Every finding on record at Complete Care at Westfield, LLC

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 1 of 3 unsampled residents (Resident #95) reviewed for EBP on 1 of 2 units ([NAME] Unit) and was evidenced by the following: On 3/04/25 at 08:10 AM, during incontinence rounds with the Unit Manager (UM) on the [NAME] Unit, the surveyor observed the UM approach unsampled Resident #95, who was lying in bed. The UM donned (put on) gloves and asked permission to check the resident's brief; the resident granted permission. The UM opened Resident #95's brief, pulled down the front of the brief, and allowed the surveyor to observe that the brief was wet, but not saturated and the linens were dry. After the surveyor's observation, the UM pulled up the front of the brief, refastened the brief, and pulled the linens up. The UM then removed her gloves and performed hand hygiene. On the way out of the room, the surveyor observed an EBP sign which indicated gloves and a gown were required for High-Contact Resident Care Activities. Examples of High-Contact Resident Care Activities listed on the sign included changing briefs or assisting with toileting. The surveyor questioned the UM about which resident the sign was referencing, and she stated that Resident #95 was on EBP. When asked about wearing a protective gown, the UM stated that she should have had a gown on (for the incontinence check). A review of the admission record reflected that Resident #95 had diagnoses that included but not limited to; Alzheimer's disease (a progress disease that destrys memory and other important mental functions) and gastrostomy tube (a feeding tube inserted through the abdomen into the stomach). A review of the interdisciplinary care plan revealed an intervention dated 11/10/23 with a focus area of Enhanced Barrier Precautions related to a feeding tube. The interventions included but not limited to; gown and gloves to be worn by staff during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Includes: dressing, . changing linens, changing briefs or assisting with toileting . On 3/05/25 at 1:56 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that if a resident has a feeding tube and was on EBP, the staff would need to wear a gown and gloves to check their incontinent brief because that was direct contact with the resident. On 3/06/25 on 12:55 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the Director of Nursing, the Regional Director of Operations and the Regional Clinical Supervisor were made aware of the above concern. A review of facility provided policy Enhanced Barrier Precautions, implemented 9/1/24 included: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 3. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room h. see table 1 for implementing contact versus enhanced barrier precautions for more information Table 1 included Has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO as an indication for EBP. 4. High-contact resident care activities include: f. changing briefs or assisting with toileting NJAC 8:39-19.4(a)(2)(c)

COMPLAINT# NJ00174720 Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to submit a report to the New Jersey Department of Health (NJDOH) within the two-hour timeframe for an allegation of abuse against Certified Nursing Assistants (CNA) for two (2) of two (2) residents (Resident #61 and #241) reviewed for abuse reporting. The deficient practice was evidenced by the following: 1. On 2/28/25 at 11:00 AM, the surveyor observed Resident #61, in the dementia care activity room, seated in a wheelchair at a table with tablemates, flipping through a magazine. The resident said hello and smiled at the surveyor. On 3/3/24 at 12:50 PM, the surveyor observed Resident #61, in the dining room, awaiting lunch. The surveyor attempted to interview the resident, but the resident was unable to answer questions. The surveyor reviewed the electronic medical record (EMR) for Resident #61. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but not limited to; unspecified dementia, unspecified severity, with other behavioral disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24 revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, indicating the resident's cognition was severely impaired. A review of the individual comprehensive care plan (ICCP) revealed a focus of has a mood and behavior problem in r/t (related to) resistive to care-refusing care, hitting staff, yelling/screaming, scratching staff, kicking, refusing medication, insomnia (difficulty sleeping) secondary to dementia with behavior problem and HOH (hard of hearing), Revision on 6/14/2024 and an Intervention of Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 10/23/2023. A review of a Reportable Event Record/Report provided by the Licensed Nursing Home Administrator (LNHA #1) dated 12/19/23, revealed it was completed by a previous LNHA, LNHA #2, which indicated Licensed Practical Nurse (LPN #1) alleged that CNA#1 yelled at Resident #61. In addition, the report indicated that the incident occurred on12/19/23 at 8:42 AM and was called in to the NJDOH by LNHA #2 on 12/20/23 at 6 PM. A review of a comprehensive MDS dated [DATE], the MDS which was nearest the date of the allegation, reflected that the resident had a brief interview of mental status (BIMS) score of one (1) out of 15, indicating the resident had severely impaired cognition. On 3/4/25 at 10:47 AM, the surveyor interviewed LPN#1, who verified that she had completed a written statement on 12/19/23. LPN#1 also verified that she had made an accusation of abuse regarding CNA#1 and Resident #61, on the morning of 12/19/23. On 3/4/25 at 11:33 AM, the surveyor interviewed LNHA #2, who verified that she had completed the Reportable Event Record/Report and was the LNHA, at that time. LNHA #2 also verified that the allegation of abuse occurred on 12/19/23 at 8:42 AM and that the NJDOH was notified of the allegation on 12/20/23 at 6 PM. LNHA #2 stated that she did not recall why there was a delay in reporting the allegation and thought that maybe she was trying to get all the information first. LNHA #2 acknowledged this was an allegation of abuse and should have been reported immediately. 41858 2. On 2/28/25 at 11:41 AM, during initial tour, the surveyor observed Resident #241 in bed, dressed, lying on a mechanical lift pad. The resident stated they were waiting to go to therapy, which was usually around lunch time. The surveyor reviewed the EMR for Resident # 241. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified fracture of lower end of left femur (thigh bone, near the knee), subsequent encounter for closed fracture with routing healing, multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, and unspecified fracture of sacrum (back of the pelvic bone), subsequent encounter for fracture with routine healing. A review of the comprehensive MDS, dated [DATE], revealed the resident had a BIMS of 15 out of 15, indicating the resident was cognitively intact. A review of the ICCP revealed a focus of an ADL (activities of daily living) self-care performance deficit r/t Activity Intolerance, Limited Mobility, Date Initiated: 02/12/2025. On 3/4/25 at 8:30 AM, during incontinence rounds with the Assistant Director of Nursing (ADON) and the surveyor, Resident # 241 was in bed and agreed to be checked, no concerns. At that time in the presence of the ADON, who was standing on the side of the resident's bed, and the surveyor, who was standing at the bottom of the resident's bed, the resident stated, I try not to complain but after therapy yesterday I was brought back to the room and was asked to stay in the chair until after lunch. The resident agreed. Resident #241 stated they fell asleep in the chair and when they woke up, they were all crooked. The resident stated they hit the buzzer (call bell) and around 2:45 (PM) a very nice CNA came in and said it was shift change and someone would be in soon. I hit my buzzer again and someone came in and I said I wanted to get back in bed. That person turned off the light. The resident further stated, then around 5:00 (PM), 2 aides came in, a male and a female, they were complaining to each other about their work, and then they yelled at me saying I never hit my call light. The surveyor asked the resident again about the event that happened the day before with the 2 CNAs, the resident stated again they yelled at me. The surveyor asked the ADON to provide her with any follow up that was done for the resident regarding the this event. On 3/4/25 at 8:45 AM, the surveyor interviewed CNA #2, who stated she was the assigned CNA for Resident #241. She stated if a resident told her that they were yelled out, she would tell the nurse, and the nurse would come and talk to the resident. She added, I am not sure if I would have to give a statement. On 3/4/25 at 8:48 AM, the surveyor interviewed CNA #3, who stated if a resident stated they were yelled out, I would get the nurse right away. On 3/4/25 at 12:48 PM, the surveyor followed up with the Director of Nursing (DON) regarding the event that occurred the day before with Resident #241. He stated he was aware of the incident Resident #241 had with a CNA and he would follow up with ADON. On 3/04/25 at 1:19 PM, the DON informed the surveyor, the ADON had left message with the agency because the CNA was an agency CNA. The surveyor requested to be provided with what was done so far for the investigation. On 3/05/25 at 10:24 AM, the surveyor asked the DON for the investigaiton for Resident # 241. The DON stated because it was a complaint we (the facility) did a grievance. He added they were conducting an investigation because they (the male and female CNAs) were both from an agency so they (the facility) called the agency. The DON stated they (the male and female CNAs) were DNR'd, meaning they cannot come back to the facility, and we (the facility) are waiting for a response from the agency. On 3/05/25 at 10:40 AM, the DON provided the surveyor with the investigation. A review of the investigation, at that time, did not reveal a statement from the ADON. The surveyor asked the DON who should be interviewed, he stated they (the facility) should interview anybody who heard or seen anything, anybody who could have been a witness. The surveyor asked where the ADONs statement was, he stated it should be there. On 3/05/25 at 12:17 PM, the DON provide the surveyor with the ADON's typed statement. At that time, a review of the statement revealed On 3/4/25 during incontinence rounds, [Identifier redacted] reported that [Identifier redacted] was not put back to bed until 5 pm on 3/3/25. [Identifier redacted] also mentioned that the 2 CNAs that were helping [Identifier redacted] are arguing. They're not arguing with [Identifier redacted] but they're arguing with each other. It was signed by the ADON. The surveyor, in the presence of the survey team, made the DON aware that during the incontinence rounds, Resident #241 had stated they (the male and the female CNA) yelled at me saying I never hit my call light. He stated he was unaware of that statement and would have to review this further. Further review of the investigation revealed a statement provided by the Regional Clinical Supervisor (RCS) who interviewed the resident. The statement did not mention the CNA's yelling at the resident, it addressed heel boots and CNAs arguing, a male and a female. On 3/05/25 at approximately 12:30 PM, the RCS interviewed the surveyor in the presence of the DON, the LNHA, and the ADON, regarding Resident #241 stating they (the male and the female CNA) yelled at me saying I never hit my call light. The surveyor reviewed the above mentioned interview that occurred during the incontinence rounds on 3/4/25 at 8:30 AM with the ADON. The ADON denied hearing the resident's statement of being yelled out. The surveyor could not explain why the ADON was not listening to the resident at that time. The RCS stated, this statement changes the investigation. The DON provided the surveyor with an email from the DON, to the NJDOH dated 3/5/25 at 1:27 PM, reporting the 3/4/25 event. On 3/6/25 at 12:55 PM, during a meeting with the survey team, the LNHA, the DON, the Regional Director of Operations and the RCS were made aware of the above concerns for Resident #61 and #241. On 3/7/25 at 10:05 AM, in the presence of the survey team, the LNHA stated he was the abuse officer. He stated an allegation of abuse should be reported immediately to DOH, within 2 hours. He added staff would be suspended right away, an investigation would be started, they would speak to the resident and all staff assigned that day including supervisors. He stated, A summary and conclusion should be done, depending on the outcome we would proceed from there. A review of the facility policy for Incident/Accident Investigating and Reporting with a date implemented 9/1/2024 provided by the LNHA reflected for Reporting/Response The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made., if the events that cause the allegation involve abuse or result in serious bodily injury, or NJAC 8:39-4.1(a)(5), 9.4(f)

Based on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties were consistently applied to prevent skin breakdown. This deficient practice was identified for 1 of 4 residents (Resident #241) reviewed for position and mobility. This deficient practice was evidenced by the following: On 2/28/25 at 11:41 AM, during initial tour, the surveyor observed Resident #241 in bed dressed, lying on a mechanical lift pad. The resident was wearing socks. The resident stated they were waiting to go to therapy, which was usually around lunch time The surveyor reviewed the electronic medical record (EMR) for Resident # 241. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified fracture of lower end of left femur (thigh bone, near the knee), subsequent encounter for closed fracture with routing healing, multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, and unspecified fracture of sacrum (back of the pelvic bone), subsequent encounter for fracture with routine healing. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/18/25, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the resident had lower extremity impairment on one side and was receiving physical and occupational therapy. A review of the individual comprehensive care plan (ICCP) revealed a focus of has potential/actual impairment to skin integrity r/t fragile skin, incontinence, limited mobility, revision on 2/12/25, and interventions of Bilateral heel boots on when in bed, may remove during care, dated initiated 2/12/25. A review of physician orders revealed a physician's order (PO) for Bilateral heel boots on when in bed, may remove during care, every shift for offloading, Active 2/12/2025. A review of the February 2025 and March 2025 Treatment Administration Records (TARs) revealed Bilateral heel boots on when in bed, may remove during care, every shift for offloading, -Order Date 02/12/2025 1424 (2:24PM) with a check starting with the Eve (evening) on 2/12/25 and continued for Day, Eve and Nigh (night) for every day including all shifts for 3/4/25. A review of the chart codes revealed a check=Administered. Further review revealed an optional code of 2=Drug refused, which was not used. A review of the physician progress notes revealed on 02/14/205 at 16:25, 2/18/25 at 16:11, 2/21/25 13:05, 02/25/2025 at16:36 (4:36 PM), 2/28/25 15:50, and 3/4/25 at 16:16 A General Note .Plan: .4. Skin: keep heels off bed. On 3/4/25 at 8:30 AM, during incontinence rounds with the Assistant Director of Nursing (ADON) and the surveyor, Resident # 241 was in bed and agreed to be checked, no concerns. The surveyor asked the ADON to pick up the blankets from the resident's feet. The surveyor observed the resident wearing blue nonskid socks with their feet resting directly on the bed. The surveyor asked the resident if they wore heel booties on their feet and they stated, No I do not, I only wear socks. On 3/4/25 at 8:45 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1, who stated she was the assigned CNA for the resident. She stated the resident had cushions on each side of them while in bed, wore a leg brace and booties (heel booties). The surveyor asked the CNA to go to the room and show the surveyor. CNA #1 showed the surveyor the cushions and the brace that was on the residents left leg. She confirmed at that time the resident was not wearing booties. Once CNA #1 and the surveyor exited the room, CNA #1 stated the surveyor misunderstood her, the resident did not have booties. She stated therapy lets them (the staff) know what devices the residents need and she finds out in report. She added she knows the resident well and knows what the resident needs. On 3/4/25 at 8:52 AM, the Regional Clinical Supervisor (RCS) approached the surveyor and stated the heel booties were in the room for Resident #241 and now the resident was refusing them. On 3/4/25 at 12:48 PM, the surveyor interviewed the Director of Nursing (DON), who stated he was aware of the above incident with the heel booties for Resident #241. The surveyor asked what a PO for heel booties while in bed, may remove during care meant, he stated heel booties should be on, if not it should be documented why they weren't such as resident refused. He added if they continued to refuse the heel booties, the doctor should be called and wound care should be made aware. On 3/5/2025, the surveyor reviewed the progress notes from admission to present, which did not reveal a note that the resident refused the heel booties. On 3/06/25 at 12:55 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the DON, the Regional Director of Operations and the RCS were made aware of the above concerns. A review of the untitled facility policy, updated 10/2021, revealed Policy: Splints/ adaptive devices are to be applied as ordered by physiatrist/attending physician/nurse practitioner. A review of the facility's policy, Support Surface Guidelines updated 10/2019, revealed Purpose: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devises for residents at risk of skin breakdown. General Guidelines: 1. Redistributing support surfaces are to promote comfort for all bed- or chair bound residents, prevents skin breakdown, promote circulation and provide pressure relief or reduction .4. Elements of support surfaces that are critical to pressure ulcer preventions and general safety include pressure redistribution NJAC 8:39-27.1 (a)(e)

Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice by not appropriately assessing, monitoring, and documenting PRN (as needed) pain medications. This deficient practice was identified for 1 of 1 resident (Resident #241) reviewed for pain management. This deficient practice was evidence by the following: Reference: New Jersey Statues, 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 or 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 a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/28/25 at 11:41 AM, during initial tour, the surveyor observed Resident #241 in bed dressed, lying on a mechanical lift pad. The resident was wearing socks. The resident stated they had their pain medicine and was waiting to go to therapy, which was usually around lunch time. The surveyor reviewed the electronic medical record (EMR) for Resident # 241. A review of the Admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified fracture of lower end of left femur (thigh bone, near the knee), subsequent encounter for closed fracture with routing healing, multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing, and unspecified fracture of sacrum (back of the pelvic bone), subsequent encounter for fracture with routine healing. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/18/25, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further review, revealed the resident had lower extremity impairment on one side, was receiving physical and occupational therapy and receiving pain medicine. A review of the individual comprehensive care plan (ICCP) revealed a focus of has potential for pain r/t (related to) Chronic Pain, Date Initiated: 02/12/2025 and an intervention of evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, Date Initiated: 02/12/2025. A review of physician orders revealed a physician's order (PO) for the following: - traMADol HCl Oral Tablet 50 MG (Tramadol HCl), 1 tablet by mouth every 4 hours as needed for moderate to severe pain, active 3/2/25, D/C (discontinue) date 3/4/25. -traMADol HCl Oral Tablet 25 MG (Tramadol HCl), Give 25 mg by mouth every 8 hours as needed for moderate to severe pain for 7 Days, Active 2/26/2025, 15:30 (3:30 PM), D/C Date 3/2/25. -traMADol HCl Oral Tablet 50 MG (Tramadol HCl), 1 tablet by mouth every 8 hours as needed for severe pain for 10 Days, Active 2/13/2025, 14:26 (2:26 PM). -Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for Mild Pain Do not exceed 3,000mg in 24 hrs, Active, 2/28/2025, 16:00 (4:00PM). -Pain flow sheet **Document with each PRN pain medication administration Characteristics 20=Aching 21=Burning 22=Crampy 23=Numbness 24=Pins/needles 25=Sharp 26=Stabbing 27=Throbbing 30=Other Frequency- 40=Rarely 41=Occasionally 42=Frequently 43=Almost constantly 44=Unable to answer Non-Med Intervention- 0=Heat 1=Cold 2=Position 3=Massage 4=Meditation 5=Music 6= Gentle ROM 7=TENS 8= Support group 10=Other, as needed **When addressing follow up address any side effects**,Active, 2/11/2025 17:33. (5:33PM). A review of the February 2025 Medication Administration Record (MAR) revealed the resident received Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for Mild Pain on 2/13, 2/15, 2/24, 2/26 and 2/27;traMADol HCl Oral Tablet 50 MG (Tramadol HCl), Give 25 mg by mouth every 8 hours as needed for severe pain was given twice each day on 2/14, 2/15, 2/18,and 2/19; once a day on 2/16, 2/17, 2/20, 2/21, 2/22, and 2/24; and traMADol HCl Oral Tablet 25 MG (Tramadol HCl), Give 25 mg by mouth every 8 hours as needed for moderate to severe pain was given once a day on 2/26; twice a day 2/27 and 2/28. A further review of the February 2025 MARs revealed Pain flow sheet **Document with each PRN pain medication administration Characteristics 20=Aching 21=Burning 22=Crampy 23=Numbness 24=Pins/needles 25=Sharp 26=Stabbing 27=Throbbing 30=Other Frequency- 40=Rarely 41=Occasionally 42=Frequently 43=Almost constantly 44=Unable to answer Non-Med Intervention- 0=Heat 1=Cold 2=Position 3=Massage 4=Meditation 5=Music 6= Gentle ROM 7=TENS 8= Support group 10=Other, as needed **When addressing follow up address any side effects**, Active, 2/11/2025 17:33. (5:33PM) was left blank (not documented as completed) from 2/11 to 2/28/25. A review of the March 2025 MARs revealed the resident received Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for Mild Pain on 3/1; traMADol HCl Oral Tablet 25 MG (Tramadol HCl), Give 25 mg by mouth every 8 hours as needed for moderate to severe pain was given three times on 3/1; traMADol HCl Oral Tablet 50 MG (Tramadol HCl), 1 tablet by mouth every 4 hours as needed was given on once a day on 3/2 and 3/3. A further review of the March 2025 MARs revealed Pain flow sheet **Document with each PRN pain medication administration Characteristics 20=Aching 21=Burning 22=Crampy 23=Numbness 24=Pins/needles 25=Sharp 26=Stabbing 27=Throbbing 30=Other Frequency- 40=Rarely 41=Occasionally 42=Frequently 43=Almost constantly 44=Unable to answer Non-Med Intervention- 0=Heat 1=Cold 2=Position 3=Massage 4=Meditation 5=Music 6= Gentle ROM 7=TENS 8= Support group 10=Other, as needed **When addressing follow up address any side effects**, Active, 2/11/2025 17:33. (5:33PM) was left blank (not documented as completed) from 3/1 to 3/4/25. On 3/5/25 at 11:36 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated she was Resident #241's assigned nurse. She acknowledged Resident #241 received PRN pain medication. The surveyor reviewed the above PO for Pain flow sheet **Document with each PRN pain medication administration. She stated she had no idea what it was, I assume it should be document with prn pain medicine. On 3/6/25 at 10:45 AM, the DON reviewed MARs with the PO Pain flow sheet **Document with each PRN pain medication administration PRN pain documentation in the presence of the surveyor. He stated it was to explain in more detail the type of pain the resident was experiencing. The surveyor asked when it should be documented on, the DON stated, according to this, whenever we give a PRN pain medication. He added if it was in the system, yes the nurses should be aware and document accordingly. On 3/06/25 at 12:55 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the DON, the Regional Director of Operations and the Regional Clinical Supervisor were made aware of the above concerns. A review of the facility's policy, Pain Management date implemented 9/1/22024 revealed Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences .Pain Assessment: 1. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. 2. Based on professional standards of practice .e. Identifying key characteristics of the pain: v. pattern (e.g. constant or intermittent; f. obtaining descriptors of pain (e/g/ stabbing, aching, pressure, spasms. NJAC 8:39-27.1 (a)

Complaint # NJ166824 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for 1 of 35 residents (Resident #14) interviewed during the initial pool process and confirmed during the lunchtime meal service on 3/6/25 on 1 of 5 nursing units tested for food temperatures by the surveyor and witnessed by the Director of Nursing. The deficient practice was evidenced by the following: On 2/28/25 at 12:13 PM, the surveyor observed Resident #14 in their room. At that time, the resident stated that the food was cold. The surveyor reviewed the electronic medical record (EMR) for Resident #14. A review of the Admission Record (an admission summary), reflected the resident had diagnoses that included but were not limited to; bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs), gastro-esophageal reflux disease (a disease in which stomach acid or bile irritates the food pipe lining), anxiety disorder (intense fear of everyday situations) and obesity (having to much body fat) due to excess calories. A review of a quarterly Minimum Data Set (MDS), a tool to facilitate the management of care dated 11/26/24, reflected the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated the resident's cognition was intact. A review of the Order Summary Report reflected a Physician's Order dated 3/7/24 for a No Added Salt Regular consistency diet. On 3/6/25 at 11:24 AM, the surveyor calibrated a state issued digital thermometer to 32 degrees Fahrenheit (F), via the ice bath method [An effective way to gauge the accuracy of your thermometer. This simple experiment compares the temperature of your thermometer to ensure it is reading to the freezing point of water (32.0 F)], in the presence of the survey team. On 3/6/25 at 11:44 AM, the first lunch food truck arrived on the [NAME] Unit. The Assistant Director of Nursing (ADON) randomly marked a regular consistency tray to be a test tray and immediately called for a replacement tray for that resident, at the request of the surveyor. The last tray was delivered at 12:02 PM. The surveyor immediately conducted food temperature checks for the test tray in the presence of the DON. The DON confirmed the following food temperature observations: Italian sausage: 116 degrees F Sauteed spinach with garlic: 127 degrees F Parmesan noodles: 123.5 degrees F There were no beverages on the tray. On 3/6/25 at 12:16 AM, the surveyor interviewed the Food Service District Manager (FSDM) in the presence of the Assistant Food Service Director (AFSD). The AFSD provided the surveyor with the completed lunch meal food temperature log (the temperatures recorded were all in safe range). The FSDM stated that residents should receive hot food at or above 140 degrees F and cold food at or below 40 degrees F for palatability. The surveyor reviewed the temperature results from the test tray, and both acknowledged the temperatures were not adequate. At that time, both stated the department conducted test tray audits and would provide copies to the surveyor. The AFSD stated that he was responsible to oversee food temperatures and that they were maintained at safe and proper temperatures. A review of the Resident Tray Assessment Report's, reflected a scoring system whereby when temperatures were taken on the nursing unit, if hot soups and beverages were less than 140 degrees F, this would result in a score of zero (indicated unacceptable), if hot entrees were 125-129 degrees F, this would result in a score of two (indicated acceptable); if hot entrees were 120-124 degrees F, this would result in a score of one (indicated needs improvement); and if a hot entree was less than 120 degrees F, this would result in a score of zero (indicated unacceptable). A review of the policy Food: Quality and Palatability dated 2/2023, from the [name redacted] contracted food service company. The policy statement reflected, Food will be palatable, attractive and served at a safe and appetizing temperature . to meet resident's needs. NJAC 8:39-17.4 (a)

Complaint #'s: NJ00167278, NJ0161406 Based on observation, interview, and review of the facility policy, the facility failed to provide proper tracheostomy care that included cleaning the skin around the stoma and cleaning the outer cannula and flange [neck plate] in accordance with professional standards for three of seven residents (Resident (R) 23, R33, and R34) reviewed for care. This failure could lead to stoma and lungs infections. Findings include: 1. Review of R23's Admission Record in the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record revealed R23's diagnoses included anoxic brain damage, respiratory failure, and speech and language deficits following cerebrovascular disease. Review of R23's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated the resident had severely impaired cognition. Review of R23's Orders dated 09/09/24, located in the Orders tab of the EMR, revealed Tracheostomy care every shift and as needed. During an observation in R23's room on 01/22/25 at 11:30 AM, Registered Nurse (RN) 3 performed tracheostomy care. During the procedure, RN3 removed and discarded the soiled split gauze from the stoma under the flange. RN3 changed gloves and applied new split gauze to stoma under the flange. RN3 did not clean the skin around the stoma, outer cannula, or flange. 2. Review of 33's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. The Admission Record revealed R33's diagnoses included chronic respiratory failure with hypoxia and dysphagia following other cerebrovascular disease. Review of R33's admission MDS with an ARD of 01/08/25, located in the MDS tab, revealed a BIMS score of zero out of 15 which indicated the resident had severely impaired cognition. Review of R33's Orders dated 01/01/25 in the Orders tab of the EMR, revealed Tracheostomy care every day and evening shift and as needed. During an observation in R33's room on 01/22/25 at 7:24 AM, RN3 performed tracheostomy care. During the procedure, RN3 removed and discarded the soiled split gauze from stoma under the flange. RN3 changed gloves and applied new split gauze to stoma under the flange. RN3 did not clean the skin around the stoma, outer cannula, or flange. 3. Review of R34's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. The Admission Record revealed R34's diagnoses included myasthenia gravis with acute exacerbation, cerebral palsy, and chronic respiratory failure with hypoxia. Review of R34's quarterly MDS with an ARD of 12/20/24, located in the MDS tab, revealed a BIMS score of ten out of 15 which indicated the resident had moderately impaired cognition. Review of R34's Orders dated 09/09/24 in the Orders tab of the EMR revealed Tracheostomy care every day and night shift and as needed. During an observation in R34's room on 01/22/25 at 7:41 AM, Licensed Practical Nurse (LPN) 4 performed tracheostomy care. During the procedure, LPN4 removed and discarded the soiled split gauze from stoma under the flange. LPN4 changed gloves and applied new split gauze to the stoma under the flange. LPN4 did not clean the skin around the stoma, outer cannula, or flange. During an observation in R34's room on 01/22/25 at 1:10 PM, LPN4 performed tracheostomy care again per R34's request. During the procedure, LPN4 removed and discarded the soiled split gauze from stoma under the flange. LPN4 changed gloves and applied new split gauze to the stoma under the flange. LPN4 did not clean the skin around the stoma, outer cannula, or flange. During an interview on 01/22/25 at 11:35 AM, RN3 stated, Yes I should have cleaned around the stoma to help prevent infection. During an interview on 01/22/25 at 1:20 PM, LPN4 stated, I didn't clean around the stoma and should have. During an interview on 01/22/25 at 8:51 AM, RN2, the unit manager for the tracheostomy [trach] unit, stated, During trach care, we have to clean every part of the trach and around the stoma even if it is a disposable cannula to prevent infection. During an interview on 01/22/25 at 9:02 AM, the Assistant Director of Nursing (ADON) stated, I do training on trach care with new hires and all staff during annuals, if there is an incident, if they need help, but at least once or twice a year. I train them when you take the dirty gauze off then you clean everything before you put new gauze on. During an interview on 01/22/25 at 9:25 AM, the Director of Nursing (DON) stated, We train them when you remove the dirty, you clean around the stoma before you put the new on. It should be second nature that cleaning is done without even having to think about. Review of the facility's policy titled, Ventilator Unit Policy and Procedures: Tracheostomy Care, undated, indicated under the section Policy: Tracheostomy care is performed by the nurse every shift and when needed. Maintain a secure artificial airway and integrity of the skin at the stoma and neck. Indicated under the section Procedure: 14. Clean area around stoma using normal saline or prescribed medication with sterile cotton tip applicators, if needed. Always wipe away from the stoma' utilizing a clean applicator with each wipe. 15. Clean the remainder of the neck with a cotton tip applicator or a 4x4 drain sponge. 16. Dry well with a 4x4 drain sponge. 17. Apply drain sponge under flanges of tracheostomy. N.J.A.C. 8:39-27.1(a)

Complaint #: NJ00172868 Based on observations, record review, interview, and facility policy review, the facility failed to ensure one out of three residents (Resident (R) 17) reviewed for side rails had interventions attempted prior to the implementation of side rails. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed. Findings include: Review of R17's electronic medical records (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R17's EMR titled Consent for the Use of Side Rails located under the Misc Miscellaneous) tab dated 08/14/24. The risks and benefits for the use of side rails were discussed at this time with the resident's representative. Review of R17's EMR titled Care Plan located under the Care Plan tab dated 08/18/24 indicated the resident used side rails for safety during the provision of care to assist with bed mobility. Review of R17's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/26/24 indicated the resident had a Brief Interview of Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated R17 required substantial/maximum assistance from staff to roll from lying on back to left and right side and return to lying on back on the bed. Review of R17's EMR titled Side Rail assessment dated [DATE] indicated the resident was able to use the side rails to move from one side to another. An observation was conducted on 01/21/25 at 10:09 AM, R17 was sitting in his/her wheelchair. During an interview at this time, Certified Nurse Aide (CNA) 1stated R17 would grab the siderails during the provision of cares while the resident was in bed. During an interview on 01/22/25 at 6:57 AM, Licensed Practical Nurse (LPN) 1 confirmed R17 will use the side rails when staff were providing his/her care while in bed. During an interview on 01/22/25 at 10:16 AM, the Director of Rehabilitation (DOR) stated therapy did not determine the use of side rails on a resident's bed. The DOR stated this was a nursing decision and typically, the side rails were already on a resident's bed before therapy decides on other positioning devices, such as a wedge or bolster. During an interview on 01/23/25 at 3:03 PM, the Director of Nursing (DON), Assistant Administrator, a former Administrator, and Regional Clinical Nurse, were all asked what prior interventions were implemented and failed prior to the use of R17's side rails. No additional information was provided on prior interventions by the end of the survey. Review of a facility policy titled Proper Use of Side Rails dated October 2019 indicated . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . Less restrictive interventions that will be incorporated in care planning include . Providing restorative care to enhance abilities to stand safely and to walk . Providing a trapeze to increase bed mobility . Placing the bed lower to the floor and surrounding the bed with a soft mat . Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . N.J.A.C. 8:39-11.1

