Every finding on record at Autumn Lake Healthcare at Memorial Bridge

COMPLAINT #2659218 Based on interview, medical record review and review of other pertinent facility documentation on 11/6/25 and 11/7/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents documented physician visit progress notes at the time of each visit. This deficient practice was identified for 3 of 4 residents reviewed (Resident #1, #2, and #3), and was evidenced by the following:1.) Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #1's electronic medical record on 11/6/25, did not include documentation of a visit from an attending physician. 2.) Resident #2 was observed seated in a wheelchair at the bedside. The resident denied having any concerns regarding care while at the facility. A review of the AR revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: cellulitis of left lower limb, obstructive sleep apnea, asthma, and hypertension According to the comprehensive MDS, dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #2's electronic medical record on 11/6/25, did not include documentation of a visit from an attending physician. 3.) Resident #3 was observed seated in a wheelchair at the bedside. The resident denied any concerns regarding care received at the facility. A review of the AR revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: spinal stenosis (the narrowing of one or more spaces within your spinal canal), type II diabetes, and an anxiety disorder. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/28/25, Resident #3 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #3's electronic medical record on 11/6/25, did not include documentation of a visit from an attending physician. During an interview with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on 11/6/25 at 4:00 PM, the surveyor informed administration that they had not received the attending physician notes as requested for Residents #1, #2, and #3 from their most recent admission. The DON stated that she had reached out to the Attending Physician's (AP) office, who was also the facility's Medical Director, and she had not heard back from them yet. The DON further stated that some of their providers entered information directly into the electronic system and some forwarded their notes to be scanned in. The DON was unsure of how the AP entered their information, but that he came onsite weekly. The DON did not know why the notes were not there. After exiting the facility on 11/6/25, at 6:42 PM, the surveyor received an email containing AP progress notes from the DON as follows:-Resident #1, dated 10/29/25-Resident #2, dated 10/23/25-Resident #3, dated 10/23/25 During a telephone interview with the AP on 11/7/25 at 10:24 AM, the AP confirmed that he was also the facility's Medical Director. The AP stated that he visited the facility weekly, and he assessed new admissions, addressed acute concerns, and followed-up with monthly assessments during those times. The AP stated that he normally documented in the electronic medical record, however there had been a recent change with the login system and he had been using dictation and hand-writing his notes when he was back in his office. The AP stated that his expectation was that after completing, his office would fax the notes to the facility within a few days so that they could be added to the medical record. The AP stated that he was not sure what happened in the case of Resident #1, #2, and #3, but that the documentation should have been there. During an interview with the LNHA, the DON, and the Regional Nurse (RN) on 11/7/25 at 12:52 PM, they each agreed that the expectation was that physicians ensure that documentation is entered into the system within a reasonable amount of time. A review of the facility's undated Attending Physician Responsibilities policy, which revealed that each Attending Physician was responsible for, . Providing appropriate, timely and pertinent documentation. The policy further revealed that, The note should be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the facility for placement on the chart within a week. A review of the facility's undated Charting Error and/or Omissions, which revealed that the facility would maintain accurate medical records. NJAC 8:39-23.2 (b)

COMPLAINT#: 2659218 Based on interview, review of medical records and other pertinent facility documents on 11/6/25 and 11/7/25, it was determined that the facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of left pubis, hypertension, and myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium). According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. During a review of Resident #1's electronic medical record on 11/6/25 at 1 PM, the surveyor viewed recorded weights for the resident as follows:-10/20/25 [2:52 PM] 171.8 pounds (lbs.)-10/11/25 [9:00 PM] 172.0 lbs.-10/11/25 [2:56 PM] 172.0 lbs.-10/11/25 [2:56 PM] 172.0 lbs. At that time, the surveyor took a screenshot of the weights to be referenced during interviews while waiting for the facility to provide printed documentation of the resident's recorded weights to the surveyor as requested. A review of Resident #1's October 2025 Progress Notes (PN), revealed a Nutrition Note dated 10/15/25 at 2:04 PM, that indicated the resident's admission weight was obtained at the facility and that weekly weights were to be followed. The resident's nutrition goals included wt [weight] stability. A further review of the PN revealed a Nursing Note dated 10/29/25 at 7:12 PM, written by the Licensed Practical Nurse (LPN #1), that indicated that the family expressed immediate concerns including fluid retention and the resident's overall care. It further indicated that the Nursing Supervisor (NS) conducted a full body assessment and noted that the resident weighed 209 lbs., and that swelling was noted to the resident's lower extremities. There were no additional weights documented in the resident's electronic medical record at the time of the review. The surveyor attempted to conduct a telephone interview with LPN #1 but was not successful. During an interview with Certified Nursing Assistant (CNA #1), on 11/6/25 at 1:50 PM, she stated that part of the CNA duties included obtaining resident weights on the day of admission, the next day after that, and then weekly for four weeks. CNA #1 stated that CNA's receive a list of their residents that needed weights when they came on shift and then after the weight was obtained, the information was provided to the nurse. CNA #1 further stated that any refusals were also to be reported to the nurse. CNA #1 further stated that she recalled Resident #1 and that she worked on 10/29/25, however, she stated that she did not assist with obtaining the weight on that shift. During an interview with the LPN Unit Manager (UM) on 11/6/25 at 2:08 PM, she stated that resident weights were obtained upon admission, the next day, and then weekly for four weeks, unless otherwise indicated. The LPN UM stated that obtaining weights were important to quickly identify any acute issues that may be going on with a resident. The LPN UM also stated that any refused weights should have a corresponding nursing note. In the presence of the surveyor, the LPN UM reviewed the documented weights in the electronic medical record for Resident #1 and she stated that there should have been a weight taken in between 10/11/25 and 10/20/25, and weekly thereafter until discharge. The LPN UM stated that she did not know why the weights were not taken, but that they should have been. In the presence of the surveyor, the LPN UM also reviewed the PN dated 10/29/25 which reflected a weight of 209 lbs. The LPN UM stated she was not aware that the resident had a weight gain to that extent. During an interview with the Registered Dietitian (RD) on 11/6/25 at 2:58 PM, she stated that she visited the facility weekly and that she reviewed the weights with the UMs. The RD stated that a resident's weight was taken immediately upon admission and weekly for four weeks thereafter, unless otherwise indicated. The RD further stated that any resident that refused a weight, there should be documentation indicating why. The RD stated that she assessed Resident #1 on 10/15/25 and wrote a corresponding note that she reviewed in the presence of the surveyor. The RD reviewed the electronic medical record along with the 10/29/25 PN, and she stated that she was not aware of the 37 lb. weight gain that was significant. The RD further stated that she was not sure why the weights were not done in between 10/11/25 and 10/20/25, and weekly thereafter until discharge. During a telephone interview with the NS on 11/6/25 at 3:34 PM, she stated that upon admission, a resident's weight was taken and then weekly for four weeks. The NS stated that all weights were provided to the RD for review. The NS confirmed that she was the supervisor working on the evening of 10/29/25. The NS stated that while she was on the unit she recalled seeing Resident #1's family on the unit and they had concerns and seemed upset. The NS stated that she could not recall exactly what was said, but she remembered completing an assessment on the resident. The NS stated that the resident's weight was taken on that date, and that she was not aware of any missed weights. During a telephone interview with the facility's Medical Director (MD) on 11/7/25 at 10:24 AM, he stated that he was familiar with Resident #1. The surveyor reviewed Resident #1's weights of 171.8 lbs. on 10/20/25, and then 209 lbs. on 10/29/25. The MD stated that he was not aware of the resident's weights but that it was a significant change. The MD further stated that he expected the facility to monitor weights per the policy. The surveyor reviewed all printed documentation received from the facility which included weights for Resident #1's most recent admission. The surveyor noticed that two additional weights had been added to the resident's weights as follows:-10/16/25 [1:19 PM] 170.6 lbs.-10/23/25 [8:47 AM] 172 lbs. During an interview with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Nurse on 11/7/25 at 12:52 PM, they all agreed that a resident's weight was taken upon admission and weekly for four weeks, unless further indication was needed. In the presence of the surveyor, they each reviewed the screenshot that the surveyor took of Resident #1's previous weights and then the printed sheet that was provided to the surveyor. They each noted the addition of the weights. The DON then stated that when reviewing the weights at the time she was printing, she noted that weights were missing. The DON contacted a former employee that used to meet with the RD weekly, who told the DON that there were additional weights on a piece of paper that should have been added, so the DON added them. The DON further stated that the weights should have been entered right away. A review of the facility's undated Weight Monitoring policy revealed that the weekly weights would be conducted weekly and that weekly meetings would be held with the DON, UMs, and the RD to discuss weekly weights. A review of the facility's undated Charting Error and/or Omissions, which revealed that the facility would maintain accurate medical records. N.J.A.C. 8:39-27.1(a)

