Every finding on record at Barnegat Rehabilitation and Nursing Center

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation during food preparation in a safe and consistent manner designed to prevent food borne illness by cross contamination.This deficient practice was evidenced by the following:On 3/27/2026 at 10:18 AM, during a follow-up visit to the kitchen, the surveyor observed [NAME] #1 on the preparation (prep) table wearing disposable latex gloves with a hair cover. The surveyor observed the cook pull a plastic tape from a blue box on the table, go to the large grey trash bin, lifted the lid of the bin with their gloved right hand, threw the plastic tape in the trash bin, and returned the lid of the bin. Without washing hands and changing gloves, the cook opened the blue box on the table, took out several raw frozen fish fillets from the box, and placed them on a tray. Wearing the same gloves, the cook then went inside the walk-in freezer and took out another blue box and placed it on the prep table. The cook turned around and touched the handle of the faucet and ran it from the nearby sink wearing the same gloves. The surveyor observed the cook pick up a bottle of red jam, lifted the lid of the trash bin and threw the bottle in the trash bin together with their gloves. The cook returned the lid of the bin with their bare hands. Without washing their hands first, the cook put on a new pair of gloves. The cook took several frozen fish fillets from the second blue box and placed them on a tray. Wearing the same gloves, the cook opened the oven and placed the tray of fish fillet in the oven. The surveyor then observed the cook transfer the trash bin to the dish machine area with their right hand simultaneously holding 2 frozen raw fish fillets and the right handle of the trash bin. Their left hand was holding the left handle of the bin. The cook threw the frozen raw fish fillets in the trash bin. The cook moved back the trash bin to the prep area with their gloved hands and threw their gloves in the bin. The cook replaced the lid with their bare hands. Without washing hands, the cook placed the blue boxes back in the freezer.On 3/27/2026 at 10:27 AM, the surveyor continued to observe [NAME] #1. The cook put on new pair of gloves without washing their hands first. The cook took 3 plastic bottles of spices from the spice rack. They put powdered spices in a large metal mixing bowl and mixed them with what the cook identified to the surveyor as ground tilapia. Without changing gloves and washing their hands, the cook took a deep pan and ladle. The cook ladled the spiced ground tilapia to the deep pan. Still wearing the same gloves, the cook took a box of plastic wrap and covered the deep pan. The cook took liquid lemon in green plastic bottle from the spice rack and placed it on prep table. The cook then took an aluminum foil from the prep table and covered the tray of frozen fish mixed with the ground tilapia, opened the oven cover and placed the tray inside. Still wearing the same gloves, the cook returned the bottles of spices in the spice rack. The cook took mittens and placed them on a ledge on the wall. The cook placed the large mixing bowl in the 3-compartment sink. The cook removed their gloves and threw them in the trash bin. The cook put the lid back with their bare hands. Without washing their hands, the cook put on another pair of gloves. On 3/30/2026 at 9:38 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that in the kitchen, the staff should always wash their hands first before wearing gloves. The IP further stated that staff in the kitchen should change their gloves after each task to prevent cross contamination. On 3/31/2026 at 9:31 AM, during an interview with the surveyor, the Food Service Director (FSD) stated that they educate the dietary staff with food safety and infection control in the kitchen. The FSD further stated that the kitchen staff are expected to wash their hands before and after using gloves and that staff had to change gloves after every task. A review of the facility policy revised in August 2019, titled Handwashing/ Hand Hygiene included under Policy Interpretation and Implementation the following: 8.) Hand hygiene is the final step after removing and disposing of personal protective equipment. 9.) The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.A review of the facility policy revised in February 2023, titled Food Preparation included under Procedures the following: 2.) Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. N.J.A.C. 8:39 - 17.2 (g)

Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to appropriate infection control practices specifically by failing to use personal protective equipment upon entering rooms that required it when performing patient care for 2 of 8 residents reviewed under enhanced barrier precautions (EBP) (Resident #10, #101). The deficient practice was evidenced by the following: On 03/26/2026 at 9:31 AM while touring the first floor, while outside of Resident # 10's room, the surveyor observed an orange sign outside the room door that revealed a stop sign symbol and the words, Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. At that time, the surveyor observed a Certified Nurse Aide (CNA) in the room. The CNA was not wearing a gown or gloves. At that time, the surveyor observed the CNA using her barehand to pick up linens from the floor and place them in a clear plastic bag. After that, she walked to the B side of the room where Resident # 10 was in bed. The surveyor observed the CNA placing her bare hands on the resident bedside table. The CNA was then observed bagging clothing for the resident by reaching in and out of the nightstand drawers. Lastly, the CNA was observed changing the trash bag on the B side of the room. Upon leaving the room, the CNA had two clear garbage bags, one in each hand. Visible within one of the bags was an incontinence brief and trash, the other bag contained linens. On 03/27/2026 at 09:39 AM during an interview with the surveyor, the CNA said she was only asking the residents in the room if they want their showers. The CNA denied she was providing care, and she denied she wasn't wearing gloves. On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Assistant Director of Nursing said, For the Enhanced Barrier Precautions portion, if staff are not interacting with devices for that portion they wouldn't need to glove or gown however if I am picking something up off the floor, one should have gloves to do so. A review of Resident # 10's Care Plan located in the Electronic Medical Record revealed a focus that, I am on Enhanced Barrier Precautions r/t [related to] history of ESBL U/A (Extended-Spectrum Beta-Lactamase; pathogen resistant to common antibiotics and may require complex treatments). N.J.A.C. 8:39-19.4(a) On 03/26/2026 at 9:39 AM surveyor #1 observed a sign on Resident #101's room door that read Enhanced Barrier Precautions: Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Care Activities . The Resident Care Activities listed on the sign included, Wound care: any skin opening requiring a dressing. At the same date and time, surveyor #1 observed an organizer hanging from Resident #101's door that contained Personal Protective Equipment (PPE) including gowns. On 03/27/2026 at 11:08 AM, with permission from Resident #101, surveyor #1 observed his/her wound care provided by Licensed Practical Nurse (LPN) #1. LPN#1 entered Resident 101's room without wearing a gown. During the observation of the wound care, LPN #1 did not wear a gown throughout the entire process. At the time the wound care concluded, surveyor #1 asked LPN #1 if she should have worn a gown while providing care. LPN #1 stated that she should have worn a gown. A review of Resident #101's diagnoses located in the EMR, revealed a diagnosis of but not limited to staphylococcal arthritis of the left hip (infectious arthritis of the left hip). A review of Resident 101's physician's orders located in the Electronic Medical Record (EMR) revealed that he/she had an order for Enhanced Barrier Precautions related to wound and to irrigate left distal hip wound with acetic acid 0.25% every day and evening shift for wound healing. The order further revealed to pack wound with silver alginate (type of dressing that reduces risk of infection) and cover with a super absorbent dressing. A review of Resident #101's personalized care plan revealed a focus of Enhanced Barrier Precautions related to history of Multidrug Resistant Organism (MDRO) . and chronic wound. Interventions include, staff will wear PPE as appropriate initiated on 12/16/2024. On 03/31/2026 at 11:20 AM, during an interview with surveyor #1, the Infection Preventionist (IP) replied yes, when asked if LPN #1 should have worn a gown when performing wound care on Resident #101. A review of the facility provided policy titled, Enhanced Barrier Precautions dated December 2024 revealed, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. and, 3. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

Based on observation, interview, record review, and facility provided documentation, the facility failed to ensure that a resident did not self administer medication without an assessment, interdisciplinary care team meeting determination, a physician's order, or care plan intervention for 1 of 3 residents (Resident #28) reviewed for the Medication Administration task.This deficient practice was evidenced by the following:During observation of medication administration on 03/27/2026 at 9:33 AM, Resident #28 told Licensed Practical Nurse (LPN) #1 that they had already administered their eye drops. Resident #28 stated, I have them in my drawer; I do it myself. When the LPN asked, You give yourself the eye drops? the resident confirmed. The surveyor then asked the LPN whether Resident #28 self medicated their eye drops, and the LPN stated, Yes.A review of Resident #28's admission Record revealed diagnoses including, but not limited to, Alcohol Abuse with Withdrawal Delirium, Attention Deficit Hyperactivity Disorder, and Post Traumatic Stress Disorder.A review of the physician's orders on 03/27/2026 revealed an order dated 09/08/2025 for Refresh Celluvisc Ophthalmic Gel 1%: instill one drop in both eyes two times a day for dry eyes. There was no physician order authorizing the resident to self administer this medication.A review of the Care Plan revealed no focus, goal, or intervention related to self administration of medication prior to the surveyor bringing the matter to the LPN Unit Manager's attention.A review of the Electronic Medical Record revealed no Medication Self Administration Safety Screen completed prior to 03/27/2026.During an interview on 03/27/2026 at 12:45 PM, the second floor LPN Unit Manager stated that for a resident to self medicate, an assessment must be completed, an interdisciplinary team (IDT) meeting must occur, and a physician's order must be in place. The LPN Unit Manager stated that no residents on the unit were approved to self medicate. When asked specifically about Resident #28, the LPN Unit Manager stated, I did not know this was happening. The LPN Unit Manager further stated that Resident #28 did not have anything in place authorizing self administration.During an interview on 03/31/2026 at 12:01 PM, the Director of Nursing (DON) stated that residents may self administer medications only after an evaluation by therapy and the IDT to determine safety. The DON stated that a physician's order and a care plan intervention addressing self administration must also be in place. The DON stated that these steps are necessary to ensure resident safety.A review of the facility provided policy titled Self Administration of Medication revealed: Residents have the right to self administer medications if the IDT has determined that it is clinically appropriate and safe for the resident to do so.N.J.A.C. 8:39 29.2(c)

