further damage to the skin.On 12/9/25 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the low air mattress pump was set to the resident's body weight to off load the pressure and the nurse was responsible to check the setting on the pump for accuracy each shift. The DON stated that if it were set too high, it could affect the pressure under the patient. On 12/9/25 at 12:49 PM, in the presence of the survey team, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the concerns that the resident's low air mattress pump settings were not accurately set according to the resident's body weight.A review of the facility's Use of Support Surfaces policy, dated 10/3/24, included:The goal and preferences of the resident and/or authorized representative will be included in the plan of care and support surface selection.Support surfaces will be utilized in accordance with manufacturer recommendations (including considerations for contraindications)A review of the Owner's Manual revealed, When the resident is placed on the mattress surface, the mattress firmness is adjusted automatically after the resident's height and weight are entered on the display panel. This distributes the body weight uniformly across the mattress surface. NJAC 8:39 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that the Minimum Data Set (MDS), an assessment tool, accurately reflected the resident's smoking status.This deficient practice was identified for 1 of 30 sampled residents (Resident #141), and was evidenced by the following: On 12/8/25 at 1:03 PM, the surveyor, accompanied by the Certified Nursing Assistant (CNA) #1, observed Resident #141 go outside in the smoking area and smoke two cigarettes. On 12/8/25 at 1:30 PM, the surveyor reviewed the medical record for Resident #141. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: chronic obstructive disease (a progressive lung disease making breathing difficult), and solitary pulmonary nodule (a single, small spot in the lung). A review of the resident's comprehensive MDS, dated [DATE], included that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS, section J1300, revealed that the resident was not a smoker. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 7/18/24, that the resident liked to smoke and had a history of smoking. Interventions included: Ascertain the resident's wishes about smoking and respect the resident's decision. A review of the Smoking/Nicotine Devices assessment, an assessment to determine the level of supervision needed for the resident who smokes, dated 6/17/25 and 9/15/25, revealed that Resident #141 used smoking/tobacco/nicotine products and did not require supervision while smoking. A review of the Progress Notes (PN) included a social services note, dated 11/4/25 at 10:31 AM, which revealed, resident was a smoker. On 12/9/25 at 10:13 AM, the surveyor interviewed CNA#1, who stated that the resident had been a known smoker to her since she had been employed at the facility since February 2025. On 12/9/25 at 10:16 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2, who stated that the resident goes out to smoke three times a day. On 12/9/25 at 10:22 AM, the surveyor interviewed the MDS Coordinator (MDSC), who also confirmed that Resident #141 was a smoker and that he/she was the facility's only smoker. The MDSC pulled up the electronic medical record (EMR) of the resident and confirmed that the comprehensive MDS, dated [DATE], was coded incorrectly and that it should reflect that Resident #141 was a smoker. She further stated that the MDS should be an accurate picture of the resident, because it drives the care plan. On 12/9/25 at 10:32 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS should be accurate. The DON further stated that when completing the MDS, the MDSC should review the hospital records, if applicable, review the progress notes, and see the residents to ensure that the MDS was completed accurately. A review of the facility's Resident Assessments policy, revised October 2023, included, Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. NJAC 8.39-11.1

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain the training room toilets in the resident shower rooms in a clean and homelike environment. This deficient practice was identified for 2 of 3 shower rooms inspected on 2 of 3 nursing units (East and West) and was evidenced by the following:On 12/5/25 at 10:57 AM, the surveyor observed the East Wing Shower Room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) #2. When the surveyor entered the training toilet bathroom, there was a strong odor noted around the toilet. When the surveyor asked LPN/UM #2 if the area smelled of urine, the LPN/UM stated, a little bit. LPN/UM #2 then stated it should have been cleaned that morning. The surveyor observed yellow staining with dirt and debris at the rear and on the sides of the base of the toilet. LPN/UM #2 stated that it appeared as if the yellow staining had not just happened. LPN/UM #2 added that the residents utilized the shower room twice a week.At 11:02 AM, LPN/UM #2 confirmed and informed the surveyor that no residents were showered yet that day.At 11:08 AM, the surveyor interviewed Housekeeping Associate (HA) #1 who stated she was not assigned to clean East Wing the day prior, and that she had cleaned it on Tuesday, 12/2/25. At that time, the HA #1 stated the yellow staining around the base of the toilet was probably urine and it did not look like it had just happened. HA #1 stated she normally cleaned both sides of the toilet. The surveyor observed brown matter below the handle on the front of the toilet. HA #1 stated it looked and smelled like someone just had a bowel movement. HA #1 further stated it looked like there was also feces above the handle on the front of the toilet. HA #1 added that if there was feces on the toilet and the toilet was not cleaned, it was an infection control problem, and a resident could catch something. At 11:19 AM, the surveyor interviewed the Environmental Services Director (ESD) in the presence of HA #1. The ESD stated that the training toilet in the East Wing bathroom was cleaned early that morning, but HA #1 then stated, no, not yet.At that time, the ESD stated the yellow staining on the base of the toilet looked dirty, like urine, and that it needed to be cleaned. The ESD stated it did not look like it had just happened to be honest. The ESD further stated the brown matter above toilet handle was dirty and may have been touched by a dirty hand with feces on it. The ESD added that the toilet was very dirty and it was an infection control concern. At 11:34 AM, the surveyor inspected the [NAME] Unit Shower Room training toilet in the presence of Concierge #1. There were dark colored matter and debris on both sides of the base of the toilet. The concierge stated the toilet needed to be cleaned because it looked like there was a combination of dirt and staining on the base of the toilet.At 1:35 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that it was an infection control issue if the toilets were not cleaned prior to resident usage. The IP further stated that hand hygiene would be required after usage to prevent the spread of infection. On 12/9/2025 at 12:49 PM, the Licensed Nursing Home Administrator (LNHA) was made aware of the concerns that were identified with the training room toilets. A review of the facility's Housekeeping-General policy, revised 8/1/2017, included:All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.NJAC 8:39-31.4 (a) (f)

COMPLAINT#: NJ00187516 / 402411Based on interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice.This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following: A review of Resident #2's admission Record revealed that that the resident was admitted to the facility with diagnoses that included but were not limited to: quadriplegia, neurogenic bowel (a condition where the nerves that control bowel function are impaired, leading to abnormal bowel movements), and neuromuscular dysfunction of bladder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 6/30/25, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. A further review of Resident #2's medical record revealed that the resident filed a grievance on 4/30/25, which indicated that a nurse had changed their wound dressing. A review of Resident #2's Treatment Administration Record (TAR) for April 2025 revealed an order dated 4/4/25, that the wound vacuum dressing was to be changed, along with an order for the application of skin prep dated 3/8/25. Both indicated that they were to be completed as needed for soilage. A further review of the TAR revealed no documentation that the dressing was changed nor the that the skin prep was applied on 4/30/25. A review of Resident #2's Progress Notes did not reveal any documentation that the resident's treatments were completed or not completed on 4/30/25. During an interview with Resident #2 on 8/26/25 at 2:35 P.M., the resident recalled filing the grievance because the primary nurse did not change the wound vacuum after a bowel movement, but that the next shift had taken care of it. The resident stated that they could not recall the exact date of the grievance at the time of the interview. During an interview with the Licensed Practical Nurse (LPN) Shift Supervisor on 8/26/25 at 3:55 P.M., in the presence of the surveyor, she reviewed the grievance for Resident #2 dated 4/30/25. The LPN stated that she recalled the incident and that while completing her rounds, she was approached by a Certified Nursing Assistant (CNA) who stated that there was a concern with Resident #2. The LPN stated that she immediately went to the resident's room, where the resident told her that wound care needed to be provided due to a bowel movement. The LPN stated that she immediately gathered the necessary supplies and went in with another nurse to provide the treatment. The LPN also stated that it was important to document all care provided to a resident, because others may think it wasn't done if it wasn't documented. In the presence of the surveyor, she also reviewed the Resident's TAR for April 2025 and stated, I made sure it got done and with it being change of shift, I forgot to document it. She further stated that she should have signed the TAR. During an interview on 8/26/25 at 4:16 P.M., the Director of Nursing (DON) stated that she expected that all care provided to a resident to be documented as done, So that everyone knows it was done. In the presence of the surveyor, the DON reviewed Resident #2's TAR for April 2025, and stated that the nurse should have signed a treatment if it was done. A review of the facility's Charting and Documentation policy, revised July 2023, revealed that all services provided to the resident would be documented in a resident's medical record, including, . Treatment or services performed. N.J.A.C. 8:39-27.1(a)

Complaint #: NJ186633 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 5/28/25 and 5/30/25, it was determined that the facility failed to provide a resident (Resident #2), who voiced a grievance, a written summary of the investigation in accordance with the facility's Grievance Policy. The deficient practice was identified for 1 of 3 residents, Resident #2, and evidenced by the following: According to the Admitting Face Sheet, Resident #2 had diagnoses which included but were not limited to: Iron Deficiency Anemia, Unspecified, Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Right Leg Below Knee, and Morbid (Severe) Obesity Due to Excess Calories. According to the resident's Minimum Data Set (MDS), an assessment tool dated 3/7/25, Resident #2 had a Brief Interview Mental Status score of 15/15, which indicated that Resident # was cognitively intact. The MDS also indicated that the Resident required assistance with activities of daily living (ADLs). A review of a facility document titled Grievance/Concern Form dated 12/30/24, with date of occurrence on 12/27/24, revealed that Resident #2 reported to the facility that he/she knows customer service and is tired of these rude young kids taking care of him/her. During interview with surveyor on 5/30/25 at 1:55 p.m., Resident #2 stated, I have never received anything in writing with the outcome of the grievance. Not once have I received anything in writing. During interview with surveyor on 5/30/25 at 2:58 p.m., the Administrator stated, We do not have a response in writing regarding the 12/30/24 grievance for Resident #2. Yes, there should have been a response in writing per policy. During Exit Conference on 5/30/25 at 3:44 p.m., the Director of Nursing (DON) stated, There was nothing that showed that a copy of the resolution was given to the resident (Resident #2) in writing. Yes, according to the policy, there should have been something in writing what the resolution was. Review of facility's policy titled, Grievances/Complaints, Filing with a Revision Date of 4/2024, Policy Interpretation and Implementation, included but were not limited to the following: 12. The resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. b. A written summary of the investigation will be provided to the resident NJAC 8:39-13.2(c)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:17 to 9:56 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen a dietary aide (DA) was observed to have lengthy braids extending to the shoulder area. The braids on either side of the head were not contained in the hair net and were exposed. 2. In the dry storage room on an upper shelf a can of Pear Diced had a significant dent on the upper seam of the can. The FSD removed the dented can to the designated dented/damaged can area on a lower shelf of the room. 3. A stack of 5 half pans on the middle rack of the pot/pan storage rack were in the inverted position. The surveyor lifted the top pan on the stack and felt the bottom of the pan below. The pan was wet to the touch and there was a watery substance on the bottom edge of the pan a condition known as wet nesting (occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The FSD agreed that the pans were wet and proceeded to remove the half pans from the rack. When interviewed the FSD agreed that all dishware should be air dried prior to storage. The FSD removed the effected half pans from the storage rack to be rewashed and sanitized and air dried before storage. 