Complaint: NJ184164 Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to provide appropriate safety interventions to a cognitively impaired resident (Resident #124) with a history of refusal of care. On 3/4/25, Resident #124 fell when a Certified Nursing Assistant (CNA #4) refused to allow the resident to close his/her door causing the resident to fall and hit the back of their head causing a laceration. Resident #124 was sent to the hospital for evaluation. This deficient practice was identified for 1 of 2 Residents, (Resident # 124), reviewed for falls and evidenced by the following: On 5/28/25 at 11:19 AM, the surveyor observed Resident #124 in the C-wing dining room sitting in a chair. The C-wing unit was a locked unit for residents with behaviors. The surveyor attempted to speak with the resident but was unable due to cognitive impairment. On 5/29/25 the surveyor reviewed the admission Record, an admission summary, that revealed Resident #124 had diagnoses which included, but were not limited to: Metabolic Encephalopathy (a brain dysfunction caused by problems with metabolism) and Dementia with Psychotic Disturbance. On 5/29/25 the surveyor reviewed the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/20/25, that documented Resident #124's Brief Interview for Mental Status (BIMS) score was 3 out of 15 indicating severe cognitive impairment. On 5/29/25 the surveyor reviewed the resident's Individual Comprehensive Care Plan (ICCP) which included a focus area, dated 2/24/25, regarding Resident #124 receiving medications to manage his/her Dementia with Psychotic Disturbances and behaviors. The ICCP documented that the resident's behaviors included: destructive and intrusive behaviors; verbal outbursts; and refusal of medications and care. Interventions included: Attempt to redirect any negative behaviors with distractions; activities, 1:1 conversation, family contact, quiet environment. An additional focus area of the ICCP, revised on 12/5/24, indicated that the resident was at risk for falls related to medication use and poor safety awareness. Interventions included to monitor for changes in gait status. On 5/29/25, the surveyor reviewed the 3/4/25 . Fall Risk Evaluation which documented that Resident #124 was at moderate risk of falls. On 5/29/25, the surveyor reviewed the facility's fall investigation file regarding Resident #124's 3/4/25 fall. Per the investigation, Resident #124 fell and hit the back of their head causing a 3 x 4 centimeter laceration after CNA #4 would not allow the resident to close their door. The resident complained of a headache and was sent to the hospital for evaluation after neurological checks were started and the laceration was cleaned. The surveyor reviewed CNA #4's written statement regarding the 3/4/25 incident. CNA #4 documented that she tried to check on Resident #124 but the resident kept refusing and tried to shut the door. CNA #4 documented that she told Resident #124 that he/she had to let CNA #4 in but Resident #124 would not allow it. CNA #4 wrote that as I was trying to get (Resident #124) to let me in (Resident #124) fell backwards onto the floor. A review of LPN #2's written statement reflected that she was called to Resident #124's room and observed the resident standing in the doorway with blood coming from the back of the resident's head. LPN #2 wrote that CNA #4 told her that she was trying to get into the resident's room but the resident was blocking the door. CNA #4 tried to get passed the resident when the resident lost their balance and fell hitting the back of their head. On 5/29/25 at 09:20 AM, the surveyor interviewed the Licensed Practical NurseUnit Manager (LPN/UM #1) who stated that employees received abuse training monthly and upon hiring. When asked about the 3/4/25 incident, LPN/UM #1 stated that she was not in the facility at the time, but was informed that CNA #4 had possibly done something she wasn't supposed to do and was terminated. On 5/29/25 at 12:16 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Regional Clinical Director of Nursing (RCDON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that based on the facility's investigation, CNA #4's actions of pushing through the door triggered Resident #124 to lose their balance and fall resulting in a laceration to the back of the head and an emergency room evaluation. On 5/30/25 at 9:03 AM, the surveyor interviewed CNA #2 who confirmed that upon hiring she received training about how to approach and care for residents with a dementia diagnosis. When asked, based on her training, if a resident refused care what should she do, CNA #2 stated that she would stop whatever she was doing, contact the nurse, and go back at a later time. CNA #2 identified that the resident's right to privacy should never be violated. Lastly, the surveyor asked if she was engaged with a resident that was pushing or pulling on an object what would she do. CNA #2 responded that she would stop because being combative is part of the disease behavior and, as a result, the resident and she could fall or get hurt. On the same date at 9:09 AM, the surveyor interviewed LPN #1 who confirmed that upon hiring and on a regular basis staff received regular in-services on how to care for residents with cognitive impairments. LPN #1 confirmed that a resident's privacy, regardless of their cognition, is not to be violated, and that they have the right to refuse care. When asked how to proceed with a resident that is refusing care, LPN #1 stated that she would give the resident time and possibly switch with another staff member to see if they could proceed with care. LPN #1 stated that she was familiar with Resident #124 and that he/she is very particular with what he/she wants and how to receive it. When asked if the resident was combative, LPN #1 stated that she had not seen that, but Resident #124 can become upset if things are not done his/her way. On 5/30/25 at 12:32 PM, during an interview with the DON, in the presence of the LNHA and the RCDON, the DON confirmed that CNA #4 should not have continued to attempt to enter the room after Resident #124 refused to let her in, and this behavior resulted in the injury to Resident #124. The DON further acknowledged that staff received training on how to care for residents with cognitive impairments. The DON stated that all residents have the right to privacy and refuse care, and that the expectation was that CNA #4 was to stop what she was doing. A review of the facility's undated Certified Nursing Assistant Job Function identified the following: [ .] Ensure that you treat all resident fairly, and with kindness, dignity, and respect; [ .]Honor the resident's refusal of treatment request. Report such request to your supervisor. A review of the facility's undated Resident Rights Policy identified the following under Policy Explanation: Employees shall treat residents with kindness, respect, and dignity. The following was located under Policy Interpretation and Implementation: Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: A dignified existence; Be treated with respect, kindness, and dignity; [ .] self-determination; Be supported by the facility in exercising his or her rights; [ .] privacy and confidentiality; [ .] orientation and in-servicing training programs are conducted quarterly to assist our employees in understanding our resident rights. A review of the facility's undated Fall Prevention Policy identified the following under Policy Explanation and Compliance Guidelines: 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. A review of the facility's undated Abuse Neglect, and Exploitation Policy identified the following under Policy Interpretation and Implementation, and subheading Employee Training: A. New employees will be educated on abuse, neglect during initial orientation; B. Existing staff will receive annual education and as needed; and C. Training topics included that understanding behavioral symptoms, such as wandering, resistance to care and outbursts, of residents that may increase the risk of abuse and neglect. NJAC 8:39-33.1 (d)

On 05/27/2025 at 11:02 AM, Surveyor #2 observed the following on A Unit: the wall to left of Resident room [ROOM NUMBER]'s door had peeling paint. The wall to the left of Resident room [ROOM NUMBER] had paint peeling under the chair rail. There was missing floor tile to the right of the nurse's station. The shower room had multiple missing tiles on the wall. On 05/27/2025 at 01:43 PM, Surveyor #2 observed the following on A Unit: the paint under the heater in Resident room [ROOM NUMBER] was chipped. The ice machine at the nurse's station was missing a tile near the drainpipe and the black pad underneath the ice machine had a straw under it. On 05/28/2025 at 12:07 PM, Surveyor #2 observed the following on A Unit: there was black debris/discoloration next to the wardrobe and under the heater in Resident room [ROOM NUMBER]. There was peeling paint on the door to the smoking area. There was a broken cover on the thermometer in the dining room. There was chipped and peeling paint on the door jam and molding near the nurse's station. On 05/30/2025 at 12:03 PM, during an interview with the maintenance and housekeeping director, he acknowledged that A Unit requires housekeeping and repairs. He said he would get back to painting the units. He furthered that he will take care of it. On 5/27/2025 at 1:37 PM during the initial tour of the facility, Surveyor # 5 observed the B-Unit shower room. At that time, the shower room contained a duffel bag and a blazer jacket left on the chair. A nail clipper was also observed left out. On the same date at 11:12 AM during the initial tour of the facility, Surveyor # 5 onbserved room [ROOM NUMBER]. Upon observation of the bathroom, there was no bathroom mirror on the wall and no toilet paper available. 8:39-31.4 (a) 4. Upon initial tour of the A Wing Unit on 05/27/2025 at 11:24 AM, surveyor #4 observed approximately 5 resident wheelchairs, 2 geriatric reclining chairs, and one resident patient lift system that prevented the enjoyment and viewing of the A Wing fish tank. On 05/29/2025 at 11:19 AM, surveyor #4 interviewed CNA #3 who confirmed that resident and facility medical equipment was usually stored in corner somewhere when they are not in use. When asked if the equipment should be stored in front of the nurses by the fish tank CNA #3 responded, that's really the only spot to put them. At this time, CNA #3 confirmed that the medical equipment blocked the view of the A Wing fish tank and did not promote a homelike environment. On 05/30/2025 at 10:07 AM, during an interview with the Assistant Director of Nursing (ADON) confirmed that the residents in A Wing should be able to access all the activities and furnishings on the wing. Upon viewing the picture of the resident and medical equipment in front of the fish tank, the ADON acknowledged that the residents would not be able to access it and that it presented as an institutional like setting. On 05/30/2025 at 12:32 PM, during an interview with the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Director of Nursing (RCDON), confirmed that the area in front A Wing fish tank should have been empty and accessible for resident viewing. A review of the facility's undated Safe and Homelike Environment Policy identified the following under Policy Explanation and Compliance Guidelines: 1. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting [ .] Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment [ .]. 3. During initial tour of C-Wing unit on 05/27/2025 at 10:03 AM, Surveyor # 3 observed the blue heaters in the hallway with peeling paint, a missing drawer in the dresser of room [ROOM NUMBER], a broken plastic covering on the door to room [ROOM NUMBER] and the thermostat box with dead bugs and cobwebs inside. During an interview on 05/30/2025 at 12:03 PM with surveyor # 3, the Maintenance and Housekeeping Director said that he does rounds on the units weekly and prioritizes safety concerns when making repairs to the units. He acknowledged the concerns on the C-wing and said they needed to be repaired. During and interview on 05/30/2025 at 12:32 PM with surveyor # 3, the LNHA acknowledge the concerns on C-wing unit and said, It's a little rougher of a unit due to the nature of the residents and the unit is next to a swamp. The LNHA also said they are working to make all repairs to the unit. Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 3 of 3 units (Units A, B, and C). This deficient practice was evidenced by the following: 1. On 05/27/2025 at 10:52 AM, Surveyor #1 observed several items in the C-Wing unit shower room. A loose, unsealed razor was in a basin on the shower bed. Hair was visible in the shower stall drain. An empty bodywash bottle was on the floor under the shower chair. A coffee cup with a red straw was sitting on the supply cart. An open container with a yellow substance inside was placed on top of the trash can liner in the trash can. On 05/27/2025 at 10:58 AM, Surveyor #1 observed a geriatric chair (specialized, high-backed reclining chair designed to provide comfort, support, and mobility for individuals with limited mobility) in the C-Wing female unit hallway with a ripped seat and a broken foot recliner. On 05/27/2025 at 11:10 AM, Surveyor #1 observed a plastic-framed picture on the wall with a crack in it, located in the hallway of the C-Wing female unit. On 05/27/2025 at 11:14 AM, Surveyor #1 observed a square-shaped hole in the wall near the window, a hole near bed B, a heater vent with brown spots, cracked windowsill molding, and cracked drywall on the ceiling in bedroom [ROOM NUMBER] on the C-Wing female unit. On 05/27/2025 at 11:22 AM, Surveyor #1 observed a loose door handle in bedroom [ROOM NUMBER] on C-wing female unit. On 05/27/2025 at 11:24 AM, Surveyor #1 observed a cracked door panel in bedroom [ROOM NUMBER] on C-wing female unit. On 05/27/2025 at 11:30 AM, Surveyor #1 observed two drains on the C-Wing female unit hallway with missing floor tiles and brown residue surrounding them. During an interview with Surveyor #2 on 05/30/2025 at 12:03 PM, the Maintenance/Housekeeping Director (MHD) said that housekeeping staff clean the shower rooms on each unit daily. He also explained that Certified Nurse Aides (CNAs) are responsible for cleaning the shower room after each resident they bathe, and confirmed that the shower room should have been cleaned. During an interview with Surveyor #2 on 05/30/2025 at 12:04 PM, the Licensed Nursing Home Administrator (LNHA) said that C-Wing presents unique challenges due to the nature of its resident population, which often results in frequent maintenance issues. While efforts are made to address problems promptly, new issues tend to arise just as quickly. Additionally, the unit's proximity to a nearby swamp contributes to high moisture levels, which impact the building's condition and appearance.

