Every finding on record at Crystal Lake Healthcare and Rehabilitation

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for 2 of 6 residents reviewed (Resident # 1 and Resident #2) by implementing the practice of double diapering, which is not an accepted standard of incontinence care and has the potential to compromise skin integrity and resident dignity.According to the admission Record (AR) Resident #1 was admitted to the facility with diagnoses which included but were not limited to: dementia (a decline in mental ability-including memory, language, and reasoning), mild intellectual disabilities, and type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar caused by insulin resistance, where body cells fail to use insulin properly, alongside relative insulin deficiency).According to the Minimum Data Set (MDS), an assessment tool dated 2/1/26, Resident #1 had a Brief Interview for Mental Status (BIMS) score 99 which indicated that the resident was unable to complete this assessment.Resident #1's CP under Focus date initiated 9/15/25: Resident #1 is at risk for skin impairment r/t impulsive scratching and fragile skin, Extrapyramidal movements, Pvd. (Peripheral Vascular Disease).According to the admission Record (AR) Resident #2 was admitted to the facility with diagnoses which included but were not limited to: urinary tract infection, altered mental status, and generalized anxiety disorder.According to the Minimum Data Set (MDS), an assessment tool dated 1/24/26, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated that the resident was severely impaired.Resident #2's CP included the following:Under Focus date initiated 2/25/21: SKIN/ INTEGRITY [Resident #2] HAS THE POTENTIAL FOR ALTERATION IN SKIN INTEGRITY RELATED TO: --INCONTINENCE. Under Interventions: KEEP SKIN CLEAN AND DRY--PROVIDE PROMPT INCONTINENCE CARE.On 4/28/26 at 5:31 AM, during care observation, Resident # 1 was noted to be wearing two incontinence diapers layered on top of each other (double diapering). The inner diaper was wet with urine, while the outer brief remained in place and dry.On 4/28/26 at 5:35 AM, during care observation, Resident #2 was noted to be double diapered. The inner diaper was wet with urine, while the outer brief remained in place and dry.On 4/28/26 at 6:43 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) from the 3rd floor who was responsible for double diapering both residents. The CNA apologized for double diapering residents and acknowledged this was not good practice. She further stated that both residents are heavy wetters and reported it was not a frequent practice she performed but due to short staffing that was why she double diapered the residents. The CNA stated that residents should not be double diapered as it could cause skin breakdown.On 4/28/26 at 6:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was covering the 3rd floor. The LPN stated that when he checked the residents, they were not double diapered. He stated if he did observe a resident being double diapered, he would change them into a single diaper. When asked why residents shouldn't be double diapered, the LPN responded that it could cause skin breakdown because urine and feces are acidic to a resident's skin and that it was an unsanitary practice.On 4/28/26 at 8:32 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she expects her staff to round on all residents, to make sure that the residents are turned and repositioned as needed, and that they are clean and dry. The ADON stated she was unaware that staff were double diapering residents but that they should not be because it can cause skin breakdown.On 4/28/29 at 9:33 AM, the surveyor interviewed the Director of Nursing (DON), who stated the expectation is for staff to not double diaper residents because skin integrity is a concern and double diapering could cause other complications to arise. The DON stated that there was no previous knowledge of staff double-diapering residents and that there were no grievances or complaints regarding this practice. On 4/28/29 at 9:33 AM, the DON provided the surveyor with training that had been completed on 4/25/26 for the CNAs regarding CNA expectations and daily duties for the facility. The facility document titled CNA DON'T'S [sic] included: 4. Do not double brief any resident - If a resident request [sic] inform nursing administration.A review of the facility's policy titled, Perineal Care with an updated date of 1/2026, included the following information under Policy Statement: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.A review of the facility's policy titled, Resident Rights with an updated date of 1/2026, included the following information Policy Statement: employees shall treat all residents with kindness, respect, and dignity. Under, Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.N.J.A.C. 8:39-27.1(b)

Complaint #: 2716119 Based on observations, interviews, review of the medical record, and other pertinent facility documentation, it was determined that the facility failed to protect a resident from self-harm and provide adequate supervision for a resident (Resident #100) with a history of suicidal ideations with plans to cut their wrist prior to admission to the facility, who cut their wrist while residing in the facility. