Every finding on record at Canterbury at Cedar Grove

Based on observation, interviews, and review of facility policies, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. This deficient practice was observed and evidenced by the following:On 12/17/25 at 9:30 AM, the surveyor in the presence of the toured the Food Service Director (FSD) toured the kitchen and dumpster area and found the following:There was garbage debris that included shower chairs, hospital bed frames, a dresser, wooden pallets and cardboard boxes all observed on the outside of dumpster. The FSD stated the maintenance department should have cleaned the dumpster area.On 12/18/25 at 11:35 AM, the Director of Operations (DO) provided the surveyor with a facility policy titled, Dumpster/Garbage Area with a revision date of 9/2025. The procedure section of the policy revealed, 3. All waste storage areas and containers must be maintained in a clean and sanitary condition to prevent fire, health, or safety hazards and avoid attracting pests.On 12/22/25 at 1:16 PM, the surveyor met with the DO, Director of Nursing (DON), Licensed Nursing Home Administer (LNHA), Administrator in Training (AIT), and Regional Registered Nurse (RRN) to review concerns found during the survey. The DO stated the garbage area concerns will immediately be addressed.On 12/23/25 at 11:15 AM the surveyor met with DO, DON, LNHA, AIT and RRN for the exit conference; no further pertinent information was provided.NJAC 8:39-19.7

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 2 of 3 units during initial tour.The deficient practice was evidenced by the following: On 12/17/25 at 10:42 AM, the surveyor toured the 2nd floor nursing unit and observed the following rooms: 1. room [ROOM NUMBER], there was a hole in the wall, and the walls were stained a brownish color, and the two privacy curtains stained. 2. room [ROOM NUMBER] observed damaged flooring tile and a damaged bathroom door. 3. In the hallway leading to the low-side rooms (rooms 200-216), the water fountain had been removed, and the wall was discolored and in need of repair. On 12/19/25 at 12:25 PM, two surveyors and the Maintenance Director toured the 2nd- and 3rd-floor nursing units and observed the following. 4. room [ROOM NUMBER] had a hole in the wall. 5. room [ROOM NUMBER]'s closet was in need of repair; the top part of the AC/Heater was missing. 6. room [ROOM NUMBER] and a hole in the wall, the closet needed repair, and the paneling on the sink was peeling. 7. room [ROOM NUMBER]'s two privacy curtains were stained with a brownish substance as well as the above-mentioned concerns 8. room [ROOM NUMBER]'s bathroom ceiling tile was stained, the toilet seat was discolored, the bathtub was stained and discolored, as well as the above-mentioned concerns. 9. room [ROOM NUMBER]'s wall was damaged behind the bed, and the wallpaper was peeling. 10. room [ROOM NUMBER]'s floor molding was peeling and in need of repair. 11. room [ROOM NUMBER]'s toilet seat was soiled and discolored, the bathroom ceiling tiles were stained, and the bathtub was stained, discolored and heavily soiled. On 12/18/25 at 11:27 AM, the surveyor interviewed the Director of Operations (DO), who stated the facility had received approval for interior renovations in November 2025 for all nursing units and the lobby. The DO provided the surveyor with the renovation schedule and a paid invoice for new bed headboards, dressers, and overbed tables. On 12/19/25 at 12:15 PM, the surveyor showed the above housekeeping concerns to the Director of Housekeeping (DHK). The DHK acknowledged the above housekeeping concerns and confirmed that this did not provide the residents with a clean, homelike environment. On 12/22/25 at 2:09 PM, the survey team met with the Licensed Nursing Home Administrator(LNHA), Director of Nursing (DON), and regional administration to discuss the above observations and concerns. A review of the facility's policy, Clean/Homelike Environment dated as reviewed 9/2025, reflected that residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on observation, interview, and record review, it was determined that the facility failed to have readily accessible physician progress notes (PPN). This deficient practice was identified for 14 of 14 residents reviewed, (Resident #3, #17, #45, #55, #74, #83, #85, #105, #116 #122, #128, 132#, #135, and #137) and was evidenced by the following: 1. On 12/19/25 at 11:01 AM, the surveyor observed Resident #3 in the 2nd floor dayroom watching television. The resident stated, they do not recall seeing their primary physician (PP#1).A review of Resident #3 Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to altered mental status (a change in mental function), pneumonia (an infection in the lungs), anemia (a blood disorder that happens when you don't have enough red blood cells).On 12/19/25 at 11:30 AM, the surveyor reviewed the Hybrid Medical Record (HMR), (combination of the physical and electronic chart) which did not reflect any PPN (process that involved assessing a patient's current vital signs, laboratory values, changes in condition, medical history and recommending care). A review of the quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 11/26/25, revealed that the resident had a score of 8 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. 2. On 12/19/25 at 11:03 AM, the surveyor observed Resident #85 in the 2nd floor dayroom watching television. The resident stated, they do not recall seeing their PP#1 recently.A review of Resident #85 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to dementia (decline in cognitive function) and hyperlipidemia (an excess of lipids or fats in your blood).On 12/19/25 at 11:31 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the annual MDS, with an ARD of 9/24/25, revealed that the resident had a score of 5 out of 15 on the BIMS, which indicated severe cognitive impairment. 3. On 12/19/25 at 11:05 AM, the surveyor observed Resident #105 in the 2nd floor dayroom watching television. The resident stated, they do not recall seeing their PP#1 recently.A review of Resident #105 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to hyperlipidemia, thyroid disorder (conditions that affect thyroid functions), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).On 12/19/25 at 11:33 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the quarterly MDS, with an ARD of 9/23/25, revealed that the resident had a score of 5 out of 15 on the BIMS, which indicated severe cognitive impairment. 4. On 12/19/25 at 11:10 AM, the surveyor observed Resident #128 in their room, in bed with their eyes closed.A review of Resident #128 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to anxiety (mental health conditions that cause fear, dread and other symptoms), hypertension (high blood pressure) and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs).On 12/19/25 at 11:31 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the annual MDS, with an ARD of 9/24/25, revealed that the resident had a score of 5 out of 15 on the BIMS, which indicated severe cognitive impairment. 5. On 12/19/25 at 11:12 AM, the surveyor observed Resident #136 in the activities room. The resident stated they do not recall the last time they saw the PP#1.A review of Resident #136 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to bipolar disease (a mental health condition that causes extreme mood swings), depression, and muscle weakness (muscle injury or fatigue).On 12/19/25 at 11:33 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the quarterly MDS, with an ARD of 10/31/25, revealed that the resident had a score of 6 out of 15 on the BIMS, which indicated severe cognitive impairment. 6. On 12/19/25 at 11:15 AM, the surveyor observed Resident #83 in their room, in bed with their eyes closed.A review of Resident #83 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to sepsis (a life-threatening organ dysfunction caused by a dysregulated host response to an infection), type 2 diabetes mellitus (a condition when the body cannot use insulin correctly and sugar builds up in the blood), and dementia .On 12/19/25 at 11:36 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the quarterly MDS, with an ARD of 10/13/25, revealed that the resident had a score of 3 out of 15 on the BIMS, which indicated severe cognitive impairment. 7. On 12/19/25 at 11:17 AM, the surveyor observed Resident #132 in the 4th floor dayroom. Resident #132 was unable to be interviewed by the surveyor due to confusionA review of Resident #132 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to anxiety, cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), and dementia.On 12/19/25 at 11:37 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the quarterly MDS, with an ARD of 9/22/25, revealed that the resident had a score of 6 out of 15 on the BIMS, which indicated severe cognitive impairment. 8. On 12/19/25 at 11:19 AM, the surveyor observed Resident #137 in the 4th floor dayroom. Resident #137 stated they do not remember if the PP#1 assessed them this month.A review of Resident #137 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to hypertension and depression.On 12/19/25 at 11:38 AM, the surveyor reviewed the HMR, which did not reflect any PPN. A review of the quarterly MDS, with an ARD of 9/10/25, revealed that the resident had a score of 6 out of 15 on the BIMS, which indicated severe cognitive impairment. 9. On 12/19/25 at 11:20 AM, the surveyor observed Resident #132 in the 4th floor dayroom. Resident #132 stated they saw the PP#1 earlier this month.A review of Resident #132 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to Parkinson's disease (movement disorder of the nervous system), anxiety and bipolar disorder.On 12/19/25 at 11:38 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the quarterly MDS, with an ARD of 9/8/25, revealed that the resident had a score of 14 out of 15 on the BIMS, which indicated intact cognition. 10. On 12/19/25 at 11:22 AM, the surveyor observed Resident #17 in their room watching television. Resident #17 stated they saw the PP#1 earlier this month.A review of Resident #17 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to cerebral palsy (a brain disorder affecting body movement and muscle coordination), multiple sclerosis (s an autoimmune condition that affects your brain and spinal cord (central nervous system), and type 2 diabetes mellitus.On 12/19/25 at 11:39 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the annual MDS, with an ARD of 10/12/25, revealed that the resident had a score of 14 out of 15 on the BIMS, which indicated intact cognition. 11. On 12/19/25 at 11:24 AM, the surveyor observed Resident #45 in their room watching television. Resident #45 stated they are not sure when they saw PP#1 last.A review of Resident #45 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to cerebral infarction, type 2 diabetes mellitus, muscle weakness.On 12/19/25 at 11:40 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the annual MDS, with an ARD of 11/11/25, revealed that the resident had a score of 5 out of 15 on the BIMS, which indicated severe cognitive impairment. 12. On 12/19/25 at 11:26 AM, the surveyor observed Resident #55 in their room watching television. Resident #55 unable to state when last seen by to PP#1 due to cognitive impairment.A review of Resident #55 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to cerebral infarction, dementia, and aphasia (a condition that inhibits the ability to speak).On 12/19/25 at 11:41 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the quarterly MDS, with an ARD of 11/25/25, revealed that the resident had a score of 0 out of 15 on the BIMS, which indicated severe cognitive impairment.13. On 12/19/25 at 11:28 AM, the surveyor observed Resident #74 in the 3rd floor dayroom watching television. Resident #74 unable to recall when last seen by PP#1.A review of Resident #74 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to schizophrenia (mental health condition that affects how people think, feel and behave) and hypertension.On 12/19/25 at 11:42 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the quarterly MDS, with an ARD of 10/21/25, revealed that the resident had a score of 13 out of 15 on the BIMS, which indicated cognition intact. 14. On 12/19/25 at 11:28 AM, the surveyor observed Resident #116 in their room in bed, with their eyes closed.A review of Resident #116 Face sheet FS was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease, anemia, and hypertension.On 12/19/25 at 11:43 AM, the surveyor reviewed the HMR, which, did not reflect any PPN. A review of the quarterly MDS, with an ARD of 10/20/25, revealed that the resident was unable to complete a BIMS due to cognitive impairment. On 12/19/25 at 11:46 AM, the surveyor interviewed [NAME] 2nd floor unit manager (LPN#1), who stated the PP#1 completes their notes in their own charting system, and the facility staff does not have access to those notes. LPN further revealed the PP#1 is supposed to send the progress notes so they can be uploaded into the into the electronic chart or printed into the physical chart.12/19/25 at 12:43 PM, the surveyor conducted a phone interview with PP#1 who stated they write their progress notes in their own system and the facility staff does not have access to their system. PP#1 acknowledged they are behind on uploading resident notes and that it is not best practice.12/19/25 12:50 PM, the surveyor interview with Director of Nursing (DON) and Director of Operations (DO), who stated PP#1 should be uploading notes in a timely fashion within 48 hours.On 12/19/25 at 1:05 PM, the DON provided the surveyor with a facility policy titled, Physician Documentation, with a reviewed date of 10/2025. The procedures section of the policy revealed, B. Progress notes.1. A progress note must be entered into the clinical record for each visit, fully disclosing the kind and extent of services provided and the medical necessity for those services.On 12/22/25 at 1:16 PM, the surveyor met with the DO, DON, Licensed Nursing Home Administer (LNHA), Administrator in Training (AIT), and Regional Registered Nurse (RRN) to review concerns found during the survey. The DO stated all PPN will be audited.On 12/23/25 at 11:15 AM the surveyor met with DO, DON, LNHA, AIT and RRN for the exit conference; no further pertinent information was provided. NJAC 8:39-35.2 (d)(5)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident receiving enteral feedings received appropriate care and services to prevent complications of enteral feedings, specifically by having the enteral feeding pump running with the resident in a supine position (head of bed flat) not elevated to prevent aspiration ((accidentally inhaling food or liquid through the vocal cords into the lungs). This deficient practice was identified for 1 of 2 residents (Resident #9) reviewed for tube feeding and was evidenced by the following:On 12/18/25 at 10:35 AM, the surveyor knocked at the door and, with the Certified Nursing Assistant's (CNA's) permission, entered the room. The surveyor observed the CNA providing care to Resident #9, who was in bed, lying flat with an enteral feeding tube pump (FT; a tube surgically inserted into the stomach to provide food and nutrients), administering Glucerna1.5 (nutritional formula) at a rate of 80 milliliters (mL) per hour. The surveyor reviewed the medical record for Resident #9. A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; acute respiratory failure with hypoxia (a severe medical condition where the lungs can't get enough oxygen into the blood), tracheostomy tube (a device inserted into a surgically created opening in the neck into the windpipe to help with breathing) and a gastrostomy tube (FT). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/4/25, indicated that the resident's cognitive skills for daily decision-making were severely impaired. A further review of Section K for Nutritional Status reflected that the resident received 51% or more of their nutrition through an enteral feeding tube. A review of the Physician Order Summary Report dated as of 12/22/25, included the following physician's orders (PO): A PO dated 8/18/25, to provide 300ml of free water flushes four times a day for a total of 1200 ml from water flushes. A PO dated 3/20/25, for Enteral feeding, Glucerna 1.5 @ 80 mL per hour; up at 4:00 PM, infused until total volume (TV) reaches 1300 mL, providing 1950 kcal per day. A PO dated 8/18/25, to keep the head of the bed elevated at least 30-45 degrees when enteral feeding is running and 1-2 hours after the total volume is delivered, unless contraindicated. A PO dated 1/24/25 to keep the head of the bed elevated greater than 30 degrees every shift for aspiration precautions. A review of the comprehensive care plan included a focus area in which the resident received tube feedings related to dysphagia (difficulty swallowing). The goal of the care plan reflected that the resident was to remain free of side effects or complications related to tube feeding. The interventions included but were not limited to:; elevate the head of the bed 45 degrees during and for thirty minutes after tube feed. On 12/18/25 at 10:43 AM, during an interview with the surveyor, the CNA acknowledged that she should have notified the nurse before she put the resident flat in bed so that the nurse could stop the feeding to prevent the resident from aspirating. On 12/18/25 at 10:55 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) assigned to Resident #9's care, confirmed that the CNA should have informed her before she provided care so that the LPN could have stopped the feeding, as the resident was at risk for aspiration if the feeding was going while the resident was lying flat. The LPN further stated that the resident's head should always be elevated during the feeding. On 12/22/25 at 2:09 PM, the survey team met with the Licensed Nursing Home Administrator(LNHA), Director of Nursing (DON), and regional administration to discuss the above observations and concerns. The DON confirmed that the Resident's head of bed should have been elevated to 30-45 degrees while the TF was being administered to prevent aspiration. The DON further stated that the CNA should have notified the LPN before lowering the head of the bed so the nurse could have stopped the feeding. A review of the CNA competency: Care of the resident with a feeding tube reflected that the CNA was responsible for ensuring that the resident's head of bed is elevated at 30-45 degrees when the enteral feeding is being administered.Notifies the nurse before providing care so the nurse can stop the feeding before the care is performed. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of facility policy, it was determined that the facility failed to a.) follow a Physician's Order (PO) for an Oxygen (O2) dependent resident in accordance with professional standards of practice and b.) store nebulizer tubing in a clean and sanitary manner for 2 of 4 residents, (Resident #9 and #97), reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 12/17/25 at 11:22 AM, the surveyor observed Resident #97 in bed with their eyes closed. Resident #97 was observed receiving O2 via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 3.5 liters/minute (LPM). On 12/17/25 at 11:45 AM, the surveyor reviewed Resident #97's electronic medical record (e-MAR) which revealed the following: The surveyor reviewed the admission Record (an admission summary) which revealed that the resident had been admitted to the facility with diagnosis that included hypertension (high blood pressure, means the force of blood pushing against your artery walls is too high), heart failure (an impairment in the heart's ability to fill with and pump blood) and cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted). A review of the quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 10/28/25, revealed that the resident had a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS also reflected that the resident received continuous O2 therapy. A review of the December 2025 PO for Resident #97's included a PO dated 12/3/25, O2 Inhalation at 2 LPM via nasal cannula as every shift for Shortness of Breath, Maintain Peripheral Oxygen Saturation (SpO2) at or greater than 92% with O2 inhalation. On 12/18/25 at 10:14 AM, in the presence of the Licensed Practical Nurse (LPN #1), the surveyor observed Resident #97's O2 machine set at 3.5 LPM. LPN#1 stated Resident #97 is on continuous O2 and the PO is for 2 L/min, unable to state why the O2 was set at 3.5 LPM. On 12/18/25 at 11:35 AM, the Director of Operations (DO) provided the surveyor with a facility policy titled, Oxygen Administration, with a revised date of 10/2025. The procedure section of the policy revealed, 1. Upon receiving an order for oxygen from the resident's physician the nurse will place the order in point click care (pcc) to be carried out. On 12/22/25 at 1:16 PM, the surveyor met with the DO, Director of Nursing (DON), Licensed Nursing Home Administer (LNHA), Administrator in Training (AIT), and Regional Registered Nurse (RRN) to review concerns found during the survey. The DON stated all residents on oxygen will be reviewed and concerns will immediately be addressed. On 12/23/25 at 11:15 AM the surveyor met with DO, DON, LNHA, AIT and RRN for the exit conference; no further pertinent information was provided. 2. On 12/18/25 at 10:35 AM, the surveyor observed Resident #9 in bed. The resident did not respond to the surveyor. Resident #9 was observed receiving O2 via a tracheostomy tube (a device inserted into a surgically created opening in the neck into the windpipe to help with breathing), delivered at 5 LPM and 28% via an EasyAir machine (a portable air compressor that supplies compressed air 24 hours a day). The surveyor observed a nebulizer machine (a medical device that turns liquid medicine into a fine mist, allowing it to be inhaled directly into the lungs) on the resident's bedside table with the nebulizer tubing on the floor. The surveyor reviewed the medical record for Resident #9. A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; acute respiratory failure with hypoxia (a severe medical condition where the lungs can't get enough oxygen into the blood), tracheostomy tube and a gastrostomy tube (a feeding tube placed through the abdomen directly into the stomach to deliver nutrition). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/4/25, indicated that the resident's cognitive skills for daily decision-making were severely impaired. A further review of Section O indicated Resident #9 received special respiratory treatments, which included oxygen therapy and tracheostomy care. A review of the Physician Order Summary Report dated as of 12/22/25, included the following physician's orders (PO): A PO dated 6/20/25 for Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) 3 ml via trach four times a day for increased secretions (to be given with 10 ml mucomyst 20%). A PO dated 1/23/25 for Pulmicort Suspension 0.5 mg/2 ml 1 unit via trach every 12 hours for shortness of breath/wheeze. A PO dated 9/23/25 for humidified oxygen at 5 lpm, 28% via trach every shift for humidification. A review of the comprehensive care plan included a focus area that the resident had a tracheostomy size six cuffed with O2 settings @ 5 lpm with Fi02 28% via trach r/t impaired breathing mechanics, and a traumatic brain injury. The goal of the care plan was for the resident to have clear, equal breath sounds bilaterally. The interventions included but were not limited to: give humidified oxygen as prescribed. On 12/18/25 at 10:55 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) assigned to Resident #9's care confirmed that the nebulizer tubing should be stored in a plastic bag for infection control prevention. At that same time, the LPN removed the nebulizer tubing from the floor and discarded it. On 12/22/25 at 2:09 PM, the survey team met with the Licensed Nursing Home Administrator(LNHA), Director of Nursing (DON), and regional administration to discuss the above observations and concerns. The DON confirmed that the nebulizer tubing should have been stored in a plastic bag to prevent the transmission of infection. A review of the facility's policy Oxygen Tubing and Respiratory Products revised 10/2025 included .It is the policy and procedure of this facility that all oxygen tubing is single-use for a single resident, clean, properly stored, and dated to prevent the transmission of infection .All nebulizer tubing shall be dated, stored in a bag when not in use, and replaced every 7 days . NJAC 8:39-27.1(a)

