Every finding on record at Belle Care Nursing and Rehabilitation Center

Based on observation, interview and review of facility documentation, it was determined that the facility failed to provide immediate access to records and requested information necessary to conduct the survey.The deficient practice was evidenced by the following: On 12/29/2025 at 9:00 AM, the survey team entered the facility and was greeted by the Assistant Director of Nursing (ADON) who was instructed by the Survey Team Coordinator to provide an alphabetical roster of residents and a roster by room number, the Facility Matrix for admissions in the last 30 days, and a list of residents who smoke.On the same date at 9:56 AM, no facility staff member brought any of the requested documents except an alphabetical list of the residents. On 12/29/2025 at 10:01 AM, the Survey Team Coordinator spoke with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) via the ADON's cellular phone. At that time, the DON said she was on vacation last week and was not expecting a survey.On 12/29/2025 at 10:36 AM, the entrance conference began with the arrival of the DON and LNHA. During the entrance conference, the Survey Team Coordinator requested the Infection Preventionist's (IP) primary professional training and specialized training documentation, the Infection Prevention and Control Program (IPCP) standards, policies and procedures, the surveillance plan, the Antibiotic Stewardship program, and the immunization policies.A review of the Facility Entrance Conference request list revealed that the IP training documentation was required to be provided within one hour of entrance and the IPCP policies were required within four hours of entrance.During the entrance conference, the LNHA was also informed that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification survey on 06/26/2024. The LNHA told the Survey Team Coordinator that the facility had the files.On 12/29/2025 at 1:12 PM, the Survey Team Coordinator requested the LNHA to complete the AAS-11 (Daily Nursing Staff Report used to track actual hours worked by shift) and AAS-12 (Facility Census and Care Evaluation used to track resident acuity and specialized clinical needs.) for the facility staffing and return them via email by 8:00 AM on 12/30/2025.On 12/30/2025 at 12:15 PM, the Survey Team Coordinator received the IP training documentation and the IPCP policies, approximately 25 hours and 21 hours after the respective deadlines.On 12/30/2025 at 1:10 PM, the facility provided the human resource portion of the employee files but did not provide the medical files. At that time, the Human Resource Manger told the survey team that the IP holds the medical records of employees.On 12/31/2025 at 10:35 AM, the survey team received the AAS-11 and AAS-12 forms.A review of the AAS-11 and AAS-12 forms completed by the LNHA, revealed inconsistent numbers and blank sections on the forms. The Survey Team Coordinator returned the forms to the LNHA for correction.On 12/31/2025 at 12:36 PM, the LNHA returned the forms via email, which were reviewed and found to have additional errors.On 12/31/2025 at 12:43 PM, the LNHA returned the forms with corrections that were again found to be missing needed data.On 1/02/2026 at 10:13 AM, the LNHA provided the forms again which again, were discovered to contain data-entry errors.On 1/02/2026 at 12:26 PM, the survey team met with the LNHA to identify continued findings of inconsistent data entry. The LNHA appeared to correct the data on her computer in the presence of the surveyors and emailed the final forms at 1:12 PM which were determined to be inaccurate again.On 1/05/2026 at 10:13 AM, the LNHA sent the forms to the survey team for the last time for Department of Health review.A review of the facility provided Job Description document titled, Position Title: Administrator' revealed, The Administrator is responsible for planning and is accountable for all activities and departments of [Facility Name] subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility assure that the highest degree of quality of care is consistently provided to the residents.A review of the document also revealed that, 3. Meets with licensing authorities as required and accompanies them throughout and survey of the facility.N.J.A.C. 8:39-9.2(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 12/29/2025 from 09:30 AM until 09:55 AM during the initial tour of the kitchen, the surveyor, in the presence of the Director of Dining (DOD) observed the following:1. In the walk-in refrigerator, a covered pie had no label and was not dated. The DOD acknowledged it should be dated and the item was removed. 2. In the walk-in freezer, bagged frozen waffles, bagged frozen fish, frozen hamburger patties and an opened package of bacon had no label and were not dated. The DOD stated the waffles, fish, hamburger patties, and the bacon should be dated. The items were removed.3.In the refrigerator, an opened wrapped package of shredded cheese not dated. The DOD stated that it should be dated. 4. In the refrigerator, a single halved tomato wrapped in clear plastic wrap with no label and not dated. The DOD stated the item should be dated. 5. In the refrigerator, a container of honey mustard had a use by date of 11/20/2025. The DOD removed the item from the refrigerator and disposed of it. The surveyor reviewed the undated facility provided policy titled, Dating and Labeling which reflected: all food items will be labeled with a received date upon acceptance of delivery. Follow the Labeling and Dating System Protocol for all dating other than the received date of all products. Use the [Trade Name] system, address label, or black marker with legible writing to date and label products in accordance with the Labeling and Dating System Protocol. Discard all foods that expire immediately. The surveyor reviewed the undated facility-provided policy titled, Labeling and Dating System Protocol, that reflected all fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has a purveyor shipping label on it. Follow manufactures expiration date on all un-opened or opened product. The policy indicated that if there is no printed manufacturers date on the product to follow the provided dating time frames based on the food item. NJAC 8:39-17.2(g)

Based on interview and review of facility documents, it was determined that the facility failed to ensure that staffing data submitted to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system was accurate and complete for 1 of 2 PBJ Staffing Data Reports reviewed under the Sufficient and Competent Nurse Staff Task.The deficient practice was evidenced by the following:The facility reported on the AAS-11 (Daily Nursing Staff Report) that no Registered Nurse (RN) services were available on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/25/2025, and 12/26/2025.A review of the PBJ Staffing Data Report (CASPER Report 1705D) for Fiscal Year Quarter 1, 2025 (October 1, 2025, through December 31, 2025) revealed that the facility had not triggered No RN Hours for the dates identified on the AAS-11.On 1/02/2026 at 11:45 AM, during an interview with the surveyor, the Human Resource Manager (HRM) confirmed there were 24-hour periods without a registered nurse as indicated on the state staffing form (AAS-11). When the surveyor asked if she reported those shifts through PBJ reporting, the HRM replied, Yes.The Licensed Nursing Home Administration (LNHA) provided the surveyor two copies of the CMS Submission Report PBJ Final File Validation Report dated 8/14/2025 and 11/14/2025.A review of the validation reports revealed that the reports both state at the bottom, NOTE: This validation Report only validates whether or not the data submitted was received successfully; however, it does not reflect the accuracy or completeness of a facility's data.A review of the facility-provided policy titled, Payroll Base Journal (PBJ)-Staffing Data Submission revealed, To establish a standardized process for the accurate collection, validation, and timely submission of staffing data through the Centers for Medicare & Services (CMS) Payroll-Based Journal (PBJ) system, in order to demonstrate compliance with federal and state staffing transparency requirements and to support quality of care for residents.A review of the policy also revealed, The facility maintains processes to ensure that staffing hours are recorded accurately, categorized correctly, and submitted to CMS via the PBJ system within required reporting timeframes.N.J.A.C. 8:39-25.2(b)3

Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 10 of 42 days reviewed 09/21/2025 through 12/27/2025. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the week of 09/21/2025 through 12/27/2025, revealed the facility had no RN coverage for all shifts on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/24/2025, 12/25/2025 and 12/26/2025. During an interview on 01/02/2026 at 11:50 AM with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), the DON stated that if a licensed nurse is unavailable, she will cover, and if an RN cannot work 8 consecutive hours, another RN, regional staff, or agency staff (last used 08/2025) will be contacted. The LNHA noted that there have been instances of no RNs documented in the nursing reports. A review of a facility policy dated 10/15/2025 titled Staffing, revealed that, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS Payroll-Based Journal system on the schedule specified by CMS, but no less than once a quarter. Inquiries or concerns regarding our facility's staffing should be directed to the administrator or his/her designee. NJAC 8:39-25.2(h)

Based on observations on 12/31/2025 and 01 02/2026 in the presence of the facility's Corporate Regional Maintenance (CRM) and Maintenance Director (MD), it was determined that the facility failed to ensure that corridors were equipped with firmly secured handrails on both sides, This deficient practice had the potential to affect the 101 Residents who reside in the facility and is evidenced by the following:During the building tour on 01/02/2026 in the presence of the facility's CRM and MD at approximately 9:50 AM, the surveyor observed on the ground floor corridor next to the elevator and lobby area had no evidence of hand rails on both sides of the corridor.The surveyor measured and recorded the following sections of wall with no evidence of hand rails,1) One 3' section of wall with no hand rail.2) One 10' section of wall with no hand rail.3) One 7'-6 section of wall with no hand rail.4) One approximately 18 foot section of wall with no hand rail.The CRM and MD confirmed the findings at the times of observations.NJAC 8:39-31.2 ( e ).

