Every finding on record at Cedar Crest/Mountainview Gardens

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell soft pad within residents' reach. This deficient practice was identified for 2 of 22 residents reviewed for accommodation of needs (Resident #57 and #112), and was evidenced by the following: 1. On 01/22/2026 at 11:40 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad (a device used to summon the staff for assistance) was on the bedside table, not within the resident's reach. On 1/23/26 at 9:35 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad was on the bedside table, not within Resident #57's reach. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Alzheimer's Disease (a progressive brain disease causing dementia), diabetes mellitus (a disease of inadequate blood levels of glucose), and chronic kidney disease (a long-term condition where the kidneys are damaged and lose their ability to filter waste and excess fluid from the blood over time.) A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/27/25, indicated that Resident #57's cognitive skills for daily decision-making were severely impaired. The MDS further indicated that the resident was dependent on staff for activities of daily living care and received hospice services. A review of the Resident's Holistic Care Plan (CP) for Falls included care plan approaches to address risks, which indicated to provide the resident with a flat sensory soft-touch call bell for easy access to call for assistance and to encourage the resident to use it. 2. On 1/22/26 at 12:28 PM, the surveyor observed Resident #112 in their room, in bed watching television. The surveyor observed that the call bell soft-touch pad was hanging off the bedside railing, not within the resident's reach. The surveyor reviewed the medical record for Resident #112 A review of the admission Record reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Alzheimer's Disease, Contracture of Right hand (a debilitating condition characterized by the stiffening and tightening of tissues, leading to reduced mobility and function), and Anxiety (feeling of worry, nervousness, or unease about something with an uncertain outcome.). A review of the Quarterly MDS, dated [DATE], indicated that Resident #112's cognitive skills for daily decision-making were severely impaired. The MDS further indicated that the resident needed moderate assistance from staff for activities of daily living care as well as having impairments of upper extremities. A review of the Resident's Holistic CP for Falls included care plan approaches to address risks, which indicated to provide a flat call bell. On 1/23/26 at11:20 AM, in the presence of the 3rd floor Unit Manager/Registered Nurse (UMRN#1), the surveyor observed Resident #112 call bell was hanging off the resident's bed, not within the resident's reach. The UMRN#1 stated the call bell needs to be within reach of the resident for safety. On 1/23/26 at 11:50 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Call Bell System Response with a revised date of 5/2021. The procedure section of the policy revealed, 1. Each guest/resident may activate the Call Bell System to contact Continuing Care Staff for their individualized needs by activating their call button or pull cord located within their individual suite and as designated within the Continuing Care neighborhood. On 1/28/26 at 12:33 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON to review concerns found during the survey. The DON stated the call bells need to be within reach of the resident. On 1/29/26 at 12:21 PM, the surveyor met with the LHNA and DON for the exit conference, no further pertinent information provided. NJAC 8:39- 27.1(a); 31.8 (c)(9)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices during dining observations in 1 of 3 dining rooms (2nd floor) and for 2 of 3 staff members (Certified Nursing Assistant (CNA)) and Registered Nurse (RN) during meal service. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications:Immediately before touching a patient .After touching a patient or the patient's immediate environmentAfter contact with blood, body fluids, or contaminated surfacesImmediately after glove removal. On 01/23/2026 at 9:45 AM, the surveyor observed meal service in the 2nd-floor dining room and observed the following: On 1/23/26 at 9:45 AM, the RN entered the dining room and assisted Resident #5 with their meal. The surveyor observed that the RN fed the resident and then, with no observed hand hygiene, went to assist Resident #87. The RN with no observed hand hygiene went back to feed Resident #5. On 1/23/26 at 10:10 AM, the surveyor observed the CNA in the 2nd-floor dining room assisted residents with meal service. After the CNA assisted an unsampled resident, the surveyor observed the CNA wet her hands and immediately placed them under the stream of water without applying soap or lathering outside of the water. On 1/23/26 at 10:12 AM, the surveyor observed that after the CNA assisted an unsampled resident with their meal, the CNA applied soap to her hands and immediately placed them under a running stream of water without lathering outside for 20 seconds. On 1/23/26 at 10:20 AM, the surveyor observed the CNA assisted an unsampled resident with their meal. The CNA applied soap to her hands, lathered for 5 seconds outside the stream of water, then placed them under the stream. On 1/23/26 at 10:30 AM, the surveyor asked the CNA about the facility's hand hygiene policy. The CNA replied that she should wet her hands, apply soap, and lather them under running water for 20 seconds. The surveyor asked the CNA who had taught her to lather with soap under a stream of water. The CNA replied to the surveyor that the Infection Preventionist or the Educator. At that time, the CNA stated that she had been mistaken and confirmed that she had been instructed to lather her hands for 20 seconds outside the stream of water, and that she should have washed her hands in accordance with the facility policy. A review of the CNA's Hand Hygiene Competency dated 8/21/25 reflected the CNA passed the competency, which included . scrubbing all surfaces of hands for at least 20 seconds .then rinsing hands under clean, running water and avoiding recontamination . On 1/23/26 at 10:35 AM, during an interview with the surveyor, the RN stated that she received hand hygiene in services yearly and that her last in-service was a year ago. The surveyor asked the RN whether she should perform hand hygiene between residents when assisting with meal service. The RN replied that she was in-service, that she only needed to perform hand hygiene before she entered the dining room, and then after assisting all of the residents, she should wash her hands before she left the dining room. The RN stated that hand hygiene before and after assisting with meals was not important. A review of the RN's Hand Hygiene Competency dated 8/21/25 reflected the RN passed the competency, which included .Perform hand hygiene immediately before, between, and after physical contact with a resident .Handwashing is required anytime you are handling food . On 1/28/26 at 9:24 AM, during an interview with the surveyor, the Infection Prevention Nurse (IPN) confirmed that she and the educator had provided hand hygiene in-services to the staff and that all staff were instructed to wet their hands, apply soap and lather outside the stream of water for at least 20 seconds before putting their hands under the water. She also confirmed that the staff should perform hand hygiene before and after assisting each resident with meal service. On 1/28/26 at 12:33 PM, the survey team met with the License Nursing Home Administrator and Director of Nursing to discuss the above observations and concerns. A review of the facility's policy, Hand Hygiene -Standard Operating Procedure dated 3/24 and reviewed annually, reflected.Purpose.To prevent the spread of potentially infectious organisms to residents/patients, staff and visitors.Procedure.When to perform some form of hand hygiene (at minimum) .Immediately before, between and after physical contact with a resident/patient.Hand washing is required anytime you are handling food. Procedure/Technique.Wet hands with clean running water.Apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, rinse hands with clean water, use disposable towels to dry hands, use a different disposable towel to turn off the faucet. On 1/29/26 at 12:21 PM, no further information was provided. NJAC 8:39-27.1 (a)

Complaint # 2705112, 2704904 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 1/7/26, it was determined that the facility failed to implement a two -person assistant when transferring Resident #1 from bed to wheelchair in accordance with the resident's care plan. This contributed to the resident exhibiting signs of pain by grimacing, after the inappropriate transfer of the resident from bed to wheelchair by their Certified Nursing Assistant (CNA#1). Further facility assessment of Resident #1 through X-ray report, revealed that the resident sustained right femoral neck fracture (hip fracture). This deficient practice was identified for 1 of 4 residents reviewed (Resident#1).The evident is as followed: On 1/7/26, a review of the Face Sheet (FS), revealed that Resident #1 was admitted to the facility with a diagnoses that included but not limited to; Parkinson's disease, Alzheimer's disease, abnormalities of gait and mobility, muscle weakness and lack of coordination.On 1/7/26, a review of the Minimum Data Set (MDS), an assessment tool dated 10/23/25 revealed that the resident Brief Interview Mental Status (BIMS) was blank indicting that resident's cognition was poor.On 1/7/26, a review of Resident#1's care plan included a focus area addressing transfers. The care plan indicated that the resident required assistance with transfers. Further review revealed that the care plan was revised on 10/28/25, at which time it documented that the resident required a sit -to -stand lift for transfer with the assistance of two staff members.On 1/7/26, a review of clinical note dated 10/1/25 at 10:47AM, revealed that Resident #1 required total assistance of 2 persons for transferring using sit - to - stand lift.On 1/7/26, a review of a clinical note dated 12/1/25 at 2:09PM, revealed that the resident required total assistance of 2 persons for transferring using sit - to - stand lift.On 1/7/26, a review of clinical note dated 12/24/25 at 3:07PM, revealed that Resident #1 exhibited nonverbal signs of pain, and that the resident was then evaluated by the physician who also ordered an x-ray of the resident's bilateral hips. The clinical note stated that staff provided pain management for the resident. Another clinical note dated12/25/25 at 6:24AM, stated that x-ray results concluded that the resident had a right femoral neck fracture (Leg fracture). The resident was then transferred to the hospital for further evaluation and treatment.On 1/7/26 a review of the radiology report dated 12/24/25 at 11:56PM, revealed that Resident #1 had an x-ray of bilateral hips and pelvis due to pain. The result of the x-ray indicated that the resident had an acute right femoral neck fracture (hip fracture) with mild displacement. The X-ray further stated that the resident's pelvis and hip were intact and that the bony structure appeared Osteopenic (weak bones).On 1/7/26 the surveyor reviewed the Facility Reportable event (FRE) record, completed by the facility and submitted to the Department of Health on December 30, 2025. The facility reported on their investigation that they interviewed the assigned Certified Nursing Assistant (CNA #1) who assisted the resident on 12/24/25, and confirmed that CNA#1 transferred the resident independently using stand-pivot technique and without help from another staff member as required by the resident's care plan. The facility further stated that they are unable to determine the exact cause of Resident#1's fracture due to the resident's past medical history of osteoporosis but they concluded within their investigation that the assigned CNA did not follow the outlined plan of care, and that the facility reeducated all licensed staff on the care plan process and mechanical lift competencies.On 1/7/26 at 10:29AM, the surveyor conducted an interview with a CNA #2 who stated that all resident's Activity of Daily Living is located on care plan. The CNA further stated that the transfer status for residents are usually on the resident's care plans, and that the care plans are located in a binder in each resident's bedroom closet.On 1/7/26 at 10:47AM, the surveyor conducted an interview with the License Practical Nurse (LPN) who stated that each CNA was aware of the location of the care plan and care card for each resident. The LPN revealed that the care plans and care cards (an abbreviated tool that reflects resident's care plan) are located in the resident's bedroom closets. She further revealed that the expectation was that the CNAs are to check the care plan, or the care card before initiating care.On 1/7/26 at 1:00PM, the surveyor conducted an interview with the Physical Therapist (PT), who stated that the resident was discharged from PT on 7/8/24. PT further stated that the resident was transferring with a rolling walker with moderate to maximum assistance upon discharge. PT also stated that after discharge from PT, it was the responsibility of the nursing staff to determine the safest mode of transfer for each resident.On 1/7/26 at 1:23PM, the surveyor conducted an interview with the DON regarding Resident#1's fracture. DON revealed that during the facility's investigation, staff were interviewed, and it was determined that Resident #1 did not sustain any fall. The DON further stated that CNA #1, who transferred the resident using a stand and pivot technique did not follow the instructions on the resident's care plan, which required that Resident #1 be transferred with sit - to- stand lift with 2 staff assistance. DON stated that her expectation is for the CNAs to review the care plan prior to providing care.Review of the CNA's position descriptions stated that they would implement each resident's individualized care plan.A review of the facility's policy Care / Service Plans revealed under Procedure number 9, All interdisciplinary team members will document any updates/ changes on care plan copy in the guest/apartment/ designated accessible location and review update with designated care associate [CNA], services and treatments to be administered .

