Every finding on record at Autumn Lake Healthcare at Oceanview

Complaint # NJ 2979687Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to initiate a complete and thorough investigation after a cognitively intact resident and their resident representative (RR) made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 3 residents (Resident #30) reviewed for abuse.On 3/31/2026 on the 3PM-11PM shift, Resident #30 alleged that a Certified Nursing Assistant (CNA #1) threw a call device and oxygen tubing /nasal cannula (a device that delivers oxygen through a tube and through the nose) at them and reported the allegation to their Resident Representative (RR). The RR notified the Registered Nurse Supervisor (RNS) during that shift and the Licensed Practical Nurse/Unit Manager (LPN/UM#1) the following day. The RNS stated that she notified the facility Director of Nursing (DON) via text message of the allegation that shift and that CNA #1 had Resident #30 removed from their assignment and was placed on another resident assignment. During interviews with the surveyor, the DON stated that she missed the text message from the RNS and did not respond. Surveyor interviews with the RR and Resident #30 confirmed the allegation and RR notification to the RNS and the LPN/UM#1. Interviews with the Licensed Nursing Home Administrator (LNHA) and the DON confirmed that they did not investigate the allegation of staff to resident abuse. CNA #1 continued to work an additional 13 shifts on 3 of 3 units having access to all facility residents.The facility's failure to implement their abuse policy by thoroughly investigating an allegation of physical abuse and immediately removing CNA #1 from resident care placed Resident #30, as well as all residents at risk for abuse. This posed the likelihood of serious physical and psychological harm, or impairment, and resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 3/31/2026, when Resident #30 and their RR made the facility's RNS aware of an allegation of physical abuse by CNA #1. The facility administration was made aware of the IJ situation on 4/22/2026 at 2:34 PM. The facility submitted an acceptable Removal Plan (RP) on 4/23/2026 at 11:03 AM. The team verified the implementation of the RP on-site during the continuation of the survey on 4/23/2026. The evidence is as follows:A review of the facility's Abuse, Neglect, and Exploitation, policy updated 11/20/2025, included: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation. Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Protection from retaliation; Room or staffing changes, if necessary, to protect the resident (s) from the alleged perpetrator. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within the specified timeframes. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.On 4/21/2026 at 11:30 AM, during the initial tour of the facility, the surveyor was approached by Resident #30's RR who stated that during a video call with Resident #30, the RR was made aware of an allegation from Resident #30 that a staff member threw oxygen tubing at Resident #30 and then proceeded to walk out of the room. The RR told the surveyor that they were not sure of the date of the incident but that they had made the Registered Nurse Supervisor (RNS) aware via telephone call the night of the alleged physical abuse. The RR further told the surveyor that Resident #30 was scared. The RR further stated that both the RR and Resident #30 made the RNS aware, and they were told that they would investigate. The RR stated that he/she did not know if an investigation had been completed at the time of interview. On 4/21/2026 at 1:31 PM, the surveyor interviewed LPN/UM #1, who was assigned to the unit where Resident #30 resided. LPN/UM #1 stated that he was made aware the day after the allegation of CNA #1 throwing a call bell device at Resident #30, but not oxygen tubing. LPN/UM #1 stated that Resident #30's RR met with him and informed him that CNA #1 threw the call bell device at Resident #30. LPN/UM#1 stated that he called CNA #1 at home and questioned her about the alleged event, and she denied that anything happened. LPN/UM #1 stated that he did not inform anyone else afterward or document the incident because he did not think there was an issue after he had spoken with CNA #1. LPN/UM #1 was unable to recall the date and time that the allegation occurred and stated that he thought that it happened over a month ago in March.On 4/21/2026 at 1:52 PM, the surveyors conducted an interview via telephone with the RNS, who stated that when she became aware of the event she immediately went down to the unit and removed the accused staff (CNA #1) from the resident's assignment and notified the DON by text message. The RNS stated that she notified the DON because it was an allegation of abuse, and she was required to report it. The RNS confirmed that she moved the accused CNA (CNA #1) to another resident assignment.On 4/21/2026 at 3:16 PM, in a follow up in-person interview with the RNS, she stated that the allegation of abuse was made by the resident's RR via telephone. The RNS further stated that the RR had an allegation of both a call bell and a nebulizer mask being thrown at the resident. The RNS stated that she investigated immediately and then notified the DON via text and telephone who stated that she would speak with the RR in the morning. The RNS stated that she told the DON what she did with CNA #1 concerning her work assignment.On 4/21/2026 at 3:38 PM, the surveyors interviewed the Registered Nurse (RN #1), who confirmed that the alleged event happened on 3/31/2026, on the 3PM-11PM shift. RN #1 stated that CNA #1 came out of Resident #30's room upset and stated that Resident #30 had accused her of throwing the call bell at the resident. RN #1 stated that the RNS was notified and got involved. RN #1 stated that CNA #1 remained on the unit for the rest of the shift and was removed from Resident #30's room assignment. RN #1 stated that she did not obtain any written statements. RN #1 further stated that she did not know if the DON or the LNHA were notified.On 4/22/2026 at 9:01 AM, the surveyor conducted an interview with Resident #30. Resident #30 was observed lying in bed awake and alert. Resident #30 was watching television and was observed receiving oxygen at 4 liters per minute via nasal cannula. The surveyor asked Resident #30 if they ever had a call bell device thrown at them by a facility staff member. Resident #30 immediately responded, Yes. Resident #30 stated she was unable to recall specifically when it happened and didn't know the staff member's name.On 4/22/2026 at 9:37 AM, the surveyors interviewed the LNHA and the DON in the presence of the survey team. The LNHA stated the surveyor brought a pretty serious concern to his attention that he had not been made aware of. The DON stated that she was made aware after the RNS had sent her a text regarding the allegation on 3/31/2026. She stated she had missed the text message and had not responded to it. The DON stated that she had a conversation with the RNS and she reiterated that the resident was fine because the call device was in place and the oxygen tubing was observed to be in his/her nose, and the call bell was pinned to the bed. The DON further explained that the RNS should have called her if there was an allegation of abuse. The DON stated that they did not receive any information from the LPN/UM #1 regarding the allegation. The DON stated that if an allegation of abuse occurred, the facility should have followed their abuse policy and conducted an immediate investigation. On the same date and time, the DON confirmed that they did not investigate immediately, and the investigation should have started with herself. The DON further stated that if there was an allegation of abuse, the involved or accused staff should have been sent home, and that an incident report, progress note, physician notification, ombudsman notification, police notification, and the New Jersey Department Of Health (NJDOH) should have been notified of the allegation of abuse. The LNHA stated, We missed this one.On 4/23/2026 at approximately 9:38 AM, the surveyor reviewed the staffing schedules provided by facility administration for CNA #1 from 3/31/2026 up to the present. Review of the staffing schedules revealed that CNA #1 provided care to facility residents for 13 shifts on 3 of 3 units on the following dates after being accused of staff-to-resident physical abuse: 3/31/2026 (3 PM-11 PM shift), 3/31/2026 (11 PM-7 AM shift), 4/2/2026 (3 PM-11 PM shift), 4/11/2026 (3 PM-11 PM shift), 4/11/2026 (11 PM-7 AM shift), 4/12/2026 (3 PM-11 PM shift), 4/12/2026 (11 PM-7 AM shift), 4/14/2026 (3 PM-11 PM), 4/14/2026 (11 PM-7 AM shift), 4/16/2026 (3 PM-11 PM shift), 4/16/2026 (11 PM-7 AM shift), 4/19/2026 (3 PM-11 PM shift) and 4/19/2026 (11 PM-7 AM shift).On 4/23/2026 at 1:20 PM, the surveyors conducted an interview with the facility medical director (MD), who stated he was familiar with Resident #30 and was not aware of any abuse at that time. The MD told the surveyors that if there were an allegation of abuse, his expectations were that the facility would investigate, notify the administrator, police, document everything and that the accused staff member should be removed from the resident. The MD stated that the abuse policy should specify what should be done with the alleged staff member. In addition, the surveyors asked if it was appropriate for the RNS to communicate an alleged incident of physical abuse by text message. The MD said the RNS should communicate with the administrator via telephone. The MD told the surveyors that the importance of an immediate investigation was to prevent further abuse of another resident and to ensure resident safety. The MD stated that he would expect to be notified of an event of abuse at the same time the administrator was notified by text and then he would call the facility in response. The MD stated his role was to ensure an investigation was completed properly and to ensure resident safety by keeping the accused away from the alleged victim.On 4/27/2026 at 8:24 AM, the surveyor conducted a phone interview with CNA #1. The surveyor asked CNA #1 if she was aware of an allegation of staff-to-resident abuse on March 31, 2026, involving her. CNA #1 explained that Resident #30's call bell was activated, and when she walked into Resident #30's room, the supervisor (RNS) was in the room, and Resident #30's RR was on the phone. She stated the supervisor pulled her aside and told her the RR made an accusation that she threw the call device at the resident. CNA #1 stated that the call device was duct taped to the dresser, so how could I have thrown it? CNA #1 elaborated that the RR also alleged that she threw an oxygen mask and a nebulizer at Resident #30. She stated she never saw a nebulizer and the oxygen mask was on the resident. The surveyor asked CNA #1 what the facility did with her assignment once the allegation of abuse had been made. CNA #1 responded that they changed her resident assignment that night and kept her off Resident #30's assignment and that she worked a double shift that night (3 PM-11 PM and 11 PM-7 AM). CNA #1 stated that she had not been assigned to Resident #30 since the allegation had been made and continued to work at the facility until a week and a half ago. CNA #1 further explained that last week she was told that an investigation was going on and she could not work until it was resolved. CNA #1 added that she received abuse training from her agencyThe surveyor reviewed the electronic medical record for Resident #30.A review of the admission Record, an admission summary, revealed that Resident #30 had the following diagnoses which included but were but not limited to; chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease-primarily caused by smoking-that obstructs airflow, causing chronic breathing difficulties), major depressive disorder, anxiety disorder, repeated falls, and acute and chronic respiratory failure.A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/12/2026, included Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that Resident #30 was cognitively intact. Section E of the MDS revealed that Resident #30 did not experience hallucinations or delusions and did display any behavioral symptoms. Section GG revealed that Resident #30 was dependent on staff for most activities of daily living. Section O of the MDS revealed that Resident #30 received hospice care while a resident at the facility.A review of the Individual Comprehensive Care Plan (ICCP) included the following focus areas:A focus area initiated on 2/26/2026, indicated that Resident #30 had mood problems related to admission. Interventions included: Report to MD (medical doctor) prn (as needed) acute episode of feelings (sic) or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.A focus area initiated on 2/26/2026, which indicated Resident #30 had oxygen therapy related to COPD. Interventions included: Oxygen Settings: [Resident #30] has O2 (oxygen) via nasal prongs (nasal cannula) (at) 4L (liters) continuously.On 4/27/2026 at 9:55 AM, the surveyor reviewed the progress notes (PN) from 3/1/226 up to 4/7/2026 at 23:43 (11:43 PM). Review of the PN did not reveal any documentation concerning the alleged physical abuse event on 3/31/2026 on the 3 PM-11 PM shift.The facility submitted an acceptable Removal Plan (RP) on 4/23/2026 at 11:03 AM, which indicated the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice which included: CNA #1 was suspended pending investigation. Resident #30 was interviewed by the DON and UM regarding the allegation of physical abuse. The allegation of physical abuse was reported to the New Jersey Department of Health (NJDOH) and the Ombudsman. County law enforcement was notified of the allegation of physical abuse. The DON obtained statements from staff assigned to the B Unit on the identified shift (3:00 PM-11:00 PM) on 3/31/26. The DON/designee initiated a facility-wide re-education on the following topics: Definition of abuse, Types of abuse, Prevention of abuse, neglect, and exploitation, and misappropriation, including physical and psychosocial indicators, Reporting process for abuse, neglect, exploitation, misappropriation of resident property, and injuries of unknown origin, Understanding behavioral symptoms that may increase risk, including: aggressive and/or catastrophic reactions, wandering or elopement behaviors, resistance to care, outbursts or yelling, difficulty adjusting to new routines or staff. Interviewable residents who were on the assignment of CNA #1 from 3/31/26, were asked if they had experienced or witnessed abuse or neglect, confirmed that they felt safe, and were educated on how to report concerns. The DON, UMs, and Infection Preventionist (IP) conducted a skin assessment of all non-interviewable residents on the assignment of CNA #1 from 3/31/26, to assess for any skin irregularities and rule out abuse. The facility Abuse Policy was updated to include immediate removal of the identified (alleged) employee from the schedule pending completion of investigation. The Regional Director of Nursing (RDON) educated the DON and Administrator on the facility Abuse Policy, including reporting and investigation requirements per facility policy and procedure. The survey team verified the implementation of the RP on-site during the continuation of the survey on 4/23/26. NJAC 8:39-4.1(a)(5)

Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) and b.) follow appropriate use of PPE during extensive contact with the environment of a resident on EBP, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 1 of 2 residents (Resident #3) reviewed for dialysis and 4 of 4 residents (3 unsampled residents and Resident #128) reviewed for infection control and was evidenced by the following: 1.) On 4/22/2026 at 12:27 PM, the surveyor conducted a dining observation on the Serenity Unit, in the front dining room. Upon entering the dining room, the surveyor attempted to sanitize their hands using the sanitizer stationed on the wall, but it was empty. The surveyor then left the dining room and obtained sanitizer from a wall unit in the hallway then returned to the dining room to continue the observation. The surveyor observed three unsampled residents seated at Table #2. At that time, CNA #7 was observed at Table #2, assisting all three residents. CNA #7 went from resident to resident rendering feeding assistance and did not perform hand hygiene between residents. On 4/22/2026 at 12:35 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2) who stated that hand hygiene should be performed after each resident was assisted. The surveyor and LPN/UM #2 stood near the dining room door observing CNA #7. LPN/UM #2 confirmed the findings. LPN/UM #2 stated that the sanitizer was empty during breakfast and it has not been replaced yet. She stated that it was her responsibility to ensure that it was refilled. She left out of the dining room to obtain a sanitizer then inserted it into the wall unit. On 4/22/2026 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of Registered Nurse (RN #1). The DON stated that the CNAs were supposed to use either hand sanitizer or wash their hands between each resident. She added that housekeeping was responsible for replenishing the sanitizer when it was empty. She further stated that the CNA should have found another source for hand hygiene and notified management so the hand sanitizer could be refilled. She added that it was important to perform hand hygiene to prevent the spread of germs and bacteria from resident to resident. A review of the facility's policy Hand Hygiene updated January 2026, revealed Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, .after touching a patient or the patient's environment . 2.) Reference: The research that was the basis for the current guidance evaluated high-contact resident care activities, not specifically the risk of transmission of MDROs to the hands or clothing of Environmental Services (EVS) or housekeeping personnel. However, changing linen is considered a high contact resident care activity; gowns and gloves should be worn by EVS personnel if they are changing the linen of residents on Enhanced Barrier Precautions and could be considered for additional environmental services or housekeeping responsibilities that involve extensive contact with the resident or the resident's environment. Gown and glove use by EVS should be based on facility policy and for anticipated exposures to body fluids, chemicals, or contaminated surfaces. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=As%20part%20of%20Standard%20Precautions,while%20using%20Enhanced%20Barrier%20Precautions On 4/22/2026 at 1:16 PM, during a tour of the nursing unit, Surveyor #2 observed Resident #128's room. An EBP signage was posted on the PPE caddy hanging on the door. The surveyor observed Housekeeper (HSK #2) enter the room of Resident #128. The HSK did not perform hand hygiene and did not donn (put on) gloves and a gown before and after entering the resident's room. The surveyor observed the HSK enter the bathroom and collect the plastic bag of trash from the trash bin and placed it on the floor. The HSK then sprayed and wiped down the sink and the surface of the toilet water tank with a purple solution. The surveyor called the attention of HSK #2 and pointed to them the EBP signage and the PPE caddy over the door. The HSK #2 stated that their supervisor did not tell them that they had to wear gloves and gown in that room. The surveyor reviewed the medical record of Resident #128. A review of the admission Record revealed Resident #128 was admitted to the facility with diagnoses cellulitis (bacterial infection) of the lower limb, encounter for orthopedic aftercare, and transplanted organ and tissue status. A review of Resident #128's most recent Annual Minimum Data Set (MDS), an assessment tool dated 4/20/2026, revealed that the resident had an intact cognition. The MDS further revealed that the resident had surgical wounds. A review of the Order Summary Report (OSR) active as of 4/22/2026, included the following physician's orders: Enhanced barrier precautions to be maintained at all times, every shift for wound care. Mycophenolate Mofetil Oral Capsule 250 milligram (mg), give 1 capsule by mouth every 12 hours for kidney transplant A review of the comprehensive care plans revised on 4/22/2026, included a focus for the resident requiring EBP for CDC targeted MDRO. The goal was to minimize cross contamination and infection for 90 days. The interventions included the following: Educate staff and Count to rationales and monitor infection control practices. On 4/24/2026 at 9:09 AM, during an interview with the surveyor, the Housekeeping Director (HD) stated that all their staff members were trained in wearing PPE in rooms of residents on EBP. The HD further stated that housekeeping staff should wear gown, face mask, gloves, and face shield when cleaning the room and bathroom of residents on EBP. A review of the undated facility policy titled Enhanced Barrier Precautions included under Policy Explanation and Compliance Guidelines the following: 1.b.) All staff receive training in high-risk activities and common organisms that require enhanced barrier precautions. 3.) A review of the admission Record (AR) an admission summary, indicated that Resident #3 was admitted to the facility with the diagnoses which included but was not limited to end stage renal disease and cerebral infarction (stroke). A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care dated 4/14/26 indicated that Resident #3 scored a 14 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident was cognitively intact. The MDS also indicated that the resident received dialysis. On 4/21/2026 at 10:02 AM, the surveyor observed Resident #3 lying in bed and had a bandage intact to the left upper arm. The resident was sleeping and unable to be interviewed. The nurse on the unit stated that the resident required dialysis and had a left AV fistula (an abnormal or surgically created connection between an artery (carrying oxygenated blood) and a vein (returning blood to the heart), allowing blood to bypass capillary networks). They are often surgically created for hemodialysis access.) to the left upper arm. The surveyor did not observe any signage posted on the resident's door that the resident was on EBP and also did not observe any personal protective equipment (PPE) readily available for staff use. The surveyor reviewed the residents' electronic medical records (EMR) which revealed the following information: Review of the physician orders dated 2/7/26, reflected an order for Enhanced Barrier Precautions to be maintained at all times every shift. The Individualized Comprehensive Care Plan (ICCP) indicated that Resident #3 required EBP related to CDC targeted MDRO for AV fistula. Interventions included: staff to follow EBP for high contact resident care activities including dressing, bathing and showering, transferring, toileting, providing hygiene, changing linen or briefs, device care or use: central lines urinary catheter, tracheostomy or wound care. EBP signage posted on the door and ensuring that proper use of PPE and availability of personal protective equipment (PPE) and hand hygiene supplies at the point of care. A gown and gloves for all high contact interactions. On 4/22/2026 at 2:12 PM, the surveyor conducted a second observation that there was no signage for EBP posted outside the resident's room and no PPE readily available for staff to use while providing direct care. On 4/23/2026 at 10:06 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that Resident #3 was on dialysis and had an AV fistula in the left upper arm. She stated that she monitored the site by checking for bruit and thrill and ensuring that the site was free from bleeding or signs and symptoms of infection. She stated that the resident was transported to the dialysis center on Monday, Wednesday and Friday. She continued to add that Resident #3 was incontinent and able to communicate needs. She confirmed that the resident should be on EBP due to the dialysis access site and admitted that the resident did not have PPE readily available or a sign posted on the door that informed family or staff that PPE was required while providing direct resident care. She continued to add that she signed the Medication Administration Record (MAR) on 4/21/26, 4/22/26, and 4/23/26 which indicated that EPB was being maintained for Resident #3, however did not check to see if there was a sign posted outside the resident room or a caddy with PPE was on the resident's door with PPE that was readily available for staff or visitors to utilize. On 4/23/2026 at 10:24 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #3 required total care with all aspects of activities of daily living (ADLs). CNA #1 stated that the resident was not on EBP because there were no signs posted on the door and usually there would be a caddy hanging on the resident's door with gloves, mask and gowns. She stated that she had not been wearing the EPB when performing direct resident care because she did not know that the resident was on EBP. She confirmed that if a resident was on EPB staff were responsible to wear PPE such as a glove and gowns to protect the resident from infections. On 4/23/2026 at 11:17 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM #1) who stated that residents identified with wounds, catheters and access to the inside of the resident's body were to be on EBP. He confirmed that a resident that received dialysis should be on EBP which required gloves and gowns utilization when providing direct contact with the resident. He stated that if there was a physician order for EBP then staff should be following the order. He confirmed that EBP protected residents from acquiring infections that could be transmitted to the resident by staff or visitors if they provided direct resident care. On 4/23/2026 at 11:59 AM the surveyor interviewed the Infection Preventionist Assistant Director of Nursing (ADON/IP) who stated that typically EBP was implemented for residents with any internal access into their body such as catheters, wounds, intravenous access and dialysis access sites. She stated that staff should wear gowns and gloves when providing direct resident care. She added that physician orders were obtained, and the staff were to sign out in the MAR that they are maintaining EPB. She stated that enhanced barrier precaution signs were to be posted on the resident's door and a caddy with PPE (gloves, gowns and mask) were to be accessible and placed on the resident's door. A review of the facility policy dated April 2025 and titled, Infection Prevention and Control Program indicated that the EBP protocol is instituted for resident who are infected or colonized with MDROs or are at increased risk of acquiring such organisms will be placed on EBP in accordance with most CDC guidelines. The policy indicated that staff must don (apply) gowns and gloves during high contact resident care activities that involve potential exposure to blood, body fluids, non-intact skin or mucous membranes. PPE is not required for casual contact or non-direct interactions. Visitors to residents on EBP will be informed by the facility of the potential risk and appropriate precautions. While PPE use is not generally required for visitors, hand hygiene and adherence to posted instructions are strongly encouraged. NJAC 8:39-19.4(a); 27.1(a)