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment for 2 of 2 units, the 1st and 2nd floor units, reviewed for environment.This deficient practice was evidenced by the following: On 12/29/2025 at 9:45 AM, on the 2nd floor in Bedroom [ROOM NUMBER], surveyor # 1 observed a fall mat positioned next to a resident's bed that contained multiple brown debris spots. On 12/29/2025 at 10:00 AM, on the 2nd floor in Bedroom [ROOM NUMBER], surveyor # 1 observed unfinished spackling on the wall behind the headboard of the B bed. Three holes were observed in the wall near the dresser. A fall mat was present on the right side of the bed with multiple areas of white debris. The floor on the left side of the bed contained a plastic fork, a knife, a paper cup, and multiple areas of brown debris and food. The bathroom contained a drop ceiling that was brown-stained and bulging. On 12/30/2025 at 9:55 AM, on the 2nd floor in Bedroom [ROOM NUMBER], surveyor # 1 observed chipped paint on the entrance door, and the unit's thermometer had exposed wiring with the protective top cover missing. During an interview with surveyor # 1 on 01/02/2026 at 12:20 PM, the LNHA stated that the issues identified do not reflect a homelike environment. The facility is aware of the infrastructure concerns and is working to improve them. A review of the facility's policy dated 09/2025, titled Homelike Environment, revealed that facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a.) a clean, sanitary, and orderly environment. On 12/29/2025 at 09:40 AM during initial tour of the 2nd floor unit surveyor # 2 observed broken blinds in room [ROOM NUMBER]. On 12/29/2025 at 10:10 AM during the initial tour of the 1st floor, surveyor # 2 observed in room [ROOM NUMBER] broken blinds and the sink leaking out the bottom when turned on. On 12/30/2025 at 09:49 AM during rounds on the 2nd floor unit, surveyor # 2 observed in the low side shower room the following: 1. No cover on the drain in the shower room floor. 2. Cracks in the ceiling. 3. An open pipe in the wall where a shower fixture had once been. 4. Molding on the floor peeling and noted with a black substance on them. 5. The bottom of the sink cabinet warped and peeling. During an interview on 01/02/2026 at 10:53 AM with the surveyors, the maintenance director (MD) said he rounds twice daily and if there are any concerns that come up the staff will add them to the maintenance book. The MD said if she sees broken blinds they replace them right away and they should not be broken. When asked about the shower room the MD simply said, I will fix it. During an interview on 01/02/2026 at 12:44 PM with the surveyors, the Licensed Nursing Home Administrator (LNHA) said that the blinds and sink should not be broken and agreed that the shower room was not in good repair. The LNHA also said that they had identified the environmental concerns and were prioritizing what needed to be fixed and updated. A review of a facility provided policy titled Homelike Environment revealed, The facility staff and management maximize, the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment. On 12/29/2025 at approximately 10:00 am during initial tour of the 1st floor unit, surveyor #3 observed the following: In the bathroom of Bedroom [ROOM NUMBER], Surveyor # 3 observed no toilet paper on the roll, no additional toilet paper rolls, a stained ceiling tile, the commode over the toilet seat was missing the left arm rest and a screw protruding up on the commode. In Bedroom [ROOM NUMBER], Surveyor # 3 observed no paper towels were available in the bathroom. In Bedroom [ROOM NUMBER], Surveyor # 3 observed a light bulb was not functioning in the bathroom. In Bedroom [ROOM NUMBER] A side, Surveyor # 3 observed four chest dresser with two drawers that could not close. In Bedroom [ROOM NUMBER], Surveyor # 3 observed a missing toilet paper holder, the toilet paper kept on the lid of the toilet seat, and a stained ceiling tile. On 12/31/2025 at 09:55am on the 1st floor unit in bedroom [ROOM NUMBER], surveyor # 3 observed a brown stain on the curtains dividing the room. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage containers closed and provide an area free of garbage and debris for 3 of 3 garbage containers. This deficient practice was evidenced by:On 12/30/2025 at 12:15 PM, the surveyor, accompanied by the Director of Dining (DOD), observed the facility's outdoor trash disposal area. The surveyor observed three garbage containers (GC) situated side by side along the exterior fence. The three GCs had an open lid and contained trash that was exposed to the elements. The area surrounding the three GCs was littered with debris, including but not limited to disposable gloves, plastic bags, and cardboard boxes. On 01/02/2026 at 10:53 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that both housekeeping and the maintenance departments are responsible for keeping the dumpster area clean. The DOM stated the GCs should be shut and the area surrounding the GCs should be clean. On 01/02/2026 at 11:04 AM, during an interview with the surveyor, the Environmental Service Director (ESD) stated that the GCs should remain free from debris and the lids should be closed. The ESD stated that the GCs are monitored at least twice a day and when other staff empty their garbage into the GC.The surveyor reviewed the facility's Garbage and Refuse policy, dated 09/01/2025, which reflected that All garbage/refuse containers in utility rooms, refuse storage rooms, and outside facility must be maintained at all times with a closed lid. The same policy reflected, Garbage/refuse pickup will be as often as necessary to prevent sanitary nuisance conditions. NJAC 8:39-19.3(c)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure medications were properly labeled and stored in an orderly manner. The facility failed to label opened multi-dose insulin vials with an open or expiration date and failed to maintain a medication cart free from loose, scattered medication. This deficient practice was identified for 1 of 2 medication carts inspected under the Medication Storage and Labeling task.The deficient practice was evidenced by:On 12/30/2025 at 10:34 AM, the surveyor inspected the 2 High - Side, 2nd Floor medication cart in the presence of Licensed Practical Nurse (LPN) # 1.While inspecting the top drawer of the cart, the surveyor observed a multi-dose vial of Lantus insulin (long-acting insulin) prescribed to an unsampled resident.The vial was in a clear, plastic bag and was observed to be opened but was not labeled with an opened date or an expiration date.The surveyor also observed a multi-dose vial of Humulin 70/30 insulin in the same drawer that did not have an expiration date labeled on it.While inspecting the second drawer from the top of the same medication cart, the surveyor discovered 15 loose medication tablets and pills scattered across the bottom of the drawer.At that time, LPN # 1 informed the surveyor that the staff check the medication cart weekly for loose tablets and pills.On 1/02/2026 at 12:26 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the facility's expectation is that insulin vials are dated.A review of the facility's policy titled Administering Medications revealed that, 13. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.A review of the facility's policy titled Medication Labeling and Storage revealed that, 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.N.J.A.C. 8:39-29.4(g)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observations conducted from 12/30/2025 to 01/02/2026, the surveyors observed four nurses administer medications to ten residents. There were 29 opportunities, and 3 errors observed, which resulted in a medication error rate of 10.34%. This deficient practice was identified for 2 of 10 residents, administered by 1 of 4 nurses. The deficient practice was evidenced by the following:On 12/30/2025 at 9:24 AM, the surveyor observed Licensed Practical Nurse (LPN) # 1 begin to administer medications for resident #63. LPN # 1 emptied 1 tablet of potassium chloride (a supplement used to treat or prevent low blood potassium) 10 milliequivalents from the medication card into a medication cup. Review of the Medication Administration Record (MAR) showed Potassium Chloride tab 10MEQ ER, Give 1 tablet orally one time a day every 2 days, at 8:00 AM. Administration documented at 9:31 AM, which was 31 minutes late per facility policy. On 12/30/2025 at 9:32 AM, the surveyor observed LPN #1 gesture to the screen of her computer. LPN #1 stated to the surveyor that resident #32 took his/her Metformin (a medication used to treat high blood sugar) with breakfast, but she did not document the medication as administered at the time of administration. LPN #1 then proceeded document the medication as administered in the Electronic Medical Record (EMR). At that time, the Metformin in the EMR changed from red to green highlight. The surveyor asked what red means on the EMR, LPN #1 stated red indicated the medication was late.A review of the MAR revealed Metformin HCl Oral Tablet 1000 MG, Give 1 tablet by mouth two times a day with meals. The morning dose was ordered at 8:00 AM, and signed out at 9:33AM.LPN #1 proceeded to pour Aspirin 81mg chewable from a medication bottle for Resident #32. The medication was administered with water to the resident. Review of the MAR reflected an order for Aspirin 81mg Enteric Coated (EC) delayed release, not the chewable tablet that was administered. On 12/31/2025 at 11:48 AM, a review of the policy titled Administering Medications, last updated 07/2025 revealed under Policy Interpretation and Implementation that, 4. Medications are administered in accordance with prescriber orders, including any required time frame. And 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). N.J.A.C. 8:39-29.2 (d)

Complaint # 366660Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to conduct a thorough investigation into an allegation of abuse by failing to document witness statements regarding the specific events of an alleged incident and instead focused on the character of the staff member involved. The deficient practice was identified for 1 of 8 residents (Resident # 112).The deficient practice was evidenced by the following:On 6/10/2025, Resident # 112 reported to the New Jersey Department of Health that on 5/02/2025, a nurse refused to give the resident needed supplies to perform their own care, kicked an oxygen concentrator, and refused to send the resident to the hospital.A review of Resident # 112's Electronic Medical Record (EMR) revealed under Care Plan that the resident had a focus of Behavior issues secondary to anxiety disorder as evidenced by: Calling 911, exaggerating events, Screaming to the point of exhaustion, yelling causing distress to self and others, extreme responses to ordinary stimuli or minor inconvenience, easily irritated/agitated, fixating.A review of the Facility-provided Investigation File revealed four witness statements.A review of the four witness statements revealed that none of the statements referred to any details regarding the incident alleged to have occurred on 5/02/2025.A review of the four witness statements revealed the statements only reflected positive personality attributes about the involved nurse.On 12/31/2025 at 10:53 AM, during an interview with the surveyor, the Director of Nursing (DON) stated Resident # 112 alleged the oxygen concentrator was broken and that the facility had the resident's documents, which the facility did not have.During the same interview, the surveyor noted that the summary of the investigation revealed, Employees interview regarding care provided by [Licensed Practical Nurse/LPN] # 1.During the same interview, the surveyor asked the DON for the documentation of those interviews. The DON referred to the Witness Statements and informed the surveyor that she was looking for more.During the same interview, the surveyor asked the DON if any of the four witness statements discussed the incident itself.The DON replied, No, we basically kept it like neutral saying we interview residents and staff.A review of the facility-provided policy titled Abuse Policy revealed that an investigation of abuse will include: i. Who was involved; ii. Residents' statements; iii. Resident's room mate statements; iv. Involved staff and witness statements of events.N.J.A.C. 8:39-9.4(i)