Complaint Intake ID #: 2585781Based on interview, record review, and review of facility documents on 11/12/25 and 11/13/25, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman immediately or within two hours of the identification of an injury of unknown origin in accordance with Federal and State laws and the facility's Abuse policy. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse. This deficient practice was evidenced by the following:On 11/12/25 at 10:50 AM, the surveyor reviewed the closed Electronic Medical Record (EMR) of Resident #1. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and difficulty in walking, not elsewhere classified. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 7/10/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident was severely, cognitively impaired. Further review of the MDS revealed that the resident received hospice services. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, initiated on 7/29/25, with a revision date of 8/8/25, included: Resident #1 is at risk for skin alteration r/t (related to) their own restlessness, impulsiveness and agitation. Resident #1 has a skin tear and abrasion to the forehead on 7/29/25. Laceration to left lower limb 8/7/25. Interventions included: Hospice HHA (Home Health Aide) was DNR (do not return) pending investigation (initiated 7/31/25). Send to hospital for evaluation/tx (treatment) (initiated 8/7/25). Wrap bilateral lower extremities with cling wrap daily and monitor (initiated 8/7/25). A review of the Order Summary Report (OSR), dated as of 8/6/24, included the following physician's order (PO):A review of a PO, dated 7/30/24, revealed Ace Wrap to bilateral lower extremities every morning and at bedtime for edema (swelling). Put on in the morning and remove at night.A review of the August 2025 Medication Administration Report (MAR) revealed a PO with a start date of 7/30/24 at 11:00 PM, and a D/C (discontinue) date of 8/7/25 at 2:47 PM, for ace wrap to bilateral extremities every day and night shift for edema on in am and off at hs (hours of sleep). The entry was signed out as administered on 8/6/25 on both the day and night shifts. A review of the Progress Notes (PN) included a Health Status Note (HSN) dated 8/7/25 at 8:06 AM, revealed, Hospice Care: Resident was received in bed asleep in a supine position and responsive with no distress noted. At about 2 AM, during routine rounds, resident was observed lying in bed grimacing and moaning softly. Respirations shallow at 22/min (per minute), pulse 85 bpm (beats per minute), BP (blood pressure) 126/81 mm/hg (millimeters of mercury), O2 sat 97% on room air. Administered Lorazepam (antianxiety medication) 0.25 ml (milliliters) sublingual (administered under the tongue) for anxiety and restlessness. Administered Oxycodone (an opioid pain medication) 0.25 ml oral solution for pain/comfort, safety/fall precautions maintained, bed to the lowest. A further review of the PN included a HSN dated 8/7/25 at 4:51 PM, revealed, During morning rounds this nurse noticed resident with a laceration to their left inner lower leg. The 11-7 nurse was notified and came to assess resident. When assessed, resident linear (straight line) laceration measures 6.5 x 1 and 1 cm (centimeter) deep. DON (Director of Nursing), Hospice, MD (Medical Doctor), and family made aware. New order for Mupirocin (antibiotic ointment) BID (twice a day) to L (left) inner lower leg. Open area was cleaned and followed by MD order and was covered with a clean dry dressing. Wrap b/l lower legs. Further review of the PN revealed a HSN dated 8/7/25 at 7:23 PM, Patient transferred out to hospital [name redacted] due to laceration on left leg. Patient left facility @ 4:23 PM via.transport. A further review of the PN included a HSN dated 8/8/25 at 8:19 AM, revealed, At 6 AM, resident returned from .hospital via stretcher awake and responsive with no respiratory distress noted. Resident had a laceration to left tibia (shin bone) closed with 7 (seven) sutures. Sutures appear intact, wound edges well-approximated. Minimal serosanguinous (clear with red tinge) drainage noted on dressing. Surrounding skin slightly erythematous (reddened), no swelling or purulent discharge observed.Resident was placed on a one to one (observation), bed to lowest position. MD and family [name redacted] made aware that resident is back to the facility. Resident will continue to be assisted with needs and monitored for falls.On 11/13/25 at 11:54 AM, the surveyor reviewed a Reportable Event Record/Report (RER/R) which indicated that a Significant Event was called into the NJDOH on 8/28/25 at 5:55 PM, for a Significant Event that occurred on 8/7/25 a 7:00 AM, 21 days later. Further review of the RER/R revealed that on 8/7/25 during morning rounds the resident was found to have a laceration to the inner, left lower leg measuring 6.5 cm x 1 cm x 0.25 cm.Further review of the RER/R revealed that an .Incident Investigation Summary included: During the investigation, a check of the environment immediately revealed the resident's newly acquired wheelchair footrests were visibly blood-stained. The blood was particularly noticeable on the attaching apparatus, the padding, and the overall structure of the footrests. The DON conducted interviews with staff assigned to the resident between the time they received the new wheelchair to the time injury noted. Staff reports the resident who typically spends most of their day in the day room for meals, activities, and close monitoring, acquired a new wheelchair from hospice yesterday. Unlike their previous wheelchair, this one had leg rests. It was determined that a laceration on their inner left leg occurred when the resident habitually stood up and stepped away from the table, contacting a bolt on the footrest. This is supported by dried blood found on the footrest, including the bolt, pads, and structure, as well as stains on the lower plates, and of their pant legs and socks. A review of the Timeline of Events included:-8/6/25 7-3-Hospice aide gave a shower, and the resident was in the dayroom where they ate lunch and dinner.-8/6/25 3-11-CNA (Certified Nurses Aide) put resident in bed around 6:30 pm. -8/6/25 11-7-CNA check and change done.-8/7/25 7-3-Laceration noted to resident's left inner LE (lower extremity)A review of an Investigation of Incident Statement dated 8/27/25, revealed that CNA #1 worked as a care partner on 8/6/25 during the 3-11 PM shift. The statement included that it was written by the DON and was copied from a text message sent by CNA #1. A review of the entry included: When providing care for patient after dinner another CNA assisted me putting the patient into bed. Patient was not wet or soiled, patient was wearing a diaper. Patient had their pants on. I took their shoes off. During my shift I checked on patient multiple times, each time I found pt. in bed. At the end of my shift, I left pt. in bed dry and without injury. On 11/12/25 at 1:21 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she noted a laceration on the resident's left lower leg during morning rounds and when the resident moved their legs up and down I saw that the resident had a long cut with black, dried blood on the left lower leg. LPN #1 stated that it must have happened during the night or when transferred, and it was not endorsed to the night shift nurse. LPN #1 further stated that the resident had pants on. On 11/12/25 at 1:30 PM, the surveyor interviewed CNA #2 who worked full-time at the facility for 20 years and had reportedly cared for the resident during the day shift. CNA #2 stated that she never saw any cuts on the resident's skin, and if she did she would report any skin issues to the nurse. On 11/12/25 at 1:49 PM, the surveyor interviewed LPN #2 who stated that she worked on the 3-11 shift on the day that the laceration occurred, and she did not see anything on the resident's leg. LPN #2 stated that CNA #1 put the resident to bed and did not report anything to me. LPN #2 further stated that CNA #1 did not work here anymore. On 11/12/25 at 2:20 PM, the surveyor interviewed the DON and asked the DON if the ace wraps were donned (put on) and doffed (removed) as indicated on the MAR on 8/6/25 during both the day night shifts, why had staff not noticed the laceration on the resident's left lower extremity timely. The DON stated that if the ace wraps were on, the cut was at the level of the resident's ankle. The DON further stated, I do not think that they did it (donned and doffed the ace wrap) even though they signed it out as completed. At that time, the DON stated that there was no written statement from CNA #1 because she was very upset and angry when approached via telephone about the resident's injury and she did not give me a chance to obtain a written statement. The DON stated CNA #1, called me a fat piece of shit, and then she showed up here and had to be escorted out of the building because she was beyond reproach. The DON stated that it was CNA #1's personality problem, and she was terminated. At that time, the DON stated, unfortunately, the resident cut their leg, and no one noticed. The DON further stated that any injury of unknown injury should be called in to the NJDOH and Ombudsman's Office right away especially if the resident was not able to tell you what happened. The DON stated that we did not call the laceration in because it only took one to two hours to determine that the injury occurred on the wheelchair. The DON stated that we reported it after surveyor inquiry during an onsite complaint investigation from the NJDOH in August 2025, because there was a little gray area of what happened. The DON further stated, Now I know that I should have just reported it immediately in hindsight. On 11/13/25 at 10:31 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that when an injury of unknown injury occurred we first need to rule out abuse. The LNHA stated that he was required to call the injury of unknown injury in immediately or within two hours, and then the electronic submission must be sent within twenty-four hours and followed up with a summary and conclusion submission within five days. The LNHA stated that the importance of reporting was because it was a required regulation, so that the NJDOH knows about it. At that time, the LNHA stated that the reason why the resident's laceration was not called in was because there was blood found on the bolt of the resident's wheelchair footrest and a piece of the resident's flesh was also on the equipment, and it was clear cut what had happened. The LNHA stated that he was aware of CNA #1's reaction when she was questioned about the incident, and he believed that CNA #1 felt accused when we requested a statement.A review of the facility's Abuse, Neglect and Mistreatment of Residents policy, reviewed 9/2025, included:.The Administrator and Director of Nursing will be made aware of all such incidents occurring in Facility and will review completed reports. If any accident is of a serious nature, medically or suspected abuse, neglect, telephone within 2 (two) hours regardless of the time of day. The Administrator/designee will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstance of the incident.The Administrator/Designee will notify the Department of Health within two (2) hours.NJAC 8:39-9.4 (e) 4

Complaint #: NJ186030 Based on interviews, review of medical records, and review of pertinent documents, it was determined that the facility failed to a.) conduct a thorough investigation and b.) follow the facility policy Incident/Accident Investigating and Reporting Policy and Procedure, after a resident fell on facility premises on 05/02/2025. This deficient practice was identified for one of three residents (Resident 2) reviewed for accidents and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to chronic diastolic (congestive) heart failure, generalized anxiety disorder, other recurrent depressive disorders, other chronic pain, opioid dependence with other opioid-induced disorder, muscle weakness (generalized), and need for assistance with personal care. Review of Resident #2's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that Resident #2 had a Brief Interview for Mental Status score of 15 out of 15 which indicated that the resident's cognition was intact. The MDS revealed that Resident #2 used a manual wheelchair for mobility. The MDS revealed that Resident #2 required the assistance of a helper prior to or following standing from sitting in a chair, wheelchair, or on the side of the bed. The MDS further revealed that Resident #2 had not had any falls since the prior assessment. Review of a Police Department Incident Report dated 05/02/25, written by Police Officer (PO) #1 was conducted. The report revealed that PO #1 contacted Resident #2 after she/he fell and was injured at another location. PO #1 and police headquarters made several unsuccessful attempts to reach facility staff regarding Resident #2. PO #1 then went to the facility with Resident #2 and went inside to speak with staff including the facility's Director of Nursing (DON). The report revealed that while PO #1 was speaking to facility staff inside, another staff member informed them that Resident #2, had fallen out of [her/his] wheelchair again while right outside of the Canterbury front entrance. The report further revealed that Resident #2 was then transported to the hospital by ambulance. A telephone interview was conducted with PO #1 on 05/21/2025 at 6:18 P.M. PO #1 stated that on 05/02/2025 after returning to the facility with Resident #2, he went inside to speak with facility staff while Resident #2 remained just outside of the facility entrance. PO #1 stated that while discussing the incident with facility staff, including the DON, another staff member informed them that Resident #2 had fallen out of their wheelchair at the facility's entrance. PO #1 further stated that the facility staff went down to the entrance to assist the resident and get her/him into an ambulance. Review of a progress note (PN) written by Registered Nurse (RN) #2 dated 05/02/2025 at 6:20 P.M. revealed that at 6:20 P.M., RN #2 was notified by the police department that Resident #2 was found with abnormalities such as difficulty verbalizing her/his needs and a possible injury to her/his forehead, and refused medical assistance. The PN revealed that the DON was made aware and got an order to transport Resident #2 to the hospital for evaluation. The PN further revealed that the resident did not return from OOP (out on pass). A telephone interview was conducted with RN #2 on 05/13/2025 at 5:17 P.M. RN #2 stated that Resident #2 was assigned to her on the 3:00 P.M. to 11:00 P.M. shift on 05/02/2025. RN#2 stated that Resident #2 informed her that she/he was going outside to get some fresh air at approximately 3:15 P.M. RN #2 stated that a few hours later the DON informed her that Resident #2 had fallen. RN #2 stated that ordinarily, if one of her assigned residents fell, she would have completed the necessary follow up. RN #2 stated that in this case the facility's DON informed her that she would complete the follow up for the incident involving Resident #2. RN #2 further stated that the information included in her 05/02/2025 6:20 P.M. PN was provided to her by the facility's DON. Review of the facility incident report dated 05/03/2025 revealed that Resident #2 returned to the facility at 6:45 A.M. after leaving a hospital emergency department against medical advice. The facility incident report further revealed under Resident Description' That Resident #2 provided a statement that at 4:30 P.M. she/he fell out of her/his wheelchair outside the facility in the patio area. A review of a handwritten statement signed by Resident #2 revealed that the resident wrote that he/she fell out of their wheelchair on 05/02/2025 at approximately 4:30 P.M., outside on the patio. The resident wrote that they were reaching for something and lost their balance. The resident further wrote that she/he was transported to the hospital by ambulance at approximately 5:00 P.M. An interview was conducted with Resident #2 on 05/08/2025 at 12:24 P.M. Resident #2 was observed sitting in her/his room in a wheelchair. The resident had a scabbed area approximately one inch long and half an inch wide above her/his left eyebrow which was surrounded by swelling. There was bruising, discoloration, and swelling to the resident's left cheek and jawline. The resident had a black eye on the left side. Resident #2 stated that on 05/02/2025 she/he signed out of the facility then went to stores close to the facility. The resident stated that she/he fell out of their wheelchair and hit their head on the pavement at around 4:00 P.M. on 05/02/2025. The resident stated that after falling out of her/his wheelchair, facility staff came outside to assist her/him. A follow up interview was conducted with Resident #2 on 05/08/2025 at 4:41 P.M. The resident confirmed that they fell out of their wheelchair just outside of the facility's front door. Review of the facility document with [Resident #2] Incident Summary 5/2/2024, at the top revealed under Summary, that Resident #2 signed out of the facility and went to a liquor store. While at the liquor store the resident fell while trying to reach for something. The facility was alerted to the fall when a police officer came to the facility and spoke to the DON. The facility document further revealed that Resident #2 was sent to the hospital for evaluation prior to ever coming into the facility from police custody. An interview was conducted with Registered Nurse (RN) #1 on 05/08/2025 at 4:18 P.M. RN #1 stated that Resident #2 told him that she/he (Resident #2) fell near the canopy just outside of the facility's door. An interview was conducted with the facility's Licensed Nursing Home Administrator (LNHA) on 05/08/2025 at 5:14 P.M. The LNHA stated that when accidents or incidents occurred facility staff completed a report in PCC (the electronic medical record). The LNHA stated that the staff would not have completed employee statement forms because the incident involving Resident #2 happened offsite. The LNHA stated that the facility's policy, Incident/Accident Investigating and Reporting Policy and Procedure, would have been followed if something happened on the premises. A follow up telephone interview was conducted with the LNHA on 05/21/2025 at 3:04 P.M., The LNHA stated that no additional summary, statements, conclusions, or other documentation were available for the incident involving Resident #2 on 05/02/2025. The facility DON was not available for interview on 05/08/2025 or 05/21/25. Review of the facility policy titled, INCIDENT/ACCIDENT INVESTIGATING AND REPORTING POLICY AND PROCEDURE with an updated date of 6/2024, revealed, POLICY: It is the policy of this facility to provide a system whereby residents' incidents/accidents are investigated, their causes identified when possible, and timely interventions are established to reduce the probability of repeated incidents. Under PROCEDURE the policy revealed, 1. It is the responsibility of the Licensed Nurse who first witnessed the incident/accident to initiate and complete the Incident/Accident Report in its entirety utilizing input from the staff present at the time of the incident/accident. [ .] 5. All employees assigned to the resident involved in an incident/accident will fill out the Employee Statement form [ .] 8. The Unit Manager will investigate, summarize and conclude all incidents/accidents. NJAC 8:39-27.1(b)