Complaint #: NJ00169314 Based on observation, interview, and review of the facility policy, the facility failed to identify and manage pain for one of 34 residents (Resident (R) 34) reviewed for pain. This failure could lead to reduced quality of life, depression and anxiety, and sleep disturbances. Findings include: Review of R34's Admission Record in the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record revealed R34's diagnoses include myasthenia gravis with acute exacerbation (chronic autoimmune disease that causes muscle weakness), cerebral palsy (group of disorders that affect a person's ability to move, balance, and maintain posture), and chronic respiratory failure with hypoxia. Review of R34's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/24, located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of ten out of 15 which indicated the resident had moderately impaired cognition. Review of R34's Orders dated 12/27/24 in the Orders tab of the EMR, revealed Acetaminophen [pain reliever] oral tablet 500 mg [milligrams], give two tablets via G-tube [gastronomy tube] every six hours as needed for pain. During an observation in R34's room on 01/22/25 at 7:45 AM, Licensed Practical Nurse (LPN) 4 was performing tracheostomy care. R34 was shaking his/her right hand and pointing to his/her groin area. LPN4 asked, You have to urinate? You urinate through your tube. R34 repeated the movement. LPN4 stated, You have a tube you urinate through that goes to a bag. R34 repeated the same movement. LPN4 stated, You have a tube that goes to your bladder that you urinate through that empty into a bag. This surveyor asked LPN4 if R34 could write on a notebook to communicate and LPN4 gave R34 a notebook from the bedside table. R34 wrote pain in the notebook. LPN4 asked, Where is your pain? Is it all over? LPN4 did not allow R34 time to respond. LPN4 asked, Do you want some Acetaminophen? R34 shrugged his/her shoulders. LPN4 let R34 know she would see what was ordered and bring something for pain. LPN4 returned to give Acetaminophen. During an interview in R34's room on 01/22/25 at 8:15 AM, when asked how frequently he/she had pain, R34 wrote, Everyday. R34 was asked to write down where pain was. R34 wrote, When I urinate. R34 was asked how long has pain been going on. R34 wrote, Two weeks. When asked if the Nurses assessed pain every day; R34 shook his/her head no. During an interview on 01/22/25 at 8:47 AM, LPN4 stated, This is the first time that R34 has ever verbalized or expressed having pain to me. I would watch facial expressions and non-verbal cues, or residents will also tell me if they have pain. Pain monitoring is completed every shift. A box automatically pops up in the EMR asking us if resident has pain and we must answer for every resident. During an interview on 01/22/25 at 8:51 AM, RN3, unit manager for tracheostomy unit, stated, I expect my Nurses to do the same as I would to monitor and manage pain. We ask the resident and use numerical, or whichever pain scale is appropriate for non-verbal residents. We watch non-verbal indicators and facial expressions as well. We assess the location of pain, palpate and watch for non-verbal indicators, watch their movement as to what is aggravating the pain. We take their pain as whatever the resident states it is. There is a protocol we follow to address and monitor pain. If their current pain management order isn't effective, then we notify the NP [Nurse Practitioner] or doctor and get new orders or direction. If it's a new pain, then it should be put in [EMR] as a change of condition. I will see it on the report and then we can care plan it appropriately. During an interview on 01/22/25 at 9:25 AM, the Director of Nursing (DON) stated, With our residents that can't verbalize like [R34], I expect my Nurses to still communicate with them to learn about their pain. If they are slow with their response, then we must have more patience to find out what their pain is. We have to allow them time to communicate in their own way to figure out specifics of their pain and what is going on with them. Review of the facility's policy titled, Pain Management, dated 09/01/24, indicated under the section, Policy: The facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Indicated under the section, Recognition: 1.a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Indicated under the section, Pain Assessment: 2.e. Identifying key characteristics of the pain: i. Duration of pain ii. Frequency iii. Location iv. Timing v. Pattern (constant or intermittent) vi. Radiation of pain. 2f. Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms). 2g. Identifying activities, resident care of treatment that precipitate or exacerbate pain. N.J.A.C. 8:39-27.1(a).

Complaint #: NJ00182358, NJ00169293 Based on observation, record review, and staff interview, the facility failed to ensure residents who were being discharged to another facility were provided with a 30-day notice of discharge and to notify the Ombudsman's office for two residents (Residents (R) 14 and R15) of three residents reviewed for resident discharge. Failure to notify residents causes stress for the resident and family and impacts the residents' ability to prepare for discharge and have a choice in discharge location. Findings include: 1. Review of R14's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including dependance on respirator (ventilator) status. Review of R14's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/25, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab, dated 12/17/24, written by revealed Social Worker (SW) revealed, SW informed resident and his/her daughter that resident would be transferred to another facility. Resident and daughter verbalized understanding and were in agreement. Transfer date scheduled for 12/30/24. Review of R15's EMR revealed no evidence that a 30-day notice of discharge was provided prior to the resident being discharged to another facility. 2. Review of R15's admission Record, located in the Profile tab of EMR revealed he/she was admitted to the facility on [DATE] with diagnoses including dependance on respirator (ventilator) status. Review of R15's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/25, located in the resident's EMR under the MDS tab, revealed the R15 did not complete the BIMS due to the resident not being understood. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab dated 12/19/24 written by Social Worker (SW) revealed, SW met with resident's parents for plan of care review. Resident is scheduled to transfer to another facility on 01/07/25. The primary focus of the meeting was to introduce the family to the team at the new facility. Review of R15's EMR revealed no evidence that a 30-day notice of discharge was provided prior to the resident being discharged to another facility. During an interview on 01/22/24 at 11:58 PM, the SW stated a 30-day notice of discharge was not provided to either R14 or R15 prior to them being discharged from the facility. She was instructed by the Regional Social Services (RSS) to inform the residents and their families they would need to transfer to the vent unit at a sister facility. The SW stated the facility was closing their vent unit, but she was not informed why. She said she was not aware at that time that a 30-day notice of discharge was required to be provided to residents. During an interview on 01/22/25 at 2:25 PM, the RSS stated the facility's process when discharging a resident was that either the Administrator or the Business Office Manager (BOM) provided the resident and their responsible party a 30-day notice or a 30-day discharge notice. The RSS stated this would be documented in a progress note or a copy of the notice could be uploaded or placed in the physical chart. The RSS stated the Ombudsman was notified by email. She stated that neither R14 nor R15 were provided with a 30-day notice of discharge because they were resident initiated discharges and were not initiated by the facility. She stated both residents and their responsible parties were made aware they would need to be transferred to another facility's vent unit, and they were both agreeable. The RSS stated the families along with the residents had full control over the discharge process and were able to decide when they wanted the discharge to occur, and they were not rushed in any way. She said they could still be at the facility had they had chosen not to have discharged earlier in the month. During an interview on 01/22/25 2:40 PM, Family Member (F)5 said the facility did not give them a choice about the transfer. She said she was told by the SW that your dad/mom is moving to [other facility]. They were supposed to have a care plan meeting on 12/30/24 and R14 was supposed to be transferred that day. F5 said one of the staff there informed them another resident was also being transferred but at a later day and advised them to see if they could get a later date as well. They were not provided a 30-day notice. F5 said they were not given a choice at all. F5 said R14 was in a single room there due to claustrophobia and staff did not even reassure them that he/she would still be in a single room at the new facility. F5 stated it was stressful. During an interview on 01/22/25 at 2:52 PM, F6 stated Oh no, no, no when asked if the facility provided an option about R15's discharge. F6 stated RSS came into the room and said they were closing the vent units, and they could offer different places for R15 to go. F6 stated they were asked if they wanted to have a care plan meeting before R15 was transferred. F6 asked RSS how fast this was happening, and she said it was only a couple days later for the meeting at the new facility. They were not given an opportunity to remain in the facility, nor were they provided with anything in writing. F6 said they were never provided with a real reason why the transfer had to happen. F6 stated they were just informed suddenly they were going to close the vent unit. She said this was very difficult because he/she spends several years in a facility where everyone knew R15, and you felt comfortable leaving him/her in their care. Since the transfer she has not felt comfortable leaving R15 by himself/herself. F6 stated they absolutely did not have a choice. During an interview on 01/23/24 at 3:15 PM the Administrator stated how they handled a discharge depended on whether the family was okay with the discharge or not. If the family was okay with it the facility would work with the family, provide them with options for a choice of facilities, and work with them on the transfer or discharge. He said when the family was not agreeable the would provide them with a 30-day notice of discharge and they would also notify the Ombudsman. He was not aware a 30-day notice should have been provided if the family agreed to the discharge. A policy was requested but no policy was provided. N.J.A.C. 8:39-5.2;5.3.

Complaint #: NJ00182358, NJ00169293 Based on interview, record review, and policy review, the facility failed to provide evidence that two of two residents (Resident (R) 5 and R30) reviewed for room transfers in a total sample of 34 residents were notified of the reason in writing for the transfer and when the transfer would occur prior to being transferred to another room in the facility. This failure had the potential to impact the emotional well-being of the residents facing the challenge of a new roommate. Findings include: 1. Review of R5's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R5's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which revealed the resident was moderately cognitively impaired. Review of a document provided by the facility titled Census List for R5 indicated R5 was admitted to R30's room on 10/30/23. 11/25/23. The document dated 11/15/23 revealed the resident was transferred to a new room at 7:59 PM. There was no evidence that R5 was provided with written notice that he/she was to move rooms on 11/15/23. 2. Review of R30's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R30's EMR titled admission MDS with an ARD of 10/26/23 indicated the resident had a BIMS score of 14 out of 15 revealed the resident was cognitively intact. There was no evidence in the medical record that R30 was provided with written notice that R5 was going to be moved into R30's room on 10/30/23. During an interview on 01/22/25 at 10:37 AM, the Social Services Director (SSD) confirmed she could not locate a written room transfer notice for R5 or R30. The SSD stated she has been in her position for the past year and currently the facility would discuss potential roommate changes and compatibility. The SSD stated she then documented in the clinical record the change and provide the resident with a written transfer notice. During an interview on 01/23/25 at 3:03 PM, when asked about the facility's process for resident/family notification of a room change notification, the Regional Clinical Nurse stated she was not aware of what the facility policy was at the time of R5's room transfer in 2023 and when the facility moved R30 into R5's room. Review of a facility policy titled Change of Room or Roommate dated 11/13/24 indicated . It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative . Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible . The notice of a change in room or roommate will be provided in a language and manner the resident and representative understands and/or requests and will include the reason(s) why the move or change is required . N.J.A.C. 8:39-4.1(a)(13)