Complaint # 366635Based on interview and record review, it was determined that the facility failed to report an allegation of a resident-to-resident altercation to the Department of Health (State Agency) within the required 24-hour time frame. This deficient practice was identified for 2 of 8 residents (Resident # 113 and 114) reviewed under Abuse.The deficient practice was evidenced by the following:A review of the facility's AAS-45 (official report that a nursing home must send to the state government whenever an accident or incident happens to a resident) revealed that a resident-to-resident altercation occurred on 11/27/2024.A review of the AAS-45 revealed the form indicated that no injuries were reported because of the altercation.A review of the AAS-45 revealed the facility indicated the event was called into the Department of Health on 11/28/2024.A review of the AAS-45 revealed that the section for the date of the report was 12/12/2024.A review of the NJ Department of Health Intake Information sheet revealed the Department received the intake via E-Mail on 12/13/2024, approximately 16 days after the incident.On 1/02/2026 at 10:13 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the date on the AAS-45 was a typographical error and the incident would have been reported on the date it occurred. The DON could not provide documentation to support that the notification was made within the required time frame.On1/02/2026 at 12:26 PM during an interview with the Licensed Nursing Home Administrator, she stated that reporting allegations of abuse must be completed within two hours if there is harm and twenty-four hours if there hasn't been.A review of the facility-provided policy titled Abuse Policy under G. Reporting and Response revealed that the facility will ensure that all alleged violations involved abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).N.J.A.C. 8:39-9.4(f)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation and failed to implement policies and procedures related to pre-employment screening. Specifically, the facility did not complete required license verifications, reference checks, or criminal background checks prior to the start of employment. This deficient practice was identified in 53 of 160 employee files reviewed (Employees #1 through # 53).The deficient practice was evidenced by the following: On 12/30/2025 at 9:15 AM, the surveyor requested that the Licensed Nursing Home Administrator (LNHA) and Human Resources Director (HRD) provide personnel files for all employees hired since the last annual recertification survey in 06/2024, regardless of current employment status. The requested documentation included the department of hire, date of hire, license verification, reference checks, criminal background checks, and pre-employment medical documentation, including physical examinations and two-step Mantoux test results (a simple skin test used to see if a person has been exposed to a germ that can affect the lungs). On 12/30/2025 at 10:15 AM, the surveyors began reviewing the personnel files of 160 newly hired employees. Of the personnel files reviewed, 53 indicated there was no evidence that license verifications, reference checks, or criminal background checks were completed prior to the start of employment. The review of the personnel files of all newly hired employees revealed the following: Employee # 1 was hired and began working at the facility on 10/01/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 2 was hired and began working at the facility on 04/21/2025. There was no evidence that a license check was completed prior to the start of employment. Employee # 3 was hired and started working at the facility on 03/15/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee #4 was hired and began working at the facility on 10/15/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee #5 was hired and began working at the facility on 07/30/2024. The criminal background check was not completed within the required timeframe prior to the start of employment. The background check was completed on 07/31/2024. Employee #6 was hired and began working at the facility on 12/23/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 7 was hired and began working at the facility on 04/19/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 8 was hired and began working at the facility on 04/21/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 9 was hired and began working at the facility on 10/15/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 10 was hired and began working at the facility on 11/26/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 11 was hired and began working at the facility on 03/15/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 12 was hired and began working at the facility on 01/16/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 13 was hired and began working at the facility on 07/27/2024. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 14 was hired and began working at the facility on 10/10/2024. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 15 was hired and began working at the facility on 03/09/2024. The criminal background check was not completed within the required timeframe prior to the start of employment. The background check was completed on 06/27/2024. Employee # 16 was hired and began working at the facility on 10/15/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 17 was hired and began working at the facility on 10/10/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 18 was hired and began working at the facility on 09/11/2025. The criminal background check was not completed within the required timeframe prior to the start of employment. The background check was completed on 09/16/2025. Employee # 19 was hired and began working at the facility on 12/22/2025. There was no evidence that a license verification was completed prior to the start of employment. Employee # 20 was hired and began working at the facility on 07/30/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 21 was hired and began working at the facility on 11/04/2024. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 22 was hired at the facility, but no hire date was documented in the personnel files. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 23 was hired and began working at the facility on 06/21/2024. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 24 was hired at the facility, but no hire date was documented in the personnel files. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 25 was hired at the facility, but no hire date was documented in the personnel files. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 26 was hired and began working at the facility on 08/12/2025. There was no evidence that a license verification was completed prior to the start of employment. Employee # 27 was hired and began working at the facility on 03/07/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 28 was hired and began working at the facility on 04/10/2025. There was no evidence that a license verification or a criminal background check was completed prior to the start of employment. Employee # 29 was hired and began working at the facility on 11/12/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 30 was hired and began working at the facility on 10/21/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 31 was hired and began working at the facility on 07/18/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 32 was hired and began working at the facility on 12/01/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 33 was hired and began working at the facility on 07/15/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 34 was hired and began working at the facility on 11/18/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 35 was hired and began working at the facility on 12/09/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 36 was hired and began working at the facility on 07/12/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 37 was hired at the facility, but no hire date was documented in the personnel files. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 38 was hired and began working at the facility on 02/08/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 39 was hired and began working at the facility on 06/29/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 40 was hired at the facility, but no hire date was documented in the personnel files. There was no evidence that a license verification, a reference check or a criminal background check was completed prior to the start of employment. Employee # 41 was hired and began working at the facility on 09/11/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 42 was hired and began working at the facility on 07/22/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 43 was hired and began working at the facility on 10/15/2025. There was no evidence that a reference check or a criminal background check was completed prior to the start of employment. Employee # 44 was hired and began working at the facility on 09/30/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 45 was hired and began working at the facility on 10/02/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 46 was hired and began working at the facility on 06/26/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 47 was hired and began working at the facility on 03/08/2025. There was no evidence that a criminal background check was completed prior to the start of employment. Employee # 48 was hired and began working at the facility on 10/02/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 49 was hired and began working at the facility on 06/03/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 50 was hired and began working at the facility on 10/15/2024. There was no evidence that a license verification was completed prior to the start of employment. Employee # 51 was hired and began working at the facility on 12/03/2025. There was no evidence that a reference check was completed prior to the start of employment. Employee # 52 was hired and began working at the facility on 12/12/2024. There was no evidence that a reference check was completed prior to the start of employment. Employee # 53 was hired and began working at the facility on 12/09/2024. There was no evidence that a reference check was completed prior to the start of employment. During an interview on 01/02/2026 at 11:45 AM, the HRD stated that background checks, reference checks, and license or certified nurse aide (CNA) verifications are completed before employees begin work. The HRD noted that reference checks may be inconsistent for staff converted from agency positions, only one reference may be documented using agency verification. The HRD emphasized that completing these checks is important for knowing who is brought into the facility, especially when working with residents. During an interview with the surveyor on 01/02/2026 at 12:20 PM, the LNHA stated that personnel files need improvement and must include the DOH, license verification, two reference checks, criminal background checks, and documentation of a pre-employment physical examination and Mantoux test completed prior to starting work at the facility. These requirements help ensure resident safety. A review of the facility's policy dated 09/2025, titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property revealed that, It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. N.J.A.C. 8:39-9.3 (b)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure proper infection prevention and control practices were implemented to prevent the transmission of infection, related to handling of an indwelling urinary catheter for 1 of 1 resident reviewed for Urinary Catheter. (Resident # 11)The deficient practice was evidenced by the following: During the initial tour of the unit on 12/29/2025 at 09:52 AM, Resident #11 was in bed with an indwelling catheter. The catheter drainage bag was in contact with the floor with no privacy bag.A review of Resident # 11's admissions record revealed that, Resident # 11 was admitted with but not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (enlarged prostate), and Obstructive and reflux uropathy (a condition where urine flow is blocked.A review of the Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter.On 01/02/2026 at 09:32 AM during an interview with the surveyor, the Infection Prevention (IP) nurse stated, indwelling catheters should be hung below the bladder and in a privacy bag. The IP also said that indwelling catheters should always be in privacy bags and never on the floor for infection control reasons. On 01/02/2026 at 12:44 PM, during an interview with the surveyor, the Director of Nursing (DON) said indwelling catheters should never be on the floor and should be hung below the bladder in a privacy bag.A review of a facility policy title Catheter Care, Urinary revealed under Infection Control to, Be sure the catheter tubing and drainage bag are kept of the floor. N.J.A.C. 8:39-19.4(a)

Complaint #: NJ182273 Based on observation, interview, review of the medical records, and pertinent facility documents on 4/21/25 and 4/24/25, it was determined that the facility's nursing staff failed to: a.) sign on the electronic Medication Administration Record (eMAR) that the medications were administered according to the physician's orders, and b.) administer medication according to the physician's order. The facility also failed to follow their policy titled Medication Administration. This deficient practice was identified for 4 of 5 residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for medication administration. 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 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 4/21/25 at 8:56 A.M., the surveyor observed the Licensed Practical Nurse (LPN) during medication administration. While the LPN prepared the medication for Resident #2, the surveyor observed the LPN remove a bingo card from the medication cart. The surveyor reviewed the medication information on the bingo card which revealed Sotalol 80 milligram (MG) and two stickers on it. One sticker stated, partial tab and the other sticker stated 1HT=40 MG. on it. The surveyor turned the bingo card over and observed the packaging seal for each medication slot stated 1/2 of 80 MG. The LPN reviewed the bingo card against the order in the eMAR. The surveyor reviewed the order on the eMAR which stated Sotalol HCL Tab 80 MG. Give 1 tablet orally one time a day for Atrial fibrillation (Afib). The LPN placed the half tab from the bingo card into the medication cup. The LPN went into Resident #7's room and identified the resident. As the LPN was about to administer the medication, the surveyor asked her what was the Sotalol dose that she had placed in the medication cup. The LPN showed the surveyor the same bingo card that contained Sotalol half tabs and stated Both doses match. Bingo card is 80 MG, and it matches order on the computer. On 4/21/25 at 9:03 A.M., the surveyor interviewed the second floor Unit Manager (UM) who confirmed that the dose in the bingo card was Sotalol 40 MG. The UM looked at Resident #2's electronic medical record (EMR) in the presence of the surveyor and stated The order should be 40 MG not 80 MG. The UM further indicated she would call the doctor to verify the Sotalol dose. At 4/21/25 at 9:08 A.M., the UM informed the LPN in the presence of the surveyor that she had received new orders from the nurse practitioner (NP), to administer Sotalol 40 MG by mouth one time a day. The UM entered the order for Sotalol 40 MG in the EMR in the presence of the surveyor and the LPN. The LPN proceeded into Resident #7's room and administered the medication in the cup. After administering the medication to Resident #2, the LPN went into the electronic MAR and signed out the order that stated Sotalol HCL Tab 80 MG. Give 1 tablet orally one time a day for Atrial Fibrillation (Afib). The surveyor asked the LPN why she documented that she administered Sotalol 80 MG when she only gave the resident 40 MG. The LPN stated I signed for 40 MG. How come you had to pick me to watch do meds, there are other people here. I am getting confused now. 1. According to the admission Record (AR), Resident #2 was admitted to the facility in June of 2020 with diagnoses which included but were not limited to Depression, Anxiety, and Bipolar Disorder. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 2/27/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #2's order Summary Report (OSR), with active orders as of 4/21/25 included but was not limited to the following Physician's Orders (Pos): Sotalol HCL Tab 80 MG. Give one tablet orally one time a day for Afib. Sotalol HCL AF Oral Tablet. Give 40 mg by mouth one time a day for Afib. Levothyroxine Tab 75 MCG. Give one tablet orally one time a day for Hypothyroidism. A review of Resident #2's April 2025 MAR revealed the LPN's initials for the PO (by mouth) Sotalol HCL Tab 80 MG on 4/21/2025 at 9:00AM. The MAR indicated that for PO (by mouth) Sotalol hydrochloride (HCL) AF Oral Tablet a start date of 4/22/25. The MAR further revealed a blank space for PO (by mouth) Levothyroxine 75 Microgram (MCG) on 4/3/25 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Levothyroxine 75 MCG was administered on 4/3/2025 at 6:00 A.M. On 4/21/2025 at 3:40 P.M., the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the Regional DON. The DON stated The nurse would not give the 80 mgs because one tablet is 40 mgs, and that tablet is half a tab. The DON further indicated You can only order Sotalol under 80 mgs, but it is 40mgs they would receive. The surveyor asked the DON for further clarification. The DON stated, The resident is never getting 80mgs because it only comes from the pharmacy as 40mgs. The surveyor asked the DON what Sotalol dose the resident should have received based on the order in the resident's MAR. The DON replied, Should be getting 40mgs. 2. According to the AR, Resident #3 was admitted to the facility in September 2025 with diagnoses which included but were not limited to Dementia, Bipolar Disorder, and Seizures. According to the admission MDS, an assessment tool dated 3/5/2025, Resident #3 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. A review of Resident #3's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 2/27/2025 for Levothyroxine Sodium Tablet 100 MCG. The PO (by mouth) instructed to administer one tablet by mouth one time a day for low thyroid hormone. A review of Resident #3's April 2025 MAR revealed the 2/27/25 PO for Levothyroxine Sodium Tablet 100 mcg and to administer one tablet by mouth one time a day for low thyroid hormone. The April 2025 MAR did not reveal a signature from the nurse that Levothyroxine Sodium Tablet 100 mcg was administered on 4/3/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Levothyroxine Sodium Tablet 100 mcg was administered on 4/3/2025 at 6:00 A.M. 3. According to the AR, Resident #4 was admitted to the facility in January of 2022 with diagnoses which included but were not limited to Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Depression. According to the Annual MDS, an assessment tool dated 4/9/2025, Resident #4 had a BIMS score of 8 out of 15, which indicated the resident's cognition was moderately impaired. A review of Resident #4's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 4/28/24 for Omeprazole 20 mg. The PO instructed to administer one capsule orally one time a day for GERD. A review of Resident #4's April 2025 MAR revealed 4/28/24 PO (by mouth) for Omeprazole 20 mg and to administer one capsule orally one time a day for GERD. The April 2025 MAR did not reveal a signature from the nurse that Omeprazole 20 mg was administered on 4/17/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Omeprazole 20 mg was administered on 4/17/2025 at 6:00 A.M. 4. According to the AR, Resident #5 was admitted to the facility in December of 2024 with diagnoses which included but were not limited to Chronic Hepatitis, Hypertension, and Major Depressive Disorder. According to the Quarterly MDS, an assessment tool dated 3/29/25, Resident #5 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #5's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 12/20/24 for Docusate Sodium Capsule 100 mg. The PO (by mouth) instructed to administer 2 capsules by mouth in the morning for constipation. A review of Resident #5's April 2025 MAR revealed 12/20/24 PO (by mouth) for Docusate Sodium Capsule 100 mg and to administer 2 capsules by mouth in the morning for constipation. The April 2025 MAR did not reveal a signature from the nurse that Docusate Sodium Capsule 100 mg 2 capsules was administered on 4/17/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Docusate Sodium Capsule 100 mg 2 capsules was administered on 4/17/2025 at 6:00 A.M. On 4/21/2025 at 10:45 A.M., the surveyor interviewed the LPN who stated that once medication had been administered it was signed out on the MAR. The LPN further indicated All meds have to be signed out after you give them. On 4/24/25 at 2:14 P.M., the surveyor interviewed the DON in the presence of the LNHA And Regional DON. The DON stated the expectation was that the nurse signs out the medications on the MAR after administering them. The DON stated this was important to ensure credit is given for administering the medication and ensure it was given as ordered. The DON indicated that if a medication is not signed on the MAR, it would indicate either an omission or refusal. The DON further stated the nurse should indicate a refusal on the MAR, if the resident refused. The DON confirmed blank spaces on MAR for Resident #2, Resident #3, Resident #4 and Resident #5. The DON stated Yes, the nurse should have signed out the MAR after administering meds. A review of the facility's policy titled Medication Administration with a last reviewed date of 09/2024 revealed under Procedure, 11. Verify the pharmacy prescription label on the drug and the manufacturer's identifcation system matches the MAR. 13. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering. 17. Document the following as applicable: Administration of medication on MAR as soon as medications are given. NJAC 8:39-11.2 (b)