Complaint#: NJ00181512, NJ00181513, NJ00181515, NJ00181438, NJ00181567 Based on observation, interview, and review of pertinent facility documents on 12/13/2024, it was determined that the facility failed to maintain a safe and comfortable room temperature levels for residents in a nursing unit [Gardenia Garden]. This deficient practice was identified in 1 of 2 nursing units in third floor and was evidenced by the following: On 12/13/2024 at 9:32 a.m. [morning], the Surveyor in the presence of the Maintenance Person (MP) checked the temperatures on the Third Floor and the following were obtained: room [ROOM NUMBER] - room temperature of 67.6 degrees Fahrenheit; occupied; radiator on with low cool air coming out; resident ambulatory; not in distress. room [ROOM NUMBER] - room temperature of 68.1 degrees Fahrenheit; occupied; resident out of room; radiator on. room [ROOM NUMBER] - room temperature of 69.4 degrees Fahrenheit; occupied; Certified Nursing Assistant (CNA) doing care; radiator on; resident not in distress. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; occupied; radiator on with low cool air coming out; 2 residents not in distress. room [ROOM NUMBER] - room temperature of 66.0 degrees Fahrenheit; occupied; radiator was on; resident not in distress. room [ROOM NUMBER] - room temperature of 65.1 degrees Fahrenheit; occupied; resident not in room; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; residents not in room; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 65.0 degrees Fahrenheit; occupied; radiator on with low cool air coming out; residents dressed warmly with blankets; residents not in distress. room [ROOM NUMBER] - room temperature of 68.3 degrees Fahrenheit; occupied; radiator on with low cool air coming out; residents not in distress. room [ROOM NUMBER] - room temperature of 64.7 degrees Fahrenheit; unoccupied; radiator on with low cool air coming out. room [ROOM NUMBER] - room temperature of 64.0 degrees Fahrenheit; residents out of room; radiator on with low air coming out. room [ROOM NUMBER] - room temperature of 68.0 degrees Fahrenheit; occupied; radiator on; residents not in distress. room [ROOM NUMBER] - room temperature of 67.6 degrees Fahrenheit; unoccupied; radiator on with warm air started to come out. room [ROOM NUMBER] - room temperature of 66.5 degrees Fahrenheit; occupied; radiator was noted off; resident (in bed 2) stated he turned off radiator; residents not in distress. room [ROOM NUMBER] - room temperature of 70.0 degrees Fahrenheit; occupied; radiator noted off; resident stated was on last night denied turning radiator off; checked radiator working and left on; residents not in distress. Third Floor - Lilac Lane Unit - hallway temperature of 73.5 degrees Fahrenheit Third Floor - Gardenia Garden Unit - hallway temperature of 67.2 degrees Fahrenheit Third Floor Nurses Unit - wall thermometer on the wall showed 77 degrees Fahrenheit. Third Floor Dayroom/Dining Room - has temperature of 68.0 degrees Fahrenheit. On 12/03/2024 at 1:26 p.m. [afternoon], the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated the first complaint for low heat was on 12/2/2024 and we had been monitoring the room temperatures and maintenance and corporate maintenance had been coming in to fix the problem. We had been monitoring the units and then last night there was a complaint from resident in 3rd floor about no heat. I called the maintenance and that was why regional maintenance person [name] was here and the company fixing the radiator units. We are expecting the room temperatures to go up after the maintenance bled the system. Our target was 71 degrees Fahrenheit per room. There was no power outage nor interruption of service occurrence. I am aware of the recommended temperature of 71-81 degrees as per regulations. On 12/03/2024 at 3:42 p.m. [afternoon], the Surveyor interviewed the regional maintenance person (RMP) in the presence of the LNHA. The LNHA and RMP were made aware of the low temperatures obtained in Unit [Gardenia Garden] in third floor. The RMP stated we did a comprehensive check on the boiler, and we were bleeding the boiler. The RMP further stated in bleeding we pushed the cold air out from the pipes by flushing hot water into it from the boiler. With the low temperatures we do not want to increase the boiler temperature to 200 degrees Fahrenheit hot as this will cause the boiler to break so we do the flushing gradually and it takes quite a while for warm temperatures to kick in the PTACH [radiator]. A review of the facility's undated Cold Stress Emergency Plan: Operational Procedures provided by the facility 4. Other duties may be required. A. Maintenance. 1)Check heating system to ensure it is working properly .3) Maintain proper room temperatures. 4) Check water lines to ensure they are adequately protected .7) Make necessary repairs as soon as possible. NJAC 8:39 -31.2(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to provide timely and appropriate incontinence care for Resident #5 who was dependent on staff for their Activities of Daily Living (ADLs) care. This was observed on 09/16/2024 during the surveyor's incontinence rounds on the third floor nursing unit. The deficient practice had the potential to affect all residents and was evidenced by the following: According to the facility's Transfer/Discharge Report (TDR), resident information revealed Resident #5 had diagnoses of but not limited to Cerebral Infarction, Seizures, Heart Failure, Aphasia, and Hypertension. Resident #5's TDR further entailed his/her list of medications which indicated should be administered via [through] a G-tube (gastrostomy tube, a tube inserted through the wall of the abdomen directly into the stomach). According to Resident #5 Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities and helps the facility identify residents' health problems, dated 08/06/2024, revealed that Resident #5 Brief Interview for Mental Status (BIMS) Cognitive Skills is severely impaired. Resident #5's MDS further indicated in Section GG Functional Abilities and Goals that Resident is dependent on staff for the completion of his/her ADLs. On 09/16/2024 at 12:17 pm [afternoon], the surveyor toured the third floor nursing unit in the presence of the Unit Manager (UM) Licensed Practical Nurse (LPN #1). The UM stated her Unit has two wings and the census was 55. The UM further stated there were two nurses and three Certified Nursing Assistants (CNA)s assigned to the residents. The surveyor with the UM observed Resident #5 in bed. UM stated Resident #5 was non-verbal and had a feeding tube. The UM further stated Resident #5 was dependent on staff for his/her ADLs. On 09/16/2024 at 12:43 pm, CNA #1 was observed going in to the Resident's room. The surveyor then asked CNA #1 if she was assigned to Resident #5 to which the CNA affirmed she was. At that point, the surveyor requested to observe CNA #1. CNA #1 proceeded after donning on a gown and putting on a mask and a pair of gloves, lowered the head of bed of the Resident and opened the front of Resident's diaper while Resident was on their back. Surveyor then asked CNA #1 to turn the Resident on their side and pulled down the Resident's diaper. In the presence of the Unit Manager and CNA #1, the surveyor observed the Resident's green diaper to be covered with brown excrement [feces] and was saturated in brown and strong-smelling urine. When asked by the surveyor, CNA #1 stated I have a lot of patients and when asked how often she would change dependent residents assigned to her, CNA #1 stated I would check on them frequently and change at least once a shift. At this point, the UM stated, CNAs would check and change residents at least once a shift. A review of the 7-3 CNA Assignment Sheet for 09/16/2024 on third floor nursing unit, revealed that for the resident census of 55, there were three CNAs assigned. One CNA for Assignment 1 had nineteen residents to care of, CNA with Assignment 2 had nineteen residents to care of, and CNA with Assignment 3 had seventeen residents for care. On 09/16/2024 at 12:53 pm, the surveyor interviewed CNA #2 (who had Assignment 2) stated she had nineteen residents to care of today. She further stated, it is always under staff everyday. On 09/16/2024 at 4:28 pm, surveyor interviewed Director of Nursing (DON) and the Regional Clinical Nurse (RCN). The DON and RCN were made aware of the incontinence observation in third floor nursing unit and the staffing ratio. The DON stated she was fully aware of the staffing deficits and the facility was working on the staffing problems were in progress. The DON acknowledged of the lack of incontinence care and was working on it as well. Review of the facility's policy on INCONTINENCE CARE revised on 09/2024, Policy: Based on the resident's comprehensive assessment, all residents who are incontinent will receive appropriate treatment and services; Policy Explanation and Compliance Guidelines: . (4) Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. NJ 8:39-25.2 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 3 of 3 nursing units on multiple dates of observation and was evidence by the following: 1. On 6/27/24 at 12:05 PM, this surveyor observed the lunch meal on the 4th floor. The main dining room had 18 residents. 18 of 18 residents were served their meal on Styrofoam plates and cups, with plastic utensils. The surveyor further observed the residents who were eating in their rooms also having Styrofoam plates and cups, with plastic utensils. The surveyor interviewed Certified Nursing Assistant (CNA #1), who stated that Styrofoam were used on most meals and it has been ongoing for the past 6 weeks. 2. 0n 6/28/24 at 8:20 AM, the surveyor observed the breakfast meal on the 2nd floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. 3. 0n 6/28/24 at 8:27 AM, the surveyor observed the breakfast meal on the 3rd floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. 4. 0n 6/28/24 at 8:33 AM, the surveyor observed the breakfast meal on the 4th floor. All the residents on the unit were being served in their rooms and were observed with the use of Styrofoam plates and bowls with plastic utensils. During the resident council meeting conducted during the survey period where 5 residents in the facility attended. There were 5 of 5 residents who stated that the meals were served on Disposable containers, plates, and utensils for a couple months and would prefer regular China and utensils. The same 5 of 5 residents further stated that they were informed by the dietary department the dish machine in the facility was broken. On 6/28/24 at 09:34 AM, the surveyor interviewed the Food Service Director (FSD), who confirmed the dish machine has not worked for the last 5 or 6 weeks. The FSD further stated, he had made frequent requests to the management to have the dish machine fixed. The surveyor further asked why the dietary department was unable to serve meals with non-disposable plates, utensils and glassware while utilizing the three compartment sink (three sink method is the manual procedure for cleaning and sanitizing dishes in commercial settings) for cleaning and sanitizing the dishes, cups utensils and other cookware, the FSD stated, they are trying to use as much non-disposable plates and such but with the size of the resident population, it's very difficult to stay on track with regards to meal preparation. On 6/28/24 at 10:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated he has sent multiple emails to corporate regarding the dish machine repair. Tha LNHA also agreed the residents should not be eating meals off disposable plates and plastic cutlery. A review of the facility's Resident Rights policy with a revised date of 11/2023 stated under the Resident Rights Acknowledgment section, 1. Resident rights, The resident has the right to a dignified existence .5. Respect and dignity; c. The right to side and receive services in the facility with reasonable accommodation of resident needs and preferences 6. Self-determination, b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. On 7/1/24 at 10:40 AM, the survey team met with the LNHA, Director of Nursing, Regional Clinical Registered Nurse, and Regional Infection Preventionist/Registered Nurse. The LNHA provided copies of emails sent to corporate regarding the dish machine. The LNHA further stated the dish machine was being replaced today 7/1/24. No further information was provided. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/25/24 at 9:35 AM, the surveyor in the presence of Food Service Director (FSD) observed the following during the kitchen tour: 1. The dry storage area was noted with a temperature of 80 degrees Fahrenheit (F), the temperature was observed on two different thermometers. FSD stated recent heatwave caused dry storage room to become warmer, and maintenance was aware. 2. In the Walk in freezer, the surveyor observed boxed items being stored on the floor and stacked to ceiling. FSD acknowledged they were not following the 6 inches (in) from the ground and 18 in from the ceiling guidelines. 3. In the cooking area of the kitchen, the surveyor observed dual ovens, both ovens noted with a black colored baked-on debris. 4. In the Chef preparatory area, the surveyor observed on the spice storage rack multiple open seasonings without open or use by dates. The following spices were open: 6 ounce (oz) kosher salt, 6oz cinnamon, 6oz granulated garlic, and 24oz adobe seasoning. The FSD could not state when they had been opened. 5. In the bread storage area, the surveyor observed multiple open bags of sliced white bread (4), hamburger buns (3) and hotdogs buns (2) without open/use by labels. FSD could not state when they had been opened. On 7/1/24 at 10:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Clinical Nurse (RCN), and Regional Infection Preventionist (RIT). The surveyor reviewed the kitchen inspections concerns. On 7/1/24 at 11:00 AM, the LNHA provided the surveyor with multiple facility polices including Food Storage and Dating and Labeling Policy both with revised dates of 2/24/24. The Food Storage policy states under the procedure section, 1. All items with be stored on shelves at least 6 inches above the floor. 3. Items will be stored at least 18 inches of a sprinkler unit. 8. The temperature of the dry storage room for food items will maintain a temperature of 50-70 degrees Fahrenheit at all times. The Dating and Labeling Policy states under the procedure section, 2. Label products in storage with the date the package was opened or the expiration date with no more than 48 hours after opening, whichever is appropriate. 3. Label all dry goods with date received. 7. Foods that are marked with manufactures use by date, once opened and or used, must be marked with the open or use by date and that date must be used. All food items need to be dated with open date once opened. On 7/2/24 at 10:13 AM, the survey team met with the LNHA, DON, RCN, and RIT. There was no additional information provided. NJAC 8:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to maintain the prior year's state of New Jersey inspection results and post the location of those results in an area that was readily accessible to residents, families and the general public. This deficient practice was evidenced by the following: On 6/27/24 at 10:47 AM, the surveyor conducted a group meeting with seven (7) residents in attendance, Resident #5, Resident #20, Resident #43, Resident #96, Resident #118, Resident #128 and Resident #199. When asked if they were aware of the location of the previous year's survey inspection report, 7 residents said no. On 06/27/24 from 10:47 AM until 11:54 AM, the surveyor conducted the resident council meeting with seven (7) facility chosen residents who regularly attend the facility's resident council meetings that were conducted monthly. The surveyor asked if they know where the results of previous Department of Health surveys were available to them if they would like to read them, all 7 of 7 residents (Resident #5, Resident #20, Resident #43, Resident #96, Resident #118, Resident #128, and Resident #199) responded they did not know where the prior survey results were located. The surveyor reviewed the resident council minutes dated 6/3/2024. The seventh item that was reviewed revealed: Residents were reminded that the current Department of Health Survey Results is located in the front lobby. Any questions to be directed to the Administrator. This item was noted to have the Staff Initials RP next to it. The surveyor did not observe any signs regarding the survey results on any of the nursing units or in the elevators. On 06/28/24 at 10:41 AM, the surveyor interviewed the Director of Recreation (DoR), who stated that the survey binder that had the survey results was at the front desk and at each nursing station and should be presented to a resident if the resident would request for it. The DoR further stated that the facility's Licensed Nursing Home Administrator (LNHA) was in charge of the survey binder. On 06/28/24 at 10:53 AM, the surveyor interviewed the Unit Manager of the third floor who stated the survey results were downstairs at the front desk. On 06/28/24 at 10:57, the surveyor interviewed the LNHA who stated there is a book at the front desk with the survey results in it. He further stated that the location of the book was discussed with the residents upon admission. He also stated that there should have been signs at each nurse's station and at the entrance by the front desk. On 06/28/24 at 11:00 AM the surveyor observed a binder at the front desk, spine facing outward. Front of book labeled Survey Book Vol.11. The spine of the binder with the original item/brand sticker. On 6/28/24 at 1:26 PM, the surveyor spoke with the facility's LNHA, Director of Nursing, Regional Clinical Registered Nurse and the Regional Infection Preventionist. The surveyor informed them regarding the concern of the most recent state survey inspection report not being available for residents, families, and the general public in an area that was easily accessible, where they wouldn't have to ask someone for them and signage directing them to the location of said results. On 07/01/24 at 11:08 AM the LNHA stated the facility does not have a policy regarding the survey results. He further stated that signs (indicating location of survey results binder) are now posted at the front reception, in the elevators and at each nurse's station. He also stated that the signs should've been posted all along. No further information was provided. N.J.A.C. 8:39-9.4(b)