Based on observation and interview, it was determined that the facility failed to ensure that the results of the most recent survey were readily accessible to residents and the public.The deficient practice was evidenced by the following:On 03/26/2026 at 09:52 AM during the initial tour, the surveyor observed the State Survey Binder located in the lobby of the facility. At that time, the surveyor did not observe any Life Safety Code Statement of Deficiencies (CMS-2567) from previous surveys within the binder.On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) replied I will check after the surveyor asked if there is a reason the Survey Binder does not include any Life Safety Code Statements of Deficiencies.On 04/01/2026 at 10:25 AM during an interview with the surveyor, the LNHA said that the Life Safey Code Statement of Deficiencies is now included in the Survey Binder.N.J.A.C. S 8:39-13.1(a)

Based on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 2 units (First and Second Floor). This was evidenced by: On 03/26/2026 at 10:06 AM, Surveyor #1 observed the first-floor shower room. In the first shower stall, on the bottom left corner, Surveyor #1 observed black discoloration and several chipped tiles. During an interview on 03/30/2026 at 11:15 AM, the Assisitant Director of Nursing (ADON) stated that housekeeping was responsible for the major cleaning of the shower room. Surveyor #1 and the ADON reviewed the shower room together. The ADON acknowledged that the shower tiles need attention. During the initial tour on 03/26/2026 at 9:26 AM, the surveyor observed room [ROOM NUMBER]A. At that time, the surveyor observed that the wallpaper was ripped behind the bed. The surveyor then observed room [ROOM NUMBER]. At that time, the surveyor observed, below the window, that there was a gap between the air conditioner/heater unit and the drywall above, with a black vegetative substance present within the gap. During the initial tour on 03/26/2026 at 9:42 AM on the second floor, the surveyor observed in the shower room cracked tiles, a clump of hair in the corner, and a black substance around the middle shower floor. During rounds on 03/27/2026 at 9:15 AM, the surveyor observed that the sink in the bathroom of room [ROOM NUMBER] had caulk that was cracked and peeling, with a gap between the wall and the sink. During an interview on 03/31/2026 at 12:01 PM with the survey team, the Licensed Nursing Home Administrator (LNHA) stated that the facility is toured daily by maintenance and the ambassador team (a team of managers). The LNHA stated that they try to be diligent in ensuring the facility is treated as they would treat their own homes. The LNHA also stated that they try to ensure it is a homelike environment for the residents. A review of a facility-provided policy titled Homelike Environment revealed: 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. N.J.A.C. 8:39-31.4(f)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility did not ensure a residents medication regimen was free from unnecessary psychotropic medications. Specifically, a psychotropic medication ordered for an extended duration lacked documented clinical rationale in the resident's record. The deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications.This deficient practice was evidenced by the following:On 03/26/2026 at 12:43 PM, the surveyor observed Resident #41 walking the facility halls speaking incoherently to themselves. A review of the Electronic Medical Record (EMR) under Diagnoses revealed that Resident #41 was diagnosed with but not limited to generalized anxiety disorder and unspecified dementia (a decline of cognitive function).A review of Resident #41's Minimum Data Set (MDS; an assessment tool used to facilitate the management of care) dated 03/11/2026, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated that Resident #'s 41's cognition was severely impaired.A review of Resident #41's physician's orders found in the EMR revealed an order for Lorazepam (a psychoactive medication) oral concentrate 2MG/ML (milligrams per milliliter) with a start date of 03/03/2026. The order further instructed to give 0.25ml by mouth every 6 hours as need (PRN) for anxiety for 90 days Hospice. Further review of Resident #41's EMR did not reveal any documented rationale for ordering Lorazepam PRN for an extended duration (90 days). On 03/31/2026 at 12:02 PM during an interview with the surveyor the Director of Nursing (DON) stated that the physician's assessment should indicate the need for the extended duration of use of the medications prescribed. A review of the facility policy titled, Psychotropic Medication Use revised July 2022 revealed under Policy Interpretation and Implementation under number 12, a. PRN orders for psychotropic medications are limited to 14 days. The policy further revealed, . if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he/she will document the rationale for extending the use and include the duration for the PRN order. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate by relying solely on an initial assessment performed by a Licensed Practical Nurse (LPN) without further RN clinical verification for 1 of 1 resident (Resident # 36) reviewed for assessment accuracy.The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.03/26/2026 10:11 AM Resident # 36 was observed to have a subclavian access device, identified as a central venous access device. The resident showed the surveyor the site on his/her chest. The Resident stated there are still sutures underneath. A review of the Resident's Electronic Medical Record under Medical Diagnoses revealed a diagnosis of but not limited to Encounter for Other Orthopedic Aftercare, and Osteomyelitis of vertebra lumbar region along with Methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere.A review of the physician's orders revealed an order for oxacillin sodium intravenous solution reconstituted. The order revealed to use 12 grams intravenously one time a day for MSSA (Type of staph bacteria, differentiated primarily by their resistance to methicillin and similar antibiotics) epidural abscess until 03/29/2026, Oxacillin12grams in normal saline 500milliliter(ml) at 21ml/hour over 24 hours. A review of Resident # 36's Admission/readmission Evaluation located in the Electronic Medical Record revealed that it was completed on 02/28/2026 by a Licensed Practical Nurse.A review of the section Z of the Minimum Data Set (an assessment tool) audit revealed the MDS Coordinator RN's (Registered Nurse) signature; that verifies the assessment completion. It was dated 3/7/2026.On 03/27/2026 at 11:43 AM during an interview with the surveyor, the MDS Coordinator RN replied That's the admission nursing assessment when the surveyor asked what the significance of the Admission/readmission Evaluation was. The surveyor asked if as the RN, she performs a physical assessment on the resident prior to signing section Z of the MDS. The MDS Coordinator RN replied, The LPN does the admission assessment and then I use that information for the MDS. Lastly, she said if at any time, something doesn't line up or is in question, she prefers to review the electronic form before she locks it.On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Director of Nursing replied, I believe she [MDS Coordinator RN] can sign based of an LPN initial assessment after the surveyor asked should the MDS Coordinator RN physically assess the resident before she signs and completed the MDS or can she sign and complete the MDS based off of an LPN initial assessment.A review of the facility-provided policy titled, Resident Assessments revised March 2022 revealed, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. N.J.A.C. S 8:39-11.1

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to ensure that nursing assessments for falls were completed by a Registered Nurse (RN) and fall care plans were formulated and evaluated for effectiveness by an RN, in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #10) reviewed for accidents.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 03/26/2026 at 9:45 AM, the surveyor observed Resident #10 sleeping in bed.The surveyor reviewed the electronic medical record (EMR) for Resident #10.A review of the admission Record face sheet (an admission summary) reflected that Resident #10 was admitted to the facility with diagnoses which included but were not limited to the following: dementia, history of falling, and bipolar disorder (a mental health condition characterized by extreme mood swings).A review of the most current quarterly Minimum Data Set (MDS), an assessment tool dated 1/16/2026, revealed the resident had severely impaired cognition and multiple falls since admission.A review of the nursing progress notes (PN) revealed that the resident fell on the following dates with no documented assessments by an RN: 5/29/2025, 7/27/2025, 8/2/2025, 8/21/2025, 11/1/2025, 12/3/2025, 12/9/2025, 1/9/2026, 1/17/2026, 1/26/2026, 2/4/2026, and 2/9/2026.A review of the individual comprehensive care plan (ICCP) included a focus area initiated on 5/23/2025 by Licensed Practical Nurse/ Unit Manager (LPN/ UM) #1, that the resident was at risk for falls. This focus and the corresponding goal have not been updated to reflect the multiple falls that the resident had. The interventions for falls did not include any intervention by an RN corresponding with falls on the following dates: 5/29/2025, 7/27/2025, 8/2/2025, 8/21/2025, 11/1/2025, 12/3/2025, 12/9/2025, 1/9/2026, 1/17/2026, 2/4/2026, and 2/9/2026.On 3/27/2026 at 1:02 PM, during an interview with the survey team, LPN/ UM #1 stated that the LPNs do the initial assessment and initiate the care plans of newly admitted residents.On 3/30/2026 at 12:46 PM, during an interview with the survey team, LPN/ UM #2 stated that they do not think that only RNs can assess new admissions and formulate care plans.On 3/31/2026 at 12:10 PM, during an interview with the survey team, the Director of Nursing (DON) stated that LPNs can assess falls. The DON further stated that the unit managers, who are both LPNs, formulate the care plans for falls, as well as put the goals and interventions after meeting as a team. The DON confirmed that whoever formulates the care plans and evaluates its effectiveness is documented in the (EMR).A review of facility policy revised in March 2018, titled Falls and Fall Risk, Managing did not define who can assess a resident's fall. There was no indication in the policy to delineate if an RN or LPN could complete an assessment.A review of facility-provided document revised in December 2021, titled Job Description - Registered Nurse included under Duties and Responsibilities the following: Provides accurate and timely documentation consistent with plan of care.A review of facility-provided document revised in December 2021, titled Job Description - Licensed Practical Nurse included under Duties and Responsibilities the following: Implements plan of care formulated by physician and Registered Nurse. N.J.A.C. 8:39 - 11.1

Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to ensure that appropriate incontinence care was provided for a resident who was dependent on staff for toileting hygiene and incontinence care. This deficient practice was identified for 1 out of 3 residents (Resident #70) reviewed for bladder and bowel incontinence. The deficient practice was evidenced by the following:On 3/26/2026 at 9:40 AM, during the initial tour of the facility, the surveyor observed a malodorous smell on the first-floor unit hallway across the room of Resident #70. The surveyor observed Certified Nursing Assistant #1 (CNA #1) 1 enter Resident #70's room.On 3/26/2026 at 9:56 AM, the surveyor observed the door to the resident's room open. From the hallway, the surveyor observed CNA #1 fixing Resident #70's hair. When CNA#1 exited the room, the surveyor asked the CNA how many residents were in their assignment. CNA #1 stated they have 16 residents in their assignment. The surveyor entered the room of Resident #70. The surveyor observed the resident sitting in their wheelchair. The room smelled malodorous of urine. The surveyor noted the resident's dark blue mattress without a bed sheet. The mattress was wet and had a very strong smell of urine. The resident stated that the last time they got changed was yesterday morning.On 3/26/2026 at 10:00 AM, the surveyor looked at the CNA Assignment Sheet of the first floor. CNA #1 was assigned to residents in rooms 124 A, 124 B, 125 A, 125 B, 126 A, 126 B, 127 A, 127 B, 128 A, 128 B, 129 A, 129 B, 130 A, 130 B, 131 A, and 131 B for a total of 16 residents. On 3/27/2026 at 9:35 AM, during an incontinence tour of the first-floor unit with Licensed Practical Nurse/ Infection Preventionist (LPN/ IP), the surveyor observed Resident #70 in bed. LPN/ IP exposed the resident's blue incontinence brief from the front and the back. Both front and back of the brief was soaked with urine. The surveyor observed a malodorous smell of urine when the resident's brief was exposed. Under the resident was a blue disposable bed liner. The surveyor asked the resident when they last got changed. The resident stated that the last time they got changed was yesterday morning. The skin on the resident's buttocks area was not red.The surveyor reviewed the electronic medical record of Resident #70.A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to pressure-induced deep tissue damage of the sacral (lower back) region, cerebrovascular disease, and congestive heart failure.A review of the resident's most current comprehensive Minimum Data Set (MDS), an assessment tool dated 3/18/2026, revealed that the resident had severely impaired cognition. The MDS further revealed that the resident required maximal assistance from staff for toileting hygiene and that the resident was frequently incontinent with bowel and bladder.A review of the Order Summary Report active as of 3/26/2026, revealed a physician order for furosemide 20 milligrams/ day indicated for congestive heart failure.A review of the Point-of-Care (POC) documentation (care staff documentation of care activities in the EMR) in March 2026, revealed no documentation that the resident received incontinence care for bladder during the following shifts and dates: a.) day shift on 3/11/26, 3/13/26, 3/20/26, 3/21/26, 3/22/26, 3/27/26, and 3/28/26; b.) evening shifts on 3/11/26, 3/14/26, 3/15/26, 3/16/26, 3/17/26, 3/19/26, 3/20/26, 3/22/26, 3/23/26, 3/24/26, 3/27/26, 3/28/26, and 3/29/26; and c.) night shift on 3/19/26 and 3/24/26.A review of the individual comprehensive care plan (ICCP) included a problem area initiated on 3/11/2026, that the resident required assistance for toileting related to recent cerebrovascular accident (stroke).On 3/30/2026 at 10:00 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that staff is expected to check residents for incontinence every 2 hours.On 3/30/2026 at 11:45 AM, during an interview with the surveyor, the Staffing Coordinator (SC) stated that they were aware of the minimum direct care staffing ratio in New Jersey and that they were 1 CNA to 8 residents in the day shift.On 3/30/2026 at 12:11 PM, during an interview with the surveyor, the DON stated that they were aware of the minimum direct care staffing ratio in New Jersey and that they were 1 CNA to 8 residents in the day shift.A review of facility policy revised in April 2018, titled Urinary Incontinence - Clinical Protocol included under Treatment and Management the following: As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. N.J.A.C. 8:39 - 27.1 (a); 27.2 (d) (h) (j)

Based on observation, interview, review of medical record and other pertinent facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 1 resident (Resident #25) reviewed for position and mobility.This deficient practice was evidenced by the following: On 3/26/2026 at 10:07 AM, the surveyor observed Resident #25 in bed. The surveyor observed the resident's right fingers flexed with short nails visible. The surveyor asked the resident if they could open their right hand. The resident's right fingers were observed with little movement but remained flexed. The surveyor observed the skin on the right palm dry under the nails with no redness. The surveyor asked the resident if the staff apply anything on their right hand. The resident stated that staff do not put anything on their right hand. The surveyor did not observe any device for the right hand in the resident's room. On 3/26/2026 at 11:40 AM, the surveyor observed the resident come out of the first-floor dining room in their wheelchair, holding a can of soda on the left hand. The surveyor did not observe any splint (a medical device, also termed an orthosis, designed to support, immobilize, or improve the function of the hand, wrist or fingers) on the right hand.On 3/26/2026 at 12:23 PM, the surveyor observed the resident in the hallway in front of the nurses' station. The resident stated that they finished their lunch. The surveyor did not observe a splint on the resident's right hand. On 3/27/2026 at 9:10 AM, the surveyor observed the resident in the hallway in front of the nurses' station in their wheelchair. The resident was not wearing a hand splint on their right hand.The surveyor reviewed the electronic medical record (EMR) of Resident #25.A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to the following: contracture of the right hand, foot drop of the right foot, and dementia.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/7/2026, reflected that Resident #25 had intact cognition.A review of the Order Summary Report (OSR) active as of 3/26/2026, included the following orders: Right resting hand splint as tolerated, every day and evening shift for right hand contracture, to be worn up to 8 hours a day as tolerated. Document tolerance of brace and refusals.A review of the corresponding March 2026 Treatment Administration Record (TAR) revealed that the right hand splint was administered (checked) during day shift on 3/26/2026 and 3/27/2026.A review of the progress notes (PN) dated 3/27/2026 to 3/27/2026 did not reveal any documented reference to the resident's refusal to wear the splint.A review of the individual comprehensive care plan initiated on 10/10/2024, included a focus for right hand splint use. The care plan has not been updated or revised since it was initiated in 2024.A review of the resident's Occupational Therapy (OT) report revealed that the resident finished an OT service from 1/14/2026 to 2/23/2026. The discharge recommendations included the following: Remain consistent with splint wearing schedule - 8 hours a day as tolerated.On 3/30/2026 at 9:27 AM, the surveyor observed the resident in their wheelchair wearing a right-hand splint. On 3/31/2026 at 9:35 AM, the surveyor observed the resident in the hallway without a hand splint. The surveyor asked their primary nurse, LPN # 1, why the resident was not wearing a hand splint. LPN #1 stated that it was the resident's shower day. The nurse further stated that the resident had shower days on Tuesdays and Fridays during day shift. The surveyor asked the nurse what time the resident's shower was. The nurse could not state what time was the resident's shower. The surveyor asked the nurse why the resident was not wearing their splint last week. The nurse stated that the resident refused to wear it. The surveyor observed the resident agreed to wear their splint when asked by the nurse. The surveyor observed the nurse applied the splint to the resident's right hand with no visible signs of discomfort. The surveyor asked the nurse again why the resident was not wearing their splint last week. The nurse stated, I did not realize that they were not doing it.On 3/30/2026 at 9:43 AM, during an interview with the surveyor, the Director of Rehabilitation (DOR) stated that the expectation is for the nursing staff to apply the orthoses when they are ordered by the physician. The DOR further stated that the hand splint is usually ordered to prevent further increase in a resident's contracture.On 3/30/2026 at 10:00 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that a check mark in the TAR meant an order was administered. When an order is not administered or if the resident refuses an order, it will be marked as #2.A review of facility policy revised in July 2017, titled Resident Mobility and Range of Motion included under Policy Statement the following: .2.) Residents with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in ROM.N.J.A.C. 8:39-27.1(a), 27.2(m)