Complaint # NJ178109 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/21/25 and 4/24/25, it was determined that the facility failed to submit the facility's investigation to the New Jersey Department of Health (NJDOH) in a timely manner for a resident-to-resident incident that occurred. The facility also failed to follow its policy titled Abuse Policy. The deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident # 2 was admitted to the facility in June 2020 with diagnoses which included but were not limited to: Depression, Anxiety, and Bipolar Disorder. According to the quarterly Minimum Data Set (MDS), an assessment tool dated 02/27/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated the resident's cognition was severely impaired. 2. According to the admission Record (AR), Resident # 8 was admitted to the facility in October 2019 with diagnoses which included but were not limited to: Major Depressive Disorder, constipation, and Schizophrenia (a mental health condition that affects the resident's ability to think and behave clearly). According to the quarterly MDS, an assessment tool dated 01/24/25, Resident #8 had a BIMS score of 3 out of 15 which indicated the resident's cognition was severely impaired. According to the Facility Reportable Event (FRE), a NJDOH document used by healthcare facilities to report incidents, with a date of 10/04/2024 and an event date of 9/16/2024 revealed that it was reported to facility administration that Resident #8 had struck Resident #2 on the back while exiting the elevator. Both residents were immediately separated, and body assessments were conducted. On 4/21/25 at 3:41P.M., the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), and the Regional DON. The DON confirmed that the FRE was not sent to the NJDOH until 10/04/24. The DON further stated the FRE was not sent in until October 4th because during this time we were deep in our DPOC (Directed Plan of Correction). On 4/24/25 at 2:13P.M., the surveyor interviewed the LNHA, in the presence of the DON and the Regional DON who stated she submitted the investigation and conclusion for the incident electronically to the DOH and would provide a copy of the email to the surveyor. The facility did not provide the surveyor with documentation that the facility's investigation was submitted electronically to the NJDOH. A review of the facilities undated policy titled Abuse Policy revealed under External Reporting, A follow up investigation will be submitted to the State Agency within five (5) working days. When making a report, the following information should be reported: The facility must include the following investigative components: Have evidence that all alleged violations are thoroughly investigated. NJAC 8.39-9.4

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing and b.) their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies. This deficient practice was identified on 2 of 2 nursing units, and was evidenced by the following: Refer F600, F610, F641, F725, F756, F761, F838, F865, F881, F882 A review of the Administrator's job description provided by the facility revealed the following: Administrator is responsible for planning and is accountable for all activities and departments at [name redacted] subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of care is constantly provided to the residents . Responsibilities/Accountabilities included but not limited to: implements [name redacted] objectives as determined and directed by the governing body; interprets practices within guidelines and recommends changes as necessary; superintends physical operations of the facility; concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents; oversees and guides department managers in the development and use of departmental policies and procedures; and ensure that residents and families receive the highest level of service in a caring and compassionate atmosphere which recognizes the individuals needs and rights . 1. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the LNHA and Director of Nursing (DON) who the facility's Infection Preventionist (IP) was, and the facility did not have an IP for two or three months, that the Assistant Director of Nursing (ADON), two unit managers, and herself reviewed antibiotic stewardship and inserviced staff on infection control. The surveyor requested a copy of their infection control certifications. On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the ADON who also was not certified. The DON stated only the Unit Manager/Licensed Practical Nurse (UM/LPN #1) had an infection control certification. The DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-serviced staff on infection control. On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. The ADON stated she had just completed May's antibiotic stewardship review yesterday. On 6/25/24 at 10:58 AM, the surveyor re-interviewed the ADON who confirmed she had no infection control certification, and she was responsible for providing staff with infection control training. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. 2. On 6/18/24 at 7:57 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN #1) entering electronic signatures for the medications that she had administered to Resident #89 in the electronic Medication Administration Record (eMAR). On 6/18/24 at 8:13 AM, RN #1 stated I had to borrow a password, explaining that she was using the login password for the UM/LPN #2 because she was an agency nurse, and she had a problem with her login. On 6/18/24 at 8:21 AM, the surveyor observed RN #1 entering electronic signatures for the 8:00 AM (8 AM) and 9:00 AM (9 AM) medications for four sampled residents, (Resident #32, #61, #79, and #84), and six unsampled residents, (unsampled Resident #1, #2, #3, #4, #5, #6). RN #1 stated that she had already administered the morning medications to those residents and needed to sign the eMAR. RN #1 explained that she administered morning medications to the residents earlier because they were a priority since the residents were either diabetic, on dialysis or had a feeding tube (surgical tube inserted into the stomach), and she had not had a chance to sign the eMAR. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 administer and electronically sign for medications that were administered to Resident #51. A review of the eMARs for Resident #89, #51, #32, #61, #79, #84 and the six unsampled residents revealed that the initials for the 8 AM and 9 AM medications on 6/18/24 had the electronic signature initials for UM/LPN #2. On 6/18/24 at 11:27 AM, the surveyor interviewed UM/LPN #2 at the nurse's station, who stated that she had given RN #1 her login because there was a problem this morning. In addition, UM/LPN #1 stated that medications should be signed for immediately after administering them to the resident. At that time, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed UM/LPN #2 should not have given RN #1 her login password. The ADON stated that when the computer system changed on 6/11/24, the staff were trained on how to use the system, but that agency nurses were already familiar with the system. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. 3. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the LNHA and DON how the facility's staff was, and the LNHA stated that the facility relied heavily on Agency staffing. On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Um/LPN #1 and observed the following: The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 asked the resident if she could check their incontinent brief and the resident gave UM/LPN #1 permission. The surveyor observed that the resident's incontinent brief was dry and the chuck (protective bed pad) that was directly under the resident was dry, however the fitted sheet located under the chuck had a large brown/yellow stain that smelled like urine and contained some dry brown stains which UM/LPN #1 identified as bowel movement (bm). UM/LPN #1 was interviewed at that time, and stated that the Certified Nursing Aide (CNA) that was assigned to care for Resident #32 should have changed the resident's sheet when performing incontinence care and should not have left a urine-soaked sheet on the resident's bed. UM/LPN #1 stated that the Agency CNA that cared for the resident on 11:00 PM to 7:00 AM shift must have left the dirty sheet on the resident's bed because the CNA (CNA #1) that came in that morning just got to the unit and had not made rounds yet. UM/LPN #1 stated that incontinence rounds were completed by the CNA every two hours. The surveyor observed the resident's skin during the tour and the resident's skin was free of skin breakdown. A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 47, there were five assigned CNAs. CNA #1 had thirteen assigned residents to care for. On 6/18/24 at 8:45 AM, the surveyor conducted an incontinence tour on the First Floor nursing unit with a Licensed Practical Nurse (LPN) and observed the following: On 6/18/24 at 9:00 AM, the surveyor accompanied the LPN into Resident #32's room observed the resident lying in bed and was non-verbal. The resident's incontinence brief was observed to be very wet with urine and the sheets were observed with a large urine stain that had a strong smell of urine. The LPN was interviewed at the time and confirmed that the stain the surveyor observed on the resident's sheet was urine and that the resident's incontinence brief should have been changed and the entire bed linen should have been changed. The resident's skin was observed, and the resident's skin was intact and free of breakdown. On 6/18/24 at 9:10 AM, the surveyor interviewed UM/LPN #2 for the First Floor nursing unit who stated that CNA #2 who was assigned to care for Resident #32 should have made rounds that morning when she had arrived at the unit and checked the residents to see if any residents were incontinent and needed to be changed right away. UM/LPN #2 could not speak to why Resident #32 was wet including the resident's bed linens. UM/LPN #2 stated it was import to assure that the residents were clean and dry to protect the resident's skin and to keep residents comfortable. A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 50, there were five assigned CNAs. CNA #2 had eleven assigned residents to care for. On 6/25/24 at 10:13 AM, the surveyor interviewed the Staffing Coordinator in the presence of the Licensed Nursing Home Administrator (LNHA), who stated she scheduled nursing staff in accordance with State regulation which required one CNA to every eight residents for the morning shift; one CNA for every ten residents for the evening shift; and one CNA to every fourteen residents for the overnight shift. The Staffing Coordinator stated it was very hard to find staff; that the facility did not always meet the required ratios. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. 4. On 6/19/24 at 1:27 PM, the surveyor requested from the LNHA and DON the Consultant Pharmacist's (CP) recommendations for Resident #34, #60, #61, and #80) from March 2024 until present. A review of the CP's recommendations revealed that recommendations made in March 2024, were acted on after surveyor inquiry. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers. The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry. On 6/20/24 at 10:16 AM, the surveyor interviewed UM/LPN #1 who stated that the CP report recommendations were usually completed by the unit manager, but could be assigned to the nurse on the unit or divided amongst the nursing staff to complete. UM/LPN #1 stated that an appropriate time to complete the CP's recommendation report was within one week. She continued to add that the unit managers usually received an email of the recommendations, but since switching over to the new electronic medical records (EMR), which was switched on 6/11/24, the DON received the recommendations. UM/LPN #1 revealed that the CP recommendations from March 2024, April 2024 and May 2024 were not given to the unit managers to complete until yesterday (6/19/24). On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. 5. On 6/17/24 at 1:00 PM, the surveyor requested from the LNHA a copy of investigations for reportable events to the New Jersey Department of Health (NJDOH) or any investigations that included injury of unknown origin or allegation of abuse and neglect for July and August 2023. The surveyor reviewed an investigation for the closed medical record for Resident #254. A review of the Incident Report dated 8/14/23 at 8:30 AM, revealed that the ADON was called to Resident #254's room to assess the resident who had blue discoloration on both ears, a three centimeter by three centimeter (3 cm x 3 cm) abrasion to right knee; discoloration on right side of face and mid arm. When staff attempted to turn the resident over, the resident screamed in pain; the physician was made aware and a new order was put in place to send to the emergency room (ER) for evaluation. The ER report indicated the resident sustained a lower back fracture. The resident's medical record revealed prior to the injury of unknown origin, they were on one to one (1:1) monitoring every shift. The incident report did not include how a resident on 1:1 monitoring sustained bruising to both ears and a lower back fracture through an unwitnessed fall. On 6/20/24 at 1:24 PM, the survey team met with the LNHA and the DON, and the surveyor requested additional information on how a resident who was on 1:1 monitoring had an unwitnessed fall that resulted in two bruised ears and a fractured back. At that time, the LNHA acknowledged that the investigation should include how the resident on a 1:1 had an unwitnessed fall. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. On 6/26/24 at 10:36 AM, the survey team met with the LNHA, DON, and ADON to discuss their concerns. The LNHA stated an investigation should have included an assessment of the resident, interviews of possible witnesses and resident, psychology if needed, psychosocial if needed with a social worker, summary, conclusion and interventions put in place so will not happen again, and individualized comprehensive care plan (ICCP) was updated. 6. During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the LNHA and the DON a copy of the facility's assessment. During initial tour on 6/17/24 at 10:29 AM, the surveyor observed Resident #26 observed in bed asleep. The surveyor observed that both the resident and their unsampled roommate were both incarcerated with four Corrections Officers (CO) present in the room. On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail. A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee and signed by the LNHA on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, ADON, and survey team acknowledged the registered sex offenders and inmates were not included in the facility assessment. 7. On 6/20/24 at 12:57 PM, the survey team met with the LNHA and DON to discuss their concerns which included accuracy of the Minimum Data Set (MDS) assessments; medication storage; acting on Consultant Pharmacy (CP) reports; and antibiotic stewardship program. On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail. A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the QAPI committee on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population. On 6/25/24 at 1:22 PM, the survey team met with the LNHA, DON, and Regional Nurse to discuss additional concerns which included the facility's assessment did not include registered sex offenders or inmates in their special population. On 6/25/24 at 1:27 PM, the surveyor in the presence of the DON, Regional Nurse, and survey team, asked the LNHA what their role was. The LNHA stated their role was to oversee operations for the facility, all departments and department heads to ensure residents received the services, were safe, and needs were met. A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies from the facility's last standard survey included the facility was cited for the following concerns: MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment to include registered sex offenders and inmates, and the facility's QAPI program. On 6/26/24 at 11:52 AM, the survey team met with the LNHA, DON, and ADON to discuss the facility's QAPI program which all three staff members were part of. When asked where the facility obtained their concerns for their QAPI program, the LNHA stated the facility utilized the CMS 2567 statement of deficiencies from previous surveys. The survey team informed the facility that there were repeated concerns from the last standard survey which included MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment, and QAPI, and asked what the facility implemented to ensure sustainability. The LNHA acknowledged that even though she started at the facility in April 2024, she was present for the April quarterly QAPI meeting as well as reviewed and signed the facility assessment and reviewed the CMS 2567 from last standard survey. At that time the DON stated she was aware of the facility's previous deficiencies and that facility educated staff and completed reports. NJAC 8:39-9.2(a); 9.3(a); 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choice including to; participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave room at will, be free from physical restraints, and wear clothing of choice for Justice Involved Residents (JIR). This deficient practice was identified for 1 of 1 JIRs (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated that they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. The facility's failure to promote and facilitate resident self-determination through support of resident choice for all residents, including JIRs, to participate in group activities and dining, leave their room at will, communicate with visitors of choice, and wear clothing of choice posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included .10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when [Resident #1] was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that [Resident #1] did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and that [Resident #1] always remained in the room alone with two armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed that the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated [Resident #1] did not require any ankle or wrist cuffs because they were a paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking, and the DOR stated that [Resident #1] was a paraplegic and rehab was working with them to walk. On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA stated that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated that Resident #1 requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed Resident #1's assigned CNA (CNA #1), who stated the resident provided their own care; that they were able to get out of bed and go to the bathroom by themselves, and Resident #1 was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. The LPN #1 stated the wound was the width of a cotton swab, and that [Resident 31] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. The LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and the LPN #2 stated she was unsure if there was a set schedule, but that [Resident #1] had an appointment today. The LPN #2 stated that the CF setup the transportation, and the COs accompanied Resident #1 to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked Resident #1 if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIRs left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. On that same date, the surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that Resident #1 stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that the resident informed the facility that the CF had to approve all visits, and the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and [Resident #1] could not be without them. The DON stated it was the CF's policies; that [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and that [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated that [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's admission agreement and resident rights. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. A review of the Concerns with Correctional Officers policy dated 9/12/23, included that COs should be treated with dignity and respect by all staff . On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)