Complaint #: 2979687 Based on observation, interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA)/Abuse Coordinator, failed to a.) ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being for an allegation of staff-to-resident physical abuse that occurred on 3/31/2026, and b). failed to protect all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 3 residents (Resident #30) reviewed for abuse and was evidenced by the following: Refer to F600, F607, F609 and F610On 4/21/2026 at 11:30 AM during the initial tour of the facility, the surveyor was approached by Resident #30s RR, who told the surveyor that he/she would like to discuss several issues with the surveyor concerning the care of their mother/father. Resident #30s RR told the surveyor that during a Facetime (an application, or app, for making video and voice calls over the internet) conversation with her mother/father the RR was made aware of an allegation that a staff member threw oxygen tubing at Resident #30 and then proceeded to walk out of the room. The RR told the surveyor that he/she was not sure of the date of the incident but that he/she had made the Registered Nurse Supervisor (RNS) aware via telephone call the night of the alleged physical abuse. The RR further told the surveyor that his/her mother/father was scared. The RR further told the surveyor that both him/her and Resident #30 made the RNS aware, and they were told that they would investigate. The RR told the surveyor that he/she did not know if an investigation had been completed at the time of interview. The facility failed to implement their abuse and neglect policies by failing to investigate an allegation of staff to-resident physical abuse.On 4/21/2026 at 1:31 PM, the surveyor interviewed LPN/UM #1 who was assigned to the unit in which Resident #30 resided. When asked if he had knowledge of an allegation of abuse which involved a staff member throwing an oxygen nasal cannula (tubing that is inserted into the nostrils to deliver supplemental oxygen) at Resident #30, he stated, No, not oxygen tubing, it was reported to me that a staff member threw a call bell device at the resident the day after the allegation allegedly occurred. LPN/UM #1 stated that the resident's family member met with him and informed him that CNA #1 was the alleged perpetrator who threw the call bell device at Resident #30. The LPN/UM#1 stated that he called CNA #1 at home and questioned her about the alleged event, and she denied that anything happened concerning the alleged physical abuse. LPN/UM #1 stated that he did not inform anybody afterward or document the incident because he did not think there was an issue after he had spoken with the CNA #1. LPN/UM #1 was unable to state the date and time that the allegation occurred and stated that he thought that it happened well over a month ago in March 2026. On 4/21/2026 at 1:52 PM, the surveyors conducted an interview via telephone with the Registered Nurse Supervisor (RNS) who stated that when she became aware of the event she immediately went down to the unit and removed the accused staff (CNA #1) from the resident's assignment and notified the Director of Nursing (DON) by text message. The RNS stated that she notified the DON because it was an allegation of abuse, and she was required to report it. The RNS confirmed that she moved the accused CNA (CNA #1) to another assignment.On 4/21/2026 at 3:16 PM, in a subsequent in-person interview with the RNS, she stated that the allegation of abuse was made by the resident's RR via telephone. The RNS further stated that she had an allegation of both a call bell and a nebulizer mask being thrown at the resident. The RNS stated that she investigated immediately and then notified the DON via telephone and the DON stated that she would speak with the RR in the AM. The RNS stated that she told the DON what she did with CNA #1 concerning her work assignment.On 4/21/2026 at 3:38 PM, the surveyors interviewed Registered Nurse (RN #1) who confirmed that the alleged event happened on 3/31/2026 on the 3PM-11PM shift. RN #1 stated that CNA #1 came out of Resident #30's room upset and stated that the resident had accused her of throwing the call bell at him/her. RN #1 stated that the RNS had been notified and got involved. RN #1 stated that CNA #1 remained on the unit for the rest of the shift and was solely removed from Resident #30's room assignment. RN #1 stated that she did not obtain any written statements. RN #1 further stated that she did not know if the DON or the Licensed Nursing Home Administrator (LNHA) were notified.On 4/22/2026 at 9:37 AM, the surveyors interviewed the LNHA and the DON in the presence of the survey team. The LNHA stated the surveyor brought a pretty serious concern to his attention that he had not been made aware of. The DON stated that she was made aware after the RNS had sent her a text regarding the allegation on 3/31/2026. She stated she had missed the text message and had not responded to it. The DON stated that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me. The DON further stated that if there was an allegation of abuse the involved or accused staff should have been sent home. The DON further stated that an incident report, Progress Note, Physician Notification, Ombudsman Notification, Police Notification, and the DOH (Department of Health) should have been notified of the allegation of abuse.On 4/22/2026 at 8:19 AM, the facility LNHA provided the surveyor with a box of incident reports from February 2026 up to the present, as requested by the surveyor and team coordinator on 4/21/2026. The surveyor reviewed all files provided and there was no incident reports related to Resident #30s alleged staff to resident abuse on 3/31/2026.On 4/22/2026 at 9:01 AM, the surveyor conducted an interview with Resident #30. Resident #30 was observed lying in bed awake and alert. Resident #30 was watching television and was observed receiving oxygen at 4 liters per minute via nasal cannula. The surveyor asked Resident #30 if they ever had a call bell device thrown at them by a facility staff member. Resident #30 immediately responded, Yes. Resident #30 stated she was unable to recall specifically when it happened and didn't know the staff member's name. On 4/22/2026 at 9:37 AM, the surveyors conducted a follow up interview with the facility LNHA and DON. The DON told the surveyors that she had been made aware of the alleged staff-to-resident abuse. The DON told the surveyors that the RNS sent her a text and that she missed it: and did not respond to it. The LNHA told the surveyors that he was not aware of the event. The LNHA further explained that he had a conversation with the RNS, and she reiterated that the resident was fine because the call device was in place and the oxygen tubing was observed to be in his/her nose, and the call bell was pinned to the bed. The surveyors then asked the LNHA and DON what the facility should do when an alleged claim of abuse occurs. The LNHA and DON told the surveyors that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me (DON). The DON further explained that the RNS should have called me over an accusation of abuse. The DON stated that they did not receive any information from LPN/UM #1. The surveyor then asked the DON what should be done when a staff member was accused of alleged abuse. The DON and LNHA told the surveyors that if there was an allegation of abuse the involved/accused staff should have been sent home. The DON stated that she could confirm that the alleged staff-to-resident abuse did occur on March 31, 2026, as that was the date she received the text message from RNS. The DON failed to allow the surveyors to observe the text message or provide a copy of the text message when requested. The DON went on to say that the ICCP was updated yesterday and that it should have been done within the first 24 hours of the investigation. In conclusion the LNHA told the surveyors, We missed on this one.On 4/23/2026 at approximately 9:38 AM, the surveyor reviewed the staffing schedules provided by facility administration for CNA #1 from 3/31/2026 up to the present. Review of the staffing schedules revealed that CNA #1 provided care to facility residents on 3 of 3 units on the following dates after being accused of staff-to-resident physical abuse: 3/31/2026 (3 PM-11 PM shift), 3/31/2026 (11 PM-7 AM shift), 4/2/2026 (3 PM-11 PM shift), 4/11/2026 (3 PM-11 PM shift), 4/11/2026 (11 PM-7 AM shift), 4/12/2026 (3 PM-11 PM shift), 4/12/2026 (11 PM-7 AM shift), 4/14/2026 (3 PM-11 PM), 4/14/2026 (11 PM-7 AM shift), 4/16/2026 (3 PM-11 PM shift), 4/16/2026 (11 PM-7 AM shift), 4/19/2026 (3 PM-11 PM shift) and 4/19/2026 (11 PM-7 AM shift). CNA #1 provided care to facility residents for another 13 shifts after an alleged accusation of staff-to-resident abuse. On 4/23/2026 at 1:20 PM, the surveyors conducted an interview with the facility medical director (MD), who told the surveyors he had been the MD since 1983. The surveyors asked the MD if he was aware of an alleged incident of staff-to-resident abuse involving Resident #30. The MD replied that he was not aware of any abuse at this time. The surveyor then asked if the MD was familiar with Resident #30. The MD stated that he was familiar with the resident. The surveyor asked the MD if he was aware of the IJ (Immediate Jeopardy) at the facility on 4/22/2026. The MD replied that he did not know of the IJ and that he was not made aware. The surveyor then asked the MD what his expectations were when an allegation of abuse was made. The MD told the surveyors that his expectations were that the facility would investigate, notify the administrator and police and document everything. The surveyor then asked what the facility should do with the accused staff. The MD stated that the accused staff member should be removed from the resident. The surveyor asked if the accused staff should be able to continue to provide care to residents after an allegation of abuse was made. The MD replied, I don't know if they can continue to work with other residents. The surveyors further questioned whether the facility abuse policy should specify what to do with a staff accused of abuse. The MD agreed that the abuse policy should specify what should be done with the alleged staff member, yes. In addition, the surveyors asked if it was appropriate for the RNS to communicate an alleged incident of physical abuse by text message. The MD said the RNS should communicate with the administrator via telephone. The MD was asked what the importance was of completing an immediate investigation when an allegation of abuse occurs. The MD told the surveyors that the importance of an immediate investigation was to prevent further abuse of another resident and to ensure resident safety. The MD was asked if he should be expected to be notified of any abuse allegations and when. The MD stated that he would expect to be notified of an event of abuse at the same time the administrator was notified by text and then he would call the facility in response. Lastly, the surveyors asked the MD what his role was during an alleged accusation of abuse. The MD stated his role was to ensure an investigation was completed properly and to ensure resident safety by keeping the accused away from the alleged victim.On 4/27/2026 at 9:55 AM, the surveyor reviewed the progress notes (PN) from 3/1/226 up to 4/7/2026 at 23:43 (11:43 PM). Review of the PN did not reveal any documentation concerning the alleged physical abuse event on 3/31/2026 on the 3 PM-11 PM shift.On 4/27/2026 at 8:24 AM, the surveyor conducted a phone interview with CNA #1. The surveyor asked CNA #1 if she was aware of an accusation of staff-to-resident abuse on March 31, 2026, allegedly involving her. CNA #1 stated that when she walked into Resident #30s room because the call bell was activated, the supervisor (RNS) was in the room, and the RR was on the phone. She stated the supervisor pulled me aside and told me the RR made an accusation that I threw the call device at the resident. CNA #1 explained that the call device was duct taped to the dresser, so how could I have thrown it. CNA #1 elaborated that the RR said that I threw an oxygen mask and a nebulizer at Resident #30. She stated she never saw a nebulizer and the mask was on the whole time. The surveyor then asked CNA #1 what the facility did with her assignment once the alleged accusation of abuse had been made. CNA #1 responded that they changed my assignment that night and kept me off the accuser's assignment. The surveyor then asked if CNA #1 had worked another shift after her 3 PM-11 PM shift. CNA #1 responded that she did work a double shift that night (3 PM-11 PM and 11 PM-7 AM). CNA #1 told the surveyor that she had not been on that assignment (Resident #30) since the accusation had been made. The surveyor then asked if CNA #1 was allowed to continue to provide care at the facility after the alleged abuse event. CNA #1 told the surveyor that she continued to work at the facility up until maybe like a week and a half ago. She further explained that last week they told me that an investigation was going on and I could not work until it was resolved. The surveyor asked CNA #1 who told her that she could no longer provide care. CNA #1 stated that she was told by the scheduler. The surveyor asked CNA #1 if she had worked at the facility since the notification by the scheduler. CNA #1 stated she had not worked. No. I guess they will let me know. The surveyor ended the interview by asking CNA #1 if the facility had provided abuse training to her. CNA #1 stated, No. I did not receive abuse training from the facility, but I did receive it from my agency.A review of the facility's Administrator-Job Description policy, undated, revealed that the Administrator had the following position purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.A review of the facility's Abuse, Neglect and Exploitation policy, updated 11/20/2025, included the following under Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The following was observed under Policy Interpretation and Implementation: 1. The facility will develop and implement written policies and procedures that:Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;Establish policies and procedures to investigate any such allegations; andInclude training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; andEstablish coordination with the QAPI (quality assurance performance improvement) program.V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and 6. Providing complete and thorough documentation of the investigation.VI. Protection of the ResidentThe facility will make efforts to ensure that all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:Responding immediately to protect the alleged victim and integrity of the investigation;Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;Increased supervision of the alleged victim and residents;Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;Protection from retaliation;Providing emotional support and counseling to the resident during and after the investigation, as needed;Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse.VII. Reporting/ResponseThe facility will have written procedures that include:Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve and/or result in serious bodily injury, orNot later than 24 hours if the events that cause the allegation do not result in serious bodily injury.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.NJAC 8:39-4.1(a)(5), 9.4(f)