Complaint #: NJ159080 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) within 2 hours for an allegation of a resident-to resident physical altercation. This deficient practice was identified for 1 of 5 investigations of reportable incidents reviewed (Resident #36, #299). This deficient practice was evidenced by the following: 1. On [DATE] at 1:21 PM, the surveyor reviewed a form titled Reportable Event Record/Report Form which involved Resident #36 and Resident #299. The form was dated [DATE] and documented an event that occurred on [DATE] at 9:00 PM involving Resident #36 and Resident #299. The report documented Resident #299 was observed by the staff holding Resident #36 and was hurting the resident. The residents were separated immediately by the staff who witnessed the incident. The report concluded, Based on witness statement and both residents account, Resident #299 annoyed Resident #36 by setting off the alarm while trying to open the exit door. Resident #299 on the other hand was provoked by Resident #36's attempt to get him to stop pushing the door. Resident #299 escalated the verbal altercation to physical altercation. Resident #299 was immediately transferred to the hospital and Resident #36 was transferred to a different unit. A review of Resident #36's Admission Record (an admission summary) (AR) indicated the resident was admitted to the facility with diagnoses that included but was not limited to Schizophrenia. A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated that the resident had moderately impaired cognition. A review of Resident #36's interdisciplinary care plan with a revision date of [DATE] included a care plan titled, The resident has potential to demonstrate verbally abuse behaviors . A review of Resident #229's AR indicated the resident was admitted to the facility with diagnoses that included but was not limited to Unspecified Psychosis. Further review of the resident's hybrid medical record revealed that the resident expired in the facility on [DATE]. A review of the Q/MDS an assessment tool used to facilitate the management of care, dated [DATE] reflected that the BIMS score was not obtained due to severely impaired cognition. A review of Resident #299's interdisciplinary care plan with a revision date of [DATE] included a care plan titled, [Resident #299] has potential to demonstrate physical behaviors related to diagnosis of dementia with behavioral disturbances . On [DATE] at 1:33 PM, the surveyor interviewed the facility's Licensed Nursing Home Administrator (LNHA) who confirmed the details of the incident that took place on, Saturday, [DATE]. The LNHA stated the incident happened on a weekend and the Reportable Event Record/Report Form was not reported to the NJDOH until Monday, [DATE]. The facility could not provide any documentation of the resident-to-resident incident being reported within 2 hours to the NJDOH. A review of the provided facility policy titled, Abuse, Neglect and Exploitation which documented under Policy Explanation and Compliance Guidelines: VII. Reporting/Response A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later thatn 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On [DATE] at 10:44AM, the surveyor informed the facility's LNHA, Director of Nursing, Regional Clinical Registered Nurse and Regional Infection Preventionist regarding the above concern. The LNHA acknowledged the reportable event was not reported to the NJDOH in a timely manner according to federal and state regulations. There was no further information provided by the facility. N.J.A.C. 8:,d+[DATE].1(a)

Based on the interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with the federal guidelines for 2 of 29 residents (Resident #16, and Resident #7) reviewed for the accuracy of MDS completion. The deficient practice was evidenced by the following: 1. On 06/25/24, at 10:45 AM, the surveyor observed Resident #16 lying in bed with their eyes closed. On 06/25/24 at 12:45 PM, the surveyor reviewed Resident #16's hybrid (paper and electronic) medical record, which revealed the following information: According to the Admission Record (an admission summary) (AR), Resident #16 was admitted to the facility with diagnoses that included but were not limited to Dementia with behavior. A review of the Quarterly MDS (Q/MDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that the resident had severe cognitive impairment. Further review of the Q/MDS Section D Mood under Section D0150 Resident Mood Interview (PHQ-2-9) which reflected that the interview was conducted and signed on 4/21/24, three (3) days before the Assessment Reference Date (ARD) (refers to a specific endpoint for the observation period in the MDS assessment process). A review of the April 2024 electronic Medication Administration Record (eMAR) revealed a physician's order which indicated, Resident is on (Zoloft) for indication of (Hitting striking out, flipping furniture) for (depression) every shift Target behavior observed of flipping furniture, Wandering at night. The listed behaviors were observed on April 22, 23, and 24, 2024, as indicated in the eMAR. A review of the 4/24/24 Q/MDS for Section E Behavior under Section E0200A - Presence and Frequency reflected 0. Behavior not exhibited. which indicated the behaviors that were observed during the look-back period did not reflect in the Q/MDS, which was 7 days before to the ARD. 2. On 06/25/24, at 10:45 AM, the surveyor observed Resident #7 in bed awake, alert, and oriented, able to answer the surveyor's inquiry. On 06/28/24 at 12:20 PM, the surveyor reviewed Resident #7's hybrid (paper and electronic) medical record, which revealed the following information: A review of Resident #7's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (disease of the brain and spinal cord). A review of the Annual MDS (A/MDS), dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, indicating that the resident had intact cognition. Further review of the Q/MDS Section D Mood under Section D0150 Resident Mood Interview (PHQ-2-9), which reflected that the interview was conducted and signed on 4/17/24, three (3) days before the ARD. On 6/28/24 at 9:40 AM, the surveyor interviewed the facility's Social Worker (SW), who was responsible for completing Section D and Section E in the MDS assessments. The SW stated that he had been interviewing the residents for Section D screening at least 2-3 days before the ARD. The SW also confirmed that the lookback period to complete Section D must be 14 days before the ARD. The SW did not provide any further information as to why he was doing the interview before the indicated ARD. The SW added that Resident #16's behavior, documented in the April 2024 eMAR, should have been coded under Section E0200A. On 6/28/24 at 9:06 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated that the Section D Mood interview completed by the SW should have been a 14-day look-back period from the date of the ARD. The MDSC/RN added that they followed the Resident Assessment Instrument (RAI) Manual. The surveyor reviewed the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, updated October 2023. The RAI manual revealed under Chapter 3, page D-2, This interview is conducted during the look-back period of the Assessment Reference Date Further review under Chapter 3 Section E0200 Behavioral Symptom - Presence and Frequency, page E-5 reflected 1. Review the medical record for the 7-day look-back period. On 6/28/24 at 12:30 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse, and Regional Infection Preventionist. No further information was provided. NJAC 8:39-33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CP) to include safe smoking. This deficient practice was identified for 1 of 29 residents reviewed for resident-centered care plans (Resident #350), and was evidenced by the following: The Admission Record (AR) indicated that Resident #350 was admitted to the facility with the diagnoses which included but was not limited to Bipolar Disorder and Seizure Disorder. The Admission Minimum Data Set (A/MDS), an assessment tool that facilitates resident care, dated 06/06/24 reflected that the resident was cognitively intact and required supervision with activities of daily living. On 06/26/24 at 10:52 AM, the surveyor interviewed Resident #350 who was outside the facility for coffee social. The resident stated that they had been in the facility for approximately three weeks. Resident #350 stated they enjoyed the recreation department and liked to attend the activities that the facility provided. The resident indicated that they had smoked, and that smoking was permitted in a designated areas. The resident stated that the facility had a smoking schedule wherein residents were permitted to smoke at 09:30 AM, 01:15 PM, 04:15 PM, and 05:30 PM. The resident further stated that the staff held the cigarettes, vapes and lighters when not in use. The resident further stated that the staff monitors the smokers during the scheduled smoking times. Resident #350 stated the facility performed a smoking assessment to ensure that the resident was a safe smoker. The resident stated that they started smoking soon after being admitted to the facility. The surveyor reviewed the form titled, Smoking Contact and Smoking Assessment for Resident #350 dated 06/04/24, which revealed that Resident #350 required supervision during smoking and there was a CP initiated for safe smoking. The surveyor reviewed Resident #350's list of CP and there was no documentation that a CP was implemented for safe smoking. Progress notes reflected the following: On 6/25/2024 at 16:52 (04:52 PM) Smoking and Safety status Resident uses vape products and has anxiety and Chain smokes. On 06/27/24 at 09:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who explained that when a resident was admitted to the facility, the nurse was responsible to complete the smoking assessment upon admission. The LPN further stated that it would be important to complete the assessment immediately to ensure that the resident was safe to use a cigarette smoke, and also for the resident to have the right protective equipment such as a smoking apron. The LPN added that it would be important to ensure the CP was implemented to include safe smoking with safety interventions. The LPN added that the CP was a communication tool which provided information on how to care for a resident. On 06/27/24 at 09:45 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on the third floor who explained that when a resident was admitted to the facility and were a smoker, the smoking assessment must be completed upon admission. The LPN/UM stated that the smoking assessment must be completed so that the resident who smoked had the proper interventions in place to ensure safety and to determine if the resident was an independent smoker. The LPN/UM confirmed that a CP must be implemented to include that the resident smoked and had the proper safety interventions. On 06/27/24 at 09:51 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been employed in the facility for [AGE] years. The CNA stated that Resident #350 went out to smoke with supervision of the staff from activities department. The CNA added that there had been no incidents or accidents reported regarding the resident smoking. On 06/27/24 at 09:55 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1) on the first floor who had been employed in the facility for about 7 months. LPN/UM #1 explained that if a resident smoked, a physician's order must be obtained, and a smoking assessment must be completed upon admission to the facility. The LPN/UM#1 further explained that a smoking assessment was a functionality test to ensure that the resident could hold a cigarette safely as well as light the cigarette. She stated that it would be important to complete the assessment at the time the resident indicated that they smoked to ensure safety to the resident. LPN/UM #1 stated that the smoking assessment would be important to complete in order to determine if protective devices such as a protective apron, would be implemented to prevent the resident from being burnt. She confirmed that a CP would also have to be completed with safety smoking interventions. The assessment included what CP interventions must be in place. She confirmed that the CP should have been implemented to include safe smoking for Resident #350. On 06/27/24 at 10:06 AM, the surveyor interviewed the LPN/UM #2 on the second floor. LPN/UM #2 stated that a smoking assessment must be completed to determine if a resident were safe to smoke and if any interventions should be implemented to ensure that the resident was safe during smoking times. She stated that a CP must be initiated for safe smoking with interventions. LPN/UM #2 reviewed Resident 350's CP in the presence of the surveyor and confirmed that a CP was not implemented for safe smoking when the smoking assessment was completed on 06/04/24. On 06/27/24 at 10:17 AM, the surveyor interviewed the Director of Recreation and the Activities Assistant who both agreed that when a safe smoking assessment was completed on 6/4/24 , a CP should have been implemented to include that the resident smoked. A review of the the facility's policy titled, Smoking dated 02/01/2024 indicated that documentation to support decision making will be included in the medical record, including but not limited to: -Resident wishes, or those of the representative. -Assessment of relevant functional and cognitive behaviors affecting ability to smoke safely. -Response to smoking cessation interventions. -Compliance with smoking policy. A review of the facility's policy titled, Comprehensive Care Plans dated 09/2023, indicated that person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The CP's policy reflected that the comprehensive CP would describe any specialized services the nursing would provide and would include measurable objectives and timeframe to meet the resident's needs and identified. The policy also indicated that qualified staff responsible for carrying out interventions specified in the CP would be notified of their roles and responsibilities for carrying out the interventions and when changes were made. On 7/1/24 at 10:44 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse, and Regional Infection Preventionist and discussed the above concern. No further information was provided. NJAC 8:39-11.2(i)