Based on observation, interview, record review and review of facility provided information, it was determined that the facility failed to ensure that a resident at risk for elopement had complete and accurate physician orders and consistent monitoring of a wander guard device following readmission from the hospital. The deficient practice was identified for 1 of 1 Resident (Resident # 52) reviewed for elopement. This deficient practice was evident by the following:During the initial tour on 03/26/2026 at 10:23 AM, the surveyor observed Resident #52 in bed with a wander guard device (a device that may trigger an audible sound when the wearer passes through an exit doorway) on the right ankle.A review of Resident #52's admission Record showed diagnoses including dementia, major depressive disorder, and Alzheimer's disease. The resident's Care Plan, initiated on 01/15/2024, identified a risk for elopement with an intervention for the resident to wear a wander Guard.A review of the Physician Order Summary revealed an order dated 03/26/2026 at 23:00 stating, wander Guard to right ankle, check for proper placement every shift. There was no order to check the device for function.A review of the Medication Administration Record (MAR) for February 2026 showed a previous order stating, wander guard applied to left ankle, check function every day.A review of the Electronic Medical Record (EMR) revealed the resident was sent to the hospital on [DATE] for seizure activity and readmitted on [DATE]. A progress note dated 02/13/2026 at 20:36 documented that the nurse practitioner instructed staff to continue the wander guard.A review of the daily wander guard check book revealed that Resident #52's wander Guard was checked for placement throughout February 2026. For March 2026, Resident #52 was not listed on the checklist, and there was no documentation of placement or function checks.During an interview on 03/27/2026 at 12:44 PM, the Licensed Practical Nurse Unit Manager (LPNUM) stated that Resident #52 had worn a wander guard for years and was known to wander throughout the unit. The LPNUM stated that the device is removed only when the resident is sent to the hospital and reapplied upon return. The LPNUM acknowledged that she forgot to reinstate the wander guard orders after the resident's readmission and confirmed that the resident should also have had an order to check function.During an interview on 03/31/2026 at 12:01 PM, the Director of Nursing (DON) stated that residents with Wander Guards must have orders to check both placement and function to ensure proper monitoring of elopement risk. The DON stated that it is important to reinstate all necessary orders after hospitalization to ensure residents receive appropriate care.A review of the facility's policy titled Wandering and Elopements stated that the facility will identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.N.J.A.C. 8:39-27-1 (a)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination and provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 1 resident (Resident # 3) investigated for Urinary Catheter or UTI.The deficient practice was evidenced by the following:On 03/27/2026 at 9:31 AM, the surveyor observed Resident #3 seated in a wheelchair in the dining room, the urinary drainage bag was observed below the resident's wheelchair in direct contact with the floor. On the same day at 9:33 AM, during an interview with the surveyor, Certified Nurse Aide (CNA) #1 stated that urinary drainage bags should be stored below the waist and should not make contact with the floor. A review of the electronic Medical Record (EMR) under Diagnoses revealed that Resident #3 was diagnosed with but not limited to urinary tract infection and retention of urine (inability to fully empty the bladder). A review of the quarterly Minimum Data Set (An assessment tool) dated 03/02/2026 revealed under section, H that Resident # 3 had an indwelling catheter. A review of the EMR revealed an active physician's order to monitor urine output every shift with a start date of 07/28/2025 and to monitor for signs and symptoms of infection every shift. A review of Resident #3's personalized Care Plan revealed a focus of, suprapubic catheter related to obstructive uropathy (condition in which the flow of urine is blocked) initiated on 12/04/2024. The focus further revealed intervention that included, monitor/record/report to MD for . cloudiness, no output.A review of Resident # 3's Treatment Administration record for March, 2026 revealed blank sections of documentation to monitor urine output every shift on the following dates and shifts:03/03/2026 evening and night shift blank03/26/2026 night shift blank03/28/2026 day shift blank03/30/2026 day shift blank A review of Resident # 3's Treatment Administration record for February, 2026 revealed blank sections of documentation to monitor urine output every shift on the following dates and shifts:02/01/2026 night shift blank02/04/2026 day shift blank02/11/2026 day shift blank02/26/2026 night shift blank02/27/2026 night shift blank02/28/2026 day shift blankA review of Resident # 3's Treatment Administration record for January, 2026 revealed blank sections of documentation to monitor urine output every shift on the following dates and shifts:01/03/2026 night shift blank01/12/2026 night shift blank01/29/2026 day shift blank01/30/2026 night shift blank01/31/2026 night shift blankA review of Resident # 3's Treatment Administration record for December, 2025 revealed blank sections of documentation to monitor urine output every shift on the following dates and shifts:12/03/2025 evening shift blank12/08/2025 day shift blank12/17/2025 night shift blank12/20/2025 night shift blankOn 03/31/2026 during an interview with the surveyor, the Director of Nursing (DON) stated that no output of urine would indicate a health concern. The DON further stated that documentation of urine output would indicate potential complications when asked of the importance of urine output documentation for residents with urinary catheters. A review of the facilities policy titled, Catheter Care, Urinary revised August 2022 revealed under the section titled Purpose that the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The policy further revealed under the section titled Infection Control to 2. Be sure the catheter tubing and drainage bag are kept off the floor. The policy further revealed under the section titled Input/Output to 1. Observe the resident's urine level for noticeable increases or decreases. N.J.A.C. S 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by leaving a nasal cannula out of a bag, exposed to air and not having a physician's order for oxygen administration. The deficient practice was identified for 1 of 1 (Resident # 12) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 03/26/2026 at 9:47 AM, during the initial tour, the surveyor observed Resident #12 in their room. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) resting on top of an oxygen concentrator and a nebulizer (machine that aerosolizes medication for inhalation) mask stored in the resident's bedside table. The nasal cannula and nebulizer mask were not in a bag and were exposed to air. At that time, during an interview with the surveyor, Certified Nurses Aide (CNA) #1 stated, that was not the way the oxygen tubing and nebulizer mask should be stored and stated they should be in a bag. On 03/27/2026 at 9:15 AM, the surveyor observed Resident #12 in their bed with the nasal cannula applied.A review of Resident #12's admission record revealed he/she was admitted to the facility with diagnosis including but not limited to chronic systolic (congestive) heart failure (when the heart muscle does not pump blood as well as it should) and dementia (a decline of cognitive function).A review of Resident # 12 order summary report dated 3/26/2026 revealed an order for hospice care and did not show any orders for oxygen.During an interview on 03/27/2026 at 10:28 AM, with Unit Manager (UM) when asked if Resident #12 had an order for oxygen, UM #1 confirmed that there was no order for oxygen. The UM further indicated that it was important to have an order because anything given to the resident must be based on a physician's order. During an interview on 03/31/2026 at 12:02 PM, the Director of Nursing (DON) stated yes when asked if there should be a physician's order for oxygen if a resident is being administered oxygen. The DON further stated, oxygen is considered a medication and should be monitored and ordered by the physician.A review of the facility policy titled Oxygen Administration revised October 2023 revealed under Preparation section, 1. Verify that there is a physicians order for this procedure. A review of the policy titled Administering Medications through a Small Volume (Handheld) Nebulizer revised October 2010 revealed under Steps in the Procedure section, 29.store in a plastic bag with the residents name and date on it. N.J.A.C. S 8:39-27.1

Based on observation, interview, record review and review of facility provided information, it was determined that the facility failed to ensure that a resident (Resident #2) with a prescribed fluid restriction had monitoring orders in place and documented intake as required for 1 of 1 resident reviewed for dialysis. This deficient practice was evidenced by the following: On 03/27/2026 at 09:19 AM, the surveyor observed Resident #2 in bed with a cup on the bedside table. Resident #2 voiced no concerns at that time. A review of Resident #2's admission record revealed diagnoses including, but not limited to, End Stage Renal Disease (kidneys do not function properly).A review of the electronic medical record showed that Resident #2 was admitted to the hospital on [DATE] for hyperpotassemia (elevation of potassium in the blood) and was readmitted to the facility on [DATE].A review of the March 2026 Medication Administration Record (MAR) revealed a previous order for a 1000 milliliter (mL) fluid restriction (660 mL dietary, 340 mL nursing) with shift specific monitoring (7-3 shift: 120 mL; 3-11 shift: 120 mL; 11-7 shift: 100 mL). This order had a start date of 08/29/2025 and was discontinued on 03/16/2026.A review of the Physician's Order Summary dated 03/19/2026 revealed a new order for a renal diet with a 1000 mL daily fluid restriction.No corresponding monitoring order was entered into the MAR following the resident's readmission on [DATE].During an interview on 03/27/2026 at 11:22 AM, the Assistant Director of Nursing (ADON) stated that Resident #2 should have been monitored for fluid restriction and that such monitoring should be documented in the MAR. After reviewing the resident's electronic MAR, the ADON stated, It must have gotten forgotten when he/she was readmitted .During an interview on 03/27/2026 at 12:45 PM, the second floor LPN Unit Manager stated that fluid restrictions must be documented on the MAR to ensure intake is monitored. The LPN Unit Manager stated that Resident #2 should have had orders in the MAR requiring staff to sign off each shift on the amount of fluid consumed.A review of the facility's policy titled Encouraging and Restricting Fluids revealed the following under General Guidelines:1. Follow specific instructions concerning fluid intake or restrictions, and 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in mLs.N.J.A.C. 8:39 27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure Licensed Practical Nurse staff practiced within their professional scope of practice. The facility permitted Licensed Practical Nurses (LPNs) to independently conduct initial nursing assessments and initiate resident care plans without Registered Nurse (RN) coordination or oversight. The deficient practice was identified for 1 of 1 resident (Resident # 36) reviewed under the Competent and Sufficient Nursing Staff. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 03/26/2026 at 10:11 AM during the initial tour, the surveyor observed Resident # 36 in his/her room. He/She was admitted on [DATE]. At that time, the surveyor observed an intravenous (IV) pole with an IV bag connected to a tube that was infusing into the resident.A review of Resident # 36's Medical Diagnoses in the Electronic Medical Record (EMR) revealed a diagnoses of but not limited to Encounter for Other Orthopedic Aftercare, and Osteomyelitis of vertebra lumbar region (a serious, often post-operative or hematogenous, infection) along with Methicillin susceptible staphylococcus aureus infection (a type of bacterium responsible for difficult-to-treat infections due to its resistance to many common antibiotics) as the cause of diseases classified elsewhere.A review of the physician's orders in the EMR revealed an order for oxacillin sodium intravenous solution reconstituted (an antibiotic). The order revealed to use 12 grams intravenously one time a day for MSSA (Methicillin-Susceptible Staphylococcus aureus, a strain of staph bacteria that causes infections but remains susceptible to treatment with penicillin-related antibiotics) epidural abscess until 03/29/2026, Oxacillin 12grams in Normal Saline 500 milliliter at 21ml/hour over 24 hours.A review of the Care Plan located in the Medical Record revealed a focus for Right internal jugular (Central Line) secondary to infection/antibiotic therapy. It was created on 2/28/2026 by the Licensed Practical Nurse (LPN). There was also a focus for IV Antibiotic therapy via right Inter Jugular (Central Line) related to MSSA epidural abscess. It was initiated on 2/28/2026 and created by an LPN.A review of the Admission/readmission Evaluation located in the EMR dated 02/28/2026, revealed that it was completed by an LPN.On 03/27/2026 at 1:02 PM during an interview with the surveyor, the first floor LPN Unit Manager (LPN/UM) # 1 said that once the admission assessment is done, medications are verified with the prescriber, she will review the hospital records for a resident and initiate care plans at that time. The surveyor asked, If there is any LPN, they do the initial assessment? The LPN/UM # 1 replied, Yes. Lastly, she said that some of the nurses do know how to start the care plans including LPNs. She concluded by saying they will just start the head-to-toe assessment if they need to and they will start the care plan.On 03/39/2026 at 12:33 PM during an interview with the surveyor, the second floor Unit Manager, an LPN (LPN/UM) # 2, described that when the facility has a new admission, she will initiate a head-to-toe assessment. She continued by saying that the nurses do the other assessments including the Admission/readmission Evaluation and Base Line Care Plan. At that time, the LPN/UM # 2 said that the Licensed Practical Nurses do the admission initial assessment but for the most part, she does them. When the surveyor asked if a Registered Nurse over sees that, she replied that she assumes the Director of Nursing looked over these. She stated, I don't know when asked if there is a designated Registered Nurse.On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Director of Nursing replied, They do the initial resident evaluations. We do a review as a team after the surveyor asked if there is a reason Licensed Practical Nurses are doing initial assessments on newly admitted residents.During the same interview with the surveyor, the Director of Nursing replied, I don't have a good answer. The reason is we direct them to do so after the surveyor asked if there is a reason Licensed Practical Nurses are initiating base line care plans on newly admitted residents.A review of the facility-provided job description document revised 12/21 titled, Licensed Practical Nurse (LPN) revealed under Duties and Responsibilities that the LPN can, Provide basic nursing care to patients within Post-Acute and Rehabilitation's scope of practice including actions that meet psychosocial needs and physical needs. Secondly, it revealed that the LPN, Provide direct and individualized nursing care to assigned patients based on nursing standards and under the supervision of the Director of Nursing and/or a Registered Nurse designee. Lastly, the document revealed that the LPN Implements plans of care formulated by physician and Registered Nurse.A review of the facility-provided job description document revised 12/21 titled, LPN Unit Manager revealed under Purpose of Your Job Position that, The primary purpose of your position is to assist the Director of Nursing Services in planning organizing, developing, and directing the day-to-day functions of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the Facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times.N.J.A.C. S 8:39-11.1