Complaint NJ #: 159451; 159783 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an environment that promoted maintenance or enhancement of the resident's quality of life. This deficient practice was identified for 1 of 1 residents reviewed for Resident Rights (Resident #60). This deficient practice was evidenced by the following: On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. Resident #60 stated that they did not like to spend time in their room because their roommate (Resident #71) urinated on the floor, causing the room to become smelly and unpleasant. When asked if the facility was aware of this behavior, Resident #60 confirmed. On 6/20/24 at 10:52 AM, the surveyor was on the Second Floor nursing unit and smelled a strong odor of urine while approaching Resident #60's room. The surveyor entered the room to discover the floor by Resident #60's bed was wet and sticky in addition to puddles of wetness observed on the bed. Upon exiting the room, the surveyor observed two facility staff sitting in the alcove across from the resident's room engaged in conversation. On 6/20/24 at 11:41 AM, the surveyor requested that Registered Nurse (RN #1) walk with them to Resident #60's room. While approaching the room, RN #1 acknowledged the strong odor of urine and confirmed that they were aware of the room's condition approximately 30 minutes prior to the surveyor being on the floor. RN #1 stated that they notified housekeeping and instructed the certified nursing aides to clean the room. RN #1 stated that they were under the impression that it was rectified. On 6/20/24 at 11:55 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) stated that the rooms were to be considered as the resident's home. The UM/LPN stated that Resident #60 should not have to sit in a room that smells of urine, confirmed that the entire hallway by Resident #60's room smelled of urine and that the two facility staff members sitting in the alcove should have attempted to identify the location of the smell to clean it up. The surveyor reviewed the medical record for Resident #60. A review of the Admission Record face sheet (an admission summary) reflected that resident was admitted to the facility with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/16/24, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. On 6/25/24 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident room should have been cleaned in a timely fashion and that residents should have the expectation to receive quality care and quality living environments. On 6/26/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Regional Nurse and Assistant Director of Nursing (ADON), and DON, acknowledged that the facility was aware of ongoing issue with Resident #60's room, but have never approached the resident to discuss whether or not this living condition impacted them. A review of the facility's Resident Rights policy, created 2/2024, included .The resident has a right to a safe, clean, comfortable and Homelike Environment, including but not limited to receiving treatment and supports for daily living safely . A review of the facility's undated Quality of Life- Homelike Environment policy included .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order .e. Pleasant, neutral scents . A review of the facility's undated Certified Nurse Aide Position document included .22. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right . A review of the facility's undated Licensed Practical Nurse Position document included .9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal regulations. 10. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right . A review of the facility's undated Registered Nurse Position document included .2. 9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal regulations. NJAC 8:39-4.1 (a), 11

