Every finding on record at Atrium Post Acute Care of Wayne

42440 Based on observation, interview, record review, facility policy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure five residents (Resident (R) 89, 138, 293, 295, and R299) out of 37 sampled residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the residents to have unmet care needs. Findings include: 1. Review of R138's Admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] and had diagnoses that included aftercare following explanation of hip joint prosthesis. Review of R138's Prog Note tab in the EMR revealed a Physician Note dated 12/05/24, which stated [discharge] in [morning] . [follow up] with [primary medical doctor] as [outpatient] for regular screening and checkup . [discharge] to home. A Nurses Notes, dated 12/06/24 stated Patient picked up by family member via private care. Review of the R138's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/24 and located in the resident's EMR section titled MDS, documented R138 discharged to home, return anticipated. During an interview on 02/20/25 at 2:05 PM, Registered Nurse (RN) 6 stated R138 had discharge home and was not expected to return to the facility. During an interview on 02/21/25 at 2:44 PM, the MDS Coordinator (MDSC) stated if a resident returned home, their MDS should reflect discharge return not anticipated. 2. Review of R293's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] and had diagnoses that included chronic respiratory failure with hypoxia and tracheostomy status. Review of R293's Orders tab in the EMR revealed no orders for a ventilator. Review of the R293's admission MDS, with an ARD of 01/23/25 and located in the resident's EMR section titled MDS, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. It further documented the resident used invasive mechanical ventilator while a resident or within the last 14 days. During an observation and interview on 02/18/25 at 10:12 AM, R293 had a tracheostomy tube in place with oxygen flowing at 4 liters per minutes via a tracheostomy mask. No ventilator was used, and R293 reported not utilizing a ventilator since admission or during the 14 days prior to admission. During an interview on 02/20/25 at 2:00 PM, Licensed Practical Nurse (LPN) 6 stated R293 did not use a ventilator, and the facility admitted no residents on ventilators. Review of the Facility assessment dated [DATE] revealed the facility did not admit residents on ventilators or respirators. During an interview on 02/21/25 at 2:44 PM, the MDSC stated unless a resident was on a ventilator, invasive mechanical ventilator should not be coded on the MDS. The MDSC was unaware of anyone in the facility who used a ventilator. 3. Review of R295's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] and had diagnoses that included metabolic encephalopathy. Review of R295's Care Plan located in the Care Plan section of the EMR revealed the resident required a foley catheter and had a colostomy. Review of the R295's admission MDS, with an ARD of 01/18/25 and located in the resident's EMR section titled MDS, revealed she scored 15 out of 15 on the BIMS, indicating intact cognition. It further documented the resident had an indwelling catheter and an ostomy and was frequently incontinent of bowel and bladder. During an observation and interview on 02/18/25 at 3:42 PM, R295 had a drainage bag from her foley catheter hanging from the bed. R295 reported the catheter was placed in the hospital prior to her admission to the facility. R295 also reported she had a colostomy. During an interview on 02/21/25 at 2:44 PM, the MDSC stated when a resident had a urinary catheter and colostomy, bowel and bladder continence needed coded as not rated. 4. Review of R299's Admission Record, located in the resident's EMR section titled Profile, revealed the resident was admitted to the facility on [DATE] and had diagnoses that included pneumonia, respiratory failure, and tracheostomy status. Review of R299's Orders tab in the EMR revealed no orders for a ventilator. Review of the R293's admission MDS, with an ARD of 01/22/25 and located in the resident's EMR section titled MDS, revealed he scored zero out of 15 on the BIMS, indicating severe cognitive impairment. It documented the resident used invasive mechanical ventilator while a resident or within the last 14 days. During an observation on 02/18/25 at 12:30 PM, R299 had a tracheostomy tube in place with oxygen flowing at 8 liters per minutes via a tracheostomy mask. No ventilator was in use. During an interview on 02/20/25 at 2:00 PM, LPN6 stated the facility admitted no residents on ventilators. Review of the Facility assessment dated [DATE] revealed the facility did not admit residents on ventilators or respirators. During an interview on 02/21/25 at 2:44 PM, the MDSC stated unless a resident was on a ventilator, invasive mechanical ventilator should not be coded on the MDS. The MDSC was unaware of anyone in the facility who used a ventilator. During an interview on 02/21/25 at 3:41 PM, the Director of Nursing (DON) stated she expected MDSs to be coded accurately. The facility's RAI Process - MDS Completion policy, last reviewed 07-2024, stated The MDSs will be filled out accurately, after proper collection of date, in a timely manner according to the RAI manual standards. Review of the RAI Manual, dated 10/01/24, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 5. Review of R89's Admission Record face sheet located in the EMR under the Admission Record tab revealed she was admitted to the facility on [DATE] with diagnoses of urinary tract infection, anxiety, dysphagia, malnutrition, acidosis, neuropathy, peripheral vascular disease, and osteoarthritis. Review of R89's annual MDS assessment located in the MDS tab of the EMR with an ARD of 05/04/24, revealed R89 had a BIMS of 15 out 15 which indicated R89 was cognitively intact. Review further revealed R89 had not received Hospice treatment. Review of R89's quarterly MDS assessment located in the MDS tab of the EMR with an ARD of 11/04/24 revealed R89 received Hospice treatment. Review of R89's quarterly MDS assessment located in the MDS tab of the EMR with an ARD of 02/04/25 revealed R89 had not received Hospice treatment. During an interview on 02/21/25 at 3:49 PM with the MDS Coordinator revealed R89 had never been with Hospice and the quarterly MDS was inaccurate. During an interview on 02/21/25 at 4:00 PM with the DON revealed the MDS coding should be accurate and timely. Review of the facility's policy titled, RAI Process-MDS Completion, revealed it was their policy to follow the requirements and standards of the latest published RAI manual. The policy further revealed all disciplines would assess all aspects of the resident's care and needs accurately. The policy revealed the MDS would be filled out accurately. NJAC 8:39-33.2(d)

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure infection control procedures were followed while lunch trays were being passed on one of the three floors. This failure puts residents at risk for infections. Findings include: Review of the facility's policy titled, Infection Control Transmission Precautions-Enhanced Barrier Precautions dated 05-2024, revealed the policy was to provide guidance on when to implement enhanced barrier precautions. The policy further revealed the facility was committed to providing a safe and healthy environment for residents to minimize or prevent the spread of disease. The policy revealed clear signage should be on the door or wall by the resident's room indicating the type of precautions. During an observation on 02/18/25 at 12:26 PM on the third-floor unit revealed lunch trays were being passed by staff. Certified Nursing Assistant (CNA)2 passed a tray to room [ROOM NUMBER] which had signage on the wall that said Enhanced Barrier Precautions (EBP) and to sanitize your hands upon entry and exit to the room. CNA2 did not sanitize his hands before going into the room and leaving the room. CNA2 continued to pass tray to room [ROOM NUMBER] which did not have EBP, and he did not sanitize his hands. CNA2 continued to pass trays to room [ROOM NUMBER], which did not have any signage, and moved the bedside table, and did not sanitize his hands. CNA2 continued to pass trays to room [ROOM NUMBER] which had EBP signage, and he did not sanitize his hands going into the room or exiting the room. CNA2 continued passing trays to room [ROOM NUMBER] and did not sanitize his hands going into the room but did us the sanitizer when he exited the room. Interview on 02/18/25 at 2:10 PM with CNA2 revealed he had never heard of enhanced barrier precautions, but he did sanitize his hands before he went into a room to pass trays and after he came out. CNA2 revealed he used the sanitizers on the wall, and he kept one in his pocket, however he checked, and he did not have any in his pocket. During an interview on 02/20/25 at 8:38 AM with the Infection Preventionist (IP) revealed if a resident was on EBP then staff should sanitize their hands before going into the room to pass a tray and then sanitize their hands when they exit, but if the resident needed assistance, then staff would have to put a gown on and gloves. The IP further revealed if staff did not follow proper precautions, it would put the residents and staff at risk to spread an infection. The IP further revealed the residents were already at risk for infection due to their conditions and if improper precautions were used it increased the risk. The IP revealed staff were educated on proper personal protective equipment (PPE). During an interview on 02/20/25 at 3:00 PM with the Director of Nursing (DON) revealed EBP protected the residents. The DON revealed before you went into a room with EBP signage you should sanitize your hands, take the tray in, and sanitize your hands when you exit the room. The DON further revealed when a resident was on contact precautions anytime you cross that barrier your hands should be sanitized, gloves, and gown should be worn even passing trays. The DON revealed improper precautions put the residents at risk for the spread of infection. The DON revealed she had been monitoring correct isolation application of PPE Review of the Handwashing, PPE in-service done on 12/23/23 revealed CNA 2 had attended the in-service. Review of the signage for EBP on the walls revealed EBP everyone must clean their hands including before entering the room and when leaving the room. Review of the contact precautions signage revealed everyone must clean their hand, including before entering the room and when leaving the room. The signage further revealed providers and staff must also put on gloves before room entry and discard gloves before room exit, put on gown before room entry. Discard gown before room exit. NJAC 8:39-19.4

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure one out of the 37 sampled residents (Resident (R)91) who had a contracture to the left hand was provided restorative services. This failure put R91 at risk for worsened contracture. Findings include: Review of the Admission Record face sheet located in the Admission Record tab of the electronic medical record (EMR), revealed R91 was admitted to the facility on [DATE] with diagnoses of contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, and dysphagia. Review of R91's annual Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/30/24 revealed R91 had a Brief Interview for Mental Status (BIMS) of zero out of 15 which indicated R91 was severely cognitively impaired. R91 had a functional limitation of the range of motion on the left upper extremity. Review further revealed R91 had received occupational therapy that started on 08/16/24. Review revealed R91 had not received any restorative therapy for splint or brace assistance. Review of the comprehensive care plan, located in the EMR under the Care Plan tab with an initiated date of 12/09/22 and revised on 04/10/24 revealed a problem for limited physical mobility. Interventions included ambulation with the assistance of one, wheelchair, bed mobility was to have the assist of one, and a mechanical lift was to be used for transfers. The contracture of the left hand was not addressed. Record review of the physician orders, dated 02/14/2025 located under the Orders tab of the EMR revealed R91 had an order for Restorative Nursing Program (RNP) to use a left carrot hand splint for four hours on and four hours off daily for flexion contracture management. During an observation on 02/19/2025 at 8:38 AM, R91 was lying in bed in her room and did not have any carrot or splint in her left hand which the fingers were partially closed. Observation further revealed a carrot splint was not laying around in the room. During an observation on 02/19/25 at 2:50 PM R91 was up in her modified wheelchair at the nurses station and did not have a carrot hand splint on her left hand. During an observation on 02/20/25 at 10:25 AM, R91 was lying in her bed in her room and the left hand did not have a carrot hand splint on the left hand. During an observation on 02/20/25 at 3:57 PM, R91 was sitting in her modified wheelchair up at the nurse's station and she did not have a carrot hand splint on the left hand. During an interview on 02/21/25 at 8:46 AM with the Restorative Aide revealed he did not do splint or carrot application to the left hand of R91 because it was the nurse's responsibility to apply them. The Restorative Aide revealed he did restorative for range of motion for R91 but since occupational therapy had picked her up, he would not be performing range of motion to her. The Restorative Aide revealed the nursing staff knew they were supposed to apply the carrot hand splint to the left hand of R91. During an interview on 02/21/25 at 8:46 AM with the Assistant Director of Therapy revealed an occupational therapy evaluation had been done on 02/20/25 and they would be working on the left hand contracture. The Assistant Director of Therapy revealed the carrot hand splints should have been applied to R91's left hand, by the nurses, up until the occupational therapy evaluation was completed. The Assistant Director of Therapy revealed R91 was at risk of not maintaining her previous level of range of motion. During an interview on 02/21/25 at 9:18 AM with Certified Nursing Assistant (CNA)9 revealed he had not applied any carrots to R91's left hand and it was not on the Kardex to apply any. Review of the Kardex as of 02/19/25 indicated the carrot hand splints were not listed on the document. During an interview on 02/21/25 at 9:25 AM with Licensed Practical Nurse (LPN)2 revealed R91 should have had carrots on to the left hand but the carrot hand splint was supposed to be applied by therapy. During an interview on 02/21/25 at 10:31 AM RN4 revealed restorative was not done until rehab therapy educated the staff on how to apply the carrots and splints to the left hand of R91 even though the physician ordered the restorative nursing program on 02/14/25 and initially on 12/27/24. RN4 revealed R91 was on a trial program right now with occupational therapy and would not be receiving any restorative. RN4 revealed an occupational therapy evaluation was done on 02/20/25. During an interview on 02/21/25 at 12:30 PM with the Director of Nursing (DON) revealed when the physician ordered the carrot hand splint on 02/14/25 it should have been applied on that day to prevent any further contracture. During an interview on 02/21/25 at 2:48 PM, MDS Coordinator (MDSC) revealed R91 should have been care planned for contractures and she reviewed the care plan, which included a problem for limited physical mobility and an intervention was for a left hand carrot but was added to the care plan on 02/19/25. Review of the undated Policy and Procedure Manual for Functional Maintenance/Restorative Nursing Program, revealed the restorative nursing program was developed to assist in the delivery of interventions that promote a resident's ability to function at their highest level. The policy further revealed a resident's ability to perform active or passive range of motion exercises would not diminish unless the clinical condition demonstrated that diminution was unavoidable. NJAC 8:39-27.1(a)