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #100). According to the progress notes, on 1/11/2026 at 10:30 PM, the resident was noted by facility staff with a two-inch laceration to their right wrist that was bleeding profusely. The resident stated, I thought that I was going home, but they said I was not. During an interview with the Licensed Practical Nurse (LPN #1) on 1/21/2026, LPN #1 stated that the Certified Nursing Aide (CNA #1) during their rounds observed that the resident was bleeding, and when LPN #1 went to the resident's room, the resident was holding their right wrist with toilet paper to reduce the bleeding. LPN #1 stated that Resident #100 disassembled a razor that they found in the shower, and that LPN #1 was unaware that the resident had a history of self-injurious behaviors. A review of the admitting facility's paperwork included on 8/27/2025, Resident #100 called 911 and informed the police officer that they were having suicidal ideations and wanted to cut themselves with a razor. A review of the resident's medical record at their current facility including, their care plan and physician's orders, did not include any safety interventions put in place to protect the resident from self-harm. The facility's failure to provide adequate supervision and protect Resident #100 from self-harm, who had a history of suicidal ideations, placed Resident #100, as well as all residents at risk of self-harm. This has the likelihood of serious physical harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 1/11/2026 at 10:30 PM, when Resident #100 cut themself on their right wrist with a razor and was bleeding profusely. The facility Administration was notified of the IJ on 1/22/2026 at 4:57 PM. The facility submitted an acceptable Removal Plan (RP) on 1/23/2026 at 11:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 1/27/2026. The facility further failed to ensure all residents with a history of suicidal ideations a.) who were placed on monitoring were monitored; b.) their behavioral monitoring sheets were completed; and c.) they did not have access to metal utensils, razors, or other sharp objects. This deficient practice was identified for 3 of 6 residents reviewed for accidents (Resident #11, Resident #75, and Resident #95). The evidence was as follows:Part A A review of the facility's Safety and Supervision of Residents policy, dated revised July 2017, included our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents . Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . A review of the facility's admission Criteria policy, dated revised March 2019, included our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: 1. The objective of our admission criteria policy are to .b. admit residents who can be cared for adequately by the facility . A review of the facility's Sharps Disposal policy, dated revised January 2012, included the facility shall discard contaminated sharps into designated containers .Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers . A review of a Facility Reported Event (FRE) submitted to the New Jersey Department of Health (NJDOH), revealed that on 1/11/2026 at approximately 10:30 PM, Resident #100, who had a psychiatric history, presented with a self-inflicted injury to the right wrist discovered during rounding. The resident had a history of metabolic encephalopathy (brain dysfunction), acute kidney failure, depression, falls, diabetes mellitus, and schizophrenia. The facility indicated the resident had no previous behaviors and no plan of care was developed prior to the incident. The immediate interventions included bleeding control, vital sign assessment and evaluation of current safety risk, and activating the emergency response/911. The resident was transferred to the emergency room. An environmental safety check was completed, and sharp objects were removed to prevent further access. A review of the Resident #100's admission Referral Packet from the resident's previous facility included the following documents: A Progress Note dated effective 9/3/2025 at 2:30 PM, revealed that on 8/27/2025, Resident #100 called 911 and informed police officers that they were having suicidal ideations and wanted to cut themselves with a razor. The police officers arrived at the facility and transferred the resident to the hospital as per physician's order. The resident returned to the facility and was placed on every 15-minute checks, and later placed on one-to-one (1:1) monitoring, and all potential items such as razors, cords, etc. were removed from the resident's room. Resident #100's individual comprehensive care plan (ICCP) from the previous facility, included a focus area dated 8/27/2025, that the resident was at risk for self-harm related to suicidal thoughts and ideation. The interventions included but were not limited to; administer medications as ordered; monitor for effectiveness and side effects, including worsening thoughts of self-harm; belts, razors, sharp objects removed from the resident's room, and dietary to send plastic utensils and paperware for meals, and ensure all utensils are collected after meals. On 1/20/2026 at 10:12 AM, the surveyor reviewed the current medical record (MR) for Resident #100, which revealed the following: A review of the admission Record, an admission summary, revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; depression, schizophrenia, and intellectual disabilities. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/28/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. A review of Resident #100's ICCP included a focus area dated 10/31/2025, that the resident was at risk for an alteration in mood and well-being. Interventions included to administer medications as ordered; monitor/document for side effects and effectiveness; and to monitor for potential signs of distress. The ICCP did not include that the resident was at risk for self-harm related to their recent history of suicidal ideations with a plan prior to admission into the facility and any related interventions. A review of the Order Summary Report (OSR) dated as of 1/11/2026, included the following physician order (PO): A PO dated 9/17/2025 at 8:52 PM, for aspirin (a blood thinner) enteric coated (EC; a special layer of coating on a tablet) daily for deep vein