Complaint # NJ00160796, # NJ00160907 Based on observation, interview, review of facility records, and other pertinent facility documents on [DATE], it was determined that the facility failed to address a new aggressive behavior displayed on [DATE] and [DATE] by a resident who, within weeks of the new aggressive behavior, assaulted their roommate on [DATE] at 5:07 AM as the roommate slept in their bed. As a result of the assault, the roommate sustained the following injuries, according to the hospital records: lacerations and hematoma to the facial area, facial trauma, a large laceration to the right forehead above the right eyelid between the right and left eye extending to the bridge of the resident's nose, a sizeable superficial laceration to the bridge of the nose, swelling around the left and right eye, bilateral eyelids swollen shut, a superficial laceration to the left cheek and below the left eye extending from the left side of the nose to the lateral area of the left eye, a right forehead hematoma, upper lip swelling, and an extensive scalp hematoma; The resident died 16 days after the assault at the facility. There was no documentation in the medical record or uncovered during multiple interviews with staff from the facility that showed the new aggressive behavior was communicated across shifts or disciplines. The facility did not initiate a formal behavior monitoring process, develop a care plan, or start interventions for this new aggressive behavior. This deficient practice was identified for 2 of 4 residents reviewed for abuse, Resident # 98 (the victim) and Resident # 190 (the assailant). The facility's failure to initiate interventions to address the new aggressive behavior displayed by Resident # 190 posed a serious and immediate threat to the safety and well-being of Resident #98 and placed all residents at risk of being abused by a resident with new unaddressed aggressive behavior. This resulted in an Immediate Jeopardy (IJ) determination. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified of the IJ and provided with the IJ template on [DATE] at 12:23 PM. The IJ began on [DATE] at 5:07 AM when Resident # 98 was assaulted while sleeping by Resident # 190 and continued until [DATE] at 4:28 PM when the facility provided an acceptable removal plan. The removal plan was verified on-site on [DATE] during the survey. The evidence was as follows: On [DATE], [DATE], and [DATE], the surveyor reviewed the electronic medical record (EMR) of Resident # 190 and Resident #98. The EMR of Resident # 190 revealed the following: An admission record included the following diagnoses; Cerebral Infarction (stroke), Aphasia following unspecified Cerebrovascular Disease (difficulty speaking after a stroke), Type 2 Diabetes, Adjustment Disorder with Depressed Mood. The admission record indicated that the resident was admitted to the facility from an acute care hospital. A Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident scored a 00 when the Brief Interview for Mental Status was done. This indicated that the resident had severe cognitive impairment. The resident scored a 00 when the mood interview was conducted. That indicated there was no mood disturbance. The behavior section indicated there had not been any physical, verbal, or other behavioral symptoms directed at others. The MDS also revealed that the resident could walk around the unit independently with supervision. The surveyor reviewed progress notes from the resident's day of admission to [DATE] at 11:05 AM when the resident was transferred to the hospital psychiatric emergency room . From [DATE] to [DATE], twenty-five entries read: Was a behavior observed? YES, There was no description of the behavior documented as being observed. On [DATE] at 9:00 AM, the surveyor spoke with the Registered Nurse/Unit Manager (RN/UM) of the unit where Resident # 190 and Resident 98 resided. The surveyor asked about the entries that were in the progress notes indicating that the resident displayed behaviors. The RN/UM said those entries were referring to signs and symptoms of depression like sadness or isolation because the resident was receiving Mirtazapine for depression, so they were monitoring the resident for symptoms of depression. The surveyor also spoke with the author of those notes, Licensed Practical Nurse #1 (LPN #1), who was regularly assigned to Resident # 190 on the 7 AM to 3 PM shift. LPN # 1 made the same statement; the entries were for signs of depression like sadness or isolation. Five entries from [DATE] to [DATE] read: Behavior Charting; Describe Behavior/Mood. Four entries described the behavior as Refused Care, and one described the behavior as Refused breakfast and lunch. An additional entry dated [DATE] at 7:31 AM read, Behavior Charting: Describe Behavior/Mood: Aggressive with staff. Coming very close to staff close to face and started to growl as if testing staff. Raised hand to hit nurse but did not. What was the resident doing prior to or at the time of the behavior/mood: Ambulating in the hallway. Interventions attempted: Discouraged behavior, endorsed to 7 to 3 to monitor. Effectiveness of the interventions: good effects. The Behavior Monitoring and Interventions Report was provided by the Corporate Registered Nurse (CRN), who provided the document to the survey team on [DATE] at 1:00 PM. The report showed a behavior noted by the Certified Nursing Assistant (CNA) on [DATE] at 7:10 PM. The behavior was hitting others. The surveyor pointed that out to the CRN, who stated that the resident was hitting staff during care. The resident had a care plan in place with a focus that read: The resident uses antidepressant medication (Mirtazapine) related to (r/t) depression. Date initiated [DATE] and revision [DATE]. There was also a care plan with a focus that read, [Resident # 190] has the potential to be physically aggressive r/t history of harm to others. [Resident # 190] was physically aggressive to [the resident's] roommate causing facial injuries. The date initiated was [DATE], and the revision was on [DATE]. There were no other care plans to address the new aggressive behavior displayed on [DATE] or the new hitting others behavior displayed on [DATE]. A Physician's Order Sheet (POS) with orders that read: Monitor for Behaviors; Resident is on Mirtazapine every shift. The order date was [DATE]. NY/NJ Psych Consult for lack of appetite. The order date was [DATE]. Mirtazapine 7.5mg. Give one tablet by mouth at bedtime for depression. The order date was [DATE]. The medication administration record (eMAR) with an entry that read, Monitor for behaviors; Resident is on Mirtazapine every shift Order date [DATE]. Many yes entries indicated a behavior observed, but as the RN/UM stated, they were symptoms of depression, such as isolation or sadness. A Psychiatric Follow up note dated [DATE] read, Pt (Patient) seen for f/u (follow up) today + expressive aphasia. Pt seen in room. No acute distress. Pt has h/o (history of) poor appetite with weight loss, depression. Staff reports patient's appetite is good. Pt had weight gain. At times can be seen walking the halls, attends social activities at will. Sleep is good. Energy is good. No evidence of [NAME], AVH (Suicidal/Homicidal Ideation or Auditory/Visual Hallucinations). No psychosis reported. Staff reports pt with 1 episode of intimidating behavior toward staff, The diagnosis and plan read: [Adjustment] Disorder w/Depression. 1. Continue Remeron for Depression, which may help the patient's appetite. Appetite improved, wt gain. 2. Continue to monitor mood/behavior and report any changes or concerns to psychiatry. 3. Continue to engage in group/unit activities. 4. Case discussed with treatment team in collaboration. The Electronic Medical Record (EMR) for Resident # 98 revealed the following: An admission record included the following diagnoses; Encephalopathy (a disease in which the brain's functioning is affected by some agent or condition), Altered Mental Status, Essential Hypertension, Other Specified Anxiety Disorder, Adjustment Insomnia, Combined Forms of Age-Related Cataracts. A quarterly MDS dated [DATE] revealed that the resident scored a 3 when the Brief Interview for Mental Status was done. This indicated that the resident had severe cognitive impairment. The MDS also indicated that the resident moved around the facility in a wheelchair. A progress note dated [DATE] at 5:07 AM read: Supervisor was called to the resident's room by the primary nurse. I assessed the resident's vital signs, which were WNL (within normal limits) and [the resident's] presentation, and contacted 911 for transport to acute care facility. A second progress note dated [DATE] at 2:30 PM read, Writer called JFK medical center for status report on resident, per [hospital employee] the resident will be kept for 24-hour observation due to head trauma and assault. A readmission note dated [DATE] at 9:21 PM Resident arrived via stretcher. Resident was admitted from hospital. A progress note dated [DATE] at 3:02 AM read: 12:00 AM resident was found unresponsive, CPR and blue code initiated, 911 was called at 12:03 AM. 12:07 AM MD informed, 12:15 AM [redacted name] POA informed. 12:15 AM paramedic arrived. Resident pronounced death at 12:27 AM. A progress note dated [DATE] at 12:27 AM read: Supervisor was called to assess the resident. Code Blue (a call for assistance due to cardiac arrest) initiated by the team. AED (automated external defibrillator) pads placed on the chest wall, and compressions initiated. No ascertainable vital signs with electronic machine. No breath sounds or breaths detected. No pulse assessed. No heartbeat assessed. EMTs arrived at 12:14 AM and assumed charge of the code in progress. Facility AED removed. CPR continued with the use of the EMT's equipment . CPR cessation at 12:27 AM upon orders of [emergency room physician of local hospital]. Resident pronounced by [emergency room physician]. On [DATE] at 12:54 PM, the surveyor spoke with the RN/UM of the unit where Resident # 190 and Resident # 98 resided (Memory Care Unit-MCU). The surveyor asked about Resident # 190 and asked why the resident was moved into the secured unit that was kept locked. The RN/UM stated, I believe because [the resident] was wandering over on [the unit where the resident previously resided]. [The resident] was moved here for security, [Resident # 190] was alert to person with confusion to place and time. [Resident #190] was a very quiet [gender], never had any behavior problems. No anger issues. Most of the time, I saw [Resident #190] [the resident] was quiet and walked up and down the hall. The surveyor asked the RN/UM about Resident # 98. The RN/UM stated [Resident #98] would self-propel in the hallway. [Resident #98] would never start anything with anyone. [Resident # 98] might say get out of my way; I gotta get through, but not in an angry way. On [DATE] at 1:05 PM, the surveyor spoke with LPN #1 of the unit where Resident # 190 and Resident # 98 resided. LPN # 1 stated she was regularly assigned to Resident # 190 and Resident # 98. The surveyor asked LPN # 1 about the incident where Resident # 190 assaulted Resident # 98. LPN # 1 stated, I was off on ,d+[DATE], but when I returned on ,d+[DATE], I received a report from the nurse. I was told there was an incident. They had to send [Resident # 98] out. The surveyor asked LPN # 1 if, prior to that assault by Resident # 190, there had been any incidents where Resident # 190 showed aggression. LPN # 1 stated, They had been roommates, and there were no issues. The surveyor asked LPN # 1 what Resident # 190 was like, and LPN # 1 responded that [Resident # 190] was confused, [the resident] spoke like [the resident] couldn't express [themself]. The words couldn't come out The surveyor asked LPN # 1 what Resident # 98 was like. LPN # 1 said, [Resident # 98] was alert but confused, [Resident # 98] could make [their] needs known. The surveyor asked LPN if Resident # 190 and Resident # 98 spoke to each other. LPN # 1 reiterated, [Resident # 190] couldn't speak. The surveyor asked if Resident # 98 spoke to Resident # 190. LPN # 1 stated, No, they were barely in the room together. They would get up and be out of the room all day. I never got anything in the report that there was any altercation prior to this or that [Resident # 190] showed any aggression at all. On [DATE] at 1:12 PM, the surveyor spoke with the Director of the Memory Care Unit (DMCU). The surveyor asked why Resident # 190 was moved from the previous unit to the MCU. DMCU stated, [Resident # 190] was not eating well, [Resident # 190] was wandering, they were concerned about an elopement risk, [Resident # 190] was confused, unable to verbally express [themself], even in Spanish [Resident # 190] was confused. I would get others to translate, and [Resident # 190] was confused in Spanish also. The surveyor asked the DMCU about Resident # 98. The DMCU stated [Resident # 98] self-propelled around the unit, confused, [Resident # 98] would wander into other residents' rooms here and there, [Resident # 98] was able to express [themself] but unable to engage in a logical conversation. The surveyor asked the DMCU if Resident # 190 ever had aggressive behavior. The DMCU stated, No behavior that concerned me, [Resident # 190] was quiet and docile. The surveyor asked the DMCU about the [DATE] incident that was written in the progress notes. The DMCU said she wasn't aware of it but said it happened with many residents when they didn't want to do something they were being asked to do. On [DATE] at 1:20 PM, the surveyor spoke with Certified Nursing Assistant # 1 (CNA # 1) on the unit where Resident # 190 and Resident # 98 resided. CNA # 1 stated that she had worked at the facility for [AGE] years, full-time days, and sometimes the two residents were on her assignment. The surveyor asked CNA # 1 if she ever noticed any aggression between the two residents. CNA # 1 stated, I never saw any aggressiveness between the two residents, [Resident # 190] was quiet, and [Resident # 98] was quiet too, not aggressive at all. Never gave me a hard time when I needed to assist [Resident # 98]. There were no issues between the two of them as roommates. I didn't see anything or hear anything that would show that they were fighting or didn't get along. I never heard about any aggression by [Resident # 190]. On [DATE] at 12:30 PM, the surveyor interviewed the Registered Nurse (RN) who worked in the MCU on the 3 PM to 11 PM shift on [DATE], the evening prior to the assault. The surveyor asked the RN to talk about how Resident # 190 was that evening/night. The RN stated [Resident # 190] walks in the hallway; I don't have any issue with him. [Resident # 190] was ok, they were ok, no problem at all between the two residents. They ate lunch, and they ate dinner. No issue at all. [Resident # 190] was never aggressive. On [DATE] at 1:10 PM, the surveyor spoke with CNA #2, who worked the 11 PM to 7 AM shift from [DATE] into [DATE]. CNA # 2 confirmed that she was assigned to Resident # 190 and Resident # 98 the night of the assault. The surveyor asked CNA # 2 to talk about Resident # 190. CNA # 2 stated, I was working nights. [Resident # 190] behavior was like a tough attitude, [Resident # 190] not answer you. [Resident # 190] don't do something you ask [Resident # 190] to do. That night [Resident # 190] didn't go in [their] room. [Resident # 190] went to [their] room at 4 AM. Before that, [Resident # 190] sit down in the chair across from [Resident # 190's] room in the hallway. I was down the hall. That night we worked short, so they added [Resident # 190 and Resident # 98] room to my assignment. We watched [Resident # 190] all night, sitting in the hallway. If the patients go to other rooms, we say something, but if they go to their room, we don't say anything. While I was doing my rounds, I already changed four people, [Resident # 190] don't need help, [the resident] does everything by [gender] self. I started at 4:45 AM. We were shocked when the Supervisor called me to the room, and we see [Resident # 98] beat up. We looked for evidence that [Resident # 190] did it. We look for a weapon, a hammer, a machete, we didn't find anything. We found a towel that had blood from [Resident # 190] washed [their] hands after [Resident # 190] do that. The surveyor asked if she heard anything after Resident # 190 went into their room. CNA # 2 stated, We don't hear anything. [Resident # 98] was a quiet [gender], a good [gender]. There were four aides that night. We each had 14 or 15 residents. At night [Resident # 190] doesn't go to sleep, [Resident # 190] walks. [Resident # 190] was stubborn, [Resident # 190] has a speech problem, [Resident # 190] would never tell you a word. The surveyor asked CNA # 2 if she feared Resident # 190. CNA # 2 stated, I was not afraid of [Resident # 190]. [Resident # 190] was never aggressive before. If I saw something like that, I would report it to my Supervisor if [Resident # 190] was fighting with anyone. On [DATE] at 9:00 AM, the surveyor spoke with RN/UM from the unit where Resident # 190 and Resident # 98 resided. The surveyor asked what the process would be if a resident displayed a new aggressive behavior. The RN/UM said they would immediately initiate behavior monitoring and develop a care plan for the behavior. The staff had discussed with her the episode of aggression displayed by Resident # 190 on [DATE] toward a nurse. She said they called psych, and [Resident # 190] was evaluated. The psychiatrist said to continue monitoring [the resident's] behavior, which they did. She said we would have documented it in the nurse's notes if there were more aggression episodes. When asked if they have a process for behavior monitoring, the UM said they have psychotropic behavior monitoring sheets. [Resident # 190] was already being monitored for symptoms of depression for the use of Remeron, but added, we should have initiated one for the new aggressive behavior and created a care plan. On [DATE] at 10:05 AM, the surveyor spoke with the family member of Resident # 98. The family member stated, There was someone from the family there at least five times a week between all of us. Prior to the assault me, my mother, brother, and grandson were there, and [Resident # 98] was fine. When [Resident # 98] came back from the hospital after the assault, [Resident # 98] never opened [their] eyes, and [Resident # 98] stopped eating. [Resident # 98] didn't speak to us. We got the call [from the facility] that [Resident # 98] had a fight and got a couple of scratches. When I saw [Resident # 98], I was in shock. I didn't even recognize [Resident # 98]. On [DATE] at 10:15 AM, the surveyor spoke with CNA # 2 again and asked about the doors on the unit. If it was the practice on the unit to keep the residents' doors closed. CNA # 2 stated, When [Resident # 190] went to [their] room, the door was not closed. It was halfway open. [Resident # 190] is a continent patient. At that time, I was changing patients, [Resident # 190] would go to the bathroom [gender] self. I was going to come and change [Resident # 98], but I didn't get there yet. I was five doors away in another room giving care to another patient, and [Resident # 190] was in [a different room]. We would have followed [Resident # 190] if we had suspected that [Resident # 190] was going to do something. The surveyor asked again about the practice on the units if the doors were kept closed. CNA # 2 stated, If they have Covid, the door is closed. If they don't have Covid, we leave the door open because they have Dementia. We want to hear what is going on. When asked CNA # 2 why she thought no one heard anything. CNA # 2 stated, One CNA was on the other side of the locked door. She had half her residents on that unit and half on the [MCU], she had been on [the MCU] all night, then she went on [the other side of the locked doors] to do care for her residents on that side. The second CNA was in the same hall as me but down a little more. If the resident says to close the door, we have to close it, but if they don't, we leave it open so we can hear. On [DATE] at 1:45 PM, the surveyor spoke with LPN # 2, the LPN who found Resident # 98 in bed injured after the assault. The surveyor asked LPN # 2 to talk about the assault that occurred on [DATE] by Resident # 190 toward Resident # 98. LPN # 2 stated, When I went into the room about 5:,d+[DATE]:07 AM, the head trauma made [the resident's] face bloody, swollen, eyes were swollen, there was blood on the sheets, on the wall in back of [Resident # 98's] bed. [Resident # 190] was standing in back of me, and I saw [Resident # 190] wiping [their] hands on [the] bed sheets. I saw blood on [Resident # 190's] sheets. [Resident # 190] went over and lay on the bed and put [the] hands behind [the] head like nothing ever happened. The surveyor asked LPN # 2 if the resident's door was open or closed when she went in. LPN # 2 stated, It was open. The surveyor asked LPN # 2 why she had gone into the room at that time. LPN # 3 said to give Resident # 98 medication. The surveyor asked LPN # 2 if Resident # 190 displayed aggression in the past. LPN # 2 stated, Never saw that; this was out of character. There was one incident where [Resident # 190] came up to me and, stared at me, went very close to my face. I documented that. I never saw that toward another patient. The surveyor asked LPN # 2 if she had heard about the incident that a CNA documented on [DATE] that the resident hit a staff member. LPN # 2 stated, No, I didn't know about that. On [DATE] at 10:30 AM, the surveyor reviewed the facility's policy and procedure titled Abuse Prevention Program, with the most recent reviewed date of ,d+[DATE]. Under Policy Interpretation and Implementation-As part of the resident abuse prevention, the administration will: Number 1. read Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Number 4. reads, Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. On [DATE] at 11:30 AM, the surveyor reviewed the facility's policy and procedure dated [DATE] titled Behavior Management: Interventions and Monitoring. Number 1 read: Observe patients for early signs of withdrawal/decreased social interaction, frustration, agitation, and anger such as physical behavior symptoms directed toward others, verbal, behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. Bullet point number four under Number 5 read: Initiate changes in care approaches and update care plan as indicated. The IJ was identified on [DATE]; the LNHA was notified of the IJ and provided with the IJ template on [DATE] at 12:23 PM. A removal plan was received the same day at 4:28 PM, which included the following: The Assistant Director of Nursing will educate staff on behavior monitoring, documentation, and care plan initiation during new hire orientation and yearly. All nursing and recreation staff are being educated on behavior monitoring, documentation, and care plan initiation, which will be done annually and as needed upon hire. Education has been initiated today, [DATE], and all shifts will be captured until it is completed on [DATE]. Anyone not receiving the training will be trained prior to the beginning of their shift. Any resident with new documented behavior will have a formal behavior documentation monitoring process, and a care plan will be initiated/updated. All residents with new behaviors will be addressed immediately to prevent any resident-to-resident altercation. The team will conduct a full assessment and initiate interventions to include behavior monitoring, update the care plan, and notify the primary care physician and the family. The clinical team will review the progress notes Monday through Friday during the morning meeting for three months, then monthly for three months. Any noted behaviors will be cross-referenced to ensure that the behavior monitoring documentation and the care plan are updated with appropriate interventions. The implementation of the removal plan was verified by the survey team on-site on [DATE] through observations, interviews, and a review of in-service education. NJAC 8:,d+[DATE].1 (a) 5