Complaint #: 2979687Based on interviews and review of other pertinent facility documents, it was determined that the facility failed to protect residents by failing to develop and implement their Abuse, Neglect and Exploitation policy and procedure after an allegation of staff-to-resident physical abuse was reported by a cognitively intact resident and resident representative (RR). This deficient practice was observed for 1 of 3 residents (Resident #30) reviewed for abuse and affected 3 of 3 nursing units in the facility. This deficient practice was evidenced by the following:Refer to F600 and F610On 4/21/2026 at 11:30 AM during the initial tour of the facility, the surveyor was approached by Resident #30s RR, who told the surveyor that they would like to discuss several issues with the surveyor concerning the care of their mother/father. Resident #30s RR told the surveyor that during a Facetime (an application, or app, for making video and voice calls over the internet) conversation with her mother/father the RR was made aware of an allegation that a staff member threw oxygen tubing at Resident #30 and then proceeded to walk out of the room. The RR told the surveyor that he/she was not sure of the date of the incident but that he/she had made the Registered Nurse Supervisor (RNS) aware via telephone call the night of the alleged physical abuse. The RR further told the surveyor that his/her mother/father was scared. The RR further told the surveyor that both him/her and Resident #30 made the RNS aware, and they were told that they would investigate. The RR told the surveyor that he/she did not know if an investigation had been completed at the time of interview. On 4/21/2026 at 1:31 PM, the surveyor interviewed LPN/UM #1 who was assigned to the unit in which Resident #30 resided. When asked if he had knowledge of an allegation of abuse which involved a staff member throwing an oxygen nasal cannula at Resident #30, he stated, No, not oxygen tubing, it was reported to me that a staff member threw a call bell device at the resident the day after the allegation allegedly occurred. LPN/UM #1 stated that the resident's family member met with him and informed him that CNA #1 was the alleged perpetrator who threw the call bell device at Resident #30. The LPN/UM#1 stated that he called CNA #1 at home and questioned her about the alleged event, and she denied that anything happened concerning the alleged physical abuse. LPN/UM #1 stated that he did not inform anybody afterward or document the incident because he did not think there was an issue after he had spoken with the CNA #1. LPN/UM #1 was unable to state the date and time that the allegation occurred and stated that he thought that it happened well over a month ago in March 2026. The facility failed to implement their abuse and neglect policies by failing to investigate an allegation of staff to-resident physical abuse.On 4/21/2026 at 1:52 PM, the surveyors conducted an interview via telephone with the Registered Nurse Supervisor (RNS) who stated that when she became aware of the event she immediately went down to the unit and removed the accused staff (CNA #1) from the resident's assignment and notified the Director of Nursing (DON) by text message. The RNS stated that she notified the DON because it was an allegation of abuse, and she was required to report it. The RNS confirmed that she moved the accused CNA to another assignment (CNA #1).On 4/21/2026 at 3:16 PM, in a subsequent in-person interview with the RNS, she stated that the allegation of abuse was made by the RR via telephone. The RNS further stated that she had an allegation of both a call bell and a nebulizer mask being thrown at the resident. The RNS stated that she investigated immediately and then notified the DON via telephone and the DON stated that she would speak with the RR in the AM. The RNS stated that she told the DON what she did with CNA #1 concerning her work assignment.On 4/21/2026 at 3:38 PM, the surveyors interviewed Registered Nurse (RN #1) who confirmed that the alleged event happened on 3/31/2026 on the 3PM-11PM shift. RN #1 stated that CNA #1 came out of Resident #30's room upset and stated that the resident had accused her of throwing the call bell at him/her. RN #1 stated that the RNS had been notified and got involved. RN #1 stated that CNA #1 remained on the unit for the rest of the shift and was solely removed from Resident #30's room assignment. RN #1 stated that she did not obtain any written statements. RN #1 further stated that she did not know if the DON or the Licensed Nursing Home Administrator (LNHA) were notified.On 4/22/2026 at 9:37 AM, the surveyors interviewed the LNHA, who was also the facility designated abuse coordinator, and the DON in the presence of the survey team. The LNHA stated the surveyor brought a pretty serious concern to his attention that he had not been made aware of. The DON stated that she was made aware after the RNS had sent her a text regarding the allegation on 3/31/2026. She stated she had missed the text message and had not responded to it. The DON stated that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. The DON stated we did not investigate immediately, and the investigation should have started with me. The DON further stated that if there was an allegation of abuse the involved or accused staff should have been sent home. The DON further stated that an incident report, Progress Note, Physician Notification, Ombudsman Notification, Police Notification, and the DOH (Department of Health) should have been notified of the allegation of abuse.The surveyor reviewed the electronic medical record for Resident #30.A review of the admission Record, an admission summary, revealed that Resident #30 had the following but not limited to diagnoses: chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease-primarily caused by smoking-that obstructs airflow, causing chronic breathing difficulties), major depressive disorder, anxiety disorder, repeated falls, and acute and chronic respiratory failure.A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/12/2026, included Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #30 was cognitively intact. Section E of the MDS revealed that Resident #30 did not experience hallucinations or delusions and did not display any behavioral symptoms. Section GG revealed that Resident #30 was dependent on staff for most activities of daily living. Section O of the MDS revealed that Resident #30 received hospice care while a resident at the facility.A review of the Individual Comprehensive Care Plan (ICCP) included the following focus areas:A focus area initiated on 2/26/2026, which indicated that Resident #30 had mood problems related to admission. Interventions included: Report to MD (medical doctor) prn (as needed) acute episode of feelings (sic) or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.A focus area initiated on 2/26/2026, which indicated Resident #30 had oxygen therapy related to COPD. Interventions included: OXYGEN SETTINGS: [name redacted] has O2 (oxygen) via nasal prongs (nasal cannula) (at) 4L (liters) continuously.On 4/22/2026 at 9:37 AM, the surveyors conducted a follow up interview with the facility LNHA and DON. The DON told the surveyors that she had been made aware of the alleged staff-to-resident abuse. The DON told the surveyors that the RNS sent her a text and that she missed it: and did not respond to it. The LNHA told the surveyors that he was not aware of the event. The DON further explained that she had a conversation with the RNS, and she reiterated that the resident was fine because the call device was in place and the oxygen tubing was observed to be in his/her nose, and the call bell was pinned to the bed. The surveyors then asked the LNHA and DON what the facility should do when an alleged claim of abuse occurs. The LNHA and DON told the surveyors that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. The DON stated we did not investigate immediately, and the investigation should have started with me. The DON further explained that the RNS should have called me over an accusation of abuse. The DON stated that they did not receive any information from LPN/UM #1. The surveyor then asked the DON what should be done when a staff member was accused of alleged abuse. The DON and LNHA told the surveyors that if there was an allegation of abuse the involved/accused staff should have been sent home. The DON stated that she could confirm that the alleged staff-to-resident abuse did occur on March 31, 2026, as that was the date she received the text message from RNS. The DON failed to allow the surveyors to observe the text message or provide a copy of the text message when requested. The DON went on to say that the ICCP was updated yesterday and that it should have been done within the first 24 hours of the investigation. In conclusion the LNHA told the surveyors, We missed on this one. The facility failed to investigate Resident #30's alleged staff-to resident physical abuse from 3/31/2026 until 4/22/2026, a period of 23 days. On 4/23/2026 at approximately 9:38 AM, the surveyor reviewed the staffing schedules provided by facility administration for CNA #1 from 3/31/2026 to present. Review of the staffing schedules revealed that CNA #1 provided care to facility residents on 3 of 3 units on the following dates after being accused of staff-to-resident physical abuse: 3/31/2026 (3 PM-11 PM shift), 3/31/2026 (11 PM-7 AM shift), 4/2/2026 (3 PM-11 PM shift), 4/11/2026 (3 PM-11 PM shift), 4/11/2026 (11 PM-7 AM shift), 4/12/2026 (3 PM-11 PM shift), 4/12/2026 (11 PM-7 AM shift), 4/14/2026 (3 PM-11 PM), 4/14/2026 (11 PM-7 AM shift), 4/16/2026 (3 PM-11 PM shift), 4/16/2026 (11 PM-7 AM shift), 4/19/2026 (3 PM-11 PM shift) and 4/19/2026 (11 PM-7 AM shift). CNA #1 provided care to facility residents for another 13 shifts after an alleged accusation of staff-to-resident abuse. On 4/27/2026 at 8:24 AM, the surveyor conducted a phone interview with CNA #1. The surveyor asked CNA #1 if she was aware of an accusation of staff-to-resident abuse on March 31, 2026, allegedly involving her. CNA #1 stated that when she walked into Resident #30s room because the call bell was activated, the supervisor (RNS) was in the room, and the RR was on the phone. She stated the supervisor pulled me aside and told me the RR made an accusation that I threw the call device at the resident. CNA #1 explained that the call device was duct taped to the dresser, so how could I have thrown it. CNA #1 elaborated that the RR said that I threw an oxygen mask and a nebulizer at Resident #30. She stated she never saw a nebulizer and the mask was on the whole time. The surveyor then asked CNA #1 what the facility did with her assignment once the alleged accusation of abuse had been made. CNA #1 responded that they changed my assignment that night and kept me off the accuser's assignment. The surveyor then asked if CNA #1 had worked another shift after her 3 PM-11 PM shift. CNA #1 responded that she did work a double shift that night (3 PM-11 PM and 11 PM-7 AM). CNA #1 told the surveyor that she had not been on that assignment (Resident #30) since the accusation had been made. The surveyor then asked if CNA #1 was allowed to continue to provide care at the facility after the alleged abuse event. CNA #1 told the surveyor that she continued to work at the facility up until maybe like a week and a half ago. She further explained that last week they told me that an investigation was going on and I could not work until it was resolved. The surveyor asked CNA #1 who told her that she could no longer provide care. CNA #1 stated that she was told by the scheduler. The surveyor asked CNA #1 if she had worked at the facility since the notification was made by the scheduler. CNA #1 stated she had not worked, she further stated, No. I guess they will let me know. The surveyor ended the interview by asking CNA #1 if the facility had provided abuse training to her. CNA #1 stated, No. I did not receive abuse training from the facility, but I did receive it from my agency.A review of the facility's Abuse, Neglect and Exploitation policy, updated 11/20/2025, included the following under Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The following was observed under Policy Interpretation and Implementation: 1. The facility will develop and implement written policies and procedures that:Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;Establish policies and procedures to investigate any such allegations; andInclude training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; andEstablish coordination with the QAPI (quality assurance performance improvement) program.V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and 6. Providing complete and thorough documentation of the investigation.VI. Protection of the ResidentThe facility will make efforts to ensure that all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:Responding immediately to protect the alleged victim and integrity of the investigation;Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;Increased supervision of the alleged victim and residents;Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;Protection from retaliation;Providing emotional support and counseling to the resident during and after the investigation, as needed;Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse.VII. Reporting/ResponseThe facility will have written procedures that include:Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve and/or result in serious bodily injury, orNot later than 24 hours if the events that cause the allegation do not result in serious bodily injury.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.NJAC 8:39-4.1(a)(5)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness b.) to prevent potential contamination by leaving used resident meal trays in a resident unit pantry in close proximity to clean items and food service supplies and c.) maintain the resident unit pantry in a safe and sanitary manner. This deficient practice was identified for 1 of 3 unit pantries (B-Unit) reviewed and was evidenced by the following:1.) On 04/21/2026 at 9:22 AM the surveyors entered the facility kitchen. The surveyors were told by the cook that there was not a director in the kitchen and that they were on the way. On 04/21/2026 at 9:29 AM, the surveyors observed that the dish machine was in active use upon entry to the kitchen. The surveyor observed three staff actively working in the dish room. The surveyor retrieved the April 2026 Dish Machine Log from the wall and entered the dish washing area for review. Review of the temperature log revealed that no dish machine temperatures were recorded on 4/20/2026 at the lunch and dinner service. In addition, on 4/21/2026 the staff failed to document the breakfast wash and rinse temperatures for the dish machine. Further review of the log revealed that the minimum wash temperature was 150-165F (Fahrenheit) and Rinse minimum was 180-194 F. On 04/21/2026 at 9:34 AM the surveyor observed the high temperature dish machine while in operation and actively washing dishes. The surveyor was accompanied by Dietary Aide #1 (DA#1). The surveyor observed the gauge panel and recorded a wash temperature of 142F and a rinse temperature of 186 F. The surveyor asked DA#1 how long the machine had been actively washing dishes and DA#1 relied, approximately 10 minutes. On 04/21/2026 at 9:38 AM the surveyor observed the dish machine that had been in use for approximately 10 minutes, according to DA #1. DA #1 stated that he recorded the dish machine minimum wash and rinse temperatures prior to initiating dish washing but accidentally documented in the blank spaces for 4/20/2026 at breakfast, which were not recorded on 4/20/2026. Observation of the wash temperature revealed a wash temperature of 140 F. The surveyor asked DA #1 to load another rack of dirty dishes into the dish machine, and the surveyor and DA #1 observed a wash temperature of 138 F. The surveyor then asked DA #1 what he should do next since the dish machine was not meeting the minimum required wash temperature of 150-160 F. DA #1 stated that he would have to shut the machine down. The machine was shut down, and DA #1 stated that they had paperware if necessary for the lunch meal. ON 4/21/2026 at 10:09 AM, the surveyors observed the single door Reach-in refrigerator adjacent to the break room. The surveyor reviewed the temperature log and determined that it was up to date. The surveyor proceeded to open the refrigerator and determined that the refrigerator had no internal thermometer. The lack of an internal thermometer was verified by the District Manager (DM), and a new internal thermometer was placed in the refrigerator by the DM. Inside of the single door reach-in refrigerator the surveyors observed the following: On the top shelf (3) bagged pork loins were defrosted and had no dates. On the shelf below an unopened plastic, white bag contained [name redacted] ground turkey. The turkey was defrosted on top of a sheet pan. The turkey had no pull or use by dates. On the second to the bottom shelf/rack a covered cardboard box contained, according to the labeling, Halal chicken. The box had a received date of 4/6/26. There was no pull or use by dates. Next to the cardboard box, a deep 1/2 pan contained a previously opened bag of defrosted Halal chicken soaking in its own juice (chicken). The pan/bag had no open/pull/or use by dates. On the bottom shelf a deep 1/2 pan on top of a sheet pan contained a clear plastic bag of what appeared to be ground beef. The pan/beef/bag had no pull or use by dates. The DM agreed that when meat was defrosted it should have a pull date and a use by date. On 4/21/2026 at 10:29 AM, the surveyor made the facility Licensed Nursing Home Administrator (LNHA) aware of the surveyor's dish machine concerns. On 4/21/2026 at 10:47 AM, the surveyor returned to the kitchen to do a follow up observation of the high temperature dish machine. The surveyor observed a wash temperature of 150 F at this time. The DM told the surveyor that he had spoken with the service company, and they told me to turn off the machine and hit the reset button. He further explained that he reset the machine twice. The DM then told the surveyor that he had put in a service call on Thursday (4/16/2026) and the service man was supposed to come on Sunday (4/19/2026) but they never came. The surveyor asked the DM why they had placed a service call for the dish machine. The director stated that he wanted to make sure the machine was right. On 4/24/2026 at 8:37 AM, the surveyor, accompanied by the DM and the Account Manager (AM), observed the following in the kitchen: On top of the ice machine a black portable fan was in operation. The fan guard was observed to be covered in dust and debris and was blowing over the ice machine causing potential for contamination to the ice machine when opened. The AM immediately removed the fan to be cleaned. On 4/24/2026 at 1:40 AM the surveyor, accompanied by the AM, observed the following in the kitchen: The wall above the double reach-in refrigerator was observed to have dust and unidentified debris on the upper wall and surrounding the electrical outlets. The AM stated that he would have the area cleaned immediately. The surveyor reviewed the facility provided policy titled Food: Preparation, [name redacted] Policy 016, revised 2/2026. The following was revealed under Policy Statement: All foods are prepared in accordance with FDA (Food and Drug Administration) Food Code. The policy did not address labeling and dating meat for defrosting. The policy included: that the Cook(s) were responsible for thawing frozen items that require defrosting prior to preparation. The surveyor reviewed the facility provided Warewashing, [name redacted] Policy 022 policy, revised 12/2024, which included: Under the heading Procedures: The Dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Temperatures and/or sanitizer logs will be completed, as appropriate. A review of the Dish Machine Log - High Temperature, undated, revealed the following: Instructions: Record temperatures at each meal and initial. If temperature(s) does not meet parameters as set forth by the standards or manufacturer's guidelines, stop washing and alert a manager or designee. 2.) On 4/22/2026 at 12:41 PM, during observation of the food pantry room on the B-Unit, two surveyors observed multiple used resident breakfast trays stored on the counter and in the sink containing leftover food, utensils and soiled dishware. The pantry also contained clean supplies including nourishment items and clean cups and utensils creating potential for cross-contamination. On 4/23/2026 at 10:12 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who confirmed that used resident meal trays were temporarily placed in the resident nourishment pantry. She stated that used food trays should not be left in the pantry for infection control purposes and to avoid getting pests. On 4/23/2026 at 11:08 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager for B-Unit (LPN/UM #1) who stated that the staff should not be storing used resident food trays in the pantry as this could pose as an infection control issue and cross contamination. On 4/23/2026 at 12:04 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that staff should not store used resident meal trays in a clean pantry. She explained that if they have left over meal trays, staff should bag the trays and call the dietary department for another cart. She confirmed that storing used food trays could draw bugs and other pests to the room. She also stated it could potentially cause cross contamination with clean supplies. 3.) On 4/22/2026 at 12:41 PM, the surveyor inspected the resident nutritional pantry room on the B-Unit. The surveyor observed a trash can up against the wall under the window, the surveyor pulled out the trash can and observed the peeling paint on the wall and brown food particles dried onto the wall. There was also a vent under the window with rust and food particles on top of the vent. There were also brown food splatters on the front of the cabinets below the sink and multiple broken cabinets. The floors were observed with black dirt and black dirt under the ice machine. The surveyor also observed that inside of the pantry refrigerator there were spills of a red food substance as well as drips and stains throughout the refrigerator. On 4/23/2026 10:12 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the nursing staff used to clean the refrigerator in the B-Unit pantry. She stated that the dietary department was responsible for supplying and checking for expired items. She then stated that she thought housekeeping was responsible for cleaning the refrigerator. On 4/23/2026 at 10:30 AM, the surveyor interviewed a housekeeper who stated that housekeeping was supposed to clean the refrigerator. She stated that there was not a schedule for pantry or refrigerator cleaning. She stated that the housekeeping supervisor sent a housekeeper to clean the refrigerators in the B-Unit pantry a week ago and she looked at it and just walked away. On 4/23/26 at 10:45, the surveyor interviewed the Maintenance Director (MD) who accompanied the survey to the pantry on B-Unit and acknowledged that he was aware that the cabinet drawers were broken and in disrepair. He stated that the cabinet under the kitchen sink was the only cabinet that he had replaced at this time but he knew that he needed to order more. On 4/23/2026 at 10:56 AM, the surveyor interviewed the Housekeeping Director (HD) who accompanied the surveyor to the pantry room on the B-Unit. The HD confirmed that the left wall of the pantry was covered with food particles and debris. He stated that it should not look like that and that staff should have cleaned the wall. He also confirmed that the pantry had black dirt on the floor and on the floor under the ice machine. He stated that the dietary department was responsible for cleaning the refrigerator and ice machine because he did not have the correct food safe chemicals for cleaning items that involve food. He stated that he would have the wall and floors cleaned immediately. He also confirmed that there was not cleaning schedule for cleaning the pantry refrigerator. On 4/23/2026 at 11:08 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) for the B-Wing who stated that housekeeping should be keeping the pantry room and pantry refrigerator clean. On 4/23/2026 at 12:04 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that there should be a cleaning schedule for the resident pantry room and pantry refrigerator. She stated that she was aware of the uncleanliness of the pantry room and would report it to the HD. On 4/24/2026 at 8:46 AM, the surveyor interviewed the District Manager Food Service Director (DFSD) who stated that nursing and housekeeping were responsible to keep the refrigerator on the B-Unit pantry clean. He stated that there was no cleaning schedule for the pantry rooms. A review of the facility policy dated April 2024 and titled, Unit Refrigerators indicated that housekeeping staff should clean the refrigerators daily and as needed. Nursing staff should discard any foods that are out of compliance and clean spills as needed. A review of the facility policy dated January 2026 and titled, Safe and Homelike Environment indicated that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The policy also specifies that staff were to report any furniture in disrepair to the Maintenance promptly and report any unresolved environmental concerns to the Administrator. A review of the facility provided Food Receiving and Storage policy, dated January 2026, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. A review of the facility provided, Tray Delivery Policy policy, dated January 2026, indicated that trays should be removed promptly from the resident rooms after meal completion and that the facility would provide meal tray delivery that maintains food safety, infection control, accuracy of diet orders and resident dignity at all times. NJAC 8:39-17.2(g), 31.4 (a)