thrombosis (DVT; a medical condition where a blood clot forms in the vein). A PO dated 9/17/2025 at 8:52 PM, for Eliquis (a blood thinner) 2.5 milligrams (MG) by mouth two times per day. A PO dated 1/11/2026 at 10:38 PM, to send the resident out to the local hospital for evaluation. The physician's orders did not include any special monitoring for the resident's behaviors related to their history of suicidal ideations with a plan (history of attempts). A review of the Progress Notes included a nurse's note (NN), dated 1/11/2026 at 11:02 PM, [Resident #1] was noted by CNA (CNA #1) during hourly rounds the resident sustained injury. This writer entered room and noted resident had an injury to the right wrist. Resident stated, I thought I was going home, but they said I'm not. It was noted that resident had a 2 inch laceration to the right wrist which was noted to be bleeding profusely. Resident was noted to have slurred speech, diaphoretic, but able remain conscious. Nurse stat was initiated and this writer held constant pressure to residents wound while fellow nurse applied [oxygen] and obtained vitals. 911 was called. On 1/20/2026 at 12:47 PM, the surveyor interviewed CNA #1, who stated he regularly cared for Resident #100, and he was not sure of the resident's recent history of suicidal ideation with a plan. CNA #1 confirmed that he worked the evening shift on 1/11/2026, and at approximately 10:30 PM that evening, when he went to do his final rounds before his shift ended, he went into Resident #100's room and saw a trail of blood on the floor. CNA #1 continued that he immediately called the nurse (LPN #1), who checked on the resident, and informed him that the resident cut themself with a razor, and to notify the nursing staff to call emergency services/911. CNA #1 also stated that he did not know how the resident obtained the razor because they never asked for one on that shift, and that the razors were kept under lock and key in the nurse's storage room. CNA #1 stated he had to go to the nurse to obtain a razor, and that residents cannot have a razor in their possession unless they were monitored. CNA #1 added that typically after the resident shaved, the used razor would then be discarded by the CNA in the sharps container located in the Shower Room, or given to the nurse to discard in the sharps container on the medication cart. CNA #1 also stated that it was the responsibility of the CNA to ensure that the razor was disposed of properly. On 1/21/2026 at 11:34 AM, the surveyor interviewed LPN #1 via telephone, who stated on 1/11/2026 at approximately 10:30 PM, CNA #1 informed him that the resident was bleeding. LPN #1 added that when he went into the room, the resident was holding their right wrist with toilet paper in an attempt to stop the bleeding. LPN #1 stated at that point, he did not look at the resident's wound, but he saw the amount of blood that was on the floor, so he grabbed a towel and wrapped it around the area that the resident was holding and the LPN applied pressure to the area. LPN #1 stated he asked the resident what happened, and they told him that they were told that they had to stay at the facility forever. LPN #1 stated that he called for help from the other nurses and called 911 from his cell phone. LPN #1 said about 30 minutes later, he noticed on the resident's bedside table, that there was a disassembled shaving razor. The blade was on the bedside table near the razor, and the shaving razor's handle was broken off. LPN #1 added that Resident #100 stated that they had found the razor in the shower. LPN #1 stated he kept asking the resident questions to keep them conscious until the paramedics arrived because they lost a lot of blood. LPN #1 stated that he was not aware that the resident had any prior suicidal or self-injurious ideations. At that time, LPN #1 stated that the razors were stored in the nurse's storage room under lock and key, and when a resident needed to shave, the nurse gave the CNA the razor, then the CNA returned it to the nurse so it could be discarded in the sharps container. LPN #1 added that Resident #100 should not have had access to a razor because they were taking Eliquis, and that the resident should use an electric razor due to the risk of bleeding when taking Eliquis. On 1/21/2026 at 12:07 PM, the surveyor interviewed the Admissions Director (AD), who stated that she was the only person who worked in the admissions department. The AD stated that the admission Referral Packet was received from the sending facility via fax or email, or the facility accessed the hospital portal, which included the resident's admission Record, Progress Notes, medication list, and Care Plan. The AD stated that both she and the Director of Nursing (DON) were responsible for reviewing the entire admission Referral Packet prior to accepting a new resident to ensure that the facility could clinically care for that resident and the criteria for admission was met. The AD stated that she printed out the admission Referral Packet and sat down with the DON to review the packet. The AD added that she tried to look at the sending facility's documentation for the last 30 days and looked at the Care Plan from the sending facility because a lot of what she and the DON needed to know was included in the Care Plan. The AD further stated that if the resident had a history of suicidal ideation or self-injurious behavior, it would be looked into a little deeper as far as stability was concerned, prior to acceptance. When asked, the AD did not recall Resident #100 having a history of suicidal ideations, and there were no additional safety measures in place for the resident's admission that she could recall. On 1/21/2026 at 12:56 PM, the surveyor interviewed the DON, who stated that the AD emailed the admission