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choice including to; participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave room at will, be free from physical restraints, and wear clothing of choice for Justice Involved Residents (JIR). This deficient practice was identified for 1 of 1 JIRs (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated that they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. The facility's failure to promote and facilitate resident self-determination through support of resident choice for all residents, including JIRs, to participate in group activities and dining, leave their room at will, communicate with visitors of choice, and wear clothing of choice posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included .10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when [Resident #1] was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that [Resident #1] did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and that [Resident #1] always remained in the room alone with two armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed that the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated [Resident #1] did not require any ankle or wrist cuffs because they were a paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking, and the DOR stated that [Resident #1] was a paraplegic and rehab was working with them to walk. On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA stated that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated that Resident #1 requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed Resident #1's assigned CNA (CNA #1), who stated the resident provided their own care; that they were able to get out of bed and go to the bathroom by themselves, and Resident #1 was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. The LPN #1 stated the wound was the width of a cotton swab, and that [Resident 31] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. The LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and the LPN #2 stated she was unsure if there was a set schedule, but that [Resident #1] had an appointment today. The LPN #2 stated that the CF setup the transportation, and the COs accompanied Resident #1 to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked Resident #1 if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIRs left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. On that same date, the surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that Resident #1 stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that the resident informed the facility that the CF had to approve all visits, and the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and [Resident #1] could not be without them. The DON stated it was the CF's policies; that [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and that [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated that [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's admission agreement and resident rights. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. A review of the Concerns with Correctional Officers policy dated 9/12/23, included that COs should be treated with dignity and respect by all staff . On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the involuntary seclusion and use of physical restraints for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs; Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated hey were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident reported they wanted to return to the CF because of it. The facility's failure to ensure all residents, including JIR, were free from abuse including involuntary seclusion and the use of physical restraints posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . A review of the facility's Abuse Prevention policy dated revised June 2024, included it is the policy of [facility] to not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse [ .] in compliance with State and Federal regulations .Involuntary seclusion: the separation of a resident from other residents or from his/her room, or confinement to his/her room against resident's will or against the will of the responsible party .Resident [NAME] of Rights: as a nursing home resident in the State of New Jersey, you have the following rights:[ .] Freedom from Abuse and Restraints: free from physical and mental abuse; freedom from chemical and physical restraints, unless they are authorized by a physician for a limited period of time to protect you or others from physical injury . A review of the facility provided Clinical Programs Manual Topic: Restraint Management dated effective October 2021, included restraints will be used only when necessary to treat medical symptoms and not used for staff convenience. The least restrictive restraint for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being .restraints include, but are not limited to the following: arm restraints [ .] leg restraints .Guidelines: 1. evaluate care plan to ensure that restraint alternative interventions have been tried prior to consideration of the restraint .4. obtain a physician's order for restraint [ .] 5. provide the Physical Restraint Information Sheet to the resident or responsible party [ .] 6. review and revise the following: the care plan . A review of the facility's Visitation policy dated revised May 2024, included the facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility to maintain contact with the community in which he/she lived or is familiar. Procedure: 1. the resident's family may visit the resident at any time subject to the protection of the rights and safety of other residents and any restrictions imposed by the resident .5. residents may visit with members of the clergy at any time subject to the protection of the rights of others during communicable disease outbreaks . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated Resident #1 had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when Resident #1 was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that [Resident #1] did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and [Resident #1] always remained in the room alone with two-armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed the resident, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A further review reflected the resident had no mood or behavior issues. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/13/24, revealed the resident used anti-anxiety medications with regards to anxiety disorder. Interventions were to educate resident/family/caregivers about risks, benefits, and side effects and toxic symptoms; give anti-anxiety medications as ordered by physician; monitor and record occurrence of target behavior and symptoms; and increased risk of confusion, amnesia, loss of balance, falls, monitor for safety. A focus area dated 8/13/24, revealed the resident used antidepressant medication with regards to depression. Interventions included to educate the resident/family/caregivers about risks, benefits, and side effects and toxic symptoms; give antidepressant medications as ordered by physician; monitor, document, and report to physician as needed any ongoing signs and symptoms of depression. A focus area dated 8/11/24, revealed the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. A review of the Psychiatric (Psych) Follow Up Note dated 7/17/24, included resident had a history of anxiety, depression, and insomnia. The resident reported I feel stressful and felt depressed and anxious at times. The resident reported sleep disturbance and eating was okay. A review of the Psychiatric (Psych) visit dated 7/24/24, included that the resident was seen today for a follow-up visit. The resident reported I am feeling a little better, less stressful, less anxious. The resident reported feeling depressed and anxious at times with disturbed sleep, and eating was okay. A review of the Order Listing Report included the following physician's orders (PO): A PO dated 8/12/24, that the resident cannot go out on pass or out of the facility unless escorted by COs and Emergency Medical Services (EMS). A PO dated 8/13/24, for trazadone (antidepressant) 50 milligram (mg) tablet; give one tablet orally at bedtime for insomnia. A PO dated 8/17/24, for Zoloft 50 mg tablet; give one tablet by mouth in the evening for depressive episodes. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated that [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking and the non-use of leg cuffs, and the DOR stated [Resident #1] was a paraplegic and rehab was working with them to walk. The DOR also stated that the use of hand and leg cuffs was the decision of the CF; that the facility could not order cuffs. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA continued that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated [Resident #1] requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed [Resident #1's] assigned CNA (CNA #1), who stated [Resident #1] always stayed in their room with two COs. CNA #1 stated that [Resident #1] was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed the LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. The LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often [Resident #1] had wound doctor appointments, and LPN #2 stated she was unsure if there was a set schedule, but [Resident #1] had an appointment today. LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked the resident if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. The surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:45 PM, the surveyor continued to review the medical record. A review of the Order Listing Report did not include a PO for the use of restraints (wrist and ankle cuffs). A review of the ICCP did include a focus area for the use of restraints. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA continued that Resident #1 stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that [Resident #1] informed the facility that the CF had to approve all visits, and [Resident #1] could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and [Resident #1] could not be without them. The DON stated it was the CF's policies; and [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and that [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that Resident #1 received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's admission agreement and resident rights. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)(5)(6)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the involuntary seclusion and use of physical restraints for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs; Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated hey were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident reported they wanted to return to the CF because of it. The facility's failure to ensure all residents, including JIR, were free from abuse including involuntary seclusion and the use of physical restraints posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . A review of the facility's Abuse Prevention policy dated revised June 2024, included it is the policy of [facility] to not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse [ .] in compliance with State and Federal regulations .Involuntary seclusion: the separation of a resident from other residents or from his/her room, or confinement to his/her room against resident's will or against the will of the responsible party .Resident [NAME] of Rights: as a nursing home resident in the State of New Jersey, you have the following rights:[ .] Freedom from Abuse and Restraints: free from physical and mental abuse; freedom from chemical and physical restraints, unless they are authorized by a physician for a limited period of time to protect you or others from physical injury . A review of the facility provided Clinical Programs Manual Topic: Restraint Management dated effective October 2021, included restraints will be used only when necessary to treat medical symptoms and not used for staff convenience. The least restrictive restraint for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being .restraints include, but are not limited to the following: arm restraints [ .] leg restraints .Guidelines: 1. evaluate care plan to ensure that restraint alternative interventions have been tried prior to consideration of the restraint .4. obtain a physician's order for restraint [ .] 5. provide the Physical Restraint Information Sheet to the resident or responsible party [ .] 6. review and revise the following: the care plan . A review of the facility's Visitation policy dated revised May 2024, included the facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility to maintain contact with the community in which he/she lived or is familiar. Procedure: 1. the resident's family may visit the resident at any time subject to the protection of the rights and safety of other residents and any restrictions imposed by the resident .5. residents may visit with members of the clergy at any time subject to the protection of the rights of others during communicable disease outbreaks . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated Resident #1 had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when Resident #1 was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that [Resident #1] did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and [Resident #1] always remained in the room alone with two-armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed the resident, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A further review reflected the resident had no mood or behavior issues. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/13/24, revealed the resident used anti-anxiety medications with regards to anxiety disorder. Interventions were to educate resident/family/caregivers about risks, benefits, and side effects and toxic symptoms; give anti-anxiety medications as ordered by physician; monitor and record occurrence of target behavior and symptoms; and increased risk of confusion, amnesia, loss of balance, falls, monitor for safety. A focus area dated 8/13/24, revealed the resident used antidepressant medication with regards to depression. Interventions included to educate the resident/family/caregivers about risks, benefits, and side effects and toxic symptoms; give antidepressant medications as ordered by physician; monitor, document, and report to physician as needed any ongoing signs and symptoms of depression. A focus area dated 8/11/24, revealed the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. A review of the Psychiatric (Psych) Follow Up Note dated 7/17/24, included resident had a history of anxiety, depression, and insomnia. The resident reported I feel stressful and felt depressed and anxious at times. The resident reported sleep disturbance and eating was okay. A review of the Psychiatric (Psych) visit dated 7/24/24, included that the resident was seen today for a follow-up visit. The resident reported I am feeling a little better, less stressful, less anxious. The resident reported feeling depressed and anxious at times with disturbed sleep, and eating was okay. A review of the Order Listing Report included the following physician's orders (PO): A PO dated 8/12/24, that the resident cannot go out on pass or out of the facility unless escorted by COs and Emergency Medical Services (EMS). A PO dated 8/13/24, for trazadone (antidepressant) 50 milligram (mg) tablet; give one tablet orally at bedtime for insomnia. A PO dated 8/17/24, for Zoloft 50 mg tablet; give one tablet by mouth in the evening for depressive episodes. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated that [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking and the non-use of leg cuffs, and the DOR stated [Resident #1] was a paraplegic and rehab was working with them to walk. The DOR also stated that the use of hand and leg cuffs was the decision of the CF; that the facility could not order cuffs. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA continued that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated [Resident #1] requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed [Resident #1's] assigned CNA (CNA #1), who stated [Resident #1] always stayed in their room with two COs. CNA #1 stated that [Resident #1] was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed the LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. The LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often [Resident #1] had wound doctor appointments, and LPN #2 stated she was unsure if there was a set schedule, but [Resident #1] had an appointment today. LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked the resident if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. The surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:45 PM, the surveyor continued to review the medical record. A review of the Order Listing Report did not include a PO for the use of restraints (wrist and ankle cuffs). A review of the ICCP did include a focus area for the use of restraints. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA continued that Resident #1 stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that [Resident #1] informed the facility that the CF had to approve all visits, and [Resident #1] could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and [Resident #1] could not be without them. The DON stated it was the CF's policies; and [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and that [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that Resident #1 received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's admission agreement and resident rights. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)(5)(6)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the use of physical restraints imposed for the purposes of discipline or convenience for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility, and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated that they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 being transported in a wheelchair to the elevator with three-armed COs, and the resident was being restrained with wrist and ankle cuffs. The facility's failure to ensure all residents, including the JIR, were free from abuse including the use of physical restraints posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, when Resident #1 was observed in the hallway with physical restraints. The facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience . A review of the facility's Abuse Prevention policy dated revised June 2024, included it is the policy of [facility] to not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse [ .] in compliance with State and Federal regulations .Involuntary seclusion: the separation of a resident from other residents or from his/her room, or confinement to his/her room against resident's will or against the will of the responsible party .Resident [NAME] of Rights: as a nursing home resident in the State of New Jersey, you have the following rights:[ .] Freedom from Abuse and Restraints: free from physical and mental abuse; freedom from chemical and physical restraints, unless they are authorized by a physician for a limited period of time to protect you or others from physical injury . A review of the facility provided Clinical Programs Manual Topic: Restraint Management dated effective October 2021, included restraints will be used only when necessary to treat medical symptoms and not used for staff convenience. The least restrictive restraint for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being .restraints include, but are not limited to the following: arm restraints [ .] leg restraints .Guidelines: 1. evaluate care plan to ensure that restraint alternative interventions have been tried prior to consideration of the restraint .4. obtain a physician's order for restraint [ .] 5. provide the Physical Restraint Information Sheet to the resident or responsible party [ .] 6. review and revise the following: the care plan . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room alone with two-armed COs, unless to go to the rehabilitation (rehab) gym. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if [Resident #1] had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A further review reflected the resident had no mood or behavior issues. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. A review of the Psychiatric (Psych) Follow Up Note dated 7/17/24, included resident had a history of anxiety, depression, and insomnia. The resident reported I feel stressful and felt depressed and anxious at times. The resident reported sleep disturbance and eating was okay. A review of the Psychiatric (Psych) visit dated 7/24/24, included that the resident was seen today for a follow-up visit. The resident reported I am feeling a little better, less stressful, less anxious. The resident reported feeling depressed and anxious at times with disturbed sleep, and eating was okay. A review of the Order Listing Report included the following physician's orders (PO): A PO dated 8/12/24, that the resident cannot go out on pass or out of the facility unless escorted by COs and Emergency Medical Services (EMS). On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated that [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The DOR also stated that the use of hand and leg cuffs was the decision of the CF; that the facility could not order cuffs. On 8/29/24 at 12:20 PM, the surveyor interviewed the LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. The LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and the LPN #2 stated she was unsure if there was a set schedule, but that [Resident #1] had an appointment today. The LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. The surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:45 PM, the surveyor continued to review the medical record. A review of the Order Listing Report did not include a PO for the use of restraints (wrist and ankle cuffs). A review of the ICCP did include a focus area for the use of restraints. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that [Resident #1] stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF. At that time, the DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated it was the COs and not facility staff using the restraints. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)(5)(6)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the use of physical restraints imposed for the purposes of discipline or convenience for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility, and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated that they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 being transported in a wheelchair to the elevator with three-armed COs, and the resident was being restrained with wrist and ankle cuffs. The facility's failure to ensure all residents, including the JIR, were free from abuse including the use of physical restraints posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, when Resident #1 was observed in the hallway with physical restraints. The facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience . A review of the facility's Abuse Prevention policy dated revised June 2024, included it is the policy of [facility] to not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse [ .] in compliance with State and Federal regulations .Involuntary seclusion: the separation of a resident from other residents or from his/her room, or confinement to his/her room against resident's will or against the will of the responsible party .Resident [NAME] of Rights: as a nursing home resident in the State of New Jersey, you have the following rights:[ .] Freedom from Abuse and Restraints: free from physical and mental abuse; freedom from chemical and physical restraints, unless they are authorized by a physician for a limited period of time to protect you or others from physical injury . A review of the facility provided Clinical Programs Manual Topic: Restraint Management dated effective October 2021, included restraints will be used only when necessary to treat medical symptoms and not used for staff convenience. The least restrictive restraint for the shortest duration of time will be applied to assist the resident in reaching their highest level of physical and psychosocial well-being .restraints include, but are not limited to the following: arm restraints [ .] leg restraints .Guidelines: 1. evaluate care plan to ensure that restraint alternative interventions have been tried prior to consideration of the restraint .4. obtain a physician's order for restraint [ .] 5. provide the Physical Restraint Information Sheet to the resident or responsible party [ .] 6. review and revise the following: the care plan . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was out of the room, and the LPN Supervisor #1 stated that [Resident #1] was a JIR who remained in their room alone with two-armed COs, unless to go to the rehabilitation (rehab) gym. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if [Resident #1] had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A further review reflected the resident had no mood or behavior issues. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. A review of the Psychiatric (Psych) Follow Up Note dated 7/17/24, included resident had a history of anxiety, depression, and insomnia. The resident reported I feel stressful and felt depressed and anxious at times. The resident reported sleep disturbance and eating was okay. A review of the Psychiatric (Psych) visit dated 7/24/24, included that the resident was seen today for a follow-up visit. The resident reported I am feeling a little better, less stressful, less anxious. The resident reported feeling depressed and anxious at times with disturbed sleep, and eating was okay. A review of the Order Listing Report included the following physician's orders (PO): A PO dated 8/12/24, that the resident cannot go out on pass or out of the facility unless escorted by COs and Emergency Medical Services (EMS). On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated that [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The DOR also stated that the use of hand and leg cuffs was the decision of the CF; that the facility could not order cuffs. On 8/29/24 at 12:20 PM, the surveyor interviewed the LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. The LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and the LPN #2 stated she was unsure if there was a set schedule, but that [Resident #1] had an appointment today. The LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. The surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:45 PM, the surveyor continued to review the medical record. A review of the Order Listing Report did not include a PO for the use of restraints (wrist and ankle cuffs). A review of the ICCP did include a focus area for the use of restraints. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that [Resident #1] stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF. At that time, the DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated it was the COs and not facility staff using the restraints. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)(5)(6)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that Justice Involved Residents (JIRs) were treated in a dignified and respectful manner by physically restraining, secluding the resident from participating in group activities, community dining, communicating with visitors, leaving the room at will, and retaining and using of personal possessions. This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they were not permitted to participate in group activities and community dining. Resident #1 stated they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. The facility's failure to ensure all residents, including JIRs, had the right to a dignified existence posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 1. prior to or upon admission, the social service designee [ .] will inform the resident and/or the resident's representative of the resident's rights and responsibilities .10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was out of the room, and LPN Supervisor #1 stated that Resident #1 was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that Resident #1 did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and Resident #1 always remained in the room alone with two armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 further stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed that the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; and that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking, and the DOR stated the resident was a paraplegic and rehab was working with them to walk. On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA stated that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated [Resident #1] requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed Resident #1's assigned CNA (CNA #1), who stated [Resident #1] provided their own care; that they were able to get out of bed and go to the bathroom by themselves, and the resident was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and LPN #2 stated she was unsure if there was a set schedule, but [Resident #1] had an appointment today. LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked Resident #1 if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. On that same date, the surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that [Resident #1] stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that [Resident #1] informed the facility that the CF had to approve all visits, and the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and that [Resident #1] could not be without them. The DON stated it was the CF's policies; that [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. A review of the Concerns with Correctional Officers policy dated 9/12/23, included that COs should be treated with dignity and respect by all staff . An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)12