Complaint #: 2979687 Based on interviews, review of the medical record, and review of other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure all other residents were protected after a cognitively intact resident and their resident representative (RR) made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 3 residents (Resident #30) reviewed for abuse and was evidenced by the following: Refer to F610 On 4/21/2026 at 11:30 AM, during the initial tour of the facility, the surveyor was approached by Resident #30s RR, who told the surveyor that she would like to discuss several issues with the surveyor concerning the care of their mother/father. Resident #30s RR told the surveyor that during a Facetime (an application, or app, for making video and voice calls over the internet) conversation with their mother/father the RR was made aware of an allegation that a staff member threw oxygen tubing at Resident #30 and then proceeded to walk out of the room. The RR told the surveyor that he/she was not sure of the date of the incident but that he/she had made the Registered Nurse Supervisor (RNS) aware via telephone call the night of the alleged physical abuse. The RR further told the surveyor that his/her mother/father was scared. The RR further told the surveyor that both him/her and Resident #30 made the RNS aware, and they were told that they would investigate. The RR told the surveyor that he/she did not know if an investigation had been completed at the time of interview. On 4/21/2026 at 1:21 PM, the surveyor interviewed the facility Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). When asked about the alleged staff-to-resident physical abuse involving Resident #30 the DON and LNHA stated that they had no knowledge of the incident concerning Resident #30 allegedly being physically abused by having oxygen tubing thrown at them. On 4/21/2026 at 1:31 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manger (LPN/UM #1) who was assigned to the unit in which Resident #30 resided. When asked if he had knowledge of an allegation of abuse which involved a staff member throwing an oxygen nasal cannula at Resident #30, he stated, No, not oxygen tubing, it was reported to me that a staff member threw a call bell device at the resident the day after the allegation allegedly occurred. LPN/UM #1 stated that the resident's family member met with him and informed him that CNA #1 was the alleged perpetrator who threw the call bell device at Resident #30. The LPN/UM#1 stated that he called CNA #1 at home and questioned her about the alleged event, and she denied that anything happened concerning the alleged physical abuse. LPN/UM #1 stated that he did not inform anybody afterward or document the incident because he did not think there was an issue after he had spoken with CNA #1. LPN/UM #1 was unable to state the date and time that the allegation occurred and stated that he thought that it happened well over a month ago in March 2026. On 4/21/2026 at 1:52 PM, the surveyors conducted an interview via telephone with the Registered Nurse Supervisor (RNS) who stated that when she became aware of the event she immediately went down to the unit and removed the accused staff (CNA #1) from the resident's assignment and notified the Director of Nursing (DON) by text message. The RNS stated that she notified the DON because it was an allegation of abuse, and she was required to report it. The RNS confirmed that she moved the accused CNA to another assignment (CNA #1).On 4/21/2026 at 3:16 PM, in a subsequent in-person interview with the RNS, she stated that the allegation of abuse was made by the RR via telephone. The RNS further stated that she had an allegation of both a call bell and a nebulizer mask being thrown at the resident. The RNS stated that she investigated immediately and then notified the DON via telephone and the DON stated that she would speak with the RR in the AM. The RNS told the DON what she did with CNA #1 concerning her work assignment. On 4/21/2026 at 3:38 PM, the surveyors interviewed Registered Nurse (RN #1) who confirmed that the alleged event happened on 3/31/2026 on the 3PM-11PM shift. RN #1 stated that CNA #1 came out of Resident #30's room upset and stated that the resident had accused her of throwing the call bell at him/her. RN #1 stated that the RNS had been notified and got involved. RN #1 stated that CNA #1 remained on the unit for the rest of the shift and was solely removed from Resident #30's room assignment. RN #1 stated that she did not obtain any written statements. RN #1 further stated that she did not know if the DON or the LNHA were notified. On 4/22/2026 at 9:37 AM, the surveyors interviewed the LNHA and the DON in the presence of the survey team. The LNHA stated the surveyor brought a pretty serious concern to his attention that he had not been made aware of. The DON stated that she was made aware after the RNS had sent her a text regarding the allegation on 3/31/2026. She stated she had missed the text message and had not responded to it. The DON stated that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me. The DON further stated that if there was an allegation of abuse the involved or accused staff should have been sent home. The DON further stated that an incident report, Progress Note, Physician Notification, Ombudsman Notification, Police Notification, and the DOH (Department of Health) should have been notified of the allegation of abuse.The surveyor reviewed the electronic medical record for Resident #30.A review of the admission Record, an admission summary, revealed that Resident #30 had the following but not limited to diagnoses: chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease-primarily caused by smoking, that obstructs airflow, causing chronic breathing difficulties), major depressive disorder, anxiety disorder, repeated falls, and acute and chronic respiratory failure.A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/12/2026, included Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that Resident #30 was cognitively intact. Section E of the MDS revealed that Resident #30 did not experience hallucinations or delusions and did not display any behavioral symptoms. Section GG revealed that Resident #30 was dependent on staff for most activities of daily living. Section O of the MDS revealed that Resident #30 received hospice care while a resident at the facility.A review of the Individual Comprehensive Care Plan (ICCP) included the following focus areas:A focus area initiated on 2/26/2026, which indicated that Resident #30 had mood problems related to admission. Interventions included: Report to MD (medical doctor) prn (as needed) acute episode of feelings (sic) or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.A focus area initiated on 2/26/2026, which indicated Resident #30 had oxygen therapy related to COPD. Interventions included: OXYGEN SETTINGS: [name redacted] has O2 (oxygen) via nasal prongs (nasal cannula) (at) 4L (liters) continuously. On 4/22/2026 at 8:19 AM, the facility LNHA provided the surveyor with a box of incident reports from February 2026 up to the present, as requested by the surveyor and team coordinator on 4/21/2026. The surveyor reviewed all files provided and there were no incident reports related to Resident #30s alleged staff to resident abuse on 3/31/2026.On 4/22/2026 at 9:01 AM, the surveyor conducted an interview with Resident #30. Resident #30 was observed lying in bed awake and alert. Resident #30 was watching television and was observed receiving oxygen at 4 liters per minute via nasal cannula. The surveyor asked Resident #30 if they ever had a call bell device thrown at them by a facility staff member. Resident #30 immediately responded, Yes. Resident #30 stated she was unable to recall specifically when it happened and didn't know the staff member's name. On 4/22/2026 at 9:37 AM, the surveyors conducted a follow up interview with the facility LNHA and DON. The DON told the surveyors that she had been made aware of the alleged staff-to-resident abuse. The DON told the surveyors that the RNS sent her a text and that she missed it: and did not respond to it. The LNHA told the surveyors that he was not aware of the event. The DON further explained that she had a conversation with the RNS, and she reiterated that the resident was fine because the call device was in place and the oxygen tubing was observed to be in his/her nose, and the call bell was pinned to the bed. The surveyors then asked the LNHA and DON what the facility should do when an alleged claim of abuse occurs. The LNHA and DON told the surveyors that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me (DON). The DON further explained that the RNS should have called me over an accusation of abuse. The DON stated that they did not receive any information from LPN/UM #1. The surveyor then asked the DON what should be done when a staff member was accused of alleged abuse. The DON and LNHA told the surveyors that if there was an allegation of abuse the involved/accused staff should have been sent home. The DON stated that she could confirm that the alleged staff-to-resident abuse did occur on March 31, 2026, as that was the date she received the text message from RNS. The DON failed to allow the surveyors to observe the text message or provide a copy of the text message when requested. The DON went on to say that the ICCP was updated yesterday and that it should have been done within the first 24 hours of the investigation. In conclusion the LNHA told the surveyors, We missed on this one. On 4/23/2026 at approximately 9:38 AM, the surveyor reviewed the staffing schedules provided by facility administration for CNA #1 from 3/31/2026 up to the present. Review of the staffing schedules revealed that CNA #1 provided care to facility residents on 3 of 3 units on the following dates after being accused of staff-to-resident physical abuse: 3/31/2026 (3 PM-11 PM shift), 3/31/2026 (11 PM-7 AM shift), 4/2/2026 (3 PM-11 PM shift), 4/11/2026 (3 PM-11 PM shift), 4/11/2026 (11 PM-7 AM shift), 4/12/2026 (3 PM-11 PM shift), 4/12/2026 (11 PM-7 AM shift), 4/14/2026 (3 PM-11 PM), 4/14/2026 (11 PM-7 AM shift), 4/16/2026 (3 PM-11 PM shift), 4/16/2026 (11 PM-7 AM shift), 4/19/2026 (3 PM-11 PM shift) and 4/19/2026 (11 PM-7 AM shift). CNA #1 provided care to facility residents for another 13 shifts after an alleged accusation of staff-to-resident abuse.On 4/23/2026 at 1:20 PM, the surveyors conducted an interview with the facility Medical Director (MD), who told the surveyors he had been the medical director since 1983. The surveyors asked the MD if he was aware of an alleged incident of staff-to-resident abuse involving Resident #30. The MD replied that he was not aware of any abuse at this time. The surveyor then asked if the MD was familiar with Resident #30. The MD stated that he was familiar with the resident. The surveyor asked the MD if he was aware of the IJ (Immediate Jeopardy) at the facility on 4/22/2026. The MD replied that he did not know of the IJ and that he was not made aware. The surveyor then asked the MD what his expectations were when an allegation of abuse was made. The MD told the surveyors that his expectations were that the facility would investigate, notify the administrator and police and document everything. The surveyor then asked what the facility should do with the accused staff. The MD stated that the accused staff member should be removed from the resident. The surveyor asked if the accused staff should be able to continue to provide care to residents after an allegation of abuse was made. The MD replied, I don't know if they can continue to work with other residents.On 4/27/2026 at 8:24 AM, the surveyor conducted a phone interview with CNA #1. The surveyor asked CNA #1 if she was aware of an accusation of staff-to-resident abuse on March 31, 2026, allegedly involving her. CNA #1 stated that when she walked into Resident #30s room because the call bell was activated the supervisor (RNS) was in the room, and the resident's representative (RR) [name redacted] was on the phone. The supervisor pulled me aside and told me the RR made an accusation that I threw the call device at the resident. CNA #1 explained that the call device was duct taped to the dresser, so how could I have thrown it. CNA #1 elaborated that the RR said that I threw an oxygen mask and a nebulizer at Resident #30. I never saw a nebulizer and the mask was on the whole time. The surveyor then asked CNA #1 what the facility did with her assignment once the alleged accusation of abuse had been made. CNA #1 responded that they changed my assignment that night and kept me off the accuser's assignment. The surveyor then asked if CNA #1 had worked another shift after her 3 PM-11 PM shift. CNA #1 responded that she did work a double shift that night (3 PM-11 PM and 11 PM-7 AM). CNA #1 told the surveyor that she had not been on that assignment (Resident #30) since the accusation. The surveyor then asked if CNA #1 was allowed to continue to provide care at the facility after the alleged abuse event. CNA #1 told the surveyor that she continued to work at the facility up until maybe like a week and a half ago. She further explained that last week they told me that an investigation was going on and I could not work until it was resolved. The surveyor asked CNA #1 who told her that she could no longer provide care. CNA #1 stated that she was told by the scheduler. The surveyor asked CNA #1 if she had worked at the facility since the notification by the scheduler. CNA #1 stated she had not worked. CNA #1 stated, No. I guess they will let me know. The surveyor ended the interview by asking CNA #1 if the facility had provided abuse training to her. CNA #1 stated, No. I did not receive abuse training from the facility, but I did receive it from my agency.The surveyor reviewed the facility provided policy titled Abuse, Neglect and Exploitation, updated 11-20-25. The following was revealed under Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. In addition the following was observed under: V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and 6. Providing complete and thorough documentation of the investigation.NJAC 8:39-4.1(a)(5)

Based on observation, interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that residents were provided adequate space for dining and dining activities according to the federal regulation and approved facility floor plan. This deficient practice had the potential to affect all 111 residents who currently live in the facility and was evidenced by the following:On 4/22/2026 at 9:25 AM, the surveyor held a resident council meeting with (eight) 8 residents. All 8 of 8 residents told surveyor that they ate in their rooms because the facility did not have a dining room. All eight residents stated that the small dayroom on the B wing (near the nursing station) was used for lunch for the residents that needed assistance with feeding. A review of the facility floor map indicated that on B-wing the lounge area was being utilized as a dining area. On 4/22/2026 at 12:48 PM, the surveyor observed a group of five residents standing in the hall on the B-Unit. All five residents stated that they did not have a main dining room to eat in and that the main dining room was used for dining by the assisted living (AL) residents. They also stated that everyone could not fit into the space and that the small dining room could not accommodate the residents because it was too small. They stated that they would enjoy eating somewhere beside their rooms, however there was nowhere else for them to eat. They stated that there was a small dining room or common area near the nurse's station on the B-unit but only the residents that required assistance with feeding would eat there. The surveyor went to the small dining room/common area and observed that there were approximately five tables in the room with no chairs. On 4/23/2026 at 10:12 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the residents were allowed to eat in the dining room with the AL residents but did not know if anyone ever had. She explained that she had never offered the residents to eat there. She explained that the small dining room on the B-wing was utilized as a common area or used for sitting room and was not used as a main dining room. She stated that before the Covid pandemic, the activity room used to be the main dining room for long-term care residents, but the facility never switched it back to a dining room. On 4/23/2026 at 11:10 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) who confirmed that prior to the Covid pandemic, the current activity room used to be the long-term care dining room. He stated that common area room is used for TV watching and some residents requiring assistance with feeding but was not considered a main dining room for the long-term care residents. He stated that the common area room used to be used as a sensory room. On 4/24/2026 at 8:46 AM, the surveyor interviewed the District Manager Food Service Director (DFSD) who stated that the residents in long-term care and residents on B-Unit do not have a designated dining room. He explained that if he was made aware that residents from long-term care wanted to eat in the AL dining room that he would obtain tables and their meal tickets and then they would be able to eat in the AL dining room. He stated that nurses would have to provide the DFSD with a list and then he would have to take the meal tickets for the residents in long-term care and set them up with a table. On 4/24/2026 at 9:00 AM, the surveyor interviewed the Director of Nursing (DON) who stated that dining rooms were sectioned off and that the activity room on B-unit (LTC) was the dining room. She stated that the residents were able to eat there if they wanted, but they needed to know if they wanted to eat there so they could bring their meals in there. She stated that staff ask residents each morning where they want to eat and if they wanted to eat there and they would accommodate them. On 4/24/2026 at 9:10 AM, the surveyor interviewed the Activity Aide (AA) for B-Unit who stated that the activity room was used strictly for activities. She emphasized that residents did not eat meals there. She stated that the residents used to use the current activity room as a dining room but for only a short period of time about a year ago, however it was only a trial period. She stated that it did not continue because an aide and nurse had to be assigned to be in there and if lunch was not on time it interfered with the residents' activities. On 4/24/2026 at 9:16 AM, the surveyor interviewed LPN #5 who stated that the only dining area the residents on LTC B-Unit go to is the common small room that was located on the unit. She stated that the activities room used to be the main dining room and the residents did not have their meals in there. She explained she had worked in the facility for approximately one year and never saw the residents from long term care B-Unit eating in the AL dining room or in the activity room. She also revealed that she did not know of any process in the facility for asking residents in the morning if they wanted to eat in the AL dining room or activities room. On 4/27/2026 at 9:55 AM, in the presence of the survey team, the DON stated that the dining program fell to the wayside because of lack of resident involvement and that now that the residents had concerns and would like to participate in the dining program it would be reinstated. A review of the facility policy dated January 2026, and titled, Safe and Homelike Environment indicated that in accordance with resident rights, the facility will provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safety and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.NJAC 8:39-18.4(c); 27.3(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to store medications securely in their packaging inside the medication carts for 3 out of 4 medications carts (Serenity Cart, Ocean Cart, and Beach Cart) inspected during the medication storage and labeling task. The deficient practice was evidenced by the following:On 4/23/2026 at 9:41 AM, during an inspection of the Serenity medication cart with Licensed Practical Nurse/ Unit Manager #1 (LPN/ UM) #2, the surveyor observed 15 loose tablets in the cart. LPN/ UM #2 stated that there should not be loose tablets in the medication cart. LPN/ UM #2 further stated that when nurses see loose pills, they should immediately put them in the drug buster for infection control.On 4/23/2026 at 10:15 AM, during an inspection of the Ocean medication cart with LPN #2, the surveyor observed 2 (two) loose tablets in the cart. LPN #2 stated that there should be no loose pills in the medication cart.On 4/23/2026 at 10:26 AM, during an inspection of the Beach medication cart with LPN #1, the surveyor observed 7 (seven) loose tablets in the cart. LPN #1 stated that there should not be loose pills in the medication cart.On 4/23/2026 at 11:34 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that there should be no loose pills in the medication [NAME] review of the facility-provided policy dated March 2026, titled Medication Labeling and Storage indicated under Policy Interpretation and Implementation the following: 1.) Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. N.J.A.C. 8:39 - 29.4 (a) (h)