Referral Packets to her and she reviewed all the referrals that came into the building to determine if the resident could be clinically accepted. The DON added that when she reviewed the admission Referral Packet, she would do a deep dive into their referral. The DON reviewed the sending facility's Care Plan, Progress Notes, medications, labs, and nursing assessment, and added she read every single Progress Note. When asked how the initial Care Plans were created, the DON stated that it was done as an interdisciplinary team and that, They look at everything, including the diagnoses, physician's orders, care plan, and progress notes from the sending facility. The DON stated that if the sending facility included in their Progress Notes that the resident had suicidal ideation, it should have been included in the resident's Care Plan and the resident should not have had access to sharp objects. On 1/21/2026 at 2:28 PM, the surveyor conducted a follow-up interview with the DON and asked if she was aware of Resident #100's recent history of suicidal ideation, and the DON hesitated and stated not off hand, she would have to review the resident's records. An acceptable Removal Plan was received on 1/23/2026 at 11:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the immediacy including; on 1/22/2026, Resident #100 was transferred to the hospital and did not return to the facility. On 1/22/2026, the facility conducted an immediate safety sweep of the entire facility including bathrooms and shower areas, to remove all sharp objects, including razor blades, from resident-accessible areas; and all razor blades were removed from common shower areas and secured in a locked central supply by the interdisciplinary teams. An immediate audit of all residents was completed on 1/22/2026, by the DON to identify residents with a history of suicidal ideation, self-injurious behaviors, and mental health diagnoses requiring enhanced supervision and placed them on appropriate safety interventions. All residents identified at risk for self-harm were placed one enhanced supervision by nursing staff by the DON including; every 15-minute checks or 1:1, environmental safety checks, and removal of potentially harmful items from resident rooms. On 1/22/2026, the DON and the Assistant Director of Nursing (ADON) re-educated all licensed nursing staff on Policy Suicide Threats, Identification of Suicide Risk, Environmental Safety, Required supervision and monitoring, and Immediate reporting and escalation procedures. On 1/23/2026, the Administrator provided education to the Ambassador Group on identifying environmental hazards, including razors and other sharp or potentially harmful objects, and initiated facility-wide Ambassador Rounds focused on environmental safety and sharp-object removal. On 1/23/2026, the DON provided staff education on; immediate escalation to clinical leadership if environmental hazards are identified and Resident Safety. The survey team verified the implementation of the Removal Plan on-site on 1/27/2026, and determined the immediacy was removed as of 1/27/2026 at 1:25 PM. Part B 1. On 1/23/2026 at 12:00 PM, the surveyor reviewed the Diagnosis Report for residents identified with suicidal ideations that was provided by the facility. Resident #75 was identified on that list as having suicidal ideations. The surveyor reviewed the medical record for Resident #75. A review of the admission Record revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; suicidal ideations, bipolar disorder, and intellectual disabilities. A review of Resident #75's quarterly Minimum Data Set (MDS), an assessment tool dated 1/1/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. A review of the Individual Comprehensive Care Plan (ICCP) revealed a focus area dated 1/22/2026, that the resident was at risk for self-directed violence related to a history of suicidal ideation. The interventions included; environmental safety checks, no sharp objects, assess for suicidal ideations every shift, and monitor for changes in mood, affect, sleep, appetite or behaviors. A review of the Order Summary Report (OSR) dated as of 1/22/2026, included a physician's order (PO) dated 1/22/2026, for one-to-one (1:1) monitoring. On 1/23/2026 at 12:55 PM, the surveyor entered Resident #75's room and observed the resident alone with no 1:1 supervision. The surveyor also observed a metal knife, fork, and spoon on the resident's overbed table. On 1/23/2026 at 12:56 PM, the Certified Nursing Aide (CNA #2) walked into Resident #75's room and confirmed that the resident was on 1:1 monitoring. A review of the 1:1 behavior monitoring sheet (a worksheet used to document the resident's behaviors, at 15-minute intervals) was blank with no entries made for the entire day. At that time, the surveyor briefly interviewed CNA #2, who stated that she did not have a pen to document the resident's behavior, and that she went to the nurses' station to ask for a pen. CNA #2 stated she saw the surveyor go to the resident's room and came back to the room. On 1/23/2026 at 1:05 PM, the surveyor observed CNA #2, who was assigned to be with Resident #75, walking in the hallway towards Resident #75's room. The surveyor followed CNA #2 into the resident's room and observed Resident #75 in bed alone not being monitored. On 1/23/2026 at 1:06 PM, the surveyor interviewed CNA #1, who stated that sharp objects or anything unsafe should be removed from the resident's drawers and closet. CNA #1 added that 1:1 supervision should be monitored closely, and the staff should not leave the resident alone when they are on a 1:1 monitoring. On 1/23/2026 at 1:39 PM, the surveyor interviewed the Registered Nurse (RN #3), who stated when a resident was on 1:1 monitoring, the CNA should be with the resident at all times, and the documentation of the resident's behaviors should be timely. RN #3 further stated that if the resident was left unattended, there was a risk of suicide or self-injurious behavior. On 1/23/2026 at 3:29 PM, the surveyor interviewed the Director of Nursing (DON), who stated that a resident should always be monitored when they were on 1:1 supervision and they should never be left alone. The DON added that the resident should not have metal utensils because they could harm themselves with it, and that the resident's behavior should be documented timely. 