Complaint #: NJ185754 Based on interviews, medical record review, and review of pertinent facility documents on 9/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a Dining Associate (DA #1) alleged a Certified Nursing Aide (CNA #1) physically abused a cognitively impaired resident (Resident #1) and did not immediately report the allegation and CNA #1 continued to provide resident care without a thorough investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #1). On 4/19/2025 at approximately 4:45 PM, DA #1 alleged observing CNA #1 feed Resident #1 in the dining room. DA #1 alleged that Resident #1 was saying that the soup was too hot, and put their hands up, while CNA #1 pushed the resident's hands down, grabbed their arm, and manipulated the resident's arm to make a gripping motion. DA #1 did not report the incident until 4/22/2025, three days later, and CNA #1 continued to work three shifts, which gave her access to Resident #1 as well as other residents, until 4/22/2025, when the incident was reported to Administration and CNA #1 was suspended pending investigation.The facility's failure to implement their abuse policy including protecting Resident #1 as well as all residents from abuse by removing CNA #1 from resident care pending a thorough investigation placed all residents at risk for abuse. This posed a likelihood of serious physical and psychological harm, injury, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 4/19/2025 at approximately 4:45 PM, after DA #1 witnessed CNA #1 allegedly abuse Resident #1, and did not immediately report it so CNA #1 continued to work having access to Resident #1 as well as other residents. The facility Administration was notified of the IJ on 9/18/2025 at 4:00 PM. The facility submitted an acceptable Removal Plan (RP) on 9/19/2025 at 3:08 PM. The surveyor verified the implementation of the RP during the on-site survey on 9/23/2025 at 11:45 AM. The evidence was as follows: A review of the facility's Abuse Prevention policy dated 5/2021, included: All employees are required to immediately report suspected or alleged incidents of apparent abuse, neglect, exploitation or mistreatment. Residents will be protected from contact with anyone implicated in an incident of suspected or alleged abuse and neglect until the investigation is completed. A review of facility's Abuse Reporting &Investigation policy dated 05/2021, included: Allegations involving abuse, neglect, exploitation or mistreatment.are reported immediately, but not later than two hours after the allegation is made.to the administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides jurisdiction in long-term care facilities). On 9/18/2025 at 9:45 AM, the facility provided a copy of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) dated 4/22/2025, with an event date 4/19/2025. The FRE included that DA #1 reported observing [CNA #1] feeding [Resident #1] soup that she believed was too hot. DA #1 reported that the resident was saying that the food was too hot, but [CNA #1] continued to attempt to feed [the resident]. DA #1 also reported that she observed [CNA #1] manipulating [Resident #1's] arm and made a gripping motion.A review of the investigation dated 4/22/2025, for the incident that occurred on 4/19/2025, revealed that CNA #1 was interviewed on 4/22/2025. CNA #1 stated that Resident #1 will often state that food is hot as a way to communicate that [the resident] is done eating rather than the food is actually too hot. When asked what CNA #1 does if it happens, CNA #1 reported that she stops feeding [the resident]. CNA #1 reported she will hold [Resident #1's] hand to comfort them while eating. The surveyor reviewed the medical record for Resident #1.According to the Face Sheet (an admission summary), Resident #1 was admitted to the facility with diagnoses which include but were not limited to: Alzheimer's disease, chronic kidney disease (kidneys are damaged and cannot filter your blood properly to remove waste), and diabetes.According to the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/2025, Resident #1 had short and long-term memory problems with severely impaired cognitive skills. A further review revealed for Functional Abilities, that the resident was dependent (a helper does all the effort) for eating (the ability to use suitable items to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).A review of Resident #1's Holistic Care Plan dated assessment 7/30/2025, included an undated focus area for dining and eating, swallowing, nutritional status, oral and dental. The care plan approaches included: encourage resident to be as independent with dining as possible and assist as needed; notify nurse if resident refuses to eat meals; prefers to eat breakfast in room; encourage by mouth intake for adequate nutrition and hydration; give frequent queuing at times, assist one person to eat meals; and health shake supplements. The care plan did not include prior to the incident on 4/19/2025, that the resident says too hot to indicate fullness. On 9/18/2025 at 2:20 PM, during an interview with the Assistant Licensed Nursing Home Administrator (ALNHA) in the presence of the Director of Nursing (DON), the ALNHA stated that DA #1 reported the allegation of abuse on 4/22/2025, to the Assistant General Manager (AGM) that they witnessed an alleged staff to resident abuse. The ALNHA further stated that the DA #1 did not work the next day and did not report the abuse. The ALNHA stated that DA #1 should have reported the incident earlier. At that time, the DON stated that DA #1 went home, thought about what she witnessed, and reported the incident on 4/22/2025, when DA #1 returned to work.A review of CNA #1 's timesheet dated 4/18/2025 through 4/30/2025, revealed that CNA #1 clocked-in at 3:00 PM and clocked-out at 11:30 PM on 4/19/2025, the day of the incident. It also revealed that CNA #1 on 4/20/2025, clocked-in at 2:53 PM, and clocked-out at 11:30 PM, and on 4/21/2025, clocked-in at 2:57 PM, and clocked-out at 11:28 PM. The abuse allegation occurred on 4/19/2025, CNA #1 was not suspended until 4/22/2025, and worked three shifts, which gave her access to Resident #1 as well as other residents. On 9/18/2025 at 2:33 PM, the surveyor attempted to conduct a telephone interview with DA #1.On 9/18/2025 at 2:58 PM, a telephone interview was conducted with the AGM, who stated that the DA #1 reported the incident of abuse to him. The AGM stated that he was unable to remember when it was reported and stated that the incident of abuse may have happened prior to the day it was reported. On 9/23/2025 at 11:14 AM, during an interview with DA #1, she stated that she was delivering soups and drinks to the residents that day, and the soup was hot. DA #1 stated she heard the resident saying, hot it's hot. DA #1 reported that CNA #1 was holding the resident's hand, and Resident #1 was moving [their] head side to side and continued to communicate it's hot it's hot, while CNA #1 continued to feed the resident the soup. DA #1 stated that she immediately reported the incident to her supervisor, which contradicted the previous interviews from her supervisor (the AGM), the DON, and the ALNHA, who all informed the surveyor that DA #1 reported it days later on 4/22/2025. An acceptable Removal Plan (RP) was received on 9/19/2025 at 3:28 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: Resident #1 received a body and pain assessment immediately after DA #1 reported the allegation of abuse on 4/22/2025, with no injuries or pain noted; and emotional support and reassurance were provided. CNA #1 was suspended immediately and educated on the facility's abuse policy before their next scheduled shift on 4/28/2025. On 9/18/2025, DA #1 and CNA #1 were educated on the facility's abuse policy. On 9/18/2025, the Licensed Nursing Home Administrator (LNHA), DON, ALNHA, Assistant Director of Nursing (ADON), or designee have conducted education with all current staff in all departments on the facility's abuse prevention policy to include immediately reporting all allegations of abuse. The LNHA or designee reviewed the last thirty days of grievances/concerns to identify abuse concerns; the Social Worker (SW) interviewed residents with Brief Interview for Mental Status (BIMS) scores of 8 or above (moderately impaired to intact cognition) to identify abuse, neglect or care related concerns; and a licensed nurse completed a physical assessment/observation of all residents with BIMS scores of 7 or below (severe cognitive impairment).The surveyor verified the implementation of the Removal Plan (RP) on-site during the continuation of the survey on 9/23/2025 11:45 AM. NJAC 8:39-4.1(a)(5)

Complaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to follow a resident's (Resident #2) wishes for a Do Not Resuscitate (DNR) status who had a signed Physician's Order (PO) and a Practitioner Orders for Life- Sustainable Treatment (POLST) in their chart when the resident experienced a cardiac arrest on [DATE]. This deficient practice was identified for one resident (Resident #2), and is 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: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care dated [DATE], reflected that the resident had a Brief Interview for Mental Status score of 10 out of 15, indicating that the resident's cognition was moderately impaired. According to the Facility Reportable Events (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated [DATE], with an event date of [DATE] and a time of event of 8:20 P.M., revealed the following for Resident #2: on [DATE], at approximately 8:10 P.M., Resident #2 had a witnessed cardiac arrest while in bed. Chest compressions were initiated following confirmation of cardiac arrest by Licensed Practical Nurse (LPN). At 8:20 P.M., chest compressions were discontinued and resident #2 was pronounced dead by the Nursing Supervisor. A review of the Resident's Order Summary Form (OSF) with an order initiated on [DATE] with a Code B status (DNR) and a signed DNR form by Resident #2 and their physician on [DATE]. On [DATE] at 12:39 P.M. during an interview with the Licensed Practical Nurse, (LPN) she stated, I was called by the primary nurse/ Registered Nurse (RN) caring for the resident (Resident #2) who stated there was something going on with Resident #2. I got to the room and observed Resident #2 with oxygen in place, head of bed elevated and pale. I called the resident by their name, but he/she was not responding. I than tried to call the RN who had gone out to check the resident's code status. I flattened the resident's bed at which time the resident appeared not to be breathing, I began chest compression while still trying to confirm the resident's code status on the phone with the RN. Someone than said, the resident was a DNR, I'm not sure who it was, it was all happening so fast. Chest compression was done for approximately two minutes, it was so fast, and I don't recall the time, but it was not done for long (chest compression). During the same interview, the LPN stated, I did not verify the resident's code status prior to initiating chest compressing. I saw the resident not breathing and try to save them because I was thinking, if the resident was a Full Code, we need to save them. When asked if the facility's policy was followed, the LPN said, No, I should have verified the resident's code status prior to initiating chest compression. On [DATE] at 1:42 P.M. during an interview with the RN, she confirmed to be the primary nurse for Resident #2 on [DATE]. She stated the resident was noted with distress while doing a body assessment. I called the LPN for assistance while I went to get another oxygen concentrator, we were unsure of the resident's code status. While away from the room, the LPN asked me to check Resident #2's code status in the front of their chart. While at the front desk, the LPN had initiated chest compression. I communicated with the LPN and told her the resident was a DNR and chest compression should be stopped. Chest compression was probably performed for approximately two minutes. The RN/Supervisor came in and pronounced Resident #2 dead. When asked by the surveyor if the facility's policy was followed, the RN said No, if a resident is a DNR, we are not supposed to perform chest compression. She continued to state, if a resident is found unresponsive, the first thing to do is check the resident's code status and follow what the POLST says. On [DATE] at 2:16 P.M. during an interview with the Director of Nursing (DON) she stated the resident's code status is usually in the front of the resident's chart under the advance directive tab. Staff are aware to check the front of the chart to determine the status of the resident. She stated, her expectation is, once the nurse identifies an issue with the resident, a resident is found unresponsive, or in a medical emergency, the resident's code status should be determined prior to providing any form of treatment for the resident. When asked by the surveyor if the facility's policy was followed for Resident #2 on [DATE], she said, No, the policy was not followed. The nurse should have determined the resident's code status once cardiac arrest was identified prior to initiating Cardiopulmonary Resuscitation (CPR) for Resident #2. A review of the facility's policy with a revision date of ,d+[DATE] titled Designation of Code Status under Purpose/Scope revealed: To maximize resident autonomy by discussing and documenting resident choices regarding life sustaining and end of life choices. Under Policy revealed: A designated code status and accompany physician order, helps the staff to understand and adhere to a resident's wishes regarding life sustaining treatment. The physician's order is the source document that drives the care of the resident. The code designation will be decided by the resident, or their legal surrogate decision maker, in consultation with the primary care provider. N.J.A.C 8:,d+[DATE].6 (g)

Complaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on 03/11/2025 and 03/12/2025, it was determined that the facility failed to completely fill out a Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident (Resident #2) who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #2), 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: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. A review of the Resident #2's Progress Notes (PN) revealed that on 02/21/2025 at 4:01 P.M., the Registered Nurse (RN) documented that Resident #2 needed to be sent out to the emergency room (ER) for tachycardia, nauseous, and complain of weakness. A review of Resident #2's MR revealed the NJUTF for the 02/21/2025 transfer to the ER was not filled out completely. During an interview with the surveyor on 03/12/25 at 2:00 P.M., the Director of Nursing (DON) stated the transfer form should be entirely filled out by the nurse prior to sending the resident out to the hospital. When presented with Resident #2's transfer form, the DON confirmed the form was not filled out completely, and it should have been completed prior to sending out the resident (Resident #2). A review of the facility's policy dated 6/2021 titled, Universal Transfer Form (New Jersey). Revealed under Policy A Universal Transfer form will be completed, including all required attachments and accompany each resident who transferred or discharged from Continuing Care. NJAC 8:39-35.2 (d) 12

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/4/24 at 9:21 AM, the surveyor in the presence of the Campus Executive Chef (CEC) observed the following during the kitchen tour: 1. On the preparatory table, the surveyor observed the can opener with a caked on black colored debris. The CEC stated, they were unsure when the can opener was cleaned last, but the can opener would be cleaned immediately. 2. In the cooking area of the kitchen, the surveyor observed the standing dual oven with a sticky yellowish substance and dust like particles on top of the oven. CEC not sure when the oven was last cleaned was last cleaned. 3. The deep fryer was observed with multiple food crumbs around the inside of the fryer. Per Chef #1 the fryer was not used today, unable to explain why food crumbs were present and not cleaned last night after use. 4. The standing combination oven was observed with a grease like substance on top of the oven. The CEC was unable to state when the last time for oven was cleaned but would address the issues immediately. On 9/5/24 at 9:55 AM, the Director of Nursing (DON) provided the surveyor with two facility policies including Cleaning and Sanitizing Food Contact Surfaces and Cleaning and Sanitizing Major Cooking Equipment both with a revised date of 1/2024. The including Cleaning & Sanitizing Food Contact Surfaces Cleaning states under the standards of practice (SOP) section, All food contact surfaces will be cleaned and sanitized at the beginning of each shift, prior to use, end of use and in between tasks. The Cleaning and Sanitizing Major Cooking Equipment states under the SOP section, Thorough cleaning and sanitizing of all cooking equipment and equipment supporting cooking is vital to the prevention of food borne illnesses and the safety of our employees. Specific examples of cleaning equipment will be documented in sperate SOP's as necessary. The procedure section of the policy states, All Food Service Cooking and preparation Equipment will be cleaned and sanitized after each use and maintained in a clean and sanitized condition. On 9/6/24 at 12:59 PM, the survey team met with the Assistant Licensed Nurse Home Administrator (ALNHA) and Director of Nursing (DON) to review concerns. The ALNHA and DON had no comments for the above mentioned concerns. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility polices it was determined that the facility failed to: a.) carry out medication orders for a hospice resident and b.) clarify an oxygen order. This deficient practice was identified for 2 of 12 Residents (Resident #67 and #3) reviewed. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 9/4/24 at 10:42 AM, the surveyor observed Resident #67 in their room, in bed. Resident stated they are always in pain but varies on the pain scale. The surveyor reviewed Resident #67 paper and electronic medical chart which revealed the following: A review of the Resident #67's Admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: Parkinson's disease, Peripheral autonomic neuropathy, and Chronic pain. A Significant Change Minimum Data Set ((MDS) an assessment tool used for the management of care) date 8/4/24, documented under Section O indicating the resident is on Hospice. In the Hospice section of the paper chart, the surveyor observed a paper titled, Supplemental Interdisciplinary Progress Note dated 8/1/24, with medication recommendations for: 1. Morphine sulfate 20 mg/ml - 5mg/0.25ml sublingual (SL) every (q) hour, per resident request (PRN) for repressions >22 and/or Heart Rate (HR) >100 or other signs and symptoms (s/s) of moderate to severe pain or respiratory distress. 2. Ativan 0.5 mg by mouth (PO)/SL q 4 hours, PRN for anxiety or terminal restlessness. The progress note was signed by the Licensed Practical Nurse (LPN #1) from Grace Hospice and was initialed by MB who is the Nurse Practitioner (NP#1) for Resident #67. A review of the August and September 2024 Physician Orders (PO) included a PO dated 11/21/23 that read, 1. Tylenol 325 milligram (mg), (2) TABLET oral by mouth every 6 hours as needed for Mild Pain (Pain Score 1-4), dated 6/27/24. Indication: low back pain for pain scale of 1-5. 2. baclofen 5 mg tablet (1 tab) Tablet Oral. Indication: muscle spasms. Morphine and Ativan were not observed in the PO in either the paper or electronic record. A review of the Physician's Orders Form in the paper chart, revealed on 8/1/24, 8/2/24 and 8/23/24 the chart had been reviewed by the 11PM to 7AM nurse had completed a 24 hour chart review without ordering the Morphine and Ativan medications. A review of the Hospice Skilled Nursing Visit Note in the paper chart revealed on 8/7/24, 8/14/24, and 8/21/24 and 8/27/24, Registered Nurse (RN#1) for the Hospice assessed and completed the current pain management regiment for Resident #67 but did see the missing pain medication orders. On 9/5/24 at 11:31 AM, the surveyor interviewed LPN#2, who is regular 7AM-3PM nurse for Resident #67. The LPN#2 reviewed current medications for the resident and did not see any orders for Morphine or Ativan. Surveyor and LPN#2 reviewed the hospice paper progress note from 8/1/24, and LPN#1 confirmed Morphine and Ativan were recommended, initialed by the NP#1, and the orders were not carried out. No further comment made. On 9/5/24 at 11:45 AM, the surveyor interviewed the 3rd floor Clinical Manager (CM#1), who stated the process for carrying out medications for a hospice resident is the hospice nurse will write out medication recommendations, the resident's doctor or nurse practitioner will review and initial the hospice recommendation paper indicating to carry out the order, and the nurse will carry out the order. The CM#1 acknowledged the hospice paper was initialed by the NP#1 and the Morphine and Ativan orders were not carried out by the nurse. The CM#1 was unable to explain why the order was not carried out. On 9/5/24 at 12:18 PM, the surveyor interviewed the LPN#1 who is the current Hospice Nurse for Resident #67. The LPN#1 stated, they had written the recommendations for Ativan and Morphine as they are standard recommendations. The LPN#2 further stated they come in twice per week but was unaware those medications had not been ordered. The LPN#1 stated they have not done their monthly medication review yet and was planned to be done tomorrow. The LPN#1 could not explain why RN#1 had not seen the missing medications orders. The RN#1 was unable to be reached for interview. On 9/5/24 at 1:13 PM the Assistant Licensed nursing Home Administrator (ALHNA) provided the surveyor with two facility polices titled, Hospice Program and Physician Orders both with revision dates of 5/2021. The Hospice Program policy states under the procedure section, 5. The hospice agency works in conjunction with the continuing care/clinical staff to implement the integrated plan of care: a. Designated hospice registered nursing coordinates the implementation of the plan of care .c. Provision of drugs and medical supplies as needed for palliation and management of the terminal illness and related conditions; and d. Involvement of facility personnel in assisting with the administration of prescribed therapies in the plan of care. The Physician Orders policy states under the procedure section, When the resident is under the care of hospice, orders received by a nurse working for the hospice will be confirmed by a licensed nurse employed by the continuing care and approved by the attending physician employed by the community/EHMG. On 9/6/24 at 12:59 PM, the survey team met with the ALHNA and Director of Nursing (DON) to review the above mentioned concerns. No comments made at that time. 37791 2. On 9/04/24 at 11:02 AM, the surveyor observed Resident #3 in bed watching television. The surveyor observed the resident was receiving oxygen at 2.5 Liters Per Minute (LPM) via a nasal cannula. The oxygen tubing was labeled and dated 9/1/24. A review of Resident #3's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), diastolic (congestive) heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), centrilobular emphysema (chronic lung disease that damages the upper lobes of the lungs), 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 (MDS), an assessment tool used to facilitate the management of care dated 8/2/24, reflected that the resident's cognitive skills for daily decision-making score was 11 out of 15, which indicated the resident had moderately impaired cognition. A review of the September 2024 Physician Order Sheet (POS) revealed a Physician's Order (PO) dated 7/13/24, for Oxygen with humidification, oxygen (O2) at 2-3 liter via N/C (nasal Cannula) at bedtime (HS) to maintain O2 above 90%. A review of the August and September 2024 electronic Treatment Administration Record (ETAR) revealed an order dated 7/13/24, for oxygen with humidification to give oxygen at 2-3 liters at 2-3 liters via N/C at H.S. to maintain O2 above 90%. A further review of the ETAR revealed that Oxygen was signed as being administered during the 3-11 PM shift. A review of the comprehensive care plan revealed a care area dated 7/24/24 for Respiratory and Cardiac care with a goal that the resident won't have signs and symptoms of respiratory distress. The care plan indicated that the resident required oxygen therapy for shortness of breath and a cardiac approach that included the resident would need assistance in keeping oxygen and maintain the prescribed liters to be administered at all times. The care plan also revealed under method of administration that the resident will be receiving 2 -3 liters per minute as needed to maintain O2 saturation above 90%. On 9/6/24 at 9:20 AM, the surveyor and the Licensed Practical Nurse (LPN#3), reviewed Resident #3's order for oxygen. The LPN #3 acknowledged that the resident was receiving oxygen via a nasal cannula at 2-3 liters per minute. After reviewing the resident's oxygen order, LPN #3 stated that the order should have been clarified with the physician and that it should have been written for either 2 LPM or 3 LPM. On 9/06/24 at 1:00 PM, the surveyor presented the above concerns to the Assistant Licensed Nursing Home Administrator, and Director of Nursing. There was no additional information provided. A review of the facility's policy entitled, Physician Orders dated 5/202 included the following: Policy: Incomplete or illegible orders will always be clarified before being implemented.' NJAC 8:39-11.2(b), 19.4 (a) (1)