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure comprehensive care plans were revised for one out of three residents (Resident (R91) of the 37 sampled residents. Specifically, R91 had a contracture to the left hand and it was not addressed in the care plan. Findings include: Review of the Admission Record face sheet located in the Admission Record tab of the electronic medical record (EMR), revealed R91 was admitted to the facility on [DATE] with diagnoses of contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, dysphagia. Review of R91's annual Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/30/24 revealed R91 had a Brief Interview for Mental Status (BIMS) of zero out of 15 which indicated R91 was severely cognitively impaired. R91 had a functional limitation of the range of motion on the left upper extremity. Review of the comprehensive care plan, located in the EMR under the Care Plan tab with an initiated date of 12/09/22 and revised on 04/10/24 revealed a problem for limited physical mobility. Interventions included ambulation with the assistance of one, wheelchair, bed mobility was to have the assist of one, and a mechanical lift was to be used for transfers. The contracture of the left hand was not addressed. Record review of the physician orders, dated 02/14/25 located under the Orders tab of the EMR revealed R91 had an order for Restorative Nursing Program (RNP) to use a left carrot hand splint for four hours on and four hours off daily for flexion contracture management. During an interview on 02/21/25 at 2:33 PM with LPN1 revealed the initial care plan was initiated by the Social Worker and the MDS Coordinator, nurses, dietary, rehab, and activities update the care plan. LPN1 further revealed the contracture of the left hand should be addressed on the care plan and it was not addressed. During an interview on 02/21/2025 at 2:48 PM, MDS Coordinator (MDSC) revealed the managers on the unit initiated the care plan, and social services, dietary, and activities all initiated and updated care plans. The MDSC revealed the team all oversaw that the care plan was accurate. The MDS further revealed R91 should be care planned for contractures and she reviewed the care plan, which included a problem for limited physical mobility and an intervention was for a left hand carrot, but was added to the care plan on 02/19/25. The MDSC stated the nurse that took the order for RNP, which included a left hand carrot, should have updated the care plan. NJAC 8:39-11.2(e)(h)

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure comprehensive care plans were initiated for two out of three residents (Resident (R) 63 and R128) of the 37 sampled residents. Specifically, R63 was on Intravenous (IV) medication and fluids, and R128 had religious and cultural preferences that were not addressed in the care plan. Findings include: 1. Review of R63's Admission Record face sheet located in the Admission Record tab of the electronic medical record (EMR), revealed R63 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, peripheral vascular disease, pleural effusion, cardiomyopathy, hypertension, benign prostatic hyperplasia, hypothyroidism, chronic kidney disease stage 2, atrial fibrillation, and acute respiratory failure. Review of R63's admission MDS under the MDS tab in the EMR, with an ARD of 06/25/24 revealed a BIMS of 15 out of 15 which indicated his cognition was intact. Review of the comprehensive care plan located under the Care Plan tab in the EMR, with a review date of 12/20/24 revealed there was not any problem for hydration or interventions for IV fluid and IV medication usage. Review of the physician orders, dated 02/17/25 for Sodium Chloride 0.45% use one liter intravenously one time only for 60 cubic centimeters (cc) at one hour for one day for IV hydration. Review of the physician orders revealed an order for a sodium chloride flush 0.9% to use ten cc IV every shift for IV hydration for one day before and after medication administration. Another physician order was for Venofer (which was iron sucrose) IV solution 200 milligram (mg) IV one time a day for low hemoglobin for five days. The physician orders included Piperacillin 3.375 grams IV every six hours for infection for seven days. A physician order was obtained on 02/18/25 for a midline insertion. During an observation on 02/18/25 at 10:03 AM R63 was lying in bed in his room and normal saline was infusing per IV. During an interview on 02/21/25 at 2:40 PM with LPN1 revealed there should be a care plan due to a change in condition and IV use for R63. LPN1 revealed, after she reviewed the care plan, there was not any care plan for the IV hydration and IV medication use and there should be. LPN1 stated a care plan informed the staff of R63's needs. During an interview on 02/21/25 at 3:30 PM with the MDSC revealed R63 should have a care plan for IV medication and IV fluids and after she reviewed the care plan state R63 did not have a care plan for IV medication and IV fluids. LPN1 revealed the purpose of the care plan was to guide the staff on R63's care. LPN1 revealed the staff that took the order should have put it on the care plan. During an interview on 02/21/25 at 12:30 PM with the DON revealed IV fluids and IV medications should be included in R63's care plan. Record review of the facility's policy titled, Care Plan Process, with a last reviewed and revised date of 09/24, revealed a care plan should be developed that was appropriate for each resident's needs. The policy further revealed a care plan should incorporate identified problems with appropriate interventions. The care plan policy further revealed the plan of care must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. 2. Review of R128's Admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] and had diagnoses that included unspecified fracture of unspecified femur. R128's religion was listed as Muslim. Review of the Orders tab of the EMR revealed R128 had an order on admission, 08/30/24 for no pork or chicken. Review of a Dietary Assessment, dated 09/03/24 and located in the resident's EMR section titled Assmnts revealed no response to the Ethnic/Religious/Cultural area and none; per nurse via phone as the response for Diet Preferences/Dislikes. Review of the R128's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/24 and located in the resident's EMR section titled MDS, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of R128's Care Plan, located in the resident's EMR section titled Care Plan, revealed [R128] is at risk for malnutrition r/t [related to] varied intakes, revised on 12/09/24. Interventions included to monitor intakes, provide diet as ordered, and obtain food preferences as needed. The Care Plan did not address R128's religion/culture and corresponding dietary restrictions or the need for a female caregiver. During an interview on 02/18/25 at 1:59 PM, R128 stated due to her religion and culture she could not eat chicken or pork and needed female staff to provide cares. She stated she had to order other foods on days there was chicken or pork on the menu, and so she often ate cereal. During an interview on 02/19/25 at 3:55 PM, Certified Nurse Aide (CNA) 10 stated only females could assist R128 with cares. If a male CNA was assigned to R128's room, a female CNA switched out a resident and provided cares. During an interview on 02/20/25 at 4:00 PM, the Registered Dietician stated she had worked at the facility for one month and could not state what alternatives were offered to R128 for chicken and pork. The facility had an always available menu. During an interview on 02/21/25 at 11:48 AM, the Dietary Manager (DM) stated she was aware of R128's dietary restrictions and that R128 frequently requested yogurt, cereal, and milk, sometimes twice for one meal. The DM said she was not involved in care planning. During an interview on 02/21/25 at 2:32 PM, Registered Nurse/Unit Manager (RN) 5 stated she or the Assistant Director of Nursing initiated care plans for the floor. Care plans were then updated as needed through report at morning meetings and as changes occurred. Updates were completed by whoever got to them first. RN5 expected cultural/religious needs and preferences to be included in the care plan. During an interview on 02/21/25 at 2:44 PM, the MDS Coordinator (MDSC) stated nursing management initiated the care plans. The care plans were then updated quarterly with MDS assessments and as needed. The MDSC stated it was a team effort to maintain the accuracy of the care plans. Preferences, such as religious/cultural, should be on the care plan. During an interview on 02/21/25 at 3:41 PM, the Director of Nursing (DON) said she expected cultural and religious preferences to be care planned and verified that R128's were not. Review of the facility's Care Plan Process policy, reviewed 09/2024, stated, The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. NJAC 8:39-11.2(e)thru(i) NJAC 8:39-27.1(a) 42440

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure one out of two resident (Resident (R)4) had an accurate Pre-Admission Screening and Resident Review (PASRR) done out of the 37 sampled residents. This failure put R4 at risk of not receiving the services needed. Findings include: Review of R4's Admission Record face sheet located under the Admission Record tab of the electronic medical record (EMR) revealed he was readmitted to the facility on [DATE], from an acute care hospital with diagnoses of Parkinson's, hemiplegia, diabetes mellitus, nephropathy, angina pectoris, schizoaffective disorder, hypertension, atherosclerosis of coronary artery bypass, bipolar, depression, anxiety, convulsions, and spinal stenosis. Review of R4's annual Minimum Data Set (MDS) assessment located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 05/10/24, revealed R4 had a Brief Interview for Mental Status (BIMS) 15 out of 15 which indicated intact cognition. Review of the comprehensive care plan, located in the EMR under the Care Plan tab with a review date of 12/08/24 revealed a problem for behaviors and an intervention for psych consults. Review of the PASRR Level I screen assessment, dated 05/15/23, revealed a bipolar diagnosis had been marked no instead of yes for the mental illness screen. The screening further revealed R4 did not qualify for a Level II screening. During an interview on 02/21/25 at 11:42 AM with the Social Services Director (SSD) revealed the PASRR came with the admission packet from the hospital. The SSD revealed she did not review the PASRR for accuracy. During an interview on 02/21/25 at 11:51 AM with the Admission Coordinator revealed she did not review the Level I for accuracy. The Admission Coordinator revealed she only uploaded the PASRR into the computer system. The Admission Coordinator further revealed the Liaison Person would review the PASRR level II. During an interview on 02/21/25 at 12:01 PM with the Director of Nursing (DON) revealed she reviewed the clinical chart on admissions and she would check the PASARR if it was included in the packet. The DON confirmed the PASARR was inaccurate because R4 had a diagnosis of bipolar and it was marked no on the screening. The DON revealed a PASARR Level II would indicate if a resident needed special services that the facility would be able to offer. The DON revealed she did not know who was responsible for ensuring the PASARR Level I and II were accurate. Review of the facility's policy titled, Preadmission Screening and Annual Resident Review (PASRR) created on 08/14 and reviewed on 08/24, revealed the PASARR process consisted of a Level I screen and a review and implementation of the Level II recommendations upon admission to the facility. The policy further revealed the PASRR process required that all applicants to the Medicaid certified Nursing Facilities be given a preliminary assessment to determine whether they might have a pertinent diagnosis which was called a Level I screen. The policy revealed those individuals who test positive at Level I will be evaluated in depth, which was called a PASRR Level II and a determination would be made of the need for an appropriate setting and a set of recommendations for services. NJAC 8:39-5.1(a)

Based on record review, staff interview, and facility policy review, the facility failed to complete a discharge Minimum Data Set (MDS) tracking form within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for one resident out of 37 sampled residents (Resident (R) 7) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes. Findings include: Review of R7's undated Admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including clostridium difficile, pressure ulcers of the right and left buttocks, chronic kidney disease, and diabetes. Review of R7's Census tab of the EMR revealed the resident discharged on [DATE]. Review of a Social Service note, dated 09/03/24 and located in the Prog Note tab of the EMR revealed, [R7] requesting discharge home tomorrow 9/4 . Referral made to [home health company]. Review of R7's MDS tab of the EMR revealed the most recent assessments that had been completed and transmitted were admission and Medicare - 5 Day MDSs with an Assessment Reference Date (ARD) of 08/26/24. During an interview on 02/21/25 at 2:44 PM, the MDS Coordinator (MDSC) stated a discharge tracking MDS should be opened and completed within 14 days of the resident discharging. During an interview on 02/21/25 at 3:41 PM, the Director of Nursing stated she expected MDSs to be completed timely. Review of the facility's policy titled RAI Process-MDS Completion, reviewed July 2024, revealed, The MDSs will be filled out accurately, after proper collection of data, in a timely manner according to the RAI manual standards and Periodic checks will be performed to ensure the MDS is being opened, filled out and transmitted timely and accurately, according to the RAI requirements. Review of the RAI Manual, dated 10/01/24, revealed a Discharge Assessment-Return Not Anticipated must be completed within 14 days after the discharge date . NJAC 8:39-11.2

Based on observation, record review and staff interview, the facility failed to ensure the facility received licensure and certification approval prior to changing the name of the facility on the facility sign located outside the facility. Failure to get approval prior to changing the name of the facility on the sign had the potential to result in confusion among visitors, employees, and residents. This had the potential to affect 144 of 144 residents in the facility. Findings include: Review of the facility State license titled New Jersey Department of Health Division of Certification of Need and Licensing License stated the facility was licensed to operate as Atrium Post Acute Care of [NAME] consisting of 209 Long-Term Care Beds. Observations upon the facility at 8:15 AM on 02/18/25, 02/29/25, 02/20/25, and 02/21/25, revealed the sign located at the driveway to the facility read Alps at [NAME]. The sign was a banner that completely covered the facility's original sign. Interview with the Administrator on 02/19/24 at 1:04 PM, revealed they were in the application process and were unable to provide approval for the name change. When asked if she had a CMS-855B form she stated they had not completed one because that gets completed further in the approval process. When asked about the name change and the Administrator stated the name change was not official, and they were in the process of getting the name changed. Further interview on 02/19/25 at 1:34 PM the Administrator provided the following documents: A letter from an attorney, dated 01/03/25, titled Change of Information referring to exhibits that were not attached to the letter. Review of a letter from an attorney. dated 01/29/25, with the Application for a Long-Term Care Facility License with attachments. The attachments include an Application for a Long-Term Care Facility License, a certificate of a Merger, and an Interim Management Agreement. A letter from an attorney, dated 02/18/25, revealed the transfer of ownership application again referred to attachments that were not attached or provided with the information she gave me. Review of an undated document titled, CHOW [Change of Ownership] application from the New Jersey Department of Health thanking them for submitting their application. The facility did not provide CMS 855B or any documentation showing the name change was approved. On 02/20/25 at 2:00 PM, the Administrator verified they did not have an approval letter from the State Licensure agency approving the name change. NJAC 8:39-2.1 thru2.7