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that Justice Involved Residents (JIRs) were treated in a dignified and respectful manner by physically restraining, secluding the resident from participating in group activities, community dining, communicating with visitors, leaving the room at will, and retaining and using of personal possessions. This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they were not permitted to participate in group activities and community dining. Resident #1 stated they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; and had no privacy which the resident reported feeling lonely and depressed being in a room twenty-four hours a day seven days a week with two CFs and a television. Resident #1 stated they wanted to return to the CF because of it. The facility's failure to ensure all residents, including JIRs, had the right to a dignified existence posed a likelihood to cause serious injury and psychological harm. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/29/24, and the facility Administration was notified of the IJ on 8/29/24 at 4:29 PM. The facility submitted an acceptable Removal Plan (RR) on 8/30/24 at 1:44 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 1. prior to or upon admission, the social service designee [ .] will inform the resident and/or the resident's representative of the resident's rights and responsibilities .10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated [Resident #1] had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was out of the room, and LPN Supervisor #1 stated that Resident #1 was a JIR who remained in their room unless to go to the rehabilitation (rehab) gym. The LPN Supervisor #1 stated that Resident #1 did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and Resident #1 always remained in the room alone with two armed COs. The LPN Supervisor #1 stated that the nurses and Certified Nursing Aides (CNAs) were permitted in the room to provide resident care. On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed Resident #1, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the CF; they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. Resident #1 stated they ate in their room on disposable ware and there were no activities. Resident #1 further stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO stated yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. 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 not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, revealed that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, indicated inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. A focus area dated 8/11/24, revealed that the resident had depression with regards to lifestyle changes. Interventions included to administer medications as ordered; monitor, document, and report as needed any signs and symptoms of depression; and monitor, record, and report to physician as needed the risk for harming others. On 8/29/24 at 11:01 AM, the surveyor interviewed the Director of Rehab (DOR), who stated Resident #1 participated in physical therapy (PT) three to five times a week in the rehab gym. The DOR stated that [Resident #1] was transferred to the rehab gym by two COs who always remained with them, and there were no other residents present. The DOR stated [Resident #1] did not require any ankle or wrist cuffs because they were paraplegic. The DOR stated that Resident #1 was working on ambulating (walk) and transferring; and that their goal was to walk in their room and use the bathroom independently. The DOR stated that [Resident #1] was currently transferring out of bed (oob) with supervision. The surveyor questioned the diagnosis of paraplegic if the resident was walking, and the DOR stated the resident was a paraplegic and rehab was working with them to walk. On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see [Resident #1] that often. The DA stated that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated [Resident #1] requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:15 PM, the surveyor interviewed Resident #1's assigned CNA (CNA #1), who stated [Resident #1] provided their own care; that they were able to get out of bed and go to the bathroom by themselves, and the resident was permitted out of their room to the shower room with the two COs, and the CNA provided the washcloth and towel. CNA #1 stated when [Resident #1] showered, it was just the resident in the room with the two COs. CNA #1 stated that [Resident #1] always ate all their meals in their room on disposable ware with the two COs in the room. On 8/29/24 at 12:20 PM, the surveyor interviewed LPN #1 in the presence of LPN #2, who stated that [Resident #1] received wound care for a small wound on their buttock that was more of a tunneling hole than a wound. LPN #1 stated the wound was the width of a cotton swab, and [Resident #1] saw a wound doctor outside the facility because they refused to see the facility's wound doctor. LPN #1 stated that there were always two-armed COs with [Resident #1], and the only time [Resident #1] left their room was for rehab and doctor's appointments. The surveyor asked how often the resident had wound doctor appointments, and LPN #2 stated she was unsure if there was a set schedule, but [Resident #1] had an appointment today. LPN #2 stated that the CF setup the transportation, and the COs accompanied [Resident #1] to and from the appointment. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and Resident #1 stated to see the wound doctor, that they did not want to see the doctor here. Resident #1 stated their appointment was at the hospital, and that their wound was improving. The surveyor asked Resident #1 if they ever received the playing card they requested, and Resident #1 stated no. The surveyor then observed Resident #1 with two COs (CO #2 and CO #3) and no residents or staff, use the elevator to go downstairs. At that time, the surveyor asked CO #1 why [Resident #1] needed to wear hand and ankle cuffs, since it was reported earlier that the resident did not need because they could not walk. CO #1 stated it was protocol when the JIR left the building. The surveyor asked how [Resident #1] was transferred to the hospital, and the CO stated on a medical bus from the CF. On that same date, the surveyor observed Resident #1 being escorted out of the building by four COs. On 8/29/24 at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA stated that [Resident #1] stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for [Resident #1] to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that [Resident #1] informed the facility that the CF had to approve all visits, and the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; and that [Resident #1] could not be without them. The DON stated it was the CF's policies; that [Resident #1] could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only [Resident #1] and the COs could be in the elevator during transportation, and [Resident #1] saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated [Resident #1] saw the facility's Psychiatrist as needed and could have seen the facility's wound doctor but refused. The DON stated that [Resident #1] received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that [Resident #1] had wrist and ankle cuffs as safety precaution that was a standard protocol by the CF, and the facility did not control that. The DON stated that the facility was in control of [Resident #1's] nursing care, and everything else was controlled by the CF. On 8/29/24 at 1:30 PM, the surveyor reviewed the facility's policies regarding JIRs which included the following: A review of the Inmate Resident Dining policy dated 8/21/23, included it is the policy of the [facility] to provide meals and snacks in a manner that supports establish security protocols. Procedure: 1. all inmates will receive their meals and snacks and dine in their room; 2. all inmate resident meals will be served on disposable paper goods; 3. all inmate resident meals will be served with plastic utensils; metal utensils are never permitted; 4. prior to delivery of meal tray to the inmate resident the CO in attendance will be offered the opportunity to check the tray .7. there is no food or drinks other than a water pitcher (when clinically approved) be stored at bedside . A review of the Inmate Phone Use policy dated 8/21/23, included 1. inmates are not routinely permitted to access telephones, not landlines or cell phones; 2. the landline will be removed from the inmate room prior to admission; 3. the staff is not to facilitate or participate in allowing inmates to use a telephone; 4. in rare circumstances when telephone use is permitted this will be entirely taken care of by the [CF staff], specifically the assigned COs; 5. at no time is [facility] staff to participate in inmate's phone use. A review of the Concerns with Correctional Officers policy dated 9/12/23, included that COs should be treated with dignity and respect by all staff . An acceptable Removal Plan (RP) on 8/30/24 at 1:44 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was returned to the CF on 8/29/24; the facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs; the LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR; and the LNHA was responsible for the implementation of all facility policies and regulations. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 8/30/24. NJAC 8:39-4.1(a)12