Complaint NJ# 00160615, 00160518 Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for failure to properly wear personal protective equipment. The deficient practices were evidenced by the following: On 1/30/23 at 11:00 AM, the surveyor observed the facility's Social Worker (SW) in the foyer near the receptionist with her N95 mask not covering her nose or mouth and there were three resident's present in the foyer at this time. At 11:05 AM, the surveyor interviewed the SW, who stated that she should have been wearing the N95 mask over her nose and mouth in the foyer and in all resident areas. At 11:15 AM, during the kitchen tour, in the presence of the Account Manager (AM), the surveyor observed two Food Service Workers with masks on that were not covering their noses. The AM stated that all the staff should be wearing a mask completely covering their nose and mouth. At 12:05 PM, the surveyor observed a Certified Nursing Assistant (CNA) in a resident's room with her surgical mask off of her nose and had a conversation with both residents who resided in that room. The CNA walked out of the room with her mask still off of her nose. At 12:10 PM, the surveyor interviewed the CNA who stated that she was having difficulty breathing but should have been wearing the face mask over her nose and mouth. On 2/01/23 at 12:20 PM, the surveyor interviewed the facility's Infection Preventionist, who stated that the facility policy is that staff should wear a mask covering their nose and mouth. Review of the facility's policy titled Use of Personal Protective Equipment Utilized by Cohort dated 5/20/2022, revealed that in a negative cohort, the minimal personal protective equipment worn is a surgical mask. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review it was determined that nursing staff failed to ensure a) each prescription medication had a pharmacy label affixed with the resident's name and prescribing information; b) medication containers were labeled with the open date; c) an expired biological was removed from active inventory for an unsampled resident (Resident #141); d) expired medications were removed from active inventory. The deficient practice was observed in 4 of 4 nursing units and evidenced by the following. 1. On 02/03/23 at 1:35 PM the surveyor inspected the [NAME] Unit Medication Cart #2 in the presence of the unit Registered Nurse (RN #1). The surveyor observed 2 unopened 2 ml. vials of Ondansetron (Zofran) 4 mg/2 ml. The vials did not have pharmacy labels or dispensing bags. RN #1 stated all prescription medications should be labeled with the resident name and pharmacy information. RN #1 stated she did not know who placed the unlabeled medication in the medication cart. RN #1 removed the medication from the cart. 2. On 02/03/23 at 2:00 PM the surveyor inspected the [NAME] Unit medication storage room and medication refrigerator in the presence of the Unit Manager (UM #1). The surveyor observed 1 Mantoux (tuberculin purified protein derivative) Tubersol multidose 1 ml. opened and undated vial. The vial was stored in the pharmacy box dated with an open date of 02/01/23. The UM #1 stated the vial should have been dated when opened in addition to dating the box. 45449 3. On 2/3/23 at 10:21 AM, the surveyor began the inspection of the non- controlled portion of [NAME] Cart One in the presence of Licensed Practical Nurse LPN #1. The surveyor and LPN #1 observed an expired, unopened bottle of Lantus Insulin 10 milliliter (ml; a medication used to control high blood sugar levels in the blood) with a pharmacy labeled date of 11/1/22 for Unsampled Resident #141's name. LPN #1 confirmed the seal was not broken on the bottle. At that time, the surveyor and LPN #1 reviewed the Lantus package that had a cautionary label, Refrigerate until opened. Further review of the Lantus package revealed the date opened label was left blank. The resident's label revealed the pharmacy dispense date of 11/1/22. LPN #1 stated the Lantus bottle should have been refrigerated until its intended use because unopened Lantus at room temperature must be discarded after 28 to 30 days. LPN #1 stated, the Lantus had been in the cart for 90 days and if administered after the expiration date, the medication would not have been effective to lower the Unsampled Resident's blood sugar level. A review of the manufacturer's specifications for Lantus under section 16.2 Storage reflected, Store unused Lantus in a refrigerator between 36 degrees Fahrenheit (F) and 46 degrees F (2 degrees Celsius (C) and 8 degrees C) .10 ml multiple-dose vial not in-use (unopened) stored in room temperature (up to 86 degrees F) are in date for 28 days. 4. At 2:17 PM, the surveyor began the inspection of the Madison/Homestead Cart 2, in the presence of LPN #2 and observed the following items: -Vitamin D3 10 microgram (mcg) expired 9/22 -Vitamin E 400 international units (IU) expired 9/22 -Zinc 50 mcg expired 10/22 At that time, LPN #2 stated that expired medications should not have been present with the active inventory. LPN #2 also stated the residents who could have received the expired medication would not receive the full effect or full benefit of the medication. The regular nurse on this cart should have frequently checked to ensure all medications were in-date. 5. On 2/03/23 at 1:29 PM the surveyor inspected medication cart # 2 on the Washington Unit in the presence of LPN # 3. Inside of the cart there was one Basaglar insulin pen that was open and undated. The date on the bag holding the pen was 1/27. LPN # 3 confirmed that the pen was being used. According to manufacturer specifications once open Basaglar insulin pens should be discarded after 28 days, even if there is still insulin left in the pen. 6. On 2/03/23 at 1:45 PM the surveyor inspected the second cart #1 on the Washington Unit in the presence of LPN # 4. Inside of that cart there were two Lantus insulin pens. One insulin pen had a resident's last name, first intitial, and the date, 1/30/23, written on it with a black marker. The second insulin pen had the same resident's last name and first intitial written on it with black marker and no date. There was no pharmacy label or bag to hold the insulin pens. The LPN/UM came over to the cart and explained that the resident ordered the insulin pens, received the insulin pens and gave them to the nurse on duty. when they were delivered. The resident ordered through a mail order pharmacy. The resident was a private pay resident and ordered the insulin pens from an outside pharmacy because it costed less than getting it from the facility's pharmacy. According to manufacturer specifications once open Lantus insulin pens should be discarded after 28 days following the first use. 7. On 2/3/23 at 1:55 PM the surveyor inspected the medication refrigerator on the Washington unit in the presence of LPN # 3. Inside of the refrigerator there was a vial of Humulin R insulin that was open and dated 2/3/23. The vial was not in a bag and had no pharmacy label attached to it. LPN # 3 confirmed that it should have been in the cart and it should have had a pharmacy label on it. Additionally, there was one unopened vial of Humulin R insulin with no pharmacy label attached to it. On 2/8/23 at 10:56 AM, the surveyor, in the presence of the survey team spoke with the Director of Nursing (DON), Regional Nurses, and the Licensed Nursing Home Administrator (LNHA) about the above concerns. The DON stated education was being given to the nurses for medication storage and medication cautionary after surveyor inquiry. A review of facility provided policy, Medication Storage reviewed 11/22 included: Policy: The facility shall store all medications and biologicals in a safe, secure, and orderly manner. 1. Medications and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. 5. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and dispose as per State guidelines. 6. Medications will be stored are the appropriate temperature in accordance with pharmacy and manufacturer labeling. NJAC 8:39- 29.2 (d); 29.4 (a)8, (b)2, (f) (g)

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care, Resident #36. This deficient practice was evidenced by the following: 1. On [DATE] at 11:00, the surveyor spoke with Resident #36 who stated she had lived there for about a year and used at electronic handheld device to communicate with the surveyor. The resident expressed concerns about her tracheostomy care. On [DATE] at 9:11 AM, the surveyor began the observation of tracheostomy care (tracheal care) by the Licensed Practical Nurse (LPN) for Resident #36. At 9:30 AM, the surveyor observed the LPN prepare her supplies that included, Tracheostomy Clean and Care kit that contained the following: -one pair of gloves -two hydrogen peroxide -one towel -two applicators -one tracheostomy brush -one twill tape -one drain sponge -four gauze sponges -one sodium chloride At 9:42 AM, the LPN confirmed with the surveyor she was ready to perform the tracheal care. At 9:44 AM, the surveyor observed the LPN pick up the gauze and opened the sodium chloride and was about to administer tracheal care. At that time the surveyor asked to speak with the LPN. The LPN identified the sodium chloride expiration date which was [DATE] and confirmed she was about to use the expired item. At 9:49 AM, outside the resident's room, the LPN stated she should have checked the expiration date of the tracheal supply kit before entering the resident's room. She also stated that expired sodium chloride was no longer sterile. 2. On [DATE] at 10:51 AM, the surveyor and the LPN/Unit Manager entered resident #36's room to observe the stocked tracheal supplies at bedside. At that time the surveyor and LPN/UM observed one Tracheostomy Clean and Care kit that expired on [DATE]. At 10:52 AM, the surveyor and LPN/UM exited the resident's room. During an interview with the surveyor, the LPN/UM stated the nurse should have checked the tracheal supplies stored in the resident's room. The LPN/UM confirmed that tracheal care is a sterile technique that required all items in the tracheal care kit to be within date. The LPN/UM stated that the expectation was that all nurses checked all items stored and prior to start of care. According to the admission record, Resident #36 was admitted to the facility with diagnosis that included chronic respiratory failure, encounter for attention to tracheostomy and Diabetes Mellitus. A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate residents care, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of ,d+[DATE] which indicated Resident # 36 was cognitively intact. The MDS also revealed the received tracheostomy care within the past 14 days. A review of the Care Plan included, keep extra trach tube and obturator at bedside. A review of the current Order Summary Report revealed physician orders for change inner cannula, trach collar and dressing as needed and at every day shift. On [DATE] at 10:56 AM, the surveyor, in the presence of the survey team spoke with the Director of Nursing, Regional Nurses, and the Licensed Nursing Home Administrator (LNHA) about the concern with the expired sodium chloride dated ,d+[DATE]. The LNHA confirmed the Unit Manager replaced all items and a new order was added to change respiratory supplies every night shift, every Monday after surveyor inquiry. A review of the facility provided policy, Tracheostomy Care with a reviewed date of ,d+[DATE] included: Purpose: This policy is to instruct how to effectively clean a patient's tracheostomy and surrounding area to reduce the risk of infection and maintain patent airway. Overview: 2. Each trach resident should have a spare back up trach at the bedside for emergency reinsertion. Procedure for Changing Disposable Inner Cannula: 9. Moisten the new inner cannula with sterile water or saline (sodium chloride). This will facilitate insertion. NJAC 8:,d+[DATE].4 (a), 27.1(a), 29.2(d), 29.4(g)

Complaint # NJ00158684 Based on interviews conducted during the 2/6/23 Resident Council Meeting and 2 additional resident representative interviews and review of facility documentation it was determined the facility failed to provide care and services in a dignified and respectful manner. The concern was evidenced by the following. On 2/6/23, the surveyor reviewed Resident Council meeting minutes for past meetings. The 6/2022 minutes noted resident complaints of staff speaking on their cell phones while in the nursing unit. On 2/6/23 at 10:30 AM, the surveyor conducted the Resident Council Facility Task group meeting with 5 alert and oriented residents who were selected for participation by the facility. Five of 5 residents stated they had seen nursing department staff members talking on cell phones while in resident care areas. One resident stated they observed a nurse speaking on a cell phone while standing at the medication cart. The Resident Council President stated they had spoken with facility administration about the concern. The residents stated the problem has continued. On 2/07/23 at 11:19 AM, the surveyor interviewed the responsible representatives of 2 sampled residents. The interviewees requested to remain anonymous. They stated they have seen staff speaking on cell phones in the hallways of 2 nursing units. On 02/08/23 at 10:46 AM, the surveyor discussed the cell phone concerns with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing. The LNHA stated staff was in-serviced in June of 2022 after he received complaints voiced at the resident council meeting. He stated he did not know it had been a continuing concern. The facility policy addressing cell phones and other communication devices was provided to the surveyor on 2/9/23. The policy was signed and dated on 2/9/23. The policy included the following statements, personal cell phones should not be used during work time. Employees should not make or receive any personal calls or texts during work time. NJAC 8:39-4.1(a)12

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 2/9/23, the surveyor observed four nurses administer medications to six residents. There were 29 opportunities, and two errors were observed which resulted in a medication error rate of 6.9%. This deficient practice was identified for one of six residents, that was administered by one of four nurses. This deficient practice was evidenced by the following: On 2/7/23 at 8:47 AM, the surveyor observed the Certified Nurse Assistant (CNA) inform the Licensed Practical Nurse (LPN) that Resident #47 was in pain. At 8:55 AM, the surveyor observed the LPN prepare medications for Resident #47. The medications included the following: -Oxycodone/ Acetaminophen 5 milligram (mg)/325 mg tablet, 1 tablet -Famotidine 20 milligram (mg), 1 tablet -Metoclopramide 5 mg/5 ml liquid, 5 milliliters (ml) -Metoprolol 12.5 mg tablet (1/2 tablet of 25 mg) -Docusate 100 mg tablet, 1 tablet -Keppra 100 mg/ml liquid, 7.5 ml -Eliquis 5 mg, 1 tablet -Famotidine 20 mg, 1 tablet -Ascorbic Acid 500 mg, 1 tablet At 9:31 AM, the surveyor observed the LPN administer the medications to Resident #47. The LPN also stated the resident was non-verbal. At that time, the LPN stated she had not observed any meal trays in the room. At 9:38 AM, the LPN stated she was unable to administer the order for Enteral Feed because the CNA had not reported the percentage of Resident #47's meal intake and it was not documented on the electronic Medication Administration Record (eMAR). At that time, the surveyor and LPN reviewed the eMAR that reflected an order for: Enteral Feed Order after meals for variable intake at meals. Isosource 1.5 bolus can after meals if PO [by mouth] intakes <50% of meals; (250 mls each /TV [total volume] 750 mls if administered), UP at 9am/1pm/and 6pm, 1,125kcals/24 hrs [hours] if administered. At 9:40AM, the LPN confirmed with the CNA the percentage of meal intake for Resident #47. The LPN informed the surveyor that Resident #47 ate their whole meal which was delivered sometime between 7:00 AM and 8:00 AM. According to the admission record, Resident #47 was admitted to the facility with diagnosis that included, encounter for attention to tracheostomy, encounter for attention to gastrostomy, and gastrostomy malfunction. A review of the Order Summary report reflected orders that included: -Metoclopramide 5mg/5 milliliters (ml) give 5 ml via PEG-tube (feeding tube inserted through the skin into the stomach and provides a passage for nutrition and medication when unable to swallow or eat well) before meals for GERD (gastroesophageal reflux disease; stomach acid that repeatedly flows back into the tube connecting the mouth and stomach and causes discomfort) monitor for dyskinesias, tremors, falls etc -Famotidine tablet 20 mg give 1 tablet via PEG-tube two times a day for acid indigestion (pain or discomfort in the stomach associated with difficulty in digesting food) During a follow up interview, on 2/7/23 at 12:48 PM, the surveyor and the LPN reviewed Resident #47's eMAR for Metoclopramide. The LPN stated, she should have administered the Metoclopramide at 7:30 AM since the medication was to prevent the acid reflux. The surveyor and the LPN reviewed the cautionary label on the Metoclopramide bottle which reflected, Take this medicine 1/2 hour before a meal . At that time, the surveyor and LPN reviewed the manufacturer specification label attached to the Famotidine bottle. The administration instruction revealed, administer 10 to 60 minutes prior to eating and drinking. The LPN confirmed both medications were not administered prior to eating and drinking as indicated. The LPN acknowledged that giving both medications at the wrong time resulted in its ineffectiveness. On 2/8/23 at 10:56 AM, the surveyor, in the presence of the survey team spoke with the Director of Nursing (DON), Regional Nurses, and the Licensed Nursing Home Administrator (LNHA) about the above concerns. The DON stated education was being given to the nurses for medication administration and medication cautionary after surveyor inquiry. A review if the facility provided policy, Administering Medication updated 10/22 included: Policy Statement, Medications shall be 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 frame. 3. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). N.J.A.C. 8:39-29.2 (d)