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 25 residents reviewed (Resident # 113). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 113's records. The resident reviewed 1/23/24, was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 6/27/24, the Type of Discharge was indicated as unplanned. A review of Resident # 113's progress notes dated 6/18/24, revealed the resident had a planned discharged to an Assisted Living (AL) facility. On 9/9/24 at 12:20 PM, the surveyor interviewed the MDS Coordinator, who stated that the MDS under section A Typer of Discharge for Resident # 113 should have indicated that the resident's discharge was planned. During an interview on 9/9/24 at 1:20 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. A review of the policy titled MDS completion and Management policy, revealed Resident Assessments will be completed for all residents accurately. NJAC 8:39-11.2(e)1

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and appropriate use of personal protective equipment (PPE) for 1 of 4 staff observed on 1 of 4 Nursing Units. This deficient practice was evidenced by the following: According to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. On 9/5/24 at 11:12 AM, the surveyor observed the Certified Nursing Assistant (CNA) on the Terrace Unit, exited room [ROOM NUMBER] wearing a pair of gloves. The surveyor observed signage outside room [ROOM NUMBER] which indicated the resident in room [ROOM NUMBER] was on Enhanced Barrier Precautions (EBP) which included: everyone must clean their hands, including before entering and when leaving the room; wear gloves and a gown for the following High-Contact Resident Care Activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube (gastrostomy tube), tracheostomy; wound care including any skin opening requiring a dressing. The surveyor observed the CNA went directly from room [ROOM NUMBER] into room [ROOM NUMBER], and provided care for the resident without removing her gloves and without performing hand hygiene. On that same day, at that same time, the surveyor observed the CNA exited room [ROOM NUMBER], walked down the hallway to the nurses' station, requested assistance from the Licensed Practical Nurse (LPN) on the floor and re-entered room [ROOM NUMBER] wearing the same soiled gloves, with no observed hand hygiene. On 9/5/24 at 12:25 PM, the surveyor observed meal service on the Terrace Unit. The surveyor observed the CNA entered the communal dining room and obtained a tray, delivered the tray to room [ROOM NUMBER] and placed the tray on the resident's bed side table with no observed hand hygiene. The surveyor observed signage outside the room which indicated the resident in room [ROOM NUMBER] was on EBP. On 9/5/24 at 12:32 PM, the surveyor discussed the above observations and concerns with the CNA. The CNA acknowledged that she should have changed her gloves and performed hand hygiene between residents. The CNA further stated that she had not been in serviced on EBP and was not aware she should have performed hand hygiene when entering and exiting the rooms of residents who are on EBP. On 9/9/24 at 12:01 PM, the surveyor interviewed the Acting Unit Manager for the Terrace Unit who stated that the facility's policy was no gloves were allowed to be worn in the hallways and further stated that all staff were in serviced on EBP policy which included everyone must perform hand hygiene before entering and exiting rooms. On 9/9/24 at 12:15 PM, the surveyor discussed the above observations and concerns with the Director of Nursing (DON) who acknowledged that hand hygiene should be performed according to CDC regulations including between residents and before entering and exiting a resident's room who was on EBP. A review of the Hand Hygiene policy and procedure, dated as revised 3/24 revealed .the purpose of Hand Hygiene is to prevent the spread of potentially infectious organisms to residents/patients, staff and visitors .the Center for Disease Control and Prevention (CDC) recognizes two methods for Hand Hygiene .Alcohol Based Hand Sanitizers (ABHS) are the most effective products for reducing the number of germs on the hands of healthcare providers .when hands are not visibly dirty, ABHS are the preferred method for cleaning your hands in healthcare settings .full handwashing with soap and water are required for visibly dirty hands . When to perform some form of hand hygiene (at a minimum): Immediately before, between and after physical contact with a resident/patient . Before entering or exiting a resident's/patient's room . Handwashing is required anytime you are handling food; before putting on (donning) and after removing (taking off) PPE, including gloves. A review of the Enhanced Barrier Precautions (EBP) policy and procedure dated as revised 6/23 revealed .the purpose of EBP .to prevent the potential spread of Multi-Drug Resistant Organisms (MDRO) during high contact care activities of residents with increased risk .EBP expand the use of PPE .Hand Hygiene should be performed before and after resident contact .Education regarding this policy will be completed with appropriate personnel as needed . On 9/9/24 at 1:21 PM, no further information was provided by the facility. NJAC 8:39-19.4 (a); (n)

Based on interviews and review of electronic medical record, as well as review of pertinent facility documents on [DATE] and [DATE], the facility failed to ensure Certified Nursing Assistant (CNA#1) used a sit to stand lift and a two-person assist transfer in 1 (Resident #1) of 4 residents as determined necessary by the Resident's Holistic Care Plan (HCP). The failure to follow this intervention during the evening care transfer of Resident #1 by CNA #1 resulted in the Resident falling to the floor and became unresponsive subsequently requiring her/his immediate transfer to acute care hospital emergency room (ER) for further evaluation. In the ER, the Resident was found to have large bilateral subdural hematoma (a condition that indicates bleeding in the brain) and expired on [DATE]. The deficient practice was evidenced by the following: According to Resident #1's Face Sheet (FS), Resident was admitted with diagnoses which included but were not limited to Hydrocephalus, Alzheimer's Disease, Epilepsy, Osteoporosis, Major Depressive Disorder, Dementia with Behavioral Disturbances, Hypertension, and Dysphagia. The Minimum Data Set (MDS), an assessment tool that reflects Resident's care needs, revealed that Resident #1 was cognitively impaired and required assistance in her/his Activities of Daily Living (ADLs). A review of Resident #1 HCP with Date of Assessment of [DATE], indicated under 3b. Transferring - Functional Status: Level of Assistance, Resident required Extensive Assist with Two persons physical assist as support and with a Sit to Stand lift device. Resident #1's HCP further indicated under 3c. Walking - Functional Status: Resident do not ambulate and need the following device (wheelchair, manual). A review of Resident #1's Clinical Notes (CN) dated [DATE] at 11:40 PM (EST) [eastern] [evening] documented and E-Signed by Registered Nurse (RN#1), I was pushing the med cart to back hall, saw [CNA#1 name] asking for help. When I went to the room, I saw [Resident #1 name] lying on the floor, CNA [CNA #1] holding her head on a bed pad. Per CNA [CNA #1], while transferring the resident, the resident's body was sliding and she lowered her to the floor. Resident noted to be verbally unresponsive [vital signs], foaming mouth noted Undersigned called 911, notified NP [nurse practitioner name] with order to transfer to [acute care hospital name], notified daughter Transferred resident via stretcher to [acute care hospital name] at 8:10pm. A review of the facility's Resident Incident Report Form (RIRF) on Resident #1 on [DATE], the RIRF revealed there was no description or entry notes of the sit to stand lift equipment malfunctioned. The RIRF further revealed under Conclusion of the Investigation and completed by RN #2 (Clinical Manager/Wellness/Nurse Manager), RN #2 documented that Per initial CNA [CNA #1] statement, while she was transferring the resident using the stand-pivot technique, the resident began to shake and lost her balance. She then attempted to lower the resident to the floor. Upon further interview the CNA [CNA #1] stated that she was unable to lower the resident and both fell to the floor. The resident landed on her back. CNA is unsure if the resident struck her head during the fall. Resident was then noted to be verbally unresponsive .foaming mouth noted. 911 was called .and resident was transferred to [acute care hospital] . A review of the facility's Investigative Summary/Conclusion (ISC) documented and completed by Director of Nursing (DON), under Incident, On the evening of February 16, 2024, at approximately 7:45 pm, CNA [CNA #1 name], was transferring [Resident#1 name] in her private apartment. At the time of transfer, [CNA#1 name] stated that the resident began to shake and she attempted to lower [Resident #1 name] to the ground. [CNA#1 name] immediately called for help and RN [RN #1] promptly responded . The ISC further revealed that on [DATE], the DON upon re-interview with CNA#1, CNA#1 reported that she had been transferring the Resident using the stand-pivot technique without additional staff assist. DON stated Resident #1 care plan indicated the need for a sit to stand lift. The ISC further revealed when the DON and the Nursing Home Administrator (NHA) took formal interview from CNA#1, CNA#1 explained that she attempted to transfer the Resident independently by holding her under the arm and back. CNA#1 stated Resident #1 began to shake and she then attempted to lower Resident #1 to the ground. When CNA#1 was asked for further clarification regarding her statement of lowering her to the ground, CNA#1 stated, I tried to lower her, but her body was too heavy, we both fell . CNA#1 was then asked if she had questions of a resident's care needs, such as transfers, where would she find this information. CNA#1 stated, I would ask my nurse or look at my assignment sheet. CNA#1 then stated that she did not read or look at her assignment sheet. The ISC, under Conclusion, It is concluded that at the time of the event, CNA#1 [name] was not following the outlined plan of care. During the tour of the [name] 3 Unit on [DATE] at 10:50 am [morning], in the presence of RN #2 Nurse Manager, surveyor asked RN#2 what were those binders on bedside desk in each room of resident in which RN#2 stated the binders contained the HCP of each resident in their room. She further stated the binder, aside from the HCP, it also entailed the ADLS of the resident in the room. RN#2 stated the nursing staff, nurses, and the CNAs, would get their reports from the nurses at start of shift and they would be updated on the HCP and ADLs of residents in the binders. The binders were being used as well during a care plan meeting or family meeting of staff with residents and their families in the room. She stated the binders were updated by her every three months or as needed if there were changes. RN#2 further stated the nursing staff would have their competency on mechanical lifts such as Hoyer or body lift, sit to stand lift, gait belt use upon orientation, as needed (once a week or monthly), and annually. During the interview with the DON and NHA on [DATE] at 3:29 pm [afternoon], they affirmed that the incident occurred because of CNA#1 not following the HCP of the Resident. They stated that CNA#1 was suspended and eventually terminated, and that the facility reeducated all licensed staff on care plan process and mechanical lift competencies. N.J.A.C. 8:,d+[DATE].1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to notify the resident or the resident's representative in writing for a facility-initiated transfer to the hospital. This deficient practice was identified for 2 of 2 residents (Resident #103 and #111) reviewed for hospitalization discharge. The deficient practice was evidenced by the following: 1. On 5/17/23 at 1:31 PM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #103. The medical record revealed that the resident was transferred to the hospital on 3/2/23. According to the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/2/23, reflected that Resident #103 was discharged to the hospital with a return anticipated to the facility. On 5/23/23 at 1:15 PM, the surveyor discussed the transfer of Resident #103 to the hospital with the Licensed Nursing Home Administrator (LNHA) regarding written notification of discharge. The Administrator stated that no written notification was sent to the family or responsible party when Resident #103 was transferred to the hospital. 46049 2. On 5/24/23 at 11:04 AM, the surveyor reviewed the hybrid medical records for Resident #111, which indicated the resident was transferred to the hospital in March 2023. The Discharge MDS with a reference date of 3/22/23, reflected that Resident #111 was discharged to the hospital with a return anticipated to the facility. On 5/24/23 at 11:35 AM, the LNHA notified the surveyor that there was no documentation that the facility had notified the resident or resident representative in writing regarding the reason for transfer to the hospital. On 5/24/23 at 3:07 PM, the surveyor informed the LNHA and Director of Nursing of the above concerns. On 5/25/23 at 10:35 AM, the LNHA and DON met with the survey team. The LNHA acknowledged that written notification to the resident or their representative was not being provided, as they thought verbal notification was sufficient and were not aware notification in writing had to be provided. A review of the facility's policy titled, Skilled Nursing Initiated Transfer/Discharge with a version date of 6/2021 indicated under Procedure: 3. Prior to Continuing Care initiating transfer or discharge, the resident and resident representative must be notified of the reason for discharge in writing and in a language and manner in which they understand. The written notice must include the following: a. Reason for transfer or discharge . b. effective date of transfer or discharge .c. Location to which the resident is transferred or discharged .a. Statement of the resident's appeal rights .d. Name Address and telephone number of the Office of the Ombudsman .7. If a resident is temporarily transferred on an emergency basis to an acute care facility (facility initiated transfer), the notice of transfer must be provided to the resident and resident representative as soon as possible both verbally and in writing. NJAC 8:39-4.1(a)32

