Every finding on record at Crest Pointe Rehabilitation and Healthcare Center

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner and b) maintain proper temperatures and logs for 2 of 2 freezer units on the nursing units. This deficient practice was evidenced by the following:On 9/14/25 at 10:28 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following:1. The can-opener blade had a metal chip on the left side. The FSD acknowledged it had not been changed. The FSD was unable to produce a maintenance log to indicate when the blade should be replaced.2. The microwave had multicolored food debris on the interior ceiling. The FSD acknowledged the debris and agreed that it was not cleaned according to facility policy. 3. One of two convention ovens (upper unit), had baked on food debris on two of the glass doors and also on the interior surfaces. The FSD did not have a cleaning schedule and acknowledged and agreed that it was not cleaned according to the facility policy. 4. One of three coffee dispenser nozzles, had white hard build up on the outside of the dispenser. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 5. The juice dispenser storage holder had dried, caked on red congealed (to change from a liquid to a solid state) substance that remained when the liquid was dumped. The FSD could not state what the sediment was. She acknowledged that it was not cleaned according to facility policy. 6. Freezer logs on 2 of 2 units were not available. The FSD stated, her department oversaw the refrigerator freezer combo on the units, and she did not have logs for the freezer temperatures. She acknowledged that there should have been temperature logs to ensure the freezer was holding temperature and that it was safe for residents to use and store food. On 9/16/25 at 10:00 AM, the surveyor interviewed the FSD, who stated, the can-opener blade should be changed regularly to ensure safety for the residents and that no metal fragments were in the food. She further stated that the cleaning of equipment should be done on a schedule to prevent food borne illness and maintain a safe and sanitary environment for the staff. The FSD acknowledged the surveyors concerns and agreed they were not done according to facility policy.On 9/16/2025 at 10:12 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged the surveyor's concerns. He stated, the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury. This ensures the safety of our residents and staff.A review of the facility's policy, Maintenance of Kitchen Equipment dated September 2021, major kitchen equipment will be maintained in good working condition by ensuring regularly scheduled and as needed service.conduct routine cleaning of kitchen equipment on a regular basis by the food service staff. A review of the facility's policy, Sanitation, dated November 2022, the food service area shall be maintained in a clean and sanitary manner. A review of the Refrigerator and Freezers dated November 2022, monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.monthly tracking sheets include time, temperature, temperature of PHF(potentially hazardous foods)/TCS (time/temperature control for food safety) food, initials, and action taken . record refrigerator and freezer temperatures daily with first opening and closing in the evening. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to; a) maintain and clean the interior of 1 of 2, (Bayside), nursing unit ice machines, and b) ensure that clean linen was stored in a manner to prevent contamination, assist in the prevention of infection(s), and be free of dirt, dust and debris as evidenced by the following: On 9/15/2025 at 11:25 AM, the surveyor toured the Bayside unit ice machine with the Licensed Practical Nurse/ Unit Manager (LPN/UM #1). The surveyor observed the ice machine was not clean on the interior of the ice dispenser shoot. The surveyor noted a white sediment and black discoloration on the interior of the ice dispenser shoot. During the tour the LPN/UM #1 stated that it was not cleaned according to facility policy. On 9/15/2025 at 11:50 AM, the surveyor toured the laundry room with the Director of Housekeeping (DoH) and the Regional Housekeeping Director (RDoH). The surveyor observed the personal laundry room, which had dust and cobwebs on the pipes, air conditioner vents, window and ceiling fan. Clean personal clothing was not covered in the bins or on the racks that were waiting to be distributed back to the residents. On 9/15/2025 at 11:55 AM, the surveyor observed in the soil linen room, which had dust, cobwebs and lint on the pipe surfaces above the washers and on the curtain track that separated the soiled linen room from the dryers and clean linen room. The white debris on the curtain track was wipeable by the surveyor and DoH. On 9/15/2025 at 11:55 AM, the surveyor observed in the clean linen room, which had dust, cobwebs and lint on the pipe surfaces above the dryers, on the vent above the dryers that was blowing outward, the corner of the room near the window, and on the bulletin board above the clean linen folding table. On 9/15/25 at 12:00 PM, the surveyor interviewed the DoH and RDoH, who acknowledged and agreed that the dust and cobwebs should not be there, and that the laundry area should be maintained to promote a clean and sanitary environment for the resident's belongings and linens. On 9/15/2025 1:02 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, they acknowledged and agreed about the surveyor's concerns. The ice machine should be cleaned and maintained according to the facility policy and the manufacture guidelines to prevent cross-contamination and illness. He further stated, the laundry room should be cleaned and maintained according to facility policy. It should be free of dust, dirt and debris that could cross contaminate on the clean linens and personal laundry. Any clean linen or personal laundry should be covered for sanitation purposes. On 9/17/25 at 11:57 AM, the surveyor interviewed the National Director of Housekeeping and Grounds, who stated that the laundry area should be free of dust, dirt and debris for the safety of the residents and employees. It needs to be clean to prevent cross contamination and prevent infection. On 9/18/25 at 10:30 AM, the survey team met with the Regional Director of Operations (RDO) and the Director of Nursing (DON) who acknowledged and agreed with the surveyor's concerns. There was no more information provided. A review of the Housekeeping and Laundry Service Agreement, dated 3/14/19 for scope of work. the contracted will provide housekeeping and laundry management, supervision, labor and materials as the contracted determines necessary, in its discretion. A review of the Amendment to Housekeeping and Laundry Service Agreement, dated 4/1/24, revealed.effective 4/1/24, the client is responsible for providing, maintaining, repairing and replacing at its sole cost all the housekeeping equipment located at the facility which shall be utilized by the contracted. A review of the Nugget Ice Machine, manufacture guidelines, dated 1/7/22, provided by the LNHA, for the Bayside unit ice machine, revealed; descaler and sanitizer are available through the manufacturer. These are the only descaler and sanitizer approved for use with [name redacted] product number 000015202 products.Ice machine descaler is used to remove lime scale or other mineral deposits, it is not used to remove algae or slime.ice machine sanitizer is used to remove algae or slime.refer to component disassembly for descaling and sanitizing. A review of the facility-provided policy titled Homelike Environment, dated revised February 2021, revealed. the characteristics of the facility that reflect a personalized, homelike environment setting. These characteristics are.clean, sanitary and orderly environment. A review of the facility policy titled Departmental (Environmental Services) --Laundry and Linen, dated January 2014, revealed . the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause humans illness) through measures designed to protect it from environmental contamination, such as covering clean linen .N.J.A.C. 8:39 - 19.4 (a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to obtain a physician's order for the use of a hand roll (a device used to maintain a resident's hand in a functional position). This deficient practice was identified for 1 of 1 resident (Resident #8) reviewed for positioning and mobility and was evidenced by the following:1.) On 9/14/2025 at 10:11 AM, the surveyor observed Resident #8 resting in bed with their eyes open and holding a hand roll in their left hand. On 9/16/2025 at 8:27 AM, the surveyor reviewed the medical record for Resident #8.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: muscle wasting and atrophy (the loss of muscle mass that results in decreased strength and impaired movement), hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (weakness on one side of the body such as the arm, leg, or face) following cerebral infarction (blockage in the brain that causes loss of oxygen) affecting left side. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/28/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 7/17/2025, that the resident was at risk for falls related to deconditioning/weakness and gait balance problems. Interventions included: the resident was to wear a left-hand roll when out of bed during daytime hours. A review of the Order Listing Report (OLR), dated as of 7/17/2025 did not include a physician's order for a hand roll. A review of the Occupational Therapy (OT) Treatment Encounter Note, dated, 5/6/2025 reflected, hand roll placed in left (L) hand to reduce risk of contractures (a progressive disorder that causes the fingers to curl inward due to the tightening of tissue in the palm). A review of the OT Discharge Summary, for dates of service 5/4/2025 to 5/27/2025, included that the resident was discharged from OT on 5/27/2025 and that the resident should wear a hand roll on the left hand for up to six hours with minimal signs and symptoms of redness, swelling, discomfort, or pain. On 9/17/2025 at 10:15 AM, during a follow-up visit, the surveyor observed the resident was again resting in bed with a hand roll in their left hand. On 9/17/2025 at 10:29 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated, Resident #8 had been using the hand roll for approximately four (4) to six (6) weeks. He further stated that the use of a hand roll required a physician's order (PO). At that time, LPN #1 reviewed the resident's electronic medical record (EMR) and confirmed that Resident #8 did not have a PO for the hand roll. On 9/17/2025 at 10:48 AM, the surveyor interviewed the Director of Rehabilitation (DoR), who stated that the resident had the hand roll since he/she was admitted to the facility and that they were supposed to wear it while in bed. On 9/17/2025 at 10:59 AM, the surveyor interviewed the Medical Director (MD), who stated that the rehabilitation (rehab) department evaluated the resident, made recommendations, and then the provider followed those recommendations. He further noted that the hand roll required a physician's order. On 9/17/2025 at 11:19 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1, who stated that a PO was needed for a hand roll. She further stated that the Occupational Therapist would obtain an order for the hand roll, document the order in the EMR, then the nurse would confirm the PO. LPN/UM #1 stated the order would then populate on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for the nurse to sign off that the hand roll was applied. On 9/18/2025 at 9:13 AM, the surveyor conducted a follow-up interview with the DoR, who stated that the Occupational Therapist or the DoR would enter the PO in the EMR. She further noted that the hours during which a resident should wear the hand roll varied for each resident. The DoR added that it was Resident #8's preference to wear the hand roll, however, a PO was still required. A review of the facility's Range of Motion (ROM) Devices policy dated March 2022, included, The licensed nurse will document in the medical record the type, duration, and frequency that the device is donned (applied) and doffed (removed). NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 Nursing units, (Oceanside) observed and reviewed for environmental concerns. This deficient practice was evidenced by the following: On 9/16/24 at 10:24 AM, the surveyor toured the oceanside unit with the Food Service Director (FSD), and observed the following concerns: 1) Resident room [ROOM NUMBER] and the hair salon windows had visible litter throughout a grassy area that had bushes. In the bush line and grass area there was an abundance of litter stuck in branches, under the bushes and on the grass. The surveyor observed water bottles, sports drink bottles, wrapping plastic, medical gloves, bubble wrap, soda cans, straws and paper litter. The FSD acknowledged the surveyor's observation and stated, the grounds of the facility should be maintained as well as the inside of the facility because this is the residents home. On 9/17/25 at 10:34 AM, the surveyor interviewed the Infection Preventionist (IP), who stated, litter should be cleaned by housekeeping for the entire grounds. It is not appropriate to have a resident look at litter from their room because this is their home. On 09/17/2025 at 11:57 AM, the surveyor interviewed the National Director of Housekeeping and Grounds (NDOH&G), who stated, the grounds should be maintained daily to prevent litter buildup, prevent pests and rodent's and maintain a homelike environment for the residents. On 09/18/2025 at 10:37 AM, the surveyor interviewed the Regional Director of Operations (RDO) and the Director of Nursing (DON), they both acknowledged and agreed that the litter should not be there, and that the grounds need to be maintained to promote a homelike environment for the residents. A review of the Homelike Environment policy, dated February 2021, revealed.Policy statement: Residents are provided with a safe, clean, comfortable, and homelike environment. Encouraged to use their personal belongings to the extent possible.Policy Interpretation and implementation: #2) The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a) clean, sanitary, and orderly environment. NJAC 8:39-4.1(a)11; 27.2(j); 31.2(e)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was accurately set according to the resident's weight and functioning properly in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity.This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for pressure ulcers and was evidenced by the following:On 9/14/25 at 9:53 AM, the surveyor observed Resident #6 lying in bed awake. The resident's air mattress pump was observed to be set at a weight of 180 pounds.On 9/14/25 at 11:26 AM, the surveyor observed Resident #6 lying in bed awake. The air mattress pump was set at 180 pounds. The resident stated that he/she believed they had a pressure ulcer, but they thought that it had since healed.On 9/15/25 at 9:57 AM, the surveyor observed Resident #6 lying in bed with their eyes closed and the air mattress was enveloping (closing in on) their sides. The air mattress pump dial was set to a weight of 150 pounds, but no lights were illuminated on the pump; and it appeared to be off. At that time the surveyor exited the room and found Licensed Practical Nurse (LPN) #1 at the nurse's station. The surveyor requested that LPN #1 accompany them and check to ensure Resident #6's pressure relieving mattress was functioning properly. LPN #1 entered Resident #6's room and confirmed that no lights were displayed on the pump; LPN #1 then pushed down on the mattress and stated that there was no air in the mattress because the pump was off. LPN #1 followed the power cord and noted it had become unplugged. LPN #1 stayed with Resident #6 as the mattress reinflated and ensured that it was set at the correct weight.On 9/17/25 at 10:30 AM, the surveyor observed that air mattress weight dial on Resident #6's air mattress was set to 250 pounds. The resident was not in bed at that time.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Muscle weakness, generalized, cognitive communication deficit (a problem with thinking, not speech), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left (non-dominant) side, type 2 diabetes mellitus, and muscle wasting and atrophy, not elsewhere classified, at multiple sites. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 8/10/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed that the resident was at risk to develop a pressure ulcer/injury, and at that time had one Stage 2 (two) pressure ulcer (partial thickness loss of dermis) present. Further review of the MDS indicated that the Skin and Ulcer/Injury Treatments included a pressure reducing device for the bed, and pressure ulcer/injury care. The resident's weight was noted to be 100 pounds.A review of the resident's Weight Summary revealed the last date a weight was entered into the resident's medical record was on 7/16/2025 at 10:54 AM and noted to be 99.7 pounds.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/22/25, that the resident had impaired skin integrity related to fragile skin, decreased mobility and incontinence. Interventions included a pressure reducing cushion when in chair and a pressure reducing mattress to bed at all times along with treatments and assessments.A review of the Order Summary Report (OSR), included the following physician orders (PO):A PO, dated 8/4/25, for Moisture Barrier Cream, apply to sacrum every shift for prevention.A PO, dated 8/22/25, for Triple Paste External (Zinc Oxide), apply to sacrum topically every day and evening shift for monitor [sic.].A PO, dated 9/15/25, for Air Mattress on bed, check inflation set by weight and function every shift for prevention. On 9/15/25 at 10:16 AM, the surveyor interviewed LPN #1 after the observation made at 9:57 AM regarding Resident #6's deflated mattress. LPN #1 stated that air mattresses work to offload pressure on wounds and pressure sores or to prevent them for at-risk residents. When asked about the importance of assessing whether a mattress worked properly and maintained the correct, ordered air pressure; LPN #1 replied that both were important for wound management and to maintain the skin integrity of the resident.On 9/16/25 at 12:46 PM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing was responsible to check the air mattress pumps for function and they should be set according to the resident's weight. The DON then stated that it was the nurse's and aide's responsibility to check proper function at least every shift. The DON stated that maintaining the correct pressure was important for proper offloading, not too firm or soft; that the mattresses are to be set by resident weight to prevent skin breakdown or further skin breakdown. She went on to say that if a resident is found on a deflated mattress; she would expect staff to first make sure it was functioning properly, plugged in, and either assess the resident if pressure was restored immediately or remove the resident from the bed and assess them if the mattress was compromised. After ensuring resident safety, the DON stated she would expect staff to let management, and the physician know about the mattress failure and whether the pressure was restored or not.On 9/17/25 at 12:34 PM, in the presence of the DON and survey team the Licensed Nursing Home Administrator (LNHA) was made aware of the surveyor's concerns related to the resident's low air loss mattress.On 9/18/25 at 9:33 AM, the DON, in the presence of the Regional Director of Operations and the survey team, stated that air mattress function should be checked at least every shift. A review of the manufacturers operator's manual for the air mattress and pump provided to the surveyor by the facility (REV4.03.15.16) revealed:.Turning the POWER switch to ON/OFF will start/stop the control unit. The switch lights up when the power is ON, and extinguishes when the power is OFF.The pressure of the mattress can be adjusted by choosing the patients' corresponding weight setting.use the weight setting to select the desired level. A review of the facility's Support Surface Guidelines policy, revised September 2013, included: Redistribution support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction.Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static air, alternating air, or air-loss when lying in bed.A review of the facility's Prevention of Pressure Injuries policy, revised April 2020, included:Select appropriate support surfaces based on resident's risk factors, in accordance with current clinical practice.NJAC 8:39-27.1(a)