Complaint # NJ 323 Based on interview and review of Medical Records (MR) and other pertinent facility documents on 10/13/22 and 10/14/22, it was determined that the facility failed to consistently implement the care plan interventions when providing bed mobility and transfer for Resident #2 who sustained fracture of right femur of unknown origin on 1/15/22. This deficient practice was identified for 1 of 2 residents (Resident #2) reviewed for person centered comprehensive care plan and was evidenced by the following: According to the Resident's Admission Record (AR), Resident #2 was admitted to the facility on [DATE]. The Physician's Progress Notes (PN) indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 9/8/22, showed that Resident #4's cognitive status was not assessed due to persistent vegetative state/no discernable consciousness. The Resident was dependent to staff for Activities of Daily Living (ADL) and required 2 staff for bed mobility and transfer. The surveyor reviewed the ADL Care Plan (CP) initiated on 12/2/21 with interventions initiated on 1/17/22 showed that Resident #2 required 2 staff assistance for bed mobility and transfer using a mechanical lift. Furthermore, the surveyor reviewed the CP for right femur fracture related to Osteopenia initiated on 2/16/22 which showed that the Resident required 2 persons assists with ADL's. The CP was updated on 1/17/22 when the facility initiated an investigation of the right femur fracture with unknown origin sustained by the Resident. The Facility Reportable Event (FRE) reported to the New Jersey Department of Health (NJ DOH) on 1/17/22, showed that on 1/15/22, Resident #2 was noted with right thigh swelling, the Attending Physician (AP) was informed and ordered a doppler examination which came back negative for [CONDITION(S)] (a medical condition that occurs when a blood clot forms in a deep vein). On 1/16/22, the Resident's right thigh swelling increased requiring transfer to the hospital for further evaluation. The FRE revealed that the Resident was admitted to the hospital for fracture of the right femur on 1/17/22 and returned to the facility on [DATE]. The facility's investigation indicated that due to the absence of signs of skin bruising and redness, the Resident's medical condition which included Osteopenia (loss of bone mineral density that weakens bones), [CONDITION(S)] (bone disease that develops when bone mineral density and bone mass decreases), and chronic dislocation of the right femoral head (the same location of the fracture) that were revealed on the hospital's x-ray could have contributed to the fracture. There was no definitive cause of the fracture on the FRE and the facility indicated that the injury was unwitnessed with unknown origin. The surveyor reviewed the Documentation Survey Report (DSR), an ADL task documented by the Certified Nursing Assistants (CNA) during their assigned shift, for the month of February to April 2022. The DSR revealed the following: Transfer: Total Dependence (TD) (4) and Support Provided (SP) One-person physical assist (2). This was documented on the following dates and shift: Day Shift 7-3 AM (DS): On 2/25/22 Evening Shift 3-11 PM (ES): On 3/25/22 to 3/27/22, and 4/3/22 Bed Mobility Extensive Assistance (EA) (3) and SP (2) This was documented on the following dates and shift: DS: On 2/1/22, 2/24/22, 3/2/22, 3/5/22, 3/9/22, 3/24/22, 3/25/22, 4/5/22, 4/6/22, and 4/8/22 Bed Mobility: TD (4) and SP (2). This was documented on the following dates and shift: This was documented on the following dates and shift: DS: On 2/27/22 and 3/1/22, ES: On 2/3/22, 2/7/22, 2/10/22, 2/15/22, 2/16/22, 2/19/22 to 2/22/22, 2/24/22, 3/2/22, 3/3/22, 3/6/22, 3/10/22, 3/11/22, 3/13/22, 3/16/22, 3/17/22, 3/19/22, 3/20/22, 3/24/22 to 3/27/22, 3/29/22, 3/31/22, 4/3/22, 4/4/22, 4/6/22, 4/8/22, 4/12/22, 4/14/22, 4/15/22, 4/18/22, 4/20/22 to 4/24/22, and 4/27/22 to 4/29/22 Night Shift 11-7 AM (NS): On 2/1/22 to 2/3/22, 2/5/22, 2/7/22, 2/922 to 2/11/22, 2/14/22, 2/16/22, 2/17/22, 2/20/22 to 2/28/22, 3/2/22 to 3/26/22, 3/28/22, 3/29/22, 3/31/22, 4/1/22 to 4/7/22, 4/9/22 to 4/16/22, 4/19/22 to 4/24/22, and 4/17/22 to 4/30/22. The surveyor interviewed CNA #1 on 10/14/22 at 11:30 AM who stated that she had provided care to Resident #2. She recalled that the Resident had a fracture in January but could not remember the details. She explained that after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #1 further explained that nursing staff uses a hoyer lift or mechanical lift to transfer the Resident out of bed and that using the lift requires 2 staff. The surveyor asked CNA #1 if she documented the task and assistance she provided for Resident #2. She answered yes, on the kiosk. Furthermore, the surveyor showed CNA #1 the printed DSR report, she acknowledged that her initial was SE and that she documented TD (4) and SP (2) on 2/27/22, 3/1/22, 3/12/22, 3/13,22, 3/21/22, 3/22/22, 3/26/22, and 3/27/22. She stated that what she documented on the kiosk was accurate and correct. The surveyor asked CNA #1 the reason she performed the task alone on the aforementioned dates despite knowing that the Resident require 2 staff assistance after sustaining a fracture of unknown origin which was also indicated in the plan of care to prevent new injury, she answered that due to staffing shortage, she avoided asking another nursing staff for help. However, she acknowledged that she should have asked for assistance for Resident's safety. The surveyor interviewed the Director of Nursing (DON) in the presence of the Regional DON on 10/14/22 at 12:36 PM and they both acknowledged that there were multiple shifts on the DSR report showing 1 staff assistance was provided to Resident #2 for bed mobility and transfer. They stated that this was not in accordance with the Resident's plan of care and that the nursing staff should have provided 2 staff assistance to prevent new injury. The surveyor reviewed the facility policy titled Care plans, Comprehensive Person-Centered updated 10/2021, under Policy Statement indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Covid-19 Infection Control Based on observation, interviews, and record review on 4/22/22, it was determined that the facility failed to ensure handwashing was performed according to their policy and acceptable standards of infection control practice according to the Centers for Disease Control and Prevention (CDC). This deficient practice was identified for 1 of 2 Employees (Certified Nursing Assistant #1), observed for Handwashing technique. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/8/2021, Healthcare Providers, When and How to Perform Hand Hygiene, Techniques for Washing Hands with Soap and Water, recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry .Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds . Review of the facility line listing (LL) provided by the facility on 4/22/22, showed that the COVID-19 outbreak started on 4/13/22 and the last tested positive for COVID 19 was on 4/17/22. During the tour of the unit on 4/22/22 at 12:45 pm, Certified Nursing Assistant (CNA #1) came out of Resident #A's room who was on isolation precaution for COVID-19. CNA #1 performed handwashing with soap and water for 9 seconds which was not according to the facility policy and CDC guidelines for health care providers. During the interview with CNA #1 on 4/22/22 at 12:50 pm, she stated that she washed her hands but did not count to ensure it was 20 seconds. The CNA was unable to verbalize the importance of handwashing. The form HAND WASHING COMPETENCY VALIDATION (HWCV) dated 4/13/2022, provided to CNA #1 showed .Apply hand-washing agent (SOAP) and thoroughly distribute over hands. Vigorously rub hands together for 20 seconds, covering all surfaces of the skin . The facility's policy titled Handwashing/Hand Hygiene updated on 1/2022, showed This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds . NJAC 8:39-19.4 (a) (1)

Covid-19 Infection Control Based on interviews, and record review, as well review of pertinent facility documents on 4/22/22, it was determined that the facility failed to provide information and the opportunity to receive the pneumococcal vaccine for 1 of 5 residents (Resident #1) reviewed for immunization status. This deficient practice is evidenced by the following: 1. According to the ADMISSION RECORD (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], the Resident was cognitively impaired. Immunization Record (IR) for Resident #1 showed no documentation to indicate that the Resident Representative (RR) had been informed about the risk and benefits of the vaccine and was given the opportunity to receive the pneumococcal vaccine. During the interview with the Unit Managers (UM #1 and UM #2) on 4/22/22 at 3:00 pm, they were not able to provide documentation why the vaccine was not provided to Resident #1. During the interview with the Director of Nursing (DON) 4/22/22 from 3:00 pm to 4:00 pm, the DON stated that the IR should have been updated whether the Resident received the vaccine or not. The DON was not able to provide documented evidenced that the RR was educated on risk and benefit of the vaccine or if the vaccine was refused in behalf of Resident #1. Review of the facility policy titled Pneumococcal Vaccine updated on 1/2022, showed . All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/ pneumococcal infections .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .if refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination . NJAC 8:39-19.4 (i)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses; and, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On [DATE] at 09:14 AM, the surveyors toured the kitchen in the presence of the Account Manager (AM) and observed the following: 1. The surveyor washed their hands at a handwashing station and observed the foot pedal did not open the lid to the trash can. The AM lifted the lid manually and stated he would get maintenance to look at it. 2. In the reach-in fridge, the AM removed one plate covered by a plastic bag and then another container covered by a plastic bag. The AM stated they were personal staff lunches and acknowledged they should not be there. 3. In the walk-in fridge, one container of chocolate pudding, two containers of vanilla pudding, and four individual cheese slices wrapped in clear plastic wrap had no prepared or use-by dates. 4. In the freezer, one 5.44 kg box of turkey bacon dated [DATE] was opened, the internal plastic bag was opened with the bacon exposed to air. The AM stated that was the received on date. One 10.5 lb box of all beef sandwich steaks dated [DATE] was opened and the internal plastic bag was opened with the meat exposed to air. The AM stated that was the received on date. The AM wrapped up the plastic and closed the boxes on each and stated they are not supposed to be left that way; He stated he would remove them so residents would not receive them. 5. On the drying rack, multiple-sized serving pans/lids were nestled on top of each other. The surveyor separated two nesting pans and two nesting lids and observed moisture between them. The AM acknowledged they should be separated and dry to prevent contamination. 6. In the Dry Food Room, one plastic bag of corn mix was opened, covered in clear plastic wrap with handwritten dates [DATE] and [DATE]. The AM stated that was the expiration date and removed the bag. On [DATE] at 10:35 AM, the surveyor toured the kitchen in the presence of the Account Manager (AM) and observed the following: 1. On the lower shelf of a stainless steel table was one opened 15 count bag of hot dog rolls wrapped in clear plastic wrap with no received by or open date, a plastic bag of cinnamon bread was opened with no received by or open date. A plastic bag of wheat bread was opened with no received by or open date. On [DATE] at 10:50 AM, the surveyor interviewed the AM, who stated that if someone took anything out, they should write the date they opened it. The AM acknowledged the hot dog rolls, cinnamon bread, and wheat bread were opened, used, and wrapped up without a date on them. He further stated it was important to let others know when things were opened and follow the use-by date, so residents don't get expired food. The AM said that expired food gets thrown out. On [DATE] at 11:29 AM, the surveyor interviewed the District Manager (DM), who stated food should be dated when opened and a use-by date or expiration date marked. The DM noted if there were undated food, it should be thrown out, and everyone needed to know when it was opened and how fresh it was. The DM acknowledged the hot dog rolls, cinnamon bread, and wheat bread were all thrown in the garbage. A review of the facility's policy Food Storage: Dry Goods, with a revision date of ,d+[DATE], revealed Procedures: 1. All food items will be appropriately dated with receive date and follow manufacturer guidelines of Best By/Use By per product packaging. A review of the facility's policy Receiving, with a revision date of ,d+[DATE], revealed Procedures: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All non-perishable foods and supplies will be stored appropriately. A review of the facility's policy, Food Storage: Cold Foods, with a revision date of ,d+[DATE], revealed Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. A review of the facility's Food Storage and Retention Guide, dated v,d+[DATE], revealed Ready-to-Eat/Prepared Foods (1)-Food in a form that is edible without additional preparation to achieve food safety. (Examples: leftovers, deli meats, and salads, opened canned fruits and puddings), Refrigerator less than/equal to 41 degrees F, Up to 7 days, Day 1 is the date of preparation. A review of the facility's policy Warewashing, with a revision date of ,d+[DATE], revealed Procedures: 4. All dishware will be air-dried and properly stored. A review of the facility's policy Manual Warewashing, with a revision date of ,d+[DATE], revealed Procedures: 3. All serviceware and cookware will be air-dried prior to storage. NJAC 8:39 17.2(g)

C#: NJ 568, NJ 578 Based on interviews and record review, as well as review of pertinent facility documents on 9/24/19 and 9/25/19, it was determined that the facility failed to follow their Comprehensive Care Plan for 1 of 4 residents (Resident #1), reviewed for implementation of Care Plans which resulted in the Resident sustaining a fall with injuries during a mechanical lift transfer on 9/20/19; requiring an emergency room transfer and admission. The deficient practice is further evidenced by the following: 1. According to the Admission Record Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 7/6/19, revealed that Resident #1 required extensive assistance to total assistance of two (2) staff with Activities of Daily Living (ADL). The Social Service assessment dated [DATE], revealed that Resident #1 was alert with confusion, and refused to participate in assessment to determine cognition status. The Care Plan (CP) initiated on 3/2/17, and revised on 8/21/18, showed that Resident #1 was noncompliant and resistive to care related to Cognitive Loss and Dementia. The CP further showed that the Resident had exhibited combative behavior during care and could not be redirected. Interventions included but were not limited to: having a nurse present during care and/or transfers when agitated, postpone care when the Resident became combative or resistive and allow time for him/her to regain composure. The CP initiated on 9/3/17, showed that Resident #1 was at risk for falls. Intervention included but was not limited to: transfer the Resident via total lift with assistance of 2 staff using a medium, divided leg sling. The Lift Transfer Reposition assessment dated [DATE] revealed that Resident #1 weighed 136 pounds (lbs), had a height of 63 inches, which equaled to 5 feet and 3 inches (5.3') and required a medium, divided leg sling for transfers. The Facility's Reportable Event Record/Report (FRE) dated 9/20/19, showed that on the morning of 9/20/19, Resident #1 became agitated, was thrashing arms and legs, and fell out of a Hoyer Lift (HL, a mechanical transfer device). The FRE further showed that there were two (2) aides present at the time of the Resident's fall. Both CNAs attempted to catch the Resident but they were unable to prevent the Resident from falling. The resident sustained [REDACTED]. HL was immediately removed and inspected and was found to be in good working order. Attached with the FRE, a statement from Certified Nursing Assistant (CNA #1) dated 9/20/19 showed that Resident #1 was agitated during care. It further showed that the CNA #1 took the mechanical lift in the room and placed the sling under Resident #1. The statement further showed that CNA #1 and CNA #2 began to transfer the Resident when the Resident began to move from side to side. CNA #2 opened the HL legs wider to turn the Resident towards the chair when he/she slid from out of the sling and fell face down on the floor. CNA #1 attempted to prevent the fall but was unable to. Attached with the FRE, a statement of CNA #2 dated 9/20/19 showed that Resident #1 was combative during care and attempted to hit the CNAs. The statement further showed that both CNAs were transferring Resident #1 when the Resident started to move from side to side, while suspended in the air. CNA #2 saw the Resident slide out of the sling and then fall face down to the floor. The Progress Note (PN) written by the Nurse Practitioner (NP) dated 9/20/19 at 5:25 pm, showed that Resident #1 was examined by the NP post fall on 9/20/19. It revealed that Resident #1 was rocking back and forth during transfer, slid from the sling and fell to the floor, landing on the face. It further showed that during an examination, Resident #1 was noted with blood coming from both nostrils, bridge of the nose and above the left eye. It showed that Resident #1 sustained an approximately 1 centimeter (cm) laceration to the left nostril, a 4 cm x 1 cm laceration above the left eye and a 2 cm laceration on the bridge of the nose. It further showed that the Resident was actively bleeding. The surveyor conducted an interview with CNA #1 (the primary CNA for Resident #1) and CNA #2 (assisted CNA #1) on 9/24/19 at 10:29 am. The CNAs demonstrated how they provided care and how they attempted to transfer Resident #1 using a HL on 9/20/19. They stated that while providing morning care to Resident #1 on 9/20/19 at 9:45 am, the Resident was agitated, spitting and hitting. CNA #2 stated and demonstrated how the CNA gently held the Resident's hands because the Resident was beating them up with his/her fists. They further stated that this was the Resident's normal behavior during care. After they completed the morning care, they put the HL sling under the Resident and the Resident continued to be agitated. The CNAs revealed that they talked to the Resident to calm down and the Resident calmed down for a few seconds. Then the CNAs attached the sling to the HL hooks and slowly lifted the Resident using the HL. The CNAs revealed as they slowly lifted the Resident, the Resident started to yell, scream, spit, and shake his/her head side to side. They then stopped for a few minutes (unable to give the exact time) and the Resident calmed down while suspended in the air. The CNAs continued to lift the Resident via the HL until the Resident was at the edge of the of bed. However, the Resident began to scream, yell, and shook his/her head side to side. CNAs stated that they were standing facing the Resident's legs and neither one of them was standing next to the Resident to support the Resident's head because the Resident was hitting and spitting. While the CNAs were waiting for the Resident to calm down, the Resident suddenly slipped from the side of the sling and landed on the floor. The CNAs went on to state that the Resident's face hit the floor first. CNA #1 stayed with the Resident in the room and CNA #2 stepped out of the room to call for help. Continued interview with the CNA #1 and #2. CNA #1 stated that Resident #1 was able to slip out of the sling because they used the extra large size, full body sling and not the medium size, divided leg sling as indicated on Resident #1's comprehensive care plan. She went on to state that she had used the full body extra large sling for Resident #1 in the past. CNAs revealed that they did not call the nurse when the Resident was agitated during the care and transfer, which was not according to Resident #1's care plan. CNAs stated that the Resident did not jump off the sling instead the Resident slipped out of it (which was 3 feet height from the sling to the floor) and landed on the floor. The surveyor conducted an interview with the Registered Nurse (RN #1) on 9/25/19 at 11:40 am, she stated that Lift Transfer assessment was done on admission, quarterly and as needed. The RN further stated that the most recent assessment revealed what type of sling (full body, or divided leg) and size (medium, large, and extra large) was appropriate for the Resident. The type and size of the sling was documented on the Resident's care plan. In addition, the staff could see the code sticker posted on the Resident's name outside the door for the type, size, and color of the sling (T= divided leg sling, TA= full body sling) appropriate for the Resident. RN #1 revealed that appropriate sling specification sticker was outside of Resident#1's door. However, during the survey on 9/24/19 and 9/25/19, the sticker with the sling specifications and Resident #1's name was already removed from the outside of the room door. Continued interview with RN #1 on 9/25/19 at 11:40 am, she stated that on 9/20/19 approximately after 9:30 a.m., she was called to check on Resident #1. She found the Resident lying on the floor. There was blood on the floor. The Resident remained awake, sustained a laceration on the left eyebrow, forehead and bridge of the nose. Emergency service 911 was called and she called the Resident's Representative and the Primary Physician. CNA #1 and #2 told her that as they were transferring the Resident using the HL, the Resident moved and fell out of the sling and it was too fast for the CNAs to prevent the fall. The RN revealed that the CNAs used the wrong size and type of the sling. The CNAs should have used the divided leg and, medium size (color purple) sling which was specified in the care plan. Instead they used the full body, extra large sling. Continued interview with CNA #1 and CNA #2 on 9/24/19 at 12:00 pm revealed that they were familiar with CP and nurses advised them what was in each Resident's CP. They both stated that they did not remember what sling specification sticker was present outside of Resident #1's door. The surveyors attempted to conduct a telephone interview with LPN #1 on 9/25/19 and 9/26/10 (post survey), however, the LPN was not available. The Acute Care Hospital Emergency Department Physician notes dated 9/20/19, showed that Resident #1 was admitted to an Acute Care Hospital with [DIAGNOSES REDACTED]. The notes further showed that the Resident was brought to the Emergency Department (ED) after falling from a HL. Physical examination showed that Resident #1 had a 2 cm laceration to left forehead with mild swelling and tenderness. It further showed that the Resident had a 3 millimeters (mm) laceration to left cheek and 2 cm laceration to left nostril with active bleeding from bilateral nostrils. The treatment of [REDACTED]. The Acute Care Hospital Physician History and Physical dated 9/21/19, showed that Resident #1 was admitted to an Acute Care Hospital with a [DIAGNOSES REDACTED].#1 was being transferred via HL and fell . This resulted in lacerations across the Resident's face as well as a nasal fracture. Resident #1 was brought to the emergency room where the lacerations were treated. An Assessment also showed that after the fall, Resident #1 had a Nasal Fracture and Facial Lacerations. The Plan of Care included but was not limited to: admitting the Resident for observation, an Ear Nose Throat (ENT) physician consultation for further recommendations regarding nasal fracture and physical and occupational therapy. The Computed [NAME]ography (CT) Scan, a diagnostic test, of Facial Bones and Orbit was performed on 9/20/19 at 3:06 pm at the Acute Care Hospital and showed that the Resident had Bilateral Nasal Bone Fractures. The facility's policy titled Person-Centered Care Plan effective on 11/28/16, and revised on 7/1/19 showed that: The Center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-cantered care to meet professional standards of quality of care .A comprehensive, individualized care plan .for each patient includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments . The same policy under the section Purpose showed: To attain or maintain the patient's highest practicable physical, mental and psychosocial well-being .To promote positive communication between patient .team .ensure effective communication, and optimize clinical outcomes . The policy further showed under the section Practice Standards: .#7. Care plans will be: Communicated to appropriate staff, patient, health care decision maker (HCDM), family . NJAC 8:39-27 (a)