Complaint #: 2979687 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within the required timeframe to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident physical abuse that allegedly occurred on 3/31/2026 on the 3PM-11PM shift for a cognitively intact resident. This deficient practice was identified for 1 of 3 residents (Resident #30) reviewed for abuse and was evidenced by the following: On 4/21/2026 at 11:30 AM during the initial tour of the facility, the surveyor was approached by Resident #30's Resident Representative (RR), who told the surveyor that he/she would like to discuss several issues with the surveyor concerning the care of their mother/father. Resident #30s RR told the surveyor that during a Facetime (an application, or app, for making video and voice calls over the internet) conversation with their mother/father the RR was made aware of an allegation that a staff member threw oxygen tubing at Resident #30 and then proceeded to walk out of the room. The RR told the surveyor that he/she was not sure of the date of the incident but that he/she had made the Registered Nurse Supervisor (RNS) aware via telephone call the night of the alleged physical abuse. The RR further told the surveyor that his/her mother/father was scared. The RR further told the surveyor that both him/her and Resident #30 made the RNS aware, and they were told that they would investigate. The RR told the surveyor that he/she did not know if an investigation had been completed at the time of interview. The facility failed to implement their abuse and neglect policies by failing to investigate an allegation of staff to-resident physical abuse. On 4/21/2026 at 1:31 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who was assigned to the unit in which Resident #30 resided. When asked if he had knowledge of an allegation of abuse which involved a staff member throwing an oxygen nasal cannula (tubing that is inserted into the nostrils to deliver oxygen) at Resident #30, he stated, No, not oxygen tubing, it was reported to me that a staff member threw a call bell device at the resident the day after the allegation allegedly occurred. LPN/UM #1 stated that the resident's family member met with him and informed him that Certified Nursing Assistant (CNA #1) was the alleged perpetrator who threw the call bell device at Resident #30. The LPN/UM#1 stated that he called CNA #1 at home and questioned her about the alleged event, and she denied that anything happened concerning the alleged physical abuse. LPN/UM #1 stated that he did not inform anybody afterward or document the incident because he did not think there was an issue after he had spoken with CNA #1. LPN/UM #1 was unable to state the date and time that the allegation occurred and stated that he thought that it happened well over a month ago in March 2026. On 4/21/2026 at 1:52 PM, the surveyors conducted an interview via telephone with the Registered Nurse Supervisor (RNS) who stated that when she became aware of the event she immediately went down to the unit and removed the accused staff (CNA #1) from the resident's assignment and notified the Director of Nursing (DON) by text message. The RNS stated that she notified the DON because it was an allegation of abuse, and she was required to report it. The RNS confirmed that she moved the accused CNA (CNA #1) to another assignment. On 4/21/2026 at 3:16 PM, in a subsequent in-person interview with the RNS, she stated that the allegation of abuse was made by the resident's RR via telephone. The RNS further stated that she had an allegation of both a call bell and a nebulizer mask being thrown at the resident. The RNS stated that she investigated immediately and then notified the DON via telephone and the DON stated that she would speak with the RR in the AM. The RNS stated that she told the DON what she did with CNA #1 concerning her work assignment. On 4/21/2026 at 3:38 PM, the surveyors interviewed Registered Nurse (RN #1) who confirmed that the alleged event happened on 3/31/2026 on the 3PM-11PM shift. RN #1 stated that CNA #1 came out of Resident #30's room upset and stated that the resident had accused her of throwing the call bell at him/her. RN #1 stated that the RNS had been notified and got involved. RN #1 stated that CNA #1 remained on the unit for the rest of the shift and was solely removed from Resident #30's room assignment. RN #1 stated that she did not obtain any written statements. RN #1 further stated that she did not know if the DON or the Licensed Nursing Home Administrator (LNHA) were notified. On 4/22/2026 at 9:37 AM, the surveyors interviewed the LNHA and the DON in the presence of the survey team. The LNHA stated the surveyor brought a pretty serious concern to his attention that he had not been made aware of. The DON stated that she was made aware after the RNS had sent her a text regarding the allegation on 3/31/2026. She stated she had missed the text message and had not responded to it. The DON stated that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me. The DON further stated that if there was an allegation of abuse the involved or accused staff should have been sent home. The DON further stated that an incident report, Progress Note, Physician Notification, Ombudsman Notification, Police Notification, and the DOH (Department of Health) should have been notified of the allegation of abuse.The surveyor reviewed the electronic medical record (EMR) for Resident #30.A review of the admission Record, an admission summary, revealed that Resident #30 had the following but not limited to diagnoses: chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease-primarily caused by smoking that obstructs airflow, causing chronic breathing difficulties), major depressive disorder, anxiety disorder, repeated falls, and acute and chronic respiratory failure.A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/12/2026, included Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #30 was cognitively intact. Section E of the MDS revealed that Resident #30 did not experience hallucinations or delusions and did not display any behavioral symptoms. Section GG revealed that Resident #30 was dependent on staff for most activities of daily living. Section O of the MDS revealed that Resident #30 received hospice care while a resident at the facility.A review of the Individual Comprehensive Care Plan (ICCP) included the following focus areas:A focus area initiated on 2/26/2026, which indicated that Resident #30 had mood problems related to admission. Interventions included: Report to MD (medical doctor) prn (as needed) acute episode of feelings (sic) or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.A focus area initiated on 2/26/2026, which indicated Resident #30 had oxygen therapy related to COPD. Interventions included: OXYGEN SETTINGS: [name redacted] has O2 (oxygen) via nasal prongs (nasal cannula) (at) 4L (liters) continuously. On 4/22/2026 at 8:19 AM, the facility LNHA provided the surveyor with a box of incident reports from February 2026 up to the present, as requested by the surveyor and team coordinator on 4/21/2026. The surveyor reviewed all files provided and there was no incident reports related to Resident #30s alleged staff-to-resident abuse allegation on 3/31/2026.On 4/22/2026 at 9:01 AM, the surveyor conducted an interview with Resident #30. Resident #30 was lying in bed awake and alert. Resident #30 was watching television and was observed to receive oxygen at 4L/min (liters per minute) via nasal cannula. The surveyor asked Resident #30 if he/she had ever had a call device thrown at them by a facility staff member. Resident #30 responded immediately, Yes. The surveyor asked Resident #30 if he/she could identify the staff by name and Resident #30 responded, No. Resident #30 could not remember the date or time of the event.On 4/22/2026 at 9:37 AM, the surveyors conducted a follow up interview with the facility LNHA and DON. The DON told the surveyors that she had been made aware of the alleged staff-to-resident abuse. The DON told the surveyors that the RNS sent her a text and that she missed it: and did not respond to it. The LNHA told the surveyors that he was not aware of the event. The DON further explained that she had a conversation with the RNS, and she reiterated that the resident was fine because the call device was in place and the oxygen tubing was observed to be in his/her nose, and the call bell was pinned to the bed. The surveyors then asked the LNHA and DON what the facility should do when an alleged claim of abuse occurred. The LNHA and DON told the surveyors that if an allegation of abuse occurred, we should have followed our abuse policy and conducted an immediate investigation. We did not investigate immediately, and the investigation should have started with me (DON). The DON further explained that the RNS should have called me over an accusation of abuse. The DON stated that they did not receive any information from LPN/UM #1. The surveyor then asked the DON what should be done when a staff member was accused of alleged abuse. The DON and LNHA told the surveyors that if there was an allegation of abuse the involved/accused staff should have been sent home. The DON stated that she could confirm that the alleged staff-to-resident abuse did occur on March 31, 2026, as that was the date she received the text message from RNS. The DON failed to allow the surveyors to observe the text message or provide a copy of the text message when requested. The DON went on to say that the ICCP was updated yesterday and that it should have been done within the first 24 hours of the investigation. In conclusion the LNHA told the surveyors, We missed on this one. On 4/23/2026 at approximately 9:38 AM, the surveyor reviewed the staffing schedules provided by facility administration for CNA #1 from 3/31/2026 up to the present. Review of the staffing schedules revealed that CNA #1 provided care to facility residents on 3 of 3 units on the following dates after being accused of staff-to-resident physical abuse: 3/31/2026 (3 PM-11 PM shift), 3/31/2026 (11 PM-7 AM shift), 4/2/2026 (3 PM-11 PM shift), 4/11/2026 (3 PM-11 PM shift), 4/11/2026 (11 PM-7 AM shift), 4/12/2026 (3 PM-11 PM shift), 4/12/2026 (11 PM-7 AM shift), 4/14/2026 (3 PM-11 PM), 4/14/2026 (11 PM-7 AM shift), 4/16/2026 (3 PM-11 PM shift), 4/16/2026 (11 PM-7 AM shift), 4/19/2026 (3 PM-11 PM shift) and 4/19/2026 (11 PM-7 AM shift). CNA #1 provided care to facility residents for another 13 shifts after an alleged accusation of staff-to-resident abuse. On 4/23/2026 at 1:20 PM, the surveyors conducted an interview with the facility medical director (MD), who told the surveyors he had been the MD since 1983. The surveyors asked the MD if he was aware of an alleged incident of staff-to-resident abuse involving Resident #30. The MD replied that he was not aware of any abuse at this time. The surveyor then asked if the MD was familiar with Resident #30. The MD stated that he was familiar with the resident. The surveyor asked the MD if he was aware of the IJ (Immediate Jeopardy) at the facility on 4/22/2026. The MD replied that he did not know of the IJ and that he was not made aware. The surveyor then asked the MD what his expectations were when an allegation of abuse was made. The MD told the surveyors that his expectations were that the facility would investigate, notify the administrator and police and document everything. The surveyor then asked what the facility should do with the accused staff. The MD stated that the accused staff member should be removed from the resident. The surveyor asked if the accused staff should be able to continue to provide care to residents after an allegation of abuse was made. The MD replied, I don't know if they can continue to work with other residents. The surveyors further questioned whether the facility abuse policy should specify what to do with a staff accused of abuse. The MD agreed that the abuse policy should specify what should be done with the alleged staff member, yes. In addition, the surveyors asked if it was appropriate for the RNS to communicate an alleged incident of physical abuse by text message. The MD said the RNS should communicate with the administrator via telephone. The MD was asked what the importance was of completing an immediate investigation when an allegation of abuse occurs. The MD told the surveyors that the importance of an immediate investigation was to prevent further abuse of another resident and to ensure resident safety. The MD was asked if he would be expected to be notified of any abuse allegations and when. The MD stated that he would expect to be notified of an event of abuse at the same time the administrator was notified by text and then he would call the facility in response. Lastly, the surveyors asked the MD what his role was during an alleged accusation of abuse. The MD stated his role was to ensure an investigation was completed properly and to ensure resident safety by keeping the accused away from the alleged victim.On 4/27/2026 at 9:55 AM, the surveyor reviewed the progress notes (PN) from 3/1/26 up to 4/7/2026 at 23:43 (11:43 PM). Review of the PN did not reveal any documentation concerning the alleged physical abuse event on 3/31/2026 on the 3 PM-11 PM shift.On 4/27/2026 at 8:24 AM, the surveyor conducted a phone interview with CNA #1. The surveyor asked CNA #1 if she was aware of an accusation of staff-to-resident abuse on March 31, 2026, allegedly involving her. CNA #1 stated that when she walked into Resident #30s room because the call bell was activated, the supervisor (RNS) was in the room, and the RR was on the phone. She stated the supervisor pulled me aside and told me the RR made an accusation that I threw the call device at the resident. CNA #1 explained that the call device was duct taped to the dresser, so how could I have thrown it. CNA #1 elaborated that the RR said that I threw an oxygen mask and a nebulizer at Resident #30. She stated she never saw a nebulizer and the mask was on the whole time. The surveyor then asked CNA #1 what the facility did with her assignment once the alleged accusation of abuse had been made. CNA #1 responded that they changed my assignment that night and kept me off the accuser's assignment. The surveyor then asked if CNA #1 had worked another shift after her 3 PM-11 PM shift. CNA #1 responded that she did work a double shift that night (3 PM-11 PM and 11 PM-7 AM). CNA #1 told the surveyor that she had not been on that assignment (Resident #30) since the accusation had been made. The surveyor then asked if CNA #1 was allowed to continue to provide care at the facility after the alleged abuse event. CNA #1 told the surveyor that she continued to work at the facility up until maybe like a week and a half ago. She further explained that last week they told me that an investigation was going on and I could not work until it was resolved. The surveyor asked CNA #1 who told her that she could no longer provide care. CNA #1 stated that she was told by the scheduler. The surveyor asked CNA #1 if she had worked at the facility since the notification by the scheduler. CNA #1 stated she had not worked and further stated, No. I guess they will let me know. The surveyor ended the interview by asking CNA #1 if the facility had provided abuse training to her. CNA #1 stated, No. I did not receive abuse training from the facility, but I did receive it from my agency.A review of the facility's Abuse, Neglect and Exploitation policy, updated 11/20/2025 included the following under Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. The following was observed below:VII. Reporting/ResponseThe facility will have written procedures that include:Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve and/or result in serious bodily injury, orNot later than 24 hours if the events that cause the allegation do not result in serious bodily injury.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. NJAC 8:39-4.1(a)(5),9.4(f)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 3 of 3 garbage containers/dumpsters. This deficient practice was evidenced by the following:On 04/21/2026 at 9:57 AM, the surveyors observed the facility designated garbage area, which had a residential home in proximity. The surveyors observed three (3) 5-yard garbage dumpsters designated for trash and one (1) 5-yard dumpster designated for recycling. 3 of 3 trash dumpsters had 1 of 2 lids open and garbage was exposed. The recycling dumpster was observed to have had both lids closed. Garbage contents included clear plastic bags with garbage. While observing the designated garbage area, two (2) staff were observed actively placing recyclables in the recycling bin in the presence of the surveyors and failed to close the dumpsters prior to leaving the area. Upon return to the kitchen the surveyor made the Account Manager (AM) aware of the surveyor garbage findings. The AM told the surveyor that ensuring the garbage area is clean and garbage is secured was a shared responsibility of all facility staff. The surveyor reviewed the facility provided policy titled, Dispose of Garbage and Refuse, [name redacted] Policy 030, revised 2/2025. The following was observed under Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner. In addition, the following was revealed under Procedures: The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior of the dumpster is maintained in a manner free of rubbish or other debris. The Dining Services Director will ensure that: All trash will be properly disposed of in external receptacles (dumpsters) with lids covered when not in use. NJAC 8:39-19.3(c)

Based on observation, interview and record review it was determined that the facility failed to ensure resident rooms and common areas were adequately furnished to meet resident needs and promote comfort and accessibility due to an insufficient number of chairs available for resident use which had the potential to limit resident comfort, reduce opportunities for socialization and impede accommodations of visitors. This deficient practice was observed on 3 of 3 nursing units (B-Unit, Long-Term Care, and Subacute) and evidenced by the following:1.) On 4/22/2026 at 12:48 PM, the surveyor observed a group of five residents standing in the hall on the B-Unit. All five unsampled residents stated that they did not have a main dining room to eat in and that the main dining room was for the assisted living residents. They stated that they would enjoy eating somewhere beside their rooms, however there was nowhere else to eat. They stated that there was a small dining room near the nurse's station on the B-unit but only the residents that required assistance with feeding ate there. They stated that there were no chairs in the small dining room for residents to sit to even just to watch TV. The surveyor went to the small dining room and there were approximately five tables with no chairs. The residents also complained that they had no chairs in their rooms to sit on for themselves or their visitors. One of the unsampled resident stated that their visitors even had to leave early because they got tired of standing. On 4/22/2026 at 1:00 PM, the surveyor interviewed Resident #45 who stated his/her visitors had to sit on the bed in their room when they visited. The surveyor observed that Resident #45 did not have any chairs for themselves or their visitors to sit. A review of admission Record (admission summary), revealed that Resident #45 was admitted to the facility with the diagnoses which included but was not limited to major depressive disorder and muscle wasting and atrophy. A review of the quarterly Minimum Data Set, an assessment tool that facilitates a resident's care, dated 4/16/26, indicated that Resident #45 scored a 15 out of 15 on the Basic Interview for Mental Status (BIMS). This score indicated that the resident was cognitively intact. The surveyor observed that the following rooms on the B-Unit did not have chairs for the residents or their visitors: 120 A and B, 121 A and B, 123 A and B, 125 A and B, 124 A and B, 127 B, 129 A and B, 128 A, 131A, 130 A and B. A review of the facility policy dated January 2026, and titled, Safe and Homelike Environment indicated that in accordance with resident rights, the facility will provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safety and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. NJAC 8:39-31.8 2.) On 4/24/26 at 12:40 PM, the surveyor toured the long-term care unit and the subacute rehabilitation unit (SAR). On the long-term care unit, the surveyor observed that rooms 102, 103, 105, and 106 all had two residents but only one chair for a visitor or the resident. rooms [ROOM NUMBER] did not have any chairs in the rooms. On a tour of the SAR unit the surveyor observed room [ROOM NUMBER], with one chair and two residents, and rooms [ROOM NUMBER] did not have any chairs. During the tour of the SAR unit the surveyor interviewed an unsampled residents' family member regarding seating accommodations as a visitor. The family member told the surveyor that they had one chair in the room and in the morning, its usually gone from the room. The surveyor asked where they sit as visitors and she stated, Wherever I can find a place, its not easy. A review of the facility policy dated January 2026, and titled, Safe and Homelike Environment indicated that in accordance with resident rights, the facility will provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safety and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. NJAC 8:39-31.8