Complaint # 173841 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to 1 of 1 resident reviewed for Bowel and Bladder (Resident # 47) and 3 of 11 resident reviewed for incontinence rounds. (Resident # 6, Resident #113, and Resident # 402) This deficient practice was evident by the following: On 05/27/2025 at 09:59 during initial rounds Resident # 47 was observed in bed in a t-shirt with the covers at the bottom of the bed. Resident # 47 was observed to have a saturated incontinent brief. Resident # 47 was unsure of the last time he/she was changed. A review of Resident # 47's admissions record revealed that, Resident # 47 was admitted with but not limited to Benign Prostatic Hyperplasia (a condition where the prostate gland is enlarged), and Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels.) A review of Resident #47's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident was frequently incontinent of bowel and bladder. On 05/28/2025 at 08:14 AM surveyor #1 accompanied the C-wing Unit Manger (UM) # 1 conducted incontinence tour on the C-wing. Four random residents who were identified by UM#1 as being dependent on staff for care, were observed. Surveyor # 1 and the UM entered Resident #6 room. Resident # 6 was in bed wearing a hospital style gown. At the time, the resident granted permission for the survey to observe his/her incontinent brief. Surveyor # 1 observed the incontinent brief to be saturated and soaked through to his/her gown. Resident # 6 said he/she was waiting for someone to come in. The UM said they were just getting done breakfast and are starting to get residents ready. A review of Resident # 6's admissions record revealed that, Resident # 47 was admitted with but not limited to Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels.) and muscle weakness. A review of Resident #6's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident was occasionally incontinent of bowel and bladder. During an interview on 05/29/2025 at 01:08 PM with Surveyor #1, the Certified Nursing Assistant #1 (CNA) said that incontinence care should be done at least every 2 hours. The CNA also said that residents that are heavy wetter's should be checked more often and should not be soaked through. During an interview on 05/30/2025 at 09:04 AM with surveyor # 1, the UM #1 said that incontinence rounds are done two to three times a shift and as needed. The UM # 1 also said that residents should not be soaked through, however sometimes it takes a while to get to all the residents. During an interview on 05/30/2025 at12:32 PM with surveyor #1, the Director of Nursing (DON) said that incontinent rounds should be done every two hours or as needed. When asked if residents should be soaked through their briefs, the DON replied, No A review of an undated policy titled Incontinent Care revealed, It is the policy of [facility name] that incontinent residents will be maintained clean and dry. NJAC 8:39- 27.2 (h) On 05/28/2025 at 8:53 AM, Surveyor #2 completed an incontinence round with Licensed Practical Nurse/Unit Manager #1 (LPN/UM #1) on B-Wing for Resident #402. The adult incontinent brief was visibly soiled with urine, which was confirmed by LPN/UM #1. The LPN/UM #1 said that she would have the Certified Nurse Aide (CNA) assigned to the resident complete the incontinence care. On 05/28/2025 at 8:59 AM, Surveyor #2 completed an incontinence round with LPN/UM #1, on B-Wing, for Resident #113. The adult incontinent brief was visibly soiled with urine and feces and confirmed with LPN/UM #1. The LPN/UM #1 said that she would have the CNA assigned to the resident complete the incontinence care. On 05/28/2025 at 9:22 AM, Surveyor #2 observed that the call light for Resident #113 on B-Wing was flashing. After knocking on the resident's door and receiving permission to enter, Surveyor #2 was informed by Resident #113 that the call light had been on for 20 minutes, he/she needed to be changed, and no staff had responded to the call bell. On 05/28/2025 at 9:24 AM, Surveyor #2 completed another incontinence round for Resident #113 with CNA #1. The adult incontinent brief remained visibly soiled with urine and feces. CNA #1 said that she would complete the incontinence care. On 05/28/2025 at 9:28 AM, Surveyor #2 completed another incontinence round for Resident #402 with LPN #2. The adult incontinent brief remained visibly soiled with urine. LPN #2 said that she would complete the incontinence care. On 05/29/2025 at 11:06 AM, Surveyor #2 reviewed the electronic medical records (EMR) for Resident #113 as follows: According to the admission record, the resident was admitted to the facility with diagnoses including, but not limited to, cerebral infarction, which occurs when blood flow to a part of the brain is blocked, leading to tissue death due to a lack of oxygen and nutrients. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 04/02/2025, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS revealed that Section GG- Functional Abilities was coded as 1, reflecting impairment on one side of both the upper and lower extremities, and Section H- Bladder and Bowel was coded as 3, meaning the resident is always incontinent of both urine and bowel. The resident's comprehensive care plan, dated 04/10/2025, included a focus area indicating that he/she is at risk for skin breakdown related to decreased mobility. Interventions included, but were not limited to, keeping the resident's skin as clean as possible and checking for incontinence and assist with changes routinely and as needed. On 05/29/2025 at 11:30 AM, Surveyor #2 reviewed the electronic medical records (EMR) for Resident #402 as follows: According to the admission record, the resident was admitted to the facility with diagnoses including, but not limited to, cerebral infarction. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/02/2025, included a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. Further review of the MDS revealed that Section GG- Functional Abilities was coded as 1, reflecting impairment on one side of the upper extremities, and Section H- Bladder and Bowel was coded as 3, meaning the resident is always incontinent of urine. The resident's comprehensive care plan, dated 04/29/2025, included a focus area indicating that he/she has bowel and bladder incontinence related to cerebral infarction. Interventions included, but were not limited to, checking the resident as required for incontinence. During an interview with Surveyor #2 on 05/28/2025 at 9:26 AM, CNA #1 said that she tries to respond to call lights immediately but was unaware that Resident #113's call light was on because she was assisting another resident in a different room. She reported that incontinent care is provided every two hours or as needed and that she feels she has enough time to complete her assigned duties. During an interview with Surveyor #2 on 05/28/2025 at 9:30 AM, LPN #2 said that she is an agency nurse and not directly employed by the facility. She explained that she tries to answer call lights immediately and that incontinent care at the facility is provided every two hours or as needed. She also expressed that she feels she has enough time to complete her assigned duties. During an interview with Surveyor #2 on 05/30/2025 at 12:04 PM, the Director of Nursing (DON) said that incontinence rounds should be completed every two hours, as needed, and upon resident request. She also confirmed that call lights should be answered immediately. A review of the undated facility policy, titled, Incontinent Care, revealed that, It is the policy of the facility that incontinent residents will be maintained clean and dry. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 4 of 33 (Resident # 13, 80, 44, 47) residents reviewed for care plans, specifically a resident that required a hand orthotic (Resident 13), a resident with a Positive Pres-admission Screening and Resident Review (PASARR) Level 2, and a resident that required oxygen (Resident #80). This deficient practice was evidenced by the following: The deficient practice was evidenced by the following: On 05/27/2025 at 10:12 AM, Surveyor #1 observed Resident # 80 in bed receiving Oxygen via nasal cannula (a device used to deliver supplemental oxygen). Surveyor #1 reviewed Resident #80's medical record which reflected that the resident had a diagnosis which included asthma (narrowing and swelling of the airway). A review of the physician orders for Resident # 80 reflected an order dated 09/09/2024 for the resident receive Oxygen via nasal cannula. The minimum data set, an assessment tool, dated 05/07/2025 reflected that Resident #80 utilized Oxygen. Surveyor #1 reviewed the Resident # 80's care plans which revealed there was no care plan developed to address the use of Oxygen. On 05/30/2025 at 10:02 AM, Surveyor #1 interviewed the Assistant Director of Nursing (ADON) who said that the nurse manager or any nurse were responsible for ensuring care plans were completed. The ADON said that Oxygen use should be included on the care plan. The ADON and surveyor reviewed the care plans of Resident #80 together. She confirmed that there was no care plan addressing the use of Oxygen. A review of the facility's undated Comprehensive Care Plan policy identified the following: it is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. NJAC 8:39-27.1(a) 3. Upon initial tour of the facility on 05/27/2025 at 11:00 AM, the surveyor observed Resident #44 in bed. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD- a common lung disease causing restricted airflow and breathing problems) and Unspecified Psychosis not due to a Substance or Known Physiological Condition. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/15/2024, identified under Section A, Question A1500, of the MDS that Resident #44 had state level 2 Preadmission Screening and Resident Review (PASRR) process to have serious mental illness. A review of the PASARR Level II Determination Notification letter by the New Jersey Department of Human Services Division of Mental Health and Addiction Services dated 05/26/2016 revealed that Resident #44 had mental health treatment needs that could be met in a nursing facility. A review of the resident's individual comprehensive care plan (ICCP) included a focus area that [the resident had] a [diagnosis] of depression and anxiety, dated 12/14/2021, but did not identify the resident's positive PASARR Level 2. During an interview with the surveyor on 05/29/2025 at 01:05 PM, the Social Worker (SW #1 and SW #2) explained that a positive PASARR Level 2 is assigned by a State of New Jersey PASARR Coordinator and will identify the resident with a mental disability. SW #1 and SW #2 further advised that when a PASARR Level 2 is confirmed it will remain until the State of New Jersey removes it. The surveyor requested that SW #1 and SW #2 review the care plan for Resident #44 and confirm if the PASARR Level 2 is identified. SW #1 and SW #2 acknowledged that Resident #44 had a care plan for Depression and Anxiety, but it did not identify that the resident had a positive PASARR Level 2. When asked if it should be identified, SW #1 and SW #2 stated that they could see the rationale behind identifying it on the care plan but we've never done it. On 05/29/2025 at 12:16 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Regional Clinical Director of Nursing and the Licensed Nursing Home Administrator, who confirmed that the PASARR Level 2 should be identified on the care plan and that the Social Workers would be responsible for updating. A review of the facility's undated Comprehensive Care Plan policy identified the following: [ .]3. The comprehensive care plan will describe, at a minimum, the following: [ .]c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations [ .]. NJAC 8:39-27.1 (a) A review of Resident # 13's admissions record revealed that, Resident # 13 was admitted with but not limited to Osteomyelitis (an infection in a bone), Cerebral Infarction (when blood flow is blocked to part of the brain causing dead tissue in the brain) and, Seizures. A review of Resident #13's Electronical Medical Record revealed a physician's order with a start date of 11/01/2024 for Handroll to left hand every day shift. A review of the current Care Plan (CP) for Resident #13 did not include documentation of a CP focus area or interventions for the use of a hand roll. A review of Resident # 47's admissions record revealed that, Resident # 47 was admitted with but not limited to Benign Prostatic Hyperplasia (a condition where the prostate gland is enlarged), and Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels.) A review of Resident #47's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident was frequently incontinent of bowel and bladder A review of the current Care Plan (CP) for Resident #47 did not include documentation of a CP focus area or interventions for incontinence. During an interview on 05/30/2025 at 09:04 AM with surveyor #2 the Unit Manger (UM)# 1 on C-wing said that care plan consists of focus areas for medication, care that is pertinent, recent incidents and any information that other departments would need to know. When asked if resident is incontinent is that something that should be on the care plan, the UM # 1 stated, yes I would but it under skin assessment. When asked about a resident with a splint or hand roll, the UM stated, Yes I usually put that under skin assessment as well. During an interview on 05/30/2025 at 12:32 PM with surveyor #2 the Director of Nursing said, there should be a focus for incontinence and on the use of splints or hand rolls on the resident's care plan. A review of the facility's undated policy titled Comprehensive Care Plan revealed under Policy Explanation and Compliance Guidelines that, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices, specifically when facility staff failed to wear the appropriate personal protective equipment while in a room under Contact Precautions. The deficient practiced was identified for 1 of 7 Residents (Resident # 258) reviewed under the Infection Control task. The deficient practice was evidenced by the following: On 05/27/2025 at 1:32 PM during the initial tour of the facility, the surveyor observed housekeeper (HK) # 1 inside Resident # 258's room. HK # 1 was mopping the floor. Outside of the room was a sign that revealed, Stop: Everyone Must: Clean their hands, including before entering and when leaving the room. The sign further revealed that, Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry, Discard grown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. At the time of observation, HK # 1 had no gown or gloves on. Attached to the door of the room was an over-door organizer containing disposable gowns and gloves. On the same date and approximate time, HK # 1 replied, It's only for aides when they change [him/her]. after the surveyor asked if HK # 1 should be wearing personal protective equipment in that room. A review of Resident # 258's orders located in the Electronic Medical Record (EMR) that he/she has an order to Maintain special contact isolation precautions every shift for VRE [Vancomycin Resistant Enterococcus) UTI (Urinary Tract Infection) for 7 days all nursing, therapy, dietary & activities services to be provided in resident's room. The order was started on 5/21/2025. A review of Resident # 258's Care Plan located in the EMR revealed a Care Plan intervention to Maintain contact isolation precautions for the duration of ABT [antibiotic] for VRE UTI On 5/30/2025 at 10:19 AM during an interview with the Infection Preventionist, the surveyor asked Should housekeeping be wearing a gown and gloves in rooms when there is a Contact Isolation sign at the doorway and PPE hanging on the door? The Infection Preventionist replied, Yes. The Infection Preventionist added further that, The housekeeper should have absolutely had PPE [Personal Protective Equipment] for sure. On 5/30/2025 at 12:35 PM, during an interview with the surveyor, the Director of Nursing replied, Yes, they should be. when the surveyor asked if a resident is on contact precautions, should house keeping be wearing a gown and gloves while inside that room. The DON further replied, They [housekeeping] could be in contact with furniture or devices. A review of the facility policy titled, Contact Isolation updated on 8-24 revealed, Staff and visitors will wear a disposable gown upon entering the room and remove them before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . N.J.A.C. § 8:39-19.4 (a)