Complaint #: NJ182922Based on interviews, medical record review, and review of other pertinent facility documents on 7/21/25, it was determined that the facility failed to implement their abuse policy by protecting Resident #4, as well as all residents from abuse, when on 1/25/25 at 8:40 PM, the Certified Nursing Aide (CNA #3) observed CNA #1 and CNA #2 physically abuse Resident #4 and CNA #3 did not report the incident until the next day, 1/26/25 at approximately 12:37 PM. This deficient practice was identified for 1 of 4 residents reviewed (Resident #4).On 1/25/25 at 8:40 PM, during the 3:00 PM to 11:00 PM shift (3-11), CNA #3 reported hearing screaming coming from Resident #4's room, and when she walked into the room, CNA #3 stated that she observed the resident sitting on their bed with CNA #1 trying to remove the resident's shirt and CNA #2 trying to put on a [NAME] coat (hospital gown). CNA #3 reported observing the resident yelling and being combative and spit at CNA #1, who appeared agitated from it and CNA #1 straddled the resident on the bed. CNA #3 reported that while resident laid on their back, CNA #2, took the resident's face and smooshed it into the mattress. At that time, CNA #3 stated she told them she would take it from here, and both CNA #1 and CNA #2 stopped and walked out of the resident's room like nothing happened. CNA #3 did not report the incident immediately and CNA #1 and CNA #2 continued to work the 3-11 shift having access to Resident #4 as well as other residents. CNA #3 reported the incident the following day almost sixteen hours later on 1/26/25 at approximately 12:37 PM, during the 7:00 AM to 3:00 PM (7-3) shift. The facility's failure to ensure Resident #4, as well as all residents were protected from abuse by immediately reporting and investigating an allegation of physical abuse to Resident #4 posed the likelihood of serious physical and psychosocial harm and impairment to all residents. This resulted in an Immediate Jeopardy (IJ) situation which ran from 1/25/25 at 8:40 PM, when CNA #1 observed Resident #4 being abused, until 1/26/25 at 12:27 PM, when CNA #1 reported the incident to the Nursing Supervisor (Supervisor #1). The IJ was Past Non-Compliance (PNC).The facility's Administration was notified of the IJ on 7/21/25 at 4:58 PM. The facility submitted an acceptable Removal Plan on 7/24/25 at 1:36 PM.The facility was back in compliance when the facility addressed the situation by immediately investigating the incident; suspending CNA #1 and CNA #2 pending an investigation and later terminating; educating CNA #3 as well as all staff on the facility's abuse policy and immediately reporting allegations to the administration; Resident #4 was assessed and x-rays were taken; and contacted outsourced provider regarding training for staff on how to deal with residents with dementia and behaviors. The surveyor verified the completion of the Removal Plan was 1/30/25, during an on-site survey on 7/25/25, and determined the IJ was PNC.The evidence was as follows:A review of the undated facility policy titled Protecting Our Residents Abuse Prevention & Reporting, Dignity, Resident's Rights included each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Employee Reporting Requirements: The center is required to ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source (e.g. bruise) [.] are reported immediately to the Administrator of the facility and to other officials in accordance with state law. Any employee who suspects or has had a resident or family member report abuse, must report immediately. Failure to report timely may result in disciplinary action. Suspending Pending an Investigation: Any employee whose conduct gives rise to a reasonable suspicion of resident abuse may be immediately removed from the floor, and where appropriate suspended without pay pending an investigation. In addition, if an allegation has been made against an employee, for the integrity of the investigation, the employee will be suspended pending an investigation. See something, say something. Even if you think that someone may have already reported it, still say something.A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if abuse, neglect, exploitation [.] is suspected, the suspicion must be immediately reported to the administrator and to other officials according to state law.Investigating Allegation.6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.According to the Facility Reportable Event (FRE) dated 1/27/25, reported to the New Jersey Department of Health (NJDOH), included the following:A review of the Summary revealed that on 1/26/25 at approximately 12:37 PM, a CNA (CNA #3) made the Nursing Supervisor (Supervisor #1) aware of care concern regarding a resident (Resident #4) pertaining to CNAs (CNA #1 and CNA #2) from previous evening shift. [CNA #1] reported upon entering the room to care for [Resident #4], [CNA #3] witnessed [Resident #4] spit on [CNA #1]. Immediately after being spit on, [CNA #1] contacted [Resident #4] striking [their] neck with hand. [Resident #4] attempted to spit at [CNA #2], [CNA #2] attempted to shield the resident's mouth and grabbed [the resident's] arm to assist with redirection. [CNA #3] instructed both employees to leave the room and she would complete care as needed for [Resident #4]. A review of the submitted timeline revealed that:-On 1/25/25 at approximately 8:30 PM, [CNA #3] noticed [Resident #4] needed to be changed.-On 1/25/25 at 8:35 PM, [Resident #4 was] ambulating in hallway with CNAs [CNA #1 and CNA #2].-On 1/25/25 at 8:40 PM, [CNA #3] heard noises coming from the bathroom, [CNA #3 went] to check on both the staff and [CNA #3] witnessed incident occur. CNA [CNA #3] instructed [CNA #1 and CNA #2] to leave the room.-On 1/26/25 at 12:37 PM, [CNA #3] reported incident to Nurse Supervisor [Supervisor #1].-On 1/26/25 at approximately 12:40 PM, [Supervisor #1] contacted the Director of Nursing (DON). A statement was obtained from [CNA #3] over the phone.-On 1/26/25 at 12:45 PM, [CNA #1 and CNA #2] suspended immediately pending an investigation. [Supervisor #1] conducted a skin assessment and interviewed [Resident #4], physician ordered an x-ray of neck and arm related to pain.-On 1/27/25 at 11:00 AM, interview with [CNA #1 and CNA #2] conducted over the phone and requested a written statement to be sent. (Suspension pending investigation continues.)A review of the conclusion included that after conducting a comprehensive investigation regarding the incident, we have ruled out any form of abuse and neglect based off the following: [Resident #4] can become combative with care, has dementia, and can be difficult to redirect at times during care. [CNA #1] did not have any intent to harm [Resident #4] by striking [the resident], this was an impulse reaction to being spit on. [CNA #2] placed hand in front of face to protect any further spitting from [Resident #4], this caused [Resident #4] to scare and lean backwards in bed, where [CNA #2] grabbed [Resident #4's] arm to redirect and reposition [Resident #4] safely in bed. Skin assessment and radiology reports show no signs of injury or fracture. Care plan updated to include paired care with activities of daily living (ADLs) and incontinence care. The surveyor reviewed the medical record for Resident #4.According to the admission Record face sheet (an admission summary), Resident #4 was admitted to the facility with diagnoses which included but were not limited to: generalized anxiety disorder, hallucinations, unspecified psychosis, mood disorder, and unspecified dementia.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 6/23/25, reflected that Resident #4 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition.A review of Resident #4's Care Plans (CP) included a focus area initiated 7/10/23, that the resident was resistive to care with regards to adjustment to nursing home, anxiety, dementia, and resists all care. The resident is aggressive when approached.Interventions include to allow resident to make decisions about treatment regime, to provide sense or control; provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine as much as possible; and provide resident with opportunities for choice during care provision.On 7/21/25 at 11:30 AM, the surveyor interviewed CNA #3, who stated at approximately 8:00 PM, she went to check on Resident #4 when she heard yelling coming their room. When she entered the room, CNA #3 observed the resident sitting on the edge of the bed yelling and being combative with assistance being rendered by two CNAs (CNA #1 and CNA #2), who were standing on either side of the resident. CNA #3 continued that CNA #1 was attempting to remove the resident's shirt over their head, while CNA #2 was attempting to apply a [NAME] coat (hospital gown) to the resident. CNA #3 stated that she observed the resident spit at CNA #1, which caused both CNA #1 and CNA #2 to become aggressive towards the resident. CNA #3 stated she observed CNA #1 jump on the resident while CNA #2 took the resident's face and smooshed it into the mattress. CNA #3 stated she repeatedly said to both CNAs, I'll take it from here until they both stopped what they were doing and walked out of the room like nothing happened. CNA #3 stated she was the only witness and was afraid of retaliation by these two CNA's if she reported them that night. CNA #3 stated I knew it was abuse, I was just so shook up. I never seen that before and have been an aide since I was [AGE] years old. CNA #3 stated she continued to work that night. The following day she reported for her 7:00 AM to 3:00 PM (7-1) shift and immediately reported what she witnessed to the Nurse Supervisor (Supervisor #1). On 7/25/25 at 3:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) Nurse Supervisor (Supervisor #1), who stated that CNA #3 approached her around 7:10 AM on 1/26/25, and said she had to speak to me about something important. Supervisor #1 stated that CNA #3 said last night (1/25/25), she went into Resident #4's room because she heard screaming. When she entered the room, she saw CNA #1 and CNA #2 attempting to change the resident's clothes. Supervisor #1 stated that CNA #3 said the resident was observed giving them a hard time, and the CNAs were Agency staff, and did not know the resident did not like to wear a [NAME] coat. Supervisor #1 stated CNA #3 stated she went to get the resident's clothes and when she turned back around, she saw the resident spit at one of the CNAs. That CNA then pulled their hand back to make contact with the resident. Supervisor #1 stated since this was a while back, it was hard to remember all the details, but as soon as CNA #3 finished her report, the Administration was notified. Supervisor #1 stated she went to assess the resident, and the resident stated, they harassed me and the resident complained of neck discomfort. Supervisor #1 stated she did not believe CNA #3 followed the abuse policy because of fear of retaliation from the two CNAs.A review of the CNA assignment sheets from the day of the incident (1/25/25) through present, revealed that CNA #1 and CNA #2 were not in the facility since the 3-11 shift on 11/25/25.On 7/21/25 at 3:40 PM, the surveyor interviewed the DON, who stated if any staff member witnessed an allegation of abuse, they should have reported it immediately to the supervisor. The DON stated that CNA #3 said she did not feel safe reporting the incident out of fear the two CNAs would be waiting. The DON stated that because of that delay, CNA #3 put the facility in a bad situation because those two staff members were still in the building after the incident. The DON stated that CNA #3 received disciplinary action for not reporting. The DON also stated that the facility believed it not to abuse and would have considered abuse if the resident was physically restrained or pushing the resident's face.The facility submitted an acceptable Removal Plan on 7/24/25 at 1:36 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: on 1/26/25, CNA #3 as well as facility wide staff education on the facility's policy on abuse and immediately report to administrative staff allegations of abuse was initiated; alleged employees suspended immediately and terminated following conclusion of investigation; Resident #4 was evaluated including review of medication, laboratory, and radiology reports, Resident #4's Responsible Party and Physician were notified; care plans reviewed and updated where appropriate; review of residents with a diagnosis of dementia with agitation; and contacted outsourced provider regarding training for staff on how to deal with residents with dementia and behaviors. The facility self-corrected the deficient practice, and it was determined that the IJ was Past Non-Compliance (PNC), and the facility corrected their non-compliance on 1/30/25.The surveyor verified the implementation of the Removal Plan on site on 7/25/25. NJAC 8:39-4.1 (a)(5)

