Every finding on record at Complete Care at Cedar Grove

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness.This deficient practice was evidenced by the following: 1. On 5/6/26 at 9:38 AM, Surveyor #1 and #2, in the presence of the Food Service Director (FSD), observed the following during the initial kitchen tour: The snack refrigerator which stored health shakes, sandwiches, and other snacks, had an external temperature on the refrigerator of 40 degrees Fahrenheit (F) and an internal thermometer reading observed at 54 F. The FSD acknowledged the reading was not an acceptable temperature and stated the temperature should be between 35-40 F. A temperature log on the refrigerator indicated the refrigerator temperature should not be above 41 degrees. At 9:51 AM, the FSD in the presence of the surveyors calibrated a facility thermometer. The FSD stated the thermometer was to be calibrated to 32 degrees using an ice bath. The FSD calibrated the facility thermometer to 33-34 F (32 F was reached but not held). At the same time, the surveyor's thermometer was calibrated to 32 degrees. At 9:55 AM, the FSD removed a chocolate health shake from the snack refrigerator to check its temperature. The health shake had a temperature of 59.2 F. The FSD acknowledged the temperature was not appropriate. The FSD stated the refrigerator had ongoing issues for months, and a maintenance request had been entered in the past to fix it. In the snack refrigerator, the temperature of a vanilla health shake stored on a tray in the refrigerator was checked and had a temperature of 58.7 F. There was a manufacturer's box of vanilla health shakes stored in the refrigerator, on the bottom shelf. The manufacturer's box indicated keep frozen. The box was not labeled with a date to indicate when it was removed from the freezer or received. The FSD stated it was delivered 2 days ago. The surveyors asked the FSD to remove a vanilla health shake from the manufacturer's box to check its temperature. The health shake had a temperature of 52.4 F. At 10:06 AM, the surveyors observed clear plastic packaging of chicken legs in a bin with water in a compartment of a two compartment sink. The chicken legs were not submerged or under running water. In the other compartment of the sink, were chicken breasts in clear plastic packaging in a bin under running water. Surveyor #1 interviewed [NAME] #1 about thawing meat products, who stated the item would be placed in cold water and under cold running water. The surveyor asked about the chicken products observed in the sink and the chicken legs not under running water or submerged in cold water. [NAME] #1 stated she could not speak to it as [NAME] #2 was working on the chicken. The FSD added [NAME] #2 pulled the chicken from the fridge less than an hour ago and was getting ready to season it. At the right side of the above food preparation sink, the surveyors observed cook ware on the counter. Surveyor #1 asked [NAME] #1 about the items. [NAME] #1 picked up a cooking pot stored there and stated that she was going to wash it now to use it. [NAME] #1 acknowledged the item was soiled and that soiled cookware were to be placed in the dishwashing area after use and not kept on the food preparation area. At 10:11 AM, the District Manager (DM) joined the surveyors and the FSD on the kitchen tour. At 10:12 AM, the FSD checked the temperature of the packaged chicken legs in the sink, which had a temperature of 62.4 F. The DM acknowledged it was not an appropriate temperature, it should have been under cold running water, and the chicken legs were not fully submerged in cold water. At 10:15 AM, the FSD checked the temperature of the chicken breast which was under running water in the other compartment of the sink. The temperature was 73 F. The FSD stated the chicken breast was pulled from the freezer three days ago, thawed in the refrigerator, and then placed in the sink under running water. At 10:18 AM, the surveyors observed on a food prep counter cooked meatloaf in pans, a pan of uncovered cooked ground meat and a pan containing cooked poultry covered with a clear plastic. [NAME] #2 stated she was responsible for the meatloaf and ground meat which were being served for lunch and were being cooled. The [NAME] stated she was not responsible for the poultry which she identified as turkey and stated it was [NAME] #1. [NAME] #1 stated the item was not supposed to be there, that it was for disposal and believed someone misplaced there. [NAME] #1 took away the pan to dispose of the turkey. At 10:23 AM, [NAME] #2 was asked about the chicken in the sink. The cook stated the chicken was pulled approximately 9: 30 AM from the Cook's refrigerator. At 10:30 AM, in the Cook's refrigerator there was a manufacturer's box which was labeled as being pulled from the freezer on 5/6/26 and contained packaged chicken breasts. The chicken breasts in the box were checked and had a temperature of 37 degrees. The FSD acknowledged the 5/6/26 date was not the accurate date, could not speak to date of item being pulled from the freezer and acknowledged that the chicken was already thawed in the refrigerator. The DM and the FSD stated for the items in the snack refrigerator and the chicken in the sink would not be used and would be discarded immediately. The DM stated the snack refrigerator had an ongoing issue with its function, which was reported to maintenance and facility management. The DM further explained that the refrigerator sometimes worked, didn't have issues all the time and that's why they have continued to use it. At 10:37 AM, in the walk-in refrigerator, the surveyors observed one torn, missing vinyl curtain in the entryway into the refrigerator. Inside the refrigerator were a crate of green peppers in which there were a couple of green peppers with a white fur-like substance and peppers with wrinkled skin. The FSD stated she checked the items in the refrigerator every 2 days and could not explain why the peppers were in the refrigerator as they should have been disposed. The FSD stated the peppers would be disposed of and removed. On a shelf in the reach in refrigerator, there was a tray labeled turkey bacon covered with clear plastic with written dates 5/4/26 to 5/9/26. The bacon was resting on a ready-to-eat product box on a shelf. The DM acknowledged the turkey bacon was uncooked and should not have been stored there. The FSD removed the item. On 5/6/26 at 11:14 AM, Surveyor #1, in the presence of Surveyor #2, informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional Director of Operations (RDO), and the Regional Clinical Director (RCD) of the above concerns. The LNHA stated she was not aware of any reported issues with the snack refrigerator in the kitchen. On 5/7/26 at 9:05 AM, the LNHA informed Surveyor #1 that the identified food items were discarded immediately; the snack refrigerator was not in use; the missing curtain was replaced; education was provided to the staff; and monitoring would be ongoing. 2. On 5/7/26 at 9:40 AM, in the presence of the FSD and the DMD, the surveyor # 3 observed the following: The surveyor # 3 observed that there was a shelf which contained steam table pans adjacent to the hand washing sink, with no partition between the sink and the shelf. The FSD was observed washing her hands and the surveyor # 3 observed that there were droplets of water coming from her hands which were landing on the steam table pans on the shelf. The FSD stated that the items on the shelf were clean. The FSD stated that the shelving unit was too close to the sink and she did not realize that the droplets of water were landing on those clean steam table pans. In the food preparation area, the surveyor # 3 observed a container filled with whole skin-on potatoes on the left side of the food preparation surface and two white colored towels dangling off the right side of food preparation surface. Both towels were observed to be wet and soiled with brown colored substances on them. There were no food service workers near the area. The DMD stated that the towels were soiled and should be discarded. The surveyor # 3 observed the three-compartment sink and observed that the second rinse sink was leaking water beneath the basin where the drainage pipes were connected. Water was leaking onto the floor. The DMD stated that the sink drain was broken and had been for quite some time. She further stated that they were waiting for it to be repaired. In the food preparation area, surveyor # 3 observed white colored food debris on the bottom shelf underneath the juice dispenser. On a shelf in the food preparation area, the surveyor # 3 observed eight 1/4 sized steam table pans and four square deep steam table pans, which were stacked with water between them. The surveyor # 3 observed a dark colored stringy material hanging off one of two fire suppression poles above the cook top area. The surveyor also observed one of two convection oven knobs soiled with white debris, which was easily lifted with the tip of the surveyors pen. The FSD stated that the oven knob does not come off but it should have been cleaned. The DMD was observed calibrating her thermometer with a water and ice mixture inside of a foam cup, so she could check the temperature of some of the food items in the kitchen. The DMD stated that she was unable to calibrate the thermometer to the correct temperature. The DMD stated that she was not aware of the water to ice ratio for calibrating her thermometer. The surveyor # 3 observed a brown colored, smeared substance on the floor between the stove and the steam table in the kitchen. The surveyor # 3 observed that there were two baffles with opened spaces between the two, above the cook top area where the stove was located. The DMD stated that she will have that fixed immediately. The surveyor # 3 observed several broken tiles on the floor in the kitchen, and the DMD stated that the facility is aware of the broken tiles and needed to fix them. The surveyor also observed the cove base between the walk-in refrigerator and the walk-in freezer was hanging off of the wall. In the cooks standing refrigerator, the surveyor # 3 observed two boxes of defrosted pork loin on the bottom shelf. One box of pork loin had a label which indicated a packed-on date of 1/28/26 and the other one had a label which indicated a packed-on date of 2/5/26. The two boxes had a received date of 4/27/26 on them. The FSD stated I think the pork items were frozen and now thawed yet, the FSD stated that there was no date on the packages to indicate when they were thawed from the freezer. In the walk-in refrigerator, on the lowest shelf, the surveyor # 3 observed a 5-pound package of ground beef, which was completely thawed and had a pulled from freezer thaw date of 5/6/26. The FSD stated that she was not sure if the beef would have been able to completely thaw in one day and stated it should be discarded. Additionally, in the same walk-in refrigerator, on higher up shelf, the surveyor # 3 observed a box which contained six individually wrapped mozzarella packages with a use by date of 4/25/26. The outside of the box had a hand written received date of 4/30/26 on it. The FSD stated that these should be discarded, as it is past the use by date, and could not explain why the received date was after the use by date. In the dry storage room, the surveyor # 3 observed above the ice machine, attached to the top of the wall, a water filtration system which had dual pre-filter canisters attached to the system. The canisters were tinted blue in color yet see through. The surveyor # 3 did not observed cartridges inside the water filter canisters and there was brown colored debris at the bottom of both canisters. The DMD and FSD stated that this is maintained by maintenance and do not know if there should be cartridges inside. The FSD and DMD stated that there should no be brown debris inside of the canisters and would have them cleaned. A review of the policy titled, nutrition quality of a standard, revealed safe food handling procedures for time and temperature control will be practiced subsequent storage of all food items. A review of the policy titled, general food and nutritional services, revealed all food preparation areas, food service area, and dining areas will be maintained in a clean and sanitary condition. On 5/7/26 at 1:20 PM, the Administrator brought the surveyor the manufacturer information for the water filtration, which revealed that there should have been a cartridge inserted into the two blue filter cartridge cannisters. The Administrator stated that she did not know when the cartridges were taken out and would have new ones put in as soon as possible. The surveyor received a hard copy of an email written from the DMD dated 4/20/26, which revealed 3-compartment sink, the leak remains an issue (see attached photo). There was a photo attached to the email which revealed that the bottom part of the sink, where the drain was located, was leaking water. On 5/7/26 at 2:20 PM, the surveyor # 3 discussed the above concerns with the Administrator and Director of Nursing (DON). 3. On 5/11/26 at 10:45 AM, Surveyor #1 with Licensed Practical Nurse (LPN) #1 inspected the pantry refrigerator on the 2 [NAME] unit and observed the following: -The refrigerator's temperature log which was checked every day in the morning and evening had two blank entries for 5/9/26 and 5/10/26 in the evening. In addition, on 5/8/26 the evening temperature was documented as 54 F and no corrective action was noted. LPN #1 stated the expected temperature range was 36 to 42 F. The temperature log indicated corrective action should be taken for a temperature greater than 41 F. The LPN confirmed the written temperature of 54 F was out of normal range and it was expected for maintenance to be notified to assess the issue. LPN #1 stated the dietary staff were responsible for checking the temperature of the pantry refrigerator. -In the refrigerator, there was a pizza box with an unsampled resident's name and room number; there was no date written to indicate how long it had been in the refrigerator. The LPN stated it was brought yesterday. LPN #1 acknowledged the item should have been dated. The LPN was not sure how long food could be stored in the refrigerator, but would find out. On 5/11/2026 at 10:49 AM, Surveyor #1 interviewed LPN Unit Manager (LPN/UM) #1 on the unit who stated an acceptable temperature range for the pantry refrigerator was 36 to 44 F and maintenance should be notified if the temperature was out of range. The surveyor informed the LPN/UM of the above concerns. On 5/11/2026 at 10:55 AM, Surveyor #1 with LPN/UM #2 on the 2 East unit inspected the pantry refrigerator and observed the following: -The refrigerator's temperature log which was checked every day in the morning and evening had two blank entries for 5/9/26 in the evening and 5/10/26 in the evening. LPN/UM #2 confirmed dietary was responsible for the temperature logs. LPN/UM #2 stated it was expected for items to be labeled with a resident's name/room number and dated by staff when going in the refrigerator. -A white recyclable bag was labeled with a resident's name which had a plastic container with food items dated 5/6/26. LPN/UM #2 stated items could be left in the refrigerator for 5-7 days but was not sure and had to confirm. - A fast-food bag containing food items was labeled with a resident's name and not dated. -A white recyclable bag with food items was not labeled with a resident's name or dated. - A black lunch bag with food items was not labeled with a resident's name or dated. LPN/UM #2 stated she did not know who it belonged to. On 5/11/26 at 11:10 AM, Surveyor #1 with LPN #2 inspected the 1 East unit's pantry refrigerator and observed the following: - The refrigerator's temperature log which was checked every day in the morning and evening had two blank entries for 5/9/26 and 5/10/26 in the evening shift. LPN #2 confirmed it was expected for items to be labeled with resident's name and dated by staff when going in the refrigerator. - In the refrigerator was a white restaurant bag containing food items, with 5/1 written on its side and no resident name. The LPN could not say who the item belonged to and was not sure how long food items could remain in the refrigerator; she would have to confirm. -In the refrigerator were two containers from a fast food chain with food items. The containers were not dated and had no resident name. The LPN acknowledged it should have been labeled. -In the refrigerator in the back of shelf was a half of a peanut butter and jelly sandwich in clear saran wrap which had no written date or name. The LPN acknowledged it should be labeled and then discarded the item. -In the refrigerator was a yellow top container with a label of a resident's name and room number. The container was not dated. The LPN stated the resident's family may have brought it yesterday but was not certain. - In the refrigerator was a brown paper bag containing a foiled food item. The bag was labeled with the resident's name and room number. There was no date. -In the refrigerator was a multicolored recyclable bag labeled with a resident's name and undated. The bag contained multiple food items including a carton of eggs that were less than half full. -In the refrigerator was a black plastic bag which contained a fast food container with chicken. The item was not labeled with a resident's name or date. LPN #2 disposed of the items. -In the refrigerator was a honey consistency beverage bottle which had a best used by date of 3/4/26. LPN #2 confirmed the item was expired, the bottle was open and had no written open date. The manufacturer's label indicated Discard if not used within 10 days of opening. LPN #2 discarded the item. -In the refrigerator was a nectar consistency beverage bottle which had a best used by date of 11/26/26. LPN #2 confirmed the bottle was open and had no written open date. The manufacturer's label indicated Discard if not used within 10 days of opening. LPN #2 discarded the item. -In the refrigerator was a blue recyclable bag labeled with a resident's name and contained a carton of eggs less than half full. The manufacturer's use by date of the eggs was May 10. -In the refrigerator was a white recyclable bag which was labeled with a room number and a date of 3/28/26. The bag contained variety of pre-packaged manufactured items and plastic bags with produce items. A clear plastic bag containing green grapes were covered in a white colored substance. A clear plastic bag of apples had some areas of dark discoloration. A clear plastic bag with two plums had wrinkled soft skin. A half pint carton of chocolate milk had a manufacturer best by date of March 30. A 6-ounce container of yogurt had a best by date of April 11, 2026. LPN #2 confirmed the items needed to be disposed. -In the freezer portion of the refrigerator there was a bag labeled with a resident's name, room number and 1-28. There was a packaged plain bread which had a clip that read [DATE]. There was also a packaged cinnamon raisin bread that had no indicated manufacturer's sell by or use by date on its packaging. On 5/11/26 at 11:29 AM, Surveyor #1 interviewed LPN/UM #3 of the unit. The LPN/UM was not sure how long food was allowed to be stored in the pantry refrigerator and believed dietary was responsible for ensuring there were not expired items in the refrigerator. Surveyor #1 informed the LPN/UM of concerns found in the refrigerator. LPN/UM #3 stated they would follow up on the concerns found. On 5/11/26 at 11:36 AM, Surveyor #1 interviewed the DON who stated food was to be stored in the refrigerator for three days and items should be labeled and dated when stored. The DON stated dietary staff were responsible for checking the temperature of the refrigerators and completing the log. The DON accompanied the surveyor to the 1 East pantry room and was informed of the concerns found in the pantry refrigerator. The DON stated that a new dietary company started recently, and the nurses may have thought dietary staff were checking the refrigerators as previously it was dietary staff who were responsible. The DON acknowledged the nurses should have been checking the refrigerators as well. The DON confirmed the pantry rooms were only accessible by staff. The staff assisted residents with storing and retrieving items in the pantry. On 5/11/26 at 11:48 AM, Surveyor #1 with LPN/UM #4 inspected the 1 [NAME] unit's pantry refrigerator and observed the following: -The refrigerator's temperature log which was checked every day in the morning and evening had two blank entries for 5/9/26 and 5/10/26 in the evening shift. LPN/UM #4 confirmed dietary was responsible for the temperature logs. - In the refrigerator was a nectar consistency beverage bottle with a best if used by date of 11/26/26. The bottle was opened and had no written date of opening. The manufacturer's label indicated Discard if not used within 10 days of opening. LPN/UM #4 acknowledged it should be labeled, could not determine when it was open and proceeded to discard the item. On 5/11/26 at 1:50 PM, Surveyor #1 informed the DON, the LNHA, the RDO, the RCD and the [NAME] President of Quality and Performance Improvement about the pantry refrigerator concerns. On 5/12/26 at 10:01 AM, the LNHA, the DON, the RCD, and the RDO met with the survey team. The DON stated all refrigerators were re-checked, staff were reeducated on the process of temperature checks and food storage in the refrigerator. Signage was placed in the pantry rooms and staff were assigned with the responsibility of checking refrigerators to prevent reoccurrence. The surveyor reviewed the facility's policy titled, Safe Storage of Food with a issued date of 9/1/21. Under Guidelines revealed, . 2. All perishable foods will be maintained at a temperature of 41 F or below, except during necessary periods of preparation and service. 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The surveyor reviewed the facility's undated policy titled, Foods Brought by Family/Visitors. Under Policy Interpretation and Implementation revealed: . 5. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 6. The nursing staff will discard perishable foods on or before the use by date. The surveyor reviewed the facility's policy titled, Safe Food Handling with a last reviewed date of 4/1/26. Under Standard revealed, All foods are prepared in accordance with the FDA Food Code. Under Guidelines of the policy revealed: 4. The Cook(s) thaws frozen items that requires defrosting prior to preparation. Thawing in the refrigerator, in a drip proof container, and in a manner that prevents cross contamination. Completely submerging the item under cold water (at a temperature of 70F or below). The total time to thaw should not allow the food temperature to exceed 41F for more than 4 hours. NJAC 8:39-17.2(g)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment. Specifically, the facility failed to: a) keep the facility's environment in an adequate state of repair on 1 of 4 nursing care units surveyed, and b) failed to clean and maintain the equipment and furnishings of 4 of 32 residents (Residents #15, #93, #154 and #183) reviewed for homelike environment.The deficient practice was evidenced by the following: 1.) On 5/6/26 at 10:45 AM, the surveyor observed in Resident #154's room, to left of the door inside the room, there were dark brown splatters on the wall about 5 feet up from the floor, light brown dry splatters noted on the base of tube feeding pole, the oxygen concentrator, the wall behind the equipment and on the floor next to the bed. there was also approximately a 2 inch by 4 inch tear in the wallpaper with a hanging flap above head board of window bed. On 5/6/26 at 11:15 AM, the surveyor observed in Resident # 15's room, there was an enteral feeding pole, which was heavily crusted with a dark brown and black substance around the base of the pole. The surveyor also observed on the resident's bedside table's door was hanging off by one hinge. On 5/7/26 at 10:21 AM, during a tour of the facility, in the common areas of the second floor east nursing care unit, the surveyor observed the following environmental concerns: several large dark round stains on carpeted hall floor between rooms 208-209, in the unit dayroom the baseboard heater in room, to left side of the windows had dented damage to it, and it was missing the front cover, the surveyor observed to the right of side of the windows the heater was covered in a dark brown substance which was crusty and dried in appearance, in the main hallway outside of the dayroom to the left of door the [NAME] molding was fractured with missing pieces, and lastly, the corner molding outside of room [ROOM NUMBER] was missing. On 5/7/26 at 10:26 AM, the surveyor interviewed the housekeeper and inquired how she reports issues, damage, and stains in carpet and the housekeeper stated I report to my supervisor or to the nurses. The surveyor inquired who cleans equipment in the resident rooms such as enteral feeding poles and bases and oxygen concentrators the housekeeper stated we wipe them down when we clean the room. On 5/7/26 at 10:42 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who was on the second floor east nursing care unit, who stated that we use TELs (a computer based log to report issues of damage or need for repair.) The LPN #1 stated I did receive training to report on TELs. The LPN acknowledged the broken corner moldings and damaged heaters in the dayroom but had not filed a report. On 5/7/26 at 10:47 AM, the surveyor interviewed the Unit Manager Nurse (UM) on the second floor west nursing care unit, the UM verbalized that broken furniture would be reported through TELs for repair. The UM acknowledged the bed side table door was broken in Resident #15's room. The UM confirmed soiled enteral feeding poles would be cleaned by housekeeping on their normal routine. The UM acknowledged enteral feeding pole in Resident #15's room was soiled and crusted with dark brown and black substance. On 5/11/2025 at 11:00 AM, the surveyor interview with Maintenance Director (MD) regarding homelike environment issues observed, The MD Acknowledged housekeeping is responsible for cleaning enteral feeding poles and resident equipment as part of their normal routine. The MD acknowledged the TELs system is used to report findings. The MD acknowledged the broken moldings, damaged heaters and soiled resident equipment noted on the second floor detract from the facility's homelike environment and need to be repaired or cleaned On 05/11/2026 at 1:25 PM, the surveyor and survey team met with Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) to discuss concerns both acknowledged environmental findings and that the findings detracted from the facility's homelike environment. 2. On 5/11/26 at 9:44 AM, on the 2nd floor, the surveyor observed an eight-inch break in the plastic corner protector, near the corner of Resident # 93's door, which was room [ROOM NUMBER]. On 5/11/26 at 9:46 AM, the surveyor observed Resident #93 in a low bed in their room. The surveyor observed a tube-feeding pole near the resident's bed. The metal base of the tube-feeding pole was brown-black in color, with chipped and rusted-like areas covering the metal surface. On 5/11/26 at 9:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who cared for Resident # 93, accompanied the surveyor into the resident's room. The LPN observed the pole and stated that the tube-feeding pole should not be dirty and rusted. The LPN stated that the maintenance department checked the resident equipment daily and they should have replaced this tube-feeding pole. On 5/11/26 at 1:20 PM, the surveyor discussed the above concerns with the Director of Nursing and Administrator. No further information was provided. 3. On 5/6/26 at 1:50 PM, the surveyor observed Resident #183 sitting in the day room in a wheelchair. The bilateral armrests of the wheelchair were worn with tears along the entire length with underlying padded exposed. A review of the resident's comprehensive care plan revealed the resident was at risk for skin breakdown related to fragile skin. Additionally, the resident was at risk for bleeding and bruising related to the use of anticoagulant medication. On 5/11/26 at 12:30 PM, the surveyor interviewed the unit Licensed Practical Nurse (LPN). He stated when he sees medical equipment which needs repair or replacement, he logs the request into the electronic reporting system and he also phones the Maintenance Director (MD). The surveyor showed the LPN Resident #183's wheelchair armrests. He stated he would contact the MD immediately. On 5/11/26 at 12:35 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) requesting further information on monitoring of the condition of medical equipment. On 5/12/26 at 10:10 AM the LNHA spoke to the surveyor and stated Resident #183's wheelchair armrests were replaced. She stated the Housekeeping and the Maintenance Departments do routine checks of equipment as they are cleaning. The LNHA provided the surveyor with the facility's policy titled Preventative Maintenance Program, implemented 9/30/25. Guideline #1 indicated the MD is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. On 5/12/26 at 11:15 AM, the surveyor interviewed the MD. He stated he has been working on his own since December 2025. He stated he did not have a preventative maintenance program. He relies on the staff to report requests for maintenance through the electronic reporting system. NJAC 8:39-31.2(e)