Based on observation, interview, and record review it was determined the facility failed to maintain professional standards of clinical practice for 3 of 29 residents reviewed by a.) not accurately documenting in the electronic Medication Administration Record (eMAR) according to the physician's order (PO) for Resident #46 b.) not obtaining a PO for a resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) for Resident #101, #146. This deficient practice was evidenced by: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a-1.) On [DATE] at 11:06 AM, the surveyor observed Resident #46 in bed. The resident stated they were missing their left hearing aid (HA) and that staff was aware. The resident further stated It has been missing for about 2 months. The resident told the surveyor that staff was aware and so was the Unit Clerk (UC). The surveyor reviewed the electronic Medical Record for Resident #46. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes Mellitus with other Circulatory complications, Cerebral Ischemic attack, unspecified, and End Stage Renal Disease. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the resident's Care plan revealed a focus titled,: Risk for Impaired Communication r/t (related to) bilateral hearing deficient, Date Initiated: [DATE]. Further review revealed: Intervention: Ensure hearing aides are placed while awake and put to charge at night, Date Initiated: [DATE]. A review of the Physician Order Summary revealed a PO for: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss, dated [DATE]. A review of the facility provided form titled, Grievance Form dated [DATE] for Resident #46 revealed: Summary of Concern: The resident reported that [identifier redacted] left ear hearing aid is missing and that it is the side [identifier redacted] needs the most. Further review revealed: Resolution: The resident and family have been notified of all the facility's attempt to locate the missing left hearing aid. Insurance was contacted for replacement. A review of progress notes revealed a Health Status Note dated [DATE] at 16:35 (4:35 PM) Note Text: Searched for reported missing left ear hearing aid in the resident's room and around roommate's [NAME] as requested, and non-found. [Name redacted] made aware of the comprehensive search. Also, the NP (nurse practitioner) completed another search on her own of the resident's room and the roommate. And was not able to locate. Housekeeping director searched as well of the laundry area and could not find the missing hearing aid. [name redacted] denied taking the hearing aid to her HD facility however, HD center will be contacted to check for the device in their facility. A review of the eMAR revealed a Chart codes/follow up code which indicated, a check symbol =administered; 5 = Hold/see Nurse Notes; 9 = Other/See Nurse notes. A review of the February 2024 eMAR's revealed a check for ,d+[DATE] night, a 9 for [DATE] day shift and a x for [DATE] night, [DATE] day and night shift. A review of the [DATE] eMAR's revealed checks for day and night shifts except for [DATE] there was a 9 for day shift; [DATE] and [DATE] there was a 5 for day shift. A review of the progress notes for the above eMAR documentation revealed the following progress notes: -[DATE] 11:14 eMAR - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss -[DATE] 10:30 eMAR - Medication Administration Note Note Text: RESIDENT HAS SURGERY -[DATE] 11:50 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss. Further review of the progress notes for [DATE] did not reveal any additional documentation regarding the HA. A review of [DATE] eMAR's revealed checks for day and night shifts for the entire month. A review of the progress notes for [DATE] did not reveal any documentation regarding the HA. A review of the [DATE] eMAR's revealed checks for day and night shifts except for the [DATE] there was a 5 for the day shift. A review of the progress notes for the above eMAR documentation revealed a note: [DATE] 12:32 eMar - Medication Administration Note, Note Text: Refused meds after x3 attempts. Further review did not reveal any additional documentation regarding the hearing aid. A review of the [DATE] eMAR's revealed checks for day and night shifts except for [DATE] there was a 9 for day shift, [DATE] was blank for day shift, [DATE] & [DATE] there was a 9 for day shifts. A review of the progress notes for the above eMAR documentation revealed the following notes: -[DATE] 11:43 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss no hearing aids, awaiting insurance approval -[DATE] 13:25 eMar - Medication Administration Note Note Text: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss no hearing aids. Further review did not reveal any additional documentation regarding the HA. On [DATE] at 11:09 AM, the surveyor interviewed the UC who stated she was aware of the missing left HA for Resident #46. The UC stated the facility tried to find the HA but they were unable to find it. She further stated she called the hearing aide company and left voice messages, but no one was returned the call. On [DATE] at 11:11 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated she was aware the left HA was missing. She stated the resident's family and the doctor were made aware at the time. The LPN/UM stated that the insurance company had been called. The LPN/UM reviewed the eMAR in the presence of the surveyor who verified the active PO dated [DATE]: Hearing aid to (bilateral) ears ON in AM and OFF in PM Red for right ear and Blue for left ear. every day and night shift for hearing loss. She stated, I would have my nurse put in a progress note if something was not done according to the order. The LPN/UM showed the surveyor the [DATE] progress note regarding the missing HA. She was unable to find additional progress notes regarding the HA at that time. The LPN/UM verified that a check symbol for the HA PO on the eMARs indicated that both hearing were signed as being administered and removed. On [DATE] at 11:31 AM, the surveyor interviewed Resident #46s assigned Registered Nurse (RN) who stated the resident had 2 HA's but one was lost and we tried to call the ENT (ear, nose, and throat physician). She stated the HA had been missing for 2 or 3 months. She verified if a PO was signed it means it was completed as ordered. The RN reviewed the eMAR in the presence of the surveyor. She acknowledged that she had signed that both HA had been administered several times on the day shift. She stated, I signed because it is one order. She further stated that she should have done a progress note because it (the order) was not done as it was ordered. The RN was unable to find any progress notes that she had made regarding the hearing aid at that time. She acknowledged that the doctor should have been called to change the PO. The surveyor asked the RN what's the purpose of accurate documentation was, she stated, to put correct information for what is going on with the patient. On [DATE] at 11:58 AM, the surveyor interviewed the facility's Director of Nursing (DON) who stated she was aware of Resident #46's missing HA. She stated the Assistant Director of Nursing (ADON) was looking into it the day it happened but she was unaware that it was still missing. The DON reviewed the electronic medical records in the presence of the surveyor who verified active PO for both the hearing aids. She reviewed the eMARs for March, April, May and June. She acknowledged that the HA's PO for both right and left ear had been signed as administered and removed. She stated, they (the nurses) signed for it. The check mark means it was done. It means they signed that they did it. She further stated, when you sign something, you need to do it, if you don't it is not happening. The DON stated, 'your (nurses) not allowed to sign for something that never happened, this (signing an order was done) is a something you did not do but you (the nurses) still signed. She stated it was important to put the order on hold until you get what you need and to call the physician to get the correct order. She further stated that she and the administrator should have been made aware that the HA had not been replaced. On [DATE] at 01:12 PM, during a meeting with the survey team, the Regional Registered Nurse (RRN), the Director of Nursing (DON), the Regional Infection Preventionist (RIP), and the Licensed Nursing Home Administrator (LNHA), the surveyor presented the above concerns. The LNHA stated, this is not acceptable to check you are doing it and your not. The regional IP stated, staff was expected to follow standards of practice for documentation. A review of the facility's policy titled, Use of Assistive Devices revealed under #3. The facility will provide assistive devices for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement. and #6. A nurse with responsibility for the resident will monitor of the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed. 37791 b-1.) On [DATE] at 10:00 AM, the surveyor observed Resident #101 who was alert and oriented and was in bed watching television. The resident was verbally responsive and had no issues with care. The Surveyor reviewed the hybrid medical record (medical record is a combination of electronic and paper records) of Resident #101 which revealed the following: According to the Admission Record (AR), Resident #101 had diagnoses that included but were not limited to, Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood, Ogilvie syndrome (is an acute dilation of the colon in the absence of any mechanical obstruction in severely ill patients), and Hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the quarterly Minimum Data Set (qMDS) assessment, a tool used to facilitate management of care, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #101 scored a 9 out of 15, which indicated the resident was moderately impaired cognition. A review of the [DATE] physician's Order Summary Report (OSR) revealed no PO for a code status. A review of the resident's medical chart that was located on the 4th floor nursing unit revealed no Practitioner Orders for Life-Sustaining Treatment (POLST) (a written medical order from physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) or any readily available documentation indication the resident's code status. On [DATE] at 10:40 AM, the surveyor in the presence of Licensed Practical Nurse (LPN#1), who was responsible of Resident #101, reviewed the resident's hybrid medical chart which included the resident's electronic and paper chart. LPN#1 could not locate any documentation that showed the resident's code status. LPN #1 stated that she will need to verify the resident's code status. LPN #1 further stated that if the resident's does not have any listed code status, the resident will be considered a full code (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat). On [DATE] at 10:45 AM, the surveyor interviewed the 4th floor Registered Nurse (RN#1) who acknowledged that Resident #101 had no POLST. RN #1 also stated that a POLST was only required if the resident had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) code status. All the other residents with no POLST in the medical chart were considered as full code status. On [DATE] at 10:50 AM, the surveyor interviewed the 4th floor Licensed Practical Nurse/Unit Manager (LPN/UM) who acknowledged that there were no code status indicated in Resident #101's medical chart. On [DATE] at 1:10 PM, the surveyor discussed the above concerns with the administration team which included the LNHA, DON, RRN and the RIP. There was no additional information provided. A review of the facility's policy titled Resident's Rights Regarding Treatment and Advanced Directives that was undated and was provided by the DON revealed the following: 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. a-2.) On [DATE] at 10:35 AM, the surveyor observed Resident #45 in bed watching television. The resident was alert and was verbally responsive and had no issues with care. The surveyor reviewed the hybrid medical record of Resident #45 which revealed the following: According to the AR, Resident #45 had diagnoses that included but were not limited to, Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), adjustment disorder with mixed Anxiety and Depressed mood (a condition that combines symptoms of both adjustment disorder with anxiety and adjustment disorder with depressed mood), and Hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the qMDS assessment, a tool used to facilitate management of care, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #45 scored a 11 out of 15, which indicated the resident was moderately impaired cognition. A review of the [DATE] physician's OSR revealed a PO dated [DATE] for Clonazepam oral tablet 0.5 mg give 1 tablet via G-tube (gastrostomy tube) every 8 hours as needed for anxiety/agitation for 2 weeks. A review of the [DATE] eMAR revealed a PO dated [DATE] for Clonazepam oral tablet 0.5 mg give 1 tablet via G-tube every 8 hours as needed for anxiety/agitation for 2 weeks. Further review of the eMAR revealed that a nurse signed indicating that the above medication was administered on [DATE] at 1935 (7:35 PM). A review of the facility progress notes dated [DATE] at 15:57 (3:57 PM) revealed a Health Status Note which documented the following received patient sitting at the nursing station ready for Endoscopy appt (appointment) at [hospital redacted]; patient is alert and verbally responsive with no apparent distress. NPO (nothing by mouth) status maintained as ordered and morning meds (medications) withheld. At 10:02 am, patient left facility via stretcher with transport and nursing staff in stable condition. At 2:10 pm, patient returned to facility, alert and stable. PEG tube(Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) removed; site checked, dressing intact, no excessive bleeding noted with less than 25% saturation. Good appetite noted post tray set up. Staff will continue to monitor patient for further care. On [DATE] at 1:10 PM, the surveyor discussed the above concerns with the administration team which included the LNHA, DON, RRN and the RIP. On [DATE] at 8:50 AM, the surveyor interviewed the 4th floor LPN/UM who stated that Resident #45's G-tube was removed on [DATE]. The LPN/UM further stated that the PO dated [DATE] for Clonazepam had the incorrect route (via G-tube) and the PO should have been verified by a nurse. There was no additional information provided. A review of the facility's policy titled, Medication Administration that was undated and was provided by the DON that revealed the following: 10. Review MAR to identify medication to be administered. 33106 b-2.) On [DATE] at 10:00 AM, the surveyor reviewed Resident #146's electronic medical records which revealed the following information: The AR indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to unspecified mood disorder, Diabetes Mellitus (DM) and Dysphasia (swallowing difficulty). The qMDS, an assessment tool that facilitates a resident's care, dated [DATE] indicated that the resident had severe cognitive deficits. A review of the progress notes (PN) documented by the facility's Social Worker, dated [DATE] at 13:05 (01:05 PM), indicated that Resident #146 had a full code status. The surveyor reviewed the nursing PN dated [DATE] at 09:07, which revealed that Resident #124 had a cardiac arrest and the staff performed CPR. The PN also indicated that 911 emergency number was called who then pronounced Resident #124 deceased . The surveyor reviewed the physician OSR which did not include a PO for the resident's code status. On [DATE] at 10:12 AM, the surveyor interviewed the facility's Director of Social Services (DSW) who stated that Resident #146 was a ward of the state (who is under the legal custody of a state or a subdivision of the state) and was considered an automatic full code status. The DSW further explained that Resident #146 had a legal guardian from the state who was making the decisions on the resident's behalf. The DSW reviewed the residents medical record in the presence of the surveyor and stated that she could not find a PO or any documentation in the resident's profile that Resident #146 had full code status. The DSW stated that the only documentation for the resident's a full code status was included the social service progress notes. On [DATE] at 09:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the third floor who explained the process regarding identifying a resident's code status. The LPN stated that if a resident coded (generally refers to cardiac arrest, in such a case, urgent life-saving measures were indicated), the nurse would immediately check the resident's profile section on the EMR to determine if the resident was a full code or if the resident was a DNR. The LPN stated that a PO would not be required for a code status. The LPN reviewed the resident's profile in the presence of the surveyor and confirmed that the code status was not documented on the resident's profile in the EMR. The LPN further confirmed that there was no PO for a code status, however there was a documentation in the PN from the DSW that the resident was a full code secondary to being a ward of the state. On [DATE] at 09:35 AM. the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) on the 3rd floor who explained the process of obtaining a code status for a resident. The LPN/UM stated that when a resident was admitted to the facility, the nurse reviewed the Universal Transfer Form (UTF) and the POLST that was found from the hospital records which would usually indicate the residents code status. The LPN/UM stated that a PO was required for a resident's code status and must be documented on the resident's physical chart and on the resident's profile in EMR. The LPN/UM reviewed Resident #146's EMR with the surveyor and confirmed that there was no code status PO for Resident #146 nor was the code status documented on the resident's profile of the EMR. The LPN/UM explained that when a resident was a ward of the state, the resident was automatically considered a full code. The LPN/UM further stated that it would be important for the staff to obtain a PO for a resident's code status and must be documented on the resident's profile because time was of the essence when determining if the resident required CPR or not in the event of an emergency. The LPN/UM added that staff would not have the time to read all the PN to determine a resident's code status, but that if the code status was readily visible in the resident's profile or in the PO where it could be seen right away in an emergency. On [DATE] at 10:44 AM, the surveyor interviewed the DON who explained that a resident's code status should be documented in the resident's profile in the EMR. The DON also stated that a PO was required for a code status. There was no further information provided. A review of the facility's policy titled, Resident Rights Regarding Treatment and Advanced Directives dated ,d+[DATE] indicated that any decision regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. NJAC 8:,d+[DATE].2 (b); 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the primary physician (PP) addressed and evaluated the resident's significant weight changes (a weight loss or gain of 5% in 30 days and/or 10% in 180 days) in a timely manner for 2 of 6 residents (Resident #131 and #95) reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted alert and responsive. Resident stated they had weight loss over the past six months and was unable to recall the last time seeing PP#1. The surveyor reviewed the Admission Record (AR) (one page summary of important information about a resident) for Resident #131. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Atrial Fibrillation, Parkinson's Disease, Schizoaffective Disorder, and Hypothyroidism. A review of the Quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care), dated 4/6/24, reflected that Resident #131 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS further reflected Resident #131 had a significant weight loss that was not a prescribed weight-loss regimen. On 6/27/24 at 9:55 AM, the surveyor reviewed Resident #131's electronic (EMR) and paper medical record (PMR). The surveyor reviewed the weight record in the EMR, the weights documented were as follows: 3/12/2024: 255.0 pounds (Lbs.) 3/21/2024: 253.9 Lbs. 3/25/2024: 239.2 Lbs. 3/25/2024: 239.2 Lbs. 4/2/2024: 237.9 Lbs. A review of the Registered Dietitian (RD) progress notes (PN), dated 3/12/24 documented that Resident #131 had a significant weight loss of 14.7 lb./5.8% in 30 days. Further review revealed there were no monthly physician's PN. The surveyor interviewed the 2nd Floor Unit Manager (UM#1) who confirmed she was not able to find any physician PN in the EMR and PMR but stated the PP#1 does come in frequently. The UM#1 called PP#1, who stated that all their notes were documented in the EMR. The UM #1 in the presence of the surveyor reviewed both EMR and PMR but could not locate any physician's PN. On 6/28/24 at 10:51 AM and 12:45 PM, the surveyor attempted to contact PP #1 via phone call but was unavailable for interview. 2. On 6/25/24 at 11:37 AM, the surveyor observed Resident #95 at bedside. The surveyor was unable to interview the resident. The surveyor conducted a phone interview with Resident #95's family, who stated the resident had gained weight since being admitted to the facility, but not sure of exact amount. The family further stated, they have not spoken to Resident's PP #2. The surveyor reviewed the AR for Resident #95. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Heart Failure, Cerebrovascular Disease, Cognitive Communication Deficit, and Dysphagia. A review of the Q/MDS, dated [DATE], reflected that Resident #95 had a BIMS score of 00, indicating severe cognitive impairment. On 6/27/24 at 9:59 AM, the surveyor reviewed Resident #95's EMR and PMR chart. The surveyor reviewed the weight record in the EMR, the weights documented were as follows: 3/27/2023: 129.0 Lbs. 5/10/2023: 129.9 Lbs. 7/26/2023: 132.2 Lbs. 8/9/2023: 133.0 Lbs. 9/14/2023: 159.2 Lbs. 9/25/2023: 159.0 Lbs. A review of the RD PN dated, 9/20/23, documented that Resident #95 had a significant weight gain of 26.2 lb./19.7% in 180 days. A review of the EMR revealed there with no monthly physician's PN in the EMR. The surveyor interviewed the UM#1, who stated the PP #2 wrote all their physician PN in the PMR. The surveyor reviewed the PMR which revealed that PP#2 documented their monthly PN, but all the PN were illegible (not clear enough to be read). The UM#1 was unable to read the physician PN and was unable to state if PP #2 addressed Resident #95's significant weight gain, UM#1 stated PP#2 is usually available when called and will decipher (interpret) the PN when needed. On 6/28/24 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON), Regional Infection Preventionist (RIP) and Licensed Nursing Home Administrator (LNHA), all agreed the PP's need to address any significant weight changes in their monthly PN. On 6/28/24 at 12:00 PM, the DON provided the surveyor with a facility policy titled, Weight Monitoring with a revised date 9/2023. Under the policy explanation and compliance guidelines it states, 3. B. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. On 6/28/24 at 1:12 PM, the survey team met with the LNHA, DON, RIP and Regional Clinical Nurse (RCN). The DON stated the PP's need to address any significant weight changes in the monthly PN. No further information was provided. On 7/1/24 at 10:11 AM, the surveyors conducted a phone interview with PP#2, who could not state the Resident #95's significant weight gain was addressed in their monthly PN. NJAC 8:39-23.2 (b)