Based on observation, interview and record review, it was determined that the facility failed to maintain an environment that was in good repair, as well as a clean and sanitary environment for the residents. This deficient practice was identified in resident living areas on 1 of 3 units (Long-Term Care Unit) and was evidenced by the following:On 4/22/2026 at 9:30 AM, during the initial tour of the long-term care unit, the surveyor observed the following: In room [ROOM NUMBER], a semi-private room with one bathroom, the soap dispenser was broken off the wall and the toilet paper holder was broken. The unsampled resident in bed 105-A told the surveyor that it had been broken for a while and that they purchased their own hand soap and just leaned the toilet paper roll on the broken holder. In room [ROOM NUMBER], another semi-private resident room with one bathroom, the soap dispenser and the toilet paper holder were broken. The unsampled resident could not tell the surveyor how long the items were in disrepair. On 4/23/2026 at 12:30 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) on the long-term care unit regarding repairs. The surveyor was told there was a book for staff to log in any repairs needed. The surveyor asked to see the book, but it could not be located. On 4/24/2026 at 11:40 AM, the surveyor interviewed the Director of Maintenance (DM) regarding repairs on the units. The DM stated that he was notified of broken equipment during the day on a telephone application. When asked about the process for nights or weekends when he was not available, he told the surveyor there was a book on each unit and the staff could write the repairs needed in the book. The DM told the surveyor the books were checked every morning by the maintenance department. The DM then told the surveyor that the maintenance book on the long-term care unit was lost and would be replaced. The surveyor asked the DM if toilet paper holders and soap dispensers should be fixed timely, he responded, They are a priority and should be fixed right away. A review of the facility policy dated January 2026 and titled, Safe and Homelike Environment indicated that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The policy also specifies that staff were to report any furniture in disrepair to the Maintenance promptly and report any unresolved environmental concerns to the Administrator.NJAC 8:39 - 31.4 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) staff stored their personal belongings in the designated area, b.) cellular phones were not used in resident areas while caring for a resident, c.) that the residents' dining experience was provided in a manner to promote dignity and respect of the residents, and d.) residents were treated with respect and dignity through staff interactions that support self-esteem and honored individual choices and right for privacy. This deficient practice was identified in 2 of 3 residents ( Resident #10 and Resident #106) reviewed for dignity and was evidenced by the following: 1) On 4/22/2026 at 10:18 AM, the surveyor observed Resident #10 in their room, sitting in a reclining chair, with a facility staff member seated in a chair across from them. Upon the surveyor entering the resident's room, CNA #6 picked up his energy drink and opened it. He was noted scrolling on his cellular phone and drinking the energy drink. On 4/23/2026 at 9:00 AM, the surveyor reviewed Resident #10's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Dementia with behavioral disturbances, mood disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/17/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/10/2024 that Resident #10 had a diagnosis of dementia with behavioral features, PTSD (Post Traumatic Stress Disorder), mood disorder and behavior history of being combative with staff and others, grabbing CNA (Certified Nursing Assistant) wrist, and verbal aggression. The interventions included that Resident #10 was placed on one to one monitoring on day shift (7-3 PM) and evening shift (3-11 PM), and periodic observation on night shift (11 PM-7 AM). On 4/23/2026 at 11:29 AM, the surveyor conducted a follow-up visit to Resident #10's room. Immediately upon entering Resident #10's room, the air was filled with the smell of fried chicken. Resident #10 was observed sitting in their reclining chair, near an energy drink, as CNA #6 sat across from them. CNA #6 got out of their chair and moved the energy drink and placed it in a red bag, in the resident's room. At that time, the surveyor interviewed CNA #6 who stated that lunch had not arrived for Resident #10, and it would be arriving within the next hour. When asked about the aroma, the CNA pointed to the same red bag and stated he had some fried chicken for his lunch that he had purchased from the grocery store. On 4/23/2026 at 11:32 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #8 who stated that staff should store their lunch in the breakroom in the front of the building, near the timeclock. Shortly thereafter, at 11:35 AM, the surveyor requested that LPN #8 and Licensed Practical Nurse/Unit Manager (LPN/UM) #2 go to Resident #10's room for an observation. LPN/UM #2 and LPN #8 went into the resident's room and confirmed that it smelled like fried chicken. She reported to the surveyor that she saw CNA #8 had his personal bag in the resident's room but did not actually observe him eating the fried chicken at that time, and agreed that it was a strong aroma. She further stated that the staff should not store their personal belongings in the resident's room. She added that if Resident #10 got a hold of the chicken, they could choke on it, if it was not consistent with their ordered diet. LPN/UM #2 stated that she would remove the staff's belongings from the resident's room right away. At 4/23/2026 at 11:45 AM, the surveyor interviewed the Director of Nursing (DON) who stated that staff's personal belongings should not be in the resident's room. She added that staff's food being present in the residents' room could make them upset because the food was not for them. She further added that the aroma could make them nauseous or it could trigger negative behaviors. On 04/24/2026 at 11:45 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the residents had their own food and staff having other foods in the resident area, could make them want that food. He further stated that having opened food could make it unsafe for the residents. He added that staff had lounges to store their food, one near the kitchen and one near the physical therapy department. He further stated that the staff should never have their personal food in the residents' rooms. He added that the staff should not be on their personal cell phones while they were on one to one observation in a resident room and that cell phone use was not permitted in the patient area. 2) On 4/22/2026 at 12:27 PM, the surveyor conducted a dining observation on the Serenity Unit, in the front dining room. The surveyor observed three unsampled residents seated at a table. At that time, CNA #7 was observed at the table, going from resident to resident rendering feeding assistance, while standing over them. On 4/22/2026 at 12:35 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated to maintain the resident's dignity, staff should be seated next to the resident while rendering feeding assistance with their meals. On 4/23/2026 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Regional Director of Nursing (RN) #1. The DON stated that when the CNA assisted a resident with feeding, the CNA should be seated next to the resident so they could assess them and see their mouth and determine if they were swallowing properly. She added that it was much easier for the staff to be face to face with the residents. She further stated that being seated maintained the resident's dignity. A review of the facility's Personal Items in the Work Area policy, reviewed and updated January 2025, included, Employees are permitted to bring personal items to the workplace with the understanding that they must not interfere with the operational environment, resident care, or the security and privacy of residents and staff. Personal items should be stored in designated areas such as lockers or drawers provided by the facility. A review of the facility's Personal Cell Phones policy updated January 2026, included, This Facility prohibits employees from using personal cell phones for any reason, in resident care areas (rooms, dining rooms, activities, .) . A review of the facility's Promoting/Maintaining Resident Dignity During Mealtimes policy updated November 2025, included, All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.All staff will be seated, if possible, while feeding a resident. 3) On 4/23/2026 at 10:45 AM, Surveyor #2 observed the resident sitting in bed. The surveyor did not observe any involuntary movements from the resident. The resident stated that they could walk with a walker. The resident also stated that their bed and chair alarms were loud and that they did not like it. On 4/23/2026 at 10:47 AM, the surveyor heard a high-pitched repeated alarm from Resident #106's room. The surveyor observed the resident transferred themselves from the hallway to the wheelchair to the bed. Certified Nursing Assistant (CNA) #4 was observed walking in the hallway and stopped at the doorway to the resident's room. CNA #4 asked the resident in a loud voice, [ Name redacted], what are you doing? Why are your pants down? The resident's roommate was on the first bed near the doorway watching television. The curtain between the two residents was open. The surveyor observed CNA #4 go to Resident#106's bed and bend down to fix the resident's pants without closing the privacy curtain between the two residents and without closing the door to the hallway. The surveyor then observed CNA #4 putting the resident's wheelchair at the foot of the bed where the resident could not reach it. The surveyor asked CNA #4 if the resident could walk on their own. The CNA stated that they have seen the resident walk, but they need to walk with the physical therapists. The surveyor asked CNA #4 why the resident had bed and chair alarms. CNA #4 stated that the resident liked to get up without ringing their bell. CNA # 4 stated that the resident was stubborn and liked to do things by themselves. The CNA stated that they used the alarms so the staff could catch the resident. The surveyor asked CNA #4 if they should have closed the privacy curtain and closed the door while pulling up the resident's pants. The CNA did not answer the surveyor directly but referred to the knots in the ties of the resident's pants. The surveyor asked the CNA why they placed the wheelchair beyond the reach of the resident at the foot of the bed. The CNA stated that the resident was not allowed to reach the wheelchair by themselves. The surveyor reviewed the hybrid medical record of Resident #106. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility from the assisted living facility with diagnoses which included but were not limited to benign neoplasm of the brain (brain tumor) status post resection (to surgically remove tissue), depression, and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/25/2026, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15,which indicated the resident was fully cognitively intact. The MDS also indicated that the resident used a walker for mobility and not a wheelchair. The MDS indicated that the resident had no falls in the facility since admission. Further review of the MDS indicated that bed and chair alarms were used daily by the resident. A review of the Order Summary Report (OSR) active as of 4/21/2026, revealed the following verbal physician orders: Bed alarm, check placement and function every shift; Chair alarm, check placement and function every shift. A review of the individualized comprehensive care plan initiated and revised on 4/7/2026 included a focus for risk for falls due to deconditioning, gait problem, and psychoactive drug use. One of the interventions included the following: Anticipate and meet the resident's needs; use of bed and chair alarms. On 4/23/2026 at 11:34 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the resident's alarm was to alert the staff if the resident was getting out of bed. A review of the facility's Personal Items in the Work Area policy, reviewed and updated January 2025, included, Employees are permitted to bring personal items to the workplace with the understanding that they must not interfere with the operational environment, resident care, or the security and privacy of residents and staff. Personal items should be stored in designated areas such as lockers or drawers provided by the facility. A review of the facility's Personal Cell Phones policy updated January 2026, included, This Facility prohibits employees from using personal cell phones for any reason, in resident care areas (rooms, dining rooms, activities, .) . A review of the facility's Promoting/Maintaining Resident Dignity During Mealtimes policy updated November 2025, included, All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.All staff will be seated, if possible, while feeding a resident. A review of the facility provided Resident Rights policy, dated January 2026, included under Policy Statement: employees shall treat all residents with kindness, respect, and dignity. Under Policy Interpretation and Implementation, the following are indicated: Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident rights to; A dignified existence; Self-determination; Privacy and confidentiality. N.J.A.C. 8:39 – 4.1 (a) (12) (16)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a cognitively intact resident was free from physical restraints through the following: a.) performing an assessment and evaluation for use of bed and chair alarms; b.) obtaining a consent with disclosure of risk versus benefits for use of bed and chair alarms; c.) monitoring the resident during the use of bed and chair alarms; d.) conducting ongoing evaluations for the continued use of the bed and chair alarms; e.) documenting the least restrictive interventions that were utilized prior to using bed and chair alarms; and f.) developing and implementing interventions for reducing and eventually discontinuing the use of bed and chair alarms when no longer required, in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 1 resident (Resident #106), reviewed for restraints and was evidenced by the following:On 4/21/2026 at 11:22 AM, the surveyor heard a high-pitched sound repeatedly from the doorway of Resident #106. The resident was observed sitting sideways on the bed with both feet on the floor, wearing shoes, and appeared anxious while pushing buttons on a blue bed alarm anchored to the right-side rail. The resident attempted to stand up, triggering the alarm, which silenced when they sat back down. This pattern repeated, and an unidentified staff member entered to turn off the alarm. The resident informed the staff they needed to use the bathroom, and the staff left the room. No rolling walker was observed in the room. When interviewed at that time, the Licensed Practical Nurse (LPN #6) explained that the resident was a fall risk and had previously fallen at the assisted living facility where they previously resided. On 4/22/2026 at 1:58 PM, the surveyor observed the resident in bed, with a wheelchair and a blue chair alarm placed next to the resident's bed. On 4/23/2026 at 10:45 AM, the surveyor observed the resident sitting in bed. The surveyor did not observe any involuntary movements from the resident. The resident stated that they could walk with a walker. The resident also stated that the alarm was loud and that they did not like it.The surveyor reviewed the hybrid medical record for Resident #106.A review of the admission Record face sheet (an admission summary) reflected that the Resident #106 was admitted to the facility with diagnoses which included but were not limited to: benign neoplasm of the brain (brain tumor) status post resection (the process of cutting out tissue), depression, and hypertension (high blood pressure).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/25/2026, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS also revealed that the resident used a walker for mobility, and not a wheelchair. The MDS also indicated that the resident had no falls in the facility since admission. Further review of the MDS revealed that both bed and chair alarms were used daily by the resident.A review of the Order Summary Report (OSR) active as of 4/21/2026, revealed the following verbal physician orders: Bed alarm, check placement and function every shift; Chair alarm, check placement and function every shift.A review of the individualized comprehensive care plan (ICCP) initiated and revised on 4/7/2026, included a focus area for risk for falls due to deconditioning, gait problem, and psychoactive drug use. One of the interventions included the use of bed and chair alarms. There was no documentation that Resident #106 was assessed for their ability to turn on and off the alarms on request. There was no evidence that ongoing reevaluation or documentation of the medical symptoms and use of the alarms for the least amount of time possible was found in the medical record.A review of the paper and electronic medical record did not reveal any consent with disclosure of risk versus benefits from the alert and oriented resident for the use of the bed and chair alarms. There was no documentation that the resident was assessed or evaluated for any psychological effects of continued use of the bed and chair alarms. There was no documentation that the resident was monitored during continued use of the restraint and that the alarms were turned off during supervised activities.On 4/23/2026 at 11:34 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the resident's alarm was to alert the staff if the resident was getting out of bed.On 4/27/2026 at 8:30 AM, during an interview with the surveyor, the resident's roommate stated that Resident 106's alarm was loud.A review of the facility provided policy dated January 2026, titled Restraints included under Policy Interpretation and Implementation the following:a.) Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.b.) Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following - the specific reason for the restraints; how the restraint will be used to benefit the resident's medical symptom; and the type of restraint and the period of time for the use of restraint.c.) A resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.N.J.A.C. 8:39-4.1(a) 3,4, 6

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the residents receiving psychoactive medication. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications, (Resident #9 and #54) and was evidenced by the following: 1.) On 4/22/26 at 12:15 PM, Resident #9 was observed ambulating with a walker to the dayroom on the Long- Term Care Unit. The resident was cooperative at the time of the observation. On 4/23/2026 at 12:20 PM, the surveyor reviewed Resident #9's Electronic Medical Record (EMR) which revealed the following: A review of the admission Summary indicated that Resident #9 was admitted with medical diagnoses that included but were not limited to: repeated falls, bipolar disorder, hypertension (high blood pressure), and schizophrenia. A review of Resident #9's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/9/2026, revealed the resident had diagnoses which included but were not limited to schizophrenia and bipolar disorder. The resident had a Brief Interview of Mental Status (BIMS) score of 6 out of 15, which indicated that Resident #9 had severe cognitive impairment. A review of Resident #9's Individualized Comprehensive Care Plan (ICCP) contained the following focus: Resident uses antipsychotic medications related to schizoaffective disorder, bipolar disorder and behavior management. The resident's target behaviors included hyperverbal speech, insomnia, psychomotor restlessness, grandiose delusions, paranoia, and hallucinations. The care plan was initiated on 8/16/2017 and revised on 3/25/2025. Interventions included but were not limited to the following: Monitor and record occurrence of target behavior symptoms: pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff and document per facility protocol. Another intervention was to monitor/record/report to medical doctor side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia (involuntary movements of the face and jaw), shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person. A review Resident #9's Physician Order Summary (POS) indicated that the resident was prescribed the following medications: Olanzapine Oral Tablet 7.5 milligrams (MG) (antipsychotic), give 1 tablet by mouth at bedtime for schizoaffective disorder, bipolar type. Divalproex Sodium Capsule, Delayed Release Sprinkle (mood stabilizer) 125 MG, give 3 capsules by mouth two times a day for bipolar disorder. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not have any behavior documentation or side effect monitoring documentation. On 4/23/2026 at 12:56 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) on the Long-Term Care B-Unit regarding behavior monitoring and documentation. LPN #1 told the surveyor that the nurses go into the progress notes in the EMR, select behaviors and document there. The progress notes showed the last behavior documented for Resident #9 was dated 7/22/2025. On 4/23/2026 at 1:20 PM, the surveyor reviewed the most recent nursing Psychotropic Monthly Summary dated 4/15/2026 which revealed that the resident had four episodes of behaviors for the month of March 2026. The summary did not include when the behaviors occurred. 2.) On 4/23/2026 at 10:10 AM, Resident #54 was observed in the dayroom on the Serenity Unit. The resident did not want to be interviewed by the surveyor. The surveyor reviewed the EMR for Resident #54 which revealed the following information: A review of the admission Summary indicated the resident had medical diagnoses which included but were not limited to dementia with agitation, hypertension, and heart disease. A review of the Nursing admission Screen, dated 3/12/2026, revealed that Resident #54 had a BIMS of 00, meaning the resident had severe cognitive impairment. A review of the ICCP dated 3/30/26, contained the following focus: resident has impaired cognitive function/dementia or impaired thought processes related to Dementia and was prescribed psychotropic medication related to Dementia with Behavioral Disturbances. Interventions dated 3/30/26, included but were not limited to the following: -Administer medications as ordered. Monitor and document for side effects and effectiveness. -Give antidepressant medications ordered by physicians. Monitor and document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Date Initiated: 3/30/2026 A review of the Physician's Order Sheet (POS) showed the resident was prescribed the following medications: Quetiapine Fumarate Oral Tablet 25 MG (antipsychotic), Give 0.5 tablet by mouth three times a day for Dementia with behavior disturbance order date 3/13/2026. Quetiapine Fumarate Oral Tablet 50 MG (antipsychotic), Give 1 tablet by mouth at bedtime for dementia with behavioral disturbance, order date 3/13/2026. Sertraline HCl Oral Tablet 50 MG (antidepressant), Give 1 tablet by mouth one time a day for depression, order date 3/13/2026. Mirtazapine 7.5 mg (antidepressant), Give 1 tablet every bedtime for depression, order date 4/23/2026. Review of the March psychotropic nursing evaluation showed the residents targeted behavior as combative with care. The evaluation revealed the resident had 3 (three) episodes of behaviors. On 4/24/2026 at 11:02 AM, the surveyor reviewed the progress notes which showed that the staff were documenting behaviors as they occurred each time. The surveyor could not locate any documentation of side effect monitoring. On 4/24/2026 at 11:15 AM, the surveyor reviewed the MAR, TAR, and the progress notes which did not reveal monitoring of side effects from the prescribed psychotropics or antidepressants. On 4/27/2026 at 9:47 AM, during an interview with the Director of Nursing (DON), she stated that the staff refer to the resident's ICCP for monitoring behaviors and side effects, but she could not provide documentation of the monitoring being completed for Resident #9 or Resident #54. The surveyor reviewed the policy titled, Behavior Management Policy, updated January 2025. Under number four Monitoring and Documentation, it revealed the staff will document all behavior incidents and interventions in the resident's health record, including the time, date, behavior observed, interventions used, and the outcome. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the care plan for a resident who was previously identified with significant weight loss was updated timely to ensure that all staff were aware of the frequency that the resident must be weighed/monitored. This deficient practice was identified for 1 of 27 residents (Resident #34) reviewed for comprehensive care plans and was evidenced by the following: On 4/22/2026 at 10:17 AM, the surveyor observed Resident #34 in the activity room, sitting in their geriatric chair. On 4/22/2026 at 11:00 AM, the surveyor reviewed Resident #34's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: mild protein-calorie malnutrition, dysphagia (difficulty eating), and dementia. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/11/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident's cognition was severely impaired. A further review revealed that Resident #34 sustained significant weight loss. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/22/2025 that Resident #34 had a nutritional problem and was at risk for malnutrition. The interventions included: super pudding (a high-calorie, nutrient-dense pudding designed to increase protein and nutrient intake) twice per day, assistance with meals, report to provider significant weight loss of three pounds in a week, greater than five percent in one month, greater than seven and a half percent in three months, greater than ten percent in six months, and to weigh them weekly. A review of the physician orders (PO), active orders as of 4/23/2026 did not include an order for the frequency that Resident #34 should be weighed. A review of Resident #34's Weight Summary revealed the following: 9/3/2025, 139.4 pounds (lbs)9/4/2025, 136.0 lbs9/8/2025, 136.6 lbs9/15/2025, 134 lbs9/22/2025, 130.1 lbs9/29/2025, 131.1 lbs10/1/2025, 128.6 lbs10/6/2025, 126.4 lbs10/13/2025, 124.0 lbs10/20/2025, 120.1 lbs10/27/2025, 119.1 lbs11/3/2025, 118.6 lbs11/10/2025, 118.4 lbs11/17/2025, 118.6 lbs11/24/2025, 119.2 lbs12/1/2025, 119.8 lbs1/4/2026, 119.1 lbs1/5/2026, 119.8 lbs1/12/2026, 118.0 lbs1/20/2026, 117.4 lbs1/26/2026, 116.2 lbs2/2/2026, 116.8 lbs2/9/2026, 115.2 lbs2/16/2026, 115.0 lbs2/23/2026, 115.8 lbs3/2/2026, 116.4 lbs4/1/2026, 114.0 lbs A review of Resident #34's most recent Nutrition Evaluation Note dated 1/9/2026 at 12:25 PM revealed, Nutrition Interventions: .Weekly weights. A review of the Dietician Quarterly Note dated 3/6/2026 at 12:45 PM, revealed Current weight 115.8 lbs.weight stabilizing since readmission.No new recommendations at this time, follow up prn (as needed). On 4/23/2026 at 8:54 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #8 who stated that the unit manager would notify the CNA on how often a resident needed to be weighed. She stated that Resident #34 was on weekly weights for a while and is currently on monthly weights. On 4/23/2026 at 8:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #8 who stated that Resident #34 had a poor appetite and some days they ate more than others, but they would drink their shakes. She added that Resident #34 was currently on weekly weights and that the CNA, nurse and unit manager was responsible to ensure that the resident was weighed weekly. LPN #8 stated that there should be a physician's order that indicated the frequency that each resident should be weighed. She pulled up the electronic medical record (EMR) for Resident #34 and stated that she did not see a physician's order for weights, and the order may have fallen off. On 4/23/2026 at 11:06 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Regional Director of Nursing (RDON). The DON stated that the care plan should be followed, and it should be updated quarterly and as soon as possible with any changes with the resident's care. She also stated that there should be a physician's order for weights. On 4/24/2026 at 10:33 AM, the surveyor interviewed the Registered Dietician (RD) who stated that Resident #34 was being monitored for significant weight loss. She stated as of March Resident #34's weight stabilized; therefore she wanted the weekly weights to be discontinued but she did not document it in the EMR and she did not always document the recommendation. She further stated that the care plan should have been updated with the frequency that Resident #34 should be weighed. On 4/27/2026 at 9:48 AM, the RDON stated that weight monitoring was clinically directed by the Interdisciplinary team, unit managers and was based off weekly meeting with the dietician. She added that weekly weights did not require a physician's order and they should be following the care plan. She further stated the care plan should have been updated that the dietician did not want the weekly weight monitoring to be continued. A review of the facility policy updated in March 2026 titled Care Plans, Comprehensive Person - Centered included under Policy Interpretation and Implementation the following: 3.) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9.) 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. 11) Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. A review of the Weight Monitoring policy updated January 2026, included Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's nutritional concerns and preferences. The care plan should address the following, to the extent possible: .Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition-related problems are identified. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate.Residents with weight loss- monitor weight weekly per IDT review analysis and decisions to weight monitoring included but not limited to indications of orders or recommendations.g. The Interdisciplinary plan of care communicates are instructions to staff.N.J.A.C. 8:39 - 11.2 (e) (2)