Complaint: NJ184164 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for 1 of 2 residents (Resident #124) reviewed for abuse. This deficient practice was evidenced by the following: On 05/28/2025 at 11:19 AM, the surveyor observed Resident #124 in the Dining Room of C Wing sitting in a chair. The surveyor attempted to speak with the resident but was unable to do so due to cognitive impairment. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy and Unspecified Dementia (Unspecified Severity) with Psychotic Disturbance. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/20/2025, identified that the resident was unable to complete the Brief Interview for Mental Status (BIMS). A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 02/24/2025, that the resident [Resident Name Redacted] has a diagnosis of Dementia with Psychotic Disturbances and takes medications to manager her diagnosis and behaviors (destructive behaviors, intrusive behaviors, verbal outbursts, refusal of meds, refusal of care). Interventions included: Attempt to redirect any negative behaviors with distractions; activities, 1:1 conversation, family contact, quiet environment and Monitor for changes in mood and behaviors such as increased agitation, increased aggression, hallucination, verbal outbursts. During the recertification survey, the surveyor reviewed a Facility Reported Event (FRE) Form submitted to the Department of Health (DOH) on 03/05/2025 in which the facility identified that an employee (a Certified Nursing Assistant {CNA}] was entering the room and [Resident #124] fell to the floor. The surveyor requested the full investigation of the incident. Per facility documentation, the incident occurred on 03/04/2025 during the evening hours. Upon review of the CNA statement that they, were trying to get [Resident #124] to let me in the [the room] [Resident #124] fell backwards onto the floor. Another employee statement reported that CNA was trying to get into residents [sic] room to check on residents [sic] roommate and resident was blocking the door and as she tried to get passed the resident [they] lost [their] balance and fell back hitting her head. On 05/29/2025 at 09:20 AM, the surveyor interviewed Licensed Nurse Practitioner Unit Manager (LPN/UM #1) who reported that as a unit manager she is responsible for gathering witness statements upon receiving notification of an alleged abuse. LPN/UM #1 indicated that she would gather a statement from aides, residents, any witnesses. Upon gathering all the information, she would also determine who was in the area at the time of the incident and make sure they provide a statement. LPN/UM #1 indicated that she reviewed the statements and if any further witnesses were identified in it a statement should be obtained from them. LPN/UM #1 confirmed that the Resident #124 resided in a room that has four beds but was unable to confirm who was present in the room at the time of incident. LPN/UM #1 further acknowledged that a care plan would be updated to identify the resident as a potential victim. When asked regarding the incident that occurred on 03/04/2024, LPN/UM #1 stated that she was not in the facility on that date but was informed that the CNA had possibly done something she wasn't supposed to do and was terminated. At this time, LPN/UM #1 advised that the incident may have been captured by the security camera that was located above the nursing station. On the same date at approximately 10:00 AM, the Director of Nursing (DON) confirmed that the video was reviewed the day after the event. On 05/29/2025 at 12:16 PM, the surveyor interviewed the DON in the presence of the Regional Clinical Director of Nursing and the Licensed Nursing Home Administrator, who confirmed that she was responsible for overseeing the investigation and ensuring that it was thoroughly conducted. The DON was provided the CNA's handwritten statement and her Investigation of Summary by the surveyor. Upon review, the DON acknowledged that the CNA identified a roommate as being present at the time of the incident but confirmed that her summary did not identify that any roommates were present at the time of the incident. When asked if any attempt was made to interview the roommates, the DON responded that she was unsure but that it should have been identified and investigated. When asked if it was possible that one of the residents could have provided some insight to the incident the DON agreed. When asked if Investigation of Summary identified that the wing of which the incident occurred had cameras and if it was viewed to assist in the incident conclusion, the DON denied. When asked if the resident's care plan should have been updated to reflect the allegation the DON denied. Upon review of the discussion and what was provided to the survey team, the surveyor inquired if a thorough investigation was completed. The DON responded that she believed it was completed but now is not sure. A review of the facility's undated Abuse Neglect, and Exploitation Policy identified the following under Policy Explanation and Compliance Guidelines and the Heading V. Investigation of Alleged Abuse, Neglect, and Exploitation: B. Written procedures for investigations include: [ .]4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations; [ .] A review of the facility's undated Abuse Investigation and Reporting Policy identified the following under Role of the Investigator: Review the completed documentation forms; [ .] Interview the resident's roommate, family members, and visitors [ .]