Based on observation, interview, and record review, it was determined that the facility failed to consistently ensure a.) against borrowing medications from another resident's medication supply, b.) the correct dose was administered, and c.) a completed medication was removed from active inventory . This deficient practice was identified for 2 of 5 residents (Resident #170 and #188) who were administered medications by 2 of 4 nurses observed, and 1 of 2 medication rooms inspected.The evidence was as follows:1.) On [DATE] at 8:25 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #188. The medications prepared included: Enoxaparin (Lovenox) injection 40 milligram/0.4 milliliters (mg/ml), inject 0.4 ml subcutaneously one time a day for deep vein thrombosis (DVT) prophylaxis. The order was started on [DATE] and scheduled for administration at 9:00 AM. At 8:33 AM, the surveyor observed LPN #1 pulled out the blister packed Enoxaparin 0.4 from a pharmacy labelled box, peeled the paper backing of the blister pack completely off, exposing the syringe.At that time, the surveyor requested to see the Enoxaparin box from which the nurse removed the medication from. The surveyor and LPN #1 reviewed the Enoxaparin box together which revealed a pharmacy label with Resident #21's name.At that time, LPN#1 stated that she read the dose without checking for the resident's name.At that time, the surveyor requested to see Resident #188's Enoxaparin box. LPN #1 searched then stated that Resident #188 did not have Enoxaparin 0.4 in the cart.The surveyor and LPN #1 reviewed the order history in the electronic Medical Record (eMR) together for when the Enoxaparin was ordered. According to the eMR, under order history the Enoxaparin was ordered on [DATE]. At that time, the surveyor requested the receipt invoice as evidence of when the Enoxaparin was delivered from the pharmacy.At that time, LPN #1 acknowledged and confirmed that she cannot borrow medications and take medications from someone else's inventory.2.) On [DATE] at 9:18 AM, the surveyor observed LPN #2 prepare medications for Resident #170 that included, Miralax Oral Packet 17 grams (polyethylene glycol 3350; gm), give 17 grams by mouth one time a day for constipation to equal (=) 1 scoop. The order was initiated on [DATE] and was scheduled for administration at 9:00 AM.At 9:36 AM, the surveyor observed LPN #2 while standing, poured the powder into the manufacturer's cap (cap), that was on the medication cart. The underside of the cap had a purple and white section. The surveyor observed that the Miralax powder poured did not reach the built in line, on white lined section of the cap.At that time, the surveyor asked LPN #2 how she measured 17 gm. LPN #2 stated that the whole white area of the cap measured 17 gm.At 9:42 AM, LPN #2 saw a facility staff member and asked the staff if they could call the Unit Manager (UM) for her. At that time, UM arrived and advised LPN #2 to follow the physician's orders. At that time, LPN #2 transferred the Miralax powder from the cap into a medication cup.At that time, LPN #2 remeasured the Miralax. LPN #2 while standing, poured the powder into cap, which was on the medication cart. The surveyor, for the second time, observed the Miralax powder poured did not reach the built in line, on white lined section of the cap. At that time, LPN #2 poured the measured powder into approximately four ounces of water and stirred with a plastic spoon.At 9:47 AM, LPN #2 stated she was ready to administer the medication.At 9:52 AM, LPN #2 placed the initial measured powder into an envelope and stated she did not have a drug disposal liquid in her medication cart but would dispose of the powder in the medication room.At 9:58 AM, the surveyor and LPN #2 reviewed the cap together. At that time, LPN #2 acknowledged and confirmed that the Miralax powder did not fill the cap to the built in line, on white lined section of the cap, did not pour at an eye level, and was not the full dose in accordance with the physician's order. 3.) On [DATE] at 9:44 AM, in the presence of LPN #3, the surveyor inspected the locked locker that contained both the house stocked over-the-counter medications and resident specific overstocked medications of 2-West. At 9:48 AM, the surveyor found a labeled blister packaged (bingo card) antiviral medication (Acyclovir) with Resident #11's name, the date on the bingo card was [DATE].A review of the electronic Medical Record (eMR) reflected that Resident #11's antiviral medication was discontinued on [DATE] [484 days including the day of the observation].On [DATE], at 9:57 AM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) stated that the expectation was a medication that was not part of a resident's active medication, would have been returned, pulled from the cart at a reasonable time of 24 to 72 hours. The ADON also stated that all the nurses in the shift were responsible for pulling all discontinued, expired, not active medications.On [DATE] at 10:00 AM, during an interview with the surveyor, the Unit Manager stated that the nurse usually pulled the medication and gave it to her and if she was not on shift, the other nursing supervisors were able and were also responsible to ensure the returns were completed. At that time, the UM stated that she would conduct an audit of the medication rooms to address the concern of unreturned medication.On [DATE] at 11:23 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Regional of Clinicals (RC), the [NAME] President of Quality and Performance Improvement (VPQPI) and the [NAME] President of Clinicals (VPC), and the Director of Nursing (DON), the surveyor discussed the concern that occurred during the medication pass when in LPN #1 used Resident #21's Enoxaparin to administer to Resident #188, LPN #2 who improperly measured Miralax, and the antiviral for Resident #11 with an end date of [DATE] was found in the medication room comingled with other Resident's active inventory.At that time, the DON acknowledged and confirmed that the Enoxaparin arrived and was in the medication room and LPN #1 should have checked the medication room for the received medication and should have not used another resident's medication and should have not taken the medication from the emergency back-up since the facility received Resident #188's Enoxaparin.No further information was provided.A review of the facility provided policy, titled Medication Administration, dated/revised on [DATE], included to ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right, route, right time, and right documentation. Further review reflected to administer medications as ordered in accordance with manufacturer's specifications.A review of the provided facility policy, titled Medication Storage, dated/revised on [DATE], included under, Unused Medication: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels. NJAC 8:39-11.2(b), 27.1(a), 29.2(d), 29.4(d)1, 29.4(g)

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on antianxiety, anticoagulant, diuretic, and hypnotic medications. This deficient practice was identified in 3 of 32 residents (Resident#7, 11, and #167) reviewed for CP. This deficient practice was evidenced by the following. 1.On 5/7/26 at 10:14 AM, the surveyor observed Resident #7 out of bed to the wheelchair and able to answer questions appropriately. On 5/12/26 at 12:04 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #7, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #7 was admitted with diagnoses that included but were not limited to heart failure, insomnia (difficulty falling asleep), and peripheral vascular disease (PVD, a disorder of the blood vessels). A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) on 3/31/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the Q/MDS reflected in Section N - Injections - High-Risk Drug Classes: Use and Indication revealed that the Resident #7 is taking hypnotic, anticoagulant, and diuretic medications. A review of the Order Summary Report (OSR) revealed the following order: -Zolpidem tartrate 10 mg (milligram) tablet by mouth at bedtime for difficulty sleeping, with an order date on 12/24/25. -Apixaban oral 5 mg tablet by mouth two times a day for peripheral artery disease (PAD, specific type of PVD) with an order date on 12/16/25. -Lasix 40 mg (furosemide) tablet by mouth one time a day for edema with an order date on 12/16/25. A review of Resident #7's comprehensive Care Plan (CP) report revealed no CP for the use of hypnotic, anticoagulant, and diuretic medications. On 5/12/26 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the hypnotic, anticoagulant, and diuretic should be included in the CP. Anticoagulant to monitor for bleeding, hypnotic and antianxiety to monitor for falls while on the medications, and diuretic to monitor effectiveness. He added that he doesn't do the CP for the residents. 2. On 5/6/26 at 9:58 AM, the surveyor observed Resident #11 in bed asleep. On 5/12/26 at 10:52 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #11, which revealed the following: A review of the AR reflected that Resident #11 was admitted with diagnoses that included but were not limited to parkinson's disease (neurological disorder), unspecified psychosis not due to a substance abuse or known physiological condition, and anxiety (feeling of fear or worry). A review of the annual Minimum Data Set (A/MDS) on 3/27/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the A/MDS reflected in Section N - Injections - High-Risk Drug Classes: Use and Indication revealed that the Resident #11 is taking an antianxiety medication. A review of the OSR revealed the physician's order for a clonazepam 0.5 mg tablet by mouth two times a day for anxiety. A review of Resident #11's comprehensive Care Plan (CP) report revealed no CP for the use of antianxiety medications. 3. On 5/7/26 at 0:10 AM, the surveyor observed Resident #167 sitting in a wheelchair inside the dayroom. On 5/12/26 at 11:35 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #167, which revealed the following: A review of the AR reflected that Resident #167 was admitted with diagnoses that included but were not limited to unspecified psychosis not due to a substance abuse or known physiological condition, and insomnia. A review of the recent Q/MDS on 4/4/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the A/MDS reflected in Section N - Injections - High-Risk Drug Classes: Use and Indication revealed that the Resident #167 is taking hypnotic medication. A review of the OSR revealed the physician's order for temazepam 15 mg capsule by mouth at bedtime for insomnia. A review of Resident #167's comprehensive Care Plan (CP) report revealed no CP for the use of hypnotic medications. On 5/12/26 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the hypnotic, anticoagulant, and diuretic should be included in the CP. Anticoagulant to monitor for bleeding, hypnotic and anxiety medications to monitor for falls while on the medications, and a diuretic to monitor effectiveness. He added that he doesn't do the CP for the residents.On 5/12/26 at 12:30 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who stated that the UM, Director of Nursing (DON), and the Supervisors are assigned to do the CP for the residents. She added that the nurses do not do the CP. On 5/11/26 at 1:11 PM, the team of surveyors met with the Licensed Nursing Home Administration, the DON, the Regional Director of Operations, the [NAME] President of Quality and Performance Improvement, and the Regional Nurse regarding the concern above, but did not provide further information. A review of the facility policy titled Comprehensive Care Plans with a revision date on 9/30/25 revealed under Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. NJAC 8:39-11.2(d)

Based on the interview, medical record review, and review of other pertinent documentation, it was determined that the facility failed to ensure that residents who receive hemodialysis (HD, a medical procedure used to treat kidney failure) receive such services consistent with professional standards of practice for 1 of 3 residents (Resident #19) reviewed for dialysis services. This deficient practice was evidenced by the following: On 5/6/26 at 10:05 AM, the surveyor observed Resident #19 in bed awake, alert, and able to answer simple questions. On 5/7/26 at 9:12 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #19, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #19 was admitted with diagnoses that included but were not limited to end-stage renal disease (kidneys can no longer function adequately to sustain life without treatment) and hypertension (HTN, when blood pressure is abnormally high) and dependence on renal dialysis. A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 3/12/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident had moderate cognitive impairment. Further review of the Q/MDS, as reflected in section O - Special Treatments, Procedures and Programs, revealed that Resident #19 was receiving dialysis. A review of the Order Summary Report (OSR) included the physician's orders for HD on Monday, Wednesday, and Friday with a pickup time at 2:45 PM, and an order for Prostat (protein supplement) SF (sugar-free) 30 ml (milliliters) PO (per oral) two times a day for the risk of malnutrition, with a start date of 3/19/26. A review of the electronic Medication Administration Record (eMAR) for the months of March, April, and May 2026 included nursing documentation for the following medications, which were charted to have been given on Mondays, Wednesdays, and Fridays (MWF) when the resident was out of the building at HD: Prostat SF 30 ml two times a day at 9:00 AM and 4:00 PM. A review of the electronic Progress Notes (ePN) documented by the Licensed Practical Nurse (LPN) in April revealed that on 4/1/26 at 2:29 PM, documented by LPN #1, and 4/3/26 at 5:19 PM, documented by LPN #2, the Prostat was not given due to Resident #19 went out to dialysis. A review of the ePN documented by the Registered Dietitian (RD) on 4/23/26 at 12:56 PM revealed that, noted afternoon Prostat administration is missed at times due to dialysis required adjustment of time to ensure administration. A review of the Care Plan (CP) report initiated on 12/12/24 focused on Resident #19, who is at risk for malnutrition related to below UBW (Usual Body Weight, the weight a person's most frequent body weight), inconsistent PO intake, need for supplement, ESRD on dialysis, edema, and history of weight loss. On 5/11/26 at 11:30 AM, the surveyor interviewed LPN#1, who confirmed that Resident #19 goes to the dialysis MWF pick up at 2:45 PM, but he said the resident comes back from dialysis during the 3-11 PM shift. On 5/11/26 at 11:31 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who stated that the nurses usually put the time for the resident's recommendation of the dietitian, especially those residents who attend dialysis. LPN/UM added that Resident #19 comes back from the dialysis between 7:00 PM and 7:30 PM. On 5/11/26 at 11:33 AM, the surveyor interviewed the RD, who stated that she gave a recommendation of Prostat 30 ml twice a day due to the resident's low albumin level of 4 (four) and elevated nutrient needs. On 5/11/26 at 1:11 PM, the team of surveyors met with the Licensed Nursing Home Administration, the Director of Nursing, the Regional Director of Operations, the [NAME] President of Quality and Performance Improvement, and the Regional Nurse regarding the concern above, but did not provide further information. A review of the facility's policy titled Hemodialysis, revised on 6/1/25, under Compliance Guidelines: 13. The facility will ensure that the physician's orders for dialysis include: f. any medication administration or withholding of specific medications prior to dialysis treatments. NJAC 8:39-33.2(c)4

Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to consistently ensure the proper positioning of a resident while the resident was receiving enteral nutrition via a g-tube (gastronomy-tube is a tube inserted into the stomach for nutrition).This deficient practice was identified for 1 of 2 residents (Resident #8), reviewed for enteral (tube) feeding and was evidenced by the followingOn 5/6/28 at 10:41 AM, during a tour of the first floor west-side, the surveyor asked the Licensed Practical Nurse (LPN) why Resident #8's door was closed. At that time, the LPN stated that the Resident's door was closed because they were receiving care from staff.On 5/6/25 at 11:07 AM, the surveyor observed Resident #8's door was opened. The surveyor entered the room, observed Resident #8 in bed, asleep, and observed the resident's head was almost flat on the bed, while the head of the bed was elevated. The surveyor also observed the residents TF of Jevity 1.5 infused at a rate of 70 milliliters/hour (ml/hr) per hour and delivered 1116 ml of volume. At that time, the surveyor observed the resident's call bell was on the floor.The surveyor reviewed the medical record for Resident #8.According to the admission Record, (face sheet) an admission summary, Resident #8 was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia (memory loss), dysphagia (swallowing disorder), gastrostomy status (G-tube; presence of a feeding tube).A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/3/26, reflected that a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. A review of section K, Swallowing/Nutritional Status reflected that the resident received 51% or more of their total calories through a parenteral IV (method of administration that bypasses the digestive system through an injection or infusion), or tube feeding (TF) and received 501 milliliters (ml) a day or more of fluids via an IV or TF.A review of the Care Plan (CP) included a focus on Resident #8's need for tube feeding related to their dysphagia, resistant [resistance] to eating and swallowing problems. The interventions included that the resident's head needed to be elevated 30 to 45 degrees during and 30 to 60 minutes after tube feed, initiated on 12/5/25.A review of the May 2026 Order Summary Report included an active order for Enteral Feed, Jevity 1.5 at 70 ml/hr for a total volume of 1425 ml and 2137 kilocalorie/24 hr.On 5/6/26 at 11:11 AM, the surveyor and the LPN entered Resident #8's room. At that time, the LPN acknowledged and confirmed the observation that the resident was not positioned properly and the resident's head should be at a 30-degree angle or higher during feeding. The LPN stated that the resident must have slid down.On 5/6/26 at 11:12 AM, the LPN informed the surveyor that she had to ask one (1) of the Certified Nursing Assistant (CNA) to help her reposition the resident to a 30-degree incline.On 5/6/26 at 11:13 AM, the surveyor observed the LPN, the CNA entered Resident #8's room, wearing personal protective equipment, and gloves. The LPN asked Resident #8 for permission to move them from a laying position, the resident was agreeable and repositioned the resident's head and upper body upright.On 5/7/26 at 2:13 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), Regional of Clinicals (RC), Regional Director of Operations (RDO), [NAME] President of Quality and Performance for Improvement (VP/QPI) and the Director of Nursing (DON), the surveyor discussed the concern with Resident #8's position that was almost flat while they received TF.On 5/11/26 at 1:12 PM, during a meeting with the survey team, the LNHA, the RC, the RDO, the VP/QPI and the DON acknowledged and confirmed that the resident's head should have been elevated, at least at a 30-degree angle. No further information was provided.A review of the provided facility policy, titled, Care and Treatment of Feeding Tubes dated/revised 1/16/26, included that the residents plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to collaborate as a multidisciplinary team and failed to clarify a diet order for one of seven residents reviewed, (Resident # 182) for nutrition.The deficient practice was evidenced by the following:On 5/11/26 at 9:37 AM, the surveyor observed Resident # 182 in bed. The resident appeared thin and greeted the surveyor when the surveyor came into their room.A review of Resident 3 182's medical record revealed the following:A review of the resident's diagnoses included, but were not limited to metabolic encephalopathy, severe protein-calorie malnutrition, dysphagia, dementia, muscle wasting and atrophy, and cachexia. A review of Resident # 182 admission minimum data set (an assessment tool), dated 4/26/26, revealed that the residents brief interview for mental status (BIMS) score of 12, which indicated moderate impairment for cognitive status. A review of the resident's physician's orders (PO) for Resident # 182 revealed that on 4/23/26 there was a PO for regular diet, minced and moist texture, and thin liquids consistency, on 4/24/26 the PO was changed to regular diet, puree texture, mildly thick / nectar consistency liquids, on 5/1/26 the PO was changed to regular diet, minced and moist texture, mildly thick / nectar consistency liquid, and on 5/5/26 the diet order was changed to regular diet, chopped texture, mildly thick/nectar consistency and dislikes eggs.A review of the diet order created on 4/24/26 by the Speech Language Pathologist (SLP) revealed food allergies: egg and egg product allergy. The egg/egg product allergy information was not added to the PO dated 4/24/26.Additionally, the SLP recommended to change the resident's diet on 5/1/26 and 5/5/26, with new diet orders, and they did not indicate egg or egg product allergy. A review of the medical nutrition therapy assessment (MNTA), dated 4/24/26, which revealed an assessment which was done by the Registered Dietitian (RD) # 1 and no known allergies was documented, minced and moist diet was noted. Further review of the MNTA revealed that there was no egg/egg product allergy noted.A review of all of Resident 3 182's progress notes did not reveal an egg/egg product allergy. A review of the resident's nutrition care plan revealed an intervention for Provide diet as ordered.On 5/11/26 at 10:50 AM, the surveyor conducted a follow up interview with Resident # 182, who was sitting in the wheelchair in the dayroom. The resident stated that they have no allergies, and that they just do not want eggs. On 5/11/26 at 11:03 AM, the surveyor interviewed the Registered Dietitian (RD # 1), who stated that she had been assessing Resident # 182 since their admission on [DATE], and the resident never told the RD that there was an egg allergy. The RD # 1 stated there were no allergies noted in the hospital records prior to the resident's admission on [DATE]. The RD # 1 stated that she was made aware that there was another part time RD (RD #2) who had seen the resident on 5/5/26. The RD # 1 stated that RD # 2 had asked for nursing to update the resident's diet order to indicated dislikes eggs on 5/5/26.There was no documentation in the resident's record to reflect the encounter with RD # 2.On 5/11/26 at 11:17 AM, the surveyor interviewed the RD # 2, who stated that on 5/5/26 she was visiting Resident # 182's roommate and then, as the RD # 2 was leaving the room, Resident # 182 told the RD # 2 that the resident cannot have eggs. The RD # 2 stated that she went to the Unit Manager (UM), and asked the UM to add dislikes eggs to the current diet order. Th RD # 2 stated that she did not document the encounter with the resident and that she should have documented it.On 5/11/26 at 11:30 AM, the RD # 1 told the surveyor that she called and interviewed the residents' close contact in the community, and the close contact stated that there was never any allergies to eggs and the resident always ate eggs while at home.On 5/11/26 at 12:39 PM, the surveyor observed lunch being served to Resident # 182 and dislikes eggs was noted the resident's tray ticket and there were no eggs on the resident's plate during lunch. The resident ate approximately 75% of meal and stated there were no issues with the meals served.On 5/11/26 at 1:08 PM, the surveyor interviewed the Speech Language Pathologist (SLP) who stated that she did write egg allergy on her initial diet order recommendation on 4/24/26, as the resident told the SLP that the resident had a sensitive stomach when eating eggs and the SLP wrote it as an allergy to alert the staff. The SLP stated that she was not sure if it was an actual egg allergy and did not follow up with anyone else about it. The SLP could not explain why the egg/egg product allergy was not on the subsequent diet orders and that she should not have written egg/egg product allergy on her initial diet order recommendation. On 5/11/26 at 1:50 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing (DON). On 5/12/26 at 10:09 AM, the DON told the surveyor that Resident # 182 did not have an egg or egg product allergy and the resident just did not want eggs. The DON stated that the SLP made an error writing it as an allergy, and the other team members, including the RDs and the nursing did not catch the error with documentation on the initial diet order written by the SLP, and they should have noticed it. The DON stated that there will be a process put into place to ensure that this does not occur again. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to: a) ensure implementation of interventions designed by the occupational therapist to stimulate functional performance and prevent further decline and b) ensure the interdisciplinary team provided timely revision to the care plan (CP).This deficient practice was identified for 1 of 2 residents reviewed for position and mobility, (Resident #17) and was evidenced by the following:On 5/6/26 at 10 :06 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the facility did not have a restorative program, was not sure about a functional maintenance program (FMP) and would get back to the surveyor. On 5/6/26 at 10 :19 AM, the surveyor observed Resident #17 in bed with their eyes closed, unaroused by surveyor's voice, and their body was covered with a blanket.On 5/7/26 at 10:29AM, the surveyor observed Resident #17 was turned to their right-hand side with their eyes closed.On 5/7/26 at 10:31 AM, the Registered Nurse (RN) entered the room and stated she was going to provide the bolus feed to the resident.The surveyor reviewed the medical record for Resident #17.According to the admission Record, (face sheet) an admission summary, Resident #17 was admitted to the facility with diagnoses which included but were not limited to; dementia (decline in mental ability that affects memory, reasoning and language), peripheral vascular disease (circulation disorder), congestive heart failure (progressive condition wherein the heart cannot pump blood well enough to meet the body's needs, causing blood to back up and fluid to collect in the lungs, legs and abdomen) and dysphagia (difficulty swallowing).A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/10/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Section GG 0115. Functional Limitation in Range of Motion reflected the resident had no functional limitation for the upper extremities and had an impairment to the lower extremity. The resident was dependent on all activities of daily living (ADL). Further review of the MDS under section O. 0500 Restorative Nursing Program, under section B for active range of motion was marked, zero.A review of the electronic Medical Record (eMR) did not reflect an order for Functional Maintenance Program.A review of the 9/8/25, Occupational Therapy (OT) Evaluation (eval) and Plan of Care reflected the resident was referred following a percutaneous endoscopic gastrostomy (PEG tube inserted through the abdomen to deliver nutrition, fluids, and medications) and to increase self-feeding. Additional reasons for the referral were due to decline in bed mobility, dynamic balance (maintain stability), functional mobility (ability to move freely), static balance (maintain a stationary posture), and proximal stability (strength and stability of the muscle closest to the body). Further review of the OT eval reason for therapy was that the resident had impairment with fine motor coordination, dexterity and strength which resulted in limitation and/or participation restriction in areas of self-care which required increased dependence on ADLs.A review of the 10/6/25, OT Discharge Summary, reflected that a Functional Maintenance Program, a range of motion program was established/trained for bilateral upper extremity (BUE) active assistance with range of motion (AAROM) during morning ADL routine in all planes [of motion, as] tolerated to maintain upper extremity function for ADLs.A review of the 1/13/26, and the 4/6/26, rehabilitation screens did not reflect a change in the FMP and reflected that the resident had no significant change from prior functional status.On 5/7/26 at 11:25 AM, during an interview with the Certified Nursing Assistant (CNA #1) she stated that she was familiar with all the residents. CNA #1 stated that the rehabilitation department taught her how to provide exercises for the residents. The care rendered was signed into the Point of Care (POC; Documentation Survey Report, located under tasks of the eMR).On 5/7/26 at 11:28 AM, during an interview with the surveyor, CNA #2 was unable to verbalize each daily service such as ADL, and FMP provided for residents and stated that all services provided to the residents were signed into the POC of the eMR.A review of May 2026 Documentation Survey Report (POC) did not reflect the OT recommendation was implemented.A review of the Care Plan was not updated with a focus and interventions related to the OT's recommendation on 10/6/25.On 5/12/26 at 12:40 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Regional of Clinicals (RC) and the [NAME] President of Quality and Performance Improvement (VPQPI), and the Director of Nursing (DON), the surveyor inquired as to what the facility's process was for FMP. The DON stated the FMP completed by the CNAs was documented in the POC for the staff to see what exercises were to be completed for the residents. The POC showed the daily care provided to the residents and signed by the CNA who provided the care. At that time, the surveyor discussed the concern regarding the missing FMP documentation to show that the program was implemented.On 5/13/26 at 11:23 AM, during a meeting with the survey team, the LNHA, the RC, the VPQPI and the [NAME] President of Clinicals (VPC), the DON stated the FMP was completed, but the CNAs did not have a place to sign on the POC to show that the FMP was provided for Resident #17. At that time, the VPC clarified the rehabilitation department initiated through a recommendation upon discharge from rehabilitation services and the nurse updated the POC to reflect the rehabilitation recommendations.A review of the provided facility policy, titled, Activities of Daily Living dated/reviewed 9/30/25, reflected that the Facility will provide a maintenance and restorative program to assist the residents in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. NJAC 8:39-11.2 (e)(1)(2), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plan (CP) report for 1 of 32 residents (Resident #11) reviewed for CP. This deficient practice was evidenced by the following: On 5/6/26 at 9:58 AM, the surveyor observed Resident #11 in bed asleep. On 5/12/26 at 10:52 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #11, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #11 was admitted with diagnoses that included but were not limited to Parkinson's disease (neurological disorder), unspecified psychosis not due to a substance abuse or known physiological condition, and anxiety (feeling of fear or worry). A review of the annual Minimum Data Set (A/MDS) (an assessment tool used to facilitate the management of care) on 3/27/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the A/MDS reflected in Section N - Injections - High-Risk Drug Classes: Use and Indication revealed that the Resident #11 is taking an antipsychotic medication. A review of the Order Summary Report (OSR) revealed the physician's order for Nuplazid 34 mg (milligram) capsule by mouth one time a day for Parkinson's disease psychosis with an order date on 1/22/26. The physician's order for Seroquel 50 mg was discontinued on 1/22/26. A review of the comprehensive Care Plan (CP) report initiated on 9/30/24 focused on Resident #11, who uses psychotropic medications Seroquel related to behavior management. The CP report was not revised for the use of Nuplazid medications. On 5/12/26 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who did not provide further information. He added that he doesn't do CPs for the residents. On 5/12/26 at 12:30 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who stated that the UM, Director of Nursing (DON), and the supervisors are assigned to do the CPs for the residents. She added that the unit nurses do not do the CP. The LPN/UM did not provide further information. On 5/11/26 at 1:11 PM, the surveyor team met with the Licensed Nursing Home Administration, the DON, the Regional Director of Operations, the [NAME] President of Quality and Performance Improvement, and the Regional Nurse regarding the concern above. No further information was provided to the survey team. A review of the facility policy titled Comprehensive Care Plans, revised 9/30/25, revealed under Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. NJAC-8:39 11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 4 of the 32 residents (Resident #8, 16, 19, and #77) reviewed for reasonable accommodations of needs/preferences. 1.) On 5/6/26 at 10:41 AM, during a tour of the first floor west-side, the surveyor asked the Licensed Practical Nurse (LPN) why Resident #8's door was closed. At that time, the LPN stated that the Resident's door was closed because they were receiving care from staff. On 5/6/25 at 11:07 AM, the surveyor observed Resident #8's door was opened. The surveyor entered the room, observed Resident #8 in bed, asleep, and observed that the resident's head was almost flat on the bed, while the head of the bed was elevated. Resident #8's enteral nutrition (small tube placed through the nose or mouth or stomach or small intestine to deliver nutrition) was being infused at a rate of 70 milliliters per hour and delivered 1116 ml of volume. At that time, the surveyor observed the resident's call bell was on the floor. On 5/6/26 at 11:11 AM, the surveyor and the LPN entered Resident #8's room. At that time the LPN acknowledged and confirmed that the call bell was on the floor and should have been within reach for Resident #8. According to the admission Record, (face sheet) an admission summary, Resident #8 was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia (memory loss), dysphagia (swallowing disorder), gastrostomy status (G-tube; presence of a feeding tube). A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/3/26, reflected that a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired and bilateral impairment to both upper and lower extremities. A review of Resident #8's care plan (CP) initiated on11/8/24 and revised on 3/6/25 reflected a focus for Resident # 8 's activities of daily living (ADL) deficit related to aggressive behavior and dementia. The interventions included, to encourage the Resident to use [call] bell to call for assistance which was initiated on 11/8/24. On 5/7/26 at 2:13 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), Regional of Clinicals (RC), Regional Director of Operations (RDO), [NAME] President of Quality and Performance for Improvement (VP/QPI), and the Director of Nursing, the surveyor discussed the concern with Resident #8's call bell that was on floor while they received their enteral nutrition. On 5/11/26 at 1:12 PM, during a meeting with the survey team, the LNHA, the RC, the RDO, the VP/QPI and the DON acknowledged and confirmed that Resident #8's call bell should have been within reach. A review of the provided facility policy, titled, Call Lights: Accessibility and Timely Response dated/revised 1/26/26 included that staff will ensure the call light is within reach of [the] resident and secured, as needed. 2.) On 5/6/26 at 10:30 AM, the surveyor observed Resident #16 in room [ROOM NUMBER], in bed awake and alert. The call bell was observed coiled on floor, toward the left side of the Resident's bed, near the head of the bed, and was out of reach. On 5/6/26 at 1:00 PM, the surveyor made a second observation of the call bell for Resident #16. The surveyor found the call bell coiled on floor, toward the left side of the Resident's bed, near the head of the bed, and was out of reach. On 5/6/26 at 1:30 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 and confirmed CNA #1 is assigned to care of the resident. CNA #1 accompanied surveyor to room [ROOM NUMBER] and confirmed the position of call bell for Resident #16. CNA #1 acknowledged it was coiled on the floor out of reach of the resident. CNA #1 acknowledged it should have been placed within residents reach. CNA #1 handed the call bell to Resident #16 at the surveyor's request and the demonstrated ability to grip device and activate button. CNA #1 positioned the call button fastened to bed rail on the residents left side within reach. On 5/6/26 at 1:40 PM, the surveyor interviewed the LPN #2 assigned to the care of Resident #16. the LPN #2 acknowledged that Resident #16 should have call bell placed within reach at all times. She acknowledged it was the CNA's responsibility to position call bells within the reach of the residents after care was provided and that CNAs and nurses are all responsible for checking the status of call bell placement between episodes of care. A review of Resident #16's electronic health record (EHR) reflected the resident was admitted to the facility on [DATE] with diagnoses including but not limited to: type 2 diabetes, hypertension and moderate protein calorie malnutrition. A review of Resident #16's minimum data set (MDS) an assessment tool, dated 3/31/26 reflects the resident has a Brief Interview for Mental Status (BIMS) reflects a score of 6 of 15 a finding of severe cognitive impairment and reflected no impairment of upper extremities including hands and wrists. A review of Resident #16 CP initiated on 2/1/26 reflected a focus for Resident # 16 to reduce the risk for falls and included the intervention of Be sure Resident #16's call light is within reach . encourage her to use it for assistance as needed . She needs prompt response to all requests for assistance. 3. On 5/6/26 at 10:05 AM, the surveyor observed Resident #19 in bed awake, alert, and able to answer simple questions. The surveyor observed that there is no call device available. Resident #19 roommate (Resident #113) told the surveyor that if Resident #19 needed to get to the nurse or aide, they were the one who called the staff for their roommate. On the same day at 12:50 PM, the surveyor observed Resident #19 out of bed to the wheelchair inside the dayroom. The surveyor went to the resident's room and observed that the resident's call device was still not available to the resident. On 5/7/26 at 9:12 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #19, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #19 was admitted with diagnoses that included but were not limited to end-stage renal disease (kidneys can no longer function adequately to sustain life without treatment) and hypertension (HTN, when blood pressure is abnormally high) and dependence on renal dialysis. A review of the recent quarterly MDS dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 8 out of 15, which indicated that the resident had moderate cognitive impairment. Further review of the quarterly MDS, as reflected in section GG, revealed that Resident #19 was dependent on staff for activities of daily living (ADL). A review of the CP report initiated on 12/10/24 focused on Resident #19, who is at risk for falls related to gait/balance problems, psychoactive drug use, and unaware of safety needs. Interventions included, but were not limited to, be sure the residents' call light is within reach and encourage the resident to use it for assistance as needed. On 5/7/26 at 9:47 AM, the surveyor interviewed the CNA # 2 , who attends to the residents regularly, who stated that they put the tap bell yesterday in the afternoon. The CNA # 2 did not provide further information regarding the call device, which was not present during the surveyor's rounds/observation yesterday. On 5/7/26 at 9:49 AM, the surveyor interviewed the LPN # 3, who stated that he does not know if the tap bell was there yesterday. On 5/7/26 at 9:51 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who stated that the tap bell was there, but could not identify the time. 4. On 5/6/26 at 12:45 PM, the surveyor observed Resident #77 in bed, awake, with both feet dangling in the bed. The surveyor observed that the call device was located all the way to the back of the resident's bedside nightstand and not within reach of the resident. The surveyor interviewed the LPN/UM regarding the concern. The LPN/UM took the call device from the back of the nightstand and put it within the resident's reach. The LPN/UM stated that the call device should be within the resident's reach. On 5/7/26 at 9:35 AM, the surveyor reviewed the hybrid medical record of Resident #77, which revealed the following: A review of the AR reflected that Resident #77 was admitted with diagnoses that included but were not limited to hemiplegia (complete paralysis of one side of the body), and hemiparesis (partial weakness or reduced movement) following unspecified cerebrovascular (impaired blood flow to the brain) disease affecting the left non-dominant side. A review of the recent Q/MDS dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the Q/MDS, as reflected in section GG, revealed that Resident #77 was dependent on staff for ADL. A review of the CP report indicates that there are no interventions that include the call device, which should be within easy reach of the resident for assistance. On 5/11/26 at 1:11 PM, the team met with the Licensed Nursing Home Administration, the Director of Nursing, the Regional Director of Operations, the [NAME] President of Quality and Performance Improvement, and the Regional Nurse regarding the concern above, but did not provide further information. A review of the facility policy title Call Lights: Accessibility and Timely Response, revised date of 9/1/25, revealed under Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call lights are within reach of the resident and secured as needed, and 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. NJAC 8:39-31.8(c)9

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the rights of a resident during the recreation activity of smoking. The deficient practice was identified for 1 of 2 residents (Resident #175), reviewed for smoking. On 5/6/26 at 11:18 AM, the surveyor observed Resident #175 seated in a wheelchair across the nurses' station. At that time, the Licensed Practical Nurse/Unit Manager identified Resident #175 as a smoker and that the resident was waiting in the hallway for a staff to escort them to the smoking area at 11:30 AM that morning.The surveyor reviewed the medical record for Resident #175.According to the admission Record, (face sheet) an admission summary, Resident #26 was admitted to the facility with diagnoses which included but were not limited to; schizoaffective disorder, bipolar type (chronic mental health condition that combines reality- distorting symptoms of schizophrenia (psychosis) with extreme mood swing of bipolar disorder and epilepsy (recurrent, unprovoked seizures).A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/14/26, reflected that Resident #175 was usually understood, had difficulty communicating some words or finishing thoughts but was able to if prompted or given time. The Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicated Resident #175 had a severely impaired cognition. Further review of the MDS reflected the resident had no limitation with upper extremity (shoulder, elbow, wrist, and hand) but had limitation with lower extremity (hip, knee, ankle, and foot) and utilized a wheelchair for mobility.A review of the Care Plan (CP) included a focus that Resident #175 was a smoker, initiated on 9/7/21. The interventions included that the resident required supervision, initiated on 9/7/21. Other interventions included that smoking supplies were stored with the Recreation [department], instructed the resident of the smoking risks and hazards, the smoking policy, location, times safety concerns and to observe clothing and skin for signs of cigarette burns, initiated on 9/7/21.Further review of the CP revealed that Resident #175 was dependent on staff for meeting their emotional, intellectual, physical and social needs due to cognitive deficits, initiated on 11/28/22. The interventions included that the recreation staff brought the resident outside two (2) times day for supervised smoking, initiated on 4/10/24.A review of the most recent Smoking Assessment, dated 3/17/26 included the following: Resident #175 smoked three (3) to four (4) times a day, had no desire to quit smoking, had no history of smoking related incidents (such as burning self, clothing, furniture, disposing of lit products in the trash/other inappropriate area, smoked in bed, dropped ashes on self, or smoking in a non-smoking area). Resident #175 had not exhibited signs of confusion, was able to make themselves understood, was able to verbalize or demonstrate understanding, was alert during smoking times, and able to communicate the need for help if lit material fell on them. Resident #175 had no visual loss and no dexterity problems. Further review of the assessment reflected the staff reviewed the policy related to smoking times and storage of smoking materials with the Resident and that the care plan was initiated/updated.On 5/7/26 at 9:57 AM, the surveyor observed Resident #175 in the hallway wearing their hearing aid, seated in their wheelchair facing the door of a locked unit.On 5/7/26 at 10:03 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated that Resident #175 liked to sit by the door and wait for their recreation of smoking which occurred at 11:30 AM and 4:00 PM to 4:30 PM.On 5/7/26 at 10:08 AM, during an interview with the surveyor, the LPN/UM stated the resident was not at risk for wandering, did not wear a monitoring device to prevent elopement, had dementia and was on seizure precaution. The LPN/UM stated that the resident was escorted for smoking and brought to the main dining area afterwards where they had their lunch.On 5/7/26 at 11:33 AM, the surveyor observed the Activities Director (AD) opened the door to the locked unit, and escorted Resident #175 who self-propelled themselves into the elevator. At that time, the surveyor observed the AD and Resident #175 self-propel through a short hall, through the dining area into the AD's office. The surveyor observed the AD remove her keys from her pocket and opened a locked cabinet that contained a locked box.At that time, the AD informed the surveyor that she was in possession of Resident #175's cigarettes and no one else. The AD removed one (1) cigarette and one (1) lighter from the locked box.At that time, the surveyor observed Resident #175 requested for 2 cigarettes to smoke outside. The AD informed Resident #175 that they could only smoke 1 cigarette without referring to any paper or computer.Resident #175 and the AD continued to argue back and forth about the number of cigarettes they wanted to smoke at that time. The surveyor observed Resident #175 inform the AD that the staff gave them 2 cigarettes in the past and the AD insisted that they could only have 1.At 11:43 AM, the argument between the AD and Resident #175 escalated to the resident wanting to hold their cigarette and lighter. The AD explained to Resident #175 that she would give their cigarette in the smoking area.At 11:53 AM, the surveyor observed Resident #175 ask the AD for another cigarette while still smoking their cigarette and self-propelled to the covered section of the designated smoking area.At that time, when the surveyor asked the AD how they knew how many cigarettes Resident #175 could smoke, the AD stated that it was in the Resident's CP. The AD also stated that she did not have the CP printed, did not review the CP prior to taking the resident out that morning, and did not have any additional documentation to show what type of assistance the resident needed or their preferences. The AD stated that she could review the CP, and that she would ask Resident #175 to self-propel their wheelchair into the facility for her to review the CP.At that time, the surveyor requested from the AD documentation the facility used as a smoking log.A review of the facility provided smoking logs from February 2026 to April 2026 reflected smoking times and staff initials.On 5/7/26 at 2:13 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), Regional of Clinicals (RC), Regional Director of Operations (RDO), [NAME] President of Quality and Performance for Improvement (VP/QPI), and the DON, the surveyor discussed the concern with the smoking observation wherein the staff had not reviewed Resident #175's CP prior to taking the resident out for their daily recreation of smoking, had no document to reference the needs and preference of the resident who smoked.On 5/11/26 at 1:12 PM, during a meeting with the survey team, the LNHA, the RC, the RDO, and the VP/QPI, the DON acknowledge and confirmed that the smoking process did not provide the staff with a list of who required an apron, how many they smoked, or their physical limitations, who needed assistance and what kind of assistance. At that time, the VP/QPI stated that a binder was in place as of 5/7/26, after surveyor inquiry that contained the smoking resident's information.No further information was provided. A review of the facility provided policy, titled Smoking Policy, dated/revised 1/5/26, included that it is the policy of [facility name redacted] to provide a safe environment for our residents, employees and visitors.A review of the facility provided policy, titled Promoting/Maintaining Resident Dignity, dated/revised 9/1/24, included that the resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. NJAC 8:39-4.1 (a) 3