Based on observation, interview, record review, and review of pertinent documentation it was determined that the facility failed to ensure the resident's environment is free of accident hazards by failing to use bilateral floor mats as ordered. The deficient practice was identified for 1 of 5 residents (Resident # 31) reviewed under Accidents. The deficient practice was evidenced by the following: A review of Resident # 31's comprehensive Minimum Data Set, dated dated dated [DATE] revealed that Resident # 31 had a fall prior to admission. A review of Resident # 31's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Mats at the bedside while in bed every shift for safety. The order became active on 09/21/2024. A review of Resident # 31's Treatment Administration Record for October of 2024 revealed the order for, Mats at the bedside while in bed every shift for Safety was indicated as administered for each shift up until the time of surveyor review. A review of Resident # 31's Care Plan located in the EMR revealed a focus, I am high risk for falls [related to] gait/balance problems, toe fractures, and multiple falls prior to admission. Actual fall 9/20/2024. The Care Plan also revealed an intervention for, Bilateral Mats next to bed while in bed for safety. The intervention was initiated on 09/21/2024. A review of the EMR under, Diagnoses revealed a diagnosis of but not limited to repeated falls. On 10/24/2024 at 10:48 AM, during an interview with the surveyor, Resident # 31 said he/she had three falls at home. At that time, the surveyor observed a mat on the floor located on the right side of the bed and the other folded against the wall. On 10/25/2024 at 8:32 AM while in Resident # 31's room, the surveyor observed Resident # 31 in bed. At that time, the surveyor also observed one mat on the floor to the resident's left side. On the right side, a mat was folded in half and placed against the wall. It was placed on the floor adjacent to the bed. On the same date at 9:35 AM, the surveyor observed Resident # 31 in bed with one of his/her legs off the bed near the floor. At that time, the surveyor observed one mat on the floor adjacent to the bed and the other folded up against the wall. At that time, Resident # 31 told the surveyor he/she had a bad fall at home prior to admission. On 10/30/2024 at 9:33 AM, the surveyor observed Resident # 31 in bed. At that time, one floor mat was folded on its side in the room. On the same date at 1:10 PM during an interview with the Director of Nursing (DON), the surveyor asked if floor mats for the bedside be folded up and against the wall. The DON replied that depending on the situation, the concern is that when you have someone with a bed side table access can be difficult. On 10/31/2024 at 10:12 AM during an interview with the surveyor, the DON explained that since Resident # 31 was becoming more independent, going forward only one fall mat on one side will be used and the bedside table will be on the other side of the bed. A review of the facility provided policy titled, Falls and Fall Risk, Managing revised October 2023, revealed under, Resident-Centered Approaches to Managing Falls and Fall Risk that, 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors(s) of falls for each resident at risk or with a history of falls. S 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 2 out of 3 medication carts inspected. This deficient practice was evidenced by the following: On 10/30/2024 at 10:06 AM, in the presence of the Licensed Practical Nurse (LPN)# 1, the surveyor inspected the medication cart on the second floor labeled the high side cart for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 8 Xanax (a narcotic medication used to treat anxiety) 5mg (milligram) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 9 were left. LPN #1 stated that he forgot to sign that out this morning, and that he should have signed it out the minute he gave it. On 10/30/2024 at 10:15 AM, in the presence of LPN# 2 the surveyor inspected the medication cart on the first floor labeled low side cart 2 for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 38 Oxycontin (a narcotic medication used to treat pain) 60mg in the blister pack but the CDS documented 39 were left. LPN #2 stated that she should have signed the CDS after giving the medication and that she thought she had signed it. During an interview on 10/30/2024 at 01:10 PM with the surveyor, the Director of Nursing said that narcotics should be signed out in the CDS when given to keep track of the medications. Review of the facility's policy titled, Controlled Substances revised June 2023, revealed under Upon Administration that The nurse administering the medication is responsible for recording: 5. Quantity of medication remaining. NJAC 8:39-29.7(c)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by failing to wear a gown when providing wound care. The deficient practice was identified for 1 of 2 (Resident # 27) residents reviewed for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 27's physician's orders located in the Electronic Medical Record (EMR) revealed that he/she was receiving Santyl External Ointment (topical ointment enzyme that breaks down collagen) applied to the left trochanter wound topically every day shift for healing. The order further revealed to cleanse with acetic acid 0.25%, pat dry, apply santyl, calcium alginate, and cover with a [clean dry dressing]. A review of Resident # 27's diagnoses located in the EMR, revealed a diagnosis of but not limited to a pressure ulcer on the left hip. On 10/25/2024 at 12:36 PM, with permission from Resident # 27, the surveyor observed his/her wound care provided by Registered Nurse (RN) # 1. At that time, the surveyor observed an orange sign on the room door that read, Enhanced Barrier Precautions. The sign revealed that, Everyone Must: clean their hands including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for following high-contact resident care activities: Dressing Bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. RN # 1 entered the room without wearing a gown. During the observation of the wound care, RN # 1 did not wear a gown throughout the entire process. At the time the wound care concluded, the surveyor asked RN # 1 whether they should have worn a gown. RN # 1 replied saying they walked right past the sign. He further stated that Resident # 27 was not on isolation but they walked past the sign on the door. The surveyor did not observe a bin outside of the room containing an personal protective equipment such as gowns. On the same date at 1:18 PM during an interview with the surveyor, the Infection Preventionist (IP) replied, He should've. when asked if RN # 1 was supposed to wear a gown when performing wound care on Resident # 27. The IP confirmed that Resident # 27 has been on Enhanced Barrier Precautions since August of 2024. The IP clarified that Resident # 27 also has a central line (catheter placed in a large vein, often in the neck, chest, or groin, to administer medication, fluids, or collect blood). The surveyor asked when does a staff member have to wear a gown in that room. The IP replied, If they are accessing any of those items, wounds . A review of the facility provided policy titled, Enhanced Barrier Precautions dated April 2024 revealed, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. and, 3. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. S 8:39-19.4 (a)