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool, for 1 of 26 residents, Resident # 17, system selected for MDS over 120 days and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. On 5/24/23 at 9:30 AM, the surveyor reviewed the medical records of Resident #17. A review of the MDS for Resident #17 revealed that a Quarterly MDS with an ARD of 1/9/23 was completed. The next quarterly assessment was due to be completed April 2023, which was not initiated or completed. On 5/24/23 at 9:38 AM, the surveyor interviewed the full-time Registered Nurse/MDS (RN/MDS) coordinator who was responsible for completing the assessments. The RN/MDS coordinator reviewed the completed MDS assessments of Resident #17 with the surveyor. The RN/MDS coordinator agreed that a quarterly MDS assessment should have been completed in April 2023. The RN/MDS coordinator acknowledged it was her responsibility to ensure that the resident's MDS assessment were accurately initiated and completed. On 5/24/23 at 3:07 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), and Director of Nursing (DON) of the above concerns. On 5/25/23 at 10:35 AM, the DON and LNHA met with the survey team and provided an MDS completion and management policy. A review of the facility's policy titled, MDS Completion and Management with a version date of 6/2021, under Policy read: Resident Assessments will be completed for all residents accurately and in compliance with the most current RAI 3.0 User's Manual. On 5/25/23 at 2:00 PM, the surveyor met with the DON and LNHA who provided no further information. NJAC 8:39 - 11.2(h)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a comprehensive person-centered care plan for a resident under Hospice care (care for a terminally ill person who's expected to have six months or less to live). This deficient practice was identified for 2 of 4 residents reviewed for Hospice comprehensive person-centered care plans, Resident #21 and Resident #35 and was evidenced by the following: 1. On 5/18/23 at 12:10 PM, the surveyor observed a STOP sign posted right outside Resident #21's room door. There was also signage indicating please keep door closed at all times thank you. On 5/18/23 at 1:53 PM, the surveyor reviewed the hybrid medical records for Resident #21. According to the resident's Admission record, the resident was admitted to the facility with diagnoses which included but were not limited to, Cerebral Infarction, Chronic Kidney Disease, and active COVID 19 respiratory infection. A review of the Significant Change in status assessment Minimum Data Set (SCSA/MDS), an assessment tool used to facilitate the management of care, dated 4/20/23 reflecting that the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately that Resident #21 had impaired cognition. Further review of the SCSA/MDS revealed that Resident #21 was under Hospice Care. On 5/18/23 at 2:00 PM, surveyor interviewed the nurse assigned to Resident #21 who stated that the resident's care plan was located in a separate binder from the resident's chart. A review of the resident's person-centered care plan revealed that there was no Hospice care plan included for Resident #21 who was receiving hospice care from 4/13/23 through 5/4/23. 31656 2. On 5/23/23 at 11:35 AM, the surveyor reviewed the hybrid medical records for Resident #35. According to the resident's Admission record, the resident was admitted to the facility with diagnoses which included, but were not limited to, Chronic Diastolic Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, and Gastrointestinal Hemorrhage. A review of the Quarterly MDS, dated [DATE] reflected that the resident could not have a BIMS evaluation, and was documented Severely impaired with no memory recall ability. Further review of the Quarterly MDS revealed that Resident #35 was under Hospice Care. On 5/23/23 at 11:50 AM, surveyor interviewed the nurse assigned to Resident #35 who stated that the resident's care plan was located in a separate binder from the resident's chart. A review of the resident's person-centered care plan revealed that there was no Hospice care plan included for Resident #35 who was receiving hospice care as of 11/25/22. . On 5/24/23 at 3:00 PM, the surveyor reviewed and discussed the above concerns with the facility's License Nursing Home Administrator and Director of Nursing who both agreed that there was no resident centered care plan addressing the that the residents were under hospice care. No further information was provided. NJAC8:39-11.2(c)

C #: NJ 986 Based on interviews and record review, as well review of pertinent facility documents on 5/26/22, it was determined that the facility failed to administer medication according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice is evidenced by the following: According to Resident #1 Face Sheet, the Resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) an assessment tool dated 5/24/22, showed that the Resident was cognitively intact. The Resident's care plan dated 5/12/22, under Acute Health Concerns showed that the Resident will not have serious complications from Acute Health Concerns. Interventions included but were not limited to the following: monitor fasting blood sugar (FBS) and provide insulin as ordered and medicate as ordered. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 units, 300-349= 3 units, 350-400=4 units, more than 400 call the physician. The Facility Reportable Event (FRE) dated 5/15/22 reported to the New Jersey Department of Health regarding a medication error involving Resident #1. The FRE showed that on 5/15/22 at 4:43 pm, Resident #1's BS was 249 milligrams per deciliter (mg/dl). According to the aforementioned sliding scale no [MEDICATION(S)] insulin was to be administered. However, Registered Nurse (RN #1, assigned to Resident #1) administered 100 units (u) of [MEDICATION(S)] to Resident #1. At approximately 5:15 pm, RN #1 mentioned administering 100 u of [MEDICATION(S)] insulin to RN #2. RN #2 reported the medication error administration to the nursing supervisor and primary physician (PP). The PP ordered to send the Resident to the Acute Hospital (AH). 911 was called, the Resident was monitored for signs and symptoms of [CONDITION(S)] (low BS). At the time emergency personnel came, Resident #1's BS was 129 mg/dl. The Resident was admitted for Insulin Overdose and in stable condition. RN #1 was suspended pending investigation. Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further showed that RN #1 administered 100 units of [MEDICATION(S)] insulin to Resident #1 on the following dates and time which was not according to the PP's order: On 5/14/22 at 9:00 pm with a BS of 242 (on the aforementioned PO the Resident should not receive [MEDICATION(S)] insulin). On 5/15/22 at 4:30 pm with a BS of 249 (on the aforementioned PO the Resident should not receive [MEDICATION(S)] insulin). The AH medical record dated 5/15/22 showed that the Resident was brought to the emergency room (ER) for evaluation of [CONDITION(S)]. The Resident stated he/she had accidental insulin overdose and received 100 u of insulin at the Facility. The Resident was treated with 150 ml of Dextrose medication in the ambulance. In the ER, the Resident's BS was 145 to 96. The Resident was admitted for Insulin Overdose, accidental or unintentional. The Resident returned to the facility on [DATE]. Interviewed with the Resident on 5/26/22 at 10:21 am, the Resident stated that he/she was notified of the medication error on 5/15/22. The Resident stated that even though he/she received the 100 u of insulin on 5/14/22 and 5/15/22, the Resident did not feel sick. The Resident further revealed that the ambulance personnel was quick to take him/her to the AH. Interviewed with RN #1 on 5/26/22 at 12:26 pm, she stated what was reported on the aforementioned FRE. She stated that RN #2 and her were discussing about the insulin medication and that was when RN #1 realized she administered 100 u of [MEDICATION(S)] to Resident #1 which was not according to the PP's order. RN #2 immediately reported the medication error to their nurse supervisor while RN #1 rushed to the Resident's bedside. The facility policy titled, Medication Administration, . dated 5/2021 showed Policy: Medication Management .and safe administration .consistent with the state requirements. All medications will be administered .consistent with the person centered comprehensive care plan .Procedure .2. Medication are administered in accordance with Nursing Standards of practice an in accordance with state law .3. Staff designated to administer medications will verify .using 5 Rights of Medication Administration .iii) right dose . NJAC 8:39-11.2(b) NJAC 8:39-27.1(b)