Based on observation, interview, record reviews, it was determined that the facility failed to 1. ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days and 2. ensure the physician reviewed and signed the monthly physician orders (PO). This deficient practice was identified for 3 of 32 residents (Resident #131, #7, and #77), reviewed for physician visits, and was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted to be alert and responsive. The resident was unable to recall the last time seeing their Physician (MD). The surveyor reviewed the Admission Record (one-page summary of important information about a resident) (AR) for Resident #131. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Atrial Fibrillation, Parkinson's Disease, Schizoaffective Disorder, and Hypothyroidism. A review of the Quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care), dated 4/6/24, reflected that Resident #131 had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. On 6/27/24 at 9:55 AM, the surveyor reviewed Resident #131's electronic and paper chart. During the review, it was revealed that there were no monthly physician's PN. The surveyor interviewed the 2nd Floor Unit Manager (UM#1), who confirmed she could not find any physician PN in either chart but stated the MD does come in frequently. The UM#1 called the MD, who stated all their notes were documented in the electronic chart. The surveyor and UM#1 reviewed both the electronic and paper charts but could not locate any MD PN. On 6/28/24 at 10:51 AM and 12:45 PM, the surveyor attempted to contact the MD for Resident #131 via phone call but was unavailable for interview. On 6/28/24 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the MD was required to have monthly PN in the electronic or paper chart but was unable to explain why the MD had not written their monthly physician PN. On 6/28/24 at 1:12 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Nurse (RCN), and Regional Infection Preventionist (RIP). The DON and RCN both stated that the MDs are expected to write a progress note monthly and after each visit. On 7/2/24 at 10:13 AM, the survey team met with the LNHA, DON, RCN, and RIP for an exit meeting. Facility staff made no further comments. 46889 2. On 06/25/24, at 10:45 AM, the surveyor observed Resident #7 in bed awake, alert, and oriented, able to answer the surveyor's inquiry. A review of Resident #7's hybrid (paper and electronic) medical record revealed the following information: According to the AR, Resident #7 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (disease of the brain and spinal cord). The Annual MDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using a BIMS. The resident scored 14 out of 15, which indicates an intact cognition. A review of the hybrid medical record for Resident #7 revealed that the resident's physician had not hand-signed or electronically signed the monthly PO for December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, and June 2024. Furthermore, there were no physician PN in February 2024 and April 2024. On 7/01/24 at 10:31 AM, the surveyor interviewed the physician for Resident #7 over the phone to inform that the monthly PO from December 2023 through June 2024 were not reviewed and signed. Additionally, there were no physician PN for February 2024 and April 2024. The MD stated he was in the facility but the staff did not tell him to sign the monthly PO. The MD added that if he needed to sign something immediately, he can come to the facility to sign them. 3. On 6/25/24 at 10:27 AM, the surveyor observed Resident #77 sitting in bed, alert with eyes open and was able to answer the surveyor's inquiry. The surveyor reviewed the hybrid medical record of Resident #77, which revealed the following: The resident's AR documented that Resident #77 was admitted with diagnoses that included but were not limited to Type 2 Diabetes Mellitus (high-level sugar in the blood). The QMDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. A review of the hybrid medical record for Resident #77 revealed the resident's physician had not hand-signed nor electronically signed the monthly PO for December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, and June 2024. On 7/01/24 at 09:46 AM, the LPN/UM stated that the MD was at the facility but didn't know why the MD missed to review and sign the PO. The UM/LPN from the 3rd floor stated she was unaware that the MD must sign the monthly PO. On 7/01/24 at 10:35 AM, the surveyor interviewed the MD over the phone regarding the above concern. The MD stated that he usually signed his monthly PO on the paper medical chart. The MD was informed that the monthly PO from December 2023 through June 2024 were not signed and the MD could not provide further information. On 7/01/24 at 10:41 AM, the surveyor team met with the LNHA, DON, RCN, and RIP to discuss the above concern. The DON stated that the unit clerk (UC) was in charge of having the MD review and sign the monthly PO's. If the UC were not in the building, the UC would call the MD to sign the monthly PO. A review of the the facility's policy dated 9/2023 provided by the DON titled Physician Visits and Delegation under Policy Explanation and Compliance Guidelines revealed that: b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate as appropriate by State law; c. Review the resident's total program of care, including medications and treatments, at each visit; d. Date, write, and sign a progress note for each visit., e. Sign and date all orders except for the flu and pneumococcal vaccines, which may be administered per physician-approved policy after an assessment for contraindications. NJAC 8:39-23.2 (b), 23.2 (d)

Complaint# NJ00166657 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's food preference were honored. This deficient practice was identified for 1 of 1 resident reviewed for food preferences (Resident #4), and was evidenced by the following: On 06/26/24 at 12:26 PM, the surveyor observed Resident #4's lunch tray. The meal ticket indicated 16 ounces of skim milk and the lunch tray contained 8 ounces of whole milk. On 06/27/24 at 12:12 PM, the surveyor observed Resident #4's lunch tray. The lunch ticket indicated 16 ounces of skim milk and lunch tray contained 8 ounces of whole milk. The surveyor interviewed Certified Nursing Assistant (CNA) #1 and Unit Manager (UM) who stated that they check the contents of the trays against the meal tickets. The Unit Manager stated that Resident #4's lunch tray was correct. On second check, the UM stated that the milk was incorrect and that she should've caught it at the cart before it was brought into the room. A review of the electronic medical record (EMR) indicated that Resident #4 was admitted with diagnosis including but not limited to Type 2 Diabetes Mellitus (high blood glucose levels) and Bipolar Disorder (a mental disorder that causes unusual shift in a person's mood, energy, activity levels and concentration.) A review of the order summary included a physician order for a CCD/NAS (carbohydrate-controlled diet/No Added Salt) diet regular texture, thin consistency, large portions. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. A review of Resident #4's care plan titled, Nutrition indicated an intervention of Provide me with my food/beverage preferences as available. A review of facility's policy titled, Tray Accuracy indicated: Policy: All trays will be properly et up according to the designated tray card ticket, reflecting the individual resident's dietary needs and preferences. Procedure: Each resident's individual meal tray will be set up and made according to the resident's personal meal tray card ticket. All items described on this ticket will be present on the tray. The defined diet and the individual needs and food preferences will be present on the tray. The defined diet and the individual needs and food preferences will be present on the tray including likes and dislikes in accordance with the compliance guidelines. All trays will be checked by the dietary representative calling the tray line and setting up each tray. Each tray will then be checked by a Dietary management team member prior to being sent to the unit. On received on the unit, the healthcare professional will check the tray prior to serving it to the resident. On 06/28/24 01:26 PM, the surveyor met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Regional Clinical Nurse and Regional Infection Preventionist to discuss the above concerns. There was no further information provided. NJAC 8:39-17.4(a)1, 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PN). This deficient practice was identified for 3 of 29 residents reviewed, Resident#121, #95 and #77, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 6/25/24 at 10:30 AM, during initial tour, the surveyor observed the Resident #121 in bed with their eyes closed. A review of the Admission Record (an admission summary) (AR) for Resident #121 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), recurrent Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and adjustment disorder with mixed Anxiety and Depressed mood (a condition that combines symptom of both adjustment disorder with anxiety and adjustment disorder with depressed mood). A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 06/19/24, reflected that the resident's cognitive skills for daily decision-making score were a 3 (three) which indicated that Resident #121's cognition was severely impaired. The Q/MDS further indicated that the resident was on Hospice. A review of the June 2024 Order Summary Report revealed a physician's order dated 03/12/24 for Hospice to evaluate and treat. A review of Resident #121's hospice care binder (HCB)which contained all the hospice care documentation for the resident, that was provided by the 4th floor Unit Clerk (UC), revealed a form titled, Hospice Visit Description Log (HVDL) and indicated it was last signed on 4/23/24. The HCB also included an interdisciplinary care plan and admission orders with initial plan of care. Further review of the HCB revealed no hospice nursing PN for June 2024. The last hospice nursing PN that was found was dated 03/13/24. There were no further nursing PN found in the hybrid medical record or in the HCB for Resident #121. On 6/28/24 at 9:30 AM, the surveyor interviewed the 4th floor Licensed Practical Nurse/Unit manager (LPN/UM) who stated that Resident #121 was under hospice care and a hospice aide would visit the resident daily. The LPN/UM further stated that the hospice nurse would visit the resident weekly and any notes from the visit must be placed in the HCB. On 6/28/24 at 11:30 AM, the surveyor interviewed the Hospice Registered Nurse/ Patient Care Coordinator (RN/PCC) who explained the operation and the process of care of the hospice company. The RN/PCC stated that the aide visits will depend on the resident's care plan and whoever would visit the resident from the hospice company would need to fill out the HVDL form that must be dated with description of care. The RN/HVDL further stated that a hospice nurse would visit the resident weekly and every visit they need to leave a care note that must be dated with a description of the visit. The surveyor informed the RN/PCC that the last hospice nursing PN found in the resident's medical record was a supplemental interdisciplinary note dated on 4/20/24 and the last entry in the form HVDL was on 4/23/24, the RN/PCC stated that the copy of the nursing PN were at the hospice company and there was no copy left at HCB for Resident #121. On 6/28/24 at 1:00 PM, the surveyor presented the above concerns to the facility administrative staff which included the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), Regional Clinical Nurse, and Regional Infection Preventionist. No additional information provided. A review of the facility's Coordination of Hospice Services policy that was undated and provided by the DON revealed the following: 7. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities. 44605 2. On 6/25/24 at 11:37, surveyor observed Resident #95 in bed. The surveyor was unable to interview the resident. The surveyor spoke with resident's family via phone. The resident's family stated they have not spoken to the Physician (MD) about Resident #95's care. The surveyor reviewed the AR for Resident #95. The resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Heart Failure, Cerebrovascular Disease, Cognitive Communication Deficit, and Dysphagia. A review of the Q/MDS, dated [DATE], reflected that Resident #95 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. On 6/27/24 at 9:59 AM, the surveyor reviewed Resident #95's electronic and paper chart which revealed there with no monthly physician's PN in the electronic chart. The surveyor interviewed the 2nd Floor Unit Manager (UM#1), who stated the MD wrote all their physician PN in the paper chart. The surveyor reviewed the paper chart which revealed the MD monthly PN were handwritten with all the writing noted to be illegible (not clear enough to be read). The UM#1 was unable to read the physician PN, but stated to the surveyor that the MD was usually available to be called and would interpret the notes when needed. On 6/28/24 at 11:35 AM, the surveyor discussed the above concern to the DON, RIP and LNHA. All agreed on the importance for staff to be able to read the physician's PN. The DON, RIP and LNHA were not able to read the physician's PN for Resident #95. On 6/28/24 at 1:12 PM, the survey team met with the LNHA, DON, RIP and Regional Clinical Nurse (RCN). The DON stated the physician's PN if handwritten needed to legible to the facility staff. No further information was provided. On 7/1/24 at 10:11 AM, the surveyors conducted a phone interview with MD, who confirmed all their notes were handwritten and who stated they are always available if the facility staff needed to clarify their notes. 46889 3. On 6/25/24 at 10:27 AM, the surveyor observed Resident #77 sitting in bed, alert and awake, able to answer the surveyor's inquiry. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #77, which revealed the following: The resident's AR documented that Resident #77 was admitted with diagnoses that included but were not limited to Type 2 Diabetes Mellitus (high-level sugar in the blood). The Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. A review of the paper copy of the handwritten physician PN from December 2023 through June 2024 showed that they were all illegible. On 6/28/24, at 11:35 AM, the surveyors met with the LNHA and DON who both could not read all the monthly physician's PN. On 7/01/24 at 10:35 AM, the surveyor interviewed the MD over the phone. The MD confirmed that he wrote all his PN on the paper and he can be reached anytime if the nurses cannot read or understand his handwriting. On 7/1/24 at 10:47 AM, the survey team met with the LNHA, DON, RIP, RCN and discussed the above concerns. There was no further information provided. A review of the facility policy titled Physician Visits and Delegation with the revised date of 9/2023 did not specify about the physician's illegible handwriting. NJAC 8:39-35.2 (d)(5)

COMPLAINT # NJ 3 Based on observations, interviews, review of the Medical Records (MR), and review of other pertinent facility documents on 10/23/20 and 10/26/20, it was determined that the facility failed to ensure a resident with severe cognitive impairment was appropriately protected to prevent actual abuse by a staff member, the facility also failed to follow their Policy titled: Abuse, Neglect and Exploitation Policy, to immediately start an investigation and to notify the police, for 1 of 3 residents (Resident #1), reviewed for abuse. When on 10/13/20, a Certified Nursing Assistant (CNA#1) tied a resident's hospital gown at the back of the knees and staff members were aware of the abuse and they failed to to report it to the supervisor or Administration. The CNA returned on 10/14/20, and again tied the resident up with a hospital gown knotted behind the knees which caused actual injury; a skin tear and bruising to both shins. Four staff members observed the resident in bed with the bottom of the gown tied behind the back of the knees on 10/14/20, they removed the knotted gown and failed to report the incident immediately to the Supervisor or the Administration until the next day on 10/15/20, when the Registered Nurse (RN) reported to Administration. This deficient practice placed Resident #1, as well as all residents with cognitive impairment, in an Immediate Jeopardy (IJ) situation. The IJ was identified on 10/26/20 at 12:40 p.m., when the Facility's Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation and were provided the IJ template. The Immediate Jeopardy ran from 10/13/20 to 10/15/20 at 3:00 p.m., when the RN reported the incident to the DON and the DON removed the CNA from her assignment and escorted her out of the building. The Facility provided an acceptable Removal Plan which included the document Actions Taken to Remove Immediacy which removed the immediacy on 10/15/20, when CNA #1 was suspended and escorted out of the building and terminated, and immediate staff inservicing was initiated. The IJ was Past Non-Compliance (PNC). This deficient practice was further evidenced by the following: 1. According to the Medical Record (MR), Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 8/19/20, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating the resident had severe cognitive impairment. The MDS also indicated that the resident required extensive assistance for activities of daily living (ADLs). Review of the Care Plan (CP) dated 8/28/19, revealed Resident #1 had impaired cognitive function, impaired thought processes related to a stroke, and a behavior of hanging the left leg off the side of the bed. Interventions included: Staff to make frequent rounds to ensure proper position while in the bed. Staff to consistently remind the resident to keep leg in bed for safety and the staff to assist the resident by placing leg back in bed each time the resident hangs it down. Review of the Reportable Event Record/Report (FRE) with an event date of 10/14/20, and a time of event of 11:15 p.m., revealed a Staff-to-Resident Abuse incident reported to the New Jersey Department of Health (NJDOH) on 10/16/20, regarding Resident #1. The Director of Nursing (DON) reported that on 10/14/20 at around 11:15 p.m., the night shift Certified Nursing Assistant (CNA#2) reported to the nurse that Resident #1 was observed tied up with a(NAME)Coat (hospital gown) under both knees and around the feet. Review of the Incident/Accident Report (IR) dated 10/15/20, at an unknown time, revealed documentation by the DON revealing the Registered Nurse (RN) reported to the DON on 10/15/20 at around 3:00 p.m., at the start of her shift, that Resident #1 was observed tied up with a(NAME)Coat (hospital gown) under both knees and feet on 10/14/20. The IR indicated that Resident #1 was alert with confusion and on assessment an injury was observed to both shins, listed as an abrasion. Review of the Facility's Progress Notes revealed documentation dated 10/16/20 at 1:28 p.m., by the Unit Manager indicating that Resident #1 had a bruise to the right shin measuring 2 cm (centimeters) x 0.5cm with a light scab, and bruising with a skin tear on the left shin measuring 0.2 cm x 0.4 cm with a light scab. The resident complained of pain when the area was touched. During a tour observation on 10/26/20 at 10:30 a.m., Resident #1 was observed sitting out of bed in a chair with her legs elevated and a 2 inch linear scab was observed to the right shin. The left leg was not visible during the observation. According to the Facility document titled Summary of Investigation, the Administration interviewed the staff and Resident #1 on 10/15/20. Review of the statements revealed the following: CNA #1 stated that at 10:00 p.m., she went into the resident room and sat down near the resident and told the resident to leave him/her gown and diaper alone, I told him/her don't take it off CNA #1 then reported that around 10:30 p.m. she gave resident #1 a snack while in bed. He/she was dressed but tried to take off clothes. I told him/her don't take it off. I tried to talk to him/her to not take off clothes. I did not restrain her in anyway. CNA #2 stated that last night while walking into work with CNA #3 who told her that a resident was tied up on Tuesday night (10/13/20), in their room CNA #2 then spoke with the Licensed Practical Nurse (LPN) about the resident being tied up on Tuesday. The LPN stated she did not know anything about it. CNA #2 then went to check on Resident #1 and found the resident with their legs tied tight with his/her gown. CNA #2 went and told the LPN to come and see. The RN and the LPN went into the residents room and saw the resident in restraints. The CNA then stated when I loosened the gown on the resident, I noticed the sides of her legs were really red. The RN statement on the FRE, revealed that around 11:15 p.m., CNA #2 came to her at the nursing station and reported to her and the LPN that a patient was tied up. She went to the room with the CNA and the LPN and I saw the patient lying in the bed with the bottom of his/her gown tied below the back of his/her knees after the Aide showed me, the Aide untied him/her. The resident seemed fine he/she was just stuck laying flat on his/her back. In addition, the RN stated on the FRE, that she did not notify a supervisor at that time, until she came to work the next day on 10/15/20, for her 3:00 p.m. to 11:00 p.m. shift. At that time, she reported it to the DON. The RN also reported to the DON that CNA #1 is not a good worker, she is verbally abusive to the residents, and she always answers back when getting instructions by supervisors. During an interview on 10/23/20 at 11:15 a.m., the DON reported that she found out about the incident on 10/15/20 around 3:00 p.m The Registered Nurse (RN) came to her office at the beginning of her shift. She reported that she wanted to share something that happened the day before around 11:00 p.m. The RN overheard a CNA saying a resident was tied up again. According to the DON, the RN waited until the next day to report the incident because she wanted to remain anonymous and keep it confidential so there would not be any retaliation against her. Both the RN and the on coming nurse (LPN) went to the room and found the resident asleep in bed with her hospital gown behind her knees and tied in the back. They assessed the resident and the RN stated she was going to report it. There were 2 RN Supervisor's there at the time. Both were interviewed by the DON and reported they were not made aware of the situation on 10/14/20. In addition, the DON stated that the Police were not notified until 10/16/20, since she did not find out about the incident until 10/15/20. During an interview on 10/23/20 at 1:38 p.m., CNA #2 stated that she did not find out about the incident until 10/14/20, when she was making rounds. I was coming on and I saw she was tied. I called the nurse and the 2 nurses came in to see. I untied her. I told them right away. I called the nurses. During an interview of 10/26/20 at 10:03 a.m., CNA #3 stated that she found out about Resident #1 being tied up on 10/13/20, I saw it. I just untied him/her during first rounds. but stated she never reported it to the nurse because it was a loose knot, and no marks were observed on the residents skin. CNA #3 also reported that her last in-service at the facility on Abuse and Dementia Care prior to the incident was June 2020. During an interview on 10/26/20 at 1:16 p.m., the Licensed Practical Nurse (LPN) stated that she found about Resident #1 being tied up on 10/14/20 around 11:00 p.m., when CNA #2 reported it to the nurses. She went to the room with the RN and observed the resident in bed with the gown knotted at the back of the knees. She never reported it because the RN indicated she was going to report it. She also indicated that she had Abuse and Dementia in-servicing at the facility, but was unable to verify a date of the last in-servicing. She also stated that if you see something don't depend on someone else to report it. Report it yourself. Report it right away and document. According to the Facility document titled: Employee In-Service Tracker, the RN was hired on 7/15/2002, and in-serviced on Abuse and Abuse Prevention prior to the incident on 9/2/20. The surveyor attempted several times to interview the RN but she did not return the surveyor's phone calls. According to the Facility document titled: Employee In-Service Tracker, CNA #1 was hired on 1/20/16, and in-serviced on Abuse and Abuse Prevention prior to the incident on 5/26/20. During an interview on 10/23/20 at 11:15 a.m., the DON reported that during interviews with the CNAs on the unit, all 3 CNAs said they were aware of the situation prior to 10/14/20. According to the Facility document titled: Summary of Investigation dated 10/15/20, the DON reported the following summary of events: 1. The CNA reported to the nurse that she found Resident #1 tied up with a(NAME)coat. 2. Two nurses reported immediately to the room and observed Resident #1 tied with the (NAME)coat around the knees. 3. The staff removed the tied gown and the resident appeared fine. 4. No report had been made that the resident tried to get out of bed or that the resident was agitated during the shift. 5. The staff who regularly provided care to Resident #1 reported that due to a history of a stroke ([MEDICAL CONDITION]), the resident had a habit of kicking the left leg off the side of the bed but does not try to get out of the bed. 6. Resident #1 had right arm weakness with contractures secondary to [MEDICAL CONDITION] can use the left hand. 7. The staff nurse (RN) reported the incident to the DON on 10/15/20, at the start of her next shift at 3:00 p.m. 8. The staff schedule was reviewed for 10/13/20 and 10/14/20, and CNA #1 was assigned to Resident #1 on both evenings. 9. CNA #1 was removed immediately after the report of alleged abuse, interviewed then sent home. 10. Resident #1 was examined on 10/15/20, and the DON observed an abrasion to the right shin and determined to be approximately 2 days old (determined by scabbing). 11. CNA #1's personnel file was reviewed, her license was current, and no other issues were found. In addition, the Summary of Investigation, indicated that Resident #1 was interviewed about the occurrence and allegation of the abuse incident on 10/14/20. The DON documented that the resident did not respond to any of the questions. Conclusion of the investigation documented by the DON: based on the investigation it was determined that CNA #1 tied Resident #1 with a(NAME)Coat/gown on two consecutive evenings as witnessed and reported by the staff. Actions related to the Allegation listed on the Summary of Investigation, included: Resident #1's family and doctor were made aware of the incident. A referral was sent to Social Services to render support to Resident #1. Psychological referral for an assessment, treatment and support. CNA #1 was suspended and to be terminated based on the results of the investigation. Immediate staff-in-servicing on Abuse, Neglect and Misappropriation and when and how to report. Disciplinary action and education was provided to any employee who failed to report. According to the Facility document In-Service Sign-In Sheet, the RN was in-serviced on the topic Abuse & Neglect & Reporting in a Timely Manner on 10/15/20. According to the Facility document In-Service Sign-In Sheet, the LPN was in-serviced on the topic Reporting of Suspected Abuse in a Timely Manner on 10/16/20. According to the facility document In-Service Sign-In Sheet, CNA #3 was in-serviced on the topic Abuse/Signs of Abuse/Reporting Abuse on 10/20/20. Review of the Facility document titled Patient Monitoring Log, showed Resident #1 was monitored hourly for safety from 10/15/20 to 10/17/20. According to the facility document titled Abuse, Neglect and Exploitation Policy, undated, under The facility must section #9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: a. Respond to the needs of the resident and protect them from further incident (document). b. Notify the Director of Nursing and Administrator (document). c. Initiate an investigation immediately. f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. g. If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency. h. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions. Resident #1, a cognitively impaired resident was tied up by a CNA on 10/13/20 and 10/14/20, with a hospital gown knotted at the back of her legs and sustained physical injuries. Several staff members were aware of the actual abuse and failed to report the incident immediately to the Supervisor or the Administration until 10/15/20. This deficient practice placed Resident #1, as well as all residents with cognitive impairment in an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy was past Non-Compliance. Interventions to remove the immediacy were verified on 10/26/20, the second day of the survey and included, in-servicing, disciplinary action and education to employees who failed to report the incident, and suspension and termination of CNA #1. N.J.A.C. 8:39-4.1(a)5