NJ00172016 Based on observation, interview, and record review, it was determined that the facility failed to assure that the Physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 4 of 4 residents (Resident #1, 2, 3, and 4) reviewed and was evidenced by the following: 1.According to the ADMISSION RECORD (AR), Resident #1 has diagnoses of including but not limited to Toxic Encephalopathy, Megaloblastic Anemia, Urinary Tract Infection, and Malignant Neoplasm of Breast and Ovary. A review of the Minimum Data Set (MDS), an assessment tool dated 01/05/24, showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 had intact cognition and was independent with Activity of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR), dated 03/2024, 02/2024, and 01/2024, revealed that the physician did not sign and date the monthly orders. 2. According to the AR, Resident #2 has diagnoses of including but not limited to Low Back Pain, Depression, Anxiety Disorder, Osteoarthritis, and Narcolepsy. A review of Resident #2's MDS, dated [DATE], showed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #2 had intact cognition and required minimal assistance with Activity of Daily Living (ADLs). A review of Resident #2's OSR, dated 02/2024, 01/2024, and 12/2023, revealed that the physician did not sign and date the monthly orders. 3. According to the AR, Resident #3 has diagnoses of including but not limited to Schizoaffective Disorder, Hypertension, Type 2 Diabetes Mellitus, and Hyperlipidemia. A review of Resident #3's MDS, dated [DATE], showed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 09, indicating that Resident #3 cognition was moderately impaired and required assistance with Activity of Daily Living (ADLs). A review of Resident #3's OSR, dated 03/2024, 02/2024, and 01/2024, revealed that the physician did not sign and date the monthly orders. 4. According to the AR, Resident #4 has diagnoses of including but not limited to Anxiety Disorder, Hyperglycemia, Hypertension, and Peripheral Vascular Diseases. A review of the Minimum Data Set (MDS), dated [DATE], showed that Resident #4 had a BIMS score of 13, indicating that Resident #4's cognition was intact and required minimal assistance with Activity of Daily Living (ADLs). A review of Resident #4's OSR, dated 03/2024, 12/2023, 11/2023, and 10/2023, revealed that the physician did not sign and date the monthly orders. During the interview on 04/05/24 at 3:52 p.m., the DON stated that all medication orders were signed electronically. She further stated that the physician was to sign orders every thirty days or monthly. The DON agreed that the orders for Residents #1, #2, #3 and #4 were not signed and dated by the physician. During the interview on 04/05/24 at 4:58 p.m., the Regional Clinical Nursing Services (RCNS) Registered Nurse (RN) stated physicians came and saw their Residents but they did not write their notes on that day. She further stated physician orders were signed but was unable to provide the documentation. The RCNS RN acknowledged that physician orders have to be signed monthly. A review of the facility's policy titled, Medication Orders, revised 2014, Under Supervision by a Physician Number 4. read Physician Orders/Progress Notes must be signed and dated every thirty (30) days . A review of the facility's policy titled, Physician Visits and Physician Delegation, reviewed and revised 07/2023, under Policy Explanation and Compliance Guidelines: 1. The Physician should: e. Sign and date all orders . NJAC-8:39 23.2

Complaint#: NJ00164781 Based on interviews, medical records (MRs), and review of other pertinent facility documentation on 7/13/23, it was determined the facility failed to thoroughly investigate an alleged staff-to-resident physical abuse allegation involving the Certified Nursing Aide (CNA #1) and Resident #1. The facility also failed to ensure its policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property was consistently implemented; when, on 6/4/23 (time unknown), a visitor (Visitor #1) reported to the Licensed Practical Nurse/Unit Manager (LPN/UM) that CNA #1 hit Resident #1. The LPN/UM then reported the abuse allegation to the Registered Nurse/Evening Supervisor (RN/ES). At approximately 4:30 PM that same day, a second visitor (Visitor #2) reported to the RN/ES that Resident #1 hand was bleeding, and someone might have hit the Resident's hand or the Resident. The RN/ES interviewed the LPN/UM, LPN #1, and CNA #1. According to the RN/ES, she was not notified of the alleged physical abuse reported by Visitor #1. However, she started an investigation focusing on CNA #1 because she was the last person with Resident #1 in the dining room. The RN/ES confirmed that CNA #1 was not immediately suspended when she initiated an investigation because it was not alarming at that time. During the investigation, the RN/ES reassigned CNA #1 to provide care to residents in another unit for the rest of the evening shift (3 PM-11 PM) without the CNA being monitored or supervised for approximately 6 hours. The facility's failure to immediately remove and/ or suspend CNA #1 until the outcome of the investigation and thoroughly investigate the allegations of abuse, per the facility's abuse policy, posed a likelihood of serious harm to the health and well-being of Resident #1 and potentially all other residents that CNA #1 provided care. This resulted in an Immediate Jeopardy (IJ) situation. This IJ was identified, and an IJ template was presented to the Administrator on 7/13/23 at 6:03 PM. The IJ began on 6/4/2023 and continued until 7/13/2023. The facility presented an acceptable removal plan which included initiating in-services for all staff on the facility's abuse policy. This was verified on-site on 7/20/23. The non-compliance remained on 7/14/23 for no actual harm, with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: According to the Admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dementia with Other Behavioral Disturbances, Hypertension, and Atrial Fibrillation. Review of the Minimum Data Set (MDS), an assessment tool, dated 5/19/23, revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated intact cognition, and the Resident required assistance with activities of daily living (ADLs). A review of the Care Plan (CP) dated 9/28/22 indicated that Resident #1 had a behavior problem, including yelling out without provocation/cause. Interventions included but were not limited to Psychiatry consult, explaining all procedures before starting and allowing to adjust to changes, attempting non-pharmacological approaches including 1:1 observation, and developing more appropriate methods of coping and interacting. A review of the nursing progress notes (NPN) dated 6/4/23 at 2:49 PM revealed Resident #1 was agitated, yelling, screaming, calling staff, and racial slurs. Redirection [was] ineffective. The responsible party (RP) was notified. Further review of the NPN, a late entry dated 6/6/23 at 2:20 PM, revealed Resident #1 was noted with multiple previous scabs opened in the left leg. The physician and the Resident's RP were notified. A review of the Investigational Summary dated 6/4/23 (timeline of events unknown) signed by the DON, revealed on 6/4/23, under the description of the event, she received a call from the supervisor [RN/ES] that Visitor #1 made an accusation that CNA #1 hit a resident. The investigation findings indicated an investigation was conducted, and the statement was immediately collected. The supervisor was told to make sure not to assign CNA #1 to the alleged Resident. The investigation findings revealed that statements from all staff present during the alleged abuse denied witnessing the incident. CNA #1 denied the allegation. According to CNA #1 interview, she was redirecting Resident #1 due to behavior when a family member (Visitor #1) saw the blood on the legs and assumed CNA #1 hit the Resident (Resident #1). Visitor #1, who made the allegation, stated they did not witness the alleged incident but referred to another (Visitor #2) who was also a witness. Visitor #2 denied witnessing the alleged abuse. The conclusion (time unknown) included that there was no substantial evidence to substantiate the alleged abuse. A review of a typewritten witness statement dated 7/4/23, unsigned, prepared by the RN/ES, revealed on 6/4/23, around 4:30 PM, Visitor #1 asked her to check on the [NAME] unit because something was happening. The RN/ES indicated the [NAME] unit was ok and nothing to report. The statement further showed that another visitor (Visitor #2) questioned if someone hit Resident #1 because there was blood on the Resident's hand. According to the statement, the RN/ES assessed the Resident, and no bruises or injuries were noted. The nurses (LPN #1 and LPN/UM) who were there stated Resident #1 was yelling, and when CNA #1 went to assist the Resident, who patient refused to have any contact, and the CNA came back to continue with her documentation without having skin contact with the resident. The DON told RN/ES to collect everybody's statement for her to start an investigation. A review of a handwritten statement dated 6/4/23 signed by the LPN/UM showed, On the day in question, I was working as a floor nurse; I did not see CNA #1 hit the resident (Resident #1). A review of a handwritten statement dated 6/4/23 (untimed) and unsigned, prepared by CNA #1 per DON, revealed that on 6/4/23, while in the dining room, Resident #1 was having an outburst. Visitor #1 and Visitor #2 were nearby, having a conversation. Another Visitor with Visitor #2 asked why Resident #1 was bleeding. CNA #1 responded that it was from a skin tear. After that, while CNA #1 and LPN/UM were talking to Visitor #2, Visitor #1 alleged somebody hit Resident #1. CNA #1 replied, No, Resident #1 always outbursts like that . he/she was not touched. According to CNA #1, during an interview on 7/24/23 at 11:06 AM, she confirmed Visitor #1 alleged that she hit Resident #1. A review of CNA #1 Detailed Hours, an employee timecard report, revealed CNA #1 worked the following hours: on 6/4/23 from 6:18 AM to 9:01 PM, 6/5/23 from 6:29 AM to 2:30 PM, 6/6/23 from 7:30 AM to 3:57 PM, and 6/7/23 from 7:37 AM to 10:13 PM. During an interview on 7/13/23 at 12:15 PM and 7/20/23 at 9:45 AM, the LPN/UM stated on 6/4/23 (time unknown), Visitor #1 alleged CNA #1 hit Resident #1. She stated she informed the RN/ES of the alleged abuse incident. During the first and second interviews on 7/13/23 at 2:40 PM, the RN/ES stated CNA #1 was not immediately suspended when she initiated an investigation because it was not alarming at that time. During the investigation, CNA #1 was reassigned to care for residents in another unit for the rest of the evening shift (3 PM-11 PM). The RN/ES stated CNA #1 was not told to go home because there was no abuse, and staff did not witness it. RN/ES confirmed she only interviewed LPN #1 and LPN/UM. Additionally, the RN/ES stated she notified the Director of Nursing (DON) immediately of the allegation made by Visitor #2, and the DON instructed her to collect written statements. The DON did not instruct her to suspend CNA #1 but reassigned her to another unit. The RN/ES confirmed she was aware of the facility's policy on abuse which included immediately removing and/or suspending staff members accused of the alleged abuse pending the investigation outcome; however, she was unable to explain why it was not followed and stated, I missed that part .I misunderstood that part. During an interview on 7/13/23 at 3:30 PM, the DON stated she completed the abuse allegation investigation summary dated 6/4/23 involving CNA #1 and Resident #1. The DON and the Administrator confirmed the alleged incident was not reported to the New Jersey Department of Health (NJDOH), and CNA #1 was not immediately suspended because it was determined within two hours of the allegation that there was no abuse. Therefore, CNA #1 was reassigned to another unit instead. However, there was no documented evidence in the MRs, including witness statements and investigation summary, that a thorough investigation was completed within two hours after the physical abuse allegation. The DON further stated all staff on the [NAME] unit were interviewed immediately after the allegation was made. Statements from these staff were all collected. However, the DON could not provide documented evidence that CNA #2, LPN #1, Resident #1, and other residents assigned to CNA #1 were interviewed or submitted witness statements. The Administrator confirmed that both visitors' statements were obtained the next day, on 6/5/23, when she was informed of the allegations. During a second interview on 7/14/23 at 2:30 PM, the DON stated she couldn't speak to the investigation summary, they may be misused words, but the investigation findings were accurate. According to the DON, the RN/ES notified her about Visitor #1's allegation to check on the [NAME] unit, and within 2 hours, the RN/ES notified her again that the issue was about Resident #1's wound. The DON stated she was not aware of a second visitor allegation until the next day when she interviewed CNA #1. The DON acknowledged she failed to prepare an accurate investigation report but asserted the alleged incident was thoroughly investigated. During an on 7/14/23 at 3:00 PM, the Administrator stated she was unaware of the alleged incident until the next day. She stated the DON or Administrator is responsible for reporting and conducting a thorough investigation of an abuse allegation. She added she could not speak for the investigation summary for 6/4/23 but confirmed she is the last person to review and approve each investigation summary. During an interview on 7/20/23 at 10:00 AM, CNA #2, assigned to Resident #1 on 6/4/23 during the day shift (7 AM-3 PM), confirmed the RN/ES or the DON did not interview or ask her to write a witness statement. During an interview on 7/24/23 at 11:06 AM, CNA #1 stated on 6/4/23 (time unknown), while she was in the dining room trying to calm Resident #1, Visitor #1 alleged she hit Resident #1. The allegation was made in front of Visitor #2 and LPN/UM. CNA #1 could not recall if she informed the RN/ES of the alleged incident but stated that LPN/UM witnessed the incident and spoke with the RN/ES. During the survey, the surveyor attempted to interview Resident #1, but he/she refused to be interviewed. Review of facility policy updated on 5/2022, titled; Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, included but was not limited to: It is the policy of (Center) that each Resident will be free from abuse .include verbal, mental, sexual, or physical abuse .No abuse or harm will be tolerated . Investigation Components: It is the policy of this center that reports of abuse .are promptly and thoroughly investigated. Procedure: The center will immediately begin a thorough investigation of any reported incident and collect information that corroborates or disproves the incident. a. When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: ii. Who was involved iii What happened: a. Resident's statements, b. Resident's roommate statements, c. interviewing the alleged perpetrator, d. Involved team members and witness statements of [the] event: i. identifying and interviewing other team members and residents in the immediate area at the time of the incident who may have witnessed what occurred, ii. Interviewing team members who worked the previous shift . iv. Where did it happen? v. How did it happen . x. Conclusion based upon findings. Additional Investigation Protocols. The Administrator or designee will inform the Resident and/ or his/her representative of the findings of the investigation and corrective action plan. Protection Components: Immediately upon receiving a report of alleged abuse, the Administrator and or designee will coordinate [the] delivery of appropriate medical and/or psychosocial care and attention. Ensuring the safety and well-being of vulnerable individuals .The center will take necessary steps to protect residents . a. Procedures must be in place to provide the Resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed, and the Resident will be protected. Team members accused of alleged abuse will be immediately removed from the center and will remain removed pending the results of a thorough investigation. (Decision of the extent of the immediate disciplinary action will be made by the Administrator or designee.), iv. Examine, assess, and interview the Resident and other residents potentially affected immediately .Notify the physician. Reporting and Response Component: It is the policy of the [center] that abuse allegations .are reported per Federal and State Law. The center will ensure that all alleged violations involving abuse, neglect .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the center and the Department of Health to in accordance with State law through established procedures. NJAC- 8:39-4.1 (a)5