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to: a.) clarifying physician orders to specify the amount and type of nutritional supplement that was to be provided and b.) develop and implement a policy for monitoring and documenting the amount of urinary output including, color, and odor, and reporting changes in bladder function of residents with an indwelling catheter, to minimize the risk for complications such as leakage and urinary tract infection. This deficient practice was identified for 1 or 1 resident (Resident #45), during the dining observation and for 1 of 2 residents (Resident #4), reviewed for urinary catheter care, respectively and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 4/22/2026 at 12:53 PM, during the dining observation, Resident #45 stated to the surveyor that they did not get shakes with breakfast, lunch or dinner. The surveyor reviewed the resident's meal ticket which indicated that the resident was on a regular diet and shakes were to be provided with breakfast, lunch, and dinner. The surveyor observed the resident's lunch tray and there were no shakes on the tray. A review of the admission Record (admission summary), revealed that Resident #45 was admitted to the facility with the diagnoses which included but was not limited to major depressive disorder and muscle wasting and atrophy. A review of the quarterly Minimum Data Set, an assessment that facilitates a resident's care, dated 4/16/26, indicated that Resident #45 scored a 15 out of 15 on the Basic Interview for Mental Status (BIMS). This score indicated that the resident was cognitively intact. The MDS also reflected that the resident's weight was stable. On 4/22/2026 at 12:54 PM, the surveyor interviewed a Certified Nursing Assistant (CNA #3) who was passing out meal trays. CNA #3 inspected Resident #45's meal tray and confirmed that the resident did not have the shakes on the tray. The CNA stated that maybe the nurse gave them to the resident. She stated that the surveyor should go and ask the nurse for the process for nutritional shake distribution. The surveyor reviewed Resident #45's physician orders (PO) which indicated the following: A PO, dated 3/20/2026, for Dietary Nutritional Supplement two times a day for risk of malnutrition. The order did not specify what type of nutritional supplement the resident was supposed to receive. A review of the Medication Administration Record (MAR) also contained an order dated 3/20/26, for Dietary Nutritional Supplement two times a day for malnutrition, however, did not specify what type of nutritional supplement or how much of the supplement was to be provided. A review of the Interdisciplinary Comprehensive Care Plan (ICCP) indicated that Resident #45 had the potential for nutritional problems and that the staff would provide and serve supplements as ordered. On 4/22/2026 at 1:11 PM, the surveyor reviewed Resident #45's meal ticket with the Licensed Practical Nurse (LPN #1) who confirmed that the meal ticket indicated that the resident was to receive a shake for breakfast, lunch, and dinner. The surveyor then reviewed the PO with LPN #1 who also confirmed that the order specified a nutritional supplement to be given to the resident two times a day. The LPN was also in agreement that the physician order was unclear on what type of nutritional supplement the resident should receive or how much. She stated that she would contact the MD (Medical Doctor) to clarify the order to specify how much and what type of supplement the resident was supposed to get. The surveyor reviewed the Dietician Quarterly Note dated 4/16/26 at 1600 hours (4:00 PM) which indicated that the resident was on a regular diet and that the resident's diet was supplemented with a dietary nutritional supplement BID (twice a day). The note also indicated that the residents' weight had stabilized over the last three weeks. On 4/23/2026 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) for the B-unit who stated that when a physician's order was written for a nutritional supplement it should specify how many ounces and what type of supplement was to be administered. He stated that if the order was not clear or specific for the type of nutritional supplement the resident should receive or how much, then the nurse should get the order clarified. A review of the facility policy dated May 2025 and titled, Medication and Physician Orders indicated that commercial dietary supplements should specify type, amount and frequency. A review of the facility policy dated 1/2026 and titled, Nutritional Supplement indicated that physician orders for resident would be written as: -Dietary Nutritional Supplement/Nutritional Supplement {type of commercial shakes redacted} may be used. -Diabetic Nutritional Supplement {type of commercial shakes redacted} may be used. -Lactose Free Nutritional supplements {type of commercial shakes redacted} may be used. -High Calorie Nutritional Supplements {type of commercial shakes redacted} may be used. -Renal Nutritional Supplements {type of commercial shakes redacted} may be used. 2.) On 4/21/2026 at 10:08 AM, Surveyor #1 observed Resident #4 in bed with a urinary catheter tubing connected to a drainage bag that was maintained within a privacy bag that was anchored on the lower bed rail. There was a strong urine-like odor in the room. On 4/22/2026 at 1:41 PM, Surveyor #2 observed the resident in bed. The resident stated that their urine bag was being emptied every shift, but they have never seen any staff measure their urine and have never been informed about it. On 4/22/2026 at 1:43 PM, during an interview with Surveyor #2, Certified Nursing Assistant (CNA) #5 stated that they were familiar with Resident #4. The CNA also stated that they usually measured the amount of urine from the urine bag and gave the information to the nurse. Surveyor #2 reviewed the hybrid (electronic and paper) medical record for Resident #4. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included obstructive and reflux uropathy (a condition where normal flow of urine is blocked or flows backward from the bladder anywhere in the urinary tract), cystitis (inflammation of the bladder usually caused by bacterial infection resulting in painful, frequent and urgent urination), and cystostomy status (an artificial opening between the urinary bladder and the abdominal wall to drain urine usually through a suprapubic catheter). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/8/2026, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated an intact cognition. Further review of the MDS indicated that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) active as of 4/21/2026, revealed physician orders that included changing the suprapubic catheter as needed if clogged or dislodged, drainage bag to be covered with privacy bag and to be placed below bladder level, catheter irrigation as needed, and catheter care every shift. There was no physician order for monitoring the resident's urinary output including amount, color, odor, and changes in bladder function. A review of the corresponding Treatment Administration Record (TAR) in April 2026, revealed no documented monitoring of urine output including amount, color, odor, and changes in bladder function. A review of the corresponding Progress Notes (PN) in April 2026, revealed no urine output was monitored and documented except for 1 (one) nursing note on the evening shift of 4/4/2026. A review of the corresponding Point of Care (POC) (documentation of care by CNAs) in April 2026, revealed no specific urine volume were documented including amount, color, odor, and changes in bladder function. A review of the comprehensive care plan revised on 4/6/2026, reflected a focus for suprapubic catheter related to obstructive uropathy and neurogenic bladder (a dysfunction of the bladder resulting from nerve damage). The goal was for the resident to show no signs and symptoms of urinary infection. Interventions included monitoring and documenting output as per facility policy. Another intervention was for monitoring/recording/reporting to the physician any signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. On 4/23/2026 at 9:55 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN #7) stated that their process for urinary catheters included entering the urine output in cc (cubic centimeters) in the electronic medical record at the end of each shift. The LPN stated that the staff do that to determine if the catheter was clogged or if there are associated symptoms like a complaint of abdominal pain. On 4/27/2026 at 10:13 AM, during an interview with the survey team, the Director of Nursing (DON) stated that it is the facility's standard of practice to monitor the resident whether they are producing urine output or not, and not the amount of output. The DON further stated that the aids (CNAs) document them in their task documentation (POC). A review of the facility-provided undated policy titled Catheter Care did not address the need for continued monitoring of urine output by licensed nursing staff to prevent complications such as urinary tract infection and leakage. NJAC. 8:39 – 11.2 (b); 27.1 (a); 29.2(d)

Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice to ensure adequate procedures for maintaining accurate records, tracking, and timely investigation of discrepancies related to controlled substances to prevent potential drug loss or diversion. This deficient practice was identified for 1 of 3 nursing units (Ocean unit) reviewed for pharmaceutical services during the medication storage and labeling tasks and was evidenced by the following:On 4/22/2026 at 8:53 AM, the surveyor and the Licensed Practical Nurse/ Unit Manager (LPN/ UM) #1 began the inspection of the long-term care unit's narcotic book which contained Individual Patient Controlled Drug Record (IPCDR; a declining inventory log), Controlled Medication and Accountability Sheets (CMAS; a shift-to-shift nursing signature sheets for the counting of controlled drugs in the form of blister pack (bingo card) and bottles stored in the medication cart. The narcotic book also contained an untitled facility nursing delivery/disposal inventory sheet/form for controlled drug cards/bottles received from pharmacy and disposed (NIS). The NIS had the following instructions on the heading: This form is to be completed when adding controlled drugs to the narcotic drawer or disposing of discontinued drugs. This form also included vital sign equipment and testing solution that were kept in the narcotic drawer. At the bottom of the sheet the following was written: Once completed, forms are to be submitted to the Director of Nursing (DON). LPN/ UM #1 stated to the surveyor that the CMAS is signed every shift by incoming and outgoing nurses. LPN/ UM #1 also stated that the NIS was completed when adding bingo cards/bottles to the narcotic drawer from pharmacy/room transfer or disposing of discontinued drugs.On 4/22/2026 at 8:57 AM, the surveyor and LPN/ UM #1 noted multiple cross-outs, erasures, and corrections on the B-Wing Ocean medication cart. The cross-outs, erasures, and corrections were not documented witnessed by another nurse's signature. The surveyor asked the unit manager what the facility process was for errors/erasures on the inventory sheets was. LPN/ UM #1 stated that these narcotics inventory sheets are turned over to the records department and are not taken to the DON. The surveyor asked the unit manager if they looked at the sheets and spoke to the nurses about the errors and corrections. The unit manager stated that they generally do not speak to the nurses about the erasures/corrections. The surveyor asked LPN/ UM #1 for any investigation they have completed for all the errors/corrections in the inventory sheets. LPN/ UM #1 stated that they did not have any investigation completed. The noted cross-outs, erasures, and corrections were located under the column marked Total Count and were noted on the following dates and shifts:1/8/2026 on 3-11 shift for clonazepam received1/9/2026 on 7-3 shift for oxycontin received1/9/2026 on 3-11 shift for clonazepam and lacosamide disposed1/10/2026 on 11-7 shift for oxycontin disposed1/10/2026 on 7-3 shift for 2 containers of morphine received11/10/2026 on 7-3 shift for oxycontin received1/11/2026 on 7-3 shift for oxycodone disposed1/13/2026 on 11-7 shift for morphine disposed1/14/2026 on 7-3 shift for lorazepam disposed1/18/2026 on 11-7 shift for valium received1/19/2026 on 3-11 shift for lorazepam received1/19/2026 on 7-3 shift for diazepam disposed1/20/2026 on 3-11 shift for lorazepam disposed1/21/2026 on 3-11 shift for lorazepam disposed1/22/2026 on 11-7 shift for 2 containers of Ativan received1/22/2026 on 11-7 shift for oxycontin received1/22/2026 on 3-11 shift for oxycontin, 2 containers of valium, MS Contin, and 2 containers of morphine received1/23/2026 on 11-7 shift for morphine disposed1/23/2026 on 11-7 shift for Ativan received1/23/2026 on 7-3 shift for oxycontin disposed1/23/2026 on 3-11 shift for oxycontin disposed2/3/2026 on 7-3 shift for oxycodone and lacosamide received2/3/2026 on 7-3 shift for oxycodone, 3 containers of morphine, and 2 containers of diazepam received2/27/2026 on 7-3 shift for APAP/codeine disposed3/24/2026 on 3-11 shift for Ativan disposed4/3/2026 on 7-3 shift for lacosamide received4/3/2026 on 3-11 shift for morphine and lorazepam disposed4/21/2026 on 11-7 shift for 3 containers of oxycodone, oxycontin, and tramadol receivedOn 4/22/2026 at 9:01 AM, the surveyor and LPN/ UM #1 noted multiple erasures on the CMAS of the B-wing/ Ocean medication cart. The erasures/corrections were noted on the following dates and shifts:4/3/2026 on outgoing 7-3 shift on the # cards4/3/2026 outgoing 3-11 shift on the # cards4/4/2026 on incoming 3-11 shift # cards4/5/2026 incoming 7-3 shift # bottles4/5/2026 incoming 11-7 shift # bottles4/6/2026 outgoing 11-7 shift # bottles4/19/2026 incoming 7-3 shift # cards4/21/2026 outgoing 7-3 shift # cardsOn 4/22/2026 at 11:06 AM, the surveyor and LPN/ UM #1 noted multiple erasures on the CMAS of the B-wing/ Beach medication cart. The erasures/ corrections were noted on the following dates and shifts:4/2/2026 incoming 7-3 shift # cards4/2/2026 outgoing 11-7 shift # bottles4/7/2026 outgoing 3-11 shift # cards4/9/2026 outgoing 3-11 shift # cards4/11/2026 incoming 7-3 shift # cards4/21/2026 outgoing 11-7 shift # cards and # bottlesOn 4/22/2026 at 9:16 AM, during an interview with the surveyor, LPN/ UM #3 stated that if there should be erasures on inventory sheet, they need to be given to Director of Nursing (DON).On 4/22/2026 at 11:06 AM, during an interview with the surveyor, LPN/ UM #1 corrected themselves and told the surveyor that they bring the narcotics book to the morning meeting when the DON would look at it. The unit manager told the surveyor that in hindsight, the errors/corrections should have been investigated.On 4/23/2026 at 9:27 AM, during an interview with the surveyor, LPN/ UM #2 stated that errors in the narcotics declining sheet (IPCDR) are documented at the back of the sheet and signed by 2 nurses.On 4/23/2026 at 11:25 AM, during an interview with the surveyor, LPN #2 stated that on 4/21/2026 during the 11-7 shift, the nurse was new to the facility and did not understand that they should have written the number of bingo cards in the NIS total count. The new nurse apparently counted and documented in error the number of narcotic tablets/capsules. LPN #2 stated that they corrected the numbers themselves but did not sign the cross-outs they made. LPN #2 stated that they usually go to the unit manager for errors and if they cannot fix it, they would go to the DON.On 4/23/2026 at 11:34 AM, the surveyor showed the DON the inventory sheets from Ocean unit with errors, cross-outs, and erasures. The DON stated that when there were errors in the narcotic log, they had to be resolved. The nurses would cross them out and write the correct number, to be witnessed and signed by another nurse or the supervisor. The surveyor asked the DON for any investigation they had completed with regards the errors/corrections in the Ocean medication cart narcotic book. The DON did not answer the question but stated that the nurses were just not counting right.On 4/24/2026 at 11:00 AM, the surveyor contacted the Consultant Pharmacist (CP) but could not leave a message because the latter's voice mail box was not set up.A review of the facility policy updated in August 2025, titled Controlled Substances included under Policy Interpretation and Implementation the following:Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.Under the heading Upon Receipt, the following were included:The nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substance being delivered. Both individuals sign the controlled substance record of receipt.Under the heading At the End of Each Shift, the following were included:Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing Services immediately. The Director of Nursing Services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the finding to the Administrator. The Director of Nursing Services consults with the provider pharmacy and the Administrator to determine whether further legal action is indicated. NJAC 8:39 - 29.4 (g) (k); 29.7 (c)

Based on observation, interviews, and review of pertinent documents, it was determined that the facility failed to ensure a resident that sustained a significant weight loss received a dietary supplement to meet their nutritional needs, as ordered by the physician. This deficient practice was identified for 1 of 3 residents (Resident #34) reviewed for nutrition and was evidenced as follows:On 4/22/2026 at 10:17 AM, the surveyor observed Resident #34 in the activity room, sitting in their geriatric chair. On 4/22/2026 at 11:00 AM, the surveyor reviewed Resident #34's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: mild protein-calorie malnutrition, dysphagia (difficulty eating), and dementia. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/11/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident's cognition was severely impaired. A further review revealed that Resident #34 sustained significant weight loss. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/22/2025 that Resident #34 had a nutritional problem and was at risk for malnutrition. The interventions included: super pudding (a high-calorie, nutrient-dense pudding designed to increase protein and nutrient intake) twice per day, assistance with meals, report to provider significant weight loss of three pounds in a week, greater than five percent in one month, greater than seven and a half percent in three months, greater than ten percent in six months, and to weigh them weekly. A review of the physician orders (PO), active orders as of 4/23/2026 included a PO dated 1/9/2026 for super pudding (a high-calorie, nutrient-dense pudding designed for increased protein and nutrient intake) with lunch and dinner. A review of the Medication administration Record did not include super pudding. A review of Resident #34's Weight Summary revealed the following: 9/3/2025, 139.4 pounds (lbs)9/4/2025, 136.0 lbs9/8/2025, 136.6 lbs9/15/2025, 134 lbs9/22/2025, 130.1 lbs9/29/2025, 131.1 lbs10/1/2025, 128.6 lbs10/6/2025, 126.4 lbs10/13/2025, 124.0 lbs10/20/2025, 120.1 lbs10/27/2025, 119.1 lbs11/3/2025, 118.6 lbs11/10/2025, 118.4 lbs11/17/2025, 118.6 lbs11/24/2025, 119.2 lbs12/1/2025, 119.8 lbs1/4/2026, 119.1 lbs1/5/2026, 119.8 lbs1/12/2026, 118.0 lbs1/20/2026, 117.4 lbs1/26/2026, 116.2 lbs2/2/2026, 116.8 lbs2/9/2026, 115.2 lbs2/16/2026, 115.0 lbs2/23/2026, 115.8 lbs3/2/2026, 116.4 lbs4/1/2026, 114.0 lbs A review of Resident #34's most recent Nutrition Evaluation Note dated 1/9/2026 at 12:25 PM revealed, Recommend to restart ensure plus 8 oz (ounces) and super pudding with lunch and dinner.On 4/22/2026 at 12:14 PM, the surveyor observed Resident #34 seated in their geriatric chair, in the small dining room, on the Serenity Unit. Resident #34 was served her lunch which consisted of ground roasted pork, open faced sandwich, mashed potatoes, chopped carrots, fortified pudding (super pudding), dessert and juice. On 4/23/2026 at 12:38 PM, during a follow-up observation, Resident #34 was observed on the Serenity Unit in the front dining room sitting in their geriatric chair. The Licensed Practical Nurse/Unit Manager (LPN/UM) #2 was observed seated next to Resident #34 assisting them with lunch. At that time, Resident #34's meal ticket was not present. LPN/UM stated that their meal ticket was on the empty food cart. When asked to identify what was on the resident's lunch plate, she stated, chopped chicken patty, rice, broccoli and bread. The surveyor also noted the resident with a cup of pink juice. There was no super pudding noted for Resident #34. During that same observation, the surveyor observed LPN/UM #2 got up multiple times to perform other tasks unrelated to Resident #34 while she rendered feeding assistance to them. At 1:04 PM, Resident #34 finished their lunch and was escorted out to the sitting area to watch television. At that time, the surveyor interviewed LPN/UM #2 who stated that Resident #34 had finished eating their lunch and they had received everything on their meal ticket and was not missing any items. She added that Resident #34 took approximately four or five bites of the rice, and they did not want the bread. When LPN/UM #2 was asked why Resident #34 did not receive their super pudding, she stated that they did not put it on the tray and she will contact the kitchen, call the doctor to see if something else should be given. She further stated that when the staff hands out the trays, they should look at the tray and the ticket to make sure that everything matches. On 4/24/2026 at 10:33 AM, the surveyor interviewed the Registered Dietician (RD) who stated that her expectation is that the dietary department ensures that super pudding was printed on the resident's meal ticket and it was provided to the resident. She added that the nursing staff also should ensure that the super pudding was present because they are another set of eyes. She further stated that she only audits trays upon request. She also stated that she relied on nursing to ensure that the meal tray was accurate because they spend the most time with the residents. She further stated that it was tough being a consultant and only coming to the facility on Fridays and she relied heavily on nursing and dietary for them to get the proper diet. She also stated that there were some issues with the kitchen that need to be worked out. She added that if the facility needed her there more hours it could be worked out. On 4/24/2026 at 11:21 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that his expectations were that the trays are 100% accurate. The nursing and dietary staff must check the ticket to make sure everything matches the resident's profile. He further stated that it was important that the resident was given enough calories in accordance with the physician's and dietician's orders. A review of the facility's Tray Identification policy Updated 2026 included The Food Service Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served. NJAC 8:39-17.4(a)(1)