2. On 1/23/2026 the surveyor reviewed the Diagnosis Report for residents identified with suicidal ideations that was provided by the facility. Resident #11 was identified on that list as having suicidal ideations. The surveyor reviewed the medical record for Resident #11. A review of the admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility in September of 2022 with diagnoses which included chronic kidney disease, morbid obesity and major depressive disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/6/2025, reflected the resident had a brief interview for mental status score of 12 out of 15, which indicated a moderately impaired cognition. Further review revealed the resident reported over the last two weeks, they had experienced little interest or pleasure in going things nearly every day, had felt depressed or helpless nearly every day, had trouble with sleep nearly every day. When asked if they had thoughts of hurting themselves, they reported no, never. A review of the individualized person-centered care plan reflected a focus area initiated 1/22/2026, for risk of self-directed violence: History of Suicide ideation. Interventions included environmental safety checks, no sharp objects (remove as needed), encourage relaxation techniques (deep breathing, imagery, decreased stimuli). Monitor for changes in mood, affect, sleep, appetite or behaviors (restlessness, agitation, anxiety. Psych follow-up. Assess for suicidal ideation every shift and PRN (as needed). Implement suicide precautions per MD (physician) order when indicated. A review of the Order Summary Report, included an order dated 1/22/2026 for one to one monitoring for 24 hours. On 1/23/2026 at 1:22 PM, the surveyor in the presence of Certified Nurse Aide #8 (CNA #8) knocked on the resident #11's closed door. There were no staff observed either outside the door or in the room monitoring the resident. The surveyor and CNA #8 performed a room safety check and no razor blades or sharp objects were found in the resident's room. The resident stated they had been in their room all day because they weren't well and had an upset stomach. On 1/23/2026 at 1:38 PM, the surveyor interviewed CNA #8 who stated their assignment did not include Resident #11's room. On 1/23/2026 at 1:41 PM, the surveyor interviewed CNA #9 who stated they had received an in-service education regarding a new policy involving the procedure for razor use as well as identifying residents that may be depressed and also on removing sharp objects from resident's rooms. CNA #9 also stated Resident #11's room was not on her assignment. On 1/23/2026 at 1:49 PM, the surveyor interviewed CNA #10 who stated Resident #11 was on her assignment that day. CNA #10 stated she had received an education recently regarding removal of sharp objects from resident rooms and a new procedure for signing out razors. When asked what it meant for a resident to be on one to one supervision, CNA #10 stated it meant a resident was having behaviors and that a staff member must stay with them. When asked if there were any residents on the unit currently on one to one monitoring she stated no. On 1/23/2026 at 2:01 PM, the surveyor interviewed Licensed Practical Nurse #2 (LPN #2) who stated she had received education on the new process for signing out razors to ensure resident safety. When asked what one to one monitoring was, LPN #2 stated it was usually when a resident was having behaviors and could be a risk to themselves or others, a staff member would need to keep eyes on them at all times. In addition, we need to fill out the monitoring sheets, whoever is watching the resident, usually every 15 minutes. When asked if any residents were currently on one to one monitoring LPN #2 stated Resident #11 was on one to one monitoring, but the order had been discontinued that morning. When asked who was monitoring Resident #11 this morning LPN #2 stated CNA #8 had been assigned during lunch she believed. On 1/23/2026 at 2:10 PM, the surveyor re-interviewed CNA #8 who confirmed he had not been assigned a one to one that day. On 1/23/2026 at 2:03 PM, surveyor #2 interviewed LPN/UM #2 who stated she had received education regarding identifying suicidal ideations. LPN/UM #2 confirmed Resident #11 was on one to one monitoring. Surveyor #2 and LPN/UM #2 went into Resident #11's room and LPN/UM #2 confirmed there were no staff present in the room monitoring the resident. RN/UM #2 stated Resident #11 would not permit it. Resident #11 was present and stated no, I won't, and confirmed no one had been sitting with her. RN/UM #2 was unaware which staff member had been assigned to monitor Resident #11. RN/UM #2 stated since Resident #11 would not tolerate a one to one, then she should call the physician to get a new order for close monitoring instead. On 1/23/2026 at 3:29 PM, the surveyor interviewed the Director of Nursing (DON), who stated that a resident should always be monitored when they were on 1:1 supervision and they should never be left alone. The DON added that the resident should not have metal utensils because they could harm themselves with it, and that the resident's behavior should be documented timely. 