Complaint # NJ 6 Based on interviews, review of medical record (MR) and other facility documentation an Immediate Jeopardy situation of Past Non-Compliance was identified. The facility failed to follow a physician's orders [REDACTED].#1) residents who was identified as being an elopement risk. As a result, Resident #1 eloped from facility unnoticed by facility staff, because the facility staff failed to monitor the resident for a total of 60 minutes. The facility's failure to follow a physician's orders [REDACTED].#1 who was identified as being at risk for elopement resulted in an Immediate Jeopardy (IJ) to Resident #1's health, safety and well-being. The IJ started on 2/10/2018 and ended the same day at 7:35 p.m. when the facility implemented a 1:1 supervision for 12 days, the resident's room window was repaired and secured and all licensed staff were verbally re-educated on close monitoring of identified residents who are at risk for elopement. The Acting Administrator, Chief Clinical officer and the Director of Nursing (DON) were notified of the IJ of past Non- Compliance on 4/3/2018 at 1:55 p.m. This deficient practice was evidenced by the following; 1. According to the medical record, Resident #1 was admitted in 1/2018 and had [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), an assessment tool dated 2/1/2018, revealed that Resident #1 had scored 3 out 15 on Brief Interview for Mental Status, an assessment to used to determine a resident cognitive status. This score indicated that the resident had severe cognitive impairments. The MDS also revealed, the resident required supervision from staff for bed mobility, transferring from the bed and into a chair. The resident was able to ambulate on and off the unit with staff supervision. The MDS identified that Resident #1 had behaviors of wandering 4-6 times during the assessment period and wander/elopement prevention devices were implemented for resident safety. A review of Resident #1's Elopement Risk assessment dated [DATE] revealed that the resident had scored a 10 out of 11 for being at risk for elopement. The instructions revealed that the resident should have been placed on an elopement risk protocol and a care-plan should be in place for wandering and elopement. A review of the care plan (CP) initiated 1/26/18, identified that Resident #1 had impaired safety awareness and was at risk for elopement/wandering. The interventions listed were placement of a warder guard, for staff to identify the resident's patterns of wandering, monitor the location of the resident, attempt diversional interventions and for staff to document wandering behaviors. Further review of the CP revealed that on 2/7/18, Resident #1 used a toothbrush to cut through the window screen and kicked out the window screen with his/her foot. The CP was updated and to add additional hardware to window stop to decrease the window from opening from 8 inches (in) to 4 in. The resident was also started on [MEDICAL CONDITION] medication for behavior management. A review of the facility's 24-hour report sheet (a written communication log used by nursing staff) dated 2/7/18 revealed that Resident #1 was on continuous 15 minutes monitoring. A review of a Social Service Note dated, 1/26/2018 at 10:35 a.m. revealed that Resident #1's family member told the social worker that the resident prior to the admission to the facility had eloped often and even left the country. A review of a Progress Note (PN) dated 2/10/2018 at 8:59 p.m. revealed that the 3:00 p.m.-11:00 p.m. nursing supervisor was informed by another nurse that the resident had made an attempt to elope from the building the week prior. On the same date at 3:55 p.m., the nursing supervisor went to Resident #1's room and notice that the door was closed. The nursing supervisor instructed the staff call a Code Gray and to look for the resident. At 4:30 p.m., the nursing supervisor notified the DON, the resident's family member and the police about the missing resident. The police informed the facility that Resident #1 found in another town at another family member's home. Resident #1 was escorted back to the facility by a family member at 7:35 p.m. on 2/10/18. The resident was assessed by the nurse and found to have no injuries. The physician was notified and the resident was placed on continuous 1:1 observation monitoring. Resident #1 was asked how he/she got out of the facility. The resident demonstrated to staff how he/she eloped from the facility through the window. A review of the continuous 15 Minute Monitoring Flowsheet dated 2/10/2018, revealed that at 2:45 p.m.- 3:00 p.m. Resident #1 was inside his/her bedroom and there was no documented evidence on the form from 3:00 p.m. to 4:00 p.m. that the resident was monitored by staff. A review of the facility Incident/Accident Report dated 2/10/2018 at 4:00 p.m., revealed that the nursing supervisor went to check on Resident #1. The resident could not be located in or outside the facility. The facility's emergency response Code Gray for missing residents was initiated. The police were notified and assisted with the search, and the resident returned to the facility. A document titled Summary of Incident completed by the DON, indicated on 2/10/2018 revealed that Resident #1 was toileted at 3:00 p.m. by a Certified Nurses Aide (CNA), and then placed in bed. At 4:00 p.m., the nursing supervisor noted the resident was not in his/her room. Code gray was called, staff were unable to locate the resident. The DON and Unit Manager (UM) were notified at 4:40 p.m., and the police were notified at 4:45 p.m. At 6:00 p.m., a family member informed the facility the resident was at his/her home. The resident was returned to the facility at 7:35 p.m. The resident was able to demonstrate how he/she was able to lift the window over the stop guard and leave the facility. After the incident, Resident #1 was placed on 1:1 continuous supervision. The facility concluded that Resident #1 eloped through the bedroom window after lifting the window pane past the window stop guard. Interventions included additional hardware to be added to all the window frames on the unit to prevent opening if lifted, 1:1 supervision, and psychiatric follow up. During an interview with the surveyor on 4/3/2018 at 9:50 a.m.,10:24 a.m., 11:00 a.m., and 11:16 a.m., the UM stated Resident #1 was an elopement risk, and had a wander guard. The UM stated Resident #1 was on 15 minute monitoring and was to be visually checked by staff every 15 minutes. The UM also stated Resident #1 had eloped from the facility by opening his/her bed room window up and over the stop guard. The UM added that the assigned nurse and CNA are responsible for documenting their observation on the 15 minute monitoring form after visually checking the resident and that they decide among themselves as to who will check the resident. During an interview with the surveyor on 4/3/2018 at 11:57 a.m., the nursing supervisor stated he/she was not aware of Resident #1's elopement risk until a nurse on another unit had informed her that Resident #1 tried to elope out the window a week prior and that the resident was being monitored. The supervisor stated at approximately 4:00 p.m., she went to the nursing unit to check on the resident and found that the resident's door was closed, and found that the resident was not in his/her room. The nursing supervisor stated she asked CNA #1 if she had saw Resident #1, and the CNA #1 said she took Resident #1 to the bathroom at 3:00 p.m. At that time, the nursing supervisor called a code gray and the staff began to search for the resident. The nursing supervisor said that she notified the DON, the police and the resident's family emergency contact. The surveyor reviewed the Q (every)15 minute Monitoring Sheet with the nursing supervisor. The nursing supervisor stated that Resident #1 was an elopement risk and the assigned nurse and CNA were responsible for looking for the resident and completing the form to verify they had visually seen the resident. The nursing supervisor added that she was aware that the form was not filled out and had asked the assigned staff as to why this was not done. The nursing supervisor stated that she did not get any answers from either the staff member. During a telephone interview conducted on 4/3/2018 at 12:20 p.m., Licensed Practical Nurse, (LPN) #1 stated he/she had not worked on that unit where Resident #1 was residing in a while. LPN #1 stated that she arrived to the unit late that on that date. LPN #1 stated the out going nurse had told her that Resident #1 was on continuous 15 minute checks and showed her the form that needed to be completed. LPN #1 admitted that she did not do the 15 minute checks. When further interviewed, LPN #1 stated that she did not even know who Resident #1 was and/or who she was looking for. When interviewed on 4/3/2018 at 3:20 p.m., CNA #1 stated she was assigned to Resident #1 on 2/10/18. The CNA stated that she was never told to do 15 minute monitoring on the resident. CNA #1 stated, when she arrived to work on that date, she began rounds and saw Resident #1 inside his/her room. The CNA stated that this was about 3:00 p.m., CNA #1 toileted the resident and left the room. At 3:30 p.m., CNA #1 stated she was assigned to the lounge to watch other residents. At around 4:00 p.m., the nursing supervisor started asking where was Resident #1 was. During an interview with the surveyor on 4/3/2018 at 11:52 a.m., the DON stated he/she reviewed the video footage on the date Resident #1 eloped from the facility. The DON stated that the video of contained images of the the unit hallway and did not show the resident however; the outside video footage did show the resident in the parking lot walking alone. The DON added that video was no longer available. During a subsequent interview with the surveyor on 4/3/2018 at 1:00 p.m., the DON stated that CNA #1 saw Resident #1 around 3:15 p.m. At 3:55 p.m., the nursing supervisor reported the resident was missing. The DON stated the assigned nurse and CNA were to take turns monitoring the resident. The DON stated that LPN #1 was informed verbally during shift report about Resident #1 being on 15 minute monitoring by LPN #3. The surveyor reviewed the 15 minute monitoring form 2/10/2018 in the presence of the DON. The DON told the surveyor that the form was not filled out from 3:00 p.m. through 4:00 p.m. The DON confirmed that the form should have been signed to indicate the resident was checked during those times. The DON added that the facility was no longer using the 15 minute monitoring form. Review of a facility policy titled, Elopements and Wandering Residents included but was not limited to; This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 2. Elopement occurs when a resident leave the premises or a safe area without authorization i.e., an order for [REDACTED]. Alarms are not a replacement for necessary supervision. 5. The facility shall establish an utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. d. Adequate supervision will be provided to help prevent accidents or elopements. NJAC 8:39-27.1(a)

Complaint # NJ Cross reference F323 Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to update/revise the care plan and implement interventions to ensure an environment free of potential smoking hazards for 1 of 2 sampled residents (Resident #1) who did not follow the facility's smoking policy. On 10/1/14, Resident #1 was observed on the third floor smoking balcony past designated smoking hours, smoking a cigarette he lit himself with a lighter he had in his possession. On 10/21/14 at 1:15am, Resident #1 was found smoking in bed with a lighter he had in his possession. Twelve hours and 20 minutes later, Resident #1 was transferred and admitted to the hospital for suicidal ideation and readmitted to the facility on [DATE]. The care plan was not updated/revised regarding Resident #1's two episodes of inappropriate smoking on 10/1/14 and on 10/21/14. This placed Resident #1 and potentially all the residents in the facility in Immediate Jeopardy (IJ). The IJ was identified and relayed to the Administrator, the Director of Nursing (DON) and the Unit Manager (UM) on 3/13/15, the second day of survey. The IJ began on 10/1/14 and ended 10/21/14 when Resident #1 was transferred to the hospital, and began again on 10/30/14 when Resident #1 was readmitted with no evidence that the facility re-evaluated the care plan. This deficient practice is evidenced by; 1. See example 1 An Immediate Jeopardy (IJ) for Resident #1 and all the residents in the facility was identified by the surveyor and reported to the Administrator, the DON and the UM on 3/13/15 the second day of survey. The IJ began on 10/1/14, ended when Resident #1 was transferred to the hospital on [DATE] and began again on 10/30/14 when Resident #1 was readmitted with no evidence that the facility re-evaluated the care plan. The IJ was corrected on 3/13/15 when an acceptable plan of correction was implemented. 1. Review and update care plan of Resident #1, care plan incidences and interventions 2. All care plans are initiated on admission and reviewed within 72 hours by the unit manager and updated during scheduled RAI assessments and as needed if there is a change in resident condition All residents are at risk. All care plans will be reviewed by the IDCP Team during RAI assessments and as needed. 3. In-service staff on timely input of initial care plans and updated care plans per resident's condition. 4. QA on care planning for accuracy and timely input. DON and ADON will review 5 care plans at random selection weekly to monitor for compliance and report the findings to the QA committee every 3 months. NJAC 8:39-11.1

C#: NJ Cross Reference F 309 Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to notify the physician of 1 of 4 sampled residents (Resident #4) complaint of pain after a fall. Resident #4, was found on the floor in his room at 6:30PM with a "complaint of pain". Although the physician was notified of the fall at 6:50PM, facility staff did not attempt to notify the physician of the resident's "complaint of pain" until 1 hour later after a second complaint of pain. Resident #2 did not receive pain management at the facility. Resident #4 was transferred to the emergency room (ER) at 7:50PM on 1/30/2013 and subsequently diagnosed with [REDACTED]. This deficient practice is evidenced by the following; See Example #1 NJAC 8:39-13.1 (d) 8:39-27.1(a)