4. At 9:34 AM the surveyor and FSD went to observe the high temperature dish machine which was actively in use at the time washing dishware used for resident meals. The surveyor upon arrival to the dishwasher area reviewed the [DATE] [facility name] DISHWASHER TEMPERATURE LOG. Observation of the log reveled the following: Minimum temperature for wash cycle: 160 F (Fahrenheit) rinse cycle: 180 F. The log further revealed that If temperatures were below standard, the person in charge was notified and dish machine was stopped. A review of the log for breakfast on [DATE] revealed the following temperatures: Wash: 160 and Rinse: 180. At 9:34 AM, the surveyor observed the high temperature dishwasher wash and rinse temperatures while staff were actively washing dishware and the FSD was present. The surveyor observed a wash temperature of 140 F and a rinse temperature of 140 F. The surveyor immediately conducted an interview with the DA responsible for loading dirty dishware into the dishwasher and monitoring machine temperatures. The DA stated that she had observed and recorded the wash and rinse temperature of the high temperature dishwasher at approximately 9:15 AM and recorded a wash temperature of around 150 F and a rinse temperature of around 140 F. The surveyor then asked the DA what the minimum temperature requirements were for the high temperature dishwasher to effectively clean and sanitize dishware. The DA responded, The rinse should be around 180 F and the wash around 160 F. The surveyor asked the DA what should happen if the dishwasher is not meeting minimum temperatures for the wash and rinse. The DA stated, I should've shut it down and notified the FSD. At that time the FSD agreed that the machine was not meeting minimum temps for wash and rinse. On [DATE] at 09:43 AM, the surveyor accompanied by the FSD and DA observed the high temperature dishwasher again for the wash and rinse temperatures. The following temperatures were observed: Wash = 142 F rinse = 140 F. The FSD agreed that the high temperature dishwasher was not meeting minimum wash and rinse temperatures and the dishwasher was shut down at 9:45 AM. The FSD stated that the facility had a sufficient supply of paper products to serve the lunch meal. The FSD also told the surveyor that all dishes that had been washed up to shutting down the dishwasher would be rewashed and that he would call the facility contracted service company immediately to service and fix the high temperature dishwasher. On [DATE] at 9:16 AM, the facility Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of the Extra Service Request for the dishwasher that was dated [DATE] at 1:53 PM. The request sheet revealed the following under the Service Comments: Arrived and tested rinse. Did not register on gauge. Replaced rinse gauge. tested . Did reach sanitation temp (error, should read did not). tested booster power. There was no power. Found circuit breaker in off position. Turned on and tested . Reached 180. Reviewed with staff. 5. In the walk-in refrigerator on an upper shelf a clear plastic bag contained whole parsley. The parsley was darker green and slimy on the bottom of the clear plastic bag. On the same shelf a cardboard box was opened and contained heads of lettuce. A clear plastic bag in the box contained 2 separate romaine lettuces. The bag was opened, and the lettuce was exposed. The lettuce was noted to be brown and slimy. The FSD removed the parsley and lettuce to the trash. On [DATE] from 08:32 to 8:38 AM, the surveyor, accompanied by the Registered Nurse/Unit Manager (UM/RN#1) observed the following on the 1st floor/East Wing pantry: 1. Observation of the Non Dietary Dept. Refrigerator/Freezer/Cold Pack Machine Temperature Log, dated ,d+[DATE] revealed that no temperatures were documented on [DATE] for the refrigerator and freezer and no temperatures were recorded for [DATE] for the refrigerator and freezer. According to UM/RN#1, temperatures are to be recorded for the refrigerator and freezer daily by the ,d+[DATE] nursing staff. 2. Inside the refrigerator four (4) what appeared to be salami sandwiches on white bread were stored on the refrigerator door shelf. The sandwiches were in wax paper bags. The bags had no dates. A resident designated, zippered, food storage/carry bag contained a clear plastic container with what appeared to be cucumber/tomato/onion salad. The container was labeled eat by ,d+[DATE]. In addition, an unidentified food item wrapped in tin foil had no date. RN/UM #1 removed all unlabeled, undated, and expired food to the trash. In addition, RN/UM #1 stated to the surveyor, The temperatures should be done daily for the freezer and refrigerator by the ,d+[DATE] nursing staff. I checked it yesterday, but I must have forgotten to write it down. The surveyor reviewed the facility policy titled Dishwasher Temperature, Date Reviewed/Revised: [DATE]. The following was revealed under the heading Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. The policy further revealed under Policy Explanation and Compliance Guidelines: 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 3. For high temperature dishwashers (heat sanitization): a. The wash temperature shall be ,d+[DATE] degrees F: b. The final rinse temperature shall be 180 degrees F or above but not to exceed 194 degrees F (165 degrees F for stationary rack, single temperature machine). Corrective actions shall be taken for final temperatures below the required final rinse temperatures. 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. The surveyor reviewed the facility policy titled Food Safety Requirements, Date Reviewed/Revised: [DATE]. The following was revealed under Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. The following was revealed under Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the foods to the resident. Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded and v. Keeping foods covered or in tight containers. 6. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. e. Hairnets should be worn during cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. However, staff do not need to wear hairnets when distributing foods to residents at the dining table(s) or when assisting residents to dine. The surveyor reviewed the facility policy titled Use and Storage of Food Brought in by Family or Visitors, Date Reviewed/Revised: [DATE]. The following was revealed under the heading Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. NJAC 18:,d+[DATE].2(g)

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that there was a physician order for the use of a Foley catheter for 1 of 2 residents reviewed for catheter use (Resident #115). This deficient practice was evidenced by the following: On 06/26/2024 at 09:49 AM the Licensed Practical Nurse/Unit Manager (LPN/UM) told the surveyor that we tried a voiding trial and the resident failed and then the Foley catheter was reinserted. The LPN/UM then told the surveyor Resident #115 was scheduled for a surgical procedure in July. On 06/26/2024 at 12:15 PM, Resident # 115 was observed self-propelling in their wheelchair in the hallway. The catheter bag was noted inside a privacy bag. A review of the Admission Record revealed Resident #115 was admitted to the facility with diagnoses including but not limited to: Benign Prostatic Hyperplasia with Lower Urinary Symptoms. A review of the most recent Minimum Data Set (MDS), an assessment tool, dated 6/13/2024, revealed Resident #115 had a Brief Interview for Mental Status (BIMS) score 15/15 indicating the resident had intact cognition. The MDS further indicated the resident used an indwelling catheter. A review of the Physician Order sheet revealed the following orders: AHC: Foley Bag Privacy cover in place at all times every shift for Care with a start date of 06/07/2024 and discontinued (d/c) date of 06/19/2024. AHC: Foley Catheter Care every shift for care with a start date of 06/07/2024 and d/c date of 06/19/2024. AHC: Foley catheter Output monitoring: Monitor catheter output every shift. Every shift for monitoring with a start date of 06/07/2024 and d/c date of 06/19/2024. AHC: Foley Catheter change PRN (as needed) change Foley catheter (size 16 Fr (French) 10 cc balloon) change prn based on clinical indications such as infection, obstruction, leakage, deterioration, or when the closed system is compromised with a start date of 06/07/2024 and d/c date of 06/19/2024. There were no further orders regarding the use and care of Resident #115's Foley catheter after having been discontinued on 06/19/2024. A review of the Treatment Administration Record (TAR) dated 6/1/2024-6/30/2024 revealed the following physician orders: AHC: Foley Bag Privacy cover in place at all times every shift for Care with a start date of 06/07/2024 and discontinued (d/c) date of 06/19/2024. AHC: Foley Catheter Care every shift for care with a start date of 06/07/2024 and d/c date of 06/19/2024. AHC: Foley catheter Output monitoring: Monitor catheter output every shift. Every shift for monitoring with a start date of 06/07/2024 and d/c date of 06/19/2024. AHC: Foley Catheter change PRN (as needed) change Foley catheter (size 16 Fr (French) 10 cc balloon) change prn based on clinical indications such as infection, obstruction, leakage, deterioration, or when the closed system is compromised with a start date of 06/07/2024 and d/c date of 06/19/2024. A review of the TAR for 7/1/2024-7/31/2024 did not include the above orders. A review of a Progress Note (PN) dated 6/19/2024 at 10:20 AM revealed the Foley catheter was removed without difficulty. A PN dated 6/20/2024 at 12:07, revealed pt (patient) foley was removed 6/18. pt was bladder scanned today by this nurse. pt is retaining at 452cc (cubic centimeters). this nurse was instructed by MD (physician) to place foley. pt was able to tolerate foley. foley is draining. During an interview with the surveyor on 07/01/2024 at 01:02 PM, Licensed Practical Nurse (LPN #1) was asked what physician orders are required for the care of residents. LPN #1 responded, In general we need physician orders for medications, if Foley placed or taken out, and if Foley remains in place, diet order, oxygen, BP, vital signs, wound treatments. When asked who is responsible for getting the orders LPN #1 said the nurses are responsible to obtain physician orders. During an interview with the surveyor on 07/01/2024 at 02:13 PM, the Director of Nursing (DON) was asked what physician orders are required for the care of residents. The DON replied, Orders to provide care, medications, treatment orders, oxygen, and Foley. The surveyor asked if the DON saw a physician order for the use and care of the Foley for Resident #115 and the DON responded I did not see a physician order for the Foley catheter. The DON confirmed, There should have been a physician order for the Foley catheter. A review of a facility policy titled Catheter Care, Urinary with a revised date of August 2022, did not include that a resident requires a physician order for use of a Foley. NJAC 8:39 27.1(a)

Based on interview and review of other facility documents, it was determined that the facility failed to maintain a detailed record of receipts and accurate reconciliation of controlled medications. This deficient practice was evidenced by the following: On 06/27/2024 at 01:38 PM, the surveyor requested and reviewed all the Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances) for the last 6 months from the Director of Nursing (DON) for the past 6 months. At that time the surveyor also requested copies of those seven forms. The DON provided the surveyor with seven (7) DEA 222 forms. A review of the DEA 222 forms showed there was no entered delivery amount and date for 7 of 7 DEA 222 forms and 2 of 7 NO. (number) of packages were not completed and accurately documented as follows: 1. DEA 222 Order form #230109741 dated 1/22/2024 contained an order for package size 6 Hydrocodone-Acetaminophen 5-325, package size 25 Oxycodone HCL 5 mg (milligrams), package size 6 oxycodone HCL 10 mg, package size 25 Oxycodone HCL 15 mg, package size oxycodone-Acetaminophen 7.5-325, package size 17 Oxycodone-acetaminophen 5-325, and package size 2 Oxycontin ER (extended release) 10 mg. 2. DEA 222 Order Form 230109749 dated 2/12/2024 contained an order for 1 package of 50 Oxycodone HCL 5mg, 1 package of 21 Oxycodone HCL 10 mg, 1 package of 9 Oxycodone HCL 15 mg, 1 package of 10 Oxycodone-Acetaminophen 7.5-325, 1 package of 14 Oxycontin 10mg and 1 package of oxycontin 20mg. A review of the DEA 222 form did not include the number of packages received and the date received. 3.DEA 222 Order Form #230109748 dated 3/18/2024 contained an order for 1 package of 30 Morphine Sulfate ER 15mg, 1 package 24 Morphine Sulfate 30mg, 1 package Oxycodone HCL 5mg, 1 package of 14 Oxycodone HCL 10mg, 1 package of 21 Oxycodone HCL 15 mg, 1 package 34 Oxycontin 10 mg, and 1 package of 30 Oxycontin 20 mg. A review of the DEA 222 form did not include the number of packages received and the date received. 4. DEA 222 Order form 230109747 dated 4/22/2024, contained an order for 1 package 16 Hydrocodone-Acetaminophen 5-325, 1 package 24 Morphine Sulfate 15 mg, 1 package 26 Morphine Sulfate 30 mg, 1 package 36 Oxycodone HCL 5 mg and 1 package Oxycodone HCL 10 mg. A review of the DEA 222 form did not include the number of packages received and the date received. 5. DEA 222 Order Form # 240397650 dated 5/1/2024, contained an order for an order for package size 3 Morphine Sulfate liquid 20mg/ml (milliliter). The DEA 222 dorm did not include the number of packages ordered. A further review of the DEA 222 form did not 5/24 contained an order for 1 package of 50 Oxycodone HCL 5 mg, and 1 package of 32 Oxycodone HCL 10 mg. A review of the DEA 222 form did not include the number of packages received and the date received. 6. DEA 222 Order Form 240397649 dated 5/15/2024 contained and order for 1 package of 50 Oxycodone HCL 5 mg and 1 package of 32 Oxycodone HCL 10 mg. A review of the DEA 222 form did not include the number of packages received or the date received. 7. DEA 222 Order Form # 03202024 dated 6/10/2024 contained an order for 1 package of 50 Oxycodone HCL 5 mg and 1 package of 40 Oxycodone 10mg. A review of the DEA 222 form did not include the number of packages received and the date received. During an interview with the surveyor on 07/01/2024 at 02:15 PM, the DON was asked who is responsible for completing the DEA 222 forms when the medications are ordered. The DON replied that she was, and she kept a copy of the form, and the original was sent to the pharmacy. The DON said she kept the delivery slips when the medications came and attached them to the copy. The surveyor asked why Part 5 was not completed on the forms and the DON responded, I didn't know I had to fill that in as I kept copies of delivery slips. On 07/02/2024 at 10:44 AM, the surveyor requested a copy of facility policy for DEA 222 form from the Licensed Nursing Home Administrator LNHA). On 07/02/2024 at 11:07 AM, the LNHA said the facility does not have a policy for DEA 222 forms. A review of the printed instructions on the front of the DEA 222 form indicated: Part 1: to be filled in by the Purchaser. A further review of the instructions revealed Part 5: To BE FILLED IN BY PURCHASER, number of packages received, and date received. NJAC 8:39-27.9(c)