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that residents were served their meals in a manner that promoted respect and dignity for 3 residents (Resident #20, #22 and #27) observed during a lunch meal service on 1 of 5 dining areas (1-West).This deficient practice was evidenced by the following:On 5/6/26 at 12:13 PM, the surveyor observed the lunch meal service in the dayroom located at 1-West. Residents #20 and #22 were seated in their respective chairs, across from each other, at a table with two other residents. At 12:14 PM, the surveyor observed Licensed Practical Nurse (LPN #1) standing over Resident #20 while feeding the resident their lunch and at the same time, observed Certified Nursing Assistant (CNA #1) standing over Resident #22 while feeding the resident their lunch.At 12:16 PM, LPN #1 stopped feeding Resident #20, who was not finished eating, walked away from the resident and exited the day room. CNA #1 covered a resident's plate [no hand hygiene performed] and continued to feed Resident #22 their lunch, while standing over the resident.At 12:22 PM, the surveyor observed CNA #2 enter the dayroom, walked over to Resident #20, and stood over the resident while feeding the resident their lunch.At 12:23 PM, the surveyor observed LPN #1 returned into the dayroom, walked over to Resident #27, stood over the resident, and began to feed the resident their lunch. There were no additional chairs in the dayroom observed.At 12:25 PM, the surveyor observed LPN #1 exited the dayroom. At that time, during an interview with the surveyor, LPN #1 stated that there were not enough nurses to help feed the dependent residents which was the reason why she had stopped feeding Resident #20 and started with Resident #27.At that time, the surveyor discussed the concern with the LPN/Unit Manager and the Director of Nursing (DON). The DON stated that she had previously provided the staff with an in-service on dining service protocol and would provide another one that day. The LPN/UM and the DON both acknowledged and confirmed that the staff should not have been standing over the residents and should have been seated next to the residents. The surveyor reviewed the medical record for Resident #20.According to the admission Record, (face sheet) an admission summary, Resident #20 was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease ( a progressive, irreversible brain disorder, a type of dementia that affects memory, thinking, behavior, an eventual loss of ability to perform daily tasks, such as eating, or walking) and peripheral vascular disease (circulation disorder). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/17/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS reflected the resident required partial/moderate assistance with eating (the helper does less than half of the effort).A review of the Care Plan (CP) reflected a focus on Resident #20's malnutrition due to dementia, was dependent on oral nutritional supplements to meet nutrient needs, initiated on 2/22/22 and revised on 5/6/26. The intervention included, to assist with meals as needed, initiated on 2/22/22. The surveyor reviewed the medical record for Resident #22.According to the face sheet, Resident #22 was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing), anxiety, and difficulty walking.A review of the MDS, an assessment dated [DATE], revealed the BIMS was not conducted and Resident #22 was rarely/never understood. Further review of the MDS reflected the resident required substantial/maximal assistance with eating (the helper does more than half of the effort).A review of the CP included a focus on Resident #22's moderate malnutrition status, attributed to 75% consumption of their needs greater than (1) week, body fat loss, and muscle mass loss, revised on 4/30/26. The intervention included, feed at mealtimes, initiated on 4/30/26. The surveyor reviewed the medical record for Resident #27.According to the face sheet, Resident #27 was admitted to the facility with diagnoses which included but were not limited to; dysphagia (difficulty swallowing), anxiety, and generalized muscle weakness.A review of the MDS, an assessment dated [DATE], revealed the BIMS was not conducted and Resident #27 was rarely/never understood. Further review of the MDS reflected the resident required substantial/maximal assistance with eating. A review of the CP included a focus on Resident #27's risk for malnutrition, attributed to variable intake, need for nutrition/protein supplements and need for feeding assistance, revised on 4/30/26. The intervention included, feed at mealtimes, initiated on 4/30/26. On 5/6/26 at 12:25 PM, the surveyor observed LPN #1 exit the dayroom. At that time, during an interview with the surveyor, LPN #1 stated that there were not enough nursing staff to pass the meal trays and feed the residents that were dependent or required assistance.At that time, the surveyor informed the LPN/UM and the Director of Nursing (DON) regarding the observation during the lunch service. The DON also stated that standing over a resident while assisting with their meal was not their practice and that a recent education was provided to the staff.On 5/7/26 at 2:13 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), Regional of Clinicals (RC), Regional Director of Operations (RDO), [NAME] President of Quality and Performance for Improvement (VP/QPI), and the DON, the surveyor discussed the concern with the nurses that stood over the residents they had assisted for eating and fed. At that time, the DON confirmed and acknowledged that the staff should not have been standing over the residents. The DON also stated that an education on dining service protocol was recently provided to staff.No further information was provided. A review of the provided facility policy, titled, Promoting/Maintaining Resident Dignity dated/revised 9/1/25 , reflected that it was the facility's practice to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residence quality of life by recognizing each residence individuality. NJAC 8:39-4.1(a)12 .

Based on observation, interview, and record review it was determined the facility failed to administer medications with parameters in accordance with a physician's order and standards of practice for 3 of 32 residents (Resident #19, #174, and #179) reviewed.The deficient practice is 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 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. 1. On 5/6/26 at 10:05 AM, the surveyor observed Resident #19 in bed awake, alert, and able to answer simple questions. On 5/7/26 at 9:12 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #19, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #19 was admitted with diagnoses that included but were not limited to end-stage renal disease (kidneys can no longer function adequately to sustain life without treatment) and hypertension (HTN, when blood pressure is abnormally high) and dependence on renal dialysis. A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 3/12/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident had moderate cognitive impairment. Further review of the Q/MDS, as reflected in section N – High-Risk Drug Classes: Use and Indication, revealed that Resident #19 was receiving diuretic medications. A review of the Order Summary Report (OSR) included the physician's orders for torsemide tablet 100 mg (milligram) PO (per oral) one time a day for HTN, hold for SBP (systolic blood pressure, top number in blood pressure reading), less than 120, with a start date of 12/9/25. A review of the electronic Medication Administration Record (eMAR) for March 24 to 31, 2026, April 1 to 30, 2026, and May 1 to 6, 2026, after the surveyor's inquiry included nursing documentation of torsemide 100 mg one time a day for HTN hold for SBP less than 120, which was charted to have been given daily at 9:00 AM revealed that there was no documentation of the resident's BP at the time of the torsemide medications administration. A review of the weights and vitals section of the electronic Medical Record (eMR) revealed no consistent documentation of Resident #19's BP for each torsemide administration to reflect that the medication was administered as per the physician's orders. A review of progress notes revealed documentation for the resident's torsemide administration; there was no consistent documentation of the resident's BP results at the time of the administration of torsemide. A review of the Resident #19 OSR included the physician's orders for metoprolol tartrate tablet 50 mg PO two times a day every Monday, Wednesday, and Friday at 9:00 AM and every Tuesday, Thursday, Saturday, and Sunday at 5:00 PM for HTN, hold for SBP less than 110 or HR less than 60, with a start date of 12/9/25. A review of the Chart codes/Follow-up codes in the eMAR revealed 3=hold/see nurses, check symbol=administered, and 7=other/see nurse notes. A review of the eMAR for March 2026 revealed the metoprolol tartrate medication was documented as administered with a BP less than 110 of the following: On 3/16/26 at 9:00 AM, BP of 108/60 On 3/27/26 at 9:00 AM, BP of 96/64 On 3/28/26 at 9:00 AM, BP of 105/61 A review of the eMAR for April 2026 revealed the metoprolol tartrate medication was documented as administered with BP less than 110 of the following: On 4/1/26 at 9:00 AM, BP of 98/59 On 4/4/26 at 9:00 AM, BP of 105/67 On 4/9/26 at 5:00 PM, BP of 96/52 On 4/13/26 at 9:00 AM, BP of 108/51 On 4/17/26 at 7:00 PM, BP of 100/71 On 4/18/26 at 5:00 PM, BP of 100/65 On 4/23/26 at 5:00 PM, BP of 105/71 On 4/24/26 at 7:00 PM, BP of 109/68 On 4/26/26 at 9:00 AM, BP of 101/58 A review of the Resident #19 OSR included the physician's orders for midodrine HCL (hydrochloride) tablet 10 mg PO every 8 hours as needed for low BP less than 100 for 10 days with an order date of 3/29/26. A review of the eMAR on March 29 and April 8, 2026, revealed that there was no documentation of the BP during the time of the midodrine medication that reflects the physician's order. A review of the weights and vitals section of the eMR revealed no consistent documentation of Resident #19's BP for the 8 hours as needed for midodrine administration to reflect the physician's orders. A review of progress notes of the eMR revealed that there was no consistent documentation of the resident's BP every 8 hours as needed for a 10-day order of midodrine to reflect the physician's order. On 5/7/26 at 9:55 AM, the surveyor interviewed the LPN, who is assigned to Resident #19, regarding the above concern, but the LPN did not provide further information. On 5/7/26 at 10:27 AM, the surveyor interviewed the LPN/UM, who stated that there must be some changes in the order, but the BP should be there so the nurses can see if they will give the medication or hold it at that time. The LPN/UM did not provide other information regarding the above concern. On 5/11/26 at 1:11 PM, the team of surveyors met with the Licensed Nursing Home Administration, the Director of Nursing, the Regional Director of Operations, the [NAME] President of Quality and Performance Improvement, and the Regional Nurse regarding the concern above, but did not provide further information. A review of the facility's policy titled Medication Administration, revised on 8/8/2025, under Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable, order physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 2. On 5/7/26 at 12:16 PM, the surveyor reviewed the electronic medical records (EMR) of Resident #174. The admission Record (a summary of important information about the resident) revealed that Resident #174 had diagnoses that included but were not limited to, End Stage Renal Disease, hypertensive heart and chronic kidney disease. A physician's order dated 12/9/25 indicated to give metoprolol tartrate 25 milligram (mg), give half a tablet by mouth two times a day hold for systolic blood pressure (SBP; the top number in a blood pressure reading which measures the maximum pressure in your arteries when the heart beats) less than 100 and heart rate (HR) less than 60. The medication was scheduled to be given to Resident #174 at 8 AM and 4 PM. A physician's order dated 12/2/25 indicated to give midodrine (a medication to help treat low blood pressure) 2.5 milligram (mg), one tablet by mouth three times a day; Hold for SBP greater than 130. The medication was scheduled to be given to Resident #174 at 9 AM, 3 PM, and 9 PM. A review of the March 2026 Medication Administration Record (MAR) revealed: - For the midodrine order entry on 5/1/26 at 9 AM, and 3 PM, the medication was administered when it should have been held as the documented SBP was greater than 130. At 9 AM, the BP result was documented as 140/77. At 3 PM, the BP result was documented as 134/81. -There was no documentation of the blood pressure (BP) and HR results at the time of the metoprolol tartrate medication's administration to the resident. A review of the Weights and Vitals section of the EMR revealed no consistent documentation of Resident #174's BP and HR for each metoprolol tartrate administration to reflect that the medication was administered as per the physician's orders. A review of progress notes revealed no additional documentation of the resident's BP and HR result for each metoprolol tartrate administration. On 5/7/26 at 1:39 PM, the surveyor interviewed a Licensed Practical Nurse (LPN) about medications with parameters. The LPN stated BP and HR were checked prior to the medication's administration and the parameters were indicated in the physician's order. The LPN further explained if the results were outside the parameters of the medication order, the medication was held, not administered to the resident, and the entry signed as to why the medication was not given. The LPN stated the BP and HR results were documented in the MAR under supplementary documentation of the entry. The surveyor asked the LPN what the expectation was if there was no supplementary documentation in the medication order entry. The LPN stated that a progress note should be included with the BP and HR results. On 5/7/26 at 1:41 PM, the surveyor interviewed the LPN Unit Manager (LPN/UM) about medications with parameters. The LPN/UM stated the nurses checked the BP and HR prior to administering the medication, followed the parameters as per the physician's order and held the medication when indicated. The LPN/UM further explained that the nurses documented the BP and HR results in the supplementary documentation section of the medication order in the MAR when administering the medication. The LPN/UM stated if there was no supplementary documentation to enter the results, it would be expected for the nurse to write results in a note and inform the LPN/UM to clarify the order. The surveyor with the LPN/UM reviewed the May 2026 MAR regarding the identified concerns. The LPN/UM confirmed the two identified entries for midodrine should have been held by the nurse as per the physician's order. The LPN/UM confirmed there was no documentation of the BP and HR on the MAR to indicate they were assessed at the time of metoprolol tartrate's administration. On 5/7/26 at 2:11 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional Director of Operations (RDO), the Regional Clinical Director (RCD), and the [NAME] President of Quality and Performance Improvement (VPQPI) of the above concern regarding Resident #174's midodrine and metoprolol administration. On 5/11/26 at 1:11 PM, the LNHA, the DON, the RDO, the RCD, and the VPQPI met with the survey team. The DON stated the orders were clarified, and education was provided to the staff. The DON explained that the nurses were assessing the residents' BP and HR but acknowledged they did not ensure documentation in the EMR for every medication administration. The DON stated education was being provided to ensure supplemental documentation was added with the medication orders to prevent reoccurrence. There was no additional information provided by the facility. 3. On 5/12/26 at 9:17 AM, the surveyor reviewed the EMR of Resident #179. The admission Record revealed that Resident #179 had diagnoses that included but were not limited to, End Stage Renal Disease, acute respiratory failure, and pneumonia. Resident #179 no longer resided at the facility. A physician's order dated 2/3/26 indicated to give metoprolol tartrate 12.5 milligram (mg), one tablet by mouth two times a day every Mon, Wed, Fri, Sun for hypertension (HTN) hold for SBP less than 100 and HR less than 60. The medication was scheduled to be given to Resident #179 at 8 AM and 4 PM. A physician's order dated 3/2/26 indicated to give metoprolol tartrate 12.5 mg, one tablet by mouth two times a day every Tue, Thu, Sat for HTN Hold for SBP less than 100 and HR less than 60. The medication was scheduled to be given to Resident #179 at 10 AM and 6 PM. A review of the March 2026 MAR revealed that there was no documentation of the resident's blood pressure (BP) and HR at the time of the metoprolol tartrate medication's administration. A review of the Weights and Vitals section of the EMR revealed no consistent documentation of Resident #179's BP and HR for each metoprolol tartrate administration to reflect that the medication was administered as per the physician's orders. A review of progress notes revealed documentation for the resident's metoprolol tartrate administration on 3/5/26, which included the resident's BP and on 3/10/26, which included the resident's SBP at the time. There was no other documentation of the resident's BP and HR result at the time of the metoprolol tartrate's administration. On 5/12/26 at 1:13 PM, the surveyor informed the LNHA, the DON, the RCD and the RDO of the above concerns. On 5/13/26 at 11:23 AM, the LNHA, the DON, the RCD, the VPQPI, and the [NAME] President of Clinical Services (VPCS) met with survey team. There was no additional information provided by the facility. The surveyor reviewed the facility provided policy titled, Medication Administration, with a last reviewed date of 8/8/25. Under Policy revealed: Medications are administered by licensed nurses, other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines of the policy revealed: . 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation and interview, it was determined that the facility failed to a.) perform hand hygiene in a manner that would decrease the possibility of spreading infection observed during kitchen tour and b.) store reusable resident medical equipment in a sanitary mannerThe deficient practice was evidenced by the following:1.)On 5/7/26 at 9:40 AM, during kitchen tour with the Food Service Director (FSD), the surveyor observed the following: The surveyor observed the FSD wash her hands at the hand washing sink. The FSD wet her hands with water, put soap on her hands, and scrubbed her hands for 10 seconds and then rinsed her hands under the running water. The FSD was also observed using the back of her hand to adjust the water while rinsing her hands. The FSD took a paper towel to dry her hands and used a new paper towel to turn off the faucet. The FSD stated that she did not count how long she was lathering, but instead sang happy birthday. The FSD acknowledged that she should have lathered her hands for a minimum of 20 seconds. A review of the Hand Hygiene policy, dated 10/14/25, revealed that the technique for hand hygiene included rubbing hands together vigorously for at least 20 seconds and then rinsing hands with water. 2.) On 5/13/26 at 9:32 AM, the surveyor and the Licensed Practical Nurse (LPN) entered the locked medication storage room on the second floor, west nursing care unit. The surveyor observed the following on the floor in the room: three Nebulizer machines, six portable oxygen concentrators and one utility pole for use with intravenous medication pumps or enteral feeding pumps. The equipment was open to the air, uncovered, and not labeled with the date they were cleaned or prepared for service. The surveyor observed that one of the six oxygen concentrators had a dried brown residue on the front surface of the machine. The surveyor also observed that the base of the utility pole was visibly soiled with a black and brown crusted, dried substance. On 5/13/26 at 9:40 AM, the surveyor met with the Director of Nursing (DON) who verbalized she was unaware that the items were in the room and confirmed that the equipment was not cleaned and should not be stored in an active medication storage room. On 5/13/26 at 9:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who was in the second floor west medication storage room. The ADON stated her understanding was before a device enters the room it was cleaned. The surveyor inquired if the equipment in the room was clean and the ADON stated, It does not look clean. On 5/13/26 12:08 PM, the DON stated that there was no policy regarding the above concern and that it was a standard of practice, not to store soiled utility devices in the medication storage room. The DON acknowledged that uncleaned utility/devices should not be stored in the medication room. On 5/12/2026 at 1:13 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON to discuss the concerns with infection control practices documented in the kitchen and the second floor west medication storage room. Both the LNHA and the DON acknowledged the observations and that the practices were breeches in infection control. NJAC 8:39-19.1; 19.2; 19.4; 19.5; 21.1