NJ Complaint #166562 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was on one-to-one (1:1) monitoring by staff was constantly monitored by staff to ensure the resident was free from neglect when they sustained bruising to both ears and a lower spine fracture from an unwitnessed fall. The deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #254), and was evidenced by the following: A review of the facility's One-to-One Observation policy and procedure, dated revised January 2024, included the aim of one-to-one nursing is to provide continuous observation for an individual patient for a period of time during acute physical or mental illness .Primary Physician/Nurse Practitioner shall be notified about the change in patient's condition and order will be obtained for continuous 1:1 observation until further evaluation. Resident/patient's care plan will be initiated and/or updated with resident centered interventions . On 6/17/24 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of investigations for reportable events to the New Jersey Department of Health (NJDOH) or any investigations that included injury of unknown origin or allegation of abuse and neglect for July and August 2023. The surveyor reviewed an investigation for the closed medical record for Resident #254. A review of the Incident Report dated 8/14/23 at 8:30 AM, revealed that the Assistant Director of Nursing (ADON) was called to Resident #254's room to assess the resident who had blue discoloration on both ears, a three centimeter by three centimeter (3 cm x 3 cm) abrasion to right knee; discoloration on right side of face and mid arm. When staff attempted to turn the resident over, the resident screamed in pain; the physician was made aware and a new order was put in place to send to the emergency room for evaluation. The report indicated no witnesses. Additional comments or steps taken to prevent recurrence included resident will be continuously monitored every shift on 1:1. A review of the statement dated 8/14/23, by the Registered Nurse (RN) included they were called to the resident's room and they observed the resident in bed with black and blue marks on right side of face. The resident was confused and unable to say what happened; upon further assessment noted multiple black and blue discoloration on both ears and right side of face. The resident complained of pain when an attempt to turn side to side was made, and the Supervisor was notified. A review of the Emergency Department Discharge Note dated 8/14/23, included the resident had an acute fracture to the transverse process of the lumbar 3 (L3) and lumbar 4 (L4) on left side (lower spine fracture) with no significant abnormalities. There was no additional reports from the hospital provided. A review of the individual comprehensive care plan (ICCP) included in the investigation, had a focus area dated effective 11/16/22, for behavior related to cognitive impairments; desire to manipulate; chronic mental illness; decline in medical condition; and mood state. Goal included to feel safe in my environment; resident to continue on 1:1 all shifts. A further review included a focus area dated effective 11/16/22, for falls due to medication use with an intervention that included to remain on 1:1 every shift. A review of an additional Incident Report included in the investigation packet dated 8/14/23 at 7:00 PM, prepared by the ADON included that they saw the resident on the ground floor, and the ADON asked the resident about their bruise, and the resident stated they fell . The resident did not know when they fell . A review of the Progress Notes included a Nursing Note (NN) dated 8/13/23 at 3:06 PM, that on arrival it was noted by the incoming 1:1 staff that the resident had an abrasion on their knee, because the resident was a poor historian, it was unknown how the abrasion got there. Resident alert and oriented to person, denied pain and on assessment no additional injuries noted except abrasion to right knee with no bleeding or discharge noted. This note indicated that the resident's abrasion was discovered on 8/13/23, and not on 8/14/23, as reported on the Incident Report dated 8/14/23 at 8:30 AM. On 6/19/24 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #254 was on a 1:1 monitoring and should have been monitored at all times so there should not have been an unwitnessed fall. The surveyor asked if staff was looked at for possible abuse, and the DON stated that usually the Certified Nursing Aide (CNA) was with the resident, and CNA #1 was looked at. The DON confirmed there were video cameras in the hallways, but could not speak to if the cameras were checked. At that time, the surveyor requested the resident's 1:1 monitoring logs for 8/13/23 and 8/14/23. On 6/19/24 at 12:00 PM, the surveyor interviewed the ADON who stated she could not recall if the resident's incident occurred on Sunday (8/13/23) or Monday (8/14/23), but when they were in the building on 8/14/23, they were asked to assess the resident. The surveyor continued to review the closed medical record for Resident #254. A review of the Resident Face Sheet (admission summary) reflected the resident was admitted to the facility with diagnoses which included schizoeffective disorder, bipolar, and slipping, tripping, and stumbling without fall due to stepping from one level to another. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 5/16/23, reflected the resident usually understood, with difficulty communicating some words or finishing thoughts, but was able if prompted or given time and sometimes understands by responding adequately to simple, direct communication only. The MDS further reflected the resident transferred between surfaces including to or from bed, chair, wheelchair, standing position with one person physical assist and used a wheelchair. On 6/20/24 at 8:59 AM, the surveyor re-interviewed the ADON who stated she thought Resident #254 was placed on a 1:1 monitoring in April of 2023, because they were combative and a fall risk. The ADON stated they were still looking for the resident's 1:1 monitoring log from August 2023, but stated CNA #1 was their aide on 8/14/23. The ADON stated CNA #1 no longer worked at the facility, and the surveyor requested their phone number. On 6/20/24 at 9:52 AM, the surveyor interviewed the DON who stated there was not necessarily a physician's order for 1:1 monitoring; that it was documented on the twenty-four hour nursing report and the shift-to-shift report; as well as the resident's care plan. The DON stated the physician was verbally made aware the resident was on 1:1 monitoring. There was no documentation in the medical record provided to confirm the physician was made aware or ordered 1:1 monitoring. On 6/20/24 at 10:12 AM, the surveyor asked the DON what the facility's process for investigating was, and the DON stated staff was interviewed and statements were obtained, resident was spoken to, and any additional witnesses. The facility investigated skin tears, injuries of unknown origin, fractures of unknown origin, complaints, verbal, physical, and sexual abuse. The DON stated they gathered statements from staff for 72 hours prior to incident of unknown origin, and the investigation was started immediately. After statements were gathered and the resident was assessed, the statements were reviewed to determined what occurred; if abuse was substantiated; and what interventions could be put into place to prevent the situation from occurring again. Review of the investigation provided by the facility dated 8/14/23, revealed that the skin abrasion discovered on 8/13/23, was not immediately investigated until further injury was discovered on 8/14/23. The investigation also did not include how the resident who was on 1:1 monitoring had an unwitnessed fall that resulted in bruising and a fractured spine. On 6/20/24 at 11:30 AM, the surveyor requested from the ADON again for CNA #1's phone number. On 6/20/24 at 12:17 PM, the surveyor observed CNA #2 and CNA #3 outside of two resident rooms. Both aides confirmed the residents in the rooms were on 1:1 monitoring; and they both confirmed that someone stayed with the resident at all times, and every hour another aide would come to switch with them. They both confirmed the resident was never left alone. On 6/20/24 at 1:24 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), and the DON. The surveyor informed them that they were still waiting for the resident's 1:1 monitoring sheets from August 2023, and they also requested additional information regarding why the Progress Notes documented the resident had a skin abrasion on their right knee on 8/13/24, but it was not investigated until 8/14/23, when the resident was observed with not only the skin abrasion, but two bruised ears. The surveyor also asked for additional information on how a resident who was on 1:1 monitoring had an unwitnessed fall that resulted in two bruised ears and a fractured back. At that time, the LNHA acknowledged that the investigation should have included how the resident who was on a 1:1 monitoring had an unwitnessed fall. On 6/25/24 at 1:28 PM, the surveyor requested from the LNHA and DON again the 1:1 monitoring sheets for Resident #254 for August 2023. On 6/26/24 at 9:45 AM, the surveyor reviewed the 1:1 monitoring logs for Resident #254 for 8/13/23 and 8/14/23. The log indicated that CNA #1 was monitoring the resident on 8/13/23 from 7:00 AM through 11:00 PM; CNA #4 and #5 monitored from 8/13/23 at 11:00 PM until 8/14/23 at 7:00 AM; and CNA #6 monitored the resident on 8/14/23 from 7:00 AM until 11 PM. A review of CNA #6's statement from 8/14/23, indicated that at around 8:00 AM on that day, they entered the resident's room to do morning care, and the resident was in bed laying on their back, and the aide noticed black and blue marks on both ears and they called the nurse. CNA #6's statement that they saw the resident at 8:00 AM for care contradicted the 1:1 assignment that indicated CNA #6 was with the resident from 7:00 AM until 11:00 PM on 8/14/23. A review of the 8/13/23 11:00 PM to 7:00 AM Certified Nursing Assistant Assignment Schedule reflected that CNA #4 and #5 both had resident assignments that night as well as an assignment of 1:1 with Resident #254. A review of CNA #4's statement dated 8/13/23, indicated that they took care of the resident on 8/13/23, during the 11:00 PM to 7:00 AM shift, and they did not observe any bruising and the resident did not complain of pain. There was no statement from CNA #5 who according to the 1:1 monitoring log took care of Resident #254 that night as well. On 6/26/24 at 10:36 AM, the survey team met with the LNHA, DON, and ADON to discuss their concerns. The ADON confirmed CNA #1, #4, and #6 no longer worked at the facility, and CNA #5 worked the overnight shift and was currently not in the building but there should have been a statement. The ADON continued that the incident either occurred on 8/13/23 or 8/14/23, but no one was certain, but she assessed the resident on 8/14/23. The ADON stated the resident's was unable to ambulate, but attempted to get out of bed or wheelchair. The ADON stated the resident was confused and unable to make their needs known, and the facility determined it was a fall because the resident later stated they fell . At that time, the DON acknowledged it should have been looked at how a resident on 1:1 had an unwitnessed fall since staff should be with the resident at all times. A review of the facility's undated Abuse Policy included each resident will be free from abuse.residents will be protected from abuse, neglect, and harm while they are residing at the facility .it is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated .the investigation is the process used to try to determine what happened . NJAC 4.1(a)(5)

Based on observation, interviews and record review, it was determined that the facility failed to stop a wound care treatment and provide pain relief after a resident continually complained of pain. This deficient practice occurred for Resident # 18, 1 of 21 residents reviewed for quality of care, and was evidenced by the following: 1. Resident #18 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The surveyor reviewed the medical record for Resident #18 on 2/5/14 at 10 a.m. The Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident reported pain "frequently" and rated it "8" on a severity scale of 1-10. Resident #18, according to the MDS, had multiple open areas on both feet that required daily treatments. Resident #18 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) at that time, indicating the resident was moderately impaired in cognition. A second MDS done on 11/18/13 revealed a "5" on the BIMS test; pain was rated by Resident #18 to still be "frequent" and at a "9" on the severity scale of 1-10. The bi-lateral open areas on the feet remained. The surveyor reviewed the January 2014 physician's orders [REDACTED]. was ordered to be administered to Resident #18 at 9 a.m. and 5 p.m. every day. Additionally, [MEDICATION NAME] 5/325 mg., one tablet every four hours, was ordered for moderate pain. On 2/6/14 at 10 a.m. the surveyor went to the room of Resident #18 to ask his/her permission to observe the Advanced Practice Nurse (APN) and the facility staff nurse perform the daily treatment to his/her foot wounds. The surveyor was given permission by Resident #18 to be present during the treatment. Outside the resident's room, the contracted APN stated she would take the dressings off and make recommendations for any treatment changes. She stated the facility nurse with her would write down the measurements of each open area and then re-dress the bilateral foot wounds when she was done. At 10:05 a.m. on 2/6/14 the surveyor entered Resident #18's room with the APN and nurse. Resident #18 was alert, lying in a bed that was very low to the floor. At 10:10 a.m. the surveyor observed the APN use scissors to cut off the dressings on Resident #18's right foot. The resident grimaced and spoke "ouch" as the foot was lifted. The APN said, "I'm sorry" and continued. At 10:15 a.m. the surveyor observed the APN lift Resident #18's right foot and use a paper ruler to measure the wounds. The resident grimaced and said "ouch." The APN told the resident "I'm sorry." At 10:18 a.m. the surveyor observed the APN cut the bandages off Resident #18's other foot (the left). During the process of lifting and measuring the left foot, again Resident #18 grimaced and said "ouch." During the process, the resident would appear to fall asleep except for becoming alert to voice pain repeatedly. At 10:20 a.m., fifteen minutes after the start of the procedure, the facility nurse asked Resident #18 "Do you want something for pain?" The resident said yes. The treatment procedure stopped at this time. At 10:23 a.m. the surveyor observed a nurse come in and give the resident one [MEDICATION NAME], 325 mg. The surveyor was told by the nurse that the standing order for [MEDICATION NAME] CR, 20 mg. was administered around 8 a.m. At 10:24 a.m. the surveyor observed the APN ask Resident #18 "Can I continue now?" The resident said "Do what ya gotta do." The surveyor observed the APN continue to lift the resident's left foot and he/she again grimaced and voiced "ouch." The APN responded "I'm sorry, I'm almost done." At 10:45 a.m. the surveyor observed the staff nurse start the treatment. When the nurse touched Resident #18's right foot, he/she grimaced and said "ouch." The nurse responded "I'm sorry." The nurse lifted the resident's right foot and applied the gauze and rolled a bandage and the resident grimaced and said "ouch." The nurse told the resident "I'm sorry." At 10:55 the surveyor observed the nurse lifted Resident #18's left foot he/she said "ouch" and the nurse continued to roll a gauze bandage. While doing so, a piece of soiled bandage, left on the blue plastic pad under Resident #18's left foot, got caught in the clean bandage. The nurse took off what bandage had been applied and stated she would have to start over. While lifting Resident #18's foot to remove the bandages, the resident again said "ouch." At 11 a.m. the surveyor observed the nurse start the dressing to Resident 18's left foot. When the foot was lifted the resident reached for the foot, grimaced and said "ouch." The nurse said to Resident #18 "I'm sorry." Resident #18 said loudly "You and this 'sorry' sh-- is getting on my nerves." The surveyor asked the nurse to stop the treatment at this time, 55 minutes after it began. (REFER to F441) NJAC 8:39-27.1(a)