C#: NJ 568, NJ 578 Based on interviews and record review, as well as review of pertinent facility documents on 9/24/19 and 9/25/19, it was determined that the facility failed to ensure that the Resident who was transferred using a mechanical lift was provided with adequate supervision according to the Resident's assessment and facility policy to prevent accident and injury for 1 of 4 residents (Resident #1), reviewed for incident and accident with injury. On 9/20/19, Resident #1, who required a Hoyer Lift (HL, a mechanical transfer device) transfer with a medium, divided leg sling was transferred using an extra large, full body sling and without adequate supervision, which resulted in a Fall and Facial Injuries, requiring emergency room services and admission. The deficient practice is further evidenced by the following: 1. According to the Admission Record Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 7/6/19, revealed that Resident #1 required extensive assistance to total assistance of two (2) staff with Activities of Daily Living (ADLs). The Social Service assessment dated [DATE], revealed that Resident #1 was alert with confusion, however, refused to participate in assessment. The Care Plan (CP) initiated on 4/21/18 showed that Resident #1 was dependent on staff for ADLs which included transfers. Intervention included but was not limited to: transfer with mechanical lift with 2 staff assistance. The CP initiated on 9/3/17 showed that Resident #1 was at risk for falls. Intervention included but was not limited to: transfer the Resident via total lift with assistance of 2 staff using a medium, divided leg sling. The Lift Transfer Reposition assessment dated [DATE] revealed that Resident #1 weighed 136 pounds (lbs), had a height of 63 inches, which equaled to 5 feet and 3 inches (5.3) and required a medium, divided leg sling for transfers. The Facility's Reportable Event Record/Report (FRE) dated 9/20/19, showed that on the morning of 9/20/19, Resident #1 became agitated, was thrashing arms and legs, and fell out of a HL. The FRE further showed that there were two (2) Certified Nursing Assistants (CNAs) present at the time of the Resident's fall. Both CNAs attempted to catch the Resident but they were unable to prevent the Resident from falling. The resident sustained [REDACTED]. HL was immediately removed and inspected and was found to be in good working order. Attached with the FRE, a statement from CNA #1 dated 9/20/19 showed that Resident #1 was agitated during care. It further showed that CNA #1 took the mechanical lift into the room and placed the sling under Resident #1. The statement further showed that she and CNA #2 began to transfer the Resident when the Resident began to move from side to side. CNA #2 opened the HL legs wider to turn the Resident towards the chair when he/she slid from out of the sling and fell face down on the floor. CNA #1 attempted to prevent the fall but was unable to. Attached with the FRE, a statement of CNA #2 dated 9/20/19 showed that Resident #1 was combative during care and attempted to hit the CNAs. The statement further showed that both CNAs were transferring Resident #1 when the Resident started to move from side to side, while suspended in the air. CNA #2 saw the Resident slide out of the sling and then fall face down to the floor. The Progress Note (PN) written by a Nurse Practitioner (NP) dated 9/20/19 at 5:25 pm showed that Resident #1 was examined by the NP post fall on 9/20/19. It further showed that during an examination, Resident #1 was noted with blood coming from both nostrils, bridge of the nose and above left eye. It showed that Resident #1 sustained an approximately 1 centimeter (cm) laceration to the left nostril, a 4 cm x 1 cm laceration above the left eye and a 2 cm laceration on the bridge of the nose. It further showed that the Resident was actively bleeding. The Invacare Reliant . User Manual (the HL used for Resident #1) advised to use approved sling that is recommended by he individual's doctor, nurse or medical assistant for the comfort and safety of the individual being lifted. The facility competency titled Competency Validation Invacare Total Lift (CVITL) dated 12/12/18 showed that CNA #1 and CNA #2 met the critical elements of the competency. The CVITL further showed that both CNAs selected appropriate weight capacity for Invacare Total Lift during evaluation and performed the lift as followed: a. One person stands next to the patient to provide assistance and ensures the hanger bar does not hit the patient. b. The second person stands on the other side of the patient (next to the lift) and uses the UP button on the hand control to slowly raise the patient to a height to clear the surface and provide the transfer . On 9/24/19 at 2:40 pm the surveyors handed CNA #1 and CNA #2 their signed copies of the CVITL and asked both of them to demonstrate Total Lift according to the CVITL. Both CNAs were unable to demonstrate correct positioning of staff while using the lift according to CVITL. Instead of one CNA standing next to patient to provide assistance and ensure that the bar did not hit the patient and the other CNA standing on the other side of the patient to operate the lift, both CNAs demonstrated that they stood on the same side of the bed, away from the bar, facing Resident #1's legs while performing the lift which was not in accordance with the CVITL that was dated and signed by both CNAs on 12/12/18. The facility's training guide titled Safe Resident Handling (SRH) showed that the divided leg sling was used on 90% of the Residents. It further showed that the full body sling was to be only used on Residents who were [MEDICAL CONDITION], had uncontrolled movements, or the ones who were assessed not to be safe in the divided leg slings. It also showed that a medium divided leg sling was to be used for Residents with weight range of 140 lbs to 275 lbs and height range form 5.0'- 5.5'. It also showed that an extra large full body sling was to be used for Residents with weight range of 200 lbs to 400 lbs and height range from 6.0' to 7.0'. Resident #1 weighed 136 pounds (lbs) and had a height of 5.3'. Attached with the facility's training guide titled Safe Resident Handling (SRH) was a form titled Invacare Reliant Slings (the slings that were used for the residents) that showed under Sling Specifications that medium divided leg sling had a width of 37.5 and length of 62.8 and an extra large, full body sling had a width of 45.5 and length of 65.3 which significantly differed in size. Sling Specifications further showed that sizes of the sling were color coded as followed: Petite - Navy, Medium - Purple, Large - Green, Extra Large - Blue, Extra Extra Large - Black. The Acute Care Hospital Emergency Department Physician notes dated 9/20/19, showed that Resident #1 was admitted to an Acute Care Hospital with [DIAGNOSES REDACTED]. The notes further showed that the Resident was brought to the Emergency Department (ED) after falling from a HL. Physical examination showed that Resident #1 had a 2 cm laceration to left forehead with mild swelling and tenderness. It further showed that the Resident had a 3 millimeters (mm) laceration to left cheek and 2 cm laceration to left nostril with active bleeding from bilateral nostrils. The treatment of [REDACTED]. The Acute Care Hospital Physician History and Physical dated 9/21/19, showed that Resident #1 was admitted to an Acute Care Hospital with a [DIAGNOSES REDACTED].#1 was being transferred via HL and fell . This resulted in lacerations across the Resident's face as well as a nasal fracture. Resident #1 was brought to the emergency room where the lacerations were treated. An Assessment also showed that after the fall, Resident #1 had a nasal fracture and facial lacerations. The Plan of Care included but was not limited to: admitting the Resident for observation, an Ear Nose Throat (ENT) physician consultation for further recommendations regarding nasal fracture and physical and occupational therapy. The Computed [NAME]ography (CT) Scan, a diagnostic test, of Facial Bones and Orbit was performed on 9/20/19 at 3:06 pm at the Acute Care Hospital and showed that the Resident had Bilateral Nasal Bone Fractures. The surveyors conducted an interview with Certified Nursing Aide (the primary CNA#1 for Resident #1) and CNA #2 (assisted CNA #1) on 9/24/19 at 10:29 am, revealed that they were both present at the time of transfer of Resident #1 from bed to chair using a mechanical lift on 9/20/19. Both CNAs revealed that they used an extra large, full body sling to transfer the Resident. They further revealed that the extra large, full body sling was the type of sling they always used to transfer Resident #1 in and out of bed. They further stated that the Resident was agitated and trashing from side to side which resulted in Resident #1 falling out of the sling and onto the floor. Further interview with CNA #1 and CNA #2 on 9/24/19 at 10:29 am. The CNAs demonstrated how they provided care and how they attempted to transfer Resident #1 using a HL on 9/20/19. They stated that while providing morning care to Resident #1 on 9/20/19 at 9:45 am, the Resident was agitated, spitting and hitting. CNA #2 stated and demonstrated how the CNA gently held the Resident's hands because the Resident was beating them up with his/her fists. They further stated that this was the Resident's normal behavior during care. After they completed the morning care, they put the HL sling under the Resident and the Resident continued to be agitated. The CNAs revealed that they talked to the Resident to calm down and the Resident calmed down for a few seconds. Then the CNAs attached the sling to the HL hooks and slowly lifted the Resident using the HL. The CNAs revealed as they slowly lifted the Resident, the Resident started to yell, scream, spit, and shake his/her head side to side. They then stopped for a few minutes (unable to give the exact time) and the Resident calmed down while suspended in the air. The CNAs continued to lift the Resident via the HL until the Resident was at the edge of the of bed. However, the Resident began to scream, yell, and shook his/her head side to side. CNAs were standing facing the Resident's legs and neither one of them was standing next to the Resident to support the Resident's head because the Resident was hitting and spitting. While the CNAs were waiting for the Resident to calm down, the Resident suddenly slipped from the side of the sling and landed on the floor. The CNAs went on to state that the Resident's face hit the floor first. CNA #1 stayed with the Resident in the room and CNA #2 stepped out of the room to call for help. The surveyor conducted an interview with the Registered Nurse (RN #1) on 9/25/19 at 11:40 am, she stated that Lift Transfer assessment was done on admission, quarterly and as needed. The RN further stated that the most recent assessment revealed what type of sling (full body, or divided leg) and size (medium, large, and extra large) was appropriate for the Resident. The type and size of the sling was documented on the Resident's care plan. In addition, the staff could see the code sticker posted on the Resident's name outside the door for the type, size, and color of the sling (T= divided leg sling, TA= full body sling) appropriate for the Resident. RN #1 revealed that appropriate sling specification sticker was outside of Resident#1's door. However, during the survey on 9/24/19 and 9/25/19, the sticker with the sling specifications and Resident #1's name was already removed from the outside of the room door. Continued interview with RN #1 on 9/25/19 at 11:40 am, she stated that on 9/20/19 approximately after 9:30 a.m., she was called to check on Resident #1. She found the Resident lying on the floor. There was blood on the floor. The Resident remained awake, sustained a laceration on the left eyebrow, forehead and bridge of the nose. Emergency service 911 was called and she called the Resident's Representative and the Primary Physician. CNA #1 and #2 told her that as they were transferring the Resident using the HL, the Resident moved and fell out of the sling and it was too fast for the CNAs to prevent the fall. The RN revealed that the CNAs used the wrong size and type of the sling. The CNAs should have used the divided leg and, medium size (color purple) sling which was specified in the care plan. Instead they used the full body, extra large sling. Continued interview with CNA #1 and CNA #2 on 9/24/19 at 12:00 pm and 2:46 pm revealed that they used a blue sling to transfer Resident #1 because blue indicated that it was a medium sling. However, sling specifications showed that a blue sling was an extra large sling. They also revealed that they were familiar with CP and nurses advised them what was in each Resident's CP. They both stated that they did not remember what sling specification sticker was present outside of Resident #1's door. The surveyors attempted to conduct a telephone interview with LPN #1 on 9/25/19 and 9/26/10 (post survey), however, the LPN was not available. Attached with the facility's competency CVITL was the form titled Resident Safe Handling Program that showed that The need for equipment for transfers and repositioning a patient while in bed is communicated through the stickers on the patient name tag by the patient doorway . It further showed that letters T and TA showed what type of sling was needed. It showed that T indicated a divided leg sling and TA indicated the full body sling. Review of facility's policy titled Safe Resident Handling Program, effective 10/1/01, and revised on 5/12/16 showed that All residents/patients will be assessed upon admission, readmission, with significant change in condition, and quarterly by a licensed nurse for assistance with transfer activities, mobility, or repositioning in accordance with MDS procedures and requirements. Assessments will included the need for lift/transfer equipment . . Mechanical lift devices will be used in accordance with manufacturer's recommended capacities . The Safe Resident Handling/Transfer Equipment facility policy effective 1/1/13, and revised on 5/15/17 showed that: Staff may use Safe Resident Handling equipment, such as lifts or repositioning equipment, for patients when needed. Patients will be assessed to determine the correct equipment to use . It further showed that: .The divided leg sling is used with the total lift for the majority of patients. The full body sling is only used when the divided sling is not appropriate. Examples include: Lift from the floor; Lower extremity amputation; History of [MEDICAL CONDITION], hip surgery, or hip replacement within the last 12 months; Inability of patient to lean forward independently or with minimal assistance while sitting for sling placement; Patient preference; Contractures that prohibit divided leg slings; Patients whose legs are too heavy/large to lift; Uncontrolled [MEDICAL CONDITION] or body movement . NJAC 8:39-27 (a)