Complaint#: NJ00164781 Based on interviews and a review of the medical records (MRs) and other facility documentation on 7/13/23, it was determined that the facility failed to immediately report an allegation of staff to resident physical abuse to the New Jersey Department of Health (NJDOH) and follow its policy titled; Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property. This deficient practice was identified for 1 of 5 residents (Resident #1) and was evidenced by the following: According to the Admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Dementia with Other Behavioral Disturbances, Hypertension, and Atrial Fibrillation. A Minimum Data Set (MDS), an assessment tool, dated 5/19/23, revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition, and the Resident required assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) included a Physician Order (PO) initiated on 6/9/23 for wound care to the left lower extremity and right lower extremity with xeroform and Vitamin A and D to peri-wound and cover with dry dressing everyday shift. A review of the Care Plan (CP) dated 9/28/22 indicated that Resident #1 had a behavior problem, including yelling out without provocation/cause. Interventions included but were not limited to Psychiatry consult, explaining all procedures before starting and allowing to adjust to changes, attempting non-pharmacological approaches including 1:1 observation, and developing more appropriate methods of coping and interacting. A review of nursing progress notes (NPN) dated 6/4/23 at 2:49 pm revealed Resident #1 was agitated, yelling, screaming, calling staff, and racial slurs. Redirection [was] ineffective. The responsible party (RP) was notified. Further review of the NPN, a late entry dated 6/6/23 at 2:20 pm, revealed Resident #1 was noted with multiple previous scabs opened in the left leg. The physician and RP were notified. A review of the Investigational Summary dated 6/4/23 (timeline of events unknown) signed by the DON, revealed on 6/4/23, under the description of the event, she received a call from the supervisor [RN/ES] that Visitor #1 made an accusation that CNA #1 hit a resident. The investigation findings indicated an investigation was conducted, and the statement was immediately collected. The supervisor was told to make sure not to assign CNA #1 to the alleged Resident. The investigation findings revealed that statements from all staff present at the time of the alleged abuse denied witnessing the alleged incident. CNA #1 denied the allegation. According to CNA #1 interview, she was redirecting Resident #1 due to behavior when a family member (Visitor #1) saw the blood on the legs and assumed CNA #1 hit the Resident (Resident #1). Visitor #1, who made the allegation, stated they did not witness the alleged incident but referred to another (Visitor #2) who was also a witness. Visitor #2 denied witnessing the alleged abuse. The conclusion (time unknown) included that no substantial evidence substantiated the alleged abuse. A review of the typewritten witness statement dated 7/4/23, unsigned, prepared by the RN/ES, revealed on 6/4/23, around 4:30 pm, Visitor #1 asked her to check on [the] [NAME] unit because something was happening. The RN/ES indicated the [NAME] unit was ok and nothing to report. The statement further showed that another visitor (Visitor #2) questioned if someone hit Resident #1 because there was blood on the Resident's hand. According to the statement, the RN/ES assessed the Resident, and no bruises or injuries were noted. The nurses (LPN #1 and LPN/UM) who were there stated Resident #1 was yelling, and when CNA #1 went to assist the Resident, who patient refused to have any contact, and the CNA came back to continue with her documentation without having skin contact with the resident. The DON told RN/ES to collect everybody's statement for her to start an investigation. A review of a handwritten statement dated 6/4/23 signed by LPN/UM revealed, On the day in question, I was working as a floor nurse; I did not see CNA #1 hit the resident (Resident #1). A review of a handwritten statement dated 6/4/23 (untimed), unsigned, prepared by CNA #1 per DON, revealed that on 6/4/23, while in the dining room, Resident #1 was having an outburst. Visitor #1 and Visitor #2 were nearby, having a conversation. Another Visitor with Visitor #2 asked why Resident #1 was bleeding. CNA #1 responded that it was from a skin tear. After that, while CNA #1 and LPN/UM were talking to Visitor #2, Visitor #1 alleged somebody hit Resident #1. CNA #1 replied, No, Resident #1 always outbursts like that .he/she was not touched. According to CNA #1, during an interview on 7/24/23 at 11:06 am, she confirmed Visitor #1 alleged she hit Resident #1. Further review of the investigation summary and attached witness statements did not include documented evidence that CNA #1, LPN #1, Resident #1, and other residents assigned to CNA #1 were interviewed and/or submitted a statement. LPN #1 was not employed at the facility during the survey. A review of CNA #1 Detailed Hours, an employee timecard report, revealed CNA #1 worked the following hours after an allegation of abuse was made on 6/3/23 at about 4:30 pm: on 6/4/23 from 6:18 am to 9:01 pm, 6/5/23 from 6:29 am to 2:30 pm, 6/6/23 from 7:30 am to 3:57 pm, and 6/7/23 from 7:37 am to 10:13 pm. During an interview on 7/13/23 at 3:30 pm, the DON stated she completed the abuse allegation investigation summary dated 6/4/23 involving CNA #1 and Resident #1. The DON and the Administrator confirmed the alleged incident was not reported to the New Jersey Department of Health (NJDOH), and CNA #1 was not immediately suspended because it was determined within two hours of the allegation that there was no abuse. However, there was no documented evidence in the MRs, including witness statements and investigation summary, that a thorough investigation was completed within two hours after the physical abuse allegation. When the surveyor asked if the facility's policy on abuse to report to the NJDOH timely any abuse allegation and immediately remove and/or suspend team members accused of alleged abuse pending the investigation outcome was followed, the DON and Administrator refused to answer. During an interview on 7/14/23 at 1:00 pm, the RN/ES stated she notified the Director of Nursing (DON) immediately of the allegation made by Visitor #2, and the DON instructed her to collect written statements. During an interview on 7/14/23 at 3:00 pm, the Administrator stated she was unaware of the alleged incident until the next day. She stated the DON or Administrator is responsible for reporting and conducting a thorough investigation of an abuse allegation. During an interview on 7/20/23 at 9:45 am, the LPN/UM stated on 6/4/23 (time unknown), Visitor #1 alleged CNA #1 hit Resident #1, and she informed the RN/ES of the alleged abuse incident. During an interview on 7/24/23 at 11:06 am, CNA #1 stated on 6/4/23 (time unknown), while she was in the dining room trying to calm Resident #1, Visitor #1 alleged she hit Resident #1. The allegation was made in front of Visitor #2 and LPN/UM. CNA #1 was unable to recall if she informed the RN/ES of the alleged incident but stated that LPN/UM witnessed the allegation and spoke with the RN/ES. Review of facility policy updated on 5/2022, titled; Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property included but was not limited to; It is the policy of (Center) that each Resident will be free from abuse .include verbal, mental, sexual, or physical abuse .No abuse or harm will be tolerated . Reporting and Response Component: It is the policy of the [center] that abuse allegations .are reported per Federal and State Law. The center will ensure that all alleged violations involving abuse, neglect .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the center and the Department of Health to in accordance with State law through established procedures. NJAC 8:39-9.4(f)

Based on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 18 of 32 residents (Resident # 81, 98, 86, 11, 5, 135, 136, 133, 120, 28, 73, 84, 9, 112, 59, 95, 12, and 66) reviewed and was evidenced by the following: 1. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #81 which revealed that the physician did not sign and date the monthly orders for these months. 2. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #98 which revealed that the physician did not sign and date the monthly orders for these months. 3. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #86 which revealed that the physician did not sign and date the monthly orders for these months. 4. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #11 which revealed that the physician did not sign and date the monthly orders for these months. 5. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #5 which revealed that the physician did not sign and date the monthly orders for these months. On 12/09/22 at 11:35 AM the unit Registered Nurse (RN #1) stated the doctor should sign the orders every month. She stated the doctors are called to remind them, but it is difficult to get them to come in. 46049 6. The hybrid medical records of Resident #135 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September 2022, October 2022, and November 2022. 7. The hybrid medical records of Resident #136 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2022. 8. The hybrid medical records of Resident #133 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September 2022, October 2022, and November 2022. 9. The hybrid medical records of Resident #120 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September 2022, October 2022, and November 2022. 10. The hybrid medical records of Resident #28 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2022, and September 2022. October 2022 monthly physician's orders not found in chart. On 12/09/22 at 11:14 am, the surveyor interviewed Licensed Practical Nurse (LPN). about where the physicians sign the orders for residents. LPN stated the physicians may sign electronically or in the paper chart. LPN further stated the physicians signed monthly physician orders sheet in the paper chart. On 12/09/22 at 11:20 am, the surveyor interviewed the RN/Unit Manager (RN/UM) about where the physician sign orders. The RN/UM stated the physicians signed monthly physician orders sheet in the paper chart. The surveyor reviewed Resident #136 chart with the RN/UM and acknowledged physician orders were not found signed. The surveyor informed the RN/UM there were several residents with physician order sheets not signed and Resident #28's October 2022 monthly physician's orders were not found in the chart. The RN/UM stated she would look for Resident #28 October 2022 physician orders sheet. The RN/UM further stated physicians are expected to sign their orders at least monthly. 26420 11. Resident #73's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2022. 12. Resident #84's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2022. 13. Resident #9's hybrid medical record revealed the resident's physician had hand signed or electronically signed the monthly physician's orders for October, or November 2022. 14. Resident #112's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September, October, or November 2022. 15. Resident #59's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September, or October 2022. 16. Resident #95's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September, October, or November 2022. 17. Resident #12's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September, October, or November 2022. 18. Resident #66's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2022. On 12/9/22 at 11:02 AM, the surveyor asked the Unit Manager/Licensed Practical Nurse how the physicians signed their orders. She said very few signed electronic. Mostly all of them signed the paper Physician's Order Sheet (POS) that the facility printed out once a month. She explained that the 11 pm -7 am shift printed the orders out and put them in the charts for the physicians to sign monthly. On 12/9/22 at 1:55 PM, the survey team spoke with the Administrator and the Director of Nursing (DON) about the concern with the physician's not signing orders for months. The DON stated This is not an issue we were aware of. When I remind the physician's please check your orders they say yes they will. The DON confirmed that the nurses should make sure they have valid, signed orders. On 12/12/22 at 12:15 PM the surveyor reviewed the facility's policy and procedure titled Physician's Medication Orders/Consultant Physician's Under Policy Interpretation and Implementation Number 2. read All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such and order. The signing of orders shall be by signature. NJAC-8:39 23.2

Based on interview, and record review, it was determined that the facility failed to provide residents and/or their representatives with the facility's notice of bed hold policy. This was found with for 5 of 7 residents reviewed for hospitalization , Residents #98, 86, 76, 69, and 135. The deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 135 which revealed that the resident was transferred to the hospital on 10/26/22 with a high fever, high blood pressure and low blood oxygen level. On 12/02/22 at 11:55 AM, the surveyor interviewed the Administrator. The Administrator confirmed written notification of the bed hold policy is not provided to residents or their representatives when transferred. 19106 2. The surveyor reviewed Resident #98's medical record. The Census List indicated the resident was transferred out of the facility on 10/12/22. On 12/05/22 at 1:06 PM the surveyor interviewed the Social Worker (SW). The SW stated written notification of the facility bed hold policy was not provided to the resident or resident representative. On 12/05/22 at 12:51 PM the Administrator confirmed written notification of the bed hold policy is not provided to residents or their representatives when transferred. 3. The surveyor reviewed Resident #86's medical record. The Census List indicated the resident was transferred out of the facility on 11/2/22. On 12/05/22 at 1:06 PM the surveyor interviewed the SW who stated the written bed hold policy was not provided to the resident or their representative at the time of emergency transfer. On 12/05/22 at 12:51 PM the Administrator confirmed written notification of the bed hold policy is not provided to residents or their representatives when transferred. 4. The surveyor reviewed Resident #76's medical record. The Census List indicated the resident was transferred out of the facility on 11/27/22. On 12/05/22 at 1:06 PM the SW stated written notification of the bed hold policy is not provided to the resident or their representative upon transfer. On 12/05/22 at 12:51 PM the Administrator confirmed written notification of the bed hold policy is not provided upon transfer. 5. The surveyor reviewed Resident #69's medical record. The Census List indicated the resident was transferred out of the facility on 11/5/22. On 12/05/22 at 1:06 PM the SW stated written notification of the bed hold policy was not provided to the resident or their representative. On 12/05/22 at 12:51 PM the Administrator confirmed written notification of the bed hold policy is not provided to residents or their representatives when transferred. The surveyor reviewed the facility's Bed Hold and Return to Center Policy which revealed Residents and their representative will be provided with bed hold and return information at admission and upon a hospital transfer or therapeutic leave. NJAC 8:39-5.3