Based on interviews and document review it was determined that the facility failed to consistently respond to issues and concerns presented during resident council meetings and resident questionnaires obtained from residents in lieu of a formalized resident council meeting. This deficient practice was evidenced by the following: 1. According to a facility summary of individual resident questionaire document dated 01/19/21, individual questionnaires were passed out to residents by activity staff. The document revealed under the discussion/ follow up section, under the dining services current comments the food could come hotter. There was no documented response from the dietary department or any administrative staff regarding the concerns expressed by the residents. 2. According to a summary of individual resident questionaire document dated 02/23/21, individual questionnaires were passed out to residents by activity staff. The document revealed under the discussion/ follow up section, under the dining services current comments one resident commented they are tired of chicken and would like more seafood and the menu needs tremendous improvement including diversification and taste. There was no documented response from the dietary department or administrative staff regarding the concerns expressed by the residents. 3. According to a summary of individual resident questionaire document document dated 03/25/21, which revealed the discussion/ follow up for an in person resident council meeting. There was no documented response from the dietary department or administrative staff regarding the prior resident concerns. During the resident council meeting conducted by the surveyor on 05/06/21 at 1:00 PM three out of four residents stated the food was cold and there was too much chicken and pasta on the menu. On 05/10/21 at 9:04 AM, the surveyor interviewed the acting manager (AM) of the activity department. The AM stated that questionnaires were completed with the residents in person until resident council meeting could resume. She stated the meeting minutes were then uploaded for the management team to address any concerns and the management team included the administrator (LHNA). On 05/10/21 at 10:47 AM the surveyor reviewed the Resident or Family Group Meeting Policy, provided by the LHNA and dated 10/2020 . The policy revealed that if any concerns were conveyed in the resident group meeting, department heads responded to the group approved designated staff person within two weeks with a written action plan and action plans and minutes were submitted to the LHNA for signature. The surveyor interviewed the LHNA about the action plans for the concerns expressed by the residents. The LHNA stated that he could not provide any action plans for the resident concerns because it was more conversational than anything and there was no action plans. On 05/07/2 at 11:22 AM the surveyor interviewed the dietary general manager (GM) regarding receiving any resident food complaints since January 2021. He stated he could not recall if there were any concerns. On 05/10/21 at 11:12 AM the surveyor interviewed the GM regarding any feedback he had received regarding resident concerns from the resident council. He stated that he had not received resident council feedback since October 2020. He then provided the surveyor with a copy of an email with the subject resident council questionnaire feedback. The email revealed multiple residents stated there was too much chicken and the residents wanted more variety and choices. The email further revealed that multiple residents stated the food was cold at times. The surveyor inquired to the GM if he had completed an action plan related to the resident complaints. He stated no he did not as he was unaware that he needed to complete an action plan based on resident council feedback. NJAC 8:39-4.1(a)(29)

Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to: a.) consistently and appropriately assess, monitor and document the care of a [CONDITION(S)] AV fistula (arteriovenous fistula is an abnormal connection between an artery and a vein used for hemodialysis) site according to professional standards of practice and b.) create a resident centered care plan for the care of an AV fistula site for 1 of 1 residents (Resident #85) reviewed for [CONDITION(S)]. This deficient practice was evidenced by the following: According the the Face Sheet for Resident # 85, the resident was admitted to the facility with the diagnoses, which included but were not limited to, hypertensive [CONDITION(S)], and [CONDITION(S)]. The comprehensive admission Minimum Data Set, an assessment tool, dated 04/19/21 reflected that the resident was cognitively intact and received [CONDITION(S)]. 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. On 05/05/21 at 09:07 AM, the surveyor attempted to interview Resident # 85 who was not in his/her room. The surveyor interviewed the primary Licensed Practical Nurse (LPN) at this time who stated the Resident # 85 was at the [CONDITION(S)] center receiving hemodialysis. The LPN stated that Resident #85 had a [CONDITION(S)] AV fistula access site in the left arm and that the AV fistula site was monitored for Bruit (A bruit is an audible vascular sound associated with turbulent blood flow heard with the stethoscope) and Thrill (Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency) daily which was documented in the nurse's notes. The LPN added that there were no physician orders to monitor the [CONDITION(S)] access sites because the facility had a new computer system and it was difficult to put these types of orders into the program. She stated that they used to write orders to monitor [CONDITION(S)] access sites, but they don't do that anymore. She said they had this new computer program for the last 2 years. On 05/05/21 at 09:10 AM, the surveyor interviewed the Registered Nurse Clinical Manager (RNCM) for Rose Court 3 who stated that when a [CONDITION(S)] resident was admitted into the facility, and on hemodialysis the nurses were expected to check access site to make sure it was intact, and there were no signs or symptoms (S/S) of infection. She also stated that all [CONDITION(S)] access sites were checked every shift for bruit and thrill, pain, bleeding, and S/S infection. The RNCM further stated that there was physician orders (PO) written for the [CONDITION(S)] schedule that included the time and days that the resident received hemodialysis. The RNCM was unsure if there a physician order was required to monitor the [CONDITION(S)] access site. In the presence of the surveyor, the RNCM reviewed the physicians orders and Treatment Administration Records (TAR) for Resident # 85 and stated there were no physicians orders for resident #85 to receive hemodialysis, nor were there physician orders to monitor the [CONDITION(S)] access site. The RNCM added that the facility usually did not obtain physician orders to monitor the access site because it was a nursing judgement. On 05/05/21 at 12:21 PM, the surveyor interviewed the primary LPN who documented that she took Resident # 85's blood pressure in the left arm on 04/2/2021 at 10:07 AM while the resident was sitting. The LPN indicated that she made an error in documentation and that she did not take Resident #85's blood pressure in the left arm. She stated that Resident #85 was cognitively intact and would not allow anyone take his/her blood pressure or draw blood labs in the left arm. The LPN also added that the resident wore a warning bracelet on the left arm to indicate that the left arm was not to be used for blood draws for labs or for blood pressures. On 05/06/21 at 08:30 AM, the surveyor interviewed Resident #85 who was observed in his/her room sitting in a wheelchair. Resident #85 was alert and oriented and answered all questions appropriately. The resident indicated that he/she had been at the facility for a couple of weeks and was admitted after 3 days at the hospital. Resident #85 stated that the staff did not take blood pressures or draw blood for labs in the left arm. The surveyor observed that the resident had an AV Fistula on left arm that was covered with two bandages. Resident #85 removed bandages from the AV fistula site to show the surveyor. According to the resident, he/she had been on hemodialysis since November 10, 2019. The surveyor also observed that Resident #85 was wearing a black bracelet on his/her left wrist which included the following information, No blood pressure/ No Intravenous Needles on this arm. Additionally, the surveyor observed a pink Alert bracelet on the resident's left wrist On 05/06/21 at 09:05 AM, the surveyor observed the primary LPN assessing the left AV fistula site for patency. The LPN palpated the vascular access site to feel for the thrill, however she did not auscultate the vascular access with a stethoscope to detect a bruit. On 05/10/21 at 11:40 AM, the surveyor interviewed the LPN who stated that on 05/06/21 at 09:05 AM when the surveyor was observing her assessing Resident #85's [CONDITION(S)] access site for bruit and thrill and she did not use a stethoscope to detect the bruit, the LPN admitted to the surveyor that she forgot to do it. The Physician Order Sheet dated May 2021 and April 2021 were reviewed and did not reflect orders for [CONDITION(S)] access site care or monitoring and also did not include specific times and frequency that the [CONDITION(S)] access site should be monitored. The Treatment Administration Record (TAR) did not reflect physician orders to monitor and care for [CONDITION(S)] assess site. The undated Care Plan (CP) reflected that the resident goals were to be free from complications associated with [CONDITION(S)]. The CP indicated that the resident had a left arm fistula and that the access site was monitored for signs and symptoms of complications, however there were no specific complications listed as to what the nurse were to monitor or the frequency as to how often it was to be monitored. The surveyor reviewed the Clinical Notes Reports for May 2021 and there was no consistent documentation from nursing department that indicated Resident #85's AV fistula [CONDITION(S)] access site was monitored/assessed for complications such as bleeding or S/S of infection or patency. On 05/10/21 at 12:31 PM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) who stated that [CONDITION(S)] access site monitoring was a nursing intervention listed on the Care Plan (CP). When the DON was asked how the nurses were to know what type of monitoring the [CONDITION(S)] access site required, she stated that it was listed on the CP. The DON did not have an answer as to why the CP was not resident specific or why there was not a list of specific complications that the nurses were to monitor for the AV fistula access site. The DON added that [CONDITION(S)] access site monitoring did not require a physician order and did not need to be documented in the TAR to ensure accountability. She stated that the facility documented by exception and only if there was problem. She then stated that the physician order operating system in the computer did not allow for these type orders and that monitoring a [CONDITION(S)] access site was not a physician order and reiterated it was a nursing intervention. On 05/10/21 at 12: 40 PM, the surveyor interviewed the Registered Nurse Staff Coordinator (RNSC) who was responsible for nursing education and competencies who stated that the facility did not have specific education or competencies for the nurses related to AV fistula access care. The RNSC and DON agreed that they could not be 100% certain that the nurses knew how to monitor for complications of a [CONDITION(S)] access site if it the procedures were not documented. On 05/11/21 at 09:09 AM, the surveyors interviewed the DON who stated that the CP, was not as descriptive as I would have liked it to be. The DON stated that staff would need to make sure that there was no bruising or bleeding and to ensure that the resident's fistula was patent. The facility policy titled, [CONDITION(S)] with a revised date of 04/2019, reflected that the facilities will establish a process for each resident receiving care and services for the provision of hemodialysis and or peritoneal [CONDITION(S)] consistent with professional standards of practice. The policy will establish a process for residents who require [CONDITION(S)] receive services, consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. The policy did not reflect how the facility will monitor or care for [CONDITION(S)] access sites. The facility policy titled Care/Service Plans with a revised date of 04/2019, indicated that the Purpose/Scope was that each guest/resident will have individualized Care/Services plan developed. Care/Services Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences, and choices as well as clinical needs. The policy also indicated that each guest/resident will have an individualized care/service plan developed at the time of admission/readmission and that the care/service plan will be revised to reflect any changes in condition. NJAC 8:39-11.2(d)