C# NJ Based on interviews and record review, as well as review of pertinent facility documents on 4/12/17, it was determined that the facility staff failed to provide the least restrictive device/intervention, as well as follow their own facility policy on Restraints: Use Of for 1 of 1 sampled residents (Resident #1) reviewed for physical restraint. On 3/20/17, while in the wheelchair, the facility staff wrapped a sheet around the front of Resident #1 and tied the sheet at the back of the Resident's wheelchair to impede the resident's movement while agitated. This deficient practice placed Resident #1, as well as all other residents that exhibit behaviors, at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 4/12/17 at 2:50 p.m., when Administration was alerted. The IJ was identified as Past Non-Compliance (PNC) for 3/20/17. The facility provided the implemented acceptable Plan of Correction (POC). This deficient practice was evidenced by the following: 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 12/6/16, showed that the Resident was moderately impaired in cognition and required extensive assist from staff in Activities of Daily Living (ADLs). According to Resident #1's Care Plan (CP), initiated on 3/16/16, Resident #1 had exhibited behaviors which included: wandering, rummaging through other residents' belongings, pulling out the Gastrostomy Tube (GT), racial slurs directed at others, and yelling. The CP interventions included: Assess and manage unmet needs such as pain, toileting, and fatigue, and provide items that can encourage self-directed activity such as cats, fire trucks, puzzles, and cars. The CP also included: During times of increased behaviors, attempt to provide decreased stimulation. The CP, initiated on 3/11/16, also indicated that the Resident had exhibited distressed mood symptoms as evidenced by Anxiety. Interventions included: Encourage activities of interest/choice, and monitor current medication regime. A review of the physician's orders [REDACTED].#1, dated 3/2017, showed [MEDICATION NAME] ([MEDICATION NAME]) 2 milligrams (mg) tablet, 1 tablet via gastrostomy tube ([DEVICE]) every 8 hours as needed for anxiety/agitation. A review of the Progress Notes (PN) documented for Resident #1 revealed the following: -3/10/17 at 3:22 a.m., written by the Licensed Practical Nurse (LPN), indicated that the Resident had frequent episodes of taking out own Gastrostomy Tube ([DEVICE]), with interventions that included: monitored frequently, abdominal binder at all times, and [MEDICATION NAME] was given at 12:00 a.m. with good effect. Slept well in bed. -3/10/17 at 10:26 p.m., written by an LPN, showed Resident alert with confusion. Resident yelling, verbally abusive, grabbing, hitting .Alarm in place .[MEDICATION NAME] 2 mg 1 tab (tablet) given via [DEVICE] with relief. -3/11/17 at 4 a.m., written by the LPN, showed Many episodes of removing [DEVICE]. Had abdominal binder and one piece jumpsuits .[MEDICATION NAME] 2 mg on frequent basis. -3/15/17 at 1:09 p.m., written by the Social Worker (SW), showed Resident exhibits behavior: Wandering, rummaging through roommates belongings, pulling [DEVICE]s, sexually inappropriate .Care Plan remains appropriate. Continue current interventions. In addition, the SW at 1:12 p.m. wrote that the Resident continued to be moderately impaired in cognition. On 3/22/17, the NJ Department of Health (NJDOH) received a Facility Reportable Event (FRE) from the facility. According to the FRE, on 3/20/17, the Administrator and the Director of Nursing (DON) were notified by the Maintenance Director (MD) that the MD observed Resident #1 sitting in the hallway across from the nursing station (NS) in a wheelchair with a sheet tied around the wheelchair, through the armrests and top spokes of the wheels, and the sheet was tied at the back of the wheelchair. The FRE further showed The assigned nurse stated the resident was very agitated and disruptively yelling and attempting to enter the residents rooms. He/she freely admitted he/she had applied the sheet to the resident to prevent him from getting to his/her [DEVICE] and slow his/her movement in order for the staff to stop the resident from entering the residents rooms on the unit .The Certified Nurse Assistants (CNAs) in their separate interviews corroborated the account of the resident's action and behaviors early this morning. All staff members indicated the resident had full mobility of his/her arms and legs . Further review of the FRE showed that the Resident #1 had a history of [REDACTED]. The FRE revealed the Resident had no awareness of the sheet placement and was observed calmly looking at a magazine. The FRE continued with: There has been no identified negative outcome or ill effect as a result of this action. The involved nurse received a re-education by the DON related to improper use of this device .will receive further disciplinary counseling, and will be monitored .for the next 60 days. The CNAs also were re-educated on following: improper placement of devices and all nursing staff re-educated on following care plans . Attached with the FRE, was a statement from the MD dated 3/21/17, showed that on 3/20/17, about 6:30 a.m., during his /her rounds, he/she noticed a sheet wrapped around Resident #1. The MD further wrote that the Resident was sitting quietly, looking at a magazine and the sheet was tied in the back of the wheelchair. Furthermore, the MD wrote I looked for some staff and could not find anyone. Attached with the FRE, was a statement from LPN #1 dated 3/20/17. LPN #1 revealed Sometimes we tie a sheet around him/her so he/she does not get to his/her [DEVICE]. Resident #1 removes the binder and he/she also tries to remove the sheet- sometimes he/she removes the [DEVICE] 2-3 times / (per) shift. I apologize and deeply sorry-before the sensor was in place in other pt's (patient's) room. I did not mean harm and it was done so he/she would not remove his/her [DEVICE]. I am sorry-I only have 2 CNAs .Sometimes only 1 CNA on unit and other very needy patients. The Resident removes the binder and jumpsuit not avail, it is all we had .The Resident was very agitated and yelling and about to enter rooms .I put sheet on and he/she was able to move chair but not enough to go down the halls .he/she was so out of control last night. A review of the statement from CNA #1 dated 3/20/17, revealed Sometimes like that Saturday night we have to go to (name of other unit) to help. Sometimes (name of another resident) also is a problem. The sheet was on him/her from about 4:30 a.m. to 6:00 a.m. or so. A review of the statement from CNA #2 dated 3/20/17, showed He/she had sheet around him/her- LPN #1 put the sheet on him/her- he/she can still move the chair.- Sheet on about 4:30 a.m.- sheet removed 6:30 a.m. when I changed him/her. The Resident goes to pt (patient) rooms .takes everything and throws on floor. In an interview with the MD, on 4/12/17 at 10:50 a.m., the MD indicated that he/she would often stop by on the unit to talk to Resident #1 during rounds because he/she had known the Resident for a long time and they both grew up in the same town. The MD revealed that on 3/20/17 at 6:30 a.m., he/she noticed a sheet wrapped around the Resident and the sheet was tied at the back of the wheelchair. The MD went on to state that was the first time he/she saw a sheet tied around the Resident. The MD further stated that the Resident was awake, with a magazine in his/her hand. Furthermore, MD stated that the Resident was quiet and not in danger. The surveyor asked the MD if he/she told the nurse about the sheet wrapped around the Resident. The MD revealed I looked for a nurse, I didn't see the nurse and I went around, continued with my rounds. I told the Administrator about 9:30 a.m. The surveyor asked why he/she did not mention his/her findings sooner than 9:30 a.m. The MD stated 'There was no nurse or CNA around the unit that I can find. The MD further added that he/she remembered the Administrator had talked about Restraints and the MD thought that he/she should inform the Administration about what he/she saw involving Resident #1. In an interview with the Director of Nursing (DON) on 4/12/17 at 10:50 a.m., the DON stated that he/she was told about Resident #1 and the sheet tied at the back of the wheelchair on 3/20/17 at 9:30 a.m. The DON stated that the sheet was tied loosely to prevent the Resident from going around residents' rooms and not to knock down the residents' stuff and wake them up. The DON stated This is to impede the Resident's movement. The DON explained that they thought the Resident was with the sheet tied around him/her for 1 and 1/2 hours and that it was removed after 6:30 a.m., for morning care and then the Resident was put on 1 to 1 monitoring. The DON stated that the nurse was crying and was upset. The DON stated that the nurse thought that he/she was impeding the Resident's movement, but did not think it was a restraint. The surveyor then asked the DON if the sheet placed around the resident and tied at the back of the chair/wheelchair was a restraint or not a restraint. The DON stated We should never impede anyone's movement. The DON also stated that he/she reported it to the DOH, even though, it wasn't a restraint. The DON presented to the surveyor that the following were in place when he/she found out about the incident involving Resident #1: The Resident was assessed for any injury - no injury noted, staff were interviewed and re-educated about the improper use of the device, on the job performance monitoring for 60 days, facility wide inservice about Reporting and no type of device used that impedes resident's movement. The DON also stated that the Resident's CP was updated, and that he/she was placed on constant monitoring or 1 to 1 monitoring if needed. In an interview with CNA #1 on 4/12/17 at 11:08 a.m., the CNA stated that on 3/20/17, there were 2 CNAs (including CNA #1) who worked on the unit. CNA #1 also stated that there were 2 residents (including Resident #1) who were agitated. CNA #1 also stated that When we were about to do the rounds, the nurse idea was to put the sheet around the Resident and tie at the back of the wheelchair, he/she won't be able to go to the patient rooms to wake them up. The surveyor asked if the nurse supervisor was notified, and CNA #1 stated Supervisor wasn't there. CNA #1 went on to explain that the sheet was tied from maybe around 4:30 a.m. to 6:00 a.m. and that we took it off after 6:30 a.m., that nurse (LPN #1) took it off. The CNA also stated that was the first time it happened, it's not really restraint, it's wrong because we know we are not supposed to do it. The surveyor asked if they knew it was wrong why was it done, and the CNA replied The nurse knows better than I, she knows better. On 4/12/17, LPN #1 and CNA #2 were not available for interview. According to the Physician's Progress Notes (PPN), dated 3/22/17, Resident #1 had a tendency to enter other residents' rooms at night and wake them up. The PPN indicated that the resident Requires close observation. A review of the Psychiatric Consultation/Evaluation Form, dated 4/2/17, indicated that Resident #1's memory was impaired. The surveyor reviewed the Nurse's PN for Resident #1, dated from 3/10/17 to 4/12/17, there was no documentation on 3/20/17, from LPN #1, to indicate that Resident #1 was agitated, going from room to room, and/or regarding the aforementioned incident. A review of Resident #1's Behavior Monitoring and Interventions, dated 3/2017, did not show documentation on 3/20/17, that the Resident had pulled at the [DEVICE], was combative, and/or exhibited signs of aggression. In addition, the Medication Administration Record [REDACTED]. A review of the physician's orders [REDACTED].#1's Physician was made aware of the use of the physical restraint, nor were there any physician's orders [REDACTED]. A review of the facility's Policy titled, Restraint: Use Of, effective date 9/15/01, and revised date 11/28/16, revealed under Policy: Patients have the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms. When the use of restraints is indicated, the Center must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. On 4/12/17 at 2:50 p.m., the Administration was notified that an Immediate Jeopardy (IJ) Past Non-Compliance (PNC) occurred for Resident #1 which began on 3/20/17, when the staff applied a physical restraint in the form of a sheet that was wrapped around the Resident and tied behind the Resident's wheelchair to prevent the Resident from getting to his/her [DEVICE] and to impede the Resident's movement from going to other residents' rooms. The facility staff did not attempt any other interventions or use the least restrictive alternatives to protect the Resident and other residents' safety. The Immediate Jeopardy (IJ) PNC for 3/20/17, began at 4:30 a.m. on 3/20/17, when the sheet was applied to Resident #1, and was corrected when the facility provided an implemented and acceptable Plan of Correction (POC) that included staff education on Restraint dated 3/20/17. The acceptable POC was documented as follows: 1. Resident #1 was affected by the deficient practice. The sheet was removed from around the resident at around 6:30-6:45 a.m. when the CNAs were bringing Resident #1 to his/her room for changes. After his incontinence care, he was placed on 1:1 until he was calm and then frequent monitoring which they normally do until he has behaviors and then 1:1. They also try to divert his attention and he likes looking at magazines. 2. Any resident with a physical restraint has the potential to be affected. Any resident with behaviors' should be placed on 1:1 and given diversional activities or what the resident likes that has a calming activity. 3. All staff were interviewed and statements signed. The nursing staff were re-educated regarding the use of restraints. All staff were re-educated on observational reporting regarding the use of restraints. (i.e. physical). The nursing staff were re-educated concerning behaviors residents may be having and how to deal with them. Immediately place resident on 1:1 to protect self and others. Call the physician for orders to transfer patient to the Crisis unit if a danger to self or others. Staff involved in the incident were re-educated, given written Performance Improvement Plans that will be re-evaluated every 2 weeks for 60 days. Social Service meets with the resident regularly as he was to be transferred that week to a group home environment. 4. Supervisors/DON/Assistant Directors of Nursing (ADONs)/Unit Directors of Nursing (UDONs) will round to ensure compliance on an ongoing basis. This is NOT something that is done here and staff are to call the Supervisor or DON if they have an issue they are not sure of. 1:1 has always been our protocol for impulsive, objectionable behaviors. 5. Compliance date: March 20, 2017 NJAC 8:39-4.1(a)6

Based on observation and interview it was determined that the facility's Administrator (LNHA) failed to assure that the facility's staff were cooking in areas that were protected by the appropriate hood and fire extinguishing methods to protect all residents, visitors and families from the potential of fire. The deficient practice was evidenced by the following: On 2/9/16 at 9:15 a.m., the surveyor, accompanied by the Administrator, Dining Services Manager and Maintenance Director observed that the facility was utilizing the bistro area of the Jefferson library for the cooking of breakfast foods such as bacon, eggs and sausage. At that time, the Maintenance Director confirmed that there were no protective hoods above the area that the Chef had been cooking or fire extinguishers appropriate to extinguish a grease fire. Refer to F 323 On 2/11/16 at approximately 11:30 a.m., the Administrator stated that she was aware that the facility had been preparing breakfast foods including bacon in the Jefferson library. A review of the Administrator's Job Description included the following responsibilities: #8 Superintends physical operations of the Center and #12 Concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents. Also ensures that the Center adheres to the legal, safety, health, fire and sanitation codes by being familiar with his/her role in carrying out the Center's fire, safety and disaster plans. NJAC 8:39-9.2(a)

Based on observation and interview it was determined that the facility failed to ensure residents were protected from the possibility of fire by cooking food items which included bacon and sausage, in an area that did not have a protective hood or fire extinguisher in the room. This deficient practice was identified in 1 of 6 dayrooms and occurred over a period of time of approximately eight months. This resulted in an immediate jeopardy situation which posed a serious and immediate threat to the safety of all residents, staff and visitors. The facility was notified of the immediate jeopardy on 2/9/16 at 9:15 a.m., and an acceptable plan of correction was received and accepted on 2/9/16 at 10:40 a.m. On 2/9/16 at 8:30 a.m., the surveyor observed the Chef in the bistro area of the Jefferson library preparing breakfast for residents on the Jefferson short stay unit. There were two alert residents eating breakfast in this area. The Chef was cooking eggs in a pan which was heated by an electric burner on top of the counter. On that same counter was an electric griddle that had visible grease drippings on the surface. Next to the griddle were two spots of grease that had spilled onto the counter top. The Chef stated that he made breakfast in this area, which included eggs, sausage, bacon and pancakes every morning during the week for the residents on the Jefferson unit and had been doing this for a while. The surveyor observed approximately 12 slices of bacon and four links of sausage, draining on an egg carton, on a table behind the counter. The electric griddle and electric burner were not under a protective cooking hood with ventilation or a fire suppression chemical system. Additionally, there were no fire extinguishers in the room. This day room was also utilized as an activity area and contained six bookshelves which had books and other combustible paper products in near proximity to the cooking area. At 9:15 a.m., the surveyor returned to the bistro area of the Jefferson unit accompanied by the Administrator, Dining Services Director and the Maintenance Director. The surveyor alerted them of the immediate concern for cooking breakfast items which included bacon and sausage without a protective hood with ventilation and no means of extinguishing a fire should one erupt. The Dining Services Director stated that they have been cooking breakfast in the Jefferson unit bistro area, which included bacon and sausage, for approximately eight months. The Administrator stated that they would remove the griddle and the burner and not cook foods in this area. At that time, the surveyor asked the Maintenance Director if the fire extinguisher, located in the hallway approximately 30 feet away, was appropriate to extinguish a grease fire. He stated, No, and that he would obtain a K type fire extinguisher and mount it on the wall. He added that this area was utilized for serving food to the residents from a steam table. On 2/9/16 at 10:40 a.m., the Administrator provided an acceptable plan of correction which consisted of the following: 1. The electric griddle and the induction burner has been removed. A K extinguisher will be installed in the bistro area of the Jefferson library. The bistro area of the Jefferson library will not be used for active cooking. 2. All residents have the potential to be affected by this deficient practice. 3. The Chef Manager and the dietary staff have been re-educated to ensure that no cooking related food products are prepared in this area. The Dining Services Director/designee and Maintenance Director/designee will monitor the Point of Service Dining program in Jefferson hall to ensure proper use of all equipment. An audit will be conducted weekly for 60 days or until sustained compliance is evident. 4. The reports will be reviewed by the Maintenance Director or his designee at the scheduled quarterly QI (Quality Improvement) Committee Meeting and Safety meeting until compliance is determined to be sustained. On 2/10/16 at 9 a.m., the surveyor observed that the Chef was not cooking breakfast in the bistro area on the Jefferson unit and a K type fire extinguisher had been mounted to the wall behind the steam table. On 2/11/16 at 9:40 a.m., the Maintenance Director told the Life Safety Code Surveyor, during a tour of the facility, that the facility had been preparing bacon and breakfast foods in the Jefferson bistro area for approximately eight months. On 2/11/16 at approximately 11 a.m., the Dining Services Director stated that the facility did not have a formal policy on the preparation of breakfast foods in areas other then in the kitchen. He stated that they had begun preparing breakfast in the bistro area of the Jefferson library for about eight months. He said that this occurred only Monday through Friday when the Chef was working. Refer to F 490 NJAC 8:39-31.7(d)