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to properly store medications and failed to maintain a sanitary environment in a medication room. The deficient practice was identified for 1 of 3 medication rooms and 2 of 7 medications carts reviewed under the Medication Storage Task. The deficient practice was evidenced by the following: On 05/28/2025 at 9:17 AM during an inspection of the B Unit Medication Room, the surveyor observed six beverages in opened containers left on the counter inside the Medication Room. Two personal bags were also in the room. At the time of observation the Licensed Practical Nurse/Unit Manager (LPN/UM) replied, No when the surveyor asked if it is reasonable staff should be keeping their beverages and bags in the medication room. The LPN/UM confirmed that there is a staff breakroom where beverages can be kept. On the same date at 9:35 AM, the surveyor inspected the B wing medication cart 2. At that time, the surveyor observed two, loose tablets inside the drawer of the medication cart. On the same date at 11:10 AM, the surveyor inspected the A wing medication cart 2. At that time, the surveyor observed eleven, loose tablets inside the drawer of the medication cart. On 05/30/2025 at 12:35 PM during an interview with the surveyor, the Director of Nursing (DON) replied, I have them check monthly to do an audit. when the surveyor asked how often are medication carts cleaned of loose tablets. Lastly, the DON replied, There is a closet on B-Wing with lockers. when the surveyor asked if a variety of beverages and person bags in a medication room contribute to a clean environment for medication preparation. A review of the undated facility policy titled, Storage of Medications revealed that, Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. and The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean safe, and sanitary manner. Lastly, the policy revealed, Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer or or other holding area to prevent the possibility of mixing medications of several residents. N.J.A.C. § 8:39-29.4 (h)

NJ Complaint: #00173841 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's annual Minimum Data Set (an assessment tool) dated 03/08/2025, revealed that Resident #77 had a brief interview of mental status score of 0 which indicated he/she was not cognitively intact. A review of Resident #77's physician's orders revealed the following orders but not limited to Jardiance 10mg (milligrams, a medication used to manage and treat diabetes) one time a day, metoprolol tartrate 25mg (milligrams, a medication used to treat high blood pressure) twice a day, and Depakote Sprinkles delayed release 125mg (milligrams, a seizure medication often used for mood disorders) 3 capsules in the morning. A review of Resident #77's Medication Administration Audit Report for May 2025 revealed the following medications were administered past the required time frame as follows: On 05/25/2025: Jardiance scheduled for 08:00 AM was given at 09:36 AM Metoprolol Tartrate scheduled for 08:00 AM was given at 09:36 AM Depakote Sprinkles scheduled for 08:00 AM was given at 09:36 AM On 05/29/2025: Jardiance scheduled for 08:00 AM was given at 10:08 AM Metoprolol Tartrate scheduled for 08:00 AM was given at 10:08 AM Depakote Sprinkles scheduled for 08:00 AM was given at 10:08 AM On 05/29/2025 at 12:08 PM, during an interview with the surveyor, the Registered Nurse (RN) stated that medications should be administered one hour before or one hour after the scheduled medication administration time. The RN acknowledged that he administered medication to Resident # 77 late. The RN said he should have administered medication to Resident #77 first. A review of the facility policy titled, Administering Medications with a revision date of November 2017, reflected under number 11., Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. N.J.A.C.: 8.39-29.2 (d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate treatment and care for a resident with a indwelling, urinary catheter. The deficient practice was identified for 1 of 3 residents (Resident # 254) reviewed for Urinary Catheter or UTI (Urinary Tract Infection). The deficient practice was evidenced by the following: On 05/27/2025 at 10:37 AM during the initial tour, the surveyor observed Resident # 254 in bed in their room. At that time, the surveyor observed a urinary catheter drainage bag containing tinged, red urine. The drainage bag did not have a cover for privacy. At that time, the surveyor asked the resident if there was a device on his/her leg that secured the tube of the indwelling, urinary catheter. Resident # 254 denied having one and showed the surveyor his/her leg. There was no securement device observed on his/her leg. On 05/28/2025 at 11:23 AM, the surveyor observed Resident # 254 in bed in their room. At that time, the surveyor observed the urinary catheter drainage bag unsecured from the frame of the bed and instead left in a privacy cover. On 05/30/2025 at 12:35 PM during an interview with the surveyor, the Director of Nursing replied, We have them [indwelling catheter drainage bag] in a privacy bag, Sometimes the cover is on them and there is a hook on the bag as well. Below the bladder. Lastly, the DON replied, We have a stat lock that would be placed on them and attach the tubing to that. when the surveyor asked how should a urinary catheter tube be secured to a resident. The DON replied, So it's not tugging or causing discomfort or harm. when asked why it would be important to secure the tube. A review of Resident # 254's orders revealed an order to maintain the catheter for a diagnosis of Urinary Retention (inability to fully empty the bladder). A review of Resident # 254's Care Plans located in the Electronic Medical Record revealed a focus that [Resident 254] has indwelling catheter for Urinary Retention. A review of the undated policy titled, Foley Catheterization revealed, The purpose of urinary catheterization is to facility urinary draining when medical necessary. Urinary catheters should be evaluated every day for need and removed promptly when no longer necessary. N.J.A.C. § 8:39-27.1 (a)

Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 05/29/2025 at 10:31 AM, four of four alert and oriented residents said they were not aware of the location of the State Survey results and that the facility had not spoken to them about the results. During a tour of each unit, the surveyor observed signs that stated the State Survey results were in the lobby. The C-wing unit is a locked unit. In the lobby the surveyor observed a sign on a buffet cabinet that said State Survey results here. The binder was located inside the buffet cabinet where a door had to be opened outward. During an interview on 05/29/2025 at 11:06 AM with the surveyor, the Unit Manager (UM) of C-wing said the Survey Results were in lobby and all the residents had to do was ask to see them. When asked if the State Survey result were readily accessible to the residents on C-wing, the UM replied No During an interview with the surveyor on 05/30/2025 at 12:32 PM, the Licensed Nursing Home Administrator (LNHA) replied, No When asked if they considered if the results binder was readily accessible to the residents on the C- wing. A review of an undated facility provided policy titled Examination of survey Results revealed Survey reports and plans of correction are readily accessible to the residents and to the public. NJAC 8:39-9.4(b)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed accommodate resident's need by not keeping the nurse's call bell within the resident's reach. This deficient practice was identified for 2 of 33 residents (Resident #27 and #45) reviewed for accommodation of need and was evidenced by the following: Upon initial tour of the A Wing Unit on 05/27/2025 at 11:07 AM, the surveyor observed the call bell of Resident #27 on the floor underneath the head of the resident's bed. On the same date and time, the surveyor observed the call bell of Resident #45 wrapped around the wall unit of the nurse's call bell system. While in the room with the residents, a Certified Nursing Assistance (CNA) who identified herself as an agency nurse confirmed that nursing call bells were to be located on the bed within resident's reach and further stated, I cant fix everything here. The surveyor reviewed the medical record for Resident #27. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes breathlessness, coughing and mucus production) and Neurosyphilis (a complication of syphilis that affects the brain and spinal cord). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/17/2025 included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/14/2021, that the resident was at risk for falls [related to] medication use, unsteady gait at times and use of assistive device during ambulation. Interventions included: Encourage [resident] to use call bell if she needs assistance. The surveyor reviewed the medical record for Resident #45 A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Alzheimer's Disease (a brain disorder that destroys memory and thinking skills) and Essential Hypertension (abnormally high blood pressure). A review of the resident's most recent comprehensive MDS dated [DATE] identified the resident has cognitively impaired. A review of the resident's (ICCP) included a focus area, dated 12/16/2021, that the resident was at risk for falls, increased need for assistance with activities of daily living [ADL]/transfers, medication use, poor safety awareness, unsteady gait. Interventions included: Encourage [resident] to use call bell if she needs assistance. On 05/29/2025 at 11:19 AM, the surveyor interviewed CNA #1 who confirmed call bells are to be on the bed and easily accessible. On 05/30/2025 at 12:32 PM, during an interview with the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Director of Nursing (RCDON), confirmed that nursing call bells should be within reach of the resident and that anyone who walks by a room should ensure that the call bell is clipped to the blanket or bed. A review of the facility's undated Certified Nursing Assistant Job Function identified the following: [ .] Keep the nurse's call system within easy reach of the resident[ .]. A review of the facility's undated Answering the Call Light/Call bell policy identified the following under General Guidelines: When the resident is in bed or confined to a chair be sure the call light or call bell is within easy reach of the resident. NJAC 8:39-27.1 (a)