Complaint #: NJ177985 Based on observations, interviews, and review of other pertinent facility documentation on 03/28/2025, it was determined that the facility failed to maintain a clean and homelike environment in the common shower rooms, follow their Certified Nursing Assistant job description, follow their Light Housekeeper job description, and follow their cleaning and disinfecting policy. This deficient practice was identified for 2 of 2 units (Oceanside Unit and Bayside Unit), had the potential to affect all residents who used the common shower rooms, and was evidenced by the following: On 03/28/2025 at 11:10 A.M., the surveyor interviewed Resident #3. During this interview the resident stated that the cleanliness of the facility's shower rooms was bad. The resident stated, the shower rooms are bad. Four out of ten for cleanliness. Resident #3 further stated that it was reported to staff that the rooms were not clean, but housekeeping was low on staff and didn't have time to clean them. During a tour of the facility on 03/28/2025 at 11:40 A.M., accompanied by the Housekeeping and Laundry Director (HLD), the surveyor observed the following: 1. In the Oceanside Unit common shower room, a small, open trash bin was full and on the floor nearby was a large adhesive bandage that had grey staining on the absorbent pad. In the same area of the common shower room floor were disposable medical gloves which had been folded over one another into a ball. The presence of the full trash bin and items on the floor was confirmed by the HLD. In the Oceanside Unit common shower room second shower stall on the left there was a towel bunched behind the handrail. The HLD confirmed that the towel was wet. 2. In the Bayside Unit common shower room, a pair of black sweat socks that appeared to have been worn was observed on the floor near the entry door. In the same area of the floor was a small pile of towels and wash cloths that appeared to have been used. The presence of these items on the floor was confirmed by the HLD. On 03/28/2025 at 11:55 A.M., the surveyor interviewed the HLD. During this interview, the HLD stated that shower rooms were cleaned and mopped in the morning and scrubbed with a push scrubber in the afternoons. The HLD stated that at night there was a [NAME] who would clean as needed. On 03/28/2025 at 12:19 P.M., the surveyor interviewed the Housekeeper (HK). During this interview, the HK stated that it was her routine to sweep and mop the shower room floors on her assigned unit between 6:30 A.M. and 7:00 A.M. The HK stated that before sweeping and mopping the shower rooms it was her routine to pick up any items on the floor of the shower rooms. On 03/28/2025 at 1:37 P.M., the surveyor interviewed the Certified Nursing Assistant (CNA). The CNA stated that it was the routine to put all dirty linen in the linen bin after showering residents. The CNA stated that used linen should not be hung over the handrails in the shower rooms and that nothing dirty should have been left in the shower rooms. On 03/28/2025 at 1:57 P.M., the surveyor interviewed Unit Manager (UM) #1. UM #1 stated that it was the expectation that CNA staff cleaned up any mess including linen and clothing immediately after they showered residents. The UM further stated that any trash that did not make it into the trash can should have been picked up and thrown away by the person who dropped it. On 03/28/2025 at 4:40 P.M., the surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that it was the expectation that shower rooms were clean and in working fashion. The LNHA stated that CNAs were responsible to remove care items to their proper place. The LNHA stated that HKs, UMs, and CNAs were responsible for making sure that shower rooms were kept clean. The LNHA further stated that shower rooms should have been cleaned between residents for infection control purposes. A review of the undated facility job description titled Certified Nursing Assistant/Geriatric Nursing Assistant was conducted. The job description document under Duties and Responsibilities and Safety and Sanitation (continued), revealed Keep resident's personal possessions off the floor and properly stored per OSHA standards. This section of the facility job description revealed Perform routine housekeeping duties (i.e., clean bedrails, overbed table, nightstand, etc, that relate to nursing procedures.) This section of the job description document further revealed Follow established procedures in the use and disposal of personal protective equipment. A review of the HEALTHCARE SERVICES GROUP, INC. (company that provides housekeeping services in the facility) job description titled Light Housekeeper, was conducted. The job description document under SECTION 2: POSITION SUMMARY. on page 1 of 7, revealed The light housekeeper is responsible for satisfactory and timely completion of assigned cleaning area according to schedule. [ .] Cleans and sanitizes bathrooms including sinks, tubs, floors and commodes. Under SECTION 2A: ESSENTIAL FUNCTIONS OF THE JOB, continued. and JOB FUNCTION, on page 2 of 7 the policy revealed All remaining jobs [ .] Cleans common area restrooms as assigned. A review of the facility policy titled Cleaning and Disinfection of Environmental Surfaces, with a revision date of August 2019, revealed, 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. NJAC 8:39-31.4 (a) (f)

Complaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow their abuse policies and procedures by ensuring residents were free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse, Resident #60 and #79, and was evidenced by the following: 1. Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments towards Resident #79 which included CNA #1 stating, bend over; you will like it, and that the resident's messy hair made the resident look sexy. This was witnessed by the nursing aide (NA) and Rehabilitation Director (Rehab Director). Resident #79 reported that the comments by CNA #1 made them feel uncomfortable. The SW handled the incident as a grievance, which was reported as Resident #79 having a poor service interaction with CNA #1 and was not investigated as an abuse allegation. This situation resulted in the resident, who had PTSD from a history of sexual abuse, to have increased anxiety with their PTSD exacerbated post incident with CNA #1. 2. A second resident, Resident #60, who had diagnoses which included depression, anxiety, ankylosing spondylitis (an autoimmune disease), had a verbal altercation with Unit Manager/Licensed Practical Nurse (UM/LPN) on 5/23/24, when the UM/LPN scolded and yelled at Resident #60 for requesting assistance with activities of daily living (ADLs) from staff which caused the resident to become afraid and fearful of the nurse which resulted in increased anxiety of who was going to help the resident. The incident was reported to the Business Office Manager (BOM) who immediately reported the incident to the Licensed Nursing Home Administrator (LNHA). The investigation was not started until 6/6/24, 2 weeks after the incident. The facility's failure to ensure all residents were free from abuse, by not investigating the witnessed actions of CNA #1, and the actions of the UM/LPN posed a likelihood of serious harm to Residents #60 and #79. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/16/24 after CNA #1 verbally sexually abused Resident #79 and continued to work twelve additional shifts. A second IJ began on 5/23/24 when the UM/LPN verbally abused Resident #60. The facility Administration was notified of the first IJ on 6/5/24 at 2:27 PM and the second IJ on 6/7/24 at 12:40 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/6/24 and 6/10/24. The evidence was as follows: A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse [ .] is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated . A review of the facility's undated Abuse Prevention Program policy included the administration would implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator had been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer would begin an investigation into the allegation .the investigation and report would include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer would coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse [ ] would be reported and investigated under guidelines for reporting abuse . 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that CNA #1, a male aide, had made sexual comments towards Resident #79. Resident #79 stated that they had refused to have male aides. The resident stated CNA #1 told the resident to bend over, the resident replied, no thank you and CNA #1 stated you will like it. The resident stated that on another the day CNA #1 stated, Don't take this the wrong way but your hair looks sexy that way. The resident stated that an NA and Rehab Director were both present and the comments, as well as CNA #1, made the resident feel uncomfortable. The resident stated that they had complained to administration regarding the comments made by CNA #1, however the LNHA, Director of Nursing (DON), and/or Assistant Director of Nursing (ADON) did not address the incident. The surveyor reviewed the medical record for Resident #79. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included PTSD and major depressive disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/29/24, the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated that the resident's cognition was intact. A review Resident #79's individualized comprehensive care plan (ICCP) included a focus area dated and initiated on 11/26/22, revealed that the resident had a history of PTSD with interventions that included to avoid situations that may cause flashbacks, to ask the resident about triggers and incorporate them into the resident's plan of care, consult psychiatry/psychology as needed, and that the resident preferred female aides when possible. A review of the Psychologist Only Initial evaluation dated 11/29/22, included an Emotional Summary that the resident had a history of PTSD symptoms after being sexually assaulted while a patient in a hospital. The resident had flashbacks, nightmares, high startle response, hypervigilance, intrusive thoughts, and mistrust. The resident was aware of their triggers, and the resident's mood was anxious and depressed. A review of a grievance dated 5/16/24 and resolved on 5/17/24, completed by the SW, indicated that Resident #79 reported the resident had a poor service interaction with Aid on the unit. The summary of the grievance included that the SW completed a follow-up which revealed that Resident #79 used profanity towards CNA #1 as they were joking and CNA #1 walked away. The SW asked Resident #79 if the resident would prefer not to have interaction with CNA #1, and the resident was satisfied. The Unit Manager was made aware, CNA #1 was not assigned to the resident and would have no contact. Further review of the grievance did not include statements from the resident, witnesses, CNA #1, any residents CNA #1 may have come in contact, or education. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who stated there was an incident between Resident #79 and CNA #1 about a month ago where she had gotten the resident ready for physical therapy and they were waiting in the dining room with CNA #1. The NA stated that CNA #1 and herself were joking with the resident, and she was unsure who initiated the interaction, but the resident stated to CNA #1 bite me and CNA #1 stated bend over and the NA left because the Rehab Director came in. The NA reported that the Rehab Director told her that after that interaction, the resident used profanity in a non-joking way, and CNA #1 stated are you sure about that and the resident responded ew. The NA stated she did not report the incident at first because she thought everyone was joking, but when the resident reported to her that it made [Resident #79] feel a certain way, she asked if they wanted to speak to the SW to report it, and the resident stated yes. The NA stated, now they are just investigating it. On 6/5/24 at 9:00 AM, the surveyor asked the DON if CNA #1 was working that day, and the DON stated CNA #1 was suspended pending investigation for an allegation of abuse from a resident as of 6/3/24 (first day of survey). On 6/5/24 at 9:08 AM, the surveyor interviewed the Rehab Director who stated about a month ago, the resident was waiting for therapy in the dining room with the NA and CNA #1. The Rehab Director informed the resident therapy was ready, and in a joking way CNA #1 stated ya go do something and the resident laughed and stated, bite me and CNA #1 said bend over and the resident responded with profanity. The Rehab Director stated while on their way to therapy, the resident saw the SW and immediately reported the incident to them. On 6/5/24 at 10:00 AM, the surveyor conducted a telephone interview with CNA #1 who stated there was an incident with the resident two or three weeks ago but was unable to recall the details. CNA #1 stated he was told there was another altercation where he told the resident that their hair looked nice, but they took it the wrong way. CNA #1 stated he spoke with the SW about the incident maybe two or three weeks ago but was never asked for a statement or instructed not to interact with the resident. CNA #1 stated after the incident, he took it upon himself to not interact with the resident. On 6/5/24 at 10:09 AM, the surveyor re-interviewed Resident #79 who stated after speaking to the surveyor about their concern with CNA #1 on Monday (6/3/24), the LNHA and DON came to speak to the resident about the incident. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated she started the grievance process, but the LNHA was the Grievance Officer who completed the grievance. The SW stated Resident #79 had an interaction with CNA #1, and she spoke to CNA #1, but she did not obtain a statement. The SW continued that the nursing department would obtain statements from the nursing staff, but she could not speak to why one was not obtained. The SW stated that the LNHA had access to that grievance. On 6/5/24 at 10:39 AM, the surveyor interviewed the DON who stated the facility investigated all allegations of abuse which included asking the resident what happened and obtain a statement, obtain statements from staff and witnesses, suspend staff that the allegation was made against pending investigation, notify the New Jersey Department of Health (NJDOH), Ombudsman, LNHA, and Corporate. The DON stated she was informed by the LNHA on Monday (6/3/24) that they needed to speak to Resident #79 but was given no additional information. The DON stated the resident reported to them that the SW was aware of the situation. The DON confirmed the allegation should have been investigated at the time, statements should have been gathered, and CNA #1 should have been suspended at the time pending investigation. The DON stated staff was suspended during the investigation because if the allegation was substantiated, you do not want to put others at risk or the same resident at risk. The surveyor requested CNA #1's timecard from May to present. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who confirmed he was the Grievance Officer with the assistance of the SW. The LNHA stated he sometimes gathered statements or sometimes the SW did, but the facility investigated all grievances. The LNHA stated the facility obtained statements, but they were not always written, and any allegation of abuse was reported to the NJDOH, Ombudsman, Medical Director, police, and family. The LNHA further stated the staff member who the allegation was made against was suspended pending investigation to determine if they were safe to be around someone. The LNHA stated he typically reviewed all grievances to ensure everything was taken care of and usually grievances were reviewed weekly at a meeting, but sooner if needed. The LNHA stated he spoke to the SW about this incident, and the SW spoke to the parties involved at the time. At that time, the surveyor reviewed the grievance dated 5/16/24, with the LNHA and asked where on the grievance did it indicate what poor experience meant, and the LNHA confirmed it did not and should be looked at to rule out abuse. The LNHA stated he did remember a conversation with the SW, but it was not documented, and there could have been a more written clarification or explanation of the poor experience. The surveyor asked why the LNHA spoke to Resident #79 on Monday (6/3/24) regarding the concern, and the LNHA stated it was mentioned in a meeting that day that he should speak to Resident #79. The surveyor asked the LNHA what the facility's policy indicated for investigating abuse, and the LNHA stated he was unsure. A review of CNA #1's timecard revealed the CNA worked twelve shifts after the allegation of abuse was made on 5/16/24, prior to being suspended on 6/3/24, after working from 6:69 AM until 3:05 PM. The surveyor continued to review the resident's medical record. A review of the Individual Psychotherapy Progress Note dated 6/4/24, indicated that the reason for the visit was for Resident #79's allegation of sexual harassment by a staff member. Further review of the progress notes included that a male staff member had made sexually inappropriate comments to Resident #79 which Resident #79 initially ignored but told him to stop. The progress note indicated that Resident #79 felt uncomfortable and was worried about the aftermath due to past sexual trauma. In addition, the resident's anxiety has increased and PTSD has exacerbated. An acceptable Removal Plan (RP) on 6/6/24 at 1:05 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including staff education on the facility abuse policy, and suspension of CNA #1, the SW, the NA, Director of therapy, and the certified occupational therapy assistant. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/6/24. 2. On 6/7/24 at 9:09 AM, the Regional LNHA in the presence of the LNHA, and DON informed the survey team that upon in-servicing staff on abuse, it was brought to their attention by the Business Office Manager (BOM) that the facility should speak to Resident #60 regarding an incident that should be investigated. The BOM stated the Resident's Representative (RR) reported to them the incident involving Resident #60; that after being discharged from Medicaid services, the Unit Manager/Licensed Practical Nurse (UM/LPN) informed a CNA (unknown) not to help a resident pick up a sock. The incident occurred maybe a week ago, but no one had a definite date. The Regional LNHA continued the BOM indicated in her written statement that the LNHA was aware of the concern and was placed on administrative leave yesterday (6/6/24), re-educated on abuse training, and the DON was now the Grievance Officer. At that time, the surveyor asked the LNHA if he was made aware, the LNHA stated he was made aware that Resident #60 had concerns with their activities of daily living (ADL) care and wanted additional help with ADLs, so he asked the UM/LPN to speak to the resident to see if additional help was needed. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who stated they needed help with ADLs such as putting their sock on since they cannot reach their feet, and yesterday the facility provided them with an assistive device to put on socks on that they could not use. The resident stated that the facility just wanted to supplement with equipment when they asked for help; it makes me feel like they care more about not taking care of me than helping me. The resident continued that they felt bad asking staff for help and ringing the call bell because people abuse the call bell and take up too much of the staff's time. The resident stated they tried to be more independent which resulted in increased physical pain, so the facility increased their pain medication. The resident stated since they did not use the call bell and tried to do tasks on their own, they were discontinued from Medicaid, and after that, when I asked for help, the [UM/LPN] came to my room angry and scolded me for asking for help and was really mad when I explained my side. Then one day, [CNA #1] helped me, and the [UM/LPN] was really mad and told me I knew I was not supposed to ask for help. Then I went out of my room and the [UM/LPN] at the nurse's station in front of people, yelled at me saying I lied to her and she was committing perjury if she allowed anyone to help me. Resident #60 stated this made the resident feel embarrassed and afraid, and fearful of her acting on her anger which caused me emotional harm and fear of what am I going to do; no one is going to help. The resident stated the BOM was aware of this, and the UM/LPN would walk passed the resident's room staring which made them uncomfortable because the look was not welcoming to want to help and she told me I did not need help. The resident stated they were unable to remember the date, but to call their RR who was aware of the whole situation and knew the dates. On 6/7/24 at 9:50 AM, the surveyor conducted a telephone interview with CNA #1 who stated the UM/LPN informed him if the resident needed help, to help them, but the resident did not need much help. CNA #1 recalled an incident at the nurse's station, but the resident was yelling at the UM/LPN and the UM/LPN was not yelling but was sternly telling the resident what was to be done. On 6/7/24 at 10:29 AM, the surveyor interviewed the BOM who stated sometime towards the end of May after the resident was denied from Medicaid the resident informed the Rehab Director, UM/LPN, and an unknown CNA was very rude to [Resident #60] because [Resident #60] started asking for help. Upon hearing that, the BOM reported that she immediately informed the LNHA that the resident reported the Rehab Director, UM/LPN, and a CNA were very rude because [Resident #60] didn't need help, but after [Resident #60] was denied Medicaid [Resident #60] started asking for help and [Resident #60] said that staff feel [Resident #60] is faking it. The BOM confirmed she had followed-up with the LNHA after a meeting, and he reported that he had already spoken to staff and not the resident about it. The BOM stated yesterday after she was in-serviced on abuse, she reminded the LNHA of the incident in front of the Regional LNHA, DON, and Regional Nurse. The BOM stated when she first informed the LNHA, she was never asked to provide a statement. On 6/7/24 at 11:00 AM, the surveyor interviewed the RR via telephone who stated the incident occurred two weeks ago yesterday (5/23/24), after the RR encouraged the resident to start asking for help from facility staff. The RR stated the resident was removed from assisted living because the resident could no longer walk and required twenty-four-hour nursing assistance. The RR stated the resident began asking for help, and the UM/LPN went to the resident and started yelling at them and the resident called and informed the RR. The RR stated the resident was now calling the RR multiple times a day; that their anxiety had increased. The RR reported that the UM/LPN brought the resident in front of all the nurses and told them not to help the resident. The RR stated they spoke with the Director of Rehab who would not let them speak and spoke over them. The RR stated they spoke to the UM/LPN to explain the resident's medical diagnosis of ankylosing spondylitis (AS) which was an autoimmune that caused systemic inflammation similar to MS (multiple sclerosis) in which the resident's spine was fusing and they could have good days or bad days. The RR stated the UM/LPN was aloof and asked what do you want me to do. The RR stated they reported this to the BOM who notified the SW. The SW called back a few days later and the RR reported that the nurses will not help the resident. The RR reported that the SW informed them the facility was aware and they spoke with staff. The RR stated staff was questioning why the resident needed help that only increased the resident's anxiety, in addition to the UM/LPN walking by the resident's room not speaking to them. The UM/LPN was also identifying the resident as an alcoholic and will be kicked out (recovering alcoholic for years) and they were committing fraud if they helped. Review of the BOM's undated statement included that during the meeting with [Resident #60], [Resident #60] told me that the Director of Rehab, the nurse (UM/LPN) and the CNAs in the unit were rude to [Resident #60]. [Resident #60] was told that they would not help, and they would not document any assistance they were providing [Resident #60]. I reported this to the LNHA right away, asked him if he could talk to the Rehab Director and staff on the unit which he told me he already did. On 6/3/24, I received a call from the [RR] and the [RR] voiced their concern of how staff treated the resident, and the [RR] wants to call the Ombudsman's office. After I spoke to the [RR], I spoke to the SW to give the [RR] a call, and she did. The surveyor reviewed the medical record for Resident #60. A review of the Admission Record face sheet indicated the resident was admitted to the facility with diagnoses which included muscle wasting and atrophy; generalized muscle weakness; depression, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review indicated the resident required supervision or touching assistance with lower body dressing and personal hygiene. A review of the ICCP included a focused area dated 4/22/24, which included that the resident was ADL self-care deficient with interventions included to encourage the resident to use call bell for assistance and that the resident required assistance of one person for ambulation and bathing. A review of a Social Services Note dated 6/3/24, did not include the resident or RR's concern about staff. An acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including staff education on the facility abuse policy, and suspension of UM/LPN, and the Rehab Director. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/8/24. NJAC 8:39-4.1(a)5

Complaint # NJ 173248; 174364 Based on interview, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring Resident #79 was free from verbal sexual abuse and b.) ensure Resident #60 was free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79). Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments which included bend over; you will like it; and the resident's messy hair made them look sexy. This was witnessed by the nursing aide (NA), Rehabilitation Director (Rehab Director). Resident #79 reported that the comments by CNA #1 made them feel uncomfortable. The SW handled the incident as a grievance, which was reported as Resident #79 having poor service interaction with CNA #1 and was not investigated as an abuse allegation. The SW stated that the LNHA was the Grievance Officer and was aware of the incident. This situation resulted in the resident, who had PTSD from a past history of sexual abuse, to have increased anxiety with their PTSD exacerbated post incident with CNA #1 and resulted in an Immediate Jeopardy (IJ) situation. A second resident, Resident #60, who had diagnoses which included depression, anxiety, ankylosing spondylitis (an autoimmune disease), who had a verbal altercation with the Unit Manger/Licensed Practical Nurse (UM/LPN) on 5/23/24, when the UM/LPN scolded and yelled at Resident # 60 for requesting assistance with activities of daily living (ADLs) from staff which caused the resident to become afraid and fearful of the nurse causing increased anxiety of who was going to help the resident. The incident was reported to the Business Office Manager (BOM) who immediately reported the incident to the LNHA, but did not start the investigation until 6/6/24, 2 weeks after the incident. The UM/LPN continued to work ten shifts with residents including Resident #60. This resulted in a second IJ situation. The facility's failure to ensure all staff, including the LNHA, implemented their facility policies to guarantee all residents were free from abuse by not investigating the actions of CNA #1 after witnessed by staff, that the SW and LNHA were aware of; as well as the actions of the UM/LPN, which the BOM made the LNHA aware of, posed a serious and immediate threat for abuse that can cause serious physical and emotional harm or impairment, resulted in two IJ situations which the facility became aware of on 6/5/24 at 2:27 PM and 6/7/24 at 12:40 PM. Refer to F 600. This resulted in an IJ situation that began on 5/16/24 after CNA #1 verbally sexually abused Resident #79 and continued to work twelve additional shifts after staff was aware of the situation. The facility Administration was notified of the IJ on 6/7/24 at 12:42 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/10/24. The evidence was as follows: A review of the Administrator's job description provided by the facility revealed the following: The primary purpose of the job position is to direct the day-to-day functions of the Center in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree or quality care can be provided to residents at all times. Administrative Functions included but not limited to: develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Center; review the Center's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations; interpret the Center's policies and procedures to employees, residents, family members, visitors, government agencies, [etcetera] as necessary; ensure all employees, residents, visitors, and general public follow the Center's established policies and procedures; assume the administrative authority, responsibility and accountability of directing the activities and programs of the Center. Safety and Sanitation included but not limited to: review accident/incident reports (falls, injuries of unknown source, abuse [etcetera]. Monitor to determine the effectiveness of the Center's risk management. Resident Rights included but not limited to: review resident complaints and grievances and make written reports of action taken. Discuss such actions with residents and family as appropriate; review complaints and grievances made by the resident and make a written/oral report to Nurse Supervisor/Charge Nurse. Follow Center's established procedures; maintain a written record of resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint; report all allegations of resident abuse and/or misappropriation of resident property. On 6/3/24 at 10:58 AM, the surveyor interviewed Resident #79 who stated CNA #1 made sexual comments towards them that made them feel uncomfortable; that staff including a Nursing Aide (NA) who witnessed the interaction. The resident stated the facility was aware of the incident, and the LNHA had not spoken to them. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who confirmed she had witnessed the incident between Resident #79 and CNA #1, that she initially thought they were joking until the resident reported it made them feel a certain way. The NA stated it was reported to the SW who spoke to the resident. The NA stated the incident happened maybe one month ago, but the facility had just asked for a statement. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated the LNHA was the Grievance Officer, and confirmed Resident #79's concern regarding sexual abuse was handled as a grievance and not an investigation. The SW reported the LNHA was aware of the situation. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who stated their role was to oversee all department heads as well as the facility in general. The LNHA confirmed he was the Grievance Officer with the assistance of the SW, and grievances were reviewed weekly at a meeting or sooner if needed. The LNHA confirmed he recalled the situation with Resident #79, and the SW spoke to both parties. The surveyor reviewed the grievance dated 5/16/24 with the LNHA who acknowledged poor service interaction with CNA #1 was not sufficient information. The surveyor asked the LNHA why he spoke to the resident on 6/3/24, regarding the incident that was previously reported on 5/16/24, and the LNHA stated during a meeting, staff informed him to speak to the resident. The LNHA stated that all allegations of abuse were investigated and reported to the New Jersey Department of Health (NJDOH), but the LNHA could not speak to the specifics of how the facility investigated abuse and stated he needed to review the policy. On 6/5/24 at 2:27 PM, the facility was made aware of an IJ situation which resulted from Resident #79's allegation of verbal sexual abuse when the facility was aware of the incident between CNA #1 and the resident, and CNA #1 continued to work twelve shifts having contact with other residents with no investigation. On 6/6/24 at 8:23 AM, the LNHA in the presence of the Director of Nursing (DON) stated he was not aware of the incident with Resident #79 and CNA #1 until 6/3/24, which contradicted the LNHA's previous interview. The LNHA again confirmed he was the Grievance Officer and could not recall exactly when he reviewed the grievance. On 6/6/24 at 10:02 AM, the LNHA informed the survey team again he was unaware of the resident's grievance until 6/3/24. The LNHA confirmed again his role was to oversee the operations of the facility, and his role as the Grievance Officer was to review all grievances, but the incident was never brought to his attention. The LNHA confirmed all grievances were typically reviewed on Wednesdays. On 6/7/24 at 9:09 AM, the Regional LNHA, in the presence of the LNHA, DON, and survey team stated while inserviced staff on abuse yesterday, it was brought to their attention from the Business Office Manager (BOM), that the facility should speak to Resident #60 regarding a complaint about Unit Manager/Licensed Practical Nurse (UM/LPN) and that the LNHA was made aware at the time. The Regional LNHA stated the LNHA placed himself on administrative leave until he was trained on abuse, and then returned to the facility as the administrator. At that time, the surveyor asked the LNHA if he was aware of the situation, and he responded that he never spoke to the resident, but he was aware the resident wanted more help with activities of daily living. The LNHA then asked the UM/LPN to speak to the resident. The LNHA confirmed the incident was not investigated and the Regional LNHA confirmed the UM/LPN was not in the facility. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who confirmed the UM/LPN had scolded and yelled at the resident for asking staff for help. The resident stated this caused increased anxiety as well as fear for who was going to help them. On 6/7/24 at 12:40 PM, the facility was made aware of a second IJ situation which resulted from Resident #60's concern regarding verbal abuse which the BOM made the LNHA immediately aware of, and the UM/LPN continued to work in the facility until 6/6/24, when the incident was brought to the Regional LNHA and DON's attention. This resulted in an second concern for the IJ situation that began on 5/16/24 after CNA #1 made sexually inappropriate comments to Resident #79 which was reported to the SW, and continued to work twelve additional shifts. The facility Administration was notified of the additional IJ concern on 6/7/24 at 12:42 PM. The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/10/24. On 6/10/24 at 9:15 AM, the Regional LNHA in the presence of the DON informed the survey team that the governing body removed the immediate threat by suspending the LNHA, and now the Regional LNHA was the facility's administrator and was inserviced by the Chief Nursing Officer on the facility's policies. The Regional LNHA stated the LNHA provided commentary on his suspension notice, which the LNHA denied knowledge of the situations. A review of the facility's undated Abuse Prevention Program policy included the administration will implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator has been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer will begin an investigation into the allegation .the investigation and report will include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse will be reported and investigated under guidelines for reporting abuse . A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated . NJAC 8:39-9.2(a) NJAC 8:39-9.3(a) NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a system was in place that non-certified Nursing Aides (NA) did not continue to work in the facility as a NA past 120 days. This deficient practice was identified for 5 of 5 NAs who worked at the facility for more than 120 days reviewed for sufficient staffing (NA #1, #2, #3, #4, and #5), and was evidenced by the following: During entrance conference on 6/3/24 at 9:17 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's nurse staffing was, and the LNHA stated it was good; that the facility did not need to use Agency staff. The surveyor asked if the facility used non-certified Nursing Aides (NA), and the LNHA stated they did; that past a certain amount of time (that he was unsure of) the NAs could have their own assignments. At that time, the surveyor requested a list of all NAs with their date of hire (DOH). On 6/5/24 at 8:26 AM, the surveyor interviewed NA #1 who stated she had been at the facility since August of 2023 and just found out this week she could no longer have an assignment. NA #1 stated that the Human Resource (HR) person was new and was unaware of the timeframe NAs could work. NA #1 stated she enrolled in school immediately upon hire, and had her own resident assignment for care sometime in September. NA #1 stated she had her own assignment on Monday 6/3/24, and then was told she could not. NA #1 reported she completed school and passed the test, but she was waiting on the state background check and licensing. On 6/5/24 at 11:43 AM, the LNHA provided the surveyor with the requested list of NAs with their DOH. The LNHA stated that the facility just identified that NAs needed to have their license within 120 days of working at the facility; he thought they had 120 days after they completed schooling. The surveyor asked the LNHA how many NAs the facility identified, and he stated one, NA #1. The surveyor reviewed the list entitled Caring Partners which contained fourteen names. Out of the fourteen names, five had worked at the facility over 120 days as follows: NA #1 DOH 8/2/23 NA #2 DOH 10/11/23 NA #3 DOH 12/20/23 NA #4 DOH 1/10/24 NA #5 DOH 1/10/24 On 6/6/24 at 12:18 PM, the surveyor interviewed NA #2, who stated he started school six months ago. NA#2 indicated that they just took the test and passed on Monday 6/3/24, and was now waiting on fingerprints and the background check from the state. When asked what took so long to take the test, NA #2 responded that he wanted to make sure he knew the information. NA #2 confirmed he previously had his own resident care assignment, but today was told to answer call bells and not do care. The surveyor requested the nursing staff assignment sheets from October 2023 to present. A review of the sheet revealed the following: NA #1 with a DOH 8/2/23 and 120 days as of 11/29/23, worked with a resident care assignment for 19 shifts in December 2023; 12 shifts in January 2024; 17 shifts February 2024; 20 shifts March 2024; 17 shifts in April 2024; 20 shifts in May 2024; and three shifts in June 2024. NA #2 with a DOH 10/11/23 and 120 days as of 2/7/24, worked with a resident care assignment for 20 shifts in February 2024; 35 shifts in March 2024; 29 shifts in April 2024; 32 shifts May 2024; and four shifts in June 2024. NA #3 with a DOH of 12/20/23 and 120 days as of 4/17/24, worked with a resident care assignment for 12 shifts in April 2024; and 27 shifts in May 2024. NA #4 with a DOH of 1/10/24 and 120 days as of 5/8/24, worked with a resident care assignment for 21 shifts in May 2024; and two shifts in June 2024. NA #5 with a DOH of 1/10/24 and 120 days as of 5/8/24, worked with a resident care assignment for 18 shifts in May 2024; and two shifts in June 2024. On 6/7/24 at 8:39 AM, the surveyor interviewed the HR/Staffing Coordinator the presence of the LNHA and DON who stated she had been the Staffing Coordinator since December and the role of HR since 2021. The HR/Staffing Coordinator stated NAs were allowed to have their own resident care assignment after completing two weeks of school and shadowing a Certified Nursing Aide (CNA) for at least ten shifts. The HR/Staffing Coordinator acknowledged that a NA could not have a care assignment past 120 days in the building. On 6/7/24 at 8:49 AM, the LNHA informed the surveyor that he was aware the facility used NAs and there was regulatory guidance regarding the usage, but he was unaware of the timing. The LNHA stated the Regional LNHA brought it to his attention on 6/3/24, and acknowledged it was important for him to be aware of the regulatory guidance because it was part of his job. NJAC 8:39-25.2(g)

Complaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to report an allegation of: a.) sexual verbal abuse between a staff member and a resident, and b.) verbal abuse between a staff member and a resident to the New Jersey State Department of Health (NJDOH) within two hours. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79), and was evidenced by the following: Refer F600 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that Certified Nursing Aide (CNA #1) had made sexual comments towards them, and they refused male aides. The resident stated CNA #1 told them to bend over and they replied, no thank you and CNA #1 stated you will like it. The resident continued on another the day; CNA #1 stated Don't take this the wrong way but your hair looks sexy that way. The resident stated that the non-certified Nursing Aide (NA) and the Rehabilitation Director (Rehab Director) were both present, and the comments as well as CNA #1 made them uncomfortable. The resident stated he/she complained to administration about it, but the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), or Assistant Director of Nursing (ADON) had not spoken to them about the incident; he/she stated they were informed CNA #1 was spoken to. The surveyor reviewed the medical record for Resident #79. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included post-traumatic stress disorder (PTSD) and major depressive disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/29/24, the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. On 6/4/24 at 9:04 AM, the surveyor requested all grievances and investigations for Resident #79. A review of a grievance dated reported 5/16/24 and resolved 5/17/24 by the SW, indicated that Resident #79 reported [he/she] had a poor service interaction with Aid on the unit. Summary of investigation included Social Worker (SW) did follow-up and [he/she] said [he/she] used profanity to him the CNA (#1) as they were joking around and then he walked away. SW asked if [he/she] would prefer not to have interaction with him [CNA #1] and [he/she] was satisfied with that. Unit Manager made aware; Aide is not assigned to resident and will have no contact. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who stated there was an incident between Resident #79 and CNA #1 about a month ago where she had gotten the resident ready for physical therapy and they were waiting in the dining room with CNA #1. The NA stated that CNA #1 and herself were joking with the resident, and she was unsure who initiated the interaction, but the resident stated to CNA #1 bite me and CNA #1 stated bend over and I had left because the Rehab Director came in. The NA reported that the Rehab Director told her that after that interaction, the resident used profanity in a non-joking way, and CNA #1 stated are you sure about that and the resident responded ew. The NA stated she did not report the incident at first because she thought everyone was joking, but when the resident reported to her that it made [him/her] feel a certain way, she asked if they wanted to speak to the SW to report it, and the resident stated yes. The NA reported now they are just investigating it. On 6/5/24 at 9:00 AM, the surveyor asked the DON if CNA #1 was working today, and the DON stated CNA #1 was suspended pending investigation for an allegation of abuse from a resident as of 6/3/24 (first day of survey). On 6/5/24 at 9:08 AM, the surveyor interviewed the Rehab Director who stated about a month ago, the resident was waiting for therapy in the dining room with the NA and CNA #1. The Rehab Director informed the resident therapy was ready, and in a joking way CNA #1 stated ya go do something and the resident laughed and stated, bite me and CNA #1 said bend over and the resident responded with profanity. The Rehab Director stated while on their way to therapy, the resident saw the SW and immediately reported the incident to them. On 6/5/24 at 10:00 AM, the surveyor conducted a telephone interview with CNA #1 who stated there was an incident with the resident two or three weeks ago but cannot recall the details, and then I was told there was another altercation where I told the resident their hair looked nice, but they took it the wrong way. CNA #1 stated he spoke with the SW about the incident maybe two or three weeks ago, but was never asked for a statement or instructed not to interact with the resident. CNA #1 stated after the incident, he took it upon himself to not interact with the resident. On 6/5/24 at 10:09 AM, the surveyor re-interviewed Resident #79 who stated after speaking to the surveyor about their concern with CNA #1 on Monday, the LNHA and DON came to speak to them about the incident. The resident confirmed they never requested to speak to them that day, or informed any staff their concern that day. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated she started the grievance process, but the LNHA was the Grievance Officer who completed the grievance. The SW stated Resident #79 had an interaction with CNA #1, and she spoke to CNA #1, but she did not obtain a statement. The SW continued the nursing department would obtain statements from the nursing staff, but she could not speak to why one was not obtained. The SW stated that the LNHA had access to this grievance. On 6/5/24 at 10:39 AM, the surveyor interviewed the DON (as of 5/29/24) who stated the facility investigated all allegations of abuse which included asking the resident what happened and obtaining a statement; obtain statements from staff and witnesses; suspend staff the allegation was made against pending investigation; notify the NJDOH, Ombudsman, LNHA, and Corporate. The DON stated she was informed by the LNHA on Monday (6/3/24) that they needed to speak to Resident #79, but was given no additional information. The DON stated the resident reported to them the SW was aware of the situation, and the DON confirmed the allegation should have been investigated at that time and reported to the NJDOH. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who confirmed he was the Grievance Officer with the assistance of the SW. The LNHA stated sometimes he gathered statements or sometimes the SW did, but the facility investigated all grievances. The LNHA stated the facility obtained statements, but they were not always written, and any allegation of abuse was reported to the NJDOH, Ombudsman, Medical Director, police, and family. On 6/5/24 at 2:27 PM, the surveyor informed the LNHA and DON of this concern. 2. On 6/7/24 at 9:09 AM, the Regional LNHA in the presence of the LNHA, and DON informed the survey team that upon in-servicing staff on abuse, it was brought to their attention by the Business Office Manager (BOM) that the facility should speak to Resident #60 regarding an incident that should be investigated. The BOM stated the Resident's Representative (RR) reported to them the incident involving Resident #60; that after being discharged from Medicaid services, the Unit Manager/Licensed Practical Nurse (UM/LPN) informed a CNA (unknown) not to help a resident pick up a sock. The incident occurred maybe a week ago, but no one had a definite date. The Regional LNHA continued the BOM indicated in her written statement that the LNHA was aware of the concern. At that time, the surveyor asked the LNHA if he was made aware, the LNHA stated he was made aware that Resident #60 had concerns with his/her activities of daily living (ADL) care and wanted additional help with ADLs, so he asked the UM/LPN to speak to the resident to see if additional help was needed. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who stated he/she needed help with ADLs such as putting his/her sock on since they cannot reach their feet, and yesterday the facility provided them with this assistive device to put my socks on that cannot use. The resident continued the facility just wanted to supplement with equipment when I asked for help; it makes me feel like they care more about not taking care of me than helping me. The resident continued that they felt bad asking staff for help and ringing the call bell because people abuse the call bell and take up too much of the staff's time, so he/she tried to be more independent which resulted in increased physical pain, so the facility increased their pain medication. The resident stated since he/she did not use the call bell and tried to do tasks on their own, he/she was discontinued from Medicaid, and after that, when I asked for help, the UM/LPN came to my room angry and scolded me for asking for help and was really mad when I explained my side. The one day CNA #1 helped me, and the UM/LPN was really mad and told me I knew I was not supposed to ask for help. Then I went out of my room and the UM/LPN at the nurse's station in front of people, yelled at me saying I lied to her and she was committing perjury if she allowed anyone to help me. The resident stated this made him/her embarrassed and afraid, and fearful of her acting on her anger which caused me emotional harm, and fear of what am I going to do; no one is going to help. The resident stated the BOM was aware of this, and the UM/LPN would walk passed his/her room staring which made him/her uncomfortable because the look was not welcoming to want to help and she told me I did not need help. The resident stated he/she was not good with dates, but to call his/her RR who was aware of the whole situation and knew the dates. On 6/7/24 at 9:50 AM, the surveyor interviewed CNA #1 via telephone who stated the UM/LPN informed him if the resident needed help, to help them, but the resident did not need much help. CNA #1 recalled an incident at the nurse's station, but the resident was yelling at the UM/LPN and the UM/LPN was not yelling but was sternly telling the resident what was to be done. On 6/7/24 at 10:29 AM, the surveyor interviewed the BOM who stated sometime towards the end of May after the resident was denied from Medicaid, was informed the Rehab Director, UM/LPN, and a CNA (unknown) was very rude to [him/her] because [he/she] started asking for help. Upon hearing that, the BOM reported that she immediately informed the LNHA that the resident reported the Rehab Director, UM/LPN, and a CNA were very rude because [he/she] didn't need help, but after [he/she] was denied Medicaid [he/she] started asking for help and [he/she] said that staff feel [he/she] is faking it. The BOM confirmed she had followed-up with the LNHA after a meeting, and he reported that he had already spoken to staff and not the resident about it. The BOM stated yesterday after she was in-serviced on abuse, she reminded the LNHA of the incident in front of the Regional LNHA, DON, and Regional Nurse. The BOM stated when she first informed the LNHA, she was never asked to provide a statement. On 6/7/24 at 11:00 AM, the surveyor interviewed the RR via telephone who stated the incident occurred two weeks ago yesterday (6/23/24), after the RR encouraged the resident to start asking for help from facility staff. The RR stated the resident was removed from assisted living because he/she could no longer walk and required twenty-four-hour nursing assistance. The RR stated the resident began asking for help, and the UM/LPN went to the resident and started yelling at him/her and the resident called and informed the RR. The RR stated the resident was now calling him/her multiple times a day; that their anxiety had increased. The RR reported that the UM/LPN brought the resident in front of all the nurses and told them not to help the resident. The RR stated when he/she was made aware, they spoke with the Director of Rehab who would not let them speak and spoke over them. The RR stated he/she then spoke to the UM/LPN to explain the resident's medical diagnosis of ankylosing spondylitis (AS) which was an autoimmune which caused systemic inflammation similar to MS (multiple sclerosis) in which the resident's spine was fusing and they could have good days or bad days. The RR stated the UM/LPN was aloof and what do you want me to do. The RR stated he/she reported this to the BOM who reported it to the SW, and the SW called back a few days later and the RR reported that the nurses will not help the resident. The RR reported the SW informed them that the facility was aware, and they spoke with staff. The RR reported staff was questioning why the resident needed help which increased the resident's anxiety, as well as the UM/LPN was walking by the resident's room not speaking to them causing more anxiety, and the UM/LPN was telling the resident they were an alcoholic and will be kicked out (recovering alcoholic for years) and they were committing fraud if they helped. Review of the BOM's undated statement included during my meeting with [Resident #60], [he/she] told me that the Director of Rehab, the nurse (UM/LPN) and the CNAs in the unit were rude to [him/her]. [He/she] was told that they would not help, and they would not document any assistance they were providing [him/her]. I reported this to the LNHA right away, asked him if he could talk to the Rehab Director and staff on the unit which he told me he already did. On 6/3/24, I received a call from the RR with regards to the Medicaid denial, and he/she voiced their concern of how staff treated the resident, and he/she wanted to call the Ombudsman's office. After I spoke to the RR, I spoke to the SW to give the RR a call, and she did. The surveyor reviewed the medical record for Resident #60. A review of the Admission Record face sheet indicated the resident was admitted to the facility with diagnoses which included muscle wasting and atrophy; generalized muscle weakness; depression, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of a Social Services Note dated 6/3/24, included SW spent time with resident and gave name of an independent living facility. Resident asked me to call RR; and the RR stated they do not need assistance finding a location as they will appeal the denial for long term care Medicaid. The note did not include the resident or RR's concern about staff. On 6/10/24 at 9:15 AM, the surveyor interviewed the Regional LNHA who was now the acting facility administrator, in the presence of the DON who stated any allegation of abuse needed to be reported to the NJDOH within two hours. This incident was not reported to the NJDOH until 6/6/24. A review of the facility's undated Abuse Prevention Program policy included the administration will implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included all alleged violations of neglect, abuse [ ] will be reported and investigated under guidelines for reporting abuse . A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse [ .] is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse . NJAC 8:39-4.1(a)5

Complaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to thoroughly investigate an allegation of: a.) verbal sexual abuse between a staff member and resident, and b.) verbal abuse between a staff member and resident. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79), and was evidenced by the following: Refer F600 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that Certified Nursing Aide (CNA #1) had made sexual comments towards them, and they refused male aides. The resident stated CNA #1 told them to bend over and they replied, no thank you and CNA #1 stated you will like it. The resident continued on another the day; CNA #1 stated Don't take this the wrong way but your hair looks sexy that way. The resident stated that the non-certified Nursing Aide (NA) and Rehabilitation Director (Rehab Director) were both present, and the comments as well as CNA #1 made them uncomfortable. The resident stated he/she complained to administration about it, but the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), or Assistant Director of Nursing (ADON) had not spoken to them about the incident; he/she stated they were informed CNA #1 was spoken to. The surveyor reviewed the medical record for Resident #79. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included post-traumatic stress disorder (PTSD) and major depressive disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/29/24, the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. On 6/4/24 at 9:04 AM, the surveyor requested all grievances and investigations for Resident #79. A review of a grievance dated reported 5/16/24 and resolved 5/17/24 by the Social Worker (SW), indicated that Resident #79 reported [he/she] had a poor service interaction with Aid on the unit. Summary of investigation included SW did follow-up and [he/she] said [he/she] used profanity to him the CNA (#1) as they were joking around and then he walked away. SW asked if [he/she] would prefer not to have interaction with him [CNA #1] and [he/she] was satisfied with that. Unit Manager made aware; Aide is not assigned to resident and will have no contact. The grievance included no statements form the resident, witnesses, CNA #1, any residents CNA #1 may have come in contact, or education. On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who stated there was an incident between Resident #79 and CNA #1 about a month ago where she had gotten the resident ready for physical therapy and they were waiting in the dining room with CNA #1. The NA stated that CNA #1 and herself were joking with the resident, and she was unsure who initiated the interaction, but the resident stated to CNA #1 bite me and CNA #1 stated bend over and I had left because the Rehab Director came in. The NA reported that the Rehab Director told her that after that interaction, the resident used profanity in a non-joking way, and CNA #1 stated are you sure about that and the resident responded ew. The NA stated she did not report the incident at first because she thought everyone was joking, but when the resident reported to her that it made [him/her] feel a certain way, she asked if they wanted to speak to the SW to report it, and the resident stated yes. The NA reported now they are just investigating it. On 6/5/24 at 9:00 AM, the surveyor asked the DON if CNA #1 was working today, and the DON stated CNA #1 was suspended pending investigation for an allegation of abuse from a resident as of 6/3/24 (first day of survey). On 6/5/24 at 9:08 AM, the surveyor interviewed the Rehab Director who stated about a month ago, the resident was waiting for therapy in the dining room with the NA and CNA #1. The Rehab Director informed the resident therapy was ready, and in a joking way CNA #1 stated ya go do something and the resident laughed and stated, bite me and CNA #1 said bend over and the resident responded with profanity. The Rehab Director stated while on their way to therapy, the resident saw the SW and immediately reported the incident to them. On 6/5/24 at 10:00 AM, the surveyor conducted a telephone interview with CNA #1 who stated there was an incident with the resident two or three weeks ago but cannot recall the details, and then I was told there was another altercation where I told the resident their hair looked nice, but they took it the wrong way. CNA #1 stated he spoke with the SW about the incident maybe two or three weeks ago, but was never asked for a statement or instructed not to interact with the resident. CNA #1 stated after the incident, he took it upon himself to not interact with the resident. On 6/5/24 at 10:09 AM, the surveyor re-interviewed Resident #79 who stated after speaking to the surveyor about their concern with CNA #1 on Monday, the LNHA and DON came to speak to them about the incident. The resident confirmed they never requested to speak to them that day, or informed any staff their concern that day. On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated she started the grievance process, but the LNHA was the Grievance Officer who completed the grievance. The SW stated Resident #79 had an interaction with CNA #1, and she spoke to CNA #1, but she did not obtain a statement. The SW continued the nursing department would obtain statements from the nursing staff, but she could not speak to why one was not obtained. The SW stated that the LNHA had access to this grievance. On 6/5/24 at 10:39 AM, the surveyor interviewed the DON (as of 5/29/24) who stated the facility investigated all allegations of abuse which included asking the resident what happened and obtaining a statement; obtain statements from staff and witnesses; suspend staff the allegation was made against pending investigation. The DON stated she was informed by the LNHA on Monday (6/3/24) that they needed to speak to Resident #79, but was given no additional information. The DON stated the resident reported to them the SW was aware of the situation, and the DON confirmed the allegation should have been investigated at that time; statements should have been gathered; and CNA #1 should have been suspended at the time pending investigation. On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who confirmed he was the Grievance Officer with the assistance of the SW. The LNHA stated sometimes he gathered statements or sometimes the SW did, but the facility investigated all grievances. The LNHA stated the facility obtained statements, but they were not always written. The LNHA stated he typically reviewed all grievances to ensure everything was taken care of, and usually grievances were reviewed weekly at a meeting, but sooner if needed. The LNHA stated he spoke to the SW about this incident, and the SW spoke to the parties involved at the time. At that time, the surveyor reviewed the grievance dated 5/16/24, with the LNHA and asked where on the grievance did it indicate what poor experience meant, and the LNHA confirmed it did not, and should be looked at to rule out abuse. The LNHA stated he did remember a conversation with the SW, but it was not documented, and there could have been a more written clarification or explanation of poor experience. The surveyor asked why the LNHA spoke to Resident #79 on Monday regarding this concern, and the LNHA stated someone had mentioned in a meeting that day that he should speak to him/her. The surveyor asked the LNHA what the facility's policy indicated for investigating abuse, and the LNHA stated he was unsure. 2. On 6/7/24 at 9:09 AM, the Regional LNHA in the presence of the LNHA, and DON informed the survey team that upon in-servicing staff on abuse, it was brought to their attention by the Business Office Manager (BOM) that the facility should speak to Resident #60 regarding an incident that should be investigated. The BOM stated the Resident's Representative (RR) reported to them the incident involving Resident #60; that after being discharged from Medicaid services, the Unit Manager/Licensed Practical Nurse (UM/LPN) informed a CNA (unknown) not to help a resident pick up a sock. The incident occurred maybe a week ago, but no one had a definite date. The Regional LNHA continued the BOM indicated in her written statement that the LNHA was aware of the concern. At that time, the surveyor asked the LNHA if he was made aware, the LNHA stated he was made aware that Resident #60 had concerns with his/her activities of daily living (ADL) care and wanted additional help with ADLs, so he asked the UM/LPN to speak to the resident to see if additional help was needed. On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who stated he/she needed help with ADLs such as putting his/her sock on since they cannot reach their feet, and yesterday the facility provided them with this assistive device to put my socks on that cannot use. The resident continued the facility just wanted to supplement with equipment when I asked for help; it makes me feel like they care more about not taking care of me than helping me. The resident continued that they felt bad asking staff for help and ringing the call bell because people abuse the call bell and take up too much of the staff's time, so he/she tried to be more independent which resulted in increased physical pain, so the facility increased their pain medication. The resident stated since he/she did not use the call bell and tried to do tasks on their own, he/she was discontinued from Medicaid, and after that, when I asked for help, the UM/LPN came to my room angry and scolded me for asking for help and was really mad when I explained my side. The one day CNA #1 helped me, and the UM/LPN was really mad and told me I knew I was not supposed to ask for help. Then I went out of my room and the UM/LPN at the nurse's station in front of people, yelled at me saying I lied to her and she was committing perjury if she allowed anyone to help me. The resident stated this made him/her embarrassed and afraid, and fearful of her acting on her anger which caused me emotional harm, and fear of what am I going to do; no one is going to help. The resident stated the BOM was aware of this, and the UM/LPN would walk passed his/her room staring which made him/her uncomfortable because the look was not welcoming to want to help and she told me I did not need help. The resident stated he/she was not good with dates, but to call his/her RR who was aware of the whole situation and knew the dates. On 6/7/24 at 9:50 AM, the surveyor conducted a telephone interview with CNA #1 who stated the UM/LPN informed him if the resident needed help, to help them, but the resident did not need much help. CNA #1 recalled an incident at the nurse's station, but the resident was yelling at the UM/LPN and the UM/LPN was not yelling but was sternly telling the resident what was to be done. On 6/7/24 at 10:29 AM, the surveyor interviewed the BOM who stated sometime towards the end of May after the resident was denied from Medicaid, was informed the Rehab Director, UM/LPN, and a CNA (unknown) was very rude to [him/her] because [he/she] started asking for help. Upon hearing that, the BOM reported that she immediately informed the LNHA that the resident reported the Rehab Director, UM/LPN, and a CNA were very rude because [he/she] didn't need help, but after [he/she] was denied Medicaid [he/she] started asking for help and [he/she] said that staff feel [he/she] is faking it. The BOM confirmed she had followed-up with the LNHA after a meeting, and he reported that he had already spoken to staff and not the resident about it. The BOM stated yesterday after she was in-serviced on abuse, she reminded the LNHA of the incident in front of the Regional LNHA, DON, and Regional Nurse. The BOM stated when she first informed the LNHA, she was never asked to provide a statement. On 6/7/24 at 11:00 AM, the surveyor interviewed the RR via telephone who stated the incident occurred two weeks ago yesterday (6/23/24), after the RR encouraged the resident to start asking for help from facility staff. The RR stated the resident was removed from assisted living because he/she could no longer walk and required twenty-four-hour nursing assistance. The RR stated the resident began asking for help, and the UM/LPN went to the resident and started yelling at him/her and the resident called and informed the RR. The RR stated the resident was now calling him/her multiple times a day; that their anxiety had increased. The RR reported that the UM/LPN brought the resident in front of all the nurses and told them not to help the resident. The RR stated when he/she was made aware, they spoke with the Director of Rehab who would not let them speak and spoke over them. The RR stated he/she then spoke to the UM/LPN to explain the resident's medical diagnosis of ankylosing spondylitis (AS) which was an autoimmune which caused systemic inflammation similar to MS (multiple sclerosis) in which the resident's spine was fusing and they could have good days or bad days. The RR stated the UM/LPN was aloof and what do you want me to do. The RR stated he/she reported this to the BOM who reported it to the SW, and the SW called back a few days later and the RR reported that the nurses will not help the resident. The RR reported the SW informed them that the facility was aware, and they spoke with staff. The RR reported staff was questioning why the resident needed help which increased the resident's anxiety, as well as the UM/LPN was walking by the resident's room not speaking to them causing more anxiety, and the UM/LPN was telling the resident they were an alcoholic and will be kicked out (recovering alcoholic for years) and they were committing fraud if they helped. Review of the BOM's undated statement included during my meeting with [Resident #60], [he/she] told me that the Director of Rehab, the nurse (UM/LPN) and the CNAs in the unit were rude to [him/her]. [He/she] was told that they would not help, and they would not document any assistance they were providing [him/her]. I reported this to the LNHA right away, asked him if he could talk to the Rehab Director and staff on the unit which he told me he already did. On 6/3/24, I received a call from the RR with regards to the Medicaid denial, and he/she voiced their concern of how staff treated the resident, and he/she wants to call the Ombudsman's office. After I spoke to the RR, I spoke to the SW to give the RR a call, and she did. The surveyor reviewed the medical record for Resident #60. A review of the Admission Record face sheet indicated the resident was admitted to the facility with diagnoses which included muscle wasting and atrophy; generalized muscle weakness; depression, and anxiety. A review of a Social Services Note dated 6/3/24, included SW spent time with resident and gave name of an independent living facility. Resident asked me to call RR; and the RR stated they do not need assistance finding a location as they will appeal the denial for long term care Medicaid. The note did not include the resident or RR's concern about staff. On 6/10/24 at 9:15 AM, the surveyor interviewed the Regional LNHA who was the acting facility administrator, in the presence of the DON who stated the facility should investigate all concerns. The Regional LNHA stated an investigation included interviewing all the parties involved and getting statements; written or verbal, and verbal statements taken over the phone should be documented. Statements generally were a seventy-two hour lookback if the incident was unwitnessed, but the purpose of the investigation was to determine what actually occurred. A review of the facility's undated Abuse Prevention Program policy included the administration will implement the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations . A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator has been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer will begin an investigation into the allegation .the investigation and report will include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations . A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated . NJAC 8:39-4.1(a)5

Based on observation, interview and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were trained to properly assess and document care of the hemodialysis access sites which includes the auscultation/palpation of the atrio-ventricular (AV) fistula (a surgical connection connection between an artery and a vein) for bruit (an abnormal sound generated by turbulent arterial blood flow) and thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 2 of 2 residents reviewed for hemodialysis treatment(Resident #4 and #50) and was evidenced by the following: On 6/6/24 at 10:55 AM, the surveyor observed Resident #50 seated in a wheelchair at the bedside. Upon inquiry, Resident #50 stated that they had kidney failure and was receiving hemodialysis (the filtration of waste when the kidneys are no longer able to do so). Resident #50 showed the left arm to the surveyor and stated, this is the site. Resident #50 added that he/she went to hemodialysis every Monday, Wednesday and Friday. The surveyor then inquired how often the nurses checked the site, Resident #50 indicated the nurses do not checked the site here; the staff at the dialysis center checked the hemodialysis site. The surveyor observed an AV shunt on Resident #50's left arm. The surveyor observed two bandages on the left arm. On 6/6/24 at 12:30 PM, the surveyor reviewed the Admission Record face sheet (an admission summary) which reflected that Resident #50 was admitted to the facility with diagnoses which included but were not limited to; anemia in chronic kidney disease, end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar) neuropathy (a type of nerve damage that can occur with diabetes). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 5/18/24, revealed that Resident #50 received a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. A review of Section O. titled Special Treatments, Procedures, and Programs (J2) was checked which indicated that the resident received hemodialysis outside the facility. A review of Resident #50's physician's orders sheet dated 5/12/24, indicated: check left peripheral access site, AV graft (shunt) site for bleeding, signs of infection, and the presence of bruit and thrill every shift. A review of the corresponding Treatment Administration Record (TAR) dated 5/12/24 to 6/5/24, revealed that the physician's order to check the left AV fistula (shunt) was documented as completed all three shifts by the nurses' initials. A review of Resident #50's Dialysis Communication Records in the resident's dialysis communication binder dated 5/15/24 to 6/5/24, included to document the bruit and thrill. The bruit and thrill was no documented as checked on 5/22/24, 5/29/24, and 5/31/24. On 6/3/24, the nurse documented, No for bruit and thrill. On 6/6/24 at 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) in charge of Resident #50's care who stated that Resident #50 had an AV fistula to the left arm. LPN#1 reviewed the order with the surveyor and confirmed that the order was for staff to check the site every shift. At that time, the surveyor asked LPN #1 if he could check the site with the surveyor, and LPN#1 accompanied the surveyor to the resident's room, and informed the resident of the procedure. LPN #1 used alcohol-based hand rub (ABHR) to sanitize his hands, then used the bell of the stethoscope to listen to the bruit, and then left the room. LPN #1 did not palpate for the thrill (thrill must be felt). In the presence of the nurse, Resident #50 informed the surveyor that the nurses never checked the site at the facility. LPN#1 did not make any comment regarding Resident #50's statement. On 6/6/24 at 11:07 AM, during an interview with LPN #1, he revealed that he had been working at the facility over nine years, and stated that he possibly had received in-service on care of dialysis access site but he could not recall. The surveyor then asked LPN #1 how many dialysis residents were under his care, and he responded there was one other dialysis resident on the nursing unit. On 6/10/24 at 9:00 AM, the Director of Nursing (DON), in the presence of the Regional Licensed Nursing Home Administrator (Regional LNHA) and survey team, acknowledged staff was only checking the resident for the bruit and not thrill. 2. On 6/6/24 at 11:12 AM, the surveyor observed LPN #2 in the hallway who confirmed that Resident #4 was on her assignment. LPN #2 informed the surveyor that she had to check the AV fistula prior to dialysis on Monday, Wednesday, and Friday. The surveyor asked the nurse to demonstrate how to check the dialysis access site. On 6/6/24 at 11:15 AM, LPN #2 accompanied the surveyor in the resident's room to demonstrated how she checked the dialysis access site. LPN #2 used the bell of the stethoscope to listen to the bruit, LPN #2 did not palpate for the thrill. Upon inquiry, LPN #2 informed the surveyor that she used the stethoscope to listen for both the bruit and the thrill, and she was not aware that she must use the palm of her fingers to palpate for the thrill. The surveyor then asked LPN #2 if she recalled any in-service education received regarding the care of the hemodialysis access site, she stated, I cannot recall. The surveyor reviewed the medical record for Resident #4. A review of the Admission Record face sheet that Resident #4 was admitted to the facility with diagnoses which included, but were not limited to; end stage renal disease, anorexia nervosa and adjustment disorder. Resident #4 was scheduled to receive dialysis treatment on Monday, Wednesday and Friday. A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of the Physician Order Sheet (POS) included a physician's order dated 5/15/2020; to check the AV fistula for thrill and bruit every shift. The order was transcribed on the TAR and initialed by the nurses on all three shifts as being checked as ordered. On 6/10/24 at 9:00 AM, the DON in the presence of the Regional LNHA and survey team acknowledged that staff was checking the resident's dialysis access site for bruit, but not the thrill. A review of the facility's Hemodialysis Catheters- Access and Care of policy dated last revised 2/2023, included the purpose: hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding use of this catheter . Care of AV Fistula and AV Grafts procedure .4(h) check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood through the access . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 4 of 10 forms provided. The evidence was as follows: On 6/4/24 at 1:00PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on four of the ten provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 231430013; 231430014; 231430015; and 231430016. On 6/7/24 at 10:31 AM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. The DON acknowledged she should have completed the Part 5 as instructed on the reverse of the DEA 222 form as required. On 6/10/24 at 9:00 AM, the DON in the presence of the survey team and facility Administration stated she had been in-serviced on the proper way to complete the DEA 222 forms and again acknowledged the previously mentioned forms had not been completed correctly. A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item . A review of the facility's provided Medication Labeling and Storage policy with a revised date of February 2023 did not include information related to the completion of the DEA 222 forms. NJAC 8:39-29.7(c)