FACILITY Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/31/2022 from 11:24 to 11:50 AM the surveyors, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. The surveyors were in the kitchen to assess food temperatures prior to start of the lunch meal. The surveyor observed the cook behind the steam table. The cook proceeded to walk down to the end of the steam table and removed a pair of disposable gloves from a box. The cook was not observed to perform hand washing prior to entering the steam table area. The cook proceeded to don the disposable gloves and grab the thermometer and alcohol wipes that were on the counter. Upon donning the gloves, the surveyor then stopped the cook and asked what the correct procedure was when donning a new pair of gloves. The FSD stated, Hand washing is to be performed before putting on gloves or changing gloves. The cook then stated, I washed my hands before putting on the gloves. The surveyor then explained to the cook and FSD that the surveyor did not observe the cook perform hand washing prior to donning gloves. The cook then proceeded to doff her gloves and perform handwashing at the designated handwashing sink according to facility policy. The surveyor reviewed the facility policy titled Glove Usage, Original Date: 11/2020. The policy revealed the following under the GUIDELINES heading: 4. Hands are washed before putting on gloves and when changing into a fresh pair of gloves. See guidelines on hand washing in this manual. The surveyor reviewed the facility policy titled Hand Washing, Original Date: 11/2020. The policy revealed the following under the heading GUIDELINES: 1. The following list includes, but is not limited to, when hands are washed: Before applying gloves NJAC 8:39-17.2 (g)

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their [CONDITION(S)] schedule for 1 of 2 residents (Resident #38) reviewed for [CONDITION(S)]. This deficient practice was evidenced by the following: On 10/24/2022 at 9:41 AM, Resident #38 was observed lying in bed. Resident #38 said he/she goes to [CONDITION(S)] on Tuesday, Thursday, and Saturday in the AM. A review of the Electronic Medical Record revealed Resident #38 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 8/10/22, revealed a Brief Interview for Mental Status score of 11/15, indicating Resident #38 has moderately impaired cognition. The MDS further revealed Resident #38 received [CONDITION(S)] while a resident at the facility. A review of the Clinical Physicians Orders revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet (medication used for high blood pressure) 100 MG (milligram) Give 100 mg by mouth every 8 hours for [CONDITION(S)] (hypertension). A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were nurses' initials and a check mark to indicate the medication was given at 6:00 AM on the following dates: 9/1/2022, 9/3/2022, 9/6/2022, 9/8/2022, 9/10/2022, 9/13/2022, 9/15/2022, 9/17/2022, 9/20/2022, 9/22/2022, 9/24/2022, and 9/27/2022. All the above dates are resident scheduled [CONDITION(S)] days. A review of the October MARs dated 10/1/2022-10/31/2022 showed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were nurses' initials and a check mark to indicate the medication was given at 6:00 AM on the following dates:10/1/2022, 10/4/2022, 10/6/2022, 10/8/2022, 10/13/2022, 10/15/2022, 10/18/2022, 10/20/2022, 10/22/2022, 10/25/2022, 10/27/2022. All the above dates are Resident # 38's scheduled [CONDITION(S)] days. A review of the Progress Notes (PN) dated 9/1/2022-10/31/2022 indicated resident #38 refused (1) [CONDITION(S)] treatment on 10/11/2022 and attended all other scheduled [CONDITION(S)] days. During an interview with the surveyor on 10/26/2022 at 9:25 AM, Resident #38 said he/she leaves at 5 AM daily and returns by lunch. During an interview with the surveyor on 10/27/2022 at 11:33 AM, the Unit Manager Registered Nurse #2 (UM/RN #2) said the resident leaves for [CONDITION(S)] between 4:00 AM-5:00 AM. During an interview with the surveyor on 10/27/2022 at 1:12 PM, the UM/RN #2 said I came up here to the 2nd floor in early September and I readjusted the resident's medication times when I saw it was a problem. I adjusted the medication times appropriately based on his/her [CONDITION(S)] schedule. Resident #38 returns from [CONDITION(S)] sometimes at 10 AM maybe 11 AM. Today was 12:30 PM. UM/RN #2 went on to say Resident #38's [MEDICATION(S)] should be given at 5:00 AM. UM/RN #2 confirmed the [MEDICATION(S)] was signed as administered at 6:00 AM on the MARS. UM/RN #2 went on to say that the expectation is medications are timed around the [CONDITION(S)] schedule. During an interview with the surveyor on 10/31/2022 at 1:19 PM, the facility Director of Nursing said, We audit the chair time and time of return from [CONDITION(S)] and adjust medications around that time. She went on to say that the nurses know the process and it wasn't communicated to me that the resident wasn't getting back by 9 AM. The facility was unable to provide a policy regarding the scheduling of medications and a resident [CONDITION(S)] schedule. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to supervise the administration of medication for 1 of 31 sampled residents, (Resident #34). This deficient practice was evidenced by the following: Upon entering Resident #34's room on 10/24/2022 at 9:18 AM, the surveyor, in the presence of another surveyor, observed an inhaler and nasal spray sitting on the bedside table. There was no nurse observed in the room. The surveyor questioned Resident #34 if he/she keeps the medications at their bedside. Resident #34 said, No, the nurse brought them and leaves them. Resident #34 said, Most nurses leave the inhaler and nasal spray. The nurse watched me take my pills and I do these (motioning to the inhaler and nasal spray) and then they pick them up. On 10/24/2022 at 9:20 AM, a nurse entered the room and went to assist a roommate and then stopped and picked up the inhaler and nasal spray on Resident #34's bedside table. At that time during an interview with the surveyor, Licensed Practical Nurse (LPN #1) said I made a mistake. I meant to grab them (inhaler and nasal spray). LPN #1 said she left them at the bedside at 8:28 AM when she administered the oral meds (medications). According to the Admission Record Report, Resident #34 was admitted with diagnosis of Chronic Obstruction Pulmonary Disease. A review of the most recent Minimum Data Set, dated dated dated [DATE], an assessment tool used to facilitate care, revealed a Brief Interview for Mental Status (BIMS score of) 14/15 indicating Resident #34 was cognitively intact. A review of the current Clinical Physicians Orders revealed an order for [MEDICATION(S)] Diskus Aerosol Powder Breath Activated (medication used to treat ongoing lung disease) 250-50 Micrograms (MCG)/ACT 1 puff orally every 12 hours for asthma rinse mouth after use. The physician's order also revealed an order for [MEDICATION(S)] Suspension 50 MCG/ACT 1 application in both nostrils two times per day for Allergy. A review of the Clinical Physicians Orders did not include an order for Resident #34 to self-administer medications. During a follow-up interview with LPN #1 on 10/24/2022 at 12:40 PM, LPN #1 said no we are not supposed to leave medications at the bedside and confirmed the medications were the [MEDICATION(S)] inhaler and [MEDICATION(S)] During an interview with the surveyor on 10/27/2022 at 10:00 AM, the Director of Nursing (DON) stated, We typically don't put medications at the bedside unless the patient is capable of self-administering medications and then they are locked in a bag, and they keep them in their drawer. The physician also evaluates if the patient can self-administer. The surveyor asked the DON if that would include an inhaler and nasal spray. The DON went on to say, Yes, that would include an inhaler if the resident says I can do it myself. The DON also explained, When she (LPN #1) came to me and said I forgot the medications and I meant to take them after Resident #34 was done. Resident #34 is able to take his/her own inhaler and I forgot it. The DON then stated to the surveyor, That would not be considered self-administering and typically we don't leave it (inhaler) on the bedside table. A review of a facility policy titled General Dose Preparation and Medication Administration with revised date of 08/2018, revealed the following under procedure section 3: dose preparation Nursing Center should not leave medications or chemicals unattended. A review of a facility policy titled Storage and expiration dating of drugs, biologicals, syringes And Needles revealed the following under procedure section 2.: The nursing center that all drugs and biologicals, including treatment items, are securely stored in locked cabinet/cart or locked medication room NJAC 8:3927.1(a) 29.2(d)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide the appropriate care and services to prevent potential injury to a resident with an indwelling, suprapubic catheter (tube inserted into the bladder to facilitate the flow of urine) by not securing the tube properly to the securement device (plastic device used to secure the tube to prevent the catheter from being pulled). The deficient practice was observed for 1 of 3 residents (Resident #1) investigated for Catheter and was evidenced by the following: On 10/24/2022 at 10:26 AM, the surveyor obtained permission from Resident #1 to observe the catheter securement device applied to the upper, left thigh. At this time, the surveyor observed that the tube was not secured properly and could move freely within the securement device. On 10/25/2022 at 11:18 AM, the surveyor obtained permission from Resident #1 to observe the catheter securement device again. At this time, the surveyor observed that a new securement device was applied to Resident #1's upper, left thigh. The surveyor further observed that the securement device tab was not secured in place, allowing the tube to move freely. On 10/25/2022 at 11:27 AM, during an interview with the surveyor, the Unit Manager Registered Nurse #1 stated, No when asked if the securement device was secured correctly in both observations. She further stated, I'll fix it now. I don't want it to pull on him. On 10/31/2022 at 1:01 PM, during an interview with the surveyor, the Director of Nursing stated, Yes when asked if the catheter tube should be secured in a securement device. A review of Resident #1's Admission Minimum Data Set (a tool used for assessments) dated 2/18/2022 revealed Resident #1 had an indwelling catheter because of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Foley Anchor securement kit package revealed a diagram showing the tube is supposed to be secured using flexible tabs on the securement device. A review of the policy titled, Indwelling urinary catheter (Foley) care and management with a revised date of November 19, 2021 revealed under the heading Implementation: Make sure that the catheter is secured properly. N.J.A.C 8:39-27.1(a)

Based on observations on 10/31/2022 in the presence of facility management, it was determined the facility failed to provide a safe environment for the residents. This deficient practice was indentified for 1 of 3 shower rooms, 2nd floor. This deficient practice was evidenced by the following: During the tour of the facility in the presence of the facility's Maintenance Director (MD) at 10:56 AM,an inspection inside the second floor Resident shower room was performed. The corridor door had a passage (no means to lock) door knob installed on the door. The surveyor observed inside the shower room a sharps container cabinet that was mounted to a wall with no evidence of the inner puncture proof sharps container with a one way drop down tray. Further inspection identified that the cabinet door was unlocked and the cabinet contained approximately 35 razors and a nail clipper. The shower room was accessible to Residents. The MD confirmed the findings at the time of observations. The facility's Administrator was informed of these findings during the Life Safety Code survey exit conference at 1:32 PM on 11/01/2022. NJAC 8:39-31.2(e)