Based on observation, staff interview, and facility policy review, the facility failed to keep the kitchen's convection oven, stove spill pan, large manual can opener and base attachment, large electric mixer, and ice machine clean. Additionally, the date opened on bread products was not labeled with an use by date. This failure had the potential to affect 107 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated January 2023, indicated, All kitchens, kitchen areas and dining areas shall be kept clean. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Review of the facility's policy titled, Dating and Labeling, dated January 2023, indicated, It is the policy of this facility for the kitchen to assure food safety by maintaining proper dates and labels to all food products. All food must have a receive date as well as a use by date. 1. Observation on 09/26/23 from 9:45 AM to 10:30 AM, during the initial kitchen inspection with the Dietary Manager (DM) present, revealed the following: a. The kitchen's convection oven was unclean with heavy accumulated blackened and dried food spills on their interior cooking compartment and on the inside of their doors. b. The stove top's spill pan was unclean with a heavy accumulation of burnt on food spills. c. One of the kitchen's large manual can openers, which was attached to a food preparation table, was unclean with accumulated food substances on its blade and metal table base attachment. d. Eight serving scoops, that were stored and ready for use, were stored wet with accumulated pooled water in them. e. The kitchen's large electric mixer was unclean with dried food substances on the mixer's underside of the mixer's head and the mixer's base that could be wiped away with a paper towel. f. The interior of the kitchen's ice machine contained a black colored substance, which appeared to be mold, which could be wiped away with a paper towel. g. Observation on 09/26/23 from 9:45 AM to 10:30 AM, during the initial kitchen inspection with the DM present, revealed four packages of opened sliced bread, two packages of opened hamburger buns, and two packages of opened hot dog buns, stored on bread racks and ready for use, which did not have a use by or expiration date on their package. Interview with the DM, during the initial kitchen inspection on 09/26/23 from 9:45 AM to 10:30 AM, the DM confirmed the kitchen's convection oven, stove top's spill pan, large manual can opener, electric mixer, ice machine and eight serving scoops were unclean and/or stored wet. The DM stated food preparation and service equipment should be kept clean and dry. The DM further confirmed the eight opened packages of bread products that were stored and ready for use in the kitchen did not have a use by or expiration dates on their package. The DM stated when bread products are delivered to the kitchen staff are expected to date the bread. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on interview, record review, and review of facility policy, the facility failed to send a final investigation report within 5-days to the Department of Health, as required for one (Resident (R)260) of one sampled resident reviewed for misappropriation of resident property in a total sample of 28. Findings include: Review of an undated facility policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revealed, .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .It is the policy of Facility (sic) that all reports of theft or misappropriation of resident property be promptly and thoroughly investigated . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R260 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/14/23 revealed, R260 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of the 07/24/23 Social Service Note located in the Progress Notes tab of the EMR revealed, Administrator, DON [Director of Nursing], Unit Coordinator, and myself met with R260 and her dgt (daughter) to discuss a number of issues. Her dgt is requesting that she be called for changes/problems regarding her mother since she is POA (Power of Attorney.) R260 is agreeable to this .R260 had reported money missing that she Kept (sic) in her pillow. R260 has two lock (sic) areas in her room. She stated she prefers to keep her money on her because nursing has a key. Administrator suggested and dgt agreed they will buy a lock and only [R260] will have a key . The final Investigation Report, summary, dated 08/02/23, provided by the Director of Nursing (DON), revealed, .On July 19th, 2023, the Administrator and Director of Nursing were made aware of the following incident. R260 reported to the social worker than (sic) she was missing $30 that she kept in a pillow case in her wheelchair. She stated she noticed the money missing Sunday morning, July 15th. The social worker immediately notified the Administrator for investigation. During an interview on 09/27/23 at 3:37 PM, the DON confirmed the initial report was sent on 07/19/23 and the final report was sent to the Department of Health on 08/02/23 which was more than five days. The DON acknowledged the final Investigation Report was sent in late however, she wanted to have the meeting with the resident's daughter prior to sending in the report so everything was in order. NJAC 8:39-9.4(f)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident in a total sample of 28 residents (Resident (R) 77) whose assessments were reviewed. The facility failed to accurately assess behaviors exhibited for R77. This failure placed the residents at risk of having unmet care needs and services. Findings include: Review of the RAI Manual 3.0, dated 10/19 revealed, .If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . Review of the Admission Record found on the Profile page of the electronic medical record (EMR) revealed R77 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, and major depressive disorder. Review of R77's behavior and medication administration notes found on the Progress Notes tab revealed the following entries: On 05/26/23 at 2:20 PM Behavior Note: Resident noted entering other resident rooms and taking their belongings. During attempt at redirection, resident punched male aide. On 05/27/23 at 11:07 AM Medication Administration Note: Resident was noted pacing corridors looking into other residents [sic] room. Resident was redirected back to his room multiple times where he would remain for a short period then attempts to enter other residents [sic] room and steal there [sic] belongings. On 05/27/23 at 7:06 PM Medication Administration Note: Resident wandering into female bedrooms and tried to hit staff members when confronted. On 05/28/23 at 12:00 PM Medication Administration Note: Resident noted entering other residents [sic] room and stealing there [sic] belongings. On 05/30/23 at 1:38 PM Behavior Note: Resident noted pacing corridors looking into other residents [sic] room. Resident was redirected back to his room multiple times where he would remain for a short period then attempts to enter other residents [sic] rooms and steal there [sic] belongings. Review of R77's discharge- return anticipated MDS with an Assessment Reference Date (ARD) of 05/30/23, located in the MDS tab of the EMR, indicated, R77 exhibited wandering behavior daily, but the assessment did not reflect that R77 was exhibiting physical behaviors directed toward others (including hitting) or other behavioral symptoms not directed toward others (including pacing and rummaging). During an interview on 09/29/23 at 8:30 AM, the MDS Coordinator (MDSC) reviewed R77's progress notes and 05/30/23 discharge MDS assessment. The MDSC stated, R77 had exhibited physical behaviors toward others and other behaviors including pacing, rummaging, and attempting to steal other resident's belongings that were not reflected on the resident's 05/30/23 MDS. The MDSC stated she coded R77's 05/30/23 discharge MDS assessment inaccurately. NJAC 8:39-11.2(g)

Based on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and person-centered interventions for two (Residents (R)100 and R59) in a total sample of 28. The facility failed to develop specific care plan and person-centered interventions related to an anti-coagulant medication for R100, and failed to develop a person-centered care plan with interventions related activities of daily living (ADLs) for R59. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included: Review of an undated facility policy titled, Care Plan, Comprehensive Person-Center, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: ~ Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. ~ Any specialized services to be provided as a result of PASARR [Pre-Admission Screening and Resident Review] recommendations and ~ Which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes. ~ builds on the resident's strengths; and ~ Reflects currently recognized standards of practice for problem areas and conditions. ~ Services provided for or arranged by the facility and outlined in the comprehensive care plan are: Provided by qualified persons; culturally competent; and trauma-informed . The Care Plan, Comprehensive Person-Centered facility policy further revealed, .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms . 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R100 admitted to the facility on [DATE] with diagnoses that included dementia, impulse disorder, and anxiety disorder. Review of the Order Summary located in the Orders tab of the EMR revealed the follow physician orders: Xarelto (a blood-thinning medication) 20 MG (milligrams) Give 1 tablet in the evening for atrial fibrillation [an irregular heart rhythm], dated 02/26/23. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/07/23 revealed R100 had a Brief Interview of Mental Status (BIMS) score of one out of 15 which indicated he was severely impaired in cognition and was administered an anticoagulant medication for seven out of seven days during the observation period, According to the Food and Drug Administration online resource at accessdata.fda.gov, revealed that Xarelto are black box warning medications. A black box warning is the strictest and most serious type of warning that the FDA gives a medication. A black box warning is meant to draw attention to a medication's serious or life-threatening side effects or risks. Review of the updated Behavior's Care Plan located in the Care Plan tab of the EMR, dated 07/17/23, did not reveal a focus, measurable goal, or specific interventions for the use of the high-risk medication, Xarelto. During an interview on 09/27/23 at 2:30 PM, the Director of Nursing (DON) was asked who was responsible for care plan development. The DON stated, It used to be me and the MDS Coordinator and now we have unit managers who are starting to do some of them. The DON was asked if a resident is on anticoagulant medication would you expect a care plan for the medication as it's a high-risk medication. The DON stated, Yes, but we just put it on the Skin Care Plan to monitor for bruising and bleeding. During an interview on 09/28/23 at 9:33 AM, the MDS Coordinator (MDSC) stated that Xarelto did not come up in the Care Area Assessment as a triggered problem therefore a care plan was not developed for the medication. 2. Review of the Admission Record located in the Profile tab of the EMR revealed, R59 was admitted to the facility on [DATE] with diagnoses that included induced dementia from alcohol abuse, post-traumatic stress disorder [PTSD], schizoaffective disorder (a mental illness that combines schizophrenia and bipolar depression), and anxiety. Review of the quarterly MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/08/23 revealed R59 had a BIMS score of six out of 15 which indicated she was severely impaired in cognition, required supervision for ambulation, limited assistance with dressing, was extensive assistance with toilet use and personal hygiene and was occasionally incontinent of bowel and bladder. Review of the updated Care Plan located in the Care Plan tab of the EMR, dated 08/23/23 revealed no focus, measurable goal, or specific person-centered interventions related to ADL's including hair washing. Review of the Kardex (a care plan for nursing assistants with direction on how to care for residents) located in the Tasks tab of the EMR revealed no information for ADLs, based on the MDS assessment on how to care for R59. During an initial observation on 09/26/23 at 10:00 AM, R59 was in her room and her hair appeared greasy and matted. R59 stated, I can toilet myself and do my own personal hygiene. During an interview on 09/28/23 at 9:12 AM, R59 was asked if she was getting her showers routinely. R59 stated, I do them myself. I don't like the shower, so I clean myself up at the sink in my room. R59 was asked if staff helped her with getting her hair washed. She stated, I do that myself. I don't like the water running over my head. R59 further stated, I just washed my hair this morning at 4:00 AM. R59's hair continued to look greasy and matted. During an interview on 09/28/23 at 9:13 AM, Certified Nurse Assistant (CNA) 2 was asked about R59's ADLs. CNA 2 stated, Basically you have to assist her a lot, change her brief, change her clothes, she says she is independent, but she requires assistance. She never wants to take a shower. CNA 2 further stated that the facility has shower caps with the dry shampoo in them and her normal aide is good with her, they aren't great but if she will let us, they are better than nothing. During an interview on 09/28/23 at 9:45 AM, MDSC was asked if there was an ADL Care Plan developed with resident-specific interventions. The MDSC stated, No, not by itself. The MDSC was asked on the Kardex there is no information for the aides to document how independent, assisted, or what support is needed or what her specific needs were related to ADLs. The MDSC stated, Yes, I am aware that it's not in the computer. Our other sister facilities have that tab, but we don't, and I don't know who it works. NJAC 8:39-11.2(e)