Complaint #: NJ 747Based on observations, record review, interviews, and facility policy review, the facility failed to ensure residents grievances were promptly resolved for two (Residents #4 and #6) of four residents reviewed for call light response times. Specifically, the facility failed to resolve grievances related to call light response times. Findings included: 1. Resident #4 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 11/17/2020 revealed the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the concern report from Resident #4, dated 09/27/2020, revealed in part, Resident stated that (he's/she's) been in bed for hours, didn't get up all morning Investigation revealed staff had gone in four times between 1pm-3pm. Interviews revealed she called for various reasons including toileting, transfer and for snacks. (Staff member) stated (she/he) wanted to stay in bed, then got busy with other residents. Contacted family, will .encourage to get (resident) out of bed (OOB) at her preference. The above concern form was not documented to reveal resolution. Resident #4 was interviewed on 12/05/2020 at 11:23 a.m. The resident said call lights did not get answered timely. He/she said the night before was the worst. He/she had pressed the button for the call light. The resident said the care associate (CA) said she would let the nurse know about the pain. He/she said a half hour went by and there was no response. The resident went down to the nurse's station to wait for the nurse. The resident said the nurse told him/her was on break and there was nobody else to help her. The resident said she/he never had to wait half an hour before and was in severe pain. Review of the call history response time records revealed call light times greater than 20 minutes, four times in December 2020 and 23 times in November 2020. Response times were above 30 minutes on seven occasions in November 2020. 2. Resident #6 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 11/18/2020, revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the concern report from Resident #6, dated 11/16/2020, revealed in part, (Family member) stated that (the resident) was in bed all morning and used (his/her) call light bell but got no response. Called (family) to review call bell report. Explained that we responded as quickly as we could with other resident needs. Thankful for call .We worked with four CNAs (certified nursing assistants) and we were so busy on the morning and call bell, it did not stop. Also, (she/he) had completed bed bath and all meals on (sic) bed. The above concern form was not documented to reveal resolution. Resident #6 was interviewed on 12/05/2020 at 9:10 a.m. The resident said she/he was looking forward to getting out of bed. The resident said they got him/her out of bed yesterday, but he/she was in bed for an extended amount of time the day before yesterday. The resident said the call light responses took a while, but they would eventually answer. A family member for Resident #6 was interviewed on 12/05/2020 at 2:30 p.m. He/she said this resident was always left in bed for an extended period. The resident was put to bed early and was transferred out of bed late. The family member said this resident could use the call light. Review of the call history response time records revealed call light times greater than 20 minutes, four times in December 2020 and 26 times in November 2020. Response times were 30 minutes or longer, two times in December 2020 and 13 times in November 2020. Response time was three hours (two times) on 11/30/2020 and one hour (two times) on 11/29/2020. Licensed Practical Nurse (LPN #1) was interviewed on 12/05/2020 at 10:19 a.m. He/she said if a call light was on for three hours, then maybe the call light was out of order. He/she was not aware of any residents declining to get out of bed. CA #1 was interviewed on 12/05/2020 at 11:09 a.m. He/she said the call lights went directly to the phone. He/she said they tried to avoid having the residents wait too long. CA #3 was interviewed on 12/05/2020 at 12:42 p.m. He/she said sometimes they were busy with other residents, but he/she would call another co-worker to help. The Director of Nurses (DON) was interviewed on 12/05/2020 at 2:24 p.m. The DON said there was no specific care plan interventions related to the resident's call light aside from encouraging use and reminder for use. The DON said the expectation was for call lights to be answered in five minutes or less. He/she said at times it may have taken 10 minutes. The DON said the call lights got sent to everyone, not just one CA. He/she confirmed, It needs more attention . Review of the Call Bell System Response policy, dated 06/2019, provided by the NHA on 12/05/2020 at 2:38 p.m. revealed in part, Continuing care staff will respond to each residents' need when a call bell system activates. Review of the Concerns/Resolution policy, dated 11/2017, provided by the NHA on 12/05/2020 at 2:38 p.m. revealed in part, Whenever possible the staff member will take the initiative to resolve the concern when received and document the analysis and resolution on the form.

Complaint #: NJ 439 Based on observations, record review and interviews, the facility failed to ensure residents that were unable to carry out activities of daily living received the necessary services to maintain grooming for three (Residents #3, #7, and #8) of eight residents reviewed for nail care. Specifically, the facility failed to provide adequate nail care for the residents. Findings included: 1. Resident #3 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 09/14/2020, revealed the resident had severe cognitive deficit with a Brief Interview for Mental Status (BIMS) score of three out of 15. The resident had a functional status for personal hygiene of extensive assistance. Resident #3 was observed on 12/05/2020 at 9:15 a.m. in bed sleeping with a breakfast meal on the tray in front of him/her. The resident's fingernails were long, with nail polish coming off the nails. Resident #3 was observed again on 12/05/2020 at 12:49 p.m. The resident was sleeping in front of the mirror in a wheelchair. The resident's fingernails remained long and with fingernail polish coming off the nails. A family member for Resident #3 was interviewed on 12/05/2020 at 1:30 p.m. He/she said the resident was not admitted with bad nails and this resident's nails were nasty. Resident #3 was observed alongside the Director of Nursing (DON) on 12/05/2020 at 1:46 p.m. He/she confirmed there was accumulation underneath the resident's nails but was unsure what it was. He/she asked the resident if he/she wanted his/her fingernails trimmed and polished, and the resident agreed. The DON asked the care associate to take care of this resident's nails. 2. Resident #7 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 10/15/2020, revealed the resident had moderate cognitive deficit with a Brief Interview for Mental Status (BIMS) score of eight out of 15. The resident had a functional status for personal hygiene of extensive assistance. Resident #7 was interviewed on 12/05/2020 at 12:20 p.m. The resident's fingernails were observed with brown matter underneath. The resident said he/she needed nail care and, If they come do it, would be greatly appreciated. The resident was unable to remember the last time it was done, likely because of the resident's [DIAGNOSES REDACTED]. Resident #7 was observed alongside the Director of Nursing (DON) on 12/05/2020 at 1:48 p.m. The DON confirmed the resident's dirty nails and asked if the resident wanted to have his/her nails cleaned up and trimmed and the resident agreed. The DON asked a care associate to complete this task for the resident. 3. Resident #8 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 08/29/2020, revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident had a functional status for personal hygiene of extensive assistance. The resident had upper extremity impairment on one side for functional limitation in range of motion. Resident #8 was interviewed on 12/05/2020 at 11:04 a.m. The resident was observed with brown matter underneath his/her fingernails on the right hand. The resident said the staff did not clean his/her nails. I can't do it. The resident said he/she was scheduled about two days ago, but the staff did not have time. The resident said she/he had been waiting a long time for a manicure/pedicure. Licensed Practical Nurse (LPN #1) was interviewed on 12/05/2020 at 10:19 a.m. He/she said nail care was provided with or without showers and it was documented. Care Associate (CA #1) was interviewed on 12/05/2020 at 11:09 a.m. He/she said the resident's fingernails were checked every day and they received nail polish if they wanted. CA #2 was interviewed on 12/05/2020 at 12:46 p.m. He/she said they washed the resident's hands, and the residents needed to tell the CAs what they wanted done. When CA #2 observed Resident #8's nails, he/she said that activities was in charge of it. The Director of Nurses (DON) was interviewed on 12/05/2020 at 1:02 p.m. The DON said nail care was supposed to be provided in the morning and in the evening but there was no documentation completed. He/she said activities completed manicures and the CAs cleaned and cut the residents' nails. The CAs were expected to complete nail care for the residents. The DON was interviewed again on 12/05/2020 at 1:46 p.m. The DON said there was no consistent schedule for nail care, and it may need to be assigned with showers. The nursing home administrator (NHA) was interviewed on 12/05/2020 at 2:38 p.m., and he/she said they did not have a specific policy for nail care.