Based on interview and medical record review, it was determined that the facility failed to complete a resident assessment that accurately reflected the resident's status/behaviors. This was identified during a review of the Minimum Data Set (MDS), an assessment tool, for 1 of 31 residents reviewed (Resident #51). This deficient practice was evidenced by the following: On 10/24/2022 at 10:29 a.m. the surveyor reviewed an Admission MDS Assessment that had a reference date of 8/25/2022. According to Section C0500 Resident #51 scored a 3 on a Brief Interview for Mental Status which indicated that the resident was severely cognitively impaired. Review of Section E0200 revealed that the resident had not displayed any physical, verbal, or other behavioral symptoms. Review of section E0800 revealed that Resident#51 did not reject care and section E0900 revealed that resident had not wandered. The MDS further indicated in Section I that Resident #51's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/24/2022 at 10:29 AM the surveyor reviewed a Progress Note (PN) dated 8/19/2022 at 4:19 AM in which a facility nurse documented that Resident # 51 was found wandering in the hallway and was constantly asking to go home. The resident complained of a backache but refused to take prn pain medicine as per patient she doesn't trust the nurse. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. A PN dated 8/19/2022 at 5:49 AM documented that Resident #51 refused to take her medicine. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. A PN dated 8/20/22 at 2:39 AM documented that Resident #51 wanted to leave and wanted to go to a door to leave. Another PN on that same day at 1:42 AM documented that Resident #51 had been going in and out of other patient rooms and was exit seeking. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. A PN dated 8/21/2022at 6:30 documented that Resident #51 was exit seeking during the night, wandering through the unit, and was looking tired. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. A PN dated 8/23/2022 at 4:12 AM documented that Resident #51 was walking into other resident rooms and banging on locked doors screaming that he/she has to get out and go home. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. A PN dated 8/25/2022 at 9:50 PM documented that Resident #51 was wandering through the unit, seeking the exit door to the point of exhaustion. The resident behaviors that were described in the PN were not documented in the Admission MDS assessment dated [DATE] as required. On 10/26/2022 at 12:07 PM the MDS Coordinator confirmed that Resident #51 had exhibited behaviors during the look back period. He stated that wandering, rejection of care, and other behavioral symptoms should have been coded in the Admission MDS dated [DATE] as required. NJAC 8.39-11.1

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to maintain an orderly environment when wallpaper was observed peeling from the wall, a closet was off the hinges, and various dried, liquid stains were observed on the floor. The observations were made in 5 resident rooms. On 10/26/22 at 08:51 AM, inside room 126, surveyor #1 observed the wall paper peeling at the seams in at least five different areas. The surveyor further observed dried brown liquid on the floor. On the same date at 09:17 AM inside room 134, surveyor #1 observed wallpaper peeling from the wall. The area peeling was approximately 48 inches long. On the same date at 09:20 AM inside room 150, surveyor #1 observed wallpaper peeling from the wall in three areas. Each peeling area was approximately 24 inches long. On the same date at 11:05 AM inside room 221, surveyor #2 observed wallpaper peeling from the wall near the room entrance. The surface behind the wallpaper revealed a dark substance. On the same date and approximate time inside room 225, surveyor #2 observed the closet door off the hinges and peeled wallpaper near the base board. On 10/31/2022 at 1:01 PM, during an interview with surveyor #1, the Licensed Nursing Home Administrator stated that wallpaper is replaced or maintained as needed when it is identified. The facility did not present a policy referencing wallpaper. N.J.A.C. 8:39-31.3

Based on observation, interview and record review, it was determined that the facility failed to provide care to Resident #7, who had a history of [REDACTED]. The resident developed a fecal impaction, necrotic bowel and required surgical intervention and a permanent [MEDICAL CONDITION], while in the facility. The facility also failed to provide care to Resident # 1, who was a staff-dependent resident with a contracted right hand. The resident developed a fungal infection of the right hand, which required treatment with medication. This deficient practice was identified for 2 of 24 residents reviewed for Quality of Care, Resident #1 and #7, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 7 on 2/25/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed self propelling his/her wheelchair in the hall. The unit manager told the surveyor at that time that the resident recently had surgery for [REDACTED]. Review of the History and Physical dated 1/15/16, revealed that the resident was admitted to the hospital after no bowel movement for several days, and an abdominal x-ray done at the facility showed fecal impaction. Upon admission to the hospital on [DATE], the resident had an abdominal CAT scan which showed a markedly distended rectum, sigmoid and descending colon with a large volume of fecal matter, likely secondary to fecal impaction with bowel wall thickening in the sigmoid and rectal colon. Stable left mild to moderate and new right mild to moderate hydro[DIAGNOSES REDACTED], likely secondary to compression of the uterus by the massively distended sigmoid colon and rectum. The resident underwent [REDACTED]. Further review of the medical record revealed that the resident was admitted to the facility on [DATE]. Upon admission, the physician orders [REDACTED]. On 2/29/16 at 10 a.m., the unit manager provided the surveyor with a computerized print-out of the resident's bowel continence from 12/7/15-1/15/16. The print-out revealed the following: 12/7/15 to12/11/15, ( 4 days ), no bowel movement until 12/11/15, when the resident was given [MEDICATION NAME], in addition to the standing order for Sennalax Tablets. The resident had bowel movements on 12/12/15, 12/13/15, 12/15/15, and 12/17/15. 12/18/15 to 12/20/15, ( 3 days), no bowel movements. On 2/21/15, the resident had 4 bowel movements. 12/21/15 to 12/28/15, (7 days ), no bowel movements. On 12/29/15, the resident had a bowel movement. 12/30/15 and 12/31/15, no bowel movement. On 1/1/16, the resident had a bowel movement. From 1/2/16 to 1/15/16, ( 15 days ), no bowel movement. On 1/2/16 and 1/8/16, the resident was given [MEDICATION NAME], for constipation. On 1/13/16 the resident was given a fleets enema and [MEDICATION NAME] (for constipation.) On 1/14/16, the resident was given [MEDICATION NAME], and additional Senna tablets. On 1/15/16, the resident was given [MEDICATION NAME] (stool softener), [MEDICATION NAME], a fleets and a soap suds enema, with no results. The resident was admitted to the hospital with [REDACTED]. Review of the above documentation revealed that when the resident did have bowel movements, the amount, character and consistency were not documented. An interview with the unit manager on 2/29/16 at 1 p.m., revealed that there was no method in place to document the information. Further review of the progress notes of Resident #7 revealed that on 12/8/15, the resident was seen by the Nurse Practioner (NP). At that time the resident's [DIAGNOSES REDACTED]. The resident was then seen on a weekly basis by the nurse practioner, who each time documented the resident's GI status as stable. On 1/13/16, the resident was seen by the NP for constipation. At that time the NP documented patient with chronic constipation receives Senna laxative maintenance dose daily. (The resident) has advanced Alzheimer's dementia with very poor memory and cannot remember last BM. Nurse notes indicate patient's abdomen appears slightly distended today. The NP ordered to continue Senna-S, give [MEDICATION NAME] and fleets enema, check KUB abdomen x-ray, STATUS: uncontrolled. There was no documented evidence that the physician or NP were notified of the intervals of days when the resident had no bowel movements. On 2/29/16 at 1 p.m., the unit manager told the surveyor that the bowel monitoring system would provide alerts if residents did not have a bowel movement after 3 days. The unit manager could not provide any evidence that the alerts occurred or were acted upon. Review of the resident's Plan of Care revealed that constipation was not addressed until 1/14/16, 1 day before the resident's hospitalization and subsequent surgery. On 2/29/16 at 2 p.m., the administrator told the surveyor that the resident was admitted to the facility with a history of chronic constipation and fecal impaction, which had occurred in the hospital, prior to admission to the facility. On 3/3/16 at 12 p.m., the Medical Director (MD) told the surveyor that during his/her hospitalization on [DATE], Resident #7 was found to have a 13 centimeter (cm) fecal impaction. The MD further stated that due to the resident's dementia he/she would not be able to verbalize to the staff any pain or discomfort related to his/her bowels. The surveyor informed the MD that there was no evidence in the medical record of an assessment by staff of the resident's bowel status or notification of the primary physician when the resident had no bowel movement for several days. The surveyor questioned if the resident had been placed on a more aggressive bowel regimen with a care plan in place from admission to include dietary interventions, if a fecal impaction could have been avoided. The MD responded, I do not disagree with you. I agree with everything you said. 2. During the initial tour on 2/25/16 at 10:30 a.m., the unit manager (UM) told the surveyor that Resident #1 had bilateral hand contractures. On 2/25/16 at 11:30 a.m., the surveyor observed the resident out of bed to a wheelchair with bilateral hand contractures with no hand devices in place. On 2/29/16 at 8:50 a.m., the surveyor observed the resident's hands without any device in place. On 2/29/16 at 9 a.m., the surveyor reviewed the resident's medical record which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed that on 5/9/12, the resident was identified as At risk for complications due to musculoskeletal problems related to bilateral hand and arm contractures, [MEDICAL CONDITION]. Interventions at that time included: Palm protectors to left and right hand as tolerated and report evidence of infection such as pain, redness, drainage, increased tenderness or other complications. Further review of the care plan revealed that on 1/10/11, the resident was identified for Pain in right hand/fingers evidenced by patient crying when hands are opened verbal and non verbal indicators related to contracture. Interventions at that time included: Administer pain medication as per MD orders and note the effectiveness, Palm protectors to left and right hand to be worn as tolerated, Rock and go chair with pillow behind back for elevation as tolerated. The interventions did not address the residents pain during daily hand hygiene, hand assessments and placement of the rolled gauze. On 2/29/16 at 11:05 a.m., the surveyor reviewed the February 2016 electronic treatment administration record that indicated an order to Change rolled gauze to bilateral palms every morning had been documented as administered from 2/1/16 through 2/28/16. Upon further record review, there was no documented evidence of a pain assessment or that the resident's physician was notified regarding pain. On 2/29/16 at 11:10 a.m., the surveyor reviewed a physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment, dated 12/11/15, revealed the resident was dependent on one person physical assistance for dressing and bathing and extensive assistance of one person in hygiene. Review of the Functional Limitation in Range of Motion revealed the resident had impairment on both sides of the upper and lower extremities. When interviewed by the surveyor on 2/29/16 at 12:30 p.m., the Certified Nursing Assistant (CNA) assigned to the resident stated that she was not placing the rolled gauze in Resident #1's hands because it was too painful. On the same day at 12:40 p.m., the UM told the surveyor that the resident mostly refuses to wear the rolled gauze due to pain. The UM provided the surveyor with a Progress Note dated 2/29/16 at 8:48 a.m. which stated, Gauze rolls removed for cleaning of hands. Resident was moaning and wincing when trying to replace rolls. Unable to replace at this time; will attempt to replace later this shift. When interviewed by the surveyor on 2/29/16 at 12:45 p.m., the Director of Rehabilitation Services told the surveyor that Resident #1 had Occupational Therapy (OT) from 1/20/14 through 2/12/14 and that OT had recommended palm grips then but there were times staff couldn't open the resident hands. The director of Rehabilitation services confirmed that the resident had not received either Physical Therapy (PT) or OT since 2/12/14. On 3/1/16 at 9:30 a.m., the surveyor observed Resident #1 in bed without rolled gauze in either the right or left hand. On the same day at 9:40 a.m., the surveyor observed the CNA wash Resident #1's right hand and a yellowish material was observed on the wash cloth and a foul odor was noted. The resident began tightening his/her hand as the CNA was washing the right hand. The CNA placed the rolled gauze in both hands. The surveyor observed at that time, that the resident's finger nails on both hands were long. The CNA told the surveyor, I cut (the resident) nails twice a week. The CNA said she didn't know if that was documented anywhere. At 9:45 a.m., a Licensed Practical Nurse (LPN) checked the placement of the rolled gauze. The LPN told the surveyor that the resident had not yet received the Tylenol arthritis medication which was due at 9 a.m. On 3/2/16 at 11:05 a.m., (during the survey), the UM told surveyor that the resident's care plan was updated with more specific interventions. The resident was observed out of bed in a wheelchair with rolled gauze in both hands. On 3/3/16 at 11:50 a.m., the surveyor observed the resident with rolled gauze in both hands. The UM told the surveyor that, his/her finger nails were cut last night by a nurse. I looked at the resident's hands on 3/1/16, her right palm had a yellowish line in the middle with foul odor. I called the doctor and received an order for [REDACTED]. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to assess Resident #7 for frequent intervals of constipation and to provide interventions to prevent fecal impaction. The resident developed a fecal impaction, required surgery and a permanent [MEDICAL CONDITION]. The facility failed to assess the care needs of Resident #1, who was a staff dependent resident with a contracted hand, which required specific hygiene practices. The resident developed a fungal infection of the right hand, which required treatment with medication. The facility also failed to accurately assess the transfer assistance needs of Resident #13,who was staff dependent, after an incident of improper transfer by staff, resulting in the resident being lowered to the floor. This deficient practice was identified for 3 of 24 residents reviewed for Quality of Care, Resident #1, #7 and #13, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 7 on 2/25/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed self propelling his/her wheelchair in the hall. The unit manager told the surveyor at that time that the resident recently had surgery for [REDACTED]. Review of the History and Physical dated 1/15/16, revealed that the resident was admitted to the hospital after no bowel movement for several days, and an abdominal x-ray done at the facility, showed fecal impaction. Upon admission to the hospital on [DATE], the resident had an abdominal CAT scan which showed a markedly distended rectum, sigmoid and descending colon with a large volume of fecal matter, likely secondary to fecal impaction with bowel wall thickening in the sigmoid and rectal colon. Stable left mild to moderate and new right mild to moderate hydro[DIAGNOSES REDACTED], likely secondary to compression of the uterus by the massively distended sigmoid colon and rectum. The resident underwent [REDACTED]. Further review of the medical record revealed that the resident was admitted to the facility on [DATE]. Upon admission, the physician orders [REDACTED]. On 2/29/16 at 10:00 a.m., the unit manager provided the surveyor with a computerized print-out of the resident's bowel continence from 12/7/15-1/15/16. The print-out revealed the following: 12/7/15 to12/11/15, ( 4 days ), no bowel movement until 12/11/15, when the resident was given [MEDICATION NAME], in addition to the standing order for Sennalax Tablets. The resident had bowel movements on 12/12/15, 12/13/15, 12/15/15, and 12/17/15. 12/18/15 to 12/20/15, ( 3 days), no bowel movements. On 2/21/15, the resident had 4 bowel movements. 12/21/15 to 12/28/15, (7 days ), no bowel movements. On 12/29/15, the resident had a bowel movement. 12/30/15 and 12/31/15, no bowel movement. On 1/1/16, the resident had a bowel movement. From 1/2/16 to 1/15/16, ( 15 days ), no bowel movement. On 1/2/16 and 1/8/16, the resident was given [MEDICATION NAME], for constipation. On 1/13/16 the resident was given a fleets enema and [MEDICATION NAME]. On 1/14/16, the resident was given [MEDICATION NAME], and additional Senna tablets. On 1/15/16, the resident was given [MEDICATION NAME], a fleets and a soap suds enema, with no results. The resident was admitted to the hospital with [REDACTED]. Review of the above documentation revealed that when the resident did have bowel movements, the amount, character and consistency were not documented. An interview with the unit manager on 2/29/16 at 1:00 p.m., revealed that there was no method in place to document the information. Further review of the progress notes of Resident #7 revealed that on 12/8/15, the resident was seen by the Nurse Practioner (NP). At that time the resident's [DIAGNOSES REDACTED]. The resident was then seen on a weekly basis by the nurse practioner, who each time documented the resident's GI status as stable. On 1/13/16, the resident was seen by the NP for constipation. At that time the NP documented patient with chronic constipation receives Senna laxative maintenance dose daily. She has advanced Alzheimer's dementia with very poor memory and cannot remember her last BM. Nurse notes indicate patient's abdomen appears slightly distended today. The NP ordered to continue Senna-S, give [MEDICATION NAME] and fleets enema, check KUB abdomen x-ray, STATUS: uncontrolled. There was no documented evidence that the physician or NP were notified of the intervals of days when the resident had no bowel movements. On 2/29/16 at 1:00 p.m., the unit manager told the surveyor that the bowel monitoring system would provide alerts if residents did not have a bowel movement after 3 days. The unit manager could not provide any evidence that the alerts occurred or were acted upon. There was no evidence that the interdisciplinary team completed a comprehensive assessment of the resident's chronic constipation history and accompanying complications. Review of the resident's Plan of Care revealed that constipation was not addressed until 1/14/16, 1 day before the resident's hospitalization and subsequent surgery. On 2/29/16 at 2 p.m., the administrator told the surveyor that the resident was admitted to the facility with a history of chronic constipation and fecal impaction, which had occurred in the hospital, prior to admission to the facility. On 3/3/16 at 12 p.m., the Medical Director (MD) told the surveyor that during his/her hospitalization on [DATE], Resident #7 was found to have a 13 centimeter (cm) fecal impaction. The MD further stated that due to the resident's dementia he/she would not be able to verbalize to the staff any pain or discomfort related to his/her bowels. The surveyor informed the MD that there was no evidence in the medical record of an assessment by staff of the resident's bowel status or notification of the primary physician when the resident had no bowel movement for several days. The surveyor questioned if the resident had been placed on a more aggressive bowel regimen with a care plan in place from admission to include dietary interventions, if a fecal impaction could have been avoided. The MD responded, I do not disagree with you. I agree with everything you said. 2. During the initial tour on 2/25/16 at 10:30 a.m., the unit manager (UM) told the surveyor that Resident #1 had bilateral hand contractures. On 2/25/16 at 11:30 a.m., the surveyor observed the resident out of bed to a wheelchair with bilateral hand contractures with no hand devices in place. On 2/29/16 at 8:50 a.m., the surveyor observed the residents hands without any device in place. On 2/29/16 at 9 a.m., the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed that on 5/9/12, the resident was identified for At risk for complications due to musculoskeletal problems related to bilateral hand and arm contractures, [MEDICAL CONDITION]. Interventions at that time included: Palm protectors to left and right hand as tolerated and report evidence of infection such as pain, redness, drainage, increased tenderness or other complications. Review of a physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment,dated 12/11/15, revealed the resident was dependent on staff of one person physical assistance for dressing and the resident had impairment on both sides of the upper and lower extremities. On 2/29/16 at 12:30 p.m., the surveyor interviewed a certified nurse aide (CNA) assigned to the resident who stated, I haven't been placing the rolled gauze because it's too painful for (the resident) to open (his/her) hands. The stuffed animals are used so we can lift the resident up so that his/her arms don't get too contracted. At 12:40 p.m., the UM told the surveyor the resident mostly refuses to wear the rolled gauze due to pain. The UM provided the surveyor with a Progress Note dated 2/29/16 at 8:48 documented by a Licensed Practical Nurse (LPN) which stated, Gauze rolls removed for cleaning of hands. Resident was moaning and wincing when trying to replace rolls. Unable to replace at this time; will attempt to replace later this shift. Review of the February 2016 electronic treatment record revealed that the order to Change rolled gauze to bilateral palms every morning was checked as administered from 2/1/16 through 2/28/16. There was no further documented evidence of a pain assessment on 2/29/16 nor was there any documented evidence that the resident's physician was notified. On 2/29/16 at 12:40 p.m., the surveyor reviewed the progress notes dated 2/27/16 and 2/28/16, which revealed the following documentation by a LPN, Check skin integrity to left and right hand every shift for skin observation. No new skin issues at this time. On 2/29/16 at 12:45 p.m., the Director of Rehabilitation services told the surveyor that Resident #1 had Occupational Therapy (OT) from 1/20/14 through 2/12/14 and OT had recommended palm grips then but there were times staff couldn't open the resident hands. The Director of Rehabilitation services confirmed that the resident had not received either Physical Therapy (PT) or OT since 2/12/14. On 3/1/16 at 9:30 a.m., the surveyor observed the resident in bed dressed. There were no rolled gauze in place in either hand. The CNA told the surveyor that AM care was already provided; she only needed to wash the residents hands and then get the nurse to place the rolled gauze. At 9:40 a.m., the surveyor observed the CNA washing the residents right hand with a wash cloth which was observed with yellowish material and a foul odor from the right hand. The resident began tightening his/her hand as the CNA was washing the right hand. The CNA placed a rolled gauze in both hands. The residents finger nails on both the right and left hand were long. The CNA told the surveyor, I cut (the resident) nails twice a week. The CNA said she didn't know if that was documented anywhere. The CNA stated she had been working with the resident for a year and the residents hands were like this then but they were now tighter. At 9:45 a.m., a LPN checked the placement of the rolled gauze. The LPN told the surveyor that the resident had not yet received the Tylenol arthritis which was due at 9 a.m. On 3/3/16 at 11:50 a.m., the surveyor observed the resident with rolled gauze in both hands. The UM told the surveyor his/her finger nails were cut last night by a nurse. I looked at the resident hands on 3/1/16. (His/her) right palm had a yellowish line in the middle with foul odor. I called the doctor and received an order for [REDACTED]. 3. On 2/29/16 at 9:22 a.m., the surveyor reviewed the medical record of Resident #13. Resident #13 had the [DIAGNOSES REDACTED]. On 3/3/16 at 8:15 a.m., the surveyor reviewed the Minimum Data Set (MDS) Quarterly assessment of 4/13/15 and 1/8/16, Section G, that indicated Resident #13 required a two person physical assist with transfers. The Annual assessment dated [DATE] indicated that Resident #13 required a one person physical assist with transfers. The surveyor also noted in the progress note dated 5/6/15 at 15:09 the Certified Nursing Assistant (CNA) was trying to transfer patient onto shower bed using sheet as a guide. When interviewed by the surveyor on 3/3/16 at 12:03 p.m., the MDS Coordinator stated that the annual MDS assessment dated [DATE] under transfers was coded wrong and that Resident #13 always required two people for transfer via a mechanical lift. NJAC 8:39-11.1 Refer to F 309

Based on observation, interview and record review, it was determined that the facility failed to develop a plan of care, based on individual assessment, with interventions to address the needs of a resident with chronic constipation and a history of fecal impaction. As a result, Resident #7 required surgical intervention and a permanent [MEDICAL CONDITION]. The facility also failed to develop interventions to address the needs of Resident #1, who was a staff dependent resident with a contracture of the right hand. The facility failed to provide care and hygiene to the resident's hand, which resulted in a fungal infection, which required treatment with medication. This deficient practice was identified for Residents #1 and #7, 2 of 24 residents reviewed for Quality of Care, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 7 on 2/25/16 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed self propelling his/her wheelchair in the hall. The unit manager told the surveyor at that time that the resident recently had surgery for [REDACTED]. Review of the History and Physical dated 1/15/16, revealed that the resident was admitted to the hospital after no bowel movement for several days, and an abdominal x-ray done at the facility, showed fecal impaction. Upon admission to the hospital on [DATE], the resident had an abdominal CAT scan which showed a markedly distended rectum, sigmoid and descending colon with a large volume of fecal matter, likely secondary to fecal impaction with bowel wall thickening in the sigmoid and rectal colon. Stable left mild to moderate and new right mild to moderate hydro[DIAGNOSES REDACTED], likely secondary to compression of the uterus by the massively distended sigmoid colon and rectum. The resident underwent [REDACTED]. Further review of the medical record revealed that the resident was admitted to the facility on [DATE]. Upon admission, the physician orders [REDACTED]. On 2/29/16 at 10a.m., the unit manager provided the surveyor with a computerized print-out of the resident's bowel continence from 12/7/15-1/15/16. The print-out revealed that Resident # 7 had 4 instances where there was no bowel movement for 4 consecutive days (12/7-12/11); 3 consecutive days (12/18 -12/20); 7 consecutive days (12/21-12/28); and 15 consecutive days (1/2 - 1/15). On 1/13/16 the resident was given a fleets enema and [MEDICATION NAME]. On 1/14/16, the resident was given [MEDICATION NAME], and additional Senna tablets. On 1/15/16, the resident was given [MEDICATION NAME], a fleets and a soap suds enema, with no results. The resident was admitted to the hospital with [REDACTED]. Review of the above documentation revealed that when the resident did have bowel movements, the amount, character and consistency were not documented. An interview with the unit manager on 2/29/16 at 1 p.m., revealed that there was no method in place to document the information. Further review of the progress notes of Resident #7 revealed that on 12/8/15, the resident was seen by the Nurse Practioner (NP). At that time the resident's [DIAGNOSES REDACTED]. The resident was then seen on a weekly basis by the nurse practioner, who each time documented the resident's GI status as stable. On 1/13/16, the resident was seen by the NP for constipation. At that time the NP documented patient with chronic constipation receives Senna laxative maintenance dose daily. She has advanced Alzheimer's dementia with very poor memory and cannot remember her last BM. Nurse notes indicate patient's abdomen appears slightly distended today. The NP ordered to continue Senna-S, give [MEDICATION NAME] and fleets enema, check KUB abdomen x-ray, STATUS: uncontrolled. There was no documented evidence that the physician or NP were notified of the intervals of days when the resident had no bowel movements. On 2/29/16 at 1 p.m., the unit manager told the surveyor that the bowel monitoring system would provide alerts if residents did not have a bowel movement after 3 days. The unit manager could not provide any evidence that the alerts occurred or were acted upon. Review of the resident's Plan of Care revealed that constipation was not addressed until 1/14/16, 1 day before the resident's hospitalization and subsequent surgery. On 2/29/16 at 2 p.m., the administrator told the surveyor that the resident was admitted to the facility with a history of chronic constipation and fecal impaction, which had occurred in the hospital, prior to admission to the facility. On 3/3/16 at 12 p.m., the Medical Director (MD) told the surveyor that during his/her hospitalization on [DATE], Resident #7 was found to have a 13 centimeter (cm) fecal impaction. The MD further stated that due to the resident's dementia he/she would not be able to verbalize to the staff any pain or discomfort related to his/her bowels. The surveyor informed the MD that there was no evidence in the medical record of an assessment by staff of the resident's bowel status, notification of the primary physician when the resident had no bowel movement for several days. The surveyor questioned if the resident had been placed on a more aggressive bowel regimen with a care plan in place from admission to include dietary interventions, if a fecal impaction could have been avoided. The MD responded, I do not disagree with you. I agree with everything you said. 2. During the initial tour on 2/25/16 at 10:30 a.m., the Unit Manager (UM) told the surveyor that Resident #1 had bilateral hand contractures. On 2/25/16 at 11:30 a.m., the surveyor observed the resident out of bed to a wheelchair with bilateral hand contractures with no hand devices in place. On 2/29/16 at 8:50 a.m., the surveyor observed the residents hands without any device in place. On 2/29/16 at 9 a.m., the surveyor reviewed the resident's medical record. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon review, the resident's care plan revealed that on 5/9/12, the resident was identified for, At risk for complications due to musculoskeletal problems related to bilateral hand and arm contractures, [MEDICAL CONDITION]. Interventions at that time included: palm protectors to left and right hand as tolerated and report evidence of infection such as pain, redness, drainage, increased tenderness or other complications. The surveyor reviewed a physician's orders [REDACTED]. The care plan initiated on 5/9/12 was not revised or updated to include the 3/31/15 PO. Upon further review of the care plans revealed that on 1/10/11, the resident was identified for Pain in right hand/fingers evidenced by patient crying when hands are opened verbal and non verbal indicators related to contracture. Interventions at that time included: Administer pain medication as per MD orders and note the effectiveness, Palm protectors to left and right hand to be worn as tolerated, Rock and go chair with pillow behind back for elevation as tolerated. The interventions did not address the residents pain during daily hand hygiene, hand assessments and placement of the rolled gauze. On 2/29/16 at 12:30 p.m., the surveyor interviewed a certified nursing assistant (CNA) assigned to the resident who stated that she hadn't been placing the rolled gauze in Resident #1's hands because it was too painful. On the same day at 12:40 p.m., the UM told the surveyor the resident, mostly refuses to wear the rolled gauze due to pain. The UM provided the surveyor with a Progress Note dated 2/29/16 at 8:48 a.m. which stated, Gauze rolls removed for cleaning of hands. Resident was moaning and wincing when trying to replace rolls. Unable to replace at this time; will attempt to replace later this shift. There was no further documented evidence of a pain assessment on 2/29/16 nor was there any documented evidence that the resident's physician was notified or that the care plan was updated. On 3/2/16 at 11:05 a.m., the UM told the surveyor that the resident's care plan was updated with more specific interventions. The resident was observed out of bed in a wheelchair with rolled gauze in both hands. N.J.A.C, 8:39 - 27.1 (a) Refer to F309

Complaint: NJ Based on interviews and review of medical records (MR) and other facility documentation, it was determined that the facility failed to report and investigate timely in accordance with facility guidelines on abuse when an allegation of staff to resident abuse was reported to staff by 1 of 3 sampled residents (Resident #1). On 4/20/2014, Resident #1 reported an allegation of inappropriate sexual contact abuse by Certified Nurses Aide (CNA #1). CNA #1 continued to work his regular work schedule and remained on Resident #1's unit for approximately 16 hours (2 consecutive shifts). CNA #1 was not suspended and after completing his 16 hours of work from 4/20/2014 (3PM-11PM shift) through 4/21/2014(11PM-7AM shift) CNA #1 was not scheduled to return to work until the following weekend, 5 days later. The facility failed to implement their own procedures, "Patient Protection Practice Guide" which included suspending the alleged abuser until completion of the investigation. CNA #1 subsequently interacted with Resident #1 and at least 9 other unsampled female residents who were provided care by CNA #1 after the alleged incident was reported. The Immediate Jeopardy (IJ) which began on 4/20/2014 was identified and relayed to the Administrator and Director of Nursing (DON) on 4/28/2014 at 2:20PM. The IJ was corrected based on an acceptable plan of correction which was implemented on 4/28/2014 at 4:30PM. This deficient practice is evidenced by the following: Interviews, observations and review of the MRs and other facility documentation occurred on 4/28/2014, unless otherwise noted. Review of a facility policy titled; "Patient Protection Practice Guide" dated 11/2011 included but was not limited to; "This booklet is considered a practice guide. The information included within this guide does not relieve a... center (facility) of the obligation to comply with all applicable (facility) policies as well as federal and state regulations." "Report any suspicion of abuse, neglect, misappropriation or crime against a patient to your supervisor immediately." "Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator..." "Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation, If the incident involves a center (facility) employee, the employee is suspended pending completion of the investigation..." "Reporting": The center (facility) must ensure that all alleged violations are reported immediately to the administrator of the center..." Review of facility "Annual Mandatory: 2014 Abuse, Neglect, Mistreatment and Misappropriation of Patient Property" Inservice for employees included but was not limited to; "Reporting: The facility must ensure that all alleged violations involving...abuse...are reported immediately to the administrator of the facility...Previously, "immediately" meant as soon as possible, but should not exceed 24 hours after discovery of the incident, however, the center (facility) should report to the administrator and other officials upon discovery and then continue with the investigation..." "How do you respond?" "...Protect the patient being abused and others from becoming victims. This could require removing the alleged abuser from the premises while the investigation is being conducted. Next the incidence should be reported immediately to your supervisor and the administrator... The supervisor or designee initiates the investigation and interviews the patient, roommates, staff, visitors and others who might have witnessed the incident...the abuse coordinator assists to make sure the process is completed and that preventive measures are in place." Review of an "Abuse Policy" given to the surveyor by the Administrator at approximately 2PM on 4/28/2014 signed by Licensed Practical Nurse (LPN #1) on 3/19/2010 (LPN #1's date of hire), included but was not limited to; "All incidents of any possible verbal/physical/mental abuse of a resident will be immediately brought to the attention of the shift supervisor. She/he will begin an immediate investigation and notify the Director of Nursing and/or the Department Supervisor and the Administrator. An investigation will consist of interviews with the resident, other residents who were in the area when the incident occurred and staff members from all departments that were working on that particular unit. If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately...If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and/or Human Resources Director will in-service employees...about facility policy regarding abuse...". The Administrator stated that all staff are inserviced on the abuse protocol at the time of hire and annually. 1. According to the facility face sheet, Resident #1 was admitted to the facility in April, 2014 with [DIAGNOSES REDACTED]. A Minimum Assessment Set (MDS), an assessment tool, dated 4/11/2014, showed Resident #1 had a "BIMS" (Brief Interview for Mental Status) score of "14" which indicated intact cognition and Resident #1 needed assistance with most activities of daily living (ADLs) which included but were not limited to; transfer in and out of bed. Resident #1 was continent of bowel and bladder. A resident care plan (CP), initiated 4/7/2014 showed Resident #1 was at risk for adverse effects related to (r/t) the use of antidepressant/antianxiety/antiolytic medication with interventions which included but were not limited to; notify the physician of a decline in ADL r/t mood/behavior r/t a dosage change and signs of an adverse reaction such as a decline in mental status. A Facility Reportable Event Record/Report (AAS-45), faxed to the NJ Department of Health (NJ DOH) on 4/25/2014, showed, on 4/20/2014 at approximately 3PM, at the change of shift, Resident #1 reported to a 7AM-3PM staff Licensed Practical Nurse (LPN # 1) that during the night (4/19-4/20/2014) Resident #1 felt the Certified Nurses Aide (CNA #1) "was coming on to her". "She (Resident #1) states the aide (CNA #1) leaned over as if to give her a hug and they locked lips". LPN #1 then reported off to 3PM-11PM shift LPN #2. LPN #2 notified CNA #1 not to go into Resident #1's room and his assignment was changed. LPN #2 obtained a statement from CNA #1. "(CNA #1) was shocked at the allegation." LPN #2 notified the 7PM-7AM Registered Nurse Supervisor (RN #1). The AAS-45 also included that Resident #1 had [DIAGNOSES REDACTED]. Resident #1 did not report the alleged incident immediately and stated that she reciprocated in the kiss and acknowledged that she was a willing participant. She stated she was not touched otherwise but now felt uncomfortable which is why she decided to report it and "feels uncomfortable now with him (CNA #1) caring for her." There were no witnesses to the alleged incident. Multiple female residents assigned to CNA #1 were interviewed with only positive responses. In addition, the AAS-45 showed that "action taken during (the) investigation" was as follows; CNA #1 was reassigned, Administration notified, investigation started, physicians and family notified, statements obtained, Incident report (IR) completed, "re-interviews" conducted, CP reviewed and updated, Administration met with Resident #1 and CNA #1 to discuss the incident... The AAS-45 noted that in conclusion, the allegation was not supported by the facts. During an entrance conference with the Administrator and DON, the surveyor requested policies and procedures r/t abuse. At 10:30AM, the DON provided the surveyor with "guidelines" that the facility follows. The surveyor questioned the DON regarding how the staff would be aware of what specific steps to follow r/t an abuse allegation and the DON stated the staff would follow the abuse "guidelines" and what was taught in the facility abuse inservices. The Administrator stated that the facility does not have "policies" but follows "practice guidelines". During an interview with the surveyor at 10:54AM, the Administrator stated that the allegation of abuse by Resident #1 was reported to her on 4/21/2014 in the morning (which would have been at least 16 hrs after the Resident #1 reported the incident to LPN #1. The Resident allegation allegedly occurred on the 11PM-7AM shift on 4/20/2014 at 3AM but was not reported by Resident #1 until 4/20/2014 to LPN #1 at approximately 3:10PM as LPN #1 was finishing up her shift. The Administrator confirmed the AAS-45 and noted that after the LPN #1 notified the oncoming shift LPN #2, LPN #2 removed CNA #1 from Resident #1's assignment. The Administrator confirmed CNA #1 remained on the unit and continued to work on the unit from 3:10PM on 4/20 through 7AM on 4/21/2014 (approximately 16 hours), however, LPN #2 "monitored" CNA #1 on the unit. In addition, the Administrator stated that all procedures had been followed; including reporting of the incident, as it was reported to the Administrator and the DON within 24 hours and when staff were made aware of the incident, the alleged abuser (CNA #1) was removed from Resident #1's assignment and monitored. The Administrator stated that 3 staff statements had been obtained the evening of the incident and the investigation was completed by the DON and Administrator with a conclusion of unsubstantiated on 4/23/2014. Review of a facility Incident Report (IR), dated 4/21/2014, showed "Pt. (Resident #1) stated to nurse that male CNA (#1) at 3am on 4/20 attempted to hug her". The physician was not notified until 4/21/2014 at 8PM. After the alleged incident was reported to the facility on [DATE], the CP was not updated until 4/23/2014 and included; [MEDICAL CONDITION] Disorder and has a tendency to have mood swings as evidenced by speaking highly of someone and then immediately cursing and making accusations against the same person, confabulates. Interventions included but were not limited to; provide female caregivers and psychiatric evaluation. There was no evidence of any allegations of abuse other that the allegation of 4/20/2014. A physician progress notes [REDACTED].