Based on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order and maintain accountability for the use of a bed alarm to ensure it's use for Resident # 120. This was found with 1 of 31 residents reviewed for professional standards of practice. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 46049 Based on observation, interview, and record review, it was determined that the facility failed to monitor and maintain accountability for the use of a bed alarm as an intervention to prevent falls for Resident # 120. This was found with 1 of 31 residents reviewed for professional standards of practice. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 12/09/22 at 8:59 am, the surveyor reviewed the hybrid [electronic and paper] medical record for Resident #120 which revealed the following: According to the Admission Record, the resident was admitted with diagnoses that included malignant neoplasm of the occipital lobe [cancerous tumor in visual processing area of the brain] and epilepsy [a neurological disorder of abnormal brain activity causing seizures]. The Significant Change Minimum Data Set (MDS), an assessment tool dated 11/07/22, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 6 out of 15. The resident was assessed as having severely impaired cognition. A review of progress notes indicated the resident had a fall incident on 10/31/22 and 11/6/22. An Interdisciplinary Team (IDT) Committee Meeting note, dated 11/7/22, indicated that an intervention of a bed alarm would be implemented. A review of care plans for Resident #120 included a care plan titled, The resident is at risk for fall. The care plan had an intervention that read, FALL RISK- BED ALARM for the resident, with an initiation date of 11/7/22. On 12/9/22 at 9:36 am, the surveyor observed the resident lying in bed resting. The resident was alert, verbally responsive to simple questions but was unable to state their name when asked. The resident was on a low air mattress and there was no bed alarm observed. On 12/9/22 at 9:39 am, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to care for Resident #120 about fall prevention and interventions in place. The LPN stated the staff monitored the resident more often, used wedge cushion for their wheelchair if applicable, and bed alarms may be used for residents with high risk for falls. The surveyor asked the LPN if Resident #120 had a bed alarm intervention. The LPN replied that she was not sure if the resident had a bed alarm in place. The surveyor accompanied the LPN to the resident's room, to check for a bed alarm. The LPN did not find a bed alarm for Resident #120. The LPN reviewed the EHR and stated there was no order for a bed alarm. The LPN further stated the resident had not had a fall since last occurrence and the resident had not tried to get out of bed on their own since their room change. On 12/9/22 at 9:49 am, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) asked about fall prevention interventions for Resident #120. The RN/UM reviewed the care plan for Resident #120 in the EHR and stated interventions included anticipating the residents needs and a bed alarm. The surveyor informed the RN/UM that the surveyor checked the resident's bedside with the LPN and there was no bed alarm found in use. The RN/UM stated it may have been misplaced, that the resident will remove and place somewhere else. The RN/UM stated she would get another bed alarm for the resident. The surveyor asked the RN/UM if it was expected for there to be an order for the bed alarm. The RN/UM stated that there was not usually an order for bed alarms and that it was found in the care plan. The surveyor asked the RN/UM how a nurse would know that a resident was to have a bed alarm in place. The RN/UM stated that nurses were updated on resident interventions and care plans. On 12/9/22 at 10:08 am, the surveyor interviewed the LPN about how nurses would know that a resident was to have a bed alarm. The LPN stated it was communicated in the 24 hours report. The LPN was asked if the nurses would document elsewhere that a resident was using a bed alarm. The LPN stated in the Treatment Administration Record (TAR), the nurses would sign for every shift that a bed alarm is in place. The LPN acknowledged an order would need to be entered to document in the TAR. 12/9/22 at 1:57 pm, the surveyor interviewed the Director of Nursing (DON) about the resident's intervention of a bed alarm not being in place and the accountability of resident using a bed alarm. The DON was informed of the interview with the LPN and RN/UM. The DON stated bed alarm interventions were documented in the care plans. The DON further stated it would not be found in the TAR and did not have to be written as an order. The DON stated the nurses were aware of residents who were fall risk or used a bed alarm from the 24-hour reports between nurses. The DON stated she would re-educate the LPN on the facility's procedure. The DON stated the resident at times removed the bed alarm and would provide nurses' progress notes. On 12/12/22 at 9:45 am, the DON provided a nurse progress note from 11/8/22, that documented the resident removed their bed alarm. The DON stated there were no other progress notes related to the resident's bed alarm use. The DON acknowledged the nurses were expected to check the resident's bed alarm every shift and they would work on a process for the documentation of bed alarm use. The surveyor reviewed the facility's policy and procedure with a revised date of 12/12/22, titled Falls-Clinical Protocol. Under Monitoring and Follow-Up, it read 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The surveyor also reviewed the facility's policy and procedure with a revised date of 12/12/22, titled Falls and Fall Risk, Managing. Under Monitoring Subsequent Falls and Fall Risk, it read The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. NJAC 8:39 - 27.1

Based on record review and interview it was determined that the facility did not provide written notification of an emergency transfer to the resident, resident representative, and/or the Office of the Long-Term Care Ombudsman (LTCO) for 5 of 7 residents reviewed for hospitalization , Residents #98, 86, 76, 69, 135. The findings are as follows: 1.The surveyor reviewed Resident #98's medical record. The Census List indicated the resident was transferred out of the facility on 10/12/22. On 12/05/22 at 1:06 PM the surveyor interviewed the Social Worker (SW) regarding written notification of emergency transfer. The SW provided documentation indicating that the LTCO was notified. However, neither the resident nor the responsible party was notified of the reason for emergency transfer for the 10/12/22 transfer. On 12/05/22 at 12:51 PM the surveyor interviewed the Administrator. The Administrator confirmed neither the resident nor the responsible party was notified in writing of the reason for transfer. 2.The surveyor reviewed Resident #86's medical record. The Census List indicated the resident was transferred out of the facility on 11/2/22. On 12/05/22 at 1:06 PM the surveyor interviewed the Social Worker (SW) regarding written notification of emergency transfer. The SW stated neither the resident, the responsible party nor the LTCO was notified of the reason for emergency transfer for the 11/2/22 transfer. On 12/05/22 at 12:51 PM the surveyor interviewed the Administrator. The Administrator confirmed neither the resident, the responsible party or the LTCO was notified in writing of the reason for transfer. 3.The surveyor reviewed Resident #76's medical record. The Census List indicated the resident was transferred out of the facility on 11/27/22. On 12/05/22 at 1:06 PM the surveyor interviewed the Social Worker (SW) regarding written notification of emergency transfer. The SW was unable to provide written documentation indicating that the resident or the responsible party was notified in writing of the reason for emergency transfer on 11/27/22 transfer. The SW provided written documentation of the LTCO notification. On 12/05/22 at 12:51 PM the surveyor interviewed the Administrator. The Administrator confirmed neither the resident or the responsible party was provided with written notification of the emergency transfer on 11/27/22. 4.The surveyor reviewed Resident #69's medical record. The Census List indicated the resident was transferred out of the facility on 11/5/22. On 12/05/22 at 1:06 PM the surveyor interviewed the Social Worker (SW) regarding written notification of emergency transfer. The SW was unable to provide written documentation indicating that the resident or the responsible party or the LTCO was notified in writing of the reason for emergency transfer on 11/5/22 transfer. On 12/05/22 at 12:51 PM the surveyor interviewed the Administrator. The Administrator confirmed the resident, the responsible party, and the LTCO weren't notified in writing of the reason for transfer. 34421 5. The surveyor reviewed the medical record of Resident # 135 which revealed that the resident was transferred to the hospital on 10/26/22 with a high fever, high blood pressure and low blood oxygen level. On 12/02/22 at 11:55 AM, the surveyor interviewed the Administrator. The Administrator confirmed neither the resident, the responsible party or the LTCO was notified in writing of the reason for transfer. On 12/2/22 the surveyor was provided with the 11/28/17 facility policy titled Transfer and Discharge from the Center. Section C included the following verbiage. Before the center will transfer or discharge a resident, the center will provide a written notice to the resident and resident representative in a manner and language in which is understood [sic]. The center will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and identified state agencies per requirements. NJAC 8:39-5.3; 5.4