C#: NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to provide a timely initial assessment when 1 of 4 sampled residents (Resident #4) was admitted to the facility. In addition, after Resident #4 fell , the facility failed to notify the physician of a complaint of pain or thoroughly/completely assess and document the pain and didn't monitor/supervise according to the facility's written policies and/or protocol. Resident #4 was admitted to the facility on [DATE] at 4:30PM and an admission assessment was done at 6PM. Resident #4 sustained a fall on 1/30/2013 at 6:30PM, was assessed with [REDACTED]. Resident #4 was transferred to the emergency room (ER) at 7:50PM, 1 hour and 20 minute after the fall. Hospital records indicated he was diagnosed with [REDACTED]. This deficient practice is evidenced by the following;1. According to the facility Admission Record and Physician order [REDACTED]. A hospital transfer sheet dated 1/30/2013 at 3:30PM, sent with the resident at the time of admission to the facility, showed Resident #4 was at risk for falls. An admission Physician order [REDACTED]. 2 times daily by mouth for agitation, puree diet with aspiration precautions and bed alarm while in bed, check for placement and functioning at every shift. There was no pain medication noted on the POS.An untimed nursing admission assessment, dated 1/30/2013, written by the admitting Registered Nurse (RN #1) showed Resident #4 was admitted via stretcher. [DIAGNOSES REDACTED]. The assessment included but was not limited to the following; "Mental Status" and "Behavior/Mood"; was alert, confused, uncooperative and stated "I want to eat", "Resident not able to give any history" and resistive during care. A "Pain Assessment", through non verbal indicators of facial expressions and vocalizations showed a score of "0" out of 0 to 10, which indicated "no pain". A "Fall Risk Assessment" showed a score of "15" which indicated; "If the total score is 10 or greater the resident should be considered at high risk for potential falls". A "Side Rail Assessment" showed; "Patient is a fall risk with on and off agitation; on fall precautions". Resident #4 was on a puree diet, was incontinent of bowel and had a Foley catheter. A nursing Interdisciplinary Progress Note (IPN), dated 1/30/2013 at 6PM, written by RN #1 showed; "admitted ... (Resident #4)... (from hospital) via ambulance. He is alert with impaired verbal communication... At 6:15 the IPN showed; "admission orders [REDACTED]. Resident was oriented to his new surroundings, call light placed within his easy reach, both half bed siderails (up) for patients safety/protection and as an enable for bed mobility. At 6:30PM; the IPN showed "(family member) (FM) came to visit and went to see (Resident #4) and reported patient is on the floor. We reported immediately and found pt. (patient) on his supine position and complained of pain on his R (right) hip area." A "3 (PM)-11(PM)" IPN showed; "PM supervisor assessed patient. R (right lower) extremity had limited movement and externally rotated...no complaint of dizziness...head supported with a pillow while on floor, 6:50PM Dr (physician)... notified and ordered to send patient to (hospital) ER (emergency room ) for evaluation. 7:50PM, picked up by ...ambulance per stretcher."Review of the IPN showed no indication that facility staff notified the physician of Resident #4's complaint of pain.A facility Incident Report (IR) dated 1/30/2013 confirmed the IPN written at 6:30PM and noted; "Patient was on his supine position, complained of pain in his R (right) hip area, R (right) Lower Extremity with limited movement and externally rotated. Alert, confused, disoriented x (times) 3...with agitation". The IR showed Resident #4's physician was notified at 6:50PM.A facility "Post Fall Inspection Tool" sheet, dated 1/30/2013, included that Resident #4 was identified as a "High Risk" prior to the fall and had no history of falls. In addition, it showed that Resident #4 was asked if he was in pain, hungry or needed to use the bathroom and the response indicated was "no". It also indicated Resident #4 was not upset/restless or agitated prior to the fall and no bed alarm was in use.An undated facility "Summary of Investigation" showed; at 6PM-6:15PM the admission process was being completed by RN #1 and at 6:30PM the facility was notified of the fall by a FM, an assessment was done as Resident #4 was noted on his back by the foot part of the bed with limited movement and external rotation of the right (R) lower extremity, complained of pain on R hip area and Resident #4 was made comfortable with head supported by a pillow, the physician was called and ordered transfer to the hospital. "After thorough investigation, although all precautions were in place to prevent any injury to the resident, a fracture resulted from the resident's confusion, dementia and [DIAGNOSES REDACTED]." Review of Hospital Records included; a Triage/Assessment Form dated 1/30/2013 at 8:33PM showed Resident #4's pain scale assessment was 7 out of 10, Physician Notes, dated 1/30/2013 at 8:36PM, showed that Resident #4 was found by the FM lying on the floor after patient fell out of bed; "Emergency Medical Services (EMS) arrived, noted patient's R (right) leg to be inverted, with severe pain". A physical examination revealed "...alert, awake and in moderate painful distress". A Pelvic x-ray revealed an "impacted subcapital R [MEDICAL CONDITION]". Resident #4 was medicated with [MEDICATION NAME] 2 mg. Intravenous (IV) in the ER.A written statement, dated 1/31/2013 from the 3-11 shift staff Licensed Practical Nurse (LPN #1) showed that Resident #4 arrived at 4:30PM via ambulance, alert, verbally responsive but confused. A hospice nurse was at the facility and there was confusion as to whether Resident #4 was hospice or palliative care and the physician was called and orders obtained for PO (by mouth) medications. LPN #1 informed the physician that Admissions had informed the staff that the resident was "NPO" (nothing by mouth) and the physician stated he would call admissions. LPN #1 indicated that all of this occurred at approximately 5-5:30PM. At 6PM, RN #1 completed the initial assessment as she (LPN) was administering medications. At 6:30PM, a FM visited Resident #4 in his room and then went to the desk to inform RN #1 that Resident #4 was on the floor. LPN #1 went to the room along with the RN Supervisor and found Resident #4 sitting on the floor leaning on the dressing table. The supervisor completed the assessment in the presence of the family member. "At this time pt. (Resident) didn't say that he was in pain, later the (FM) asked if he was in pain and he pointed to this R (right) hip...I called Dr. (physician) and RN Supervisor stayed with the resident...I called the ambulance and the supervisor told the family member it would be about 30 Min. (minutes)". In addition, the statement showed that after the fall and assessment the FM said she would sit on the floor beside the resident to keep him company. "We didn't want to move the resident and cause harm" and the RN supervisor called the ambulance and the LPN completed the transfer form. During a telephone interview by the surveyor on 9/5/2013 at 4:40PM, LPN #1 stated that she obtained the admission orders [REDACTED]. She stated that she was aware of the bed alarm order but "we did not think he was in any danger so we did not tell anyone to get it. ...We kept watching..and checking the room ...saw him at 5-5:15 (PM), last time (before fall)". She stated that she would determine if he needed a bed alarm right away on admission, but "he was calm".LPN #1 also stated Resident #4 did not complain of pain or show any facial or body movements which indicated pain when she observed him after the fall. She confirmed she spoke with the physician related to the transfer order to the hospital but did not mention pain. At about 6:45-7PM, "We made preparations to transfer to the hospital and the (FM) said she would stay with Resident #4". LPN #1 stated the staff would periodically check on the resident but no staff were in his room after approximately 7PM. She stated she was unsure of the time the FM came out to ask for pain medication but thought it was around 7:30PM and she called the physician, but he did not call back. There was no indication that a staff member assessed the resident for pain after the FM reported Resident #4's pain at 7:30PM. A written statement, dated 1/30/2013 by RN #1 showed she admitted the resident at 6PM and he was alert, uncooperative to routine admission procedures, asking for food, claiming "I haven't eaten since breakfast". RN #1 oriented the resident to the room, call bell (CB) placed within reach and half side rails (SR) were up for mobility. At 6:30PM, a FM visited and reported the fall. RN #1 noted the resident was found on the floor in the supine position. "My supervisor assessed patient, the R (right) lower extremity had limited movement and was externally rotated. "Patient complained of pain on his R (right) hip area." A neurological check was done and his head was supported with a pillow while on the floor. The physician was notified at 6:50PM and ordered the resident sent to the ER for an evaluation. During a post survey telephone interview with the surveyor on 9/12/2013 at 4:45PM, RN #1 stated she didn't complete the initial assessment until 6PM due to a question regarding the resident's status with hospice and review of the paperwork. She confirmed that Resident #4 was confused and agitated and RN #1 further stated she obtained the physician order [REDACTED]. In addition, she confirmed she entered the room with the RN Supervisor and LPN #1 at 6:30PM and found Resident #4 on the floor, he did complain of pain in his R hip area. She also stated that the LPN #1 followed up with the physician and RN #1 continued to finish up the admission paperwork and did not see Resident #4 until he was being transferred to the hospital. A written statement dated 1/31/2013 from Resident #4's assigned 3-11 shift Certified Nurses Aide (CNA) showed Resident #4 was admitted at about 4:45PM. The CNA made him comfortable and at 5:30 the CNA attended to other residents during dinner, then took her break and did not see the resident until after the fall. During a telephone interview with the surveyor on 9/5/2013 at 4:15PM, the CNA confirmed her written statement. She stated she did not see Resident #4 from 5:30PM until after the fall at 6:30PM when he was on the floor. She further stated the nurses were with the resident but she did check on him 2 times after, at approximately 6:40PM and 6:50PM and asked the resident and FM if he was "ok", but she got no response. She stated she did not observe the resident after 6:50PM and the FM stayed with the resident. She confirmed that she did not apply a bed alarm to Resident #4.A written statement, dated 1/31/2013 from the 3-11 shift RN Supervisor confirmed Resident #4 was admitted at 4:30PM and the admission assessment was completed by RN #1 between 6PM and 6:15PM. At 6:30PM, a FM visited and was directed by the LPN #1, "who was giving meds (medications)", to Resident #4's room. The FM came out of the room and reported to LPN #1 that Resident #4 was on the floor. The RN Supervisor, LPN #1 and RN #1 went to the room and saw Resident #4 on the floor by the foot of the bed wearing non skid socks and the Foley catheter was intact. The RN Supervisor completed the assessment with the FM present and noted the R lower extremity externally rotated with limited movement and R hip swollen. "Patient too confused to indicate if there's pain" however the FM "asked him where it hurts and he pointed to his R (right) hip". The RN Supervisor informed the family member that the resident could not be moved as he may have a fracture and he was made comfortable with a pillow. The RN Supervisor documented that she informed the Director of Nursing (DON) of the incident who then suggested to ask the FM if they wanted to keep the resident at the facility to complete the x-ray and manage the pain or transfer out to the hospital. The RN Supervisor further documented in her statement that LPN #1 called the physician who ordered the resident to be sent to the hospital for an evaluation and the FM agreed. The FM volunteered to sit with the resident and the RN Supervisor called the ambulance, informed the FM it would arrive in 30 minutes and then attended to another resident admission. The FM came to the desk "asking if we can give pain med (medication)" however, there was a discrepancy regarding the admission orders I told her the amb (ambulance) is on the way and that he will (be) given pain medication in the ER. I did not notice when the amb arrived as I was (with another resident)" . The LPN informed the RN Supervisor that the resident left at 7:50PM.During a telephone interview by the surveyor on 9/4/2013 at 5:05PM, the RN Supervisor confirmed her statement and added that the CB, SR and low bed were in place when she observed Resident #4 after the fall. When asked by the surveyor if the resident should have had a bed alarm applied at admission per the POS, she stated that "he should have had an alarm". She also noted that she had just come up to the unit with an alarm after being called to bring an alarm at approximately 6PM, "but he was on the floor". She stated that the usual protocol is for a nurse to see a new admission on arrival, ensure resident safety, review the paperwork brought with the resident from the sending facility, call the physician for orders and implement the orders.Additionally, the RN Supervisor stated that during the assessment after the fall, Resident #4 was kept on the floor because the R leg was externally rotated could be a sign of a fracture. Although Resident #4 pointed to his hip when asked by the FM if he was in pain, he showed no facial grimacing which would have indicated pain and she did not assess/document a level of pain because of that and did not inform the physician of Resident #4's pain. She stated she would have documented it at a "level of 5 out of 10". She confirmed that the FM came to the desk later to ask for pain medication after the fall but she informed the FM they were waiting for a call back from the physician and Resident #4 would be able to get pain medication in the ER. The RN Supervisor stated she was working with another admission and did not follow up regarding a pain assessment for Resident #4 or call the physician to request an order, but LPN #1 was checking on Resident #4 during that time. She stated the ambulance was called at approximately 6:45-7PM and she did not see Resident #4 after that because the unit had 3 new admissions at that time.During an interview with the surveyor on 9/10/2013 at 2:00PM, the 7AM-3PM RN Unit Manager (UM) (RN #2) stated the usual protocol for a new admission is to meet with the resident in the room, orient the resident to the room and complete the initial assessment. She stated that if a transfer sheet showed the resident was at risk for falls and the facility assessed as a high fall risk, an alarm should be placed on the bed or chair immediately until the resident is observed for a few days. She stated if there was a physician order [REDACTED]. If the physician does not respond in 15 minutes the Medical Director is called for an order. During an interview with the surveyor on 9/10/2013 at approximately 10:30AM, a RN UM (RN #3) from another unit stated that the usual protocol for a new admission is to meet the resident on arrival, orient to the room and complete the initial assessment. She confirmed that a resident transferred to the facility as a fall risk, assessed by the facility as a fall risk and had an order for [REDACTED]. RN #3 confirmed that if a resident is asked if there is pain and pointed to an area, an assessment is completed and pain medication is given. If there is no order the physician is called and if the physician doesn't respond in 15-30 minutes, the facility's Medical Director is called. During an interview with the surveyor on 9/10/2013 at 10:50AM, a unit staff per diem RN (RN #4) stated that the usual protocol for a new admission is to be greeted on arrival. A body check and mental status check is done. If there is a risk for falls, the resident is either kept by the nursing station to be observed or a staff member should stay with the resident until an alarm is applied. She stated that "we try to complete the assessment right away" and if unable, a CNA is assigned to the room. RN #4 also stated that after a fall, if the resident is assessed with [REDACTED]. If the physician doesn't respond in 15 minutes we would call again or call the facility's Medical Director. RN #4 stated that a staff member should stay with the resident until the ambulance arrives for transfer.During a telephone interview with the surveyor on 9/5/2013 at 5:30PM and on 9/10/2013 at 2:30PM the DON confirmed that in review of the initial nursing assessment, Resident #4 was initially assessed as uncooperative, confused and a high risk for falls by RN #1 and should have had a bed alarm applied on admission. She confirmed that if a resident has a change in condition/fall and is being transferred out of the facility, a resident is not to be left alone by staff. Additionally, she stated that if a resident indicates a location of pain, the nurse should assess, document and notify the attending physician. If the physician does not call back in 15-30 minutes the facility Medical Director should be notified. She confirmed that when Resident #4 was asked if he had pain and pointed to his hip at approximately 6:30-6:45PM, one of the nurses should have called the physician for pain medication. Review of an undated facility policy titled "Incident/Accident Reporting" showed "The nurse assesses the resident's condition, renders appropriate treatment or calls the physician who orders specific treatment or decides if the resident is to be transferred to the ER..." Review of an undated facility policy titled "Change of Resident Condition" showed; it is the policy to promote resident safety by observing, recording and reporting any condition change to the attending physician so proper treatment will be implemented. After all falls possible injuries or changes in physical or metal function can occur. Assess the resident's need for immediate care. Do not leave alone. Assess and notify the physician of the resident's condition comparing current condition to the prior level of function. Assessment and monitoring include, but are not limited to; take vital signs including temperature and pain location and level, monitor resident's condition frequently until stable. Review of an undated facility policy titled "Change of Resident Pain Management Protocol" showed that it is the policy to assess residents for the presence of pain and manage pain accordingly to improve quality of life. "The resident will be provided with the most effective method of pain relief and their response to the treatment plan will be monitored... Resident shall be assessed ....during a significant change in status... Pain Management will be completed for all residents regardless of current pain level. Pain Assessment Interview will determine the following; pain presence, frequency, effect on function and intensity (use numeric rating scale or verbal description scale). When resident presents with pain (verbally complained of pain or showed indication of pain, this information is included on the 24-hr. report. NJAC 8:39-27.1(a) 8:43E-6.4 (b,d,e)

C#: NJ Cross Reference F 309 Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to perform an initial admission assessment in a timely manner to ensure an intervention, a bed alarm, to prevent falls was implemented for 1 of 4 sampled residents at risk for falls. In addition, the facility didn't monitor/supervise the resident according to the facility's written policies and protocol. Resident #4 was admitted to the facility on [DATE] at 4:30PM and an admission assessment was completed at 6PM. A bed alarm, although ordered by the physician, was not implemented and Resident #4 was left in his room unsupervised by staff and subsequently fell out of bed at 6:30PM and sustained an "impacted subcapital R (right) hip fracture" requiring a transfer to the emergency room (ER) at 7:50PM. Hospital records indicated Resident #4 was medicated with Intravenous (IV) Morphine for pain. This deficient practice is evidenced by the following; See Example #1 NJAC 8:39-27.1 (a)