Based on interviews, record review, and review of pertinent facility documentations on 3/30/26 and 3/31/26, it was determined that the facility failed to provide documentation of completion of Activities of Daily Living (ADL) tasks of getting residents out of bed and providing turning and repositioning for dependent residents for the time period of of September 2025 through December 2025. This deficient practice was identified for 1 of 5 residents, Resident #1, that were reviewed for ADL documentation as follows: A review of Resident #1's admission Record (AR), an admission record summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 Diabetes Mellitus, dysphagia, pressure ulcer of sacral region-stage 4, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness. A review of the resident's Minimum Data Set (MDS), a comprehensive assessment tool, dated 03/03/2026, showed that Resident #1's Brief Interview for Mental Status (BIMS) Score was 00 which indicated the resident's cognition was severely impaired. The resident's MDS further revealed the resident required staff assistance in completing their ADLs. A review of the resident's Care Plan Report (CP) revealed a with Focus [health problem], initiated 09/10/2025 and revised on 03/06/2026, of has MASD [moisture-associated skin damage] to sacrum r/t [related to] incontinence of B & B [bowel & bladder], immobility, poor cognition, PVD [peripheral vascular disease], and diabetes. Interventions which included, but were not limited to, turning and repositioning and offloading per policy; limit sitting 2 hours per session; ROHO cushion [an air-filled, cellular wheelchair cushion designed to provide premium pressure relief, skin protection, and stability for users], and treatment as per MD's [physician] order. A review of Resident #1's Documentation Survey Report (DSR) from January 2026 to March 2026 revealed Intervention/Tasks which included skin observation, turned and repositioned, and amount eaten. The DSR reflected the days of each month that the tasks were performed. The facility was unable to produce any DSR reports or other documentation of performing ADL tasks for the months of September 2025-December 2025. On 03/31/26 at 1:04 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) #1, Resident #1's regular aide. CNA #1 stated that Resident #1 had a wound on their back or sacral area. CNA #1 they would turn and position Resident #1, as well as get the resident out of bed. CNA #1 further stated that they would document the care given to the resident in the POC (Point of Care) or kiosk daily. On 03/31/26 at 1:08 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, Resident #1's regular nurse. LPN #1 stated that Resident #1 is taken out of bed when the resident is able to tolerate it and when the resident was not having episodes of diarrhea. LPN #1 further stated Resident #1 was turned and repositioned and that this care would be documented in the POC by the aides or by the nurses in the skilled progress notes (PN). On 03/31/26 at 1:37 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the turning and repositioning tasks were documented by the CNAs in the POC. The DON further stated that Resident #1 was turned and repositioned every two hours or more frequently but she was unable to provide more than 1 month of ADL task sheets due to a recent program change.The surveyor requested the task care record, ADLs documentation, POC documentation for Resident #1 for the months of September 2025 to December 2025. The facility was not able to provide the documentation. A review of a facility policy titled Turning and Repositioning with a review/revised date of 10/1/2025 revealed under Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Under Policy Explanation and Compliance Guidelines: 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to medical record. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. The frequency of turning and repositioning will be documented in the resident's plan of care .A review of a facility policy titles Pressure Injury Prevention and Management with a review/revised date of 10/01/2025 revealed under Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Under Policy Explanation and Compliance Guidelines: 4. Interventions for Prevention and to Promote Healing, c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning .). N.J.A.C. 8:39-35.2(b)

NJ00183439 Based on observation, record review and interview on 04/28/25, it was determined that the facility failed to provide a clean and homelike physical environment for their residents. This deficient practice was identified in 2 of 4 bedrooms observed and was evidenced by the following: During tour on 4/28/25 at 10:12 a.m., the surveyor entered room [ROOM NUMBER] and noted black dried substance behind dresser under wallpaper. During tour on 4/28/25 at 10:14 a.m., the surveyor entered room [ROOM NUMBER] and noted black dried substance behind dresser under wallpaper. During tour on 4/28/25 at 11:21 a.m. with the Director of Maintenance and the Maintenance staff, both confirmed the black dried substance on the walls behind the wallpaper behind the dressers in rooms [ROOM NUMBERS]. The Director of Maintenance (DOM) further stated, yes, we confirm the presence of the black fungi looking substance behind the wallpaper behind dresser. The DOM stated that the sheet rock should have been replaced in both room because of the black fungi looking substance. The Maintenance staff stated that he had informed the Administrator both prior and present, and nothing had been done. During tour on 4/28/25 at 2:45 p.m. with the Administrator, Director of Maintenance, and maintenance staff, the Administrator confirmed the black dried, fungi looking substance in rooms [ROOM NUMBERS]. The administrator stated that he was not aware and further stated that there should be no black dried substance in the rooms because it is not safe for living space. The administrator stated that he would be moving residents from the rooms today. During interview with surveyor on 4/28/25 at 11:01 a.m., the Director of Maintenance stated that walls were checked when rounds were done. He further stated that he was responsible for ensuring rooms were up to standard and homelike for residents. During interview with surveyor on 4/28/25 at 11:45 a.m., the nurse (RN #1) stated that she noticed black dried substance in room [ROOM NUMBER] and reported it to the Administrator and one of the maintenance staff but could not recall how she submitted the issue whether by paper request or the TELS system. RN #1 further stated that there should have been no black dried substance in resident's room, because it could cause health issue, and it is their home, and it should be clean. During interview with surveyor on 4/28/25 at 3:28 p.m., the Regional Director of Operations (RDO) confirmed that he saw black spotted areas behind dressers in rooms [ROOM NUMBERS] behind the wall papers. He further stated that residents will be moved out of the rooms today and that families would be contacted. The RDO stated that the company has been contacted and email was sent. A review of an undated Maintenance Assistance Job description revealed, move furniture to complete assignments. A review of an undated Director of Maintenance Job description revealed, Ensures the facility remains in compliance with all federal, state, and local regulations . A review of the facility's Homelike Environment Policy revealed that In accordance with the residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. NJAC 8:39-31.4(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure respiratory tubing cannula was stored in accordance with infection control measures for 1 of 4 residents, (Resident #55) and b.) administer oxygen therapy according to the physician's order for 3 of 4 residents, Resident #28, #160 and #273). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 11/12/24 at 12:00 PM, the surveyor observed Resident #55 in bed with a portable oxygen tank at bedside, not in use. The surveyor observed a nasal cannula (NC) tubing dated 9/26/24, wrapped around the tank, suspending down onto the floor. The tubing was not stored in a bag. Resident #55 stated that he/she used the oxygen mostly at night for shortness of breath. The surveyor reviewed the medical record for Resident #55. According to the Admission Record, the resident was admitted to the facility with diagnoses that included but were not limited to obstructive sleep apnea and hypertension. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/8/24, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #55's cognition was intact. A review of the resident's Individual Care plan (CP) included a focus area initiated on 4/19/23 that indicated the resident used oxygen therapy as needed for ineffective gas exchange. The interventions included monitoring for signs and symptoms of respiratory distress and reporting to MD. A review of the November Order Summary Report (OSR) reflected an order for Oxygen at 2 Liters per minute (LPM) via nasal cannula (NC) as needed (PRN) for shortness of breath. On 11/13/24 at 11:30 AM, the surveyor observed Resident #55 in his/her room seated in a wheelchair. The surveyor observed the portable oxygen tank not in use with the NC tubing stored in a plastic bag dated 9/26/24. On 11/13/24 at 11:40 AM the surveyor accompanied by the Licensed Practical Nurse (LPN #1) entered the resident's room and observed that the NC tubing stored in a plastic bag was dated 9/26/24. LPN #1 stated that the facility policy was for the NC tubing to be changed every Wednesday by the night nurses. LPN #1 acknowledged that she should have checked it earlier and then discarded the tubing. 2. On 11/12/24 at 12:20 PM, the surveyor observed Resident #28 in bed with their eyes closed. The surveyor observed the NC tubing undated and suspending off the back of the tank not stored in a plastic bag. The surveyor reviewed the medical record for Resident #28. According to the Admission Record, the resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure, Parkinson's disease, diabetes mellitus, and gastrostomy status (a tube inserted into the stomach to provide nutrition.) The quarterly MDS dated [DATE] reflected a BIMS score of 9 out of 15 which indicated Resident #55 had a moderate cognitive impairment. A review of the resident's CP included a focus area that indicated the resident used oxygen therapy as needed. The interventions included monitor for signs and symptoms of respiratory distress and report to MD, initiated on 11/13/24. A review of the November OSR reflected an order for Oxygen at 2 LPM via NC as needed (PRN) for shortness of breath. 3. On 11/14/24 at 10:25 AM, the surveyor observed Resident #160 in their room, seated in a wheelchair. The surveyor observed the resident wearing a NC tubing with the oxygen concentrator gauge set at 3.5 LPM. The surveyor reviewed the medical record for Resident #160. According to the Admission Record, the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus, Parkinson's disease, and hypertension. The quarterly MDS dated [DATE] reflected a BIMS score of 15 out of 15 which indicated Resident #55's cognition was intact. A review of the resident's CP included a focus area that indicated the resident was receiving Oxygen therapy for CHF initiated on 8/28/24. The interventions included administering oxygen as ordered, monitoring for signs and symptoms of respiratory distress, and reporting to MD. A review of the November OSR reflected an order for Oxygen at 2 LPM via nasal cannula (NC) every shift for Congestive Heart Failure (CHF) with a start date of 11/1/24. On 11/14/24 at 10:30 AM, the surveyor accompanied by LPN #2 entered Resident #160's room. LPN #2 confirmed that the oxygen was set at 3.5 LPM. At that time LPN #2 reviewed the PO, which reflected an order for 2 LPM. LPN#2 stated that he usually checked the oxygen gauge for accuracy during his morning rounds, but was so busy that he had neglected to check it this morning. On 11/15/24 at 1:14 PM, the surveyor discussed the above observations and concerns with the Administration. The Director of Nursing (DON) confirmed that the Physician orders should be followed, tubing should be changed and dated weekly, and should be stored in a plastic bag for infection control prevention. 45449 4.) On 11/13/24 at 11:05 AM, the surveyor observed Resident #273 in bed receiving oxygen (O2) via nasal cannula (a tube with 2 prongs at the end that deliver oxygen through the nose) that was connected to an oxygen concentrator that was set to 3 liters per minute (LPM). The resident was awake and conversant. On 11/14/24 at 1:17 PM, the surveyor observed the resident lying in bed awake, and alert. The O2 concentrator was on and set to 3LPM. The surveyor reviewed the medical record for Resident #273. According to the Admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD; restrictive breathing affecting lung capacity), and chronic diastolic congestive heart failure (CHF; a heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). The Comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/10/24, reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS revealed the resident required respiratory treatment and received continuous oxygen. A review of the electronic Medication Administration Record (eMAR) for November 2024 reflected the following orders: - O2 at 2 LPM via nasal cannula every shift O2 at 3LPM via nasal cannula. The order was initiated on 11/9/24 and discontinued on 11/13/24. The eMAR was not signed as checked or administered on the night shift on 11/12/24. -O2 at 2 LPM via nasal cannula every shift for COPD oxygen at 2LPM via nasal cannula. The order was initiated on 11/13/24 and discontinued on 11/14/24 at 2:06 PM. The eMAR was signed checked or administered on all three shifts on 11/13/24 and was not signed checked or administered 11/14/24 on the day shift. A review of the ongoing Care Plan (CP) reflected a focus that included, the resident's required O2 therapy which was initiated on 11/13/24. An intervention dated 11/13/24, included to administer oxygen as ordered. On 11/14/24 at 1:20 PM, the surveyor and the Licensed Practical Nurse/ Unit Manager (LPN/UM) entered Resident #273's room to observe the resident's O2 concentrator, greeted the resident and walked out of the resident's room. At that time, the LPN/UM confirmed with the surveyor that the O2 concentrator was set to 3 LPM. The LPN/UM and the surveyor reviewed the eMAR together which reflected an order for O2 at 2 LPM. The LPN/UM stated that the expectation was that the nurse should have checked during the morning visit of each room and ensured the O2 was set according to the physician's order. At 1:23 PM, the surveyor and the LPN/UM walked back into the resident's room. The LPN/UM explained to the resident that she had to titrate the O2 concentrator to 2L as per physician's order, and used a pulse oximeter (SPO2; device used to measure blood oxygen saturation level) which reflected low saturation without a numerical value (normal values are 95% to 100%). An LPN walked in with another SPO2 device that reflected the same result, low saturation without a numerical value. At 1:30 PM, the LPN/UM stated that all nurses on all shifts were responsible to ensure the resident's oxygen orders were followed. The LPN/UM stated that she would inform the physician and the hospice nurse to request for Resident #273 to be evaluated. On 11/14/24 at 1:14 PM, in the presence of the survey team, the Regional Associated Clinical Supervisor (RACS), the Regional Director of Operations (RDO), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the failure to follow the physician's order for the O2 and to maintain the respiratory services for Residents #55, #28, #160 and #273. On 11/18/24 at 12:17 PM, in the presence of the survey team, the RACS, the RDO, and the LNHA, the DON stated that the nurse who received the order from the physician should have adjusted the oxygen concentrator for the resident and the nurses should have ensured the physician's orders were followed. A review of the facility provided policy, Administering Medication, updated on 1/2024 included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. medications must be administered in accordance with the orders, including any required time. A review of the provided facility policy Oxygen Administration, dated/revised 11/2018 included the following: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. NJAC 8:39-11.2(b) 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a.) intravenous bags were stored in a tamper and contaminant resistant packaging, b) accurate dispensing and administration of pain medication c.) a narcotic medication that was ordered by the physician was available for administration. The deficient practices were identified for one (1) of two (2) medication rooms and two (2) of four (4) medication carts inspected during the medication storage and observation and was evidenced as follows: 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 11/15/22 at 9:27 AM, during the inspection of the medication room located on the East/West, the surveyor with the Licensed Practical Nurse#1 (LPN #1) observed the following parenteral (biological or medications administered via intravenous or injectable route): -one (1) bag of sodium chloride for injection 1000 milliliter (ml) without an outer packaging or seal -one (1) bag of dextrose for injection 250 ml, without an outer packaging or seal. On 11/15/24 at 9:27 AM, during an interview with the surveyor, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated that the parenteral products should have had an outer covering to ensure against tampering and contaminants. 2. On 11/15/24 at 9:36 AM, in the presence of LPN #2, the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart B (narcotic box) located on 2-West/North. At that time, the surveyor and LPN #2 observed Resident #135's Oxycodone Immediate Release 5 mg (milligram; narcotic medication indicated for pain) bingo card (a multidose card containing individually packaged medications) contained 66 tablets. At that time, the surveyor compared the count of the bingo card against the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #135's Oxycodone IR 5 mg tablet which reflected a balance of 67 tablets and was last signed by the administering nurse on 11/15/24 at 6:00 AM. At that time, the surveyor and LPN #2 reviewed the electronic Medication Administration Record (eMAR) together which revealed an order for Oxycodone IR 5 mg, give 1 tablet four times a day for left and right hip pain, and was started on 6/25/24. The administration schedule was for 6:00 AM, 11:00 AM, 4:00 PM and 10:00 PM. At that time, the surveyor questioned the one (1) tablet discrepancy of the count. LPN #2 stated that the resident had requested for their Oxycodone earlier than scheduled and it was the resident's right to receive their medication when requested. LPN #2 administered the medication at 9:00 AM (3 hours after the scheduled dose at 6:00 AM) as opposed to the physician's scheduled order of 11:00 AM. LPN #2 also stated that she had not informed the physician. LPN #2 explained that since she administered the Oxycodone at 9:00 AM, which was earlier than the physician's order, the eMAR would not allow her to sign for the administration. At that time, The LPN acknowledged that she should have should have informed the physician prior to the administration of the narcotic medication earlier than scheduled for the resident to be properly assessed for pain and that the declining inventory log should have been signed immediately after she removed the Oxycodone from the narcotic box for dispensing and administration. 3.) On 11/15/24 at 9:56 AM, the surveyor began the in the presence of LPN #3, the surveyor began the narcotic medication inspection, which was stored in the narcotic box located on 2-South/East. At that time, the surveyor and LPN #3 observed Resident #70's declining inventory log for Clonazepam 0.5 mg (a narcotic medication with indications that include anxiety relief). The declining inventory log reflected the following: -on 11/1/24 at 12:59 PM, two (2) tablets were removed. -on 11/2/24 at 9:00 PM, two (2) tablets were removed. -on 11/3/24 at 1:00 PM, two (2) tablets were removed. -on 11/4/24 at 9:00 PM, two (2) tablets were removed. At that time, the surveyor and LPN #3 reviewed the eMAR which revealed the following orders: -Clonazepam 0.5 mg, give 1 tablet by mouth one time a day for anxiety, and was started on 9/26/24. The administration time was for 9:00 PM. -Clonazepam 1 mg, give 1 tablet by mouth one time a day for anxiety, and was started on 9/26/24. The administration time was for 1:00 PM. --Clonazepam 1 mg, give 1 tablet by mouth one time a day for anxiety, and was started on 8/15/24. The administration time was for 9:00 PM. At that time, LPN #3 confirmed with the surveyor that she had administered two (2) tablets of the Clonazepam 0.5 mg on 11/1/24 to for the 1 mg order since the pharmacy had not sent the supply. The LPN #3 stated she was unsure if the medication was available as part of the emergency back-up supply. LPN #3 stated she did not call the physician for an order to administer double of the dose of Clonazepam 0.5 mg. On 11/15/24 at 10:27 AM, during an interview with the surveyor, the LPN/Unit Manager (UM) stated that the nurses should not have been administering double the dose against the physician order which caused the inventory for Clonazepam 0.5 mg to be cut shorter, that would result in the resident to not have enough medication before the next refill. The surveyor requested for the receipt of the Clonazepam 1 mg. On 11/14/24 at 1:14 PM, in the presence of the survey team, the Regional Associated Clinical Supervisor (RACS), the Regional Director of Operations (RDO), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the storage of the intravenous medications found that was not in a standard packaging that protected against tampering and contamination, the administration of Resident #135's medication ahead of the physician's scheduled order and the facility's failure to ensure that Resident #70's medication ordered by the physician was available for administration. On 11/18/24 at 12:17 PM, in the presence of the survey team, the RACS, the RDO, and the LNHA, the DON stated that the nurse who administered Resident #135's medication was given an education to inform and obtain a physician's order for early administration of the Oxycodone when appropriate. Additionally, the DON stated that regarding Resident #70's Clonazepam, the nurses were educated to call the pharmacy when an order was not available for administration and were instructed to escalate the issue to the supervisors after having to call the pharmacy more than once. No further information was provided. A review of the provided facility policy, Medication Storage dated/reviewed on 1/2024, reflected under policy that the facility shall store all medications and biologicals in a safe, secure and orderly manner and that medications and biologicals shall be stored in the packaging, containers, or other dispensing system in which they are received. A review of the facility provided policy, Administering Medication, updated on 1/2024 included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. medications must be administered in accordance with the orders, including any required time. NJAC 8:39-29.2 (d), 29.4(f)(g) (h)(l) 29.6(a)29.7(c)

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for medications with parameters for 1 of 1 residents reviewed (Resident # 148). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. The surveyor reviewed the medical records for Resident #148 that revealed the following: According to the Order Summary Report Resident # 148 had an order dated 8/16/24 for Entresto (a medication to treat high blood pressure) 24-26 MG, give 1 tablet by mouth two times a day. Hold if SBP (systolic blood pressure) is less than 110. The November 2024 Electronic Medication Administration Records revealed there were several dates that the nurse gave the Entresto 24-26 MG medication when the resident's systolic blood pressure was below 110. Entresto 24-26 was given when the SBP was below 110 by the 3-11 nurse on 11/4, 11/5, 11/8, and 11/9/24. The surveyor interviewed the Licensed Practical Nurse on 11/15/24 at 11:47 AM, who stated that the medication should have been held for the dates of 11/4, 11/5, 11/8 and 11/9/24, when the resident's SBP was lower than 110. She stated that there were no negative outcomes after that medication was administered. At 12:35 PM, the DON stated that the facility did not have a specific policy regarding following a physician's order. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of 35 residents reviewed for the accommodation of needs (Resident #108, #128, and #116), and was evidenced by the following: 1. On 11/12/24 at 11:55 AM, the surveyor observed Resident #108 in bed on a specialty mattress with a contracture to their right hand. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was affixed to the right upper enabler and dangling down towards the floor, not within his/her reach. The surveyor reviewed the medical record for Resident #108. A review of the resident's Admission Record reflected that Resident #108 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body), dysphagia and gastrostomy status (surgical procedure creating an opening into the stomach through the abdominal wall to provide nutrition). A review of Resident #108's Annual Minimum Data Set (MDS) an assessment tool dated 9/26/24 revealed Resident #108 had a long- and short-term memory problem and a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene. A review of Resident 108's Individualized Care Plan (CP) included a focus that indicated the resident had impaired vision r/t cataracts with interventions to tell the resident where items are placed; and to be consistent. 2. On 11/13/24 at 12:00 PM, the surveyor observed Resident #128 in bed on a specialty mattress with the call bell dangling down on the right side of the bed between the upper enabler and the mattress, not within the Resident's reach. A review of Resident #128's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to cerebrovascular disease, aphasia, and hypertension. A review of Resident #128's quarterly MDS dated [DATE] revealed Resident #128 had highly impaired vision, long- and short-term memory problems, and severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene. A review of Resident 128's CP included a focus that indicated the resident had a cerebral vascular accident (stroke) affecting the right side with interventions to keep the call bell on the left side of the resident where his/her arm is stronger. On 11/13/24 at 12:10 PM, the surveyor and Certified Nursing Assistant (CNA #1) assigned to Resident #128's care, entered the resident's room and observed the call bell dangling down on the right side of the bed between the upper enabler and the mattress, not within the Resident's reach. The CNA stated that she should have placed the call bell within the resident's reach as the resident was unable to speak and the call bell was their only means of summoning staff assistance. 3. On 11/13/24 at 12:05 PM, the surveyor observed Resident #116 in bed on a specialty mattress with the call bell on the floor under the resident's bed. The surveyor interviewed Resident #116 who stated that he/she would usually use their call bell to call for staff assistance, but they were unable to locate it today. Resident #116 further stated, She forgot to give it to me. A review of Resident #116's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to dependence on dialysis, glaucoma, and visual loss in both eyes. A review of Resident #116's quarterly MDS dated [DATE] revealed Resident #116's vision was severely impaired. The MDS further assessed resident #116 had a BIMS score of 15 out of 15 which indicated the resident's cognition was intact. A review of Resident 116's CPs included a focus that indicated the resident was at high risk for falls with interventions to keep the call bell within their reach and a CP which included a focus that indicated Resident #116 had visual function loss with interventions to place the call bell near the resident's hand and to move the resident's hand so that he/she could feel the call bell was within reach. On 11/13/24 at 12:22 PM, the surveyor accompanied by the Licensed Practical Nurse (LPN) entered Resident #116's room. The LPN observed the call bell on the floor and confirmed that the call bell should always be kept within the resident's reach. On 11/13/24 at 12:33 PM, the surveyor interviewed the CNA (CNA #2) assigned to Resident #116's care who confirmed she should have ensured the call bell was placed within the resident's reach. On 11/15/24 at 1:14 PM, the surveyor discussed the above observations and concerns with the Administration. The Director of Nursing (DON) confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