NJ # 164925 Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to ensure a resident (Resident #299) received adequate supervision to prevent an accident, specifically by a staff member operating a mechanical lift to transfer the resident from a bed to a wheelchair without another staff member as required resulting in the resident falling from the mechanical lift concluding in a fractured femur (thigh bone), head laceration, and a shoulder injury. The deficient practice was evident for 1 of 4 residents reviewed for Accidents. The deficient practice was evidenced by the following: A review of Resident #299's Minimum Data Set (MDS; an assessment tool) dated 5/31/2023 revealed under section C that he/she had a Brief Interview for Mental Status score of 11/15 indicating that he/she had moderate cognitive impairment. The MDS also revealed under section G, that he/she required total assistance to transfer from bed to wheelchair with two people providing support to physically assist. A review of Resident #299's Diagnoses located in the Electronic Medical Record (EMR) revealed but not limited to; Seizures (a sudden, uncontrolled burst of electrical activity in the brain), Hemiplegia (paralysis of one side of the body) affecting his/her left side, and left and right knee contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). A review of Resident #299's Care Plan located in the EMR with revision date of 12/27/2022 revealed a readmission continuation Care Plan focus that read, I require extensive to total assistance for ADL (Activities of Daily Living) care in Bathing , grooming , dressing, bed mobility, transfer . Further, the Care Plan revealed an intervention for a mechanical lift for transfer using two persons and a medium sling (device used during mechanical transfers to support the resident during the lift). A review of Resident #299's Care Plan located in the EMR with an initiated date of 01/12/2016 revealed another readmission continuation Care Plan focus that read, I am at risk for falls/Injury related to: use of psychotropic medications, History of falls, Impaired mobility and dx of seizures . A review of Resident #299's Nursing Progress Notes located in the EMR dated 6/03/2023 revealed that a Certified Nurses Aide (CNA) was heard calling for help. The Nursing Progress Note revealed that Resident #299 was observed on the floor in between the base of the mechanical left with sanguineous fluid (bodily fluid containing blood) also on the floor. A review of the facility's Reportable Event Record/Report document revealed that on 6/03/2023 at 11:50 AM, Resident #299 sustained a fall from a mechanical lift while being transferred from his/her bed into a wheelchair. The document further revealed that Resident #299 sustained an open laceration to the right side of his/her forehead and complained of right elbow, leg, and hip pain. Resident #299 was transferred to the emergency room for evaluation. The document revealed that Resident #299 was admitted to the hospital for a facial laceration, right femur fracture, and a shoulder fracture. On 8/02/2023 at 12:00 PM during an interview with the surveyor, CNA #1 stated, I asked for help. As I was waiting for help, I took it upon myself to (Brand name of mechanical lift) her. CNA #1 replied, I might have thought she (another staff member) was outside the door coming. when asked by the surveyor if there was a reason she did not wait for help to transfer Resident #299 with the mechanical lift. CNA #1 replied, No when asked if Resident #299 could sit up. CNA #1 replied, Not at all when asked if Resident #299 could move on his/her own. Further, CNA #1 confirmed Resident #299 required total assistance and that he/she is dependent for everything. CNA #1 said that Resident #299 fell forward. Lastly, CNA #1 stated, Two people when asked by the surveyor if the facility policy required one person or two people to operate a mechanical lift. On 8/07/2023 at 12:47 PM during an interview with the surveyor, the Director of Nursing (DON) replied, Two staff members. Always explain what you are going to do and have the right sized sling. when the surveyor asked what was the expectation of care from staff members who use the mechanical lift to transfer a resident from the bed to a wheelchair. Secondly, the DON replied, No when the surveyor asked if it is ever reasonable for a staff member to operate a mechanical lift to transfer a resident between a bed and a wheelchair without another staff member. Lastly, the DON replied, Safety, guidance. Something could happen when the surveyor asked why it was not reasonable. A review of the facility-provided document titled, Initial Education and Competency Checklist - Invacare Lift dated 4/14/21, revealed that CNA #1 identified that two staff are involved while using the lift. The document revealed that CNA #1 met criteria for identifying components of the lift, sling use and operation, and portable lift operation. The document was signed by the Infection Prevention Licensed Practical Nurse as the trainer and CNA #1 as the employee. A review of the facility-provided document titled Individual In-Service Sheets for CNA #1, year 2022 revealed that on 7/13/2022, CNA #1 attended 0.5 Hrs (hours) of Safe Resident Handling A review of the facility policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018 revealed under Policy Interpretation and Implementation that, 2.) Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. Mobility (transfer and ambulation, including walking) . A review of the facility policy titled, Lifting Machine, Using a Mechanical with a revised date of July 2017 revealed under General Guidelines that, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A follow-up review of Resident #299's imaging orders and results from the hospital he/she was transferred to after the fall revealed an X-Ray result that concluded Resident #299 sustained a distal femur fracture in the right leg. A further review of Resident #299's hospital record revealed an assessment for pain on 6/03/2023 at 18:46 (06:46 PM) that showed he/she verbalized his/her pain was 10 based on a 0-10 pain scale. 10 indicates the highest level of pain. The hospital record further revealed that Resident #299 was prescribed a hydromorphone (medication used to treat moderate to severe pain) injection of 0.4mg (milligrams) every three hours as needed. According to the hospital record under ED Provider Note, Resident #299 was last administered the hydromorphone on 06/04/2023 at 5:15 AM. S 8:39-27.1 (a)

Based on observation, interviews and review of facility documentation, it was determined that the facility failed to provide adequate pain medication for a resident observed writhing in pain and aware that the resident had stated the pain level was over 10 on a scale of 1 to 10. The resident was told to wait until the next dose was scheduled to be administered according to the clock. This deficient practice occurred for Resident #14, 1 of 21 residents reviewed for pain and was evidenced by the following. On 5/30/14 at 10:05 a.m. the surveyor approached a nurse who was opening the medication cart. The nurse stated that she was going to go to the PYXIS (automated medication dispensing system) machine to get a [MEDICATION NAME] 2 mg. tablet for Resident #14. This medication was ordered as needed every four hours for pain and the resident last had it at 6 a.m. At this same time, 10:05 a.m., the surveyor asked the nurse what Resident #14 stated his/her pain level to be on a scale of 1 to 10. As she walked toward the PYXIS she stated, "Oh, it's a ten. It was way, way over a ten at 9 a.m." While awaiting the nurse's return with Resident #14's medication, the surveyor reviewed the Medication Administration Record [REDACTED]. The times plotted on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The nurse returned to the medication cart at 10:07 a.m. The surveyor asked the nurse taking care of Resident #14 that morning why the box on the MAR indicated [REDACTED]. The nurse stated "the meds are not yet in from pharmacy." At 10:10 a.m. on 5/30 the surveyor asked the Assistant Director of Nursing (ADON) what times medications get delivered to the facility. She stated "between 2:30 p.m. and 3 p.m." At 10:20 a.m. on 5/30 the surveyor knocked on the door of Resident #14's room and asked permission to speak with him/her. The resident was rocking from side to side and writhing in pain, moving both arms from the siderails to over the head and back again. The resident stated that he arrived at the facility around 8:30 p.m. last night and his/her pain was at a 5/6 on a scale of 1 - 10 at that time. Resident #14 stated he/she asked for pain medication around 10 p.m. and the facility did not have the [MEDICATION NAME] IR 60 mg. the doctor ordered upon admission. The resident was given 2 mg. of [MEDICATION NAME]. The resident stated that the [MEDICATION NAME] 2 mg. did nothing (for the pain) but would put him/her to sleep for about 15 minutes. Resident #14 stated that he/she then awakes in severe pain again. The resident stated that when they asked for medication they were told to wait as the order (for [MEDICATION NAME]) was for every four hours. The surveyor reviewed all "Team Notes" written from the time of Resident #14's arrival on 5/30 at 10:15 a.m. The notes indicated the resident had the [DIAGNOSES REDACTED]. At 10 p.m. on 5/29 a nurse called the attending physician and told the doctor that the [MEDICATION NAME] IR 60 mg was not available as the pharmacy would not deliver until 3 p.m. the next day. The physician ordered [MEDICATION NAME], 2 mg. every 4 hours as needed for pain "until the [MEDICATION NAME] IR arrives from pharmacy." That dose was administered at 10 pm 5/29, and 2 am and 6 am on 5/30/14. At 10:45 a.m. a member of the survey team went to the PYXIS machine to see what other narcotic pain medications were readily available at the facility. There were [MEDICATION NAME] and [MEDICATION NAME] Patches, [MEDICATION NAME] IR (40 mg), [MEDICATION NAME] ER, [MEDICATION NAME] ER and [MEDICATION NAME]. At 10:45 a.m. on 5/30 the surveyor observed a physician seated at the nursing station. The surveyor asked the physician if staff had spoken to him about Resident #14's unmanaged pain, and the physician replied they had not. The surveyor asked the physician to accompany her into Resident #14's room to see him/her rocking and writhing in pain. The physician was told the same things by Resident #14 that the resident had earlier told the surveyor. The physician apologized to the resident for being left in pain and ordered a STAT (now) dose of [MEDICATION NAME] 2 mg. from the PYXIS. The surveyor was told by the physician "Nobody called me. I didn't know (he/she) was so big (421 pounds). No wonder the 2 mg isn't working." At 10:48 a.m. the surveyor asked the nurse why she did not call the physician and mention that the [MEDICATION NAME] 2 mg. every four hours was not relieving the resident's pain and tell the doctor what other options were available. She said again that the facility was awaiting delivery from the pharmacy and the [MEDICATION NAME] IR that was originally ordered for 60 mg. and the PYXIS only had 40 mg. The surveyor reviewed the facility and the hospital Medical Records for Resident #14 on 6/4/2014 at 10 a.m. The resident was admitted to the facility on [DATE] at approximately 8:30 p.m. from an acute care hospital. Resident #14 had elective surgery to amputate the left leg above the knee due to two failed knee replacements and intractable pain. The amputation was done 5/19/14, 10 days prior to admission to the facility. A review of the hospital records indicated that on 5/28 at 11:12 a.m., Resident #14 was administered 4 mg of [MEDICATION NAME] (narcotic pain reliever) intravenously for severe pain. Also administered that day at the hospital was [MEDICATION NAME] IR, 60 mg, every four hours around the clock. The resident arrived at the facility for rehabilitation at 8:30 p.m. that same day. NJAC 8:39-27.1(a)