3. A review of the admission Record (AR), an admission summary, indicated that Resident #95 was admitted to the facility with the diagnoses which included but was not limited to dementia, malignant neoplasm of the thyroid gland and alcohol abuse. A review of the quarterly MDS dated [DATE], indicated that the resident had scored of 9 out of 15 on the Basic Interview for Mental Status (BIMS) which reflected moderate cognitive impairment. The MDS also indicated that the resident was independent with activities of daily living (ADLs) and exhibited not behaviors during the review period. On 1/23/2026 at 12:28 PM. the surveyor reviewed Resident #95's electronic medical record (EMR). The facility identified the resident as an at-risk resident due to a history of suicidal ideation. A review of the physician orders dated 1/22/26 reflected a physician's order for the resident to have one-to-one monitoring for a duration of 24 hours. The surveyor reviewed six months of Progress Notes (PN) and there was no documentation indicating that Resident #95 expressed or voiced any suicide ideations while residing in the facility or to facility staff. A review of the ICCP revealed a Focus Area dated 3/25/21 which identified a long psychiatric history with a history, including suicidal ideation and history of suicidal attempts. Interventions included the following: -Monitor thyroid levels and reassure the resident that correct medication dosage was being administered. -Provide diversions to address obsessive thoughts including snacks, music, smoking and activities. -Remind the resident of 12 step program with date and times. - Ensure no sharp objects per psychiatric recommendations and remove as needed. -Monitor for any return of suicidal ideations. -Maintain safety for all and remove objects that can harm. Attempt to de-escalate resident and attempt to have resident verbally contract for safety and notify physician and psychiatry promptly. On 1/23/2026 at 12:53 PM, the surveyor interviewed LPN #3, who stated that the facility administration had provided education regarding a new policy or razor blades and sharps. She stated that the policy indicated that all razor blades were not to be stored anywhere on the unit. The policy specified the storage of sharps and there were to be no sharps stored anywhere on the unit. She further stated that all sharps were to be stored in central supply and that no sharps were to be accessible on the unit at any time. The LPN explained that is a resident required shaving, the nurse was responsible for retrieving the razor blade from central supply, providing it to the CNA, and ensuring the razor blade was returned immediately following use. She stated that residents were not permitted to handle razor blades at any time. She further explained that razors were signed out in a sharps inventory log maintained in central supply. On 01/23/2026 1:05 PM, the surveyor inspected Resident #95's room and handled razor and three unopened packages of razor blades, each containing four razor blade heads, located on the windowsill in the resident's bathroom. The surveyor also observed a large nail clipper sitting on the shelf inside bathroom stall. At the time of observation, a staff member was present in the resident's room monitoring the resident. On 1/23/2026 at 1:12 PM, the surveyor interviewed the staff member who identified herself and a Monitor. The Monitor stated she was assigned to monitor Resident #95 and reported that she had been informed the resident had a history of attempting to harm themselves. She stated that she was not provided with instructions regarding her responsibilities while monitoring the resident and was not instructed to conduct environmental checks every 15-minutes. The Monitor further stated she had not received any in-service education in the previous 24 hours. On 1/23/2026 at 1:08 PM, surveyor interviewed a CNA #11, who stated he received in-service education on reporting residents who express suicidal thoughts to administration. He stated that razor blades were required to be signed out and obtained from central supply and that there should be no sharps accessible anywhere on the unit. On 1/23/2026 at 1:18 PM, the surveyor interviewed a CNA #12 who stated that he was educated on sharps. He stated that the staff routinely checked all residents' drawers for sharps. He further stated that if a resident was identified as a suicide risk, no sharps were permitted in the resident's room and that any expression of suicidal ideation must be reported immediately. On 1/23/2026 at 1:24 PM, the surveyor interviewed CNA #13 who was the primary CNA for Resident #95. The CNA stated

Based on observation, interview, review of medical records and pertinent facility documentation, it was determined that the facility failed to ensure that a cognitively impaired resident (Resident #2), who was dependent on staff for activities of daily living (ADLs) a.) received appropriate interventions to prevent the development of a facility-acquired full thickness pressure injury; b.) ongoing skin assessments were completed and documented in accordance with a physician's order; c.) hospice recommendations for pressure reducing devices were communicated to the physician; and d.) consistently follow-up documentation to monitor the progression or resolution of the skin breakdown. On 11/22/25, Resident #2 was identified as having a Stage 1 reddened area on their sacrum, that subsequently progressed to a full thickness wound and the wound measured on 1/18/26, as 10 centimeters by 7.5 centimeters by 7.5 centimeters (10 cm x 7.5 cm x 7.5 cm) by the Wound Care Nurse Practitioner (NP) during their initial assessment. This deficient practice was identified for 1 of 1 resident reviewed for wounds (Resident #2), and was evidenced by the following: A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, dated