Based on interviews, during the resident council meeting (an independent group of residents who meet regularly to discuss quality of life, share concerns, and influence facility policy), and other pertinent facility documentation, it was determined that the facility was not consistently offering nighttime snacks to all residents on a nightly basis. This practice was identified for 8 of 8 residents who attended the resident council meeting and 6 of 6 unsampled residents on the Long-Term Care B- Unit and was evidenced by the following: On 4/22/2026 at 10:30 AM, the surveyor held a resident council meeting with eight residents in attendance (Residents #29, #42, #45, #47, #94, #100, #101, and #114). All the residents in attendance told the surveyor they were not offered snacks in the evening. On 4/22/26 at 1:00 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 regarding snacks. He told the surveyor that the unit received snacks, Around 4:00 PM. The LPN/UM told the surveyor they brought cookies and cream pies, but the snacks varied. The surveyor asked about the process for offering residents nighttime snacks to ensure all residents were being offered a nighttime snack and the LPN/UM said, I just know they hand them out. The surveyor asked if there was a par for the number of snacks being delivered to the unit to ensure there was enough for all the residents and he stated, No. On 4/22/26 at 1:10 PM, the surveyor observed the pantry on the Long-Term Care B-Unit. The pantry had two boxes of crackers and cartons of ensure plus (a physician ordered nutritional supplement). There were no other snacks available for the residents. On 04/22/26 at 1:20 PM, the surveyor interviewed two unsampled residents on the Long-Term Care B-Unit regarding snacks. One resident told the surveyor they were a diabetic and they had to purchase their own snacks and proceeded to show the surveyor the snacks purchased. The second resident told the surveyor they were never offered a snack in the evening. On 4/23/2026 at 12:44 PM, the surveyor interviewed another four unsampled residents on the Long-Term Care B-Unit regarding snacks. The residents told the surveyor that the diabetics received a snack, but the unit usually does not have any other snacks. On 4/23/2026 at 1:15 PM, the surveyor interviewed CNA #2 on the subacute unit regarding nighttime snacks. CNA #2 told the surveyor that snacks do not get delivered to the unit and the residents' friends or family provided the residents with snacks. On 4/24/2026 at 11:39 AM, the surveyor interviewed the Regional Food Service Director (RFSD) regarding nighttime snacks for residents. The RFSD told the surveyor that a tray of snacks went to the unit at 2:00 PM. The surveyor asked to see the par for each unit and the RFSD stated, There's no par, there is no system. The surveyor asked what snacks are delivered to the units, he said, Maybe cookies and cheese snacks, it depends. The RFSD then told the surveyor that things do not get labeled or dated and he hopes to get a system in place with a new food service director. The facility failed to provide a policy related to snack distribution when requested. NJAC 8:39-17.4 (b)

Based on observation, interview and record review on 10/13/15 in the presence of facility management, it was determined that the facility failed to maintain a resident safe environment by failing to follow proper fire safety procedures to prevent the spread of fire. Facility staff moved live fire material through the facility in a combustible container. This deficient practice was determined to be a Past Non-Compliance Immediate Jeopardy and had posed a serious and immediate threat to the safety of residents, staff and visitors. This deficient practice was evidenced by the following: In an interview on 10/13/15 at 9:30 a.m., the facility's Director of Maintenance (DM) stated that the facility had experienced an actual fire event in April, 2015. A review of a reportable event sent to the Department of Health (DOH), dated 4/23/15, revealed that there had been a fire in the attic above a corridor in the B-Wing nursing unit at approximately 10:45 a.m. The documentation noted that Maintenance gained access to the attic through the ceiling in the shower room to extinguish the fire but the documentation did not include that live fire material had been transported through the facility. In another interview on 10/13/15 at 11:35 a.m., the facility's DM stated that the alarm had sounded and the fire alarm panel indicated the B-Wing nursing station area as the location. According to the fire report the alarm was activated at 11:11 a.m., the fire department was dispatched at 11:12 a.m. and arrived on scene at 11:19 a.m. Residents were evacuated off of the unit and smoke was discovered coming from the attic by the air handler. The DM stated that he and the assistant put a ladder in the central bathing room and gained access to the attic through the ceiling tiles. The DM said he observed smoke and flames coming from a stack of used air filters for the air handler and used a portable fire extinguisher to try and put out the fire. The DM stated that he then grabbed the debris that still had smoke, flame and embers and threw them down into a plastic trash receptacle with the help of the assistant. The assistant then wheeled the trash bin through the corridor to an exit and out to the driveway. The actual distance traveled was measured by another surveyor on 10/15/15 and was found to be a distance of 50 feet. The assistant then dumped the burning material onto the driveway to fully extinguish it. The DM stated that, at that same time, he continued to spray the attic area with the portable fire extinguisher. The DM stated that the fire department arrived to extinguish the attic area and vent the smoke condition. At that time, the responding fire fighters instructed the DM and assistant that moving the fire from the point of origin and through the facility was dangerous and to never do that again. The DM stated that he was just trying to get the smoldering materials out of the building and did not realize the dangers at the time. The DM stated that he and the assistant were treated and released at the hospital for smoke inhalation. This was validated by surveyor review of the Emergency Dept. records In another interview on 10/13/15 at 1:15 p.m., the facility's DM stated that the trash container used to transport the burning material through the facility was plastic and combustible in nature, it was an empty linen hamper The DM stated that only he and the assistant were instructed by the fire department on the importance of leaving the fire at the point of origin and that there were no in-services performed with other staff in regards to this fire safety procedure. A review of the fire department reports confirmed the fire event for 4/23/15 but did not include this pertinent information. A review of the facility's Fire Disaster Plan Procedures revealed that the facility uses the R.A.C.E. procedure for fire events. Rescue, Alarm, Contain, and Extinguish if possible. The facility did not follow this procedure as the DM and assistant moved the fire and failed to contain the fire at its point of origin. On 10/13/15 at 2 p.m. the facility's Administrator was notified that the deficient practice had posed a serious and immediate threat to the safety of residents, staff and visitors. The Past Non-Compliance Immediate Jeopardy was corrected when the maintenance staff were in-serviced by the fire department at the fire event on 4/23/15 and with an acceptable Plan Of Correction (POC) provided at 3:35 p.m. on 10/13/15 with verification of the elements of the POC by the survey team. The survey team continued the verification of in-services related to the POC throughout the survey. The elements of the POC included the following: 1. The 2 maintenance staff were immediately instructed by responding fire officials that burning or smoking materials may never be moved through the facility.2. All staff will be in-serviced immediately and annually thereafter of the importance of utilizing R.A.C.E. and P.A.S.S. (Pull pin, Aim nozzle, Squeeze handle, Sweep base of fire) to contain a fire situation. 3. All new staff will be in-serviced upon hire and annually thereafter of the importance of utilizing R.A.C.E. and P.A.S.S. to contain a fire situation. 3. All staff were in-serviced in regards to the facility policy of being free from portable heaters of any kind. 4. All in-services will be conducted by the Administrator and In-service Coordinator. 5. The annual education will include a post-test to ensure that staff understand the information. The F323 tag continued at a D level based until 10/13 based on the following: The Maintenance staff who are the facility personnel that would in most cases be the staff that responded to an alarm/fire/smoke situation were in serviced at the actual time of the incident, the facility failed to educate other staff members such as nursing, kitchen and housekeeping until October 13, 2015. The facility submitted a Plan of correction to address this simultaneously with the Plan of Correction for the Immediate Jeopardy, past non-compliance. The surveyors validated that the inservices to staff on all shifts was conducted on 10/13/15. NJAC 8:39 - 31.2(e)

Complaint # NJ 191 Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for 1 of 4 residents (Resident #4) who was assessed as a high risk for falls. This resulted in Resident #4 falling out of the wheelchair, sustaining a fracture of the right greater trochanter. This deficient practice is evidenced by the following: All interviews, review of medical records and facility documents were conducted on 4/8/14 unless otherwise indicated. The medical record reflected that Resident #4 was admitted to the facility with medical [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS) an assessment tool dated 1/30/14, the resident scored a 13/15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. In addition, the MDS reflected the resident required extensive assistance of one staff member for dressing, bathing and hygiene and extensive assistance of two staff members for transfers. The "Fall/Mobility Risk Assessment" dated 3/13/14 indicated a score of "14" which represented a high risk for falls. A Reportable Event Record/Report was faxed in by the facility to the Department of Health on 3/21/14. The report reflected that on 3/13/14 an aide heard Resident #4 call for help from her room. The aide found the resident on the floor between her wheelchair and the bed. The nurse and the attending physician assessed the resident. A mobile x-ray indicated a "suspected fracture of the right greater trochanter". Resident #4 was sent to the emergency room for a Computed Tomography Scan, which confirmed the fracture of the right greater trochanter. Resident was not a surgical candidate and was to remain non-weight bearing until re-evaluated by her physician in three weeks. In addition, the report indicated that the Certified Nursing Assistant (CNA) indicated that he forgot to clip the alarm to her clothes after he assisted her to the bathroom. An interview was conducted with the Administrator at 9:00 a.m. The Administrator told the surveyor that Resident #4 slipped out of the wheelchair on 3/13/14 at 2:30 p.m. Resident #4 could not remember how or why she fell . The CNA forgot to clip the alarm to the resident's clothes after toileting her at 2:00 p.m. The Administrator told the surveyor that the clip alarm was changed to a chair pad alarm after Resident #4 fell on [DATE]. The "Interdisciplinary Progress Note" (IPN) dated 3/13/14 at 2:30 p.m. reflected that Resident #4 was found sitting on the floor between the wheelchair and the bed. No visible signs of injury noted. The chair alarm was on the wheelchair, but not connected to the resident. The resident was assisted by two staff members back to the wheelchair. A IPN note dated 3/13/14 at 2:40 p.m. indicated that Resident #4 complained of pain in the right hip. The resident was medicated with Tylenol 650 mg. At 3:00 p.m. the attending physician assessed resident ordered x-rays of the right hip and right femur. The family was notified of the fall. The Medication Administration Record (MAR) dated 3/13/14 at 10:05 p.m. reflected that Resident #4 was given Vocodin 5/300 for moderate to severe pain. A IPN note dated 3/13/14 at 11:00 p.m. indicated x-ray of right femur was done and results show "new fracture of the right greater trochanter". A IPN note dated 3/13/14 at 11:30 p.m. indicated that the primary care physician was notified of Resident #4's x-ray results, which reflected fracture of the right greater trochanter. The physician ordered the resident be sent to the emergency room . The family was notified and the Administrator was notified. The resident was sent to the emergency room and admitted with a [DIAGNOSES REDACTED]. A IPN note dated 3/14/14/ at 4:00 a.m. indicated that Resident #4 was readmitted back to the facility and was not a surgical candidate for the Right Great Trachantor fracture. The "physician's orders [REDACTED]. The "Pain Flow Sheet" indicated that on: On 3/15/14 at 8:10 a.m. Resident #4 was medicated with Percocet 5/325 one tablet due to a pain of right hip at a level "7" which indicated severe pain. On review of "Medication Administration Record" (MAR) dated 3/15/14 at 6:00 p.m. and 10:00 p.m., Resident #4 was medicated with Percocet one tablet by mouth due to pain of right hip at a level of "8" which indicated severe pain. On review of MAR dated 3/16/14 at 11:00 a.m. and 6:00 p.m., Resident #4 was medicated with Percocet one tablet by mouth due to a pain of right hip at a level of "8" which indicated severe pain. A "Physician order [REDACTED]. A "Physician order [REDACTED]. A "Physician order [REDACTED]. The "Treatment Administration Record" (TAR) dated March 2014 indicated an order for [REDACTED]. The TAR dated 3/1/2014 until 3/20/2014 reflected the nurses were signing out the chair pad alarm was in place, however at the time of the fall, Resident #4 had a "clip" alarm. Upon review of all medical records and physician's orders [REDACTED]. The "Resident Interdisciplinary Care Plan" dated 11/26/13 indicated that Resident #4 had behaviors such as refusing medications, being uncooperative at times, resisted change in medications and self determination and independence. The "Interdisciplinary Team Conference" note dated 2/4/14 indicated that Resident #4 exhibited impulsive behavior at times and could become very agitated with uncontrolled behaviors and was difficult to redirect or calm down and was at a risk for falls. The "Resident Interdisciplinary Care Plan" dated 2/1/14 indicated that staff is to assure chair and bed alarm are in place and functioning. The Care Plan does not indicate what type of alarm Resident #4 is to have, however the physician orders [REDACTED]. The "Interdisciplinary Team Conference" note dated 3/3/14 indicated that Resident #4 fell on [DATE] in the bathroom. The note reflected that there was no injury and a referral was made with therapy for transfers, mobility and ambulation. An "Occupational Therapy" (OT) note dated 2/28/14 indicated that Skilled OT would be initiated and the short term goal was for Resident #4 to exhibit anatomically correct position while sitting in the wheelchair with use of adaptive equipment for 4 hours with fair sitting balance during activities of daily living in order to reduce the risk of falls. The long term goal of OT was to increase that to 7 hours. An "Physical Therapy" (PT) note dated 3/4/14 indicated that Resident #4 was to receive Skilled PT due to onset of pain, reduced ability to safely ambulate, decreased strength, decreased mobility and functional activity tolerance. The PT note indicated the reason for referral was due to recent fall incident. A "Resident Interdisciplinary Care Plan" dated 3/14/14 reflected interventions to apply pad alarm to wheelchair and check placement and functioning every shift and staff is to remain with the resident while the resident is using the toilet. In addition, every 15 minute checks were started for safety. This was initiated after the second fall dated 2/28/14 and 3/13/14. The facility "Summary Investigation Report", the facility documented that the chair alarm was changed from clip-style to an alarming pressure pad. The physicians orders indicated that the alarming pressure pad was ordered for Resident #4 in February 2014 and March 2014. There was no documentation of a physician's orders [REDACTED]. The "C.N.A Statement" reflects that the alarm pin wasn't on Resident #4's clothes. "I might have forgotten it". An interview was conducted with the Administrator at 2:15 p.m. The Administrator told the surveyor that during the facility investigation of the fall for Resident #4, the TAR was reviewed and this is when the error was recognized. Resident #4 had an order for [REDACTED]. She also told the surveyor that Resident #4 should not of had a clip alarm, as she was alert and could easily remove it. "We think the pad wasn't working so they used the "back-up" clip alarm and then forgot to tell us they needed a pad alarm." An interview was conducted with the Administrator at 3:00 p.m. The Administrator told the surveyor that the Director of Nurses educated the nursing staff that when a specific type of alarm is ordered by the physician, they are to make sure that it's in place. Documented evidence of this education was not provided to the surveyor. An interview was conducted with a Licensed Practical Nurse (LPN) from B-Unit at 3:10 p.m. The LPN told the surveyor that Resident #4 had a chair pad alarm, but maybe the resident threw it out because she wasn't always compliant. A telephone interview was conducted on 4/9/14 at 9:25 a.m. with LPN #2 from B-unit. The LPN told the surveyor that Resident #4 had a "tab-clip" alarm but the resident would always take it off. "I don't remember her ever having a pad alarm on her chair". The LPN was asked by the surveyor if she remembered signing her signature on the TAR, indicating the chair pad alarm was in place. The LPN stated, "I don't know, that was in March". A telephone interview was conducted on 4/9/13 at 3:00 p.m. with the Administrator. The Administrator told the surveyor that the Unit Managers usually conduct weekly checks of alarms to ensure compliance with proper function and placement. "They do it with their weekly skin checks." "The Unit Managers are not submitting monthly reports to the Director of Nursing at this time". It's not part of the Quality Assurance Program. A telephone interview was conducted on 4/9/14 at 3:05 p.m. with the Unit Manager (RN) on B-Wing. The RN told the surveyor that she usually checks alarms as part of her routine and compares the TAR to what the resident has. "I do it with my rounds". "I don't have documentation that I do it". I'm not sure that I checked alarms the week that Resident #4 fell . The facility's undated written policy titled, "Fall Management" indicated: It is policy of this facility to ensure a fall assessment is completed on a resident, their environment is assessed, and staff are educated on fall management. Residents who may have a history of falls, or have been assessed to have an increase in factors for potential for falls, will be identified in an effort to manage/reduce falls. The facility's undated written policy titled, "Bed and Chair Alarm" indicated: 2. Receive physicians orders for chair/bed alarm. 8. Bed and chair alarms will be checked for proper function and placement every shift by licence nurse and documented in the TAR's. 9. Unit managers will conduct weekly checks to ensure compliance with proper function and placement. 8:39-27.1 (a)