NJ Based on interviews and a review of medical records and facility documents, it was determined that the facility failed to assure that all residents were provided with a living environment free from verbal and/or psychosocial abuse for 1 of 3 sampled residents (Resident #1). Multiple staff statements indicate that, although concerns of verbal abuse and/or isolation of Resident #1 by specific staff members had been reported to the Director of Nursing by other staff members on more than one occasion, the situation was not effectively addressed. This deficient practice is evidenced by the following: 1. According to the Face Sheet, Resident #1 was originally admitted to the facility on [DATE]. The November 2010 physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], reflects the resident was moderately impaired in cognitive skills for daily decision-making and required extensive assistance for transfers, ambulation and activities of daily living (ADL's.) The resident was followed by geriatric psychiatry for medication management and behaviors. A progress note, dated 9/20/10, indicates continued episodes of yelling out and verbal abusiveness, periods of confusion with disorientation and memory problems, poor social judgement, distractiveness and anxiety. The Plan of Care includes an 8/18/10 entry identifying the resident to be at potential risk to be a victim of verbal abuse secondary to her cognitive status. The identified intervention directed staff to observe for "out of the ordinary" behaviors or mood changes. An additional focal point addressed constant attention-seeking behaviors and wanting "things done on her time." Staff were to toilet the resident on request and allow time to for her to express her needs. The Plan of Care also addressed the need for a daily ADL routine. The resident required assistance of 2 staff for transfers and toileting and was able to propel a wheelchair independently. A Interdisciplinary (IDC) Summary, dated 9/7/10, additionally references her identified potential to become an abuse victim related to her behaviors. A Reportable Event Record/Report, faxed by the facility to the Department of Health and Senior Services (DHSS) on 10/27/10, indicates that, on 10/26/10, the facility received a visit from a representative of the Ombudsman's office. This visit was regarding an anonymous complaint of 10/1/10 that Resident #1 was not being allowed out of bed on the 11 PM to 7 AM shift as she preferred. Review of the facility investigation revealed that between approximately 9/22/10 through 9/24/10, the Director of Nursing (DON) had received several notes from 11 PM-7 AM staff members with concerns that this resident was not being allowed to get out of bed on request. On 9/27/10 at 12:30 AM (9/26-9/27/10, 11 PM-7 AM shift), the DON and Clinical Manager made an unannounced visit to the facility and spoke with staff. Staff indicated they sometimes left Resident #1 in bed as "she frequently requests to be up and down every 15-20 minutes, or she falls asleep in her chair." According to the facility investigation, during the visit by the DON, she re-educated staff on resident rights, specifically, that Resident #1 should be assisted in and out of bed per her request. Numerous written staff statements, dated 10/26/10 and 10/27/10 that were included with the facility investigation, indicated concerns regarding mistreatment of [REDACTED]. The specific allegations included telling the resident she wasn't allowed out of bed until 4 AM, threatening to remove the wheelchair from the resident's room if she attempted to climb out of bed, kicking the resident's door, threatening to close the resident's door and keep her in bed longer if she did not behave and/or threaten to withhold snacks. The statements additionally note that the 11 PM to 7 AM LPN charge nurse advised a new unit LPN on orientation that this was the behavior management "system" for the resident. Additional staff statements reflect that staff observed the involved CNA verbally taunting the resident by calling her a "princess" when other staff got her out of bed. The resident was noted to have expressed fear of the LPN and CNA to other staff members and asked not to be left alone with the accused staff. On at least one occasion, the resident was noted to be visibly upset and/or "shake" upon seeing the accused staff and, another time during care, the resident was overheard by staff telling the CNA not to hit her. According to facility records, the accused LPN and CNA continued to work on the unit and provide care to the resident until 10/26/10, at which time they were suspended pending investigation. Surveyor review of Team Notes revealed numerous nursing entries of resident behaviors including agitation, impatience, yelling, screaming and repetitive and continuous demands. Documented staff interventions included redirection, snacks, activities, 1:1 emotional support and use of anti-anxiety and [MEDICAL CONDITION] medication. On 7/1/10, the resident underwent [REDACTED]. While on unit tour with the charge LPN on 11/5/10 at 11:40 PM, the surveyor observed the resident being assisted out of bed into a wheelchair by staff. The LPN stated that the resident had been assisted out of bed three times at her request since initially being put to bed at 10:00 PM. During an interview with the surveyor on 11/5/10 at 11:40 PM, the resident became visibly anxious when the surveyor began to close the room door to provide privacy during the interview. The resident indicated she did not like the door closed. When asked how staff treated her, the resident initially stated that she had no complaints, however, later added that some staff were "bossy" and she didn't like people to tell her what to do as she is very independent. The resident was unable and/or unwilling to state which specific staff she considered bossy. The surveyor interviewed the DON on 11/5/10 at 12:35 AM. The DON stated that after reviewing the initial 11 PM-7 AM staff notes from September 2010, she considered their concerns a resident rights issue and did not have concerns of abuse. She indicated that upon reading the staff concerns, she was aware the LPN was specifically mentioned and she personally counseled the LPN and generated a written warning. The DON denied awareness of any resident rights or abuse concerns regarding the CNA, however, she did indicate that other staff had complained the CNA was "bossy" toward her staff peers. She further stated that she believed she had addressed all staff concerns and resident rights issues during her 9/27/10 night-shift visit and that she had not received any other unit staff concerns regarding treatment of [REDACTED]. The DON indicated she first became aware of actual abuse allegations on 10/26/10 when new staff interviews were conducted related to the Ombudsman's visit. The surveyor conducted numerous telephone interviews with 11 PM-7 AM staff including agency staff which worked frequently on the unit. The interviews were consistent concerning verbally abusive statements, threats of retribution for behaviors and mistreatment of [REDACTED]. In a telephone interview with the surveyor on 11/16/10 at 2:45 PM, a LPN, who was new to the unit, stated that while providing 1:1 for the resident during a behavioral episode, the resident appeared fearful and began visibly shaking when the involved LPN, who was "very stern with her" came to the room. This nurse verbally reported her concerns to the DON and also provided a written statement at the DON's request. However, she indicated that the same issues continued after she had initially reported to the DON and after the DON's 9/27/10 visit to the facility. In fact, the night after the DON's visit, she witnessed the involved CNA be verbally abusive to another resident, saying to the resident, "you're a pain in my ass." This nurse indicated the CNA was "very flip" with both staff and residents. She noted she wrote a statement regarding this incident as well and presented it to the DON. Although during surveyor interview the DON stated she had not found indications of abuse prior to 10/26/10, the surveyor reviewed a written statement from the new staff LPN, dated 9/28/10, and addressed to the DON which references mistreatment concerns by both the accused LPN and CNA. This statement reflects that the resident became extremely upset upon seeing the accused LPN and that both the involved LPN and the involved CNA would "yell" at the resident and tell her she was not allowed up until 4 AM. They additionally told Resident #1 that if she didn't listen and stop acting up, she'd have to wait even longer to get up. During orientation to the unit, the new LPN was advised by the involved LPN that she should remove the resident's wheelchair from her room if she acted up. In a telephone interview with the surveyor on 11/17/10 at 2:30 PM, the facility Administrator stated that, although the DON had advised him of possible resident rights concerns and her 9/26-9/27/10, 11 PM-7 AM visit and meeting with staff, at no time was he advised of resident abuse allegations. He further indicated that since no further concerns were reported to him by staff or the DON, he assumed all issues had been addressed by the DON. He did not become aware of the abuse allegations until 10/26/10 relative to the Ombudsman's investigation. In a subsequent telephone interview with the surveyor on 12/8/10 at 10:50 AM, the Administartor stated that the DON is the designated Abuse Coordinator and responsible for all abuse investigations. On 10/26/10, the involved LPN and CNA were suspended pending investigation. Newly obtained staff statements revealed possible involvement of an additional staff nurse who was also immediately suspended pending investigation. The facility policy on Abuse, Neglect & Mistreatment- Staff to Resident section V(e) states "The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in progress, under the direction of the assigned Abuse Coordinator. The Abuse Coordinator or his/her designee will report all findings to the Administrator or his/her designee." NJAC 8:39-27.1(a)