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) for one of one resident observed (Resident) (R) 72) during medication pass. Findings include: Observation during medication pass on 09/27/23 at 1:32 PM revealed Licensed Practical Nurse (LPN) 2 placed the medication cart by the door to R72's room. Posted on the wall by the entrance to R72's room was a sign that indicated R72 was on EBP. The signage revealed, Staff must wear gloves and gown for the following high contact resident care activities; device care use, central line, urinary catheter, feeding tube LPN2 removed a stethoscope from a drawer in the medication cart, placed two-barrel syringes on top of the cart and removed a 10 milligram (mg) tablet of Isosorbide from R72's bubble pack. LPN2 entered R72's room without donning (putting on) a gown and placed all the gathered supplies on the top of R72's over the bed table without cleaning the table or using a barrier. After doffing gloves and performing hand hygiene, LPN 2 picked up the potentially contaminated stethoscope and placed it back in the drawer of the medication care. During an interview with LPN2 at 1:45 p.m. on 09/27/23 when questioned about a gown not donned prior to entering R 72's room and potentially contaminating the stethoscope, LPN 2 replied, I was going to check it [placement of the G-tube] with the stethoscope but decided to aspirate instead. Yes I forgot to clean it off. I should have worn a gown. I didn't think of that. During an interview with the Director of Nursing (DON) at 12:30 PM on 09/29/23, the above observations of LPN2's breaks in infection control were reviewed. The DON indicated that he/she was aware and stated, I've already done some education with that LPN. Review of the facility policy titled Enhanced Barrier Precautions updated June 2023 revealed, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity. g. The use of gown and gloves, device care or use (central line, urinary catheter, feeding tube). NJAC 8:39-19.4(a)

Based on observation, review of the maintenance log, and interview, the facility failed to provide a clean, comfortable, homelike environment for two of three units (B and C units) of the facility. Findings include: 1. Observation on 09/26/23 at 12:20 PM of C unit revealed in room [ROOM NUMBER] on the B side of the room there were water marks going down the wall by the air conditioning window unit. The molding around the air conditioner appeared dark in color and not clean. There was no resident currently residing on the B side, however there was a resident in the room on the A side. 2. Observation on 09/26/23 at 12:50 PM of the B unit revealed the plastic handrail on the B hall across from the nurse's station had a crack in the rail which could fit a hand inside and could cause possible injury. There was also a handrail with a crack and hole in it across from room [ROOM NUMBER]. Review of the Maintenance Log provided by the Maintenance Director (MD) dated August 2023 did not reveal the handrails or room [ROOM NUMBER] to be on the log to be fixed. Interview and observation on 09/29/23 at 11:28 AM with the MD confirmed the plastic handrail on the B unit hall across from the nurse's station had a crack in it which could fit a hand inside and could cause possible injury. Observation of room [ROOM NUMBER] on C unit revealed the air conditioner unit was installed above B bed and there were water marks down the wall. The molding was dark in color. The MD stated the box was not installed properly to drain backwards outside. He confirmed that this could cause a problem for residents residing in the room. The MD confirmed he did not have room [ROOM NUMBER] and the handrails on the maintenance log to be repaired. NJAC 8:39-4.1(a)11 NJAC 8:39-31.2(e) NJAC 8:39-31.4(a)(f)

COMPLAINT#: NJ162927, NJ164068 Based on interview, record review, and facility policy review, the facility failed to ensure two (Resident (R) 20 and R57) of six sampled residents reviewed for abuse were free from resident-to-resident physical abuse out of a total sample of 28 residents. Findings include: 1. Review of R20's Admission Record, located in the Profile section of the electronic medical record (EMR), revealed R20 was admitted to the facility on [DATE]. Review of R20's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/12/20, located in the MDS tab of the EMR, revealed R20 scored seven of 15 on the Brief Interview Mental Status (BIMS) which indicated severe cognitive impairment. Review of R20's Nursing Notes,' located in the Progress Notes section of the EMR, dated 05/05/23 at 4:48 PM, revealed, Called to C wing by nurse on floor s/p [status post] resident to resident altercation. Observed [R20] seated in WC [wheelchair] at nurse's station with 3-centimeter (cm) skin tear to left posterior forearm visible. Assessed area and initiated treatment. Review of R77's Admission Record, located in the Profile section of the EMR revealed R77 was admitted to the facility on [DATE]. Review of R77's annual MDS assessment with an ARD of 02/17/23, located in the MDS tab of the EMR, revealed R77 scored five of 15 on the BIMS which indicated severe cognitive impairment. Review of R77's Nursing Notes, located in the Progress Notes section of the EMR dated 05/05/23 at 5:16 PM, revealed, Called to C wing by nurse on floor s/p resident to resident altercation in which [R77] was the aggressor. Resident was observed standing in the hallway. Assessed for injury, none noted. When asked about incident, the resident did not give verbal response & shrugged shoulder. Escorted resident back to room & placed on 1:1 [one on one] supervision. Review of the facility's Investigation and Summary, dated 05/08/23, of the resident-to-resident altercation between R20 and R77 revealed, On May 5th the following incident occurred. At approximately 3:45 PM, the district nurse notified the supervisor that there was a resident-to-resident altercation occurred between resident [R20] and [R77]. The district nurse heard yelling coming from the room of [R20], when she entered, she found [R20] sitting in his wheelchair with a skin tear noted to his forearm and resident [R77] standing in front of the closet. The two residents were immediately separated. The supervisor interviewed [R20] who stated, He came into my room and was going through my closet. I took the sweatshirt away from him, he tried to take it back and scratched my arm. Then the nurse walked in. Then [sic] supervisor then interviewed [R77], who was unable to provide information due to cognitive status. [R20] denied any pain at the time of the incident. [R77] was placed on 1:1 close monitoring. IDC [Interdisciplinary Care Team] met to discuss the incident and believe that abuse did not occur. [R77] made contact with [R20's] arm while trying to obtain the sweatshirt back from him. [R77] intention was not to harm [R20] but to obtain the sweatshirt from him. Interview with the Director of Nursing (DON) on 09/28/23 at 3:16 PM confirmed on 05/05/23 R77 entered R20's room and scratched R20's arm. The DON stated the facility investigated this resident-to-resident altercation between R77 and R20 and the IDC team did not believe abuse occurred. 2. Review of R57's Admission Record, located in the Profile section of the EMR, revealed R57 was admitted to the facility on [DATE]. Review of R57's annual MDS assessment with an ARD of 05/15/23, located in the MDS tab of the EMR, revealed R57 scored 15 of 15 on the BIMS which indicated R57 was cognitively intact. Review of R57's Nurses Notes in the Progress Notes section of the EMR, dated 03/23/23 which specified R57 called a nurse to her room following a physical altercation between her and another resident (R79). Residents were immediately separated with no apparent injuries and no complaints of pain or discomfort. Review of R79's Admission Record, located in the Profile section of the EMR revealed R79 was admitted to the facility on [DATE]. Review of R79's annual MDS assessment with an ARD of 02/10/23 located in the MDS tab of the EMR, revealed R79 scored zero of 15 on the BIMS which indicated severe cognitive impairment. Review of the facility's Investigation and Summary, dated 03/24/23, of the resident-to-resident altercation between R57 and R79 revealed, on 03/23/23 At approximately 5:45 PM, a nurse was called to [R57's] by resident [R57]. Resident [R57] stated that resident [R79] wandered into his/her room. [R57] stated that she attempted to coach [R79] out of her room by the arm when [R79] began hitting [R57] in the chest. The nurse immediately separated the two residents .No skin impairments or complaints of pain were noted upon assessment. [R79] was placed on 1:1 close monitoring. IDT [Interdisciplinary Team] met to discuss the incident and believe that abuse did not occur. Due to [R79's] cognitive impairment, she did not understand what was occurring when [R57] attempted to redirect [R79] out of her room and became defensive due to the redirection. During an interview on 09/28/23 at 3:16 PM the DON confirmed that the 03/23/23 incident occurred and added that R79 is no longer combative and has not been combative since the incident of 03/23/23. Interview with the facility's Regional Nurse on 09/29/23 at 12:35 PM revealed the facility's expectation was residents would be free from abuse. Review of the facility's undated policy titled, Preventing Resident Abuse, indicated, It is the policy of the facility that our facility will not condone any form of resident abuse and will continually monitor our facility's policies and procedures, training programs, systems, etc., to assist in preventing resident abuse. NJAC 8:39-4.1(a)5 05409