Based on observation, interview and record review, it was determined that the facility failed to ensure: a.) the accurate reconciliation of a controlled drug/[MEDICATION NAME] ([MEDICATION NAME]) from (MONTH) 2019 until (MONTH) 2019, and b.) an accurate accountability for a controlled drug/[MEDICATION NAME] ([MEDICATION NAME]) by resolving discrepancies in a timely manner. This deficient practice was identified for 1 of 1 electronic dispensing machines used to supply a back-up for controlled drugs. The evidence was as follows: On 6/6/19 at 9:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Clinical Manager (CM) was responsible for the reconciliation of the facility's back-up supply of controlled drugs (CD) stored in the electronic dispensing machine (EDM). On 6/6/19 at 9:59 AM, the surveyor and the CM observed the EDM which had a screen indicating a scrolling message that read, There are unresolved discrepancies. The CM accessed the EDM and made no mention of the scrolling message. At that time, the CM stated that the controlled drug back-up supply inventory was completed daily through an inventory count of each drug, and the count was recorded on the EDM Narcotic Count (a declining inventory log used for the accountability of controlled drugs). The CM also stated that the inventory was usually completed by the Nursing Supervisor and a nurse on the 11 PM to 7 AM shift, but if it was not done at that time, the 7 AM to 3 PM shift would complete the daily inventory count. The CM then stated that the inventory count had not been done for 6/6/19 yet, and she was responsible for completing the daily inventory. On 6/6/19 at 10:05 AM, the surveyor observed the CM with an RN, reconcile the controlled drug back-up supply stored in the EDM. On 6/6/19 at 10:20 AM during the controlled drug inventory count, the surveyor observed the RN state that according to the EDM Narcotic Count log, there were zero (0) tablets of [MEDICATION NAME] 5 milligram (MG). The surveyor reviewed the EDM Narcotic Count log and confirmed the count indicated zero (0) tablets for the [MEDICATION NAME] 5 MG. The CM counted the [MEDICATION NAME] 5 MG tablets in the drawer and stated that there was an actual count of 18 tablets. The CM stated that she was not sure how the discrepancy had happened, and would have to look into it. On 6/6/19 at 10:22 AM, the surveyor observed the CM and RN continue their controlled drug inventory. The CM stated that she thought there may be two separate drawers for the [MEDICATION NAME] 5 MG tablets, because there were two digital entries on the screen of the electronic dispensing machine. The CM spoke to the process of the inventory count, stating that there were two ways to access the inventory count. She stated that an inventory count could be conducted by entering the name of each controlled drug listed on the EDM Narcotic Count log and choosing the controlled drug entry on the screen. The CM stated that this may have been what the nurses had been doing, because the screen would not have indicated there was another drawer with additional tablets. The CM added that another method to complete a CD inventory was to chose a cycle count on the EDM screen which prompted the EDM to follow the internal electronic list of CD to be inventoried. The CM explained that a cycle count would open only the CD drawers that were programmed. The CM added that if the second drawer of [MEDICATION NAME] 5 MG tablets were not programmed, then it would not be prompted for the drawers to open and be counted. The CM then showed the surveyor on the EDM screen that there were two entries on the screen for [MEDICATION NAME] 5 MG, and therefore two drawers designated for [MEDICATION NAME] 5 MG. The CM stated that there was a drawer for [MEDICATION NAME] 5 MG tablets that had a count of zero (0), and a drawer for [MEDICATION NAME] 5 MG tablets that had a count of 18. The CM added that when there were two drawers for the same controlled drug, the EDM Narcotic Count log should indicate that. She confirmed the EDM Narcotic Count log only specified the drawer with the [MEDICATION NAME] 5 MG that had zero tablets, and not the one with the 18 tablets of [MEDICATION NAME] 5 MG. The CM added that the Provider Pharmacy would have to update the entries for the cycle count. The CM could not speak to why the EDM Narcotic Count log had not indicated that there were two drawers for [MEDICATION NAME] 5 MG. The CM also could not speak to if the second drawer for the [MEDICATION NAME] 5 MG tablets had been inventoried prior to surveyor inquiry. On 6/6/19 at 10:25 AM, the surveyor continued to interview the CM. The CM stated that she was responsible for resolving discrepancies in the EDM. The surveyor asked the CM if there were any outstanding discrepancies. The CM stated that there could be possible discrepancies, but she was not aware of any. The CM stated that she usually checked the EDM for discrepancies once a week. At that time, the surveyor with the CM reviewed the EDM for discrepancies. The screen revealed that there were two discrepancies both dated 05/31/19 for [MEDICATION NAME] 50 MG. The CM explained that the first discrepancy indicated that 22 tablets of [MEDICATION NAME] 50 MG were expected, and there were 23 tablets found in inventory. The CM stated that the second discrepancy was a continuation of the first discrepancy because the first [MEDICATION NAME] 50 MG discrepancy had not been resolved. The CM also stated that she kept a discrepancy log. On 6/6/19 at 10:36 AM, the surveyor and the CM reviewed the log of discrepancies which reflected the reason for each discrepancy. The CM stated that she had not resolved the [MEDICATION NAME] 50 MG discrepancy dated 5/31/19 yet. On 6/6/19 at 10:39 AM, the surveyor interviewed the DON who stated that all discrepancies for CD should be checked immediately. The DON added that she would have to review the discrepancies for the [MEDICATION NAME] 5 MG and [MEDICATION NAME] 50 MG with the CM. On 6/7/19 at 9:57 AM, the survey team met with the Administrator and the DON. The DON stated that 30 tablets of [MEDICATION NAME] 5 MG were received and stocked in the EDM on 3/26/19 into a second drawer. The DON also stated that the EDM Narcotic Count log was not updated for the second drawer. The DON could not speak to why the EDM Narcotic Count log was not updated. The DON also stated that the second drawer with the 30 tablets of [MEDICATION NAME] 5 MG stocked on 3/26/19 had not been inventoried during the daily count, because staff were not aware of the second drawer. The DON further stated that there were electronic entries which revealed the dates, times, and names of residents for the removal of [MEDICATION NAME] 5 MG tablets from the second drawer which reconciled the current count of 18 tablets. The DON stated there was no daily inventory being done for the second drawer from 3/27/19 until surveyor inquiry. The DON added that the Provider Pharmacy was going to review the need for two drawers for the same CD. In addition, the DON stated that the discrepancies for the [MEDICATION NAME] 50 MG tablets were resolved. The DON explained that the nurse who removed a [MEDICATION NAME] 50 MG tablet on 5/31/19 had inadvertently entered the same amount for the quantity found as the quantity remaining after removing one (1) tablet of [MEDICATION NAME] 50 MG for a resident. The DON added that discrepancies should be reviewed immediately and resolved within 24 hours. At that time at approximately 10:00 AM, the Administrator added that the facility policy for Narcotics/Controlled Substances was not specific for the EDM but that the policy was accurate for procedures regarding CD. On 6/7/19 at 11:06 AM, the surveyor conducted a phone interview with the Consultant Pharmacist (CP). The CP stated that she had done a unit inspection for the unit that had the EDM. The CP added that she does not have access to the EDM so she does not review the actual counts of CD. The CP explained that she reviewed the EDM Narcotic Count log which indicated if a daily inventory count was being done. A review of the facility policy, provided by the DON and dated (MONTH) 2019 for Narcotics/Controlled Substances included that the purpose of the policy was to ensure a strict control of narcotics be maintained at all times. The policy also included that controlled substances were counted on a regular basis, and all discrepancies required an investigation to begin immediately. NJAC 8:39-29.7(d)

Based on observation, interview and record review, it was determined that the facility failed to implement Care Plan (CP) interventions that were in place to prevent falls for Resident #7. As a result of this failure, Resident #7 sustained 2 falls, 1 which resulted in a fracture. This deficient practice was identified for 1 of 19 residents reviewed for implementation of CP interventions and was evidenced by the following: During the initial tour on 2/17/16, the Registered Nurse (RN) told the surveyor that Resident #7 had a history of [REDACTED]. Review of the electronic Fall assessment dated [DATE] indicated Resident #7 was at high risk for falls. Review of a Clinical Note dated 10/29/15 indicated that Resident #7 stood up from a wheelchair (w/c) unassisted and fell . Review of the falls CP included an updated intervention to seat resident at table in living room instead of by couch. Review of fall investigations dated 11/12/15 and 12/15/15 indicated that at the time of each of the falls, Resident #7 was not positioned at a table. The fall of 12/15/15 resulted in a left humerus fracture. On 2/22 at 1:30 p.m. the surveyor observed the resident seated in a wheelchair in the livingroom next to the couch. The resident was not seated at a table in accordance with the falls CP. Refer to F323 NJAC 8:39-11.1; 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide care consistent with identified safety interventions to prevent falls for Resident #7. As a result, the resident had a fall with a fracture. In addition, the facility failed to provide an environment free from potential safety hazards on one corridor of the facility. This deficient practice was identified for 1 of 8 residents reviewed for falls and for environmental safety as evidenced by the following: 1. During the initial tour on 2/17/16, the Registered Nurse (RN) told the surveyor that Resident #7 had a history of [REDACTED]. On 2/18/16 at 10:05 a.m., the surveyor observed Resident #7 seated in a wheelchair (w/c) in the living/dining room. The TV was on and music was playing. The w/c was positioned directly behind a couch and was locked in place. The surveyor reviewed Resident #7's medical record on 2/22. The initial Minimum Data Set (MDS), an assessment tool, dated 10/8/15 revealed that Resident #7 required extensive physical assistance of one person for transfers to and from a bed and/or chair, and was totally dependent on one person for locomotion on and off the nursing care unit. The surveyor reviewed the initial Fall Assessment for Resident #7, with any score higher than a 10 signifying a high risk for falls, indicated a score of 22. Review of the Admission Care Plan (ACP) for cognitive functioning revealed that Resident #7 has impaired cognitive skills as evidenced by: Decision making problems and Short term memory problems. Review of the ACP for falls indicated Assist for toileting & transfers PRN (when needed). Review of a Clinical Note (CN) dated 10/29/15 and timed 4:15 p.m. indicated that Resident #7 was in the living room during an activity, stood up without assistance, and fell before a staff member could intervene. The resident had no assessed injuries from the fall, however, 15 minute monitoring for two weeks was started, and a new safety intervention was initiated to seat resident at table during activities instead of by the couches. Review of a CN dated 11/12/15 and timed 7:20 p.m. indicated that Resident #7 was found lying flat on the floor in another resident's room. According to the note, the resident's shoes were off and a rolling walker (rollator) was next to the shoes. In addition to documented injuries which included pain in the left knee with a skin tear, pain in the left hand with bruising near the knuckle area of the middle finger, and a red, bruised area of the right elbow, the resident complained of back pain at a level of 5/10. Again, 15 minute monitoring for two weeks was started, the intervention to please seat resident at table continued and a new intervention to offer nap after rehab in afternoon was added. The surveyor reviewed the Investigation for the fall of 11/12/15. There were no staff statements provided to explain when staff last observed Resident #7 prior to being found in another resident's room. During an interview on 2/24/16 at 10:30 a.m., the Director of Nursing (DON) and Administrator stated that Resident #7 ambulated from the living room at dinner time when staff were busy assisting other residents. The DON stated that the staff did not see Resident #7 leave the living room, but agreed that the resident should not have been able to ambulate down a hallway unassisted which resulted in a fall in another resident's room. Review of the Care Plan dated 11/20/15 indicated to Assist w/(with) transfers (Mod/Max Assist of 2), and continued with the intervention to seat Resident #7 at tables, not on couches. Review of a CN dated 12/15/15 at 4:45 p.m. revealed Resident was in living room when (he/she) attempted to stand unassisted. According to the documentation, the resident lost balance and fell to the floor, left side down. Resident #7 sustained a left forehead laceration and complained of left shoulder pain at level 8-9 on a scale of 1-10. The resident was sent to the ER for an evaluation and returned the same day with a left shoulder immobilizer due to a fracture of the left humerus bone. On 2/22/16 at 1:30 p.m., the surveyor observed Resident #7 seated in a wheelchair in the living room next to the couch and upholstered chairs. The resident was not seated at a table in accordance with the Care Plan. On 2/23/16, the surveyor reviewed the facility investigation for the fall of 12/15/15 which indicated that prior to the fall, Resident #7 was sitting in the living room in a chair, speaking to a family member on the phone. The statements written by staff present at the time of the fall failed to clearly indicate whether or not Resident #7 was positioned at a table prior to the fall with injury. During an interview on 2/24/16 at approximately 10:30 a.m., the Administrator and DON stated that after talking with staff working that day, it was confirmed that the resident was seated in a chair which was positioned next to a wall while talking on the phone. The facility provided a staff statement clarification which indicated that Resident #7 was sitting in a regular chair by the wall and not at a table. According to other statements, staff were assisting other residents with meal clothing protectors and, although they observed Resident #7 getting up from the chair, they were unable to prevent the fall. 2. On 2/22/16 at 12:25 p.m., the surveyor observed a painter's work cart on the second floor. There was an opened can of paint with a paint brush inside it, as well as various paint rollers, wooden sticks and a set of keys on the top shelf. Two buckets attached to the side of the cart contained additional painting supplies. The cart was unattended and no staff or residents were in the immediate area. At 12:40 p.m., the RN moved the cart to a supervised area. During an interview on 2/24/16 at 10:30 a.m., the facility Administrator acknowledged that the cart should not have been left unattended due to the potential for hazard. NJAC 8:39-27.1(a) 8:39-31.4(a)