C#: NJ 6, NJ 9 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documents on [DATE] and [DATE], it was determined that the facility failed to provide the services necessary to prevent neglect of a severely cognitively impaired Resident after a fall with significant injuries for 1 of 3 sampled residents (Resident #2) reviewed for neglect. Specifically, the facility neglected to provide immediate assistance for Resident #2 with a [DIAGNOSES REDACTED].#2) left Resident #2 sitting at the edge of the bed unattended and went to wet a towel to provide care for the Resident. Resident #2 fell off of the edge of the bed and sustained a laceration, hemorrhaging and a hematoma to the head. CNA #2 then placed Resident #2 back into bed and cleansed off the blood from Resident #2's forehead. CNA #2 neglected to immediately notify the Registered Nurse/Unit Manager (RN #1) that Resident #2 fell off of the bed and had injuries which prevented Resident #2 from receiving immediate medical care. CNA #2 then went out of Resident #2's room and saw Resident #1 in the hallway and escorted Resident #1 into Resident #2's room, where CNA #2 staged Resident #2's room by turning over the television (TV), the chest of drawers and the wheel chair (W/C), and got blood onto Resident #1's shirt when preventing Resident #1 from leaning over Resident #2. CNA #2 then continued with his/her routine assignment in the dayroom. On [DATE] at approximately 11:40 a.m., CNA #2 went into Resident #2's room to toilet the Resident's roommate, after placing Resident #2's roommate on the toilet, CNA #2 then went over to Resident #2's bedside and found the Resident bleeding on the forehead and blood on the Resident's sheets and notified RN #1 that Resident #2 needed help. When RN #1 arrived at Resident #2's bed side the RN found Resident #2 in bed bleeding and activated code blue (medical emergency), facility staff responded, 911 was called and Resident #2 was sent to the hospital for evaluation. Resident #2 subsequently died in the emergency room (ER) at 2:08 p.m. The facility also neglected to protect a cognitively impaired resident with a known history of behaviors from mental and emotional abuse for 1 of 3 sampled residents (Resident #1) reviewed for abuse. On [DATE] at approximately 10:40 a.m., CNA #2 escorted Resident #1 into Resident #2's room and to Resident #2's bedside, where Resident #2 lay hemorrhaging with a laceration and hematoma to the forehead. CNA #2 wiped the blood off of Resident #2's forehead and got blood on Resident #1's T-shirt while preventing Resident #1 from leaning over Resident #2. CNA #2 staged Resident #2's room, by placing the television (TV) onto the floor, turned the Resident's wheel chair upside down and turned the TV stand over, which was a previous behavior displayed by Resident #1, on [DATE], when Resident #1 threw the Resident's roommate's television on the floor and turned the roommate's chair upside down. This staging of the room resulted in the facility unnecessarily transferring Resident #1 to the hospital ER for evaluation due to Behavioral Disturbance on [DATE], and resulted in Resident #1 being admitted and treated with multiple unnecessary medications. The facility also failed to follow the facility's own policies titled Assessment, Abuse Prohibition, Falls Management, and Person Centered Care Plan. This placed Resident #1 and Resident #2, as well as all other residents in the facility in an Immediate Jeopardy (IJ) situation. This IJ ran from [DATE] through [DATE] at 2:52 p.m., when the IJ was identified and reported to the Administrator and RN/Clinical Quality Specialist (CQS), and the facility was presented with the IJ template. The IJ was lifted that same day at 2:52 p.m., when the facility provided an acceptable Removal Plan. A revisit was done on [DATE], to validate that the facility implemented their removal plan. This deficient practice was evidenced by the following: 1. According to Resident #2's Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had short-term and long-term memory problems and was severely cognitively impaired. The MDS also indicated that Resident #2 required assistance with Activities of Daily Living (ADLs). Review of Resident #2's CP dated [DATE], included the following: Under Focus: The resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Under Interventions: Provide resident with total assist of two for transfers using a total lift. Review of Resident #2's CP revised on [DATE], included the following: Under Focus: The resident demonstrates deficit in transferring r/t Cognitive loss/Dementia and [MEDICAL CONDITION]. Under Goal: initiated [DATE], revealed: The resident will safely transfer via hoyer lift .Under Interventions: Ensure surfaces are stable. Further review of Resident #2's Care Plan (CP) dated [DATE], included the following: Under Focus: The resident is at risk for falls related to (r/t) cognitive loss, lack of safety awareness, [MEDICAL CONDITION], Dementia and Impaired Mobility Under Goal: The resident will have no falls with injury Under Interventions: Bed sensor while in bed for safety. Tabs monitor while in wheelchair for safety. Total lift for transfers. Assess for changes in medical status, pain status, mental status and report to MD (Medical Doctor) as indicated. Floor mat at bedside when in bed. Utilize low bed. Assist resident getting in and out of bed with ,[DATE] assistance. Review of Resident #2's Visual/Bedside Kardex Report, undated, included the following: Under Ambulation/ Mobility/Transfers: Assist resident getting in and out of bed with ,[DATE] person assistance Provide resident/patient with total assist of two for transfers using a total lift Review of Resident #2's Order Summary Report (OSR) included the following: Bed sensor on at all times to prevent falls while in bed, check placement and function every shift, dated [DATE]. Bilateral ,[DATE] (half) side rails up as enabler at all times every shift, dated [DATE]. Floor mat by bedside when patient (resident) is in bed for safety every shift, dated [DATE]. Review of the Facility's Reportable Event (FRE) dated [DATE], revealed that on [DATE] at approximately 11:45 a.m., Resident #2 was discovered in bed with blood noted on the Resident's forehead by the assigned aide (CNA #2), also the CNA alerted RN #1 who responded to Resident #2's room and called Code Blue and activated the medical emergency response to summon additional assistance. The FRE also indicated that first aid was rendered to Resident #2 and the Resident was sent to the hospital. In addition, the FRE also included the police was notified and involved; and the facility was actively investigating the incident. Further review of the FRE revealed that Resident #2 was non ambulatory and would not be able to get back into bed. The FRE also revealed that Resident #2 expired, unsure if from injuries, and Resident #2 was frail and bed bound. Review of a Facility form titled RMS Event Summary Report (a facility's incident report tool) dated [DATE] at 11:45 a.m., revealed under Event: Injury of Unknown Origin: The report also revealed that Resident #2 was noted with laceration from right side of the forehead, bump to R (right) forehead and a cut to L (left) upper forehead and under right eye. In addition, the report showed that first aid was rendered to Resident #2 and the Resident was sent out to ER (emergency room ) for evaluation. Review of Resident #2's Progress Notes (PN) dated [DATE] at 3:09 p.m., revealed that Resident #2 had a laceration to the R (right) forehead 1.5 inch and about 0.3 inch deep; bump to the right forehead 1.5 inch x (by) 1.5 inch and about 1.5 inch high, 1 inch cut above the left upper forehead w/ (with) about 0.2 inch deep; 0.8 inch cut to under right eye with 0.2 inch deep. Wounds cleansed with saline and pressure dressing applied. Right [MEDICAL CONDITION] covered with dry dressing and wrapped with a cling. Review of Resident #2's PN dated [DATE] at 3:42 p.m., revealed that Resident #2 was transferred from the facility to the hospital at 12:10 p.m., for evaluation. Review of Resident #2's PN dated [DATE] at 8:30 p.m., written by the Nurse Practitioner (NP) revealed Resident #2 presenting problem to be bleeding from head wound related to trauma The PN also revealed that Resident #2 was noted with deep a laceration on the right side of (the) head, and a large hematoma to forehead close proximity to the head wound. The PN also showed Resident #2 had laceration with bleeding noted to the left side of head. Also, to the outer corner of the right eye noted lacerations, due to trauma. BP (blood pressure) ,[DATE] (which indicated the resident's BP was elevated) In addition, the PN showed that Resident #2 had sluggish pupils and a poor respiratory effort Further review of the PN showed that Resident #2 was transferred to the hospital via ambulance. Review of Resident #2's Universal Transfer Form ( a form that is used to communicate pertinent, accurate clinical patient care information at the time of an emergency call to a facility or a patient transfer between health care facilities) dated [DATE], showed that Resident #2 was transferred to the hospital due to Profuse bleeding secondary to big laceration on R (right) forehead, bump on right forehead (hematoma) above right eye, right eye cut Post survey review of Resident #2's Emergency Department Medical Record (EDMR) Emergency Department Provider Note (EDPN) dated [DATE] at 1:04 p.m., included but was not limited to the following: Under ED (Emergency Department) Course: CT Scan (a computed tomography scan that uses a combination of X-rays and a computer to create pictures of one's organs, bones, and other tissues) showed that Resident #2 had traumatic subdural hemorrhage. Resident #2's EDPN also revealed, Resident #2 continued to have worsening neurologic decline no longer responsive, apneic (a cessation of breathing) with worsening [MEDICAL CONDITION] (slow heart rate). In addition, Resident #2's EDPN showed, given concerns that this being acute traumatic injury unexplained will contact police for further evaluation for possible homicide Under Number of [DIAGNOSES REDACTED]. Under Imaging CT Head Without Contrast included the following under Findings: Acute right hemispheric subdural hematoma Additional smaller interhemispheric subdural hematoma seen anteriority on the right adjacent to the frontal lobe Mild midline shift to the left Acute fractures involving he anterior arch of C1 which are comminuted mildly displaced In addition, the EDPN also revealed Resident #2 had traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter Review of Resident#2's EDPN dated [DATE] at 1:20 p.m., revealed that Resident #2 had decreased respiratory effort and low oxygen saturation The EDPN also showed that Resident #2 was placed on oxygen therapy at 15 liters via a Non-Rebreather (NRB), (a mask used to assist in the delivery of oxygen) and continued on cardiac monitor. Further review of Resident#2's EDPN dated [DATE] at 2:07 p.m., revealed that Resident #2's cardiac monitor noted to be asystole (a cardiac flatline that shows a state of total cessation of electrical activity from the heart) The EDPN also showed no detectable pulses or respiratory effort, time of death 2:08 p.m. During an interview on [DATE] at 10:10 a.m., RN #1 stated he/she was in another Resident's (Resident #1) room when the aide (CNA #2) assigned to Resident #2 called the RN to take a look at Resident #2. RN #1 indicated he/she went into Resident#2's room and saw the sheets with blood and a laceration on Resident#2's forehead seeing how bad the bleeding is, I called for code blue (medical emergency) on the overhead, so I can get help with the rest of the team. RN #1 further stated that he/she asked CNA #2 what happened to Resident #2 and the CNA indicated, I found him/her like this, I don't know what happened. RN #1 then indicated, the Resident cannot walk. RN #1 explained that the TV, the chest drawer which was about 3 feet tall and the wheel chair was seen turned over on the floor in Resident #2's room. During an interview with the Regional Director of Clinical Services (RDCS) on [DATE] at 11:40 a.m., the RDCS stated, Resident #2 was confused, disoriented and total dependent and was seen lying in the bed in blood-soaked sheets with multiple lacerations. The RDCS also stated CNA #2 came to the nurse yelling with Resident #2's name and stated I don't know what happened In addition, the RDCS indicated that when RN #1 walked into Resident #2's room, RN #1 saw a TV on the floor and a wheelchair turned upside down at the foot of Resident #2's bed. The RDCS also stated that on the day after the incident, CNA #2 stated he/she found the Resident like that. The RDCS further indicated that certain things did not seem right and with the facility's investigation, it was concluded that the TV should have broken if it fell . The RDCS also indicated that the police were not happy because facility staff moved the TV and wheelchair, so the police taped the room off and a police officer stood in the hallway outside of Resident #2's room, not allowing any facility staff into the Resident's room. In addition, the RDCS mentioned, we started to get interviews, and I can tell you, I've been a nurse for [AGE] years, and it just didn't add up How did the TV fall on the floor and did not break? . How did the wheelchair topple over? The RDCS further indicated that at this point, we feel the patient fell out of bed and the CNA intentionally covered it up and put the blame on another Resident (Resident #1) During an interview on [DATE] at 12:20 p.m., CNA #2 stated on [DATE] around 10:30 a.m., while CNA #2 was giving Resident #2 a.m. care, he/she first washed Resident #2's lower body, put the Resident's pants on, pulled the pants on halfway to the knees, and left Resident #2 sitting on the edge of the bed, when he/she went to the bathroom to wet the wash cloth to clean the Resident's upper body. CNA #2 indicated that when he/she was on the way back to continue with providing care to Resident #2, the Resident flipped out of the bed, fell on the floor and sustained a cut on the forehead. In addition, CNA #2 further stated that he/she picked up Resident #2 and put the Resident back into bed, and cleansed the blood off of the Resident's forehead. CNA #2 further indicated that he/she did not tell anyone and left Resident #2's room without immediately reporting Resident #2's injury and/ or incident to anyone. CNA #2 also stated that he/she saw another Resident (Resident #1) in the hallway and took Resident #1 to Resident #2's room. CNA #2 also stated that he/she put the TV on the floor and turned the wheel chair upside down in Resident #2's room. CNA #2 further indicated that Resident #1 was trying to move toward Resident #2's bed and he/she pushed Resident #1 back to prevent him/her from leaning on Resident #2's bed, which caused blood from his/her hand to get onto Resident #1's t-shirt. CNA #2 also indicated that he/she left the room with Resident #1 and returned to the dayroom he/she was monitoring from 11:00 a.m. to 11:30 a.m. CNA #2 further indicated that while he/she was monitoring the dayroom, Resident #3 (Resident #2's roommate) stood up and wanted to go to the bathroom, so he/she asked another CNA (CNA #1) to monitor the dayroom and then the CNA took Resident #3 to toilet the Resident. CNA #2 further indicated that he/she checked on Resident #2 and found out that Resident #2 was still bleeding and the CNA called RN #1 to come into Resident #2's room to take a look at the Resident. In addition, CNA #2 stated that two staff were needed to transfer Resident #2. It wasn't me at this time, I don't know what happened. CNA #2 also indicated that if a Resident fell , he/she is supposed to put the call light on and show his/her head outside of the Resident's room; and if no one comes into the room, he/she will call for help and then report the incident to the nurse. During an interview with RN #1 on [DATE] at 11:42 a.m., RN #1 stated Resident #2 was two-person transfer via hoyer lift. During an interview with the Clinical Reimbursement Coordinator (CRC) on [DATE] at 1:25 p.m., the CRC stated a score of ,[DATE] on the MDS means totally dependent and two persons assist. The CRC also stated the CP and the MDS should be the same relating to transferring residents. During an interview with the Administrator (Admin) on [DATE] at 2:45 p.m., the Admin. stated that it was either the EMT (Emergency Medical Transport) or the hospital that called the police. The Admin. further indicated that the police came into the facility on [DATE], before the facility could even conclude their investigation and yellow taped Resident #2's room from [DATE] to [DATE]. In addition, the Admin. indicated that the police informed him/her that the area was a crime scene. The Admin. further indicated that he/she did not report to the New Jersey Department of Health (NJDOH) that the police yellow taped the area and the area was a crime scene because he/she already reported the incident to DOH as an Incident of Unknown Origin. 2. According to Resident #1's Admission Record (AR), Resident #1 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #1 had short-term memory problem and was severely cognitively impaired. The MDS also indicated that Resident #1 required assistance with Activities of Daily Living (ADLs). Review of Resident #1's Care Plan (CP) dated [DATE], included Under Focus: The resident exhibits, or has the potential to exhibit physical behaviors related to Cognitive loss/Dementia: wandering, disrobing clothes, shaking/banging doors, resistive/combative with care, pushing/pulling things. Under Goals: The Resident will exhibit no episode of physical behavior The Resident will not harm others. Under Interventions: Evaluate the need for psychiatric /behavioral health consult. Observe for non-verbal signs of physical aggression Review of Resident #1's PN were as follows: On [DATE] at 11:07 a.m., Resident #1 was found in her room during routine monitor wandering in the corner of the room, by the window, TV was found on the floor all drawers open, tray table upside down, roommate chair upside down, and drawers door open, resident was moved from the room and redirected On [DATE] at 2:45 p.m., Resident #1 was seen by physician and recommended to discontinue (D/C) the Resident's [MEDICATION NAME] and titrate (lowering the dose) his/her [MEDICATION NAME] orders from total of 250 milligrams (mg) three times a day to total of 250 mg twice a day. On [DATE] at 10:08 a.m., patient (Resident #1) constantly pushing and throwing tables in dining room, attempting to hit staff members On [DATE] at 10:14 p.m., Resident #1 was throwing chairs and trying to turn over the tables, needs redirection, also resistive to care On [DATE] at 5:10 p.m., Resident #1 spouse agreed to transfer the Resident to another facility in regards to the higher level of care conducive to the Resident's needs. On [DATE] at 12:49 p.m., Resident #1 had a change in condition, which included behavioral disturbance, pushing or pulling things down in the morning on [DATE]. In addition, the PN revealed that Resident #1's Primary Care Physician (PCP) was notified and Resident #1's PCP gave an order to send the Resident out to the hospital for evaluation. On [DATE] at 3:43 p.m., Resident #1 left the facility around 1:00 p.m., to the hospital for Behavioral Disturbance. Review of Resident #1's OSR were as follows: [MEDICATION NAME] Sprinkles Capsule Sprinkle 125 mg, two capsules (total 250 mg) by mouth two times a day for Dementia with mood disturbances, dated [DATE]. [MEDICATION NAME] tablet 0.5 mg, give one tablet by mouth every eight (8) hours as needed for anxiety for 14 days, dated of [DATE] and D/C date of [DATE]. Review of Resident #1's OSR dated [DATE], revealed the following: Resident #1 out to the hospital for psychiatric evaluation secondary to Behavioral Disturbance. Review of Resident #1's UTF dated [DATE] at 1:25 p.m., showed that Resident #1 was transferred to the hospital due to Behavioral Disturbance, pushing, pulling things down. Review of Resident #1's Emergency Department Medical Record (EDMR) Emergency Department Note -Physician (EDN-P) dated [DATE] at 2:07 p.m., included but was not limited to the following: patient (Resident #1) sent to ED from extended care facility for aggressive behavior. Patient calm, cooperative at time of triage Under ED Course and Treatment: Patient condition remained stable during ED evaluation Patient was placed on 1:1 line of sight. On re-examination, patient is awake, alert, remains calm, and in no distress. Patient is asymptomatic, and offers no further complaints at this time The EDN-P also revealed after the evaluation in the ED, the physician's clinical impression was Dementia and agitation. Under Inpatient medications: [REDACTED] Klonopin: 0.5 mg tablet, oral, 2 (two) times a day, start [DATE] at 4:30 p.m., duration of seven days. [MEDICATION NAME]: 100 mg tablet, oral, bedtime, start [DATE] at 10:00 p.m., duration of 30 days. [MEDICATION NAME]: 50 mg tablet, oral, daily, start [DATE] at 4:30 p.m., duration of 30 days. [MEDICATION NAME]: 25 mg capsule, oral, every six hours as needed (PRN) extrapyramidal symptoms (EPS), start [DATE] at 1:24 p.m., duration of 30 days. [MEDICATION NAME]: 25 mg Injection, IntraMuscular (IM), every six hours PRN EPS severe, start [DATE] 1:24 p.m., for 30 days. Do not overlap per oral (PO) and IM doses. [MEDICATION NAME]: 2 mg tablet, oral, every six hours PRN [MEDICAL CONDITION] start [DATE] at 10:12 a.m., do not overlap oral and Injectable medications. [MEDICATION NAME]: 2 mg Injection, IM, every eight hour, PRN [MEDICAL CONDITION]-severe, start [DATE] at 12:00 p.m., Do not overlap oral and Injectable medications. [MEDICATION NAME]: 50 mg capsule, oral, every six hour, PRN Agitation-severe, start [DATE] at 3:16 p.m., duration of 30 days. [MEDICATION NAME]: 25 mg Injection, IM, every six hour, PRN Agitation-severe, start [DATE] at 3:17 p.m., duration of 30 days. [MEDICATION NAME]: 50 mg tablet, oral, bedtime PRN [MEDICAL CONDITION], start [DATE] at 1:24 p.m., duration of 30 days. Further review of the EDN-P revealed the following: Recommended admission to inpatient psychiatric service. The Patient does not comprehend the significance or need for this at this time. The recommendation has been discussed with the clinicians and staff. Review of the EDMR Neurology Consultation Note (NCN) dated [DATE] at 4:37 p.m., revealed the following: Under Reason for consult: Dementia and clonus. Under Clinical Indication: Trauma. Resident #1's NCN also revealed that the Resident had Computer [NAME]ography (CT) scan of the head. In addition, the NCN revealed that Resident #1's CT scan result showed no evidence of acute infarct, hemorrhage, extra-axial fluid collection or [DIAGNOSES REDACTED] Under Impression: No acute abnormality. Resident #1's NCN also revealed that Resident #1 had CT scan of the cervical spine and revealed the following: Under Impression: Rotary subluxation of C1 (first cervical spine) on C2, (second cervical spine) which may be posttraumatic versus due to patient positioning Mild [MEDICAL CONDITION] changes in the cervical spine without spinal canal stenosis or neural foraminal narrowing. Under Recommendations: The Patient symptoms of hyperreflexia and bilateral clonus most likely chronic related to cervical [DIAGNOSES REDACTED]. Review of EDMR Behavioral Health Progress Note (BHPN) dated [DATE] at 12:17 p.m., revealed that Resident #1 was calmer but remained mute. Under Assessment: Resident #1 appeared disorganized in his/her behavior. Inpatient care was medically necessary for stabilization and for safety. Under Diagnosis: [REDACTED]. During an interview with the Clinical Quality Specialist (CQS) on [DATE] at 9:17 a.m., the CQS stated that immediately after the incident on [DATE], the facility initiated an investigation. The CQS indicated that it was thought Resident #1 might have caused the incident because Resident #1 has a history of knocking things down. The CQS further indicated Resident #1 could have flipped Resident #2's chair over. In addition, the CQS indicated that the suspected resident (Resident #1) was sent out to the hospital to rule out any psychiatric causes. The CQS further stated that Resident #1 had no history of physical aggression. However, Resident #1 was sent out because the resident wanders and goes into other residents' rooms During an interview with RN #1 on [DATE] at 10:25 a.m., RN #1 stated when he/she first came on the floor, Resident #1 was in front of the nursing station. RN #1 indicated that Resident #1 was walking around and did not seem agitated. RN #1 also indicated that Resident #1 could be aggressive with objects but not people so this could be a change in condition for him/her. In addition, RN #1 indicated that he/she had seen Resident #1 go into other residents' rooms; however, the Resident only walks in and out. During an interview with RDCS on [DATE] at 11:40 a.m., the RDCS stated that another CNA (CNA #1) who provided care for Resident #1 indicated he/she changed Resident#1's t-shirt and left the soiled t-shirt in Resident #1's room. The RDCS also stated that the CNA could not tell how Resident #1's t-shirt got on Resident #2's bed and covered with blood. Review of the Facility's Policy titled NSG205 Assessment with a revised date of [DATE], included but was not limited to the following: Under Policy: The facility will conduct initially and periodically a comprehensive, standardized reproducible assessment of each patient's functionally capacity The assessment must accurately reflect the patient's status at the time of the assessment. Under Purpose: To determine the patient's condition and clinical needs. Review of the Facility's Policy titled OPS300 Abuse Prohibition with a revised date of [DATE], included but was not limited to the following: Under Policy: The facility prohibit abuse, mistreatment, neglect, misappropriation of Resident property, and exploitation of all Residents. The facility also strive to comply with the Elder Justice Act (EJA). Under EJA, employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a Resident. Under Federal Definitions: Neglect is defined as the failure of the center, its employees or service providers to provide good and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Under Purpose: To ensure that facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property of all patients N.[NAME][NAME]C:,[DATE].2(b)