revised April 2018, included that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers for example immobility, recent weight loss and history of pressure ulcers. In addition, the nurse shall describe and document/report the following: a.) Full assessment of pressure sore including location, stage, length width, depth, presence of exudate [fluid drainage] or necrotic [dead] tissue; b.) Pain assessment; c.) Resident's current mobility status; d.) Current treatments to include support surfaces and all active diagnoses; e.) The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches and dressings. A review of the facility's Prevention of Pressure Injuries policy, dated revised April 2020, included Risk Assessments.2. Use a standardized pressure injury screening tool to determine and document risk factors; 3. Supplement the use of a risk assessment tool with assessment of additional risk factors. Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge; 2. During the skin assessment, inspect: a. Presence of erythema; b. temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care ADLs: a. Identify any signs of developing pressure injuries (I.e., non-blanchable erythema).b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.).Prevention.Support Surfaces and Pressure Redistribution: 1. Select appropriate surfaces based the resident's risk factors, in accordance with current clinical practice. A review of the facility's undated Care Planning-Interdisciplinary Team policy indicated that comprehensive, person-centered care plans are based on resident assessments and developed by the interdisciplinary team. A review of the facility's Care Plans, Comprehensive Person-Centered policy, dated revised March 2022, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. On 1/15/26 at 11:36 AM, the surveyor observed Resident #2 sitting in a reclining chair in the dayroom. A Certified Nursing Assistant (CNA) who was present at that time in the dayroom stated that the resident had an excoriation (skin damaged from scratching or picking) on the buttocks area. At that time, the surveyor did not observe the resident sitting on an anti-pressure device. The surveyor further observed that the resident's mattress in their room was not an anti-pressure mattress. On 1/21/26 at 10:59 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #3), who stated that skin assessments were done for residents on shower days. LPN #3 stated that the nurse initialed on the Treatment Administration Record (TAR) that the assessment was done and then documented on the skin observation tool (SOT), located in the computer, exactly what they observed. LPN #3 stated that if she observed a wound, she documented the measurements and description of the wound. LPN #3 stated that she would notify the physician, Unit Manager, and consult the wound consultant team. LPN #3 also stated that a risk management form was completed, and statements would have to be obtained. LPN #3 further stated that treatments would be ordered, and interventions would be put in place to aid in wound healing to prevent development of further breakdown. LPN #3 revealed that the development of the care plan and interventions was the responsibility of the nurse that identified the wound. On 1/21/26 at 11:10 AM, the surveyor interviewed CNA #4, who stated Resident #2 did not speak or talk, they required complete washing and dressing and had bowel and bladder incontinence. CNA #4 revealed that the nurses performed treatments on the resident's buttocks because the resident had a wound. CNA #4 described the wound as red and odorous. The surveyor reviewed Resident #2's Electronic Medical record (EMR) which revealed the following: A review of the admission Record, an admission summary, indicated that Resident #2 was admitted to the facility with the diagnoses that included but were not limited to; metabolic encephalopathy (broad term for brain dysfunction caused by systemic illness, such as diabetes, liver/renal failure, or infection, rather than a direct brain injury), acute respiratory failure, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (psychosis) and a mood disorder, like bipolar disorder or depression). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/22/25, indicated that Resident #2 had short- and long-term memory deficits with severe impairment in decision making. The MDS further indicated that the resident was dependent on staff for all aspects of activities of daily living (ADLs) and was at risk for pressure ulcers; however, the resident did not have a pressure injury at that time. The MDS also indicated that the resident was receiving hospice services. A review of the Interdisciplinary Care Plan (ICP) included a focus dated 5/12/25, that the resident had the potential for alteration in skin integrity related to scratching and picking of their right temporal area (temple) and a wound to the sacrum (lower back) measuring [10 cm x 7 cm x 5 cm]. (There was no date of the initial development of the wound.) The goal indicated that the skin would heal by the next review of 4/14/26. Interventions included Dietician consult; keep nails short and clean; keep skin clean and dry; use skin barrier with each change; and skin checks two times a week per policy. There were no interventions initiated for the resident's actual skin breakdown including treatments or pressure relieving devices. A review of the physician's orders (PO) included a PO dated 7/21/25, for hospice services. A review of the treatment orders included a PO dated 10/8/25, for skin assessments to be done twice weekly on shower days during the day shift on Wednesday and Saturday for skin monitoring. The order specified that the nursing staff were to complete the Skin Observation Tool (SOT) during these assessments. A review of the