Based on observation and interview, it was determined that the facility failed ensure potentially hazardous food was stored in a sanitary manner. The deficient practice was evidenced by the following: On 6/3/24 at 10:22 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: In dry storage, five stacks of boxes containing food and beverage were stored directly on the floor which included a case of fruit cup salad; a case of pear juice; a case of coffee; a case of diced pears; two cases of cranberry juice; and a case of ketchup which were directly on floor. The FSD stated the food was just delivered and usually mats were placed on the floor first. The FSD acknowledged that food should not be stored directly on the floor. At that time, the Regional FSD stated the boxes should have been placed on a mat or palate and not directly on the floor. On 6/7/24 at 12:33 PM, the surveyor informed the Regional Licensed Nursing Home Administrator (LNHA) who was acting facility administrator, in the presence of the Director of Nursing and survey team these findings. A review of the facility's Food Receiving and Storage policy dated revised November 2022, included food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example dollies, pallets, racks, and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents . NJAC 8:39-17.2(g)

Complaint NJ #173248 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to perform proper hand hygiene during wound care to reduce the risk of infection. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #4), and was evidenced by the following: On 6/4/24 at 9:25 AM, Resident #4 was observed lying in bed on an air mattress. Resident #4 refused to be interviewed stating he/she was tired. The surveyor reviewed the medical record for Resident #4. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes mellitus, chronic pain, end stage renal disease, and dependence on renal dialysis. A review of the most recent quarterly Minimum Data Set, an assessment tool dated 3/4/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15; which indicated a fully intact cognition. A review of the Order Summary Report included a physician's order dated 6/1/24; for Bacitracin (antibiotic) ointment 500 unit per gram (unit/gm) to apply to the left great toe topically every day shift for wound care; cleanse with normal saline solution (NSS); pat dry; apply ointment to the affected area and wrap with [name redacted] gauze wrap. On 6/7/24 at 8:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare to administer Resident #4's wound care treatment. The LPN placed some antibiotic ointment into a small cup; obtained a sterile cotton tip applicator; obtained sterile gauze; and obtained the bottle of NSS. The surveyor observed the treatment and the following: At 9:03 AM, the LPN went into the resident's bathroom and performed hand hygiene using soap and water; then donned (put on) personal protective equipment (PPE) of a gown and gloves. The LPN removed the dressing on the resident's toe; doffed (removed) her gloves, and with no observed hand hygiene, donned a new pair of gloves. The LPN cleaned the toe with the NSS and patted the area dry; then doffed the contaminated gloves, and with no observed hand hygiene, opened the sterile cotton tip applicator and donned a new pair of gloves. The LPN used the cotton tip applicator to apply the antibiotic ointment to the wound; doffed the contaminated gloves, and with no observed hand hygiene, donned a new pair of gloves and applied the gauze dressing to the toe and foot. The LPN doffed the contaminated gloves, and with no observed hand hygiene, applied a numbing cream on the resident's hemodialysis injection area of the arm. The LPN then doffed the contaminated gloves, and with no observed hand hygiene hygiene, donned a new pair of gloves, and placed a wrap on the hemodialysis access site. The LPN then went into the resident's bathroom and doffed the contaminated gloves; performed hand hygiene using soap and water by rubbing her hands with soap outside the flow of running water for seventeen seconds. On 6/7/24 at 9:13 AM, during an interview with the surveyor, the LPN stated that hand washing should be done for 15-20 seconds and stated, I guess I should do it [apply friction] outside of the water. When asked about hand hygiene during the wound care, the LPN acknowledged that she should have been performing hand hygiene between glove changes. On 6/7/24 at 9:22 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the process of hand washing was to wet your hands, apply soap, and lather hands all over for at least 20 seconds outside the stream of water. The DON stated that if performed under the stream of water, you would be washing the soap off. The DON further stated that hand hygiene must be done in between glove changes to remove germs. A review of the facility provided, Hand Hygiene Comp [competency] Validation dated 05/16/24, documented that the LPN performed a competent return demonstration of hand hygiene which was signed by the LPN and the staff member conducting the competency. On 6/10/24 at 9:00 AM, the DON in the presence of the Regional Licensed Nursing Home Administrator and survey team acknowledged that the nurse should have performed hand hygiene after removing her gloves prior to donning new gloves. The DON also acknowledged hand hygiene using soap and water was performed by rubbing your hands with soap outside the flow of running water for twenty seconds. A review of the facility provided policy and procedure, Handwashing/Hand Hygiene revised October 2023, included but was not limited to; Policy Statement . hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene 1.trained and regularly in-serviced on the importance . in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene 1.a. immediately before touching a resident; c. after contact with . contaminated surfaces; d. after touching a resident; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Procedure Washing Hands 1. Wet hands first . apply an amount of product recommended. 2. Rub hands together . for at least 20 seconds . 3. Rinse hands with water and dry thoroughly . Applying and removing gloves 1. Perform hand hygiene before applying gloves. 5. Perform hand hygiene [after removing gloves]. A review of the facility provided policy and procedure, Wound Care revised October 2010, included but was not limited to; Purpose . to provide guidelines for the care of wounds to promote healing. Steps in the Procedure 2. Wash and dry your hands thoroughly. 4. Put on exam gloves. Loosen tape and remove dressing. 5. discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. 7. Use sterile tongue blades and applicators to remove ointments from their containers. 8. Pour liquids directly on gauze . 12. apply treatments as indicated. 13. Dress wound. 15. Discard disposable items. Remove gloves and discard . wash and dry your hands thoroughly. NJAC 8:39-19.4 (a)

Based on interviews and record review, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 2 of 4 residents (Resident # 99 and 75) reviewed for hospitalization s. The deficient practice was evidenced by the following: 1. On 4/22/22 at 9:40 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident # 99. The New Jersey Universal Transfer Form (NJUTF) and nurse progress notes revealed that the resident was transferred to the hospital on 2/5/22. Review of the the electronic medical record (EMR), revealed a document titled Notice of Intent to Transfer Resident with less than 30 Days completed by the Social Worker (SW), dated 2/5/22, which indicated that the bed hold policy was not provided to the resident or resident representative. There was no documented evidence in the hybrid medical record that written notification of the facility's bed hold policy was provided upon the resident's transfer to the hospital. On 4/22/22 at 11:39 AM, the surveyor interviewed the SW, who stated that the notification of the facility's bed hold policy of a resident's transfer to the hospital was done over the phone and documented by the SW in the EMR. The SW stated she didn't provide written notification of the bed hold policy upon resident's transfer to the hospital. The SW added that the written bed hold policy was reviewed with the resident or resident representative upon admission as part of the admission packet. On 4/22/22 at 11:55 AM, the surveyor interviewed the Director of Admissions (DA), who stated the written notice for the bed hold policy was reviewed with the resident or the resident's representative upon admission and would be reviewed with the resident representative over the phone upon transfer to the hospital. 2. On 4/25/22 at 9:41 AM, the surveyor reviewed the hybrid medical records of Resident # 75. The NJUTF and nurse progress notes revealed that the resident was transferred to the hospital on 1/29/22. Review of the MDS dated [DATE], indicated Resident # 75 was discharged to the hospital with a return anticipated. Review of the Notice of Intent to Transfer/Discharge Resident with less than 30 day notice dated, 1/29/22, reflected that the transfer to the hospital was necessary for the resident's welfare and the facility could not meet the resident's needs at the time of transfer. Further review of the facility's Notice of Intent to Transfer/Discharge Resident with less than 30 day notice reflected that the bed hold policy was checked as not applicable to provide to the resident or responsible party. On 4/26/22 at 10:09 AM, the surveyor interviewed the Administrator, who stated the DA reviewed the written bed hold policy with the resident or resident representative upon resident's admission, it is signed and filed in the resident's EMR. The Administrator stated the resident's representatives were not receiving written notification of the bed hold policy upon transfer to the hospital and that the SW was not aware it was her responsibility to complete. The surveyor reviewed the facility's policy titled Bed-Holds and Returns, modified on 1/4/22, which indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. The policy also indicated a resident and resident's representative would be provided written notification of the facility's bed hold policy, including reserve bed payment and the details of the transfer. The surveyor reviewed the facility's undated policy titled, Transfer or Discharge Notice which indicated that the facility shall provide to the resident and/or representative a written notification of the facility's bed-hold policy. NJAC 8:39-4.1(a)(32)

REFER to F 610 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) made by a resident representative who reported the allegation to the Licensed Nursing Home Administrator (LNHA). The resident representative alleged that a staff member had been rude during care of a resident on 4/8/22. This deficient practice was identified for one (1) of two (2) residents reviewed for abuse, (Resident #348) and was evidenced by the following: On 4/21/22 at 10:17 AM, the surveyor interviewed a resident representative (RR) in the room of Resident #348. The RR stated that the resident was recently placed on hospice services and was hoping to take the resident home soon, if possible. The RR stated that he/she had an incident during the first week of admission with a Certified Nursing Aide (CNA#2) who had come into the resident's room to render care to the resident. The RR stated that he/she refused to give the name of the CNA because other CNA's, such as the CNA #1 caring for the resident that day, were very good. The RR explained that a CNA#2 was rude, and he/she was uncomfortable with the way the CNA#2 had taken care of the resident. The RR added that he/she was aware that the job of a CNA was difficult but felt the CNA#2 was unhappy with having to do her job or she was having a bad day. The RR further explained that the CNA#2 had asked him/her to leave the room when she was going to change the resident and when he/she refused the CNA#2 became annoyed with him/her. The RR stated that he/she saw the CNA#2 had rolled the resident on their side to change the resident and was concerned because there were no bedrails on the bed to prevent the resident from rolling off the bed. The RR stated that he/she felt the CNA#2 spoke very rudely to him/her while she was changing the resident. The RR continued that the CNA#2 was going to leave a soiled linen on the bed after changing the resident until he/she had told the CNA#2 to change it. The RR also stated that the CNA#2 had placed the bedspread on a chair in the room, but part of the bedspread had touched the floor and the CNA#2 was going to put that bedspread back on the bed. The RR stated that he/she had to tell that CNA#2 the bedspread was touching the floor and could not be returned to the resident's bed. The RR stated that the CNA#2 dropped the bedspread on the floor and went to get another bedspread. The RR stated that he/she had spoken to the Licensed Nursing Home Administrator (LNHA) and explained the incident and the LNHA knew who the CNA was. When asked by the surveyor if he/she felt the issue had been resolved, the RR shrugged his/her shoulders. Then, the RR stated that he/she knew that the CNA#2 still worked on the floor but had not taken care of the resident since the incident. The RR was unsure of the exact date. On 4/22/22 at 10:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she was unaware of any issue with Resident #348 and had positive interactions with the RR for Resident #348. The DON stated that she would have to check for documentation. On 4/22/22 at 11:23 AM, the surveyor interviewed the Director of Social Services/Licensed Social Worker (DOSS/LSW) who stated that she had been working at the facility for four (4) months and also had previous experience in long term care as a LSW. The DOSS/LSW stated that any grievance or allegation was required to be investigated. The DOSS/LSW added that if any resident's representative had a complaint or grievance then she would have to take a statement and review with the team to decide whether it was necessary to immediately report to the NJDOH. The DOSS/LSW added that usually she would err on the side of caution and report more often. The DOSS/LSW added that usually the DON or LNHA had done the reporting to the NJDOH but she could be involved in the decision. The DOSS/LSW was unsure of any incident regarding Resident #348. On 4/22/22 at 1:14 PM, the surveyor, in the presence of the survey team, interviewed the DON who stated that she felt the incident was presented to her by the LNHA as a customer service issue. The DON stated that she had read the CNA #2's statement and had not thought there was an issue of abuse. The DON added that if the incident was presented as an allegation of abuse, she would have removed the CNA #2 from the floor immediately, reported to the NJDOH immediately and investigated. The DON acknowledged that any complaint regarding a staff member required an investigation to be completed. The DON stated that she could not find any documentation that a report was sent to the NJDOH and was unsure if the LNHA had any further documentation. A review of the documentation provided by the DON revealed an Employee Statement dated 4/8/22, by the CNA #2 which described that the CNA #2 was rendering care and the RR had told the CNA #2 to clean the resident better and the CNA #2 had answered that she wasn't done yet. The description continued that the RR had said she couldn't roll the resident on wet linens but the CNA #2 was tucking in the linens and rolled the resident and put clean linens under. The CNA #2 also wrote that the comforter corner was on the floor and the RR had said it was on the floor, so she put the comforter back on the floor and bagged it up. Further review revealed an In-Service Meeting Minutes dated 4/8/22, performed by the DON with the CNA #2 on the topic of Customer Service. There was no evidence of documentation of a report sent to the NJDOH. On 4/25/22 at 10:40 AM, the survey team met with the LNHA. The LNHA stated that he was the grievance officer and the abuse coordinator. The LNHA explained that the grievance process would be to review and investigate by speaking to all the involved parties and it would depend on the type of grievance, or it could be abuse so that would have to be differentiated. The LNHA further explained that differentiating involved how the person took it and would make a multidisciplinary decision with the DON and DOSS/LSW. The LNHA stated that he was aware of the incident involving the RR for Resident #348 and the CNA #2. The LNHA stated that there was no further documentation of the incident with Resident #348 and that was an oversite that it wasn't done. The LNHA stated that he thought the DON had followed up with an investigation. The LNHA stated that a report was not sent to the NJDOH because he did not think this was an allegation of abuse. The LNHA stated that the DON was aware of the incident and that he thought he had told the DOSS/LSW about the incident the next day. The LNHA acknowledged that an investigation was not completed and that a collaboration on the decision whether to report as an abuse allegation had not occurred. The LNHA explained that he had seen the RR checking in at the facility lobby and the RR looked sad, so the LNHA approached the RR to see if the RR wanted to talk. The LNHA added that the RR had told him that he/she had an interaction with the CNA #2. The LNHA stated that he felt that the RR was offended when the CNA #2 asked the RR to step out of the room. The LNHA added that the RR also expressed that the CNA #2 was going to place a bedspread that the RR said was touching the floor back on the bed. The LNHA stated that he did not feel that the complaint from the RR was an allegation of any abuse because it had no effect on the resident. The LNHA stated that he and the DON had spoken with the CNA #2 to understand both sides. The LNHA stated that the CNA #2 had a death in the family and felt that the interaction was between the RR and the CNA #2 and had nothing to do with the resident. On 5/4/22 at 9:57 AM, the survey team met with the LNHA and DON. The LNHA stated that all policies on abuse and grievances were provided and current. A review of the undated policy provided by the LNHA for Abuse Prevention Program reflected that all possible incidents of abuse are identified and assessed. In addition, any allegation of abuse is investigated and reported within timeframe's as required by federal requirements. A review of the undated policy provided by the LNHA for Grievances/Complaints, Recording and Investigating reflected that The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. N.J.A.C. 8:39-5.1(a)