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident returning from the dialysis center for any complications. The deficient practice was observed for 1 of 3 residents (Resident # 141), reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 11/30/22 at 12:11 pm, the surveyor observed Resident #141 lying in bed and the resident had a tracheostomy collar. The tracheostomy collar delivered the oxygen to the resident via the tracheostomy (a surgical opening in the windpipe). The resident had unclear speech related to their tracheostomy, but the resident was able to communicate with simple gestures. On 11/30/22 at 1:26 pm, the surveyor reviewed the electronic health record (EHR) of Resident #141 which revealed: According to the Admission Record, Resident #141 was admitted with diagnoses that included Acute Kidney Failure, Unspecified. A physician's order, dated 11/10/22, indicated the resident received hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) every Tuesday, Thursday, and Saturday. On 12/5/22 at 11:26 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who stated the resident goes to dialysis on Tuesdays, Thursdays, and Saturdays via stretcher and with supplementary oxygen. The LPN stated Resident #141 had a right chest permacath (a hemodialysis access site) which was monitored for signs and symptoms of bleeding, drainage, and infection. The LPN showed the surveyor the dialysis communication report form, titled Dialysis Center Communication Report, that was found in the resident's chart. The LPN explained to the surveyor the first section was to be filled out by the facility nurse prior to the resident going to their dialysis session. The first section would include up to date information on the resident's status, including access site assessment and vital signs. The second section was to be filled out by the dialysis center nurse. It included for the dialysis nurse to document the resident's pre and post dialysis weights and vital signs, medications given to the resident and any pertinent information of the resident's condition. The last section of the form was to be filled out by the facility nurse upon the resident's return from the dialysis center. The LPN stated that when the resident returned from dialysis the vital signs, dialysis access site and the resident's condition were assessed and documented on the Dialysis Center Communication Report. The surveyor asked the LPN if there was anywhere else a nurse would document other than the dialysis communication report. The LPN said that the nurses may sometimes write a progress note in the EHR. On 12/5/22 at 11:40 am, The surveyor interviewed the RN Unit Manager (RN/UM) about the nurses' responsibilities for the care of dialysis residents and documentation. The RN/UM stated that the nurses were expected to fill out the appropriate sections on the Dialysis Center Communication Report form and it should be completed upon the resident's return from dialysis. The surveyor reviewed the dialysis communication forms located in the resident's chart with the RN/UM. The RN/UM acknowledged the post dialysis section on several of the forms were not completed. The RN/UM stated she would review if progress notes were written by the nurses for those days. The surveyor reviewed the Dialysis Center Communication Report forms in the resident's chart for November and December 2022. For 10 of 15 dialysis days, the post dialysis section on the Dialysis Center Communication Report were not completed and there were no nurses' progress note documented for those days upon the resident's return to facility from dialysis. On 12/6/22 at 11:00 am, the surveyor interviewed the Director of Nursing (DON) about the expectations and policy for nurses' documentation for residents receiving dialysis. The DON stated that the nurses were to complete the dialysis communication report form and if not able to, a progress note should be written in the EHR. The DON stated she followed up with the nurses who did not complete the post dialysis section of the dialysis communication form. The DON stated the nurses did assess the resident upon their return from dialysis but did not fill out the dialysis communication form. The DON further stated the nurses documented a late progress note entry after she spoke with them. On 12/7/22 at 1:41 pm, the surveyor informed the DON, Licensed Nursing Home Administrator (LNHA), and Assistant LNHA, about the concern of assessments not being documented for Resident #141 upon their return from dialysis. The DON acknowledged the post assessment on the Dialysis Communication Report should have been completed upon the resident's return to the facility. The DON further stated if it could be documented on the form, a progress note should have been written by the nurse. On 12/8/22 at 10:30 am, the surveyor reviewed the facility's policy and procedure with a revised date of April 2022, titled End-Stage Renal Disease, Care of Resident with, provided by the. The policy did not address documentation by nurses for dialysis residents. NJAC 8:39 - 27.1(a)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans and sheets pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/30/22 at 10:02 AM, in the presence of the Food Service Director the surveyor observed the following: 1. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - One #10 sized cans of grape jelly with 1/4-inch sized dent on the upper lip, - One #10 sized can of blueberry pie filling with 1-inch sized dent on the body of the cans, -One #10 sized can of mandarin oranges with a 1/2-inch sized dent on the upper lip of the can. 2. In the food preparation area, on metal dishware drying shelving unit, the surveyor observed seven 1/2 sized steam table pans which were stacked with water between them, seven full sized steam table which were stacked with water between them, nine sheet pans which were greasy to the touch and stacked with water between them. The surveyor interviewed the Food Service Worker (FSW) who was responsible for washing the dishware and the FSW stated that he stacked the dishware because there was no space for dishware to be air dried. 3. In the food preparation area, the surveyor observed that the can opener blade was soiled with black and white colored debris and it had paper stuck to the blade as well. On 11/30/22 at 11:35 AM, the surveyor discussed the above concerns with the Administrator and the Assistant Administrator. The surveyor reviewed the facility's Dented Can policy which revealed all cans must be inspected for dented imperfections and placed into designated dented can bin or discarded and the Sanitization policy and procedure which revealed all utensils, counter, shelves and equipment shall be kept clean and all equipment, food contact surfaces and utensils shall be washed to removed or completely loosen soil by using manual or mechanical means necessary. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to accommodate the needs of a resident (dependent on staff) to utilize their call bell system for assistance. This deficient practice was identified for 1 of 25 residents reviewed; Resident #49, and was evidenced by the following: On 10/5/20 at 10:40 AM, the surveyor observed Resident #49 in bed with their head and neck leaning to the left side. The alert resident greeted the surveyor, stated that they had [MEDICAL CONDITION], and had no neck muscle control. Resident #49 stated that they wanted to get out of bed, but the Certified Nursing Assistant (CNA) had not yet come to assist. The surveyor asked the resident if they were able to use the call bell to obtain assistance. The resident replied that they were unable to reach it and gestured toward the call system. The surveyor observed that the call bell was inaccessible to Resident #49 as it was wedged behind the bed that was pushed against the wall. The surveyor reviewed the resident's Admission Record that indicated Resident #49 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the 4/26/20 Part C of the Quarterly Minimum Data Set (MDS), an assessment tool, Brief interview for Mental Status (BIMS) documented a score of 9 out of 15, indicating that the resident had moderate cognitive impairment. The 4/26/20 MDS also assessed Resident #49 as requiring extensive assistance from staff for transfers and that the resident was occasionally incontinent of bowel and bladder. On 10/5/20 at 11:06 AM, the surveyor observed the CNA enter Resident #49's room. The CNA assisted the resident out of bed to a standing position and stated, you're very wet. The surveyor asked the CNA if she had provided incontinence care for the resident that morning. The CNA replied, no, the resident will usually call when they need to be changed. The surveyor asked how the resident would typically call for assistance. CNA #1 replied that the resident uses the call bell. The resident then stated, I can't reach the call bell. The CNA did not acknowledge or respond to the resident's statement and assisted Resident #49 into the bathroom and provided morning care. On 10/5/20 at 12:33 PM, the surveyor and the CNA entered Resident #49's room to find that the call bell was still wedged behind Resident #49's bed frame and would be inaccessible to the resident. The CNA stated she did not check to ensure that Resident #49's call bell was within their reach at any time that morning, and further stated, I just assumed she could reach it; I should have checked. On 10/9/20 at 2:15 PM, the surveyor discussed the above observations and concerns with the Administrator, Director of Nursing, and Regional Nurse. No further documentation was provided. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to respect the resident's right to mail delivery privacy. This deficient practice was identified for 1 of 25 residents reviewed; Resident #58, and was evidenced by the following. On 10/5/20 at 11:47 AM, the surveyor observed Resident #58 lying in bed. Resident #58 greeted the surveyor, and after obtaining the resident's permission, agreed to be interviewed. At that time, Resident #58 told the surveyor that the facility Social Worker (SW) delivered a letter that was opened on 10/2/20. The resident explained that it was a letter from a law firm suing for monies owed to the facility. Resident #58 further stated that it was upsetting that someone would have the nerve to open mail addressed to the resident. The resident showed the surveyor the letter that was clearly addressed to Resident #58. The surveyor reviewed the Admission Record that indicated Resident #58 was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed the Annual Minimum Data Set (MDS), an assessment tool that reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #58 was cognitively intact. On 10/6/20 at 1:15 PM, the surveyor interviewed Resident #58, who stated that they had spoken to the Business Office Manager (BOM) yesterday in the late afternoon. The BOM informed the resident that she had opened the letter by mistake. The resident mentioned that the letter came inside another large envelope addressed to him/her. The resident showed the envelope to the BOM, which was addressed to the resident, stamped and postmarked September 30, 2020. The resident stated that the BOM then apologized for opening the resident's mail. On 10/7/20 at 11:10 AM, the surveyor asked the administrator to meet with the BOM. The administrator replied that the BOM would be in the following day and that she was aware of the issue. On 10/8/20 at 11:01 AM, the surveyor met with the BOM. During the interview, the BOM stated that the resident's open letter came inside another envelope and that she thought it was addressed to her and mistakenly opened it. The BOM further noted that in the late afternoon on 10/2/20, she was running late and asked the SW to hand-deliver the opened piece of mail to Resident #58, without any explanation as to why the letter was opened. The BOM acknowledged that on 10/2/20, she should have delivered the letter to Resident #58 with an explanation as to why the letter was mistakenly opened. On 10/8/20 at 11:35 AM, the surveyor met with the SW, who explained that the activities staff generally deliver mail to residents. On Friday, 10/2/20, the BOM asked her to do her a favor and hand-deliver the envelope to Resident #58. The SW further stated that the BOM did not tell her that she had mistakenly opened the resident's letter nor informed her to speak to Resident #58 about it. On 10/8/20 at 11:56 AM, the surveyor met with the Administrator, who stated that she was not certain how she first became aware of the open mail being delivered, and noted that she thought the resident called her Monday, 10/5/20. The Administrator further stated that the resident informed her that she didn't understand what the letter was about in the phone call. On 10/8/20 at 12:30 PM, Resident #58 informed the surveyor that the phone call to the Administrator was made on Monday 10/5/20 in the morning before the resident had informed the surveyor about the opened letter. Resident #58 further stated that he/she told the administrator that receiving the opened private letter on Friday 10/2/20, made the resident very upset. The resident said that the Administrator suggested speaking to the SW about it. On 10/9/20 at 2:15 PM, the surveyor discussed the above observations and concerns with the Administrator, Director of Nursing (DON), and Regional Nurse. On 10/15/20 at 11:46 AM, the surveyor and Team Coordinator met with the Administrator and DON at the facility's request. The Administrator stated that she now remembered that the resident had called her Monday morning before 9:30 AM. She noted that she did not recall the resident mentioning the mail being opened. The Administrator stated that she asked both the SW and BOM to go to Resident #58's room to discuss the nature of the letter. The surveyor asked the Administrator why she had sent both the BOM and SW to Resident #58's room if she wasn't aware of the concern. The administrator did not answer that question. The administrator then stated, maybe the (BOM) should have waited until Monday and delivered the opened letter herself. The surveyor requested the facility Policy and Procedure for mail delivery to residents. The facility provided no further information. N.J.A.C. 8:39-4.1 (a) 16, 19

Based on observation, interview, and facility documentation review, it was determined that the facility failed to ensure the resident's right to be treated with dignity and respect. This deficient practice was identified for 2 of 25 residents observed; Resident #49 and #58. This deficient practice was evidenced by the following: 1. On 10/5/20 at 10:40 AM, the surveyor, observed Resident #49 in bed with their head and neck leaning to the left side. The alert resident greeted the surveyor, speaking in a low voice with slurred speech, and informed the surveyor that they had [MEDICAL CONDITION] and had no neck muscle control. The surveyor reviewed the Admission Record indicating that Resident # 49 was admitted to the facility with diagnoses, including [MEDICAL CONDITION], Muscle Weakness, Depression, and Dysphagia (difficulty swallowing). A review of the Quarterly Minimum Data Set (MDS), an assessment tool, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which reflected that the resident had moderately impaired cognition. On 10/5/20 at 11:05 AM, the surveyor observed Certified Nursing Assistant (CNA) #1 enter Resident #49's room without knocking or obtaining permission before entering the room. When the surveyor questioned CNA#1, she responded that she was delivering ice water and was not the resident's assigned CNA. On that same day at 11:06 AM, CNA #2 entered Resident #49's room without knocking or obtaining permission before entering the room. When the surveyor questioned CNA #2, she responded that she was assigned to Resident 49's care. On that same day at 12:33 PM, during an interview, the surveyor asked CNA #2 if her routine practice was to enter resident rooms without first knocking. CNA #2 stated that she usually knocks on the door and should have knocked on Resident #49's door before entering. On 10/9/20 at 11:53 AM, the surveyor interviewed CNA #1, who acknowledged that she should not enter resident rooms without knocking first, and that she should have knocked before she entered Resident #49's room. On 10/9/20 at 9:15 AM, the surveyor observed Resident # 49's door open. The surveyor knocked on the door, and CNA #3 told the surveyor to come in. The surveyor observed Resident #49 seated on the toilet in the bathroom with the door wide open. At that time, the surveyor asked CNA #3 why she had not closed Resident #49's bathroom door to ensure privacy. CNA #3 stated that she provided morning hygiene care for Resident #49 and left the bathroom to obtain powder. CNA #3 further acknowledged that she should have provided privacy by closing both the bathroom door and the resident's room door. 2. On 10/05/20 at 11:47 AM, the surveyor observed Resident #58 lying in bed. Resident #58 greeted the surveyor and agreed to an interview. After obtaining the resident's permission, the surveyor closed the door and began the interview. At that time, CNA#2 opened Resident #58's door without first knocking and said, wrong room. CNA#2 then left the room, closing the door behind her. Resident #58 stated that sometimes staff enter the room without knocking and further said, it's rude. The surveyor reviewed the Admission Record indicating that Resident #58 was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed the Annual Minimum Data Set (MDS), an assessment tool, that reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #58 was cognitively intact, alert, and oriented. On 10/5/20 at 12:33 PM, during an interview, the surveyor asked CNA #2 if her routine practice was to enter resident rooms without first knocking. CNA#2 stated that she usually knocked before entering and acknowledged that she should have knocked on Resident #58's door before entering. On 10/14/20 at 1:31 PM, the surveyor discussed the above observations and concerns with the Administrator, Director of Nursing (DON), and Regional Nurse. No further documentation was provided. On 10/15/20 at 11:46 AM, the surveyor and Team Coordinator spoke with the Administrator and DON via a phone conference call at the facility's request. The DON stated that residents' (room) doors should be closed when hygiene and personal care were being rendered. N.J.A.C. 27.1 (a)

C# NJ & NJ Based on a review of facility documentation and staff interviews, it was determined that the facilty failed to maintain a safe environment for 1 out of 3 sampled residents (Resident #3.) Resident #3 had some confusion, a history of falls and a fractured right humerus. A Certified Nurses Aide (CNA) while assisting a resident with toileting, left that resident seated on the toilet with a family member present, but no other staff members. Resident #3 fell off of the toilet, sustained a fractured left humerus, a laceration to the head which required suturing and was admitted to the hospital. This deficient practice was evidenced by: Observations, interviews and record review occurred on 4/02/14 unless otherwise noted. 1. According to a "Face Sheet," Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]." A document, "history and physical examination [REDACTED]. According to the H&P, the resident's "Chief Complaint" was status [REDACTED]. The H&P further stated that Resident #3 was awake and confused with some expressive difficulty and was unsteady. According to the H&P, the resident's right arm was bruised and in a sling. A "Nursing Admission Assessment (Section A)" dated 3/03/14, stated that Resident #3 was alert and confused. The document further stated that the resident was "dependent" in the following areas of "Physical Functioning:" bed mobility, transfer, walking/locomotion, dressing, eating, toileting, personal/hygiene and bathing. The fall assessment, in "section C and D" stated that within the last 90 days, Resident #3 had 1-2 falls and had a change in cognitive status. The document further stated that Resident #3 required assistance with elimination and was not able to attempt a test for balance without physical help. The resident's "Total Score" for the fall assessment was 24. According to the same document, "A Resident who scores a 10 or higher is at risk. Consider Environmental Risk factors in resident's interventions." A "Care Plan" dated 3/04/14 contained a "Problem/Need" of Resident "is at risk for falls/injury related to: Impaired balance and gait, impaired cognition, poor safety awareness." The "Goal and Target Date" stated: "Will decrease risk for falls/injury within the next 90 days." "Approaches" to manage the problem/need included but was not limited to: "Falling star to alert staff that resident is at risk for falls - place star above the bed, resident name on the door, wheelchair or walker." A "Reportable Event Record/Report" (AAS-45) dated 3/17/14 and faxed to the Department of Health contained an "Investigational Summary" also dated 3/17/14, which was reviewed by the surveyor. The "Description of Event" section stated that on 3/15/14 at 11:45 AM, a Certified Nurses Aide (CNA) was asked by a family member to assist the resident to the bathroom. The CNA assisted Resident #3 to the bathroom, placed the resident on the toilet and noted her brief to be wet. The resident's family member was in the resident's room. The bathroom door was open because the resident's family member was talking with the CNA. The CNA informed the daughter that she needed to get a brief for the resident. The family member "acknowledged that she would be there with her mom in the CNA's absence." The CNA left to get the brief. Staff members then heard the resident's family member "yelling and screaming for assistance." The family member stated that the resident "stood up and fell face forward." The resident sustained [REDACTED]. Resident #3 was sent to the Emergency Department (ED), diagnosed with [REDACTED]. The "Conclusion" section of the summary stated that staff members observed the resident's daughter "standing over her mother" and "pulling on her mother's arm in an attempt to get her up." The facility was unable to conclude if the resident sustained [REDACTED]. The surveyor conducted a post survey telephone interview on 4/04/14 at 2:00 p.m. with the CNA caring for Resident #3 when she fell . The CNA stated that she assisted the resident, who was sitting in a wheelchair, to the toilet without incident. The CNA realized that she did not have a clean brief with her, so the CNA told the resident's daughter that she was going to go and get a brief. The CNA asked the resident's family member if she was going to remain with the resident. The family member stated that they would be with the resident. The CNA stated that she was out of the room for approximately 2 minutes. The CNA further stated that she heard screaming, returned to the resident's room and observed the resident's daughter standing over the resident holding onto her arm. The CNA stated that she did not leave the resident alone, but left her with her daughter who was only to ensure that the resident did not stand up, not to assist the resident. The surveyor reviewed the ED record dated 3/15/14. According to the ED record, Resident #3 arrived there at 12:54 PM. The physician's note stated that the resident was transferred to the ED for evaluation after "slipping and falling off of a toilet." "Patient is in rehabilitation for a recent right humerus fracture." "The patient complains of non-specific diffuse pain..." The physician's "Physical Examination" revealed that the resident was anxious, awake and in mild painful distress. Documentation by the MD further stated that the resident had a 2.5 cm (centimeter) stellate laceration to the right forehead. There was no deformity to the left shoulder but there was "mild tenderness." The resident's right shoulder was in a shoulder immobilizer. An X-Ray of both of the resident's shoulders were completed with the following results: "New proximal left humerus fracture, stable old right proximal humerus fracture..." The resident's left shoulder was placed in a shoulder immobilizer. The ED physician further documented that after the area was anesthetized and cleansed, the resident received six sutures to the head laceration. The resident was admitted to the hospital in guarded condition with the [DIAGNOSES REDACTED]. The surveyor conducted an interview with the Director of Nursing (DON) at 1:05 p.m. According to the DON, the CNA was suspended and re-educated for leaving the resident on the toilet with only the family member present. The DON further stated that the CNA should only leave the resident with a "trained person." The surveyor conducted an interview with the facility's Administrator (ADM) at 1:35 p.m. The ADM stated that it was "not o.k. and not our policy" to leave the resident with a family member in this situation. The CNA was re-educated by the facility regarding resident safety issues. A policy, "Falls and Fall Risk, Managing" dated 7/28/11 contained a "Policy Statement" as follows: "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to minimize the risk of resident from falling and try to minimize complications from falling." NJAC 8:39-27.1(a)

C# NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to develop a nursing care plan to address the specific care needs for 1 of 6 sampled residents (Resident #1) who was on antibiotic therapy (ABT) from admission (3/19/12), and had reported episodes of diarrhea/LBM on separate occasions from 3/23/12 up to her discharge from the facility for hospital evaluation on 4/3/12 due to critical laboratory results, and positive stool for [MEDICAL CONDITIONS]. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on 11/7 and 11/8/12 revealed the following: Cross Reference to F-309/G 1. See Sample #1. NJAC 8:39- 27.1(b) 8:39- 11.1 8: 39-11.2 (e) 1, 2

C# NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to notify the physician (MD) in a timely manner when 1 of 6 sampled residents (Resident #1) had a change in medical condition manifested by refusing to participate with therapies due to complaints of diarrhea/LBM (Loose Bowel Movement), stomach upset and/or feeling sick on separate occasions (3/23/12 and 3/30/12) causing a delay in medical interventions. On 4/1/12, 7 days after the resident's initial complaint of LBM, the physician was notified and ordered to "collect stool X (times) 3 for [MEDICAL CONDITIONS]" with subsequent orders on 4/2/12 for Intravenous Hydration (IV), antibiotics, and laboratory (lab) work. On 4/3/12, Resident #1 was ordered to be sent to the hospital for evaluation due to positive [MEDICAL CONDITION], dehydration, and critical lab results. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on 11/7/12 and 11/8/12 revealed the following: Cross Reference to F-309/G 1. See Sample #1. NACL 8:39-27.1 (a) 8:39-27.1 (b) 8:39-13.1 (d)

C# NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to ensure that necessary care and services including an adequate and/or timely assessment, treatment, monitoring, and/or care planning were provided for 1 of 6 sampled residents (Resident #1) who reported to facility staff and/or visiting family members as having episodes of loose bowel movements (LBM/diarrhea), stomach upset and/or feeling sick on separate occasions ([DATE], [DATE], [DATE], and [DATE]). In addition, the facility failed to follow their own facility policy and procedure on Change in Resident's Condition or Status, Charting and Documentation, [MEDICAL CONDITION], and Comprehensive Care Plans for the same resident. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on [DATE] and [DATE] revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated [DATE], reflected Resident #1 with moderately impaired cognitive ability with a Brief Interview for Mental Status (BIMS) score of "12". She was also assessed as continent of bowel and bladder, non-ambulatory, needed limited assistance with personal hygiene, and required extensive assistance with transfers, dressing, and bathing. An Interdisciplinary Care Plan (IDCP) from admitted d [DATE], and was last evaluated on [DATE], reflected resident #1 with self care deficit requiring assistance with her activities of daily living (ADL's) which include toileting. Interventions included but were not limited to offer assistance to toilet, assist with ADL needs, and provide ,[DATE] person transfer assistance. A physician's orders [REDACTED].#1 was on antibiotic therapy [MEDICATION NAME] 500 mg, twice a day x 10 days for [MEDICAL CONDITION]. A care plan conference note dated [DATE] for Resident #1, documented that "On [DATE], she complained of diarrhea and IV fluids for hydration was started on [DATE]." There was no indication on the IDCP that Resident #1 was careplanned for diarrhea or LBM from her ,[DATE] admission to her discharge on [DATE]. There was also no indication on the IDCP that Resident #1 was on antibiotic therapy (ABT) from admission. A review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A C.N.A. (Certified Nursing Assistant) care log (CCL), used by the certified nursing assistants (CNA) to log their assigned resident's care including bowel movements every shift, included a legend for the resident's bowel monitoring as; 0 = none, L = loose, and F = formed. A review of Resident #1's CCL for ,[DATE] to ,[DATE], reflected the following documentation on dates and shifts specified: >Night Shift: [DATE]- LBM [DATE]- "L" >Day Shift: [DATE]- "L" >Evening Shift:[DATE] - "Lg" [DATE]- "1 Lg" [DATE]- "2L" [DATE]- "L" [DATE]- "2L" The daily/weekly PT (Physical Therapy) progress summary dated ,[DATE] to ,[DATE], documented the following notes on dates indicated: [DATE]- "No skilled PT provided today (secondary) pt. c/o feeling sick." [DATE]- "Attempted to see pt several times, pt decline pt c/o stomach upset. Offered bedside PT however pt refused. Daughter was present bedside. Family meeting held, discussed functional states of pt, will do week/week depending on pt's progress & motivation." [DATE]- "Pt. was upset (with) diarrhea." [DATE]- "Pt. decline to go to gym for skilled PT; however agreed to have bedside PT." "pt c/o diarrhea and stomach upset, nursing notified." The daily/weekly OT (Occupational Therapy) progress summary dated ,[DATE] to ,[DATE], documented the following notes on dates indicated: [DATE]- "Pt states, "I had diarrhea last night and this morning. I can't do anything today. PT contacted the nurse also pt continued to state that she is not up to participation today." [DATE] - Documented that no OT provided. [DATE]- "Pt seen only 15 mins pt refused to do..." Wanted to go back to bed and was verbally abusive to the OT. "Assisted pt into bed and pt was then satisfied and happy." A review of the interdisciplinary progress notes (IPN) ([DATE] to [DATE]) including the 7-day Nursing Summary and Evaluation (NSAL) ([DATE] to [DATE]) from Resident #1's admission to her discharge from the facility revealed no documentation that the resident complained, reported and/or had episodes of LBM/diarrhea and/or that the physician was notified due to LBM/diarrhea until [DATE] at 3:00 PM when it was documented on the IPN that "Resident had LBM x 2 large amount..." and "Call placed to (physician) MD- awaiting CB." It was further documented that at 4:30 PM, that the MD called back with new orders to start intravenous fluids (IVF), and on ,[DATE] shift, the resident was received alert, verbally responsive, but weak. "Feels very weak to stand." On [DATE], at 8:30 AM, it was further documented on the IPN that the resident had poor oral intake, and at 1:00 PM had critical laboratory results of urea nitrogen at 68.0 (normal ,[DATE]), creatinine at 3.30 (normal 0XXX,[DATE].5), and WBC at 32.8 (normal 3.5 to 11.0), including positive stool for [MEDICAL CONDITION]., and the physician was notified. The MD returned call at 2:30 PM with order to send the resident out for evaluation due to "critical lab. results and (positive) [MEDICAL CONDITION]." On ,[DATE] shift, on the same day, Resident #1 was documented as admitted for "A fib, Septic Shock & [MEDICAL CONDITION]." A review of the 24 hour report sheets dated [DATE], [DATE], [DATE], [DATE], and [DATE] when Resident #1 was either not participating with therapy and/or complained of LBM/diarrhea or feeling sick revealed the following on the shifts indicated: >[DATE]: ,[DATE] shift, had no documentation of Resident #1 not feeling well or complained of (c/o) LBM/ diarrhea. ,[DATE] shift; documented "(check) LBM" ,[DATE] shift, "no LBM" There was no documentation on the 24 hour report sheet of why the ,[DATE] nurse on [DATE] wants the staff to check for LBM. There was also no documented reason on the [DATE] IPN or NSAL why Resident #1 needed to be monitored for LBM and/or that she was monitored for LBM on all shifts. In addition, there was no documentation that the nurses received a report from therapy on [DATE] about the resident's condition including her refusal to participate with therapy due to diarrhea and how they addressed it. >[DATE] ,[DATE] shift, "c/o LBM as per daughter...." There was no evidence that Resident #1 was assessed and/or interviewed by staff on [DATE] to address her c/o LBM that was relayed by her family. >[DATE] ,[DATE] shift, "to monitor for LBM" ,[DATE] shift, "no noted LBM" ,[DATE] Shift, had no documentation of LBM being monitored. The 24 hour report sheet did not reflect the 2 LBM's that was documented by the ,[DATE] shift CNA on the [DATE] CCL, and no documentation about the LBM's on the IPN or NSAL as well. >[DATE] ,[DATE] shift, documented "(no) complaints" ,[DATE] shift, no LBM this shift, and no c/o pain noted. There was no documentation about how or if nursing assessed the resident on [DATE] who was refusing her therapy due to stomach upset as documented by PT while the family was present. In addition, there was no indication on the [DATE] IPN when the facility had a meeting with the family about the the resident's condition and/or concerns, and how they would address her issues with LBM or therapy refusals. >[DATE] ,[DATE] shift, "c/o LBM x 2, awaiting call back from (MD)" New order to collect stool for [MEDICAL CONDITION]. ,[DATE] shift, stool [MEDICAL CONDITION] x 1 in the fridge, please follow up. There was no documentation on the [DATE] IPN of an assessment when the resident had LBM, and no documentation of when the MD was notified. During an interview by the surveyor, on [DATE] at 11:40 AM, with the charge nurse/RN from Resident #1's unit who has been working in the facility for 9 years, revealed that she cannot remember about the resident, but looking through her medical record she described Resident #1 as alert, oriented, and could verbalize her needs. When asked by the surveyor about what check LBM meant on the 24 hour report from [DATE], the RN stated that it wasn't her writing, and there was another nurse who worked on the unit aside from her. The RN further stated that if check LBM was documented, it meant that someone reported of the resident having LBM. When asked by the surveyor about their facility practice when a report of diarrhea/LBM is received by nurses, the RN stated that they assess, and speak with the resident, notify the MD, and inform other staff to report their observations. In addition, there should be documentation on the IPN about LBM being reported, the assessment and interview with the resident, physician notification, and interventions implemented. The RN further stated that the therapy department always notifies nursing when there's a change in their resident's condition, and nursing would usually document on the IPN and follow up until the concerns are resolved including concerns about having LBM. An IDCP can also be initiated by any nurse once diarrhea/LBM is reported. When asked by the surveyor if the documentation on the 24 hour report from [DATE] on ,[DATE] shift was sufficient assessment for someone with reported LBM, the RN stated that there should have been documentation about the resident's assessment and her LBM on the IPN every shift, including the MD notification from [DATE]. During an interview by the surveyor, on [DATE] at 1:55 PM, with the Licensed Practical Nurse (LPN) who worked in the facility for three years, and was the ,[DATE] shift nurse on Resident #1's unit, verified that she wrote to check LBM on the 24 hour report sheet dated [DATE], but could not recall why. She further stated that if it was reported to her that Resident #1 had diarrhea she would go to the resident, perform a thorough assessment, interview the resident if alert and oriented, and would also ask the CNA's for information, and everything would be documented on the IPN. She further stated that if she received a report that the resident had LBM/diarrhea, she would document it on the IPN or the comment section of the NSAL. Further interview with the LPN, revealed that she was also the nurse who wrote on the [DATE] 24 hour report that Resident #1 had LBM x 2, and waiting for call back from the MD. According to the LPN she should have written "everything" on the IPN, and "maybe I missed it". The LPN further stated that assessment related to the LBM as well as physician notification, and interventions should have been documented on the IPN. A post survey interview by the surveyor, on [DATE] at 11:00 AM, with the ,[DATE] shift CNA who documented "2L" on the [DATE] CCL for Resident #1 and was also documenting Lg at different times, revealed that she could not recall about Resident #1. She further stated that "L" meant loose, and Lg meant large. When asked by the surveyor if the Lg she documented meant large loose or large formed stools, the CNA stated, "I don't remember", that was a long time ago. An interview by the surveyor, on [DATE] at 11:50 AM, with the resident's MD, revealed that he could not recall much about Resident #1. According to the MD, if he was notified that the resident had diarrhea "I would have ordered to collect the stool" to determine if it was bacterial or [MEDICAL CONDITION]. He further stated that once he gets a report of someone having diarrhea, he would not immediately medicate, but "would collect stool". The MD also stated, "that sometimes residents would say they have diarrhea, and would not have any during stool collection". A review of the hospital's patient assessment record dated [DATE] documented Resident #1 with chief complaint for dehydration, "abnormal labs", persistent diarrhea, and positive for stool [MEDICAL CONDITION]. A physician's note dated [DATE], reflected that Resident #1 was seen immediately on arrival because of high probability of imminent or life threatening deterioration in patient's condition. The emergency department medical record dated [DATE], documented that Resident #1 was admitted to ICU (Intensive Care Unit) with [DIAGNOSES REDACTED]. A Discharge Summary from the hospital dated [DATE], documented that Resident #1 was admitted to the facility due to [MEDICAL CONDITION] and [MEDICAL CONDITION], and was admitted with a positive [MEDICAL CONDITION] of stool from the nursing facility where she was started on ABT (Antibiotic), however her condition deteriorated, unable to take her medications, became lethargic, severely dehydrated, hypotensive, and was transferred to the hospital where she was found to have a blood pressure of ,[DATE], white count of 31,000 (normal 4.5- 11.0), and creatinine of 3.3 (normal 0.60- 1.30) for which she was admitted to the ICU. It was further documented that during her hospital stay, her clinical status declined, required an NGT (Nasogastric Tube) from admission, ABT therapy, and was later made a DNR (Do Not Resuscitate) . On [DATE] she expired with [DIAGNOSES REDACTED]. The Certificate of Death for Resident #1 dated [DATE], reflected that the resident expired on [DATE] at 3:24 AM with [MEDICAL CONDITION] due to "[MEDICAL CONDITIONS]." A review of the facility's undated policy and procedure on "Change in Resident's Condition or Status", documented that our facility policy shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the the resident's medical/mental condition or status. The Nurse Supervisor/ Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status. The facility's undated policy and procedure on "Charting and Documentation", documented that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record. Entries may only be recorded in the resident's clinical record by licensed personnel in accordance with the state law and facility policy. All incidents, accidents, or changes in the resident's condition must be recorded. The facility's undated policy on "[MEDICAL CONDITION]", documented that preventative measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents. Suspected infections with [MEDICAL CONDITION] will be verified by culture or by evidence of positive cytotoxin assay. Residents considered at high risk of developing symptoms associated with [MEDICAL CONDITION] include those with advancing age, and antibiotic therapy. When residents with these risks have diarrhea (i.e., three loose stools in 24 hour period), [MEDICAL CONDITION] should be considered a possible cause. A review of the facility's undated policy and procedure on "Comprehensive Care Plans", documented that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. There was no evidence that the facility policies were consistently followed by staff. NJAC 8:,[DATE].1 (a) 8:39- 27.1 (b)