corresponding November 2025, December 2025, and January 2026 TARs revealed that skin assessments were performed on the following dates: 11/1/25, 11/5/25, 11/8/25, 11/12/25, 11/15/25, 11/19/25, 11/22/25, 11/26/25, 12/3/25, 12/6/25, 12/10/25, 12/13/25, 12/17/25, 12/20/25, 12/23/25, 12/26/25, 12/29/25, 1/3/26, 1/7/26, 1/10/26, 1/14/26, and 1/17/26. A review of the corresponding November 2025 SOTs did not include a description of the resident's skin condition on 11/5/25, 11/12/25, 11/19/25, and 11/26/25. The SOT dated 11/22/25, indicated that the resident had a reddened sacral area, that the physician was notified, and a new treatment order was obtained. There were no measurements of the reddened area documented on the SOT, and the following SOT on 11/26/25, did not include the reddened area. A further review of the treatment orders included a PO dated 11/23/25, to cleanse the sacral area with normal saline solution (NSS), pat dry and apply hydrocolloid dressing (used to manage a variety of lightly exuding wounds, such as pressure ulcers, leg ulcers, burns, and surgical wounds) every three days and as needed (prn) if soiled or dislodged. A review of the corresponding November 2025, December 2025, and January 2026, TARs revealed the nurses were signing that the treatment was completed as ordered until the order was discontinued on 1/8/26. A review of the corresponding SOTs from the time the treatment was ordered (11/23/25), until the treatment was discontinued (1/8/26), there was only one SOT completed on 11/29/25. On 11/29/25, it was documented, Continues to receive treatment for prior skin issue to sacrum. There was no documentation on the SOT that included measurements or a description of the resident's sacral skin condition. A review of the Hospice Communication Note (HCN) dated 11/28/25, indicated that the resident had redness on their back, but the note did not specify the location of the affected area. The note further indicated that the mattress was not functioning properly and included recommendations for a gel cushion for the wheelchair and a foam mattress. There was no documentation that the facility implemented the hospice recommendations, and the Interdisciplinary Care Plan (ICP) was not updated to reflect the recommendations. A review of the subsequent HCNs did not include the redness on the resident's back on 12/12/25, 12/17/25, 12/22/25, 1/2/26, and 1/9/26. The HCN dated 12/15/25, documented that the resident's skin was intact. A review of the Physician's Progress Notes dated 11/3/25, 12/5/25, and 1/14/26, reflected that the physician documented that the resident's skin was normal with no rash, lesion, or ulcer. This contradicted the PO dated 11/23/25, for the treatment to the resident's sacral area. A review of the Dietary Note dated 12/17/25 at 9:41 AM, indicated that a treatment continued to the resident's sacral area which was complicated by incontinence and episodes of agitation versus lethargy, shearing and prolonged pressure increasing risk with continued treatment. The Dietician continued to document that the resident had altered skin integrity and that the goals were to support skin integrity. A review of the January 2026 TAR included a PO dated 1/11/26, to cleanse the sacral area with NSS, pat dry and apply hydrocolloid dressing every three days and prn if soiled or dislodged until discontinued on 1/14/26. The only SOT that was documented in the EMR providing a description of the resident's skin was dated 1/10/26, which indicated that the resident had an excoriation on the sacral area with no signs of infection and scant to no exudate and no surrounding erythema. The SOT also indicated that the physician was made aware and a new treatment was ordered. A review of the Progress Note (PN) dated 1/10/26 at 1:13 PM, indicated that the resident had an excoriation on the sacrum/coccyx area and the physician was made aware, and a new order was obtained and carried out. The ICP was not updated at that time to include any interventions to prevent or protect the resident from further deterioration of the resident's skin. A further review of the January 2026 TAR included a PO dated 1/14/26, to apply silicone foam dressing to boney prominence as needed every day shift for preventative treatment. There was no site indicated on the order. A review of the SOT dated 1/15/26, indicated that Resident #2 had two pressure ulcers measuring 1cm x 0.5 cm and 1.5 cm x 1.0 cm. Neither wound included the depth. The SOT further indicated that a treatment was in place, and a wound care consultant was notified to assess the resident's wounds. A review of the Skin/Wound Note dated 1/15/26 at 9:32 AM, indicated that wound rounds were conducted for Resident #2 and the resident was assessed as having two wounds on their left buttocks measuring 1.0 cm x 0.5 cm and 1.5 cm x 1.0 cm and that treatment would continue. A review of the PN dated 1/15/26 at 4:46 PM, indicated that while the nurse was applying the hydrocolloid dressing to the sacral area around 2:30 PM, skin abrasions were noted on the sacral area measuring 1.0 cm x 0.5 cm and 1.5 cm x 1.0 cm. A new dressing order in place to apply medihoney, and calcium alginate to the wound and cover with silicone foam dressing. The author documented that a message was left with the physician, and they were awaiting reply and that the family was notified. The ICP was updated on 1/15/26, with the new intervention for a wound care consult to be provided. There were no additional skin protection interventions initiated or documented on the care plan. A review of the Wound Care Consultant evaluation dated 1/18/26, indicated that the resident had one sacral wound measuring 10 cm x 7.5 cm x 7.5 cm. The consultation indicated that the resident had end of life skin failure. The skin on the sacral area was