REFER to F609 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to thoroughly and timely investigate an allegation of abuse reported to the Licensed Nursing Home Administrator by a resident representative. The deficient practice was identified for one (1) of two (2) residents reviewed for abuse (Resident #348 ), and was evidenced by the following: On 4/21/22 at 10:17 AM, the surveyor interviewed a resident representative (RR) in the room of Resident #348. The RR stated that the resident was recently placed on hospice services and was hoping to take the resident home soon, if possible. The RR stated that he/she had an incident during the first week of admission with a Certified Nursing Aide (CNA#2) who had come into the resident's room to render care to the resident. The RR stated that he/she refused to give the name of the CNA#2 because other CNA's, such as the CNA #1 caring for the resident that day, were very good. The RR explained that a CNA#2 was rude, and he/she was uncomfortable with the way the CNA#2 had taken care of the resident. The RR added that he/she was aware that the job of a CNA was difficult but felt the CNA#2 was unhappy with having to do her job or she was having a bad day. The RR further explained that the CNA#2 had asked him/her to leave the room when she was going to render care to the resident and when he/she refused the CNA#2 became annoyed with him/her. The RR stated that he/she saw the CNA#2 had rolled the resident on their side to change the resident and was concerned because there were no bedrails on the bed to prevent the resident from rolling off the bed. The RR stated that he felt the CNA#2 spoke very rudely to him/her while she was changing the resident. The RR continued that the CNA#2 was going to leave a soiled linen on the bed after changing the resident until he/she had told the CNA#2 to change it. The RR also stated that the CNA#2 had placed the bedspread on a chair in the room, but part of the bedspread had touched the floor and the CNA#2 was going to put that bedspread back on the bed. The RR stated that he had to tell that CNA#2 the bedspread was touching the floor and could not be returned to the resident's bed. The RR stated that the CNA#2 dropped the bedspread on the floor and went to get another bedspread. The RR stated that he/she had spoken to the Licensed Nursing Home Administrator (LNHA) and explained the incident and the LNHA knew who the CNA#2 was. When asked by the surveyor if he/she felt the issue had been resolved, the RR shrugged his/her shoulders. Then, the RR stated that he/she knew that the CNA#2 still worked on the floor but had not taken care of the resident since the incident. The RR was unsure of the exact date. On 4/22/22 at 10:07 AM, the surveyor interviewed the CNA #1 who stated that she was frequently assigned to Resident #348 and was familiar with the resident and the RR. The CNA #1 stated that the resident was nonverbal, on hospice and had to provide total care for the resident. The CNA #1 also stated that the RR could be demanding but she would try as best as she could to address the RR's concerns and care for the resident. The CNA #1 stated that she was aware of an incident that occurred between the RR and a CNA because the RR had told her that he/she had spoken to the Licensed Nursing Home Administrator (LNHA). The CNA #1 knew that the incident had occurred with CNA #2 because CNA #2 had told her. On 4/22/22 at 10:12 AM, the surveyor interviewed the CNA #2 who stated that her last day of work at the facility was next Friday because she had resigned to take another job. The CNA #2 added that she was burning out because she was hired approximately one year ago as a rehabilitation CNA with a 10AM to 6PM shift and was frequently pulled to be a CNA with a floor assignment and work the 7AM to 3PM shift. The CNA #2 stated that she was familiar with Resident #348 and the RR because the RR was rude to her. The CNA #2 explained that approximately two (2) weeks ago she had to perform care for Resident #348 and asked the RR to leave to provide privacy for the resident and the RR was offended by that. The CNA #2 added that the RR stayed in the room while she changed the resident and critiqued everything I was doing. The CNA #2 stated that she had to keep telling the RR during care that she was not done yet. The CNA #2 stated that she changed the resident as she would any other resident and that when she went to put the bedspread back on the bed, the RR told her that the bedspread was touching the floor and was not to be put it back on the bed, so she dropped the bedspread on the floor and went to get a new one. The CNA #2 then stated that she then bagged all the linens and left. The CNA #2 stated that she felt the RR was very demanding. The CNA #2 further explained that she was called to the office and was told that the RR made a complaint and she had to write a statement. The CNA #2 stated that she wrote a statement and received an inservice education on customer service. The CNA #2 stated that she was not assigned to care for the resident again and added that she usually was not assigned to that hallway anyway. On 4/22/22 at 10:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she was unaware of any issue with Resident #348 and had positive interactions with the RR for Resident #348. The DON stated that she would have to check for documentation. On 4/22/22 at 11:47 AM, the surveyor further interviewed the CNA #2 who stated that when she was called to the office, the DON and LNHA were there and told her that the RR had made a complaint. The CNA #2 was unaware as to what the RR had said. The CNA #2 added that she was not sent home that day or suspended. On 4/22/22 at 11:49 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that she was familiar with Resident #348 and the RR. The UM/LPN added that she was unaware of any issues with CNA #2. The UM/LPN stated that the RR, DON nor LNHA had not spoken to her regarding any issue with CNA #2. On 4/22/22 at 11:51 AM, the surveyor interviewed the 3 PM to 11 PM shift Supervisor/LPN (S/LPN) who stated that he was familiar with Resident #348 and the RR. The S/LPN added that he was unaware of any issues with CNA #2. The S/LPN stated that the RR, DON nor LNHA had not spoken to him regarding any issue with CNA #2. The S/LPN stated that if he was aware of a complaint by a resident's representative then he would have to bring the complaint to the attention of administration and if the complaint was regarding care, then he would have to remove the staff member immediately from the assignment of the resident and start an investigation. On 4/22/22 at 11:23 AM, the surveyor interviewed the Director of Social Services/Licensed Social Worker (DOSS/LSW) who stated that she had been working at the facility for four (4) months and had previous experience in long term care as a LSW. The DOSS/LSW stated that any grievance or allegation was required to be investigated. The DOSS/LSW added that if any resident's representative had a complaint or grievance then she would have to take a statement and review with the team to decide whether it was necessary to immediately report to the NJDOH. The SW added that usually she would err on the side of caution and report more often. The DOSS/LSW added that usually the DON or LNHA was reporting to the NJDOH, but she could be involved in the decision. The DOSS/LSW was unsure of any incident regarding Resident #348. On 4/22/22 at 11:31 AM, the surveyor interviewed the DON who stated that she had remembered that there was an incident regarding the RR for Resident #348 and had found documentation. The DON added that CNA #2 wrote a statement dated 4/8/22 and the DON performed an inservice educationwith the CNA #2 on Customer Service dated 4/8/22. A review of the documentation provided by the DON revealed an Employee Statement dated 4/8/22, by the CNA #2 which described that the CNA #2 was rendering care and the RR had told the CNA #2 to clean the resident better and the CNA #2 had answered that she wasn't done yet. The description continued that the RR had told the CNA #2 that she couldn't roll the resident on wet linens, but the CNA #2 was tucking in the linens and put clean linens under the resident. The CNA #2 also wrote that the comforter corner was on the floor and the RR had told the CNA #2 it was on the floor, so she put the comforter back on the floor and bagged it up. Further review revealed an In-Service Meeting Minutes dated 4/8/22, performed by the DON with the CNA #2 on the topic of Customer Service. There was no evidence of documentation of a report to the NJDOH or a Grievance Report with an investigation. On 4/22/22 at 12:06 PM, the survey team met with the DON and the Regional Director of Clinical Services (RDCS). The DON stated that she was not present when the LNHA had spoken with the RR, so she was unsure of what had transpired. The DON was unable to find documentation of the RR's statement. The DON stated that a grievance was usually documented on a Grievance Report and usually all documentation was completed together, but was unsure if the LNHA had additional documentation. The RDCS also stated that all documentation of an investigation of a grievance should be complete and together. The DON added that the LNHA was on high holiday and was unable to be reached. The DON then stated that she thought the LNHA had made the decision that an investigation was not needed. The DON stated that any complaint, grievance, allegation was usually discussed in morning meeting, but was unsure if this was discussed. The DON stated that the discussion would usually include a regional staff member to discuss whether it was necessary to report to the NJDOH. The DON stated that the UM/LPN was probably unaware of any incident because the staffing coordinator with the CNAs on the floor make the assignment schedule so the CNA #2 would not have been assigned to Resident #348. The DON added that she thought the RR was not a fan of CNA #2 but had not thought it was an abuse situation. The DON added that an allegation of any kind of abuse would require the staff member to be removed from work and an investigation started which would include statements and asking other residents on the staff member's assignment. On 4/22/22 at 1:14 PM, the surveyor, in the presence of the survey team, interviewed the DON who stated that she felt the incident was presented to her by the LNHA as a customer service issue. The DON stated that she had read the CNA #2 statement and had not thought there was an issue of abuse. The DON added that if the incident was presented as an allegation of abuse, she would have removed the CNA #2 from the floor immediately, reported to the NJDOH immediately and investigated. The DON stated that she should have communicated to the UM/LPN that there was an issue. The DON acknowledged that any complaint regarding a staff member required an investigation to be completed. The DON stated that she could not find any documentation that a report was sent to the NJDOH and was unsure if the LNHA had any further documentation. The DON also stated that after hearing the CNA #2 had expressed that she was burning out, the DON had sent the CNA #2 home. On 4/25/22 at 10:40 AM, the survey team met with the LNHA. The LNHA stated that he was the grievance officer and the abuse coordinator. The LNHA explained that the grievance process would be to review and investigate by speaking to all the involved parties and it would depend on the type of grievance, or it could be abuse so that would have to be differentiated. The LNHA further explained that differentiating involved how the person took it and would make a multidisciplinary decision with the DON and DOSS/LSW. The LNHA stated that he was aware of the incident involving the RR for Resident #348 and the CNA #2. The LNHA stated that there was no further documentation of the incident with Resident #348 and that was an oversite that it wasn't done. The LNHA stated that he thought the DON had followed up with an investigation. The LNHA stated that a report was not sent to the NJDOH because he did not think this was an allegation of abuse. The LNHA stated that the DON was aware of the incident and that he thought he had told the DOSS/LSW about the incident the next day. The LNHA acknowledged that an investigation was not completed and that a collaboration on the decision whether to report as an abuse allegation had not occurred. The LNHA explained that he had seen the RR checking in at the facility lobby and the RR looked sad, so the LNHA approached the RR to see if the RR wanted to talk. The LNHA added that the RR had told him that he/she had an interaction with the CNA #2. The LNHA stated that he felt that the RR was offended when the CNA #2 asked the RR to step out of the room. The LNHA added that the RR also expressed that the CNA #2 was going to place a bedspread that the RR said was touching the floor back on the bed. The LNHA stated that he did not feel that the complaint from the RR was an allegation of any abuse because it had no effect on the resident. The LNHA stated that he and the DON had spoken with the CNA #2 to understand both sides. The LNHA stated that the CNA #2 had a death in the family and felt that the interaction was between the RR and the CNA #2 and had nothing to do with the resident. On 4/29/22 at 2:11 PM, the survey team met with the administrative team. The Regional LNHA stated that an investigation was completed for a care concern from the RR of Resident #348 after surveyor inquiry. The LNHA provided a Grievance Report dated 4/26/22 which included an in-person interview and follow-up with the CNA #2 which revealed that at the time of the incident the CNA #2 had had a death in the family and had been in an accident which entailed an increase in costs for the CNA #2. The investigation also included as an action taken to perform a competency with the CNA #2. In addition, alert and oriented residents on the assignment of CNA #2 were interviewed regarding any interactions with the CNA #2. A review of the undated policy provided by the LNHA for Abuse Prevention Program reflected that all possible incidents of abuse are identified and assessed. In addition, any allegation of abuse is investigated and reported within timeframes as required by federal requirements. A review of the undated policy provided by the LNHA for Grievances/Complaints, Recording and Investigating reflected that Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. Further review of the policy reflected what the investigation and report should include and that the report will be filed with the administrator within five (5) working days of the incident. In addition, the resident or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended. N.J.A.C. 8:39-4.1(a)(5), 5.1(a), 9.4(e)(3)(i)

Based on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for two (2) of 25 residents, (Resident #16 and Resident #54) reviewed for accurate coding of MDS's and was evidenced by the following: 1. On 4/21/22 at 10:20 AM, the surveyor observed Resident #54 sleeping in bed with his/her eyes closed. The surveyor further observed a sign over the resident's bed that indicated the resident was to wear nonskid socks at all times. The surveyor did not attempt to interview the resident because the resident was observed sleeping. On 4/25/22 at 9:42 AM, the surveyor observed the resident lying in bed. The surveyor asked the resident how he/she was feeling, and the resident lifted his/her right hand and shook it from side to side, indicating so, so. The surveyor asked the resident if he/she had a fall, and the resident lifted his/her hand and shook it the same way. The surveyor asked the resident if he/she got hurt when they fell and the resident shook his/her head, no. The surveyor reviewed the medical record for Resident #54. A review of the resident's Admission Record (An Admission Summary) reflected that the resident had resided at the facility for several years and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's, Full QA Report dated 11/30/21 and timed at 5:00 PM, revealed that the resident had an unwitnessed fall in his/her bathroom which resulted in no injury. A review of the facility's progress notes dated 12/2/21, indicated that the interdisciplinary team met to discuss Resident #54's fall that occurred on 11/30/21. The progress note revealed that the resident was wearing non-skid socks, had the ability to self-propel himself/herself in the wheelchair and transferred himself/herself into the bathroom without asking for assistance from staff. The progress notes further reflected that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff educated the resident to ask for assistance prior to transferring himself/herself to the bathroom and the resident communicated understanding with a head nod. A review of the resident's Care Plan dated 4/02/20, reflected a focus area that the resident was at risk for falls related to wernicke's [CONDITION(S)]. The goal of the resident's care plan was the resident would have a decreased risk of falls with injury through the next review date. The interventions for the resident's Care Plan included to anticipate the residents needs, educate the resident and family about safety awareness, and to wear non-skid socks every shift. A review of the quarterly MDS dated [DATE], indicated that the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) out of 15 which indicated the resident's cognition was moderately impaired. A review of the resident's MDS, Section J1800 - Any Falls Since Prior Assessment indicated that the resident had one fall. A further review of Section J1900 - Number of Falls Since Prior Assessment indicated that the resident had one fall with no injury and one fall with major injury. The documentation in the MDS contradicted the resident's history of falls. The resident had one fall with no injury. On 4/27/22 at 12:41 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that she regularly cared for Resident #54 and to her knowledge, the resident had never had a fall which resulted in a major injury. At 10:51 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she had been regularly providing care to the resident for nine months and the resident had not had a fall with a major injury. At 10:54 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the resident had no falls with injury. At 11:04 AM, the surveyor reviewed the 3/01/22, quarterly MDS in the presence of the MDS Coordinator who stated that the MDS reflected that the resident had two falls, one with no injury and one with major injury. At 11:19 AM, the surveyor conducted a follow up interview with the MDS Coordinator who stated that the resident had one fall with no injury and the MDS was coded incorrectly. According to the (Resident Assessment Instrument) RAI Manual 3.0, falls are the leading cause of morbidity and mortality among nursing home residents and previous falls, especially recurrent falls and falls with injury, are the most important predictor of future falls and injurious falls. A further review of the RAI Manual 3.0 provides coding instructions for falls and indicates to code zero (0), none: if the resident had no major injurious falls since prior assessment. 