C# NJ UNCORRECTED DEFICIENCY A plan of correction submitted by the facility failed to correct the problem. Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to consistently follow their own policy and procedure on monitoring/tracking and documentation of the Certified Nursing Assistant (CNA) Care Log. In addition there was a failure of nursing to supervise the CNA's documentation of Bowel Movement (BM) function which could result in a change in condition for 2 of 3 sampled residents (Resident #2 and Resident #3) reviewed. This deficient practice was cited during the complaint survey of 11/8/12. This deficient practice is evidenced by the following: A review of Resident #2 and Resident #3's medical records by the surveyor during the revisit on 12/28/12 revealed the following. 1. According to the face sheet, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's (MD) history and physical dated 12/4/12, reflected Resident #2 as admitted due to [MEDICAL CONDITION], and status [REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 12/10/12, reflected Resident #2 had moderately impaired cognitive ability, was non-ambulatory, and required extensive assistance with transfers, dressing, and hygiene. She was also assessed with [REDACTED]. Resident #2's Interdisciplinary Care Plan (IDCP) for nutrition dated 12/3/12, and updated on 12/14/12, reflected the resident as S/P colon resection, and "having frequent LBMs (Loose Bowel Movements)". Another IDCP, dated 12/7/12, reflected Resident #2 as at risk for dumping syndrome secondary to S/P Colon Resection, and "at risk for diarrhea." Interventions included to notify the MD if nausea and vomiting or abdominal discomfort was noted. On 12/27/12, an updated intervention included stool for [MEDICAL CONDITIONS] due to diarrhea, and on 12/28/12 the resident was placed on "BRAT diet" (bananas, rice, applesauce, and toast) and to notify MD if diarrhea persisted. Further review of the IDCP, reflected that on 12/4/12, Resident #2 was identified as at risk for bleeding related to anti-coagulant therapy ([MEDICATION NAME]), and interventions included to "monitor urine for any blood, and stool for any blood." Report to MD at once. A nutritional assessment dated [DATE], documented Resident #2 as S/P colon resection, and presently having LBM. Further review of the dietary progress note dated 12/7/12, documented Resident #2 with a negative (-) [MEDICAL CONDITION] laboratory result. A review of the interdisciplinary progress notes (IPN) from Resident #2's admission of 12/3/12 prior to the facility's alleged compliance date of 12/11/12 indicated: -12/3/12 at 6:30 PM, Resident #2 was admitted S/P hospital stay for Colon Resection. -12/6/12 at 2:00 PM, Resident in bed with episodes of "4 x LBM liquid". The physician ordered a stool sample be obtained for [MEDICAL CONDITION] testing, then start [MEDICATION NAME] 250 mg by mouth every 6 hours daily, and [MEDICATION NAME] every 6 hours as necessary (PRN) for diarrhea. On 12/7/12 at 3:00 PM, Resident "stated that she had loose bowel movements x 3." Bowel sounds were assessed, and the resident was told to notify staff if she had LBMs and to comply with waiting 1/2 hour before taking fluids after eating her meal. The next IPN of BM status was 12/10/12 at 4:00 PM indicated bowel sounds, needs total assistance with "ADL", and needs to be reminded to wait 30 minutes after meals to drink fluids. After the facility's compliance date of 12/11/12 there was documentation related to bowel function in the IPN. On 12/12/12 during the 11-7 shift the resident was "continent of B&B (bowel and bladder) functions with accidents". On 12/13/12 an untimed IPN indicated abdomen soft with minor distention, positive bowel sounds heard and no episodes of diarrhea or constipation noted this shift. On 12/15/12 at 4:00 PM the resident "still had episodes of both accidents". On 12/16/12 at 4:00 PM the resident was incontinent with no episodes of diarrhea this shift. On 12/19/12 (no shift/time indicated) the resident was incontinent and had bowel sounds. On 12/23, 24 and 25 during the 3-11 shift the resident was continent with accidents. On 12/27/12, 3-11 shift at 9:45 PM, Resident #2 had "LBM x (times) 1", complained of nausea and the physician ordered a stool specimen be obtained. On 12/28/12 during the 11-7 shift at 7:00 AM, "LBM x 2," and vomited x 1. The physician changed the resident's diet to BRAT. On 12/28/12 at 10:00 AM, no complaints of LBM or nausea was noted. The CNA Care Log for 12/2012, used by the CNAs to record Resident #2's bowel movements (BM) every shift included a legend/instructions that BMs were to be documented as 0=none, L=Loose, and F=Formed. Review of the CNA Care Log reflected the following: >EVENING shift from 12/3 to 12/27/12 There were blanks on 12/3, 9, 17, 18, 22, 23, and 27. A "1" on 12/5, 6, 7, 11, 12, 13, 16, 24, and 25. A "2" on 12/8, and 10. A "0" (no BM) on 12/4, 14, 20, 21, and 26. An "L" (loose BM) on 12/15, and 19. > NIGHT shift from 12/4 to 12/27/12 There were blanks from the 4th to the 27th, except for 12/5 when a "1" was documented, on 12/10 and 12/26 there was a "0" , and a check/slash mark on the 12/12. > DAY shift from 12/4 to 12/27/12 There were blanks on 12/4, 6, 8, 12, 13, 18, 22, 23, and 27. A "1" on 12/5 and 12/9, "3X" and/or 3 on 12/10, 11, and 24. A "1 x 3" on 12/19. A "3XL" on 12/7. An "L" on 12/14, 15, 16, 17, 20. An "L2" on 12/21. An "F" (Formed BM) on 12/25 and 26. The Surveyor requested the 24 Hour Reports from 12/12 to 12/27/12 (after the facility's compliance date) which included information on Resident #2. On 1/2/13 the facility faxed 24 Hour Reports dated 12/13, 17 and 18. A review of the faxed 24 Hour Reports did not indicate that Resident #2 had LBMs, despite the CNA Care Log indicating LBMs on 12/14, 15, 16, 17, 20 and 21 and the IPN indicated LBM only on 12/27 and 28. The CNAs were not documenting Resident #2's BM consistently according to the legend/instructions printed on the form and in accordance with their own facility policy and procedure. In addition, the LBM documentation for [DATE] on the CNA Care Log for Resident #2 did not coincide with the IPN or 24 Hour Reports. There was no indication in the IPN that the resident's bowel movements were monitored for blood. During an interview by the surveyor on 12/28/12 at 11:55 AM with the Assistant Director of Nursing (ADON), she revealed that the CNA Care Log should be filled out every shift by the assigned CNA and she could not explain why the 12/2012 form was not filled out properly, and further stated that the nurses are supposed to check the care logs. During an interview by the surveyor on 12/28/12 at 1:10 PM with the RN/Unit Manager (RN/UM) from Resident #2's unit, she corroborated the ADON's statement that the CNA Care Log should be filled out by the CNAs daily on every shift. The RN/UM further stated that all nursing staff (CNA and Nurses) were inserviced recently on how to complete the CNA Care Log documentation including if there is a change in condition. The RN/UM also revealed that she randomly checks the CNA Care Logs, and just "picked up" during the day of the surveyor's visit that the CNA Care Log for Resident #2 was not being completed daily and correctly. Further interview with the RN/UM, revealed that it was very important to document Resident #2's BMs due to her "dumping syndrome", and "she had resection GI (gastrointestinal)," and verified that the CNAs were inserviced to follow the BM legend. 2. According to the face sheet, Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected Resident #3 had intact cognitive abilities, required extensive assistance with transfers, ambulation, dressing, and hygiene and was continent of bowel and bladder . An IDCP dated 2/8/12, identified Resident #3 as positive for [MEDICAL CONDITION] (MRSA) below his right knee. Interventions included monitoring for signs and symptom (S/S) of diarrhea due to use of antibiotics (ABT). On 12/20/12, the IDCP was updated to collect stool for [MEDICAL CONDITION]. After the facility's compliance date of 12/11/12 there was documentation related to bowel function in the IPN. On 12/12/12 an untimed note indicated "C+1 bowel sounds...cont (continent) B/B". The IPN reflected the resident was continent of bowel and bladder function during the 3-11 shift on 12/13 and 12/22, during the 11-7 shift on 12/14 and 12/26 and on 12/27/12 (untimed note). On 12/19/12 the resident stated he was "moving bowels OK" and on 12/20/12 at at 11:30 AM the resident complained of three LBMs, the physician was notified and ordered stool collection for [MEDICAL CONDITION] and to start on [MEDICATION NAME] after stool collection. Resident #3 was discharged on [DATE], and was not available for interview by the Surveyor. The CNA Care Log for 12/2012, used by the CNAs to record Resident #3's bowel movements (BM) every shift included a legend/instructions that BMs were to be documented as 0=None, L=Loose, and F=Formed. A review of Resident #3's CNA Care Log from 12/1/12 to 12/28/12 did not differ prior to or after the facility's plan of correction compliance date of 12/11/12. The CNA Care Log showed thirty five BRs on the 7-3 and 3-11 shifts. There were blanks during the 11-7 shift on 12/17 and 12/26 and during all shifts on 12/27/12. During an interview on 12/28/12 at 12:25 PM with the ADON, the surveyor asked what "BR" meant and she replied that BR meant bathroom and the CNAs should document either "O", "L" or "F" as indicated on the CNA Care Log. She further stated that if a resident is alert and oriented, the CNAs should ask the resident what kind of stool they had, they should also observe the stool and document according to the BM legend. During an interview at 1:25PM with a CNA who began working in the facility on 9/2012, she verified that she received orientation and a recent inservice on how to fill out the CNA Care Log. According to the CNA, the BM legend should be filled out every shift, and there should be no blanks. The CNA further stated that they should not be documenting numbers, and should write either O, L, or F. If a resident had a LBM, they should report and show it to the nurse. An interview at 1:30PM with another CNA verified what the previous CNA told the Surveyor. A review of the Employee Inservice Record on CNA Care Logs/documentation, and responsibilities of nursing staff, including reporting of resident condition, dated 12/18/12 and 11/30/12, reflected that the CNA Care Log "must be filled out appropriately & each shift. End of shift procedure compliance with legend on CMA (CNA) Care Log". A Procedure for Change of Resident Condition form used to inservice the nursing staff on 11/30/12, documented that once a change in the resident's condition is noted, this means brought to you by a resident, family member, any staff member, or doctor, the following steps must be taken including; assess the resident for the noted change and document in the resident's chart your assessment on the nurse's notes, document also on the 24 hour report sheet, notify the physician, family, unit manager, and or DON/ADON, and document on your nurse's notes. Examples of change in resident's condition included but are not limited to; change in bowels (loose stools or not having a bowel movement.) NJAC 8:39-27.1 (a), (b)