NJ , NJ , NJ Based on interviews and review of Medical Records (MRs) and other facility documentation, it was determined that the facility failed to administer antianxiety medication timely to 1 of 5 sampled residents (Resident #1), an alert and oriented resident, who requested the medication due to feeling anxious. Resident #1 requested [MEDICATION NAME], an antianxiety medication, at approximetely 11 p.m. on 7/8/2015, however, it was not administered until 12:15 a.m. on 7/9/2015, 1 hour and 15 minutes later, because the nurses were busy. Resident #1 subsequently exhibited aggressive behaviors. This deficient practice is evidenced by the following; 1. According to the facility Face Sheet, Resident #1 was admitted to the facility in 10/2015 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 4/18/2015, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition and could ambulate and transfer without assistance. A Care Plan (CP), initiated 10/16/2014 and re-evaluated on 5/26/2015, indicated [DIAGNOSES REDACTED]. Behaviors included but were not limited to; physical and verbal outbursts, aggression, attention seeking, refusing medications and care. The CP indicated that Resident #1 took medication to manage diagnoses, behaviors and agitation at times. Goals included to manage behaviors and decrease episodes of outbursts over the next quarter and to manage on the lowest possible dose of medications without any negative side effects. Interventions included but were not limited to; take medications as ordered, monitor, document any change in behaviors. If behaviors noted, attempt to determine contributory cause i.e.; loud noise, another resident.and remove from the situation if able, attempt to redirect with activities, 1:1 conversation, take to calm quiet area, smoke break, etc. Document all attempts at re-direction regardless of success. A Psychiatric Consult, dated 6/17/2015, indicated to continue treatment for [REDACTED]. A review of a 7/2015 Physician order [REDACTED]. A 7/2015 Medication Administration Record [REDACTED]. A review of the 6/2015 MAR indicated [REDACTED]. A physician progress notes [REDACTED]. A Nurses Note (NN), dated 6/19/2015, confirmed that [MEDICATION NAME] was ordered PRN for anxiety. A Psychological Progress Note consult, dated 6/29/2015, indicated Resident #1 was attention seeking, demanding and repetitively questioning. Recommendations for staff included to offer praise and thanks when behaving appropriately, not demanding. On 6/28/2015, a NN revealed that the resident requested [MEDICATION NAME] for an upset stomach and later in the day, Tylenol for pain, both of which were administered and effective. A NN, dated 6/29/2015 indicated the resident was alert and oriented times 3. A Nursing Behavior Log Note (BLN), dated 7/1/2015 at 11:45 p.m., revealed Resident #1 requested to go to crisis, however, did not appear anxious but was calm and alert. The resident expressed that no one likes her.Resident (#1) stated she was 'a nervous wreck'. The nurse encouraged the resident to go to a quiet place. PRN [MEDICATION NAME] offered for c/o (complaint of) anxiety and tearfulness. A NN, dated 7/2/2015 at 1 a.m., revealed; Resident c/o (complained of) anxiety at 12 a.m. stating 'Nobody likes me, everyone is mean, I need more pain meds (medication).' Resident very tearful. offered PRN [MEDICATION NAME] at 12 a.m. voiced (positive) relief by 1 a.m. Will monitor. There was no documention on the MAR indicated [REDACTED] NN on 7/3/2015 at 6 a.m.; No issues r/t (related to) [MEDICATION NAME] PRN order No c/o (complaint of) anxiety, no behaviors. A BLN on 7/4/2015 at 10 p.m. indicated Resident #1 was observed in the courtyard smoking and was told that she would lose her good behavior cigarette on 7/5/2015 (because it was after approved smoking times). The resident approached the nurse and requested to go to crisis because she felt very anxious; she (Resident #1) exhibited no symptoms of.crying, yelling or agitation.requested to speak with a supervisor. Review of the Medication Administration Record [REDACTED] On 7/5/2015 at 11 p.m., a BLN revealed; Resident consistently calling desk throughout shift expressing she was anxious and wanted to be able to smoke when she wanted. PRN [MEDICATION NAME] 0.5 mg given with (positive) effect. A BLN, dated 7/5/2015 at 8 p.m. revealed; Resident expressed that she was feeling very anxious.started crying. [MEDICATION NAME] administered as per order with (positive) results. Review of the MAR indicated [REDACTED]. On 7/5/2015, a BLN at 11:45 p.m., 12:30 am. and 12:52 a.m. revealed Resident #1 requested to go to crisis for a c/o anxiousness however, showed no signs or symptoms of anxiety. Resident was speaking in slow even tone and not crying, and not yelling. The resident called 911 who responded, interviewed the resident who was a/o (alert and oriented) x 3 and able to make decisions. The resident was transferred to the hospital and returned at 7:15 a.m. with no new orders. A BLN, dated 7/6/2015 at 2 p.m., indicated Resident (#1) medicated with PRN [MEDICATION NAME] at this time. Resident yelling and screaming in hall. Redirection and snacks offered without success. The MAR indicated [REDACTED]. A BLN, dated 7/6/2015 at 10 p.m., Resident (#1) asking for [MEDICATION NAME] when no s/s (sign or symptom) of anxiety are present. Educated resident (#1) on when it is appropriate to give [MEDICATION NAME] PRN-Resident (#1) demanding to know s/s (signs and symptoms) of anxiety-explained to resident (#1) that this nurse does not need to give her exact s/s (signs and symptoms)of anxiety. Resident in shower, c/o (complained of) not being able to breath, explained to resident that if you could not breath you would not be able to talk. Resident got out of shower yelling, screaming and crying- gave PRN [MEDICATION NAME] at 9:50 p.m. Review of the MAR indicated [REDACTED]. 7/8/2015 at 12:30 a.m., the BLN revealed that on the 3-11 shift, Resident #1 had been caught outside smoking, against the smoking policy and was upset she was caught. At 11:30 p.m., the resident stated; I want my [MEDICATION NAME] now , I'm having anxiety and I can't breath. The Nurse documented that the resident was not displaying any s/s of anxiety and tried to educate her (Resident #1) that she could not give her [MEDICATION NAME] because she demands it. That she has to actually have anxiety to receive her prescribed [MEDICATION NAME]. Resident then asked how she has to act to get her [MEDICATION NAME]. Explained to resident that if she is having true anxiety that this nurse would recognize that and would medicate her as needed. Resident demanded to speak with supervisor, he was made aware and came to speak with her. Resident became aggressive and was banging and pushing on the door to go out to the court yard, yelling out, 'I want my [MEDICATION NAME] yelling out profanity to staff, became tearful, medicated with PRN [MEDICATION NAME] at 12:15 a.m. for anxiety. As soon as resident took medication the crying and yelling stopped and she proceeded outside.to smoke, against smoking policy. Additionally, the BLN indicated that the facility received a call from the police department stating Resident #1 had called them requesting to be sent to crisis for her anxiety. The nurse advised the police the resident was medicated and was showing no s/s of anxiety, was calm at this time and the decision was made that there was no medical necessity to be sent for an evaluation. At 1 a.m., 2 Emergency Medical Transport (EMTs) arrived and were informed that there was no medical need for the resident to go and as the EMTs preceded to leave the facility the resident became upset and body slammed herself against the unit doors and busted through. The resident was escorted back to the unit with staff assistance. Review of the MAR indicated [REDACTED]. Review of an employee statement, dated 7/7-7/8/ from the 11-7 shift Registered Nurse (RN) Supervisor revealed that he was called to Resident #1's unit on 7/8/2015 at approximetely 11:15-11:30 p.m., because the resident was apparently distracting nurses during (narcotic) count and report. Resident (#1 ) was at desk screaming and crying asking for [MEDICATION NAME] b/c (because ) she couldn't breath and was anxious. I (RN Supervisor) explained to resident (#1) that the nurses were busy. She asked to be let outside to which I let her out. Several minutes later I received a call from 911 asking the status of the resident. 911 responders also arrived not long after (PRN ([MEDICATION NAME]) was given to resident before arriving). The resident followed the 911 responders to the unit door and pushed her way through the doors to another unit. The resident was escorted back to her unit and threw her whole body into the unit courtyard door for 30-45 minutes despite multiple attempts at redirection. The resident continued to call 911 multiple times and continued with behaviors. The DON and NP were all made aware. During an interview with the surveyor on 7/14/2015 at approximetely 9:30 a.m., the RN Supervisor confirmed his statement and added that Resident #1 was not agitated when he arrived on the unit but was repeatedly asking for her [MEDICATION NAME]. The resident then went outside while the nurses were counting and getting report and he received a call from 911 that the resident called and complained she was not getting her medication for anxiety. I (RN Supervisor) explained to them (911) that they (nursing staff) were in the middle of shift report and the nurse coming on did not have the key (to the medication cart) as they were counting. The RN Supervisor added that the 911 caller then asked to speak with the medication nurse (11-7 LPN) and by that time Resident #1 was inside and had been given her [MEDICATION NAME]. When the ambulance arrived they did not take Resident #1 because she got her medication. The resident started crying and telling them she wanted to go to crisis. The resident pushed though a door but was escorted back to the unit with the assistance of the RN Supervisor. The surveyor asked why [MEDICATION NAME] was not administered to Resident #1 when she requested it for anxiousness and the RN Supervisor stated Resident #1 was not initially showing any outward signs of anxiousness such as crying or yelling and the staff were receiving the nursing report for the unit. A clarification statement, dated 7/22/2015 from the 11-7 RN Supervisor, inlcuded that he observed Resident #2 standing at the desk asking for [MEDICATION NAME] in a normal voice, not crying, no tearfulness or any apparent sign of anxiousness when he arrived on the unit. The resident c/o not being able to breath, asked for [MEDICATION NAME]. The RN Supervisor attempted to use a non-pharmacological intervention at that time as resident was breathing normally however there was no evidence of shortness of breath. During an interview with the surveyor on 7/14/2015 at 8:30 a.m. and in a telephone interview on 7/24/2015 at 2:20 p.m., the 11-7 License Practical Nurse (LPN) who worked on 7/7-7/8/2015 stated that she started her shift at 11 p.m. and as soon as she walked on the unit, the Resident #1 was asking for [MEDICATION NAME] because she was anxious. I hadn't even counted or got report. The LPN stated she was completing the narcotic count, when Resident #1 came up again to the medication cart and asked calmly for her [MEDICATION NAME] because she was anxious. The LPN stated she told Resident #1; let me get report and count first and see what's going on. The resident was asked to calm down and she did somewhat but continued to ask for her [MEDICATION NAME] during report. The Supervisor came up about 11:30 p.m. and the resident was at the nursing station, he spoke with her and she went outside. She then became anxious after report, started yelling and stomping, she went outside. The LPN stated the resident went outside while getting report and smoked. The LPN stated she asked Resident #1 what she was anxious about and the resident started yelling; She (Resident #1) was very tearful at that time so I gave [MEDICATION NAME]. The LPN confirmed the police called and inquired about the resident and she informed them she was calm and referred them to the RN Supervisor. When the ambulance arrived, we told them no need to take Resident #1 but the resident said don't leave without me. The surveyor asked the 11-7 LPN why she did not administer [MEDICATION NAME] when Resident #1 requested it initially on 7/8/2015 at 11 p.m. LPN stated that she did not administer the medication because staff try non-pharmacological interventions first and the resident was not exhibiting any signs of anxiousness. Additionally, the LPN stated she had not yet received report from the previous shift and she needed to find out what was going on and then complete the narcotic count. During an interview with the surveyor on 7/22/2015 at 12:30 p.m., the 7-3 shift Unit Manager (UM) stated that examples of anxiety symptoms would be fidgety, feeling uncomfortable; It's their feelings; sometimes we see yelling. The UM stated that if a resident is asking for a PRN medication during nursing report, a medication pass or count, then the report or medication pass should be stopped and the nurse should assess the resident and give the PRN medication if warranted. NJAC 8:39-27.1