#1 had a history of [REDACTED]. She (Resident #1) reported to staff that CNA made advances toward her and has now perseverated on same issue in recent days. Administration is addressing concerns, (change) in staff..." and a psychiatric evaluation was ordered. "(Resident #1) She did not raise that issue with me today but spent a good deal of visit talking about her ambulance ride yesterday...Doesn't respond when I (NP) raise the unlikelihood of various stories, just continues on (with) details..." Review of the MR showed no indication that a psychiatric consult had been completed before Resident #1 was discharged from the facility on 4/26/2014. On the day of survey, Resident #1's roommate (Resident #3) was unavailable for interview due to being discharged from the facility. Review of Resident #3's face sheet showed she was admitted in 4/2014 with [DIAGNOSES REDACTED]. The admission assessment for "mental status", dated 4/17/2014, showed Resident #3 had cognitive skills of "modified independence; some difficulty in new situations". Review of the nursing progress notes (NN), dated 4/18/2014 at 7:30AM and 4/22/2014 at 6:58AM, showed Resident #3 was alert and oriented times 3. The facility could not provide a statement r/t the reported incident by Resident #3 on 4/20/2014 to the surveyor. Review of the facility's investigation included but was not limited to the following statements dated 4/21 and 4/22/2014; Review of a written statement, dated 4/21/2014, by LPN #1 and RN #3 during an interview with Resident #1 showed the following; "The patient (Resident #1) stated that around 3AM Saturday into Sunday that (CNA #1) leaned over and kissed her on the lips with tongue for about 3-4 min (utes). Patient stated she didn't stop him but knew it didn't feel right. Then she stated that Friday (4/19/2014) into Saturday (CNA #1) was her aid and he was coming into her room and they were joking around saying how they were going to get married and she said she doesn't cook and he stated oh then your already getting a strike against you. Then she said to him am I the only one or do you cheat on me. The patient stated she did not feel threatened but knew he is a big guy so she didn't stop him. Patient stated she did tell her (Family Member) last night around dinner and did point (CNA #1) out to her (Family Member). Patient began to become tearful when (RN #3) told her we have to reach out to her (Family Member) because she said he has a lot going on at home and she does not want him to get upset. Another written statement, dated 4/22/2014, showed an interview with Resident #1 by the Administrator which included but was not limited to; "...(CNA #1) has been really good to me... We are going to get married (CNA #1) said. I (Resident #1) asked him (CNA #1) what he wanted of me and he told me cooking and cleaning. I (Resident #1) told him I (Resident #1) don't cook. Then a while later I (Resident #1) found out he (CNA #1) was married..." The Administrator asked; "Who told you he (CNA #1) was married?" and Resident #1 responded; "Oh, I don't know. He (CNA #1) came over to me when I (Resident #1) was in the bed and he (CNA #1) kissed me and I (Resident #1) kissed him back...It felt like forever but it was only a minute or less. Then he (CNA #1) got up and went to do the other rooms and I (Resident #1) didn't see him again. In my mind I (Resident #1) toyed with this and I (Resident #1) went back and forth whether to say anything. The Administrator asked; "Why do you think he may have done this?" and Resident #1 responded; "Well, he came to clean the bathroom and stuff and I (Resident #1) thought he (CNA #1) was getting the trash when he (CNA #1) came around to my right side and kissed me." In addition, Resident #1 stated in the interview that she reciprocated in the "kiss" and CNA #1 did not touch her otherwise and there were no witnesses. "There was bantering between us, not flirtation, just banter. I just wanted to tell someone. What if it were three guys doing it?" The Administrator asked Resident #1 why she thought it may have happened and Resident #1 stated "I don't know. I don't think much of myself..." Resident #1 asked why the facility keeps calling her family member and told the Administrator that "I am competent and I told them not to call my (Family Member)...He is having a nervous breakdown...(due to a work issue)". During an interview with the surveyor at 12PM, the Administrator confirmed her interview statement with Resident #1 and stated that Resident #1 was alert and calm during the interview, however, she needed to be redirected back to the alleged incident. During an interview with the surveyor at 11:14AM with RN #3 and in an interview with LPN #1, both confirmed their statement related to the interview with Resident #1 and verified that the resident had no prior allegations. RN #3 and LPN #1 stated that Resident #1 was calm during the interview but did have a concern about informing her family member of the incident and that was when she became "tearful". Review of a written statement, dated 4/21/2014 from CNA #1, showed that although he assisted Resident #1 at times during the 11PM-7AM shift on 4/19- 4/20/2014, he had no physical contact with Resident #1 on 4/20/2014. He noted that on 4/20/2014 at 3:30AM, he answered her call light for a request of medication and saw her again at 6AM on 4/20/2014 in her wheelchair (w/c) and she did not need any assistance. An additional written statement from an interview conducted by the Administrator with CNA #1, dated 4/22/2014, showed that on Sunday (4/20/2014/ 3-11 shift) while checking on Resident #1's roommate Resident #1 engaged in conversation related to (r/t) another staff member and that was when LPN #2 asked him (CNA#1) to step out of the room and he was informed by LPN #2, LPN #1 and 7AM-7PM shift RN Supervisor (RN #2) of the allegation that he "came onto her and kissed her [MEDICATION NAME]. I was shocked. I felt slapped...I really don't have any contact with her". CNA #1's statement confirmed he had no physical contact with Resident #1 on the previous day (4/19/2014 on 3PM-11PM shift - 4/20/2014 on 11PM-7AM shift). During a telephone interview by the surveyor on 4/28/2014 at approximately 3:20PM, CNA #1 confirmed his statement and stated that he was removed from Resident #1's assignment on 4/20/2014 at approximately 3PM by LPN #2 and was told of the allegation by LPN #1 and LPN #2. However, he continued to work on the unit and in the same hallway where Resident #1 was located. He stated that his assignment included other female residents, he worked alone on the 3PM-11PM shift on 4/20/2014 and worked with an orientee on the 11PM-7AM shift on 4/20-4/21/2014. CNA #1 stated he was monitored while in the hallways by LPN #2 but not monitored while in resident rooms providing care during his shifts. CNA #1 added that at some point after he was told of the allegation of abuse, during the 3PM-11PM shift on 4/20/2014, he was in the hallway when Resident #1 came out of her room and asked him for pain medication and he then notified LPN #2 and after that he had no further contact with Resident #1. Review of the CNA assignment sheets for CNA #1 on 4/20/2014 for the 3PM-11PM shift showed that he had 4 female residents on his assignment and on 4/20-4/21/2014 for the 11PM-7AM shift he cared for 6 female residents. Although CNA #1 cared for female residents during 2 shifts on 4/20 and 4/21/2014, the DON gave the surveyor interview/statements from only 3 female residents assigned to CNA #1. There were no care issues or concerns r/t CNA #1. Review of a written statement, dated 4/21/2014, by LPN #1 showed that at approximately 3:10PM on 4/20/2014, Resident #1 called her over and stated that she "felt like (CNA #1) was coming on to her last night...it appeared he was going to give me a hug and I turned my head and we locked lips." Resident t#1 then stated she was going to tell her family member (FM) when the FM visited later in the evening. LPN #1 noted that she made LPN #2 aware. LPN #1 noted that Resident #1 did not seem distressed or uncomfortable about the situation and Resident #1 had multiple opportunities to have spoken with LPN #1 throughout the shift and the resident did not appear to be upset when she (LPN #1) left. Review of the personnel file for LPN #1 showed an "Employee warning notice", completed by the Director of Care Delivery RN #3, dated 4/23/2014 for "failure to report alleged inappropriate behavior" and counseling included the review of the "importance of reporting inappropriate behavior of staff/resident and failure to report may result in harm to pts. (patients)" During an interview with the surveyor at 11:42AM, LPN #1 confirmed her statement and added that she did not complete an IR or notify the Nursing Supervisor, RN #2, as she was going off duty and she informed LPN #2. LPN #1 stated she was counseled by the DON and Administrator that an IR should have been completed which would have reminded her to notify the Nursing Supervisor. Review of a written statement, dated 4/21/2014 by LPN #2, showed that she was made aware of the allegation by Resident #1 from LPN #1, that CNA #1 was "coming onto her" last night (4/19-4/20/2014 11PM-7AM shift) and she was going to tell her FM what happened. LPN #2 noted that she reassigned Resident #1's room to other CNAs. Review of a second undated statement by LPN #2 obtained via telephone and signed by the Administrator confirmed her statement and added that; "I made sure (CNA #1) was off that assignment and told him not to go into the room, I told (RN # 1) and she told me to write a statement and make sure CNA # 1 knows not to got into the room. I pulled (CNA #1) to the side and told him. I asked him, did she say anything to you an(d) (CNA #1) said "no". The resident (#1) is very tearful and tangential and goes off topic all the time." During a post survey telephone call with the surveyor on 4/29/2014 at 3:20PM, LPN #2 confirmed that she pulled CNA #1 from Resident #1's assignment on 4/20/2014 at approximately 3:10PM, but kept him on the same unit with other female residents on his assignment. "I made sure he did not have contact" with Resident #1, however, she stated that since she had other assignments such as administering medications and treatments she was not with CNA #1 at all times and LPN #2 verified that she never entered a resident room while CNA #1 was giving care. LPN #2 stated she did not notify the 7AM-7PM RN #2 Supervisor of the allegation as she thought LPN #1 informed her but she did notify the 7PM-7AM RN #1 Supervisor on 4/20/2014 at approximately 7:00-7:30PM and RN #1 asked her to write statements and make sure CNA #1 did not have Resident #1 on his assignment. LPN #2 stated she did not interview and/or obtain a statement from Resident #1 about the allegation because during a conversation with the resident on 4/20/2014 on the 3-11 shift, while administering Resident 1's medications, Resident #1 never mentioned the incident. "I was waiting for her to mention it and she did not complain to me so I thought she was OK...Her (FM) came in that night and the (FM) did not say anything about it so I assumed she made it up". "I thought it was not serious, I thought it did not happen because she didn't say anything to me and it was the first time I ever had an incident like this". In addition, LPN #2 stated she did not complete an IR and/or concern form because she thought Resident #1 "made up the allegation". Review of a written statement from the 7AM-7PM shift RN #2 Supervisor, who worked on 4/20/2014, taken via telephone on 4/21/2014 and in person on 4/25/2014 by the DON, showed; "No one ever came to me (RN #2) and told me (RN #2) what had happened. I (RN #2) overheard (LPN #2) tell (CNA #1) I (LPN #2) have to take you (CNA #1) off the schedule/assignment. I didn't know what they were talking about. I left at 7PM." Review of a written statement from 7PM-7AM shift RN #1 Supervisor who worked on 4/20-4/21/2014, dated 4/21/2014, showed that she was notified at approximately 12AM by LPN #2 r/t the incident. "The patient (Resident #1) didn't say anything about this on the night shift....Will follow up in AM". During a telephone interview with the surveyor at 1:35PM, RN #1 stated she was not informed by RN #2 during the change of shift report of the alleged incident reported by Resident #1 and wasn't notified until 12AM on 4/21/2014 by LPN #2. At that time she wrote her statement and obtained statements from LPN #2 and CNA #1, she was unable to interview Resident #1 as she was sleeping. RN #1 stated she did not complete an IR or contact the Administrator/DON because she thought that LPN #1 would have already done it since LPN #1 was the initial contact. RN #1 confirmed that CNA #1 had no special monitoring with residents, but he did not have Resident #1 on his assignment and he was aware not to go into Resident #1's room. RN #1 stated; "We did not think he (CNA#1) would do that to a patient...He said he didn't do it". Additionally, RN #1 stated that she received verbal counseling from the DON and Administrator that they should have been notified immediately of the incident. After review of the "practice guidelines", the surveyor asked the Administrator and DON why they were not notified immediately, why CNA #1 had not been suspended according to the "practice guidelines" and the Administrator stated that although they follow the practice guidelines they refer to the facility inservice information also. She stated that staff removed CNA #1 from Resident #1's care which kept her safe. In addition, the Administrator and DON both stated that the incident was reported to her and the DON within 24 hours which is the "regulation". During an interview with the surveyor at approximately 11:15AM, RN #3 who worked in the facility 5 months stated that any abuse incident is reported to the Nurse Supervisor immediately, if it is employee to resident abuse, the staff member is removed from the assignment or sent home depending on the individual issue and the DON is notified immediately. She stated that the investigation is begun immediately with completion of an IR, interviews and statements. During an interview with the surveyor at 11:34AM, Nursing Supervisor LPN #3, who had worked at the facility for [AGE] years, stated that the usual protocol for an abuse allegation would be to remove the staff member from the area, notify the Nursing Supervisor, DON and Administrator immediately, complete an IR and obtain statements. She stated the DON/Administrator make the decision whether or not to suspend someone. Review of staff inservice records showed abuse inservices were conducted in 3/2014. During an interview with the surveyor at 4PM the facility's Regional Director of Operations stated that both the "Practice Guide" and abuse inservice information is what the facility should follow. She confirmed that if the guidelines say suspend, then the employee should be suspended. The immediate jeopardy, which began on 4/20/2014, was identified on 4/28/2014 was lifted on 4/28/2014 as evidenced by the following; 1. Resident #1 was discharged from the facility prior to the survey date. 2. All staff inserviced on Abuse Prevention Guide which included; notify immediately, as soon as facility staff become aware, to supervisor on duty and Administrator of any abuse allegation. 3. LPN #1, LPN #2 and RN #1 received counseling related to the abuse protocol. 4. Nursing Supervisor or Designee will protect residents by suspending the employee pending completing of investigation and its outcome. 5. When facility staff are made aware, an IR will be initiated by the licensed nursing staff to include notification of the Nursing Supervisor, Administrator and Director of Nursing. 6. Random interviews of residents to determine that all concerns have been reported timely and results will be forwarded monthly to the Quality Assessment and Assurance committee for review and action. NJAC 8:39-4.1 a (5)