C#: NJ 6 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documents on [DATE] and [DATE], it was determined that the facility failed to provide a safe environment to prevent a severely cognitively impaired resident with a history of falls and a [DIAGNOSES REDACTED]. In addition, the facility failed to implement identified Care Plan (CP) interventions to prevent a resident from a fall, as well as follow the facility's own policies titled Person-Centered Care Plan and Falls Management for 1 of 3 sampled residents (Resident #2), reviewed for incidents/ accidents. When on [DATE] at approximately 10:40 a.m., the assigned Certified Nursing Assistant (CNA #2) left Resident #2 sitting at the edge of the bed unattended and went to wet a towel to provide care for the Resident. Resident #2 then fell from the edge of the bed and sustained a laceration, hemorrhaging and a hematoma to the head. CNA #2 then picked Resident #2 up from the floor without an assistant device and placed the resident back into bed. CNA #2 cleansed off the blood from Resident #2's forehead and did not notify the Registered Nurse/Unit Manager (RN #1) that Resident #2 fell from the bed and had injuries, and did not call for assistance which prevented Resident #2 from receiving immediate medical care. CNA #2 then went out of Resident #2's room, and continued with his/her routine assignment in the dayroom. On [DATE] at approximately 11:40 a.m., CNA #2 went into Resident #2's room to toilet the Resident's roommate, after placing Resident #2's roommate on the toilet, CNA #2 then went over to Resident #2's bedside and found the Resident bleeding on the forehead and blood on the Resident's sheets and notified RN #1 that Resident #2 needed help. When RN #1 arrived at Resident #2's bed side the RN found Resident #2 in bed bleeding and activated Code Blue (medical emergency), facility staff responded, 911 was called and Resident #2 was sent to the hospital for evaluation. Resident #2 subsequently died in the emergency room (ER), on [DATE] at 2:08 p.m. The facility also failed to follow the facility's own policies titled Assessment, Abuse Prohibition, Falls Management, and Person Centered Care Plan. This placed Resident Resident #2, as well as all other residents in the facility in an Immediate Jeopardy (IJ) situation. This IJ ran from [DATE] through [DATE] at 2:52 p.m., when the IJ was identified and reported to the Administrator and RN/Clinical Quality Specialist (CQS), and the facility was presented with the IJ template. The IJ was lifted that same day at 2:52 p.m., when the facility provided an acceptable Removal Plan. A revisit was done on [DATE], to validate that the facility implemented their removal plan. This deficient practice was evidenced by the following: 1. According to Resident #2's Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had short-term and long-term memory problems and was severely cognitively impaired. The MDS also indicated that Resident #2 required assistance with Activities of Daily Living (ADLs). Review of Resident #2's CP dated [DATE], included the following: Under Focus: The resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Under Interventions: Provide resident with total assist of two for transfers using a total lift. Review of Resident #2's CP revised on [DATE], included the following: Under Focus: The resident demonstrates deficit in transferring r/t Cognitive loss/Dementia and [MEDICAL CONDITION]. Under Goal: initiated [DATE], revealed: The resident will safely transfer via hoyer lift .Under Interventions: Ensure surfaces are stable. Further review of Resident #2's Care Plan (CP) dated [DATE], included the following: Under Focus: The resident is at risk for falls related to (r/t) cognitive loss, lack of safety awareness, [MEDICAL CONDITION], Dementia and Impaired Mobility Under Goal: The resident will have no falls with injury Under Interventions: Bed sensor while in bed for safety. Tabs monitor while in wheelchair for safety. Total lift for transfers. Assess for changes in medical status, pain status, mental status and report to MD (Medical Doctor) as indicated. Floor mat at bedside when in bed. Utilize low bed. Assist resident getting in and out of bed with ,[DATE] assistance. Review of Resident #2's Visual/Bedside Kardex Report, undated, included the following: Under Ambulation/ Mobility/Transfers: Assist resident getting in and out of bed with ,[DATE] person assistance Provide resident/patient with total assist of two for transfers using a total lift Review of Resident #2's Order Summary Report (OSR) included the following: Bed sensor on at all times to prevent falls while in bed, check placement and function every shift, dated [DATE]. Bilateral ,[DATE] (half) side rails up as enabler at all times every shift, dated [DATE]. Floor mat by bedside when patient (resident) is in bed for safety every shift, dated [DATE]. Review of the Facility's Reportable Event (FRE) dated [DATE], revealed that on [DATE] at approximately 11:45 a.m., Resident #2 was discovered in bed with blood noted on the Resident's forehead by the assigned aide (Certified Nursing Assistant / CNA #2), also the CNA alerted RN #1 who responded to Resident #2's room and called Code Blue and activated the medical emergency response to summon additional assistance. The FRE also indicated that first aid was rendered to Resident #2 and the Resident was sent to the hospital. In addition, the FRE further showed the police was notified and involved; and the facility was actively investigating the incident. Further review of the FRE revealed that Resident #2 was non ambulatory and would not be able to get back into bed. The FRE also revealed that Resident #2 expired, unsure if from injuries, and Resident #2 was frail and bed bound. Review of a Facility form titled RMS Event Summary Report (a facility's incident report tool) dated [DATE] at 11:45 a.m., revealed under Event: Injury of Unknown Origin: The report also revealed that Resident #2 was noted with laceration from right side of the forehead, bump to R (right) forehead and a cut to L (left) upper forehead and under right eye. In addition, the report showed that first aid was rendered to Resident #2 and the Resident was sent out to ER (emergency room ) for evaluation. Review of Resident #2's Progress Notes (PN) dated [DATE] at 3:09 p.m., revealed that Resident #2 had a laceration to the R (right) forehead 1.5 inch and about 0.3 inch deep; bump to the right forehead 1.5 inch x (by) 1.5 inch and about 1.5 inch high, 1 inch cut above the left upper forehead w/ (with) about 0.2 inch deep; 0.8 inch cut to under right eye with 0.2 inch deep. Wounds cleansed with saline and pressure dressing applied. Right [MEDICAL CONDITION] covered with dry dressing and wrapped with a cling. Review of Resident #2's PN dated [DATE] at 3:42 p.m., revealed that Resident #2 was transferred from the facility to the hospital at 12:10 p.m., for evaluation. Review of Resident #2's PN dated [DATE] at 8:30 p.m., written by the Nurse Practitioner (NP) revealed Resident #2 presenting problem to be bleeding from head wound related to trauma The PN also revealed that Resident #2 was noted with deep a laceration on the right side of (the) head, and a large hematoma to forehead close proximity to the head wound. The PN also showed Resident #2 had laceration with bleeding noted to the left side of head. Also, to the outer corner of the right eye noted lacerations, due to trauma. BP (blood pressure) ,[DATE] (which indicated the resident's BP was elevated) In addition, the PN showed that Resident #2 had sluggish pupils and a poor respiratory effort Further review of the PN showed that Resident #2 was transferred to the hospital via ambulance. Review of Resident #2's Universal Transfer Form ( a form that is used to communicate pertinent, accurate clinical patient care information at the time of an emergency to a facility or a patient transfer between health care facilities) dated [DATE], showed that Resident #2 was transferred to the hospital due to Profuse bleeding secondary to big laceration on R (right) forehead, bump on right forehead above right eye, right eye cut Post survey review of Resident #2's Emergency Department Medical Record (EDMR) Emergency Department Provider Note (EDPN) dated [DATE] at 1:04 p.m., included but was not limited to the following: Under ED (Emergency Department) Course: CT Scan (a computed tomography scan that uses a combination of X-rays and a computer to create pictures of one's organs, bones, and other tissues) showed that Resident #2 had traumatic subdural hemorrhage. Resident #2's EDPN also revealed, Resident #2 continued to have worsening neurologic decline no longer responsive, apneic (a cessation of breathing) with worsening [MEDICAL CONDITION] (slow heart rate). In addition, Resident #2's EDPN showed, given concerns that this being acute traumatic injury unexplained will contact police for further evaluation for possible homicide Under Number of [DIAGNOSES REDACTED]. Under Imaging CT Head Without Contrast included the following under Findings: Acute right hemispheric subdural hematoma Additional smaller interhemispheric subdural hematoma seen anteriority on the right adjacent to the frontal lobe Mild midline shift to the left Acute fractures involving he anterior arch of C1 which are comminuted mildly displaced In addition, the EDPN also revealed Resident #2 had traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter Review of Resident#2's EDPN dated [DATE] at 1:20 p.m., revealed that Resident #2 had decreased respiratory effort and low oxygen saturation The EDPN also showed that Resident #2 was placed on oxygen therapy at 15 liters via a Non-Rebreather (NRB), (a mask used to assist in the delivery of oxygen) and continued on cardiac monitor. Further review of Resident #2's EDPN dated [DATE] at 2:07 p.m., revealed that Resident #2's cardiac monitor noted to be asystole (a cardiac flatline that shows a state of total cessation of electrical activity from the heart) The EDPN also showed no detectable pulses or respiratory effort, time of death 2:08 p.m. During an interview on [DATE] at 10:10 a.m., RN #1 stated he/she was in another Resident's (Resident #1) room when the aide (CNA #2) assigned to Resident #2 called to take a look at Resident #2. RN #1 indicated he/she went into Resident#2's room and saw the sheets with blood and a laceration on Resident#2's forehead seeing how bad the bleeding is, I called for code blue (medical emergency) on the overhead, so I can get help with the rest of the team. RN #1 further stated that he/she asked CNA #2 what happened to Resident #2 and the CNA indicated, I found him/her like this, I don't know what happened. RN #1 then indicated, the Resident cannot walk. RN #1 explained that the TV, the chest drawer which was about 3 feet tall and the wheel chair was seen turned over on the floor in Resident #2's room. During an interview on [DATE] at 11:40 a.m., the Regional Director of Clinical Services (RDCS) stated Resident #2 was confused, disoriented and total dependent and was seen lying in the bed in blood-soaked sheets with multiple lacerations. The RDCS also stated CNA #2 came to the nurse yelling with Resident #2's name and stated I don't know what happened In addition, the RDCS indicated that when RN #1 walked into Resident #2's room, RN #1 saw a TV on the floor and a wheelchair turned upside down at the foot of Resident #2's bed. The RDCS also stated that on the day after the incident, CNA #2 stated he/she found the Resident like that. The RDCS further indicated that certain things did not seem right and with the facility's investigation, it was concluded that the TV should have broken if it fell . The RDCS also indicated that the police were not happy because facility's staff moved the TV and wheelchair, so the police taped the room off and a police officer was stood in the hallway outside of Resident #2's room, not allowing any facility staff into the Resident's room. In addition, the RDCS mentioned, we started to get interviews, and I can tell you, I've been a nurse for [AGE] years, and it just didn't add up How did the TV fall on the floor and did not break? . How did the wheelchair topple over? The RDCS further indicated that at this point, we feel the patient fell out of bed and the CNA intentionally covered it up and put the blame on another Resident (Resident #1) During an Interview with CNA #2 on [DATE] at 12:20 p.m., CNA #2 stated on [DATE] around 10:30 a.m., while CNA #2 was giving Resident #2 a.m. care, he/she first washed Resident #2's lower body, put the Resident's pants on, pulled the pants on halfway to the knees, and left Resident #2 sitting on the edge of the bed, when he/she went to the bathroom to wet the wash cloth to clean the Resident's upper body. CNA #2 indicated that when he/she was on the way back to continue with providing care to Resident #2, the Resident flipped out of the bed, fell on the floor and sustained a cut on the forehead. In addition, CNA #2 further stated that he/she picked up Resident #2 and put the Resident back into bed and clean the blood off of the Resident's forehead. CNA #2 further indicated that he/she did not tell anyone and left Resident #2's room without immediately reporting Resident #2's injury and/ or incident to anyone. CNA #2 also stated that the CNA saw another Resident (Resident #1) in the hallway and took Resident #1 to Resident #2's room. CNA #2 also stated that he/she put the TV on the floor and turned the wheel chair upside down in Resident #2's room. CNA #2 further indicated that Resident #1 was trying to move toward Resident #2's bed and he/she pushed Resident #1 back to prevent him/her from leaning on Resident #2's bed, which caused blood from his/her hand to get onto Resident #1's t-shirt. CNA #2 also indicated that he/she left the room with Resident #1 and returned to the dayroom he/she was monitoring from 11:00 a.m. to 11:30 a.m. CNA #2 further indicated that while he/she was monitoring the dayroom, Resident #3 (Resident #2's roommate) stood up and wanted to go to the bathroom, so he/she asked another CNA (CNA #1) to monitor the dayroom and then he/she took Resident #3 to toilet him/her. CNA #2 further indicated that he/she checked on Resident #2 and found out that Resident #2 was still bleeding and the CNA called RN #1 to come into Resident #2's room to take a look at the Resident. In addition, CNA #2 stated that two staff were needed to transfer Resident #2. It wasn't me at this time, I don't know what happened. CNA #2 also indicated that if a Resident fell , he/she is supposed to put the call light on and show his/her head outside of the Resident's room; and if no one comes into the room, he/she will call for help and then report the incident to the nurse. During an interview with RN #1 on [DATE] at 11:42 a.m., RN #1 stated Resident #2 was a two-person transfer via hoyer lift. During an interview with the Clinical Reimbursement Coordinator (CRC) on [DATE] at 1:25 p.m., the CRC stated a score of ,[DATE] on the MDS means totally dependent and two persons assist. The CRC also stated the CP and the MDS should be the same relating to transferring residents. During an interview with the Administrator (Admin) on [DATE] at 2:45 p.m., the Admin. stated that it was either the EMT (Emergency Medical Transport) or the hospital that called the police. The Admin. further indicated that the police came into the facility on [DATE] before the facility could even conclude their investigation and yellow taped Resident #2's room from [DATE] to [DATE]. In addition, the Admin. indicated that the police informed him/her that the area was a crime scene. The Admin. further indicated that he/she did not report to New Jersey Department of Health (NJDOH) that the police yellow taped the area and the area was a crime scene because he/she already reported the incident to DOH as an Injury of Unknown Origin. Review of the Facility's Policy titled NSG215 Falls Management with a revised date of [DATE], included but was not limited to the following: under Policy: Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Under Purpose: To reduce risk for falls and minimize the actual occurrence of falls and to address injury and provide care for a fall. Review of the Facility's Policy titled Falls Care Delivery Process dated [DATE], included but was not limited to the following: If a staff member is present as a patient falls, follow Guidelines fo Managing a Fall to aide the patient to the floor which 4. Remain calm and stay with the patient. 5. Call for help 6. Call for licensed nurse to assess patient. Review of the Facility's Policy titled NSG205 Assessment with a revised date of [DATE], included but was not limited to the following: Under Policy: The facility will conduct initially and periodically a comprehensive, standardized reproducible assessment of each patient's functionally capacity The assessment must accurately reflect the patient's status at the time of the assessment. Under Purpose: To determine the patient's condition and clinical needs. Review of the Facilities Policy titled OPS416 Person Centered Care Plan with a revised date of [DATE], included but was not limited to the following: Under Policy: The center must develop and implement a baseline person-centered care plan within 8 hours for each patient that includes the instructions needed to provide effective care that meet professional standards of quality care Under Purpose: To maintain the patient's highest practicable physical, mental and psychosocial well-being N.[NAME][NAME]C:8:,[DATE].1(d)