2. On 4/22/22 at 1:00 PM, the surveyor reviewed the immunization record for Resident #16. The electronic medical record did not contain evidence that the resident had been offered the influenza vaccination. A review of the resident's quarterly MDS, dated [DATE], reflected that the facility did not offer the influenza vaccine to Resident #16. During an interview with the surveyor on 5/02/22 at 9:28 AM, the Regional Administrator presented the Influenza Immunization Informed Consent form signed by the spouse of Resident #16 and witnessed by the LPN. The form indicated that Resident #16 received the influenza vaccine on 10/21/2021. This contradicted what was coded in the quarterly MDS, dated [DATE]. During an interview with the surveyor on 5/04/22 at 11:34 AM, the Regional MDS Coordinator stated the PRN (as needed) MDS Coordinator had made, some mistakes while coding the MDS. According to the RAI Manual influenza - associated mortality results not only from pneumonia, but also from subsequent events arising from cardiovascular, [CONDITION(S)], and other chronic or immunocompromising diseases that can be exacerbated by influenza. NJAC 8:39-33.2(d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) follow the appropriate physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for one (1) of three (3) residents, (Resident #59) reviewed for pressure ulcers and was evidenced by the following: On 4/26/22 at 9:29 AM, the surveyor observed Resident #59 sitting upright at the edge of his/her bed on a functional air mattress eating cheerios for breakfast. The surveyor observed that the resident had light brown adhesive bandages attached to both feet. The brown adhesive bandage on the resident's right foot was dated 4/26. The surveyor further observed that the light brown adhesive bandage had detached from the residents left foot, and the residents foot remained placed on top of the adhesive bandage that was no longer adhered to the residents left foot. At that time, the surveyor exited the room and interviewed the Licensed Practical Nurse (LPN#1) who stated that the treatment to the resident's bilateral lower extremities had already been done by the nurse that morning. The surveyor reviewed the medical record for Resident #59. A review of the resident's Admission Record (An Admission Summary) reflected that the resident had resided at the facility for approximately three years and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated, 1/28/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. A further review of the residents quarterly MDS, Section M - Skin Conditions indicated that the resident was at risk for developing pressure ulcers. A review of the resident's April 2022 Order Summary Report (OSR) reflected a PO dated 4/9/22, to cleanse left medial plantar area (side and bottom of the left foot) opening with normal saline, apply iodosorb (a type of ointment that helps heal wounds), ABD pad and cling wrap two times a day for wound care. A further review of the resident's April 2022 OSR reflected an additional PO dated 4/9/22, to cleanse right heel with normal saline, apply iodosorb, ABD pad and cling wrap two times a day. On 4/27/22 at 9:23 AM, the surveyor observed the resident seated on the edge of his/her bed eating breakfast. The surveyor observed that the resident had white cling wrapped around his/her bilateral lower extremities. At 11:24 AM, the surveyor in the presence of another surveyor observed the Licensed Practical Nurse/Unit Manger (LPN/UM) perform the wound care treatments for Resident #59. The surveyors observed the LPN/UM remove the white cling wrap from the resident's right heel. The surveyors observed that the resident had a light brown adhesive bandage attached to his/her right heel. At 11:32 AM, the LPN/UM stated that when she removed the white cling dressing from the resident's right heel there was no ABD pad on the resident's heel. At 11:35 AM, the surveyors observed the LPN/UM remove the white cling dressing from the residents left foot. At that time, the surveyors observed that the resident had a light brown adhesive bandage attached to the bottom of his/her left foot. At 12:16 PM, the surveyor interviewed LPN#1 who stated that when the nurse performed the wound care treatment, the nurse should follow the PO that were prescribed by the physician. At 12:17 PM, the surveyor interviewed the LPN/UM who stated that the expectation was to follow the appropriate PO for treatments that were ordered for the resident. The LPN/UM further stated that if for whatever reason, the original dressing or topical medication was not available, the nurse would call the physician to make the physician aware and change the PO to reflect the care provided to the resident. On 4/28/22 at 10:32 AM, the surveyor interviewed LPN#2 who stated that she performed the wound care treatments on Resident #59 on 4/26/22. LPN#2 told the surveyor that she cleansed the resident's wounds with normal saline, applied iodosorb and put clean dry dressings to the resident's lower extremities. The surveyor asked LPN#2 what type of dressing she applied to the resident's lower extremities. LPN#2 stated, The border gauze, the ones that stick. LPN#2 further stated that she then wrapped the cling around the dressings she applied on the resident. LPN#2 told the surveyor that she performed the wound treatment that way because that was the way the previous nurse had performed the treatment on the resident. On 04/29/22 at 12:14 PM, the surveyor interviewed the Director of Nursing who stated that when a nurse was performing a wound care treatment, they should absolutely follow the PO and if there was an issue with supplies or something needed to be changed, the nurse should notify the resident's physician. A review of the resident's April 2022 electronic treatment administration record (eTAR) revealed that the nurses were signing at 0900 (9:00 AM) and 1700 (5:00 PM) from 4/9/22 to 4/27/22 that they had cleansed the resident's left medial below plantar area opening with normal saline, applied iodosorb to area, applied an ABD pad and cling wrap two times a day for wound care. A further review of the resident's April 2022 eTAR revealed that the nurses were signing at 0900 (9:00 AM) and 1700 (5:00 PM) from 4/9/22 to 4/28/22, that they had cleansed the resident's right heel with normal saline, applied iodosorb to area, applied an ABD pad and cling wrap two times a day for wound care. A review of the residents undated Care Plan revealed a focus area that the resident had a chronic right heel wound and left plantar foot wound that would close and reopen frequently. The goal of the resident's Care Plan was to maintain skin integrity and to keep chronic ulcer/callous to right heel healed. The interventions of the resident's Care Plan indicated to provide wound treatment as ordered and for the treatment nurse and podiatry nurse to evaluate discoloration. A review of the facility's undated Dressings, Dry/Clean Policy and Procedure indicated to verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Dressings, Dry/Clean Policy and Procedure further indicated, Apply the ordered dressing and secure with tape or bordered dressing per order. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to identify the causal factors of falls and provide adequate supervision to prevent falls. This deficient practice was identified for Residents # 4 and # 15, 2 of 9 residents reviewed for accidents. The fall interventions in place for Resident # 4 were not reviewed periodically to determine their effectiveness or revised as necessary. The facility also failed to provide adequate supervision to prevent Resident # 15, with a history of falling, from experiencing unnecessary falls. Both residents had numerous falls: Resident #4 had 12 falls that encompassed 6 months; Resident #15 experienced 25 falls from July through December 2014. Both Residents # 4 and # 15 suffered fractures of the humerus. This deficient practice was evidenced by the following: 1. During the initial tour of the facility on 2/2/15 at 10:30 a.m. the nurse stated that Resident #4 had fallen at the facility and was a high fall risk. At that time the surveyor observed Resident #4 self- propelling the wheelchair in the room. On 2/3/14 at 10:30 a.m., the surveyor reviewed the medical record of Resident #4 which revealed the resident was admitted to the facility on January, 2014 following repair of a left hip fracture. The resident had [DIAGNOSES REDACTED]. On 2/3/15 at 9:10 a.m., the surveyor observed the resident in the room. An interview on 2/3/15 at 10:15 a.m. with the Certified Nursing Assistant (CNA) who cared for the resident, revealed that the resident required total care for all activities of daily living, used the wheelchair for ambulation and was aware of his/her toileting needs. A review of the Interdisciplinary Progress Notes from 2/7/14 to 1/28/15 revealed the resident sustained [REDACTED]. 2/7/14 5:35 p.m. resident sitting on edge of bed and slipped to floor. 2/10/14 2 p.m. was found on the floor in the bathroom. 6/7/14 12:30 a.m. was found on the floor by bed. 6/10/14 8 a.m. was found on the floor next to the bed. 7/16/14 8 p.m. fell in the bathroom, sustained a laceration to the head. Was transferred to the hospital and returned with sutures. 11/2/14 5:45 a.m. fell in the bathroom. 11/4/14 8 p.m. was found on the floor next to the bed. 11/23/14 4:30 a.m. resident ambulated to bathroom without assistance, fell and sustained a right humerus fracture. 12/22/14 10:15 a.m. slid out of the wheelchair in bedroom. 12/25/14 10 a.m. fell in the room. 1/15/15 2:30 a.m. found sitting on the floor in the bathroom. 1/19/15 7 a.m. fell in the bathroom. Further review of the Progress Notes revealed that the resident fell in the bathroom on 11/23/14 and fractured the right arm. The resident was sent to the hospital and required surgical intervention to repair the fracture. The surveyor reviewed the Minimum Data Set (MDS), a resident assessment tool, dated 5/8/14, 8/9/14, 11/9/14 and 12/5/14, that indicated the resident was not assessed for a toileting program after any of the falls. A review of the MDS dated [DATE] indicated that the facility implemented a toileting program after the fall of 11/23/14. The surveyor reviewed Resident #4's care plan for falls. After the 2/10/14 fall, the Interdisciplinary Team (IDT) added, "schedule toileting upon rising and after meals." After the 6/7/14 fall, the IDT added, monitor and assist toileting needs." After the 11/4/14 fall, the IDT added," schedule toileting upon rising and after meals." However, the facility could not provide any documentation to verify that the resident was on a toileting program. There was no documented evidence that the Interdisciplinary Team had resident-specific interventions implemented after the falls. There was no documented evidence that the facility increased monitoring of the resident's whereabouts to keep the resident safe. Interventions that were in place were repetitive in nature, they were not reviewed after each fall to determine if they were working, nor were they revised as necessary. On 2/6/15 the surveyor asked the Director of Nursing (DON) how the facility addressed Resident #4's multiple falls in the bathroom. According to documentation provided by the facility, the resident could not ambulate and had to use the wheelchair for ambulation. The facility identified the resident as being cognitively impaired with poor safety awareness. The resident required an extensive assistance of one person with bed mobility transfer and toileting needs. Despite all the falls from the wheelchair, the resident's wheelchair was continually left at the bedside and was accessible to the resident. On 2/6/15 at 2:15 p.m., in the presence of the administrative staff, the DON stated , " I should have implemented a toileting program and ensured that the wheelchair was not left at the bedside." 2. The surveyor reviewed the medical record of Resident #15 on 2/5/15 at 10 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. During the initial tour of the facility on 2/2/15 at 10:30 a.m., the nurse stated the resident was a high fall risk. On 2/5/15 at 9:50 a.m., the surveyor observed Resident #15 seated in the Dining room. The resident was seated in a high back chair and was leaning forward and favoring the right side. Further review of the medical record revealed a Quarterly Minimum Data Set (MDS) a resident assessment tool, dated 6/23/14 which indicated that Resident #15 required a 2 person physical assist for transfer. The resident was cognitively impaired. On 2/5/15 at 12:30 p.m., the surveyor reviewed the Interdisciplinary Notes (IDCP) from 5/6/14 to 1/18/15 which revealed that Resident #15 sustained multiple falls at the facility. The following were documented: 7/11/14 2 a.m. fell in front of the nursing station. 7/12/14 2:30 p.m. fell in front of the nursing station. Another resident alerted the staff of the fall. 8/18/14 1 p.m. found on the floor. 8/30/14 8:15 a.m. rolled out of bed unto crash mat. 9/7/14 5:30 p.m. found on the floor between the wheelchair and the bed. 9/9/14 6:30 a.m. found on the floor mat. 9/18/14 2:45 a.m. rolled out of bed. 10/14/14 5 a.m.; 10/18/14 2:30 p.m.; 11/9/14 2:45 p.m.; 11/10/14 3:15 p.m.; 11/27/14 2:45 p.m.; 11/28/14 3:00 p.m.; 11/29/14 2 p.m.; 11/29/14 10:20 p.m.; 12/01/14 2:50 p.m.; 12/09/14 2:50 p.m.; 12/10/14 7:15 p.m.; 12/11/14 2 a.m.; and 12/18/14 2 a.m. rolled out of bed. 11/12/14 6 p.m. found on the floor in the room. 11/25/14 found on the floor. 12/17/14 5:59 p.m. found on the floor at the nurse's station sustained skin tear to the the left wrist and a raised area to the forehead. 12/18/14 2:52 p.m. fell on the floor in the room. 12/24/14 found with large bruise to right upper arm. X-ray revealed proximal non displaced right humerus fracture. Most of the falls occurred either at the nursing station or the resident's room. A review of the Incident/accident Report provided by the facility revealed that the falls were not witnessed. The resident was either found on the floor or the resident's roommate alerted the staff of the falls. The resident fell in the hallway on 12/17/14. Another resident alerted the staff of the fall. There was no staff at the nursing station to supervise the resident. An interview with the Unit Manager on 2/5/15 at 11:15 a.m., revealed that the resident had 46 incidents since admission. The Unit manager stated that the resident had a mental disorder and the falls were due to the restless behavior exhibited by the resident. A review of the investigative reports lacked evidence that staff attempted to intervene or re-direct the resident. There was no evidence of any attempts to engage the resident in activities to manage the behavior. Interventions were not revised accordingly. The resident was left unsupervised in the room or at the nursing station. An interview with the CNA who cared for the resident on 2/5/15 at 10:15 a.m. revealed that the resident was very unpredictable and required extensive assistance from staff with care. The resident was left unattended in the room. The line of supervision required by the resident was not specified in the medical record. The resident was cognitively impaired and could not follow directives from staff. NJAC 8:39-27.1

C# NJ Based on interviews, review of medical records and facility documentation, it was determined that the facility failed to notify a physician of a significant change in a resident's condition, for 1 of 5 residents sampled by this surveyor, (Resident #5). This deficient practice is evidenced by the following: Interviews and record reviews were performed on 12/14/2012 unless otherwise specified. 1. According to a Physician order [REDACTED]. In additional medical record review, a history of [MEDICAL CONDITION] was documented in a 9/22/12 care plan titled "Risk for decreased cardiac output related to Hx (history) [MEDICAL CONDITION](hypertension), CAD [MEDICAL CONDITION] Fib, [MEDICAL CONDITIONS]". According to the 9/13/2012 Minimum Data Set (MDS), an assessment tool, the resident scored fifteen out of fifteen on the Brief Interview for Mental Status (BIMS), denoting that the resident is cognitively intact. The resident however, requires the assist of staff for all ADLs (Activities of Daily Living). A nurse's note dated and timed 4/12/2012 at 4:37 a.m. revealed: "At 3 am, Resident #5 complained of SOB (shortness of breath). Resident head of bed raised to semi-fowlers position...SPO2 (peripheral oxygen saturation) 92%. No further complaints of SOB at this time. Will continue to monitor." There was no documentation that the physician was notified of the Resident's complaint of SOB or the SPO2. In a nurse's note dated and timed 4/13/2012 at 14:47 p.m. (2:47 p.m.), Resident #5 "...was able to carry on simple conversation and gave unusual answers when spoken to. SPO2 78% on room air. Applied O2 (oxygen) via nasal cannula at 2 L/min (liters per minute). There was no documentation provided that the physician was notified of the Resident's complaint of SOB or the application of oxygen. The note went on to say "SPO2 began to drop to 58. Non-rebreather (oxygen mask) applied and O2 set at 5 L/min. SPO2 came up to 98-99%." There was no documentation that the physician was notified of the continued drop of SPO2 to 58% and the application of a rebreather mask with an increase of oxygenation from 2 l/m to 5 l/m. A nurse's note, dated and timed, 4/13/2012 at 16:34 p.m. (4:34 p.m.) indicated: "Received resident with report of SOB ...SPO2 - 96%-97% on O2 at 3 liters...resident very tired...Unit Manager (UM), a Registered Nurse (RN), spoke with (the doctor) who ordered (the resident) be sent to (the hospital)...". This notification of the physician was more than 13 hours after Resident #5's initial complaint of SOB. The writers of the 4/12/2012, 4:37 a.m. nurse's note and the 4/13/2012, 14:47 p.m. (2:47 a.m.) nurse's note were no longer employed by the facility and not available for interview. On 12/14/2012 at 3:55 p.m. the surveyor interviewed the UM/RN, about the above situation of 4/13/2012 at 2:47 p.m. When the surveyor asked the UM/RN if she would call the physician regarding a change in Resident condition, she replied: "Days are really intense, (the nurse) may have said something to me, but I don't really recall." On 12/18/2012 at 12:20 p.m., the surveyor conducted a telephone interview with the 11pm-7am nursing supervisor, an RN. The nurse recalled the resident, (Resident #5), but did not remember the specifics of the night in question. On 12/14/2012 at 4:40 p.m., the surveyor interviewed the Director of Nursing (DON) about Resident #5 and the nurse's notes of 4/12/2012 and 4/13/2012. When the DON was asked about the lack of physician notification, the DON stated, "Doctor ... is a very difficult person to get a hold of...the nurse should have called the Medical Director, but the Medical Director doesn't like to give orders for someone else's residents." On 12/14/2012 at 4:40 p.m., the surveyor interviewed the DON about a facility policy on Physician Notification when a resident has a change in condition, to which the DON replied "...we have the Accidents, Incidents, and Adverse Events Policy which encompasses that", and added that they did not have a specific physician notification policy. The surveyor then reviewed the "Accidents, Incidents, and Adverse Events" policy, dated 6/1/1996 with a revision date of 2/9/2012. The surveyor noted under the "Assessments, Medical Assistance, Documentation" in Item # 2.1.3. it stated: "The nurse will notify the attending or covering physician of the incident, report the physical findings and extent of injuries, and obtain orders if indicated." On 1/9/2013 at 2:35 p.m., the surveyor conducted a telephone interview with the DON to clarify what the nurses should be documenting in the nurses notes. The DON replied, "anything out of the ordinary, anything critical, change of conditions, assessments." The resident was admitted to the hospital the day of transport, 4/13/12, with a [DIAGNOSES REDACTED]." NJAC 8:39-13.1 (d)