Based on observation, interview and record review, it was determined the facility failed to consistently provide assistance with eating in accordance with the established plan of care for a resident who was assessed with [REDACTED]. This failure deprived the resident of the opportunity to consume available nourishment, resulting in further weight loss totaling 31.4 pounds in less than 3 months. This deficient practice was identified for Resident #12, 1 of 6 residents reviewed for weight and nutritional concerns, and was evidenced by the following: During the initial tour on 11/3/10 at 10:30 a.m., the nurse accompanying the surveyor said Resident #12 was confused and was receiving palliative care. According to the medical record, the resident was admitted to the facility on [DATE] following a [MEDICAL CONDITION], or Stroke. The Admission Resident Assessment Instrument (RAI) dated 8/16/10 identified that the resident had impaired cognition, had highly impaired hearing and severely impaired vision, requiring the use of glasses. The RAI also identified that the resident had impaired abilities in using and understanding the spoken word, had a partial loss of movement in one hand and required extensive assistance with eating. The RAI identified that the resident weighed 173 lbs and measured 60 inches in height. The 8/18/10 initial Nutritional Risk Assessment identified the resident was at high risk for nutritional problems, citing a contributing factor as inadequate oral intake of food. In a 9/13/10 Nutritional Progress Note, the Registered Dietitian (RD) wrote that the family felt the resident's poor intake was due to "food preferences, change in meals" and "Pt (patient) is use(d) to eating light for breakfast and lunch and a large dinner with snacks in the evening." An Occupational Therapy (OT) Evaluation dated 8/17/10, identified that the resident's recent stroke resulted in right sided weakness and [MEDICAL CONDITION] (the loss of the ability to elaborate, comprehend or express various aspects of speech or language). A second OT Evaluation dated 9/13/10 identified the resident displayed moderate to severe right sided neglect (this is a symptom that causes the stroke survivor to "forget" or "ignore" objects or people on one side). A third OT evaluation dated 9/30/10, also identified that the resident's [MEDICAL CONDITION] was "global" in nature (This is the most severe form of [MEDICAL CONDITION]. Those affected can only produce a few recognizable words and understand little or no spoken language). In untimed OT progress notes dated 10/5/10, 10/6/10 and 10/7/10, the therapist identified that the resident was able to eat a single container of yogurt or pudding with close supervision, occasional cues and minimal spillage, but did not identify the location or circumstances surrounding these observations. The OT note dated 10/8/10 identified the resident with increased distractibility. An OT note dated 10/12/10 also identified that the resident was noted to have less of an attention span, more rigidity of the right arm and a decline in initiation and follow through of tasks and that the resident's overall abilities had declined, requiring maximum cueing and the use of "hand over hand" demonstrations. (When using the hand over hand technique the therapist places his/her hand over the resident's hand with the resident actually touching the material to be used in the task. The therapist's hand acts as a guide, assisting the resident in manipulating the materials in order to complete the activity). According to the facility's weight records, the resident's weight had declined from 172.8 lbs on 8/16/10 to 141.4 lbs on 11/1/10. This represented a significant weight loss of 31.4 lbs since the time of admission which was under 3 months. The resident's interdisciplinary care plan identified the significant weight loss and identified interventions that staff were to encourage and assist the resident as needed to consume all foods, fluids and/or supplements provided. Additionally, a Nutritional Progress Note written on 11/4/10 at 2:55 p.m. revealed "Significant Weight loss continues. Palliative care. Weights discontinued secondary to comfort measures, pain. Pt is assisted with meals/snacks/fluids. Extensive encouragement provided. Individualized care plan in place." The assistance with meals documented in the 11/4/10 Nutritional Progress note was not consistently observed by the surveyor. On 11/4/10 at 12:15 p.m. the surveyor observed the resident at the noon meal in the unit dining room. The resident's meal ticket identified the resident received a mechanical soft diet with enhanced (fortified) foods. The surveyor observed the resident was wearing eyeglasses and was seated in a wheelchair at a table with 2 other residents. The resident was served a ground hot dog on a bun, sauerkraut and baked beans and was holding a can of ginger ale, drinking it through a straw. A Certified Nursing Assistant (CNA) was sitting at the table with the resident. The resident put down the ginger ale and picked up a container of juice covered with a lid. The resident struggled to peel the lid off while the CNA made no attempt to assist. Eventually the resident managed to peel off a small portion of the lid and began to suck the juice out of the small opening that had been created. The resident put down the partially consumed container of juice and picked up a container of sherbet and again struggled to peel off the lid. The resident was eventually able to free the lid from the container, picked up a straw and attempted to eat the sherbet with it, unsuccessfully. The first CNA made no attempt to assist the resident. A second CNA sat down at the table but made no attempt to assist or cue the resident who was still trying to eat the sherbet with the straw. At 12:30 p.m. the resident was still attempting to dig out the sherbet from the container with the straw, without success and with no assistance or cueing from staff. The remainder of the meal had not been touched. The surveyor observed the first CNA interacting with the other 2 residents at the table, but not with Resident #12. The second CNA returned to the table with a grilled cheese sandwich for one of the other residents and interacted with that resident, but not with Resident #12 who had still made no attempt to eat the provided meal. At 12:45 p.m. the resident had still not received any assistance from staff in an effort to promote consumption of the meal. At 12:50 p.m. a nurse approached the table and asked Resident #12 "how's your lunch?" The resident replied "Good." The nurse looked down at the resident's untouched meal and walked away. The second CNA then returned to the table and removed the resident's uneaten meal and walked away, leaving Resident #12 holding a fork. Staff documented that the resident consumed 25% of the meal. On 11/5/10 at 12:15 p.m. the surveyor observed the resident wearing eyeglasses and seated in a wheelchair in the resident's room. The resident's lunch had been served. All of the foods had been cut into bite sized pieces and beverages were opened. A nurse came in and said she was going to assist the resident with the meal. The resident consumed 100% of the fish, 25% of the vegetable, 25% of the yogurt, 50% of a liquid supplement and 100% of 2 containers of juice. On 11/8/10 at 12:15 p.m. the surveyor observed the resident in the dining room, seated in a wheelchair at a different table with another resident who was alert and oriented. The resident was not wearing eyeglasses. Lunch had been served to both residents. Resident #12's meatloaf was not cut and the resident's juice container and milk carton were unopened. A dinner roll situated to the right of the resident's place setting was not buttered or placed within the resident's reach. The resident made no attempt to begin eating the meal and received no assistance or cueing from staff. At 12:20 p.m., a CNA walked by the table and asked if the resident was eating. Without waiting for a response, the CNA looked at the uneaten food and walked away. At 12:35 p.m. a second CNA stopped at the table but made no attempt to assist the resident with the meal and also walked away. The resident then picked up a can of ginger ale that was opened and had a straw inside, situated to the left of the place setting, and began drinking it. At 12:40 p.m., the resident put down the ginger ale, picked up a spoon and scooped up a small amount of potato. The surveyor observed the resident having difficulty holding the utensil and the potato fell into the resident's lap. The resident looked down and attempted to scrape up the dropped potato portion without success. Throughout the meal observation, the resident frequently looked around the room, distracted from the meal by the activity and not focused on eating. At 12:50 p.m., 35 minutes after the resident was served, the nurse who had assisted the resident the previous day sat down at the table and placed a straw in the resident's milk carton and offered it to the resident. The resident accepted the milk and began to drink. The nurse encouraged the resident to eat the meal but the resident refused. The nurse made no attempt to determine if the food had become cold after 35 minutes and not palatable. When the nurse offered to get the resident a peanut butter and jelly or grilled cheese sandwich, the resident said no. The nurse never prepared or offered the resident the roll or the dessert of homemade cookies which were still to the right of the resident's place setting. When the resident pushed the lunch plate away, the nurse removed the meal, including the roll and cookies. Staff documented that the resident consumed 25% of the meal. On 11/9/10 at 12:15 p.m., the surveyor observed the resident at the noon meal in the same dining room. The resident was wearing eyeglasses and was seated in a wheelchair at the same table as 11/4/10. The resident was eating a grilled cheese sandwich, which was cut in half, by holding it with both hands. The resident was also drinking a can of ginger ale with a straw. All beverages had been opened and prepared for consumption by the resident. At 12:30 p.m. the resident had consumed 50% of the grilled cheese sandwich and 100% of the ginger ale without cueing or assistance from staff. The resident did not attempt to eat again until 12:40 p.m. when the surveyor observed the resident holding the other half of the grilled cheese sandwich, attempting to slice it down the middle with a fork. The resident had eventually pulled the sandwich apart with both hands and began eating a piece with both hands. At 12:45 p.m., 30 minutes after the start of the meal, a nurse approached the table and told the resident to try eating the fortified mashed potatoes which were in a separate opaque bowl situated to the right of the resident's place setting. The resident picked up a fork with the right hand, scooped out a small amount of potato and attempted to bring it towards the mouth. The resident lost control of the spoon and the potato fell into the resident's lap. The nurse made no attempt to assist the resident with eating the fortified food. The resident reached for dessert which was cake. However, the cake had been placed at the rear of the place setting and the resident was unable to grasp it. As of 12:45 p.m., the resident had consumed 100% of the ginger ale, 75% of the grilled cheese sandwich and 25% of a carton of milk. The juice, fortified potatoes and cake remained untouched and staff made no attempt to assist the resident with these items. At 12:50 p.m. the nurse approached the resident and asked "Are you finished?" The resident replied, "Yes". The nurse cleared the table except for the container of juice. The nurse placed a straw inside and offered it to the resident. The resident drank 100%. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined the facility failed to carry out the established plan of care following the identification of unplanned, significant weight loss. This failure deprived the resident of the opportunity to consume available nourishment, resulting in continued significant weight loss totaling 31.4 pounds in under 3 months. This deficient practice was identified for Resident #12, 1 of 6 residents reviewed for weight and nutritional concerns, and was evidenced by the following: The surveyor reviewed the medical record for Resident #12 who was admitted to the facility on [DATE] following a Stroke with right sided weakness and a loss of the ability to elaborate, comprehend or express various aspects of speech or language. The resident was assessed with [REDACTED]. The nutritional assessment and progress notes identified that the resident was at risk for nutritional problems due to decreased oral intake. The Occupational Therapy Evaluations and Progress notes identified that the resident required an increased amount of assistance with activities of daily living. Weight records provided by the facility identified that the resident's weight declined from 172.8 lbs on 8/16/10 to 141.4 lbs on 11/1/10 indicating a weight loss of 31.4 lbs since the time of admission (less than 3 months total). The resident's interdisciplinary care plan identified the significant weight loss and developed interventions which included encouraging and assisting the resident as needed to consume all foods, fluids and/or supplements provided. On 11/4/10, 11/8/10 and 1/9/10 the surveyor observed that the nutritional interventions which were put into place on the resident's care plan, were not consistently followed. Refer to F 325 NJAC 8:39-27.1(a)