C #: NJ 4 Based on observation, interviews, and record review, as well as review of pertinent facility documents on 4/19/18, it was determined that the facility failed to ensure that Resident #1 did not receive and/or consume food that the Resident was allergic to for 1 of 3 sampled residents (Resident #1). This deficient practice created an Immediate Jeopardy (IJ) to the health and well-being of Resident #1, who had an allergic reaction and the potential to impact all residents with food allergies [REDACTED].#1, who was allergic to peanuts and peanut oil was served with peanut butter mousse on 3/10/18. In addition, on that same day, the Resident was sent out to the hospital and admitted for an Allergic Reaction. The IJ for 3/10/18, was identified on 4/19/18, at 3:26 p.m. when the Administration was alerted. The IJ was identified as past non-compliance (PNC) for 3/10/18 to 3/11/18, when the facility provided an implemented acceptable Plan of Correction (P[NAME]). This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The AR revealed under the section allergies [REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 3/19/18, showed that the Resident was cognitively intact and required extensive assistance from staff with Activities of Daily Living (ADLs) According to Resident #1's Care Plan (CP) initiated on 3/10/18, the Resident was allergic to peanut mousse. The Resident had food allergies [REDACTED]. The CP interventions included but not limited to: Red identification band to wrist to indicate food allergy and transfer to emergency room for further management and observation. A review of the Facility Reportable Event (FRE) for Resident #1, dated 3/12/18, showed: On 3/10/18 during dinner time, resident was served peanut butter mousse. Resident has known allergy to peanut and peanut oil. MD (Medical Doctor) was notified and ordered [MEDICATION NAME] 50 mg (milligrams) x (times) 1 dose, which was administered to the resident. Attached with the FRE, the Saturday's Dinner Specials undated, that showed: Pork Chop Milanese with Gravy, [MEDICATION NAME] Potatoes, Italian Spinach or Savory Beef Pot Pie, California Blend Vegetables, Wheat Bread, and Peanut Butter Mousse with Whipped Topping. Attached with the FRE, a statement from the CNA #1, dated 3/10/18, and showed that CNA #1 served Resident #1 pudding dessert. The CNA documented I didn't know it was peanut pudding, it wasn't labelled (sic) and I didn't smell it. A review of the Progress Notes (PN), dated 3/10/18 at 6:45 p.m., showed that there was a change in Resident #1's condition, The PN showed that the Resident complained of throat discomfort and swollen throat. The PN also showed that Registered Nurse (RN #1) called the MD and obtained the following orders: [MEDICATION NAME] 25 mg (50 mg) x 1 dose now (given), and transfer to the emergency room if the Resident did not improve. The PN dated 3/11/18 at 6:58 a.m., showed that the Resident was admitted with [DIAGNOSES REDACTED]. During the tour with the Assistant Director of Nursing (ADON) on 4/19/18 at 9:28 a.m., the ADON indicated that Resident #1, was able to feed self, however, the Resident would require assistance with tray set-up. The ADON revealed that the Resident was transferred to the hospital around 3/2018, because the Resident was served peanut butter mousse cake. The ADON stated that the mousse cake looked like cookie dough, and later on, they discovered that the mousse cake had peanut butter ingredients In an interview with Resident #1 on 4/19/18 at 9:50 a.m., the Resident confirmed that she was allergic to peanuts and peanut oil. The Resident stated that the aforementioned food allergies [REDACTED]. Resident #1 continued to state that on 3/10/18, no one told the Resident what kind of dessert would be served that night. According to the Resident, a Certified Nurse Assistant (CNA) served him/her dinner, then left the room. While the Resident was eating, the same CNA came back to the room and stated We forgot to put this (referring to the peanut butter mousse) on your tray, and left the room without telling the Resident the name of the dessert. The Resident revealed that the dessert was not labeled. The Resident went on to state that the dessert looks like pudding and smelled like cookie dough, then added, After 4 bites my throat started getting scratchy, then it was too late. Resident #1 called Registered Nurse (RN #1) and asked what was in the pudding, then RN #1 smelled the pudding and stated that the pudding had peanut ingredients. Resident #1 further revealed that he/she was transferred to the hospital because the Resident felt that his/her throat was tight and could not talk. In an interview with the Executive Chef (EC), on 4/19/18 at 11:03 a.m., the EC indicated that the cook who worked on 3/10/18, made an in-house peanut butter mouse. The EC stated that the peanut butter mousse looked like pudding. The EC stated that the Dietary Aide and the CNAs knew about the peanut butter mousse because it was written on the dinner menu. In an interview with RN #1 on 4/19/18 at 1 p.m., the RN stated that on 3/10/18, at dinner time, he/she was called to check Resident #1 because the Resident ate a dessert with peanut ingredients. RN #1 stated that he/she remembered looking at the dessert container and noticed that there was no label on it. The RN stated that the Resident complained of itchy throat. RN #1 called the Primary Physician and was given orders. RN #1 revealed that Resident #1 was transferred to the emergency room after not getting relief from the medication that was administered. In an interview with the CNA #1 on 4/19/18 at 2:17 p.m., the CNA indicated that he/she was not the assigned CNA for Resident #1 on 3/10/18. However, the CNA revealed that he/she served the dinner tray and gave the peanut butter mousse to the Resident. The CNA stated that they did not have to ask the residents about dessert choices because there was only one kind of dessert that was brought to the floor, the peanut butter mousse, and there was no substitute. The CNA explained that he/she did not know that it was peanut butter mousse because there was no label on the container. CNA #1 revealed that after the incident involving Resident #1, the CNA received an inservice regarding checking the menu and resident's food allergy before serving the food. In addition, the CNA stated that now they pay more attention on checking resident's food allergies [REDACTED].#1. During a follow-up interview with the EC on 4/19/18 at 2:56 p.m., the EC stated that after the incident with Resident #1 on 3/10/18, they implemented a new plan such as: they now post the dessert on the tray/ food truck and using colored (i.e., pink) meal ticket on a resident with food allergies [REDACTED].>In an interview with CNA #2 on 4/19/18 at 3:06 p.m., the CNA stated he/she was the regular CNA assigned to Resident #1, however, that night on 3/10/18, he/she was not the one who served the dinner to Resident #1. CNA #2 confirmed that he/she did not ask the Resident about the dessert and/or dessert substitute that night. A review of the Summary and Conclusion (SC) dated 3/10/18, under the Summary and Investigation, showed that on 3/10/18 at 5:40 p.m., Resident #1 reported to RN #1 that the Resident's throat felt itchy and uncomfortable after eating 4 spoons of dessert. The SC further showed that the dessert was peanut butter mousse and the RN called the Primary Physician and obtained orders. The SC revealed that Resident #1 was transferred to the emergency room , was admitted with [DIAGNOSES REDACTED]. Further review of the SC, under Conclusion showed that the Resident #1's CP was updated, a red ID (identification) band was placed on Resident #1's wrist to alert the staff of the food allergy, peanut butter mousse was removed from the menu cycle, inservice education was provided to staff to check on daily menus, resident's meal tickets and red ID bands that will indicate food allergy. A review of the facility policy, Meal Service, revised date on 6/15/16, showed under Process: 1. As food production is completed, employees begin to transfer items to the meal assembly area and set-up tasks are completed. 1.1 Menu substitutes are recorded. 6. The Director of Dining Services is responsible to ensure meals are complete and accurate for diet, .preferences . The IJ was identified on 4/19/18, and was PNC for 3/10/18 to 3/11/18, when the facility provided an acceptable P[NAME] which included staff education on Meal Service Policy and Allergy Policy. The acceptable policy was documented as follows: 1. On 3/10/18, Resident #1 was served a peanut butter mousse dessert. A red ID wristband was placed on resident wrist to alert staff of the Resident's food allergy. 2. All residents with food allergies [REDACTED]. 3. Nurse Practice Educator or designee will inservice all staff on meal service policy and allergy policy. Director of Nursing or designee will perform monthly Food Allergy audit x 3 months then quarterly thereafter. Results of the Food Allergy audit will be reported to the Administrator on a monthly basis for review comment and recommendation. 4. Results of the monthly Food Allergy audit will be reported by the Director of Nursing or Designee at the monthly QAPI meeting for review, comment and recommendation for the next three months. 5. Completion date: 3/11/18. NJAC 8:39-17.4(e)

A. Based on observation, interview, and record review, it was determined that the facility failed to provide a resident who was on a Dysphagia (difficulty or discomfort in swallowing) Advanced Diet including Nectar Thick Liquids with the correct consistency of food and liquids. This deficient practice was noted for 1 of 3 residents sampled on Puree diets, Resident #19, who was given whole grapes, a grilled cheese sandwich, and unthickened coffee which were all a potential for a choking hazard if consumed. The deficient practice resulted in an immediate jeopardy situation for Resident #19 who had moderate cognitive impairment and was given whole grapes and a grilled cheese sandwich as a substitute for the regular lunch scheduled. The resident also received unthickened coffee when he/she should have received nectar thickened coffee. The immediate jeopardy for Resident #19 was identified on 9/8/16 at 10:30 a.m. and the Administrator and Director of Nursing (DON) were notified at 10:42 a.m. and abated on 9/8/16 at 3:10 p.m. when an acceptable Plan of Correction (POC) was received and implemented. The deficient practice was evidenced by: 1. On 9/2/16 at 12:50 p.m. the surveyor observed Resident #19 in the day room eating lunch. The resident's lunch tray was observed with thickened milk and thickened juice. The meal ticket on the tray indicated the resident was to have NTL (Nectar Thick Liquids) but the coffee on the tray was observed to be thin. On 9/7/16 the surveyor observed the resident in the day room with again with coffee that was not thickened. The Certified Nursing Assistant (CNA) stated she added thickener. The nurse then came over to where the resident was seated and asked what the concern was. The surveyor showed the nurse the thin coffee liquid and the nurse removed the coffee from the tray. The nurse returned a few minutes later with thickened coffee for the resident. On 9/7/16 at 12:20 p.m. the surveyor observed Resident #19 sitting in a wheelchair in the day room. Due to the meal non compliance on 9/2/16 the surveyor observed the resident during lunch meal on 9/7/16. The resident had an over bed table in front of him/her with lunch on it. The residents lunch did not look like very much had been eaten and the surveyor asked if s/he was going to eat lunch. The resident said that s/he could not eat it because it was cold. A Certified Nursing Assistant (CNA) went to the resident and the resident said the food was cold. The CNA said the food was not cold and gave the resident a bite of food. The resident made a face and said it was cold. The CNA said she would get the resident something else to eat. At 12:38 the surveyor observed the resident eating a grilled cheese sandwich. There was a bowl of whole grapes on the over bed table in front of the resident. The surveyor told the nurse that the resident had whole grapes and a grilled cheese sandwich but the resident was on an Advanced Dysphagia Diet. The nurse did not immediately take any action to remove the grapes and grilled cheese sandwich away from the resident. The Food Service Director (FSD) was on the unit. The surveyor told the FSD about the food the resident had and the FSD went to the resident and took the grapes away. On 9/8/16 at 9:10 a.m. the surveyor reviewed Resident #19's medical record. The resident had [DIAGNOSES REDACTED]. On 8/22/16 the Interdisciplinary Care Team (IDC) assessed the resident utilizing a Quarterly Minimum Data Set, an assessment tool, as being moderately cognitively impaired, as as being on a mechanically altered diet, and as eating independently with set up help only. A review of Resident #19's care plan dated 2/24/16 reflected the resident was at risk for impaired swallowing and exhibited the symptoms of the same. The interventions included: Provide Dysphagia advanced diet, ground meat, extra gravy, puree fruit, no raw veg (vegetables), no pizza. no french fries, and provide nectar consistency liquids as ordered. The care plan also included: Encourage small sips/bites and cue as needed, encourage resident to chew and swallow each bite, encourage resident to alternate liquids and solids, encourage resident to perform double swallows, monitor for sign/symptoms of aspiration, i.e. coughing, watery eyes, choking, moist sounding voice, if coughing occurs, no food/liquids until coughing resolves, and provide general supervision during meals' (eat in day room). The surveyor observed the resident on multiple days for lunch in the day room, on only one day did the surveyor observe anyone cueing or encouraging the resident as per the above interventions. The surveyor also observed Resident #19 eating breakfast multiple times in his/her room with no staff present to monitor for potential choking episodes. On 9/12/16 at 9:08 a.m. the surveyor observed the resident in bed awake. The resident had thickened coffee and milk. Staff were not present in the room. On 9/13/16 the surveyor observed the resident in bed eating breakfast. The resident was alone in the room eating without any staff present. The immediate jeopardy was corrected on 9/8/16 at 3:10 p.m. based on acceptable plan of correction which included: 1. Speech Therapist and Dietitian along with Nurse Practice Educator (NPE) will immediately educate staff on Therapeutic Diets, what they mean in terms of choice of food served, the type of consistency expected for the end product and where the information is located on the meal tickets. Food items placed on a tray from the kitchen will be checked by the kitchen staff and then again at the point of service to ensure accuracy. 2. Nursing staff on the Units and staff in the main dining room will be immediately educated that beverages requiring thickener will be prepared by a nurse at the beverage cart or other equivalent area and that no beverage is to be thickened in the resident's room or area of dining. After thickened the beverage may be delivered to the resident. 3. All food servers whether on the kitchen, on the units, or in the main dining room will be immediately educated on the importance of reading each meal ticket prior to plating to review any dietary restrictions such as but not limited to allergies. Nursing staff will be immediately trained to review the diet ticket after receiving the plated food to ensure the food meets the dietary restrictions on the ticket. 4. All cooks will immediately be reeducated in the proper technique of preparing therapeutic diet foods by the director of dining services with the goal of consistent and proper texture. 5. The temperature of the therapeutic diet foods will be checked in the kitchen prior to plating. The food will be kept hot and plated just before the food cart is ready to be brought to the point of service. The therapeutic diet plates will be randomly checked for temperature again at the point of service. 6. The Speech Therapist and Dietician will maintain a list of all special diets for all residents. This list will be reviewed against the diet orders on all of the resident's charts as well as against the software that generates the meal tickets for accuracy. 7. Upon hire, annually and as needed, education will be provided to staff by the Dietician regarding therapeutic diets, what they mean in terms of food choice and consistency and where the information is located on the meal tickets. 8. Upon hire, annually and as needed, education will be provided to staff by the NPE regarding the process of preparing the thickened liquids at the beverage cart and that no beverage is to be thickened in the resident room or dining area. 9. Upon hire, annually and as needed, education will be provided by the Director of Dining Services and the NPE regarding the importance of reading each meal ticket prior to plating to review any dietary restrictions such as but not limited to allergies. 10. Upon hire, annually and as needed, education will be provided by the Director of Dining will review with all cooks the proper technique of preparing therapeutic diet foods by the director of Dining serves with the goal of consistent and proper texture. In addition, the dietary staff will be educated on the proper timing for handling and plating therapeutic diet foods. 11. The Director of Dining Services, the Executive Chef, Kitchen Supervisor or the Dietician will do complete audits for all food items placed on trays in the kitchen for specific residents to ensure their accuracy. These audits will be done for each meal over the next two weeks and then random audits will be done four times a month. Any corrections will be reviewed immediately with the necessary staff and further education and/or disciplinary actions taken as needed. All data from these audits will be presented quarterly at the Quality Assurance Process Improvement (QAPI) Committee on a monthly basis to the center Executive Director. 12. Nursing Managers and Trained Nurses will do complete audits of the beverage service at each meal for the next weeks and then random audits will be done four times a month to ensure that beverages are thickened in the proper location prior to being served to a resident. Any corrections will be reviewed immediately with the necessary staff and further education and/or disciplinary actions taken as needed. All data from these audits will be presented quarterly at the QAPI Committee and on a monthly basis to the Center's Executive Director. 13. The Director of Dining Services, the Executive Chef and the Dietician will audit food items served on the units from the portable carts to ensure their accuracy regarding dietary restrictions such as but not limited to allergies. These audits will be done in random locations for each meal over the next weeks and then random audits will be done four times a month. Any corrections will be reviewed immediately with necessary staff and further education and/or disciplinary actions taken as needed. All data from these audits will be presented quarterly at the QAPI Committee and on a monthly basis to the Center's Executive Director. 14. The Director of Dining Services and the Executive Chef will do random audits of the consistency of therapeutic diet foods in the kitchen and on the unit prior to serving at least eight times a month. In addition the proper timing for handling and plating therapeutic diet foods will be monitored. Any corrections will be reviewed immediately with the necessary staff and further education and/or disciplinary actions taken as needed. All data from these audits will be presented quarterly at the QAPI Committee and on a monthly basis to the Center's Executive Director. This deficiency is continued at a lower scope and severity level of E based on the following in Part B: Complaint #NJ 652 Complaint # NJ 309 B. Based on observation, interview and review of the medical record, the facility failed to provide the correct resident with the correct meal inclusive of resident needs and allergy restrictions. This deficient practice was noted for 2 of 27 residents sampled, Residents #28 and # 29. The facility also failed to provide puree meals with proper consistency including solid foods noted in the puree food. This deficient practice was noted for 2 of 26 residents observed, Residents #28 and #30, as evidenced by the following. 1. On 9/8/16 at 8:20 a.m. the surveyor observed Resident #28 in their room with a breakfast tray in front of him/her. The plate contained a half plate of scrambled eggs, toast, and hot cereal. The surveyor asked the resident how breakfast was. The resident stated terrible, the only thing I can eat is the toast. I don't like hot cereal. I am supposed to only get cold cereal. The surveyor asked the resident if s/he would like something else and the resident said yes. The surveyor told the nurse that the resident wanted something else for breakfast because s/he did not eat eggs or hot cereal. The surveyor looked at the resident's meal ticket which included, Allergies: EGG, Chocolate, Fish. The surveyor told the nurse who was unaware of the resident's allergies and the nurse went to the resident and asked what s/he would like. The surveyor and the nurse went to the meal truck and the surveyor showed the meal ticket to the cook. The cook did not respond. At 8:38 a.m. the surveyor met with the team leader to inform her of the resident's allergy to eggs. The survey team then met with the Administrator (Adm), Director of Nursing (DON), and Corporate Nurse (CN) and informed them of the above findings for Resident #28. On 9/12/16 at 9:30 a.m. the surveyor reviewed Resident #28's medical record. The resident had [DIAGNOSES REDACTED]. On 8/15/16 the IDC Team assessed the resident utilizing a Quarterly Minimum Data Set (MDS), an assessment tool, as being cognitively moderately impaired, able to feed him/herself, and as having a mechanically altered diet. The surveyor reviewed the resident's physician's orders [REDACTED]. 2. During tour of the unit on 9/2/16 at 10:30 a.m. the surveyor spoke with Resident #20, who was standing in the doorway of the room. The resident had multiple complaints of poor food and cold food. The Registered Nurse informed the surveyor that Resident # 20 was alert and oriented, had intact skin, and had refused to be weighed for the last 9 months. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. At 12:45 p.m. on 9/2/16 the surveyor observed the resident's puree lunch meal. The orange puree was shiny. The tan puree was thin and running off the plate when the plate was tilted. The resident's lunch tray included puree food, but also included whole mandarin oranges on a Puree diet. Due to the poor consistency of the puree diet, the surveyor met with the Administrator and Food Service Director (FSD) on 9/6/16 at 8:50 a.m. and the surveyor questioned what recipes were in place when making the puree diet since the surveyor observed some of the food was thick and some of it was very thin. The interview revealed there was no set amount of liquid versus thicker to use. The FSD stated the cooks made a chicken tarragon broth and that was used to thin foods in the food processor. Review of the Puree menus supplied, the directions included: Pureed BBQ Chicken 1. Prepare per recipe. Remove needed portions, reserve sauce. Transfer to food processor, blend until smooth, if too thick, add small amount of reserved sauce or LS broth or hot water, if too thin, add small amount of non-nutritive food thickener. Puree Pear Crisp 1. Prepare per recipe. Remove needed portions. Transfer to food processor, blend until smooth, if too thick, add small amount of apple juice; if too thin, add small amount of non-nutritive food thickener. In each of the recipes it allows for cooks discretion on determining if too thin or too thick. There was no exact recipe to indicate using a teaspoon or a tablespoon or the exact of amount of liquid to be used to prepare the food. The FSD indicated all 4 cooks had backgrounds in food service/cooking. On 9/14/16 at 10:30 a.m. the surveyor reviewed the Progress Notes in the medical record dated 2/22/16 which indicated the resident complained of food 'too running, wants it 'thicker' pureed. FSD (Food Service Director) informed to offer closer care for resident's food texture per poor po (oral) intake at meals. Nutritional assessment dated [DATE] under Section C. Swallowing indicated Resident #20 had complaints of difficulty or pain when swallowing. 3. During tour of the unit on 9/2/16 at 11:10 a.m. the surveyor was told by the Registered Nurse Charge Nurse that Resident #29 was alert and oriented, but forgetful, had intact skin, and used a wheelchair for locomotion. Review of the medical record revealed the resident had [DIAGNOSES REDACTED]. Resident #29 was observed in the main dining room on 9/8/16 at 12:55 p.m. The Certified Nursing Assistant (CNA) was observed by the surveyor and the CNA called the resident by their first name and the resident responded yes. The CNA mentioned the last name and the resident stated What? and the CNA then said here is your lunch tray. The resident started to eat. During this observation, the surveyor confirmed that the name of the resident on the meal ticket was actually Resident #13 who was eating in the resident's room. The surveyor then interviewed the Assistant Director of Nursing (ADON) for clarification of the resident in the dining room. The ADON verified the residents had the same first name, but Resident #29 actually received the menu/food intended for Resident #13. Resident #13 was observed eating lunch in the resident's room. The care plan for impaired swallowing indicated Resident #29 was on a regular consistency diet; chopped meat; assist with cutting food. Provide thin liquids consistency. Resident #13 was ordered a regular diet with thin liquids - large portions. 4. The surveyor observed Resident #30 on 9/2/16 at 10:00 a.m. in bed with a Private Duty Companion (PDC) at the bedside. The Registered Nurse Unit Manager (RNUM) stated the resident was confused, had a gastrostomy feeding tube removed and now ate by mouth, and had a healed pressure ulcer. The surveyor reviewed the resident's medical record on 9/13/16. The resident had been admitted to the facility in 2013 and re-admitted [DATE] with [DIAGNOSES REDACTED]. On 8/15/16 the Speech Therapist recommended a continuation of a Dysphagia puree consistency diet and a downgrade to nectar thick consistency liquids. The September 2016 physician's orders [REDACTED]. The care plan for impaired swallowing, initiated on 3/15/13, included interventions for Resident #30 to be spoon-fed a puree consistency diet with thin consistency liquids. The surveyor interviewed Resident #30's Health Care Proxy (HCP) on 9/13/16 at 10:35 a.m. The HCP stated either family or a PDC fed the resident breakfast, lunch and dinner daily. The HCP further stated the puree was often lumpy with visible pieces of meat in the puree. The surveyor interviewed the resident's PDC on 9/13/16 at 12:20 p.m. and on 9/14/16 at 12:50 p.m The PDC stated the puree consistency has been too thick with pieces of meat frequently in the past. The facility also failed to monitor and protect a resident, Resident #28, from receiving a food item that was identified as a food allergy. The resident had an allergy to eggs which was clearly identified on the diet slip, but was observed on the resident's breakfast tray. Resident #28 who was severely cognitively impaired, had a known allergy to eggs and was given half a plate of scrambled eggs for breakfast. Resident #20 who had a physician's orders [REDACTED]. The facility also failed to provide food in the correct consistency for the puree diet ordered by the physician for Resident #20, as indicated by the observation of mandarin oranges on the resident's food tray during lunch meal. These deficient practices were identified for 2 of 26 residents reviewed for altered diet consistency secondary to swallowing difficulty (Resident #19, #20), and 1 of 26 residents reviewed for facility compliance with food and/or drug allergies (Resident #28). NJAC 8 :39-17.4(a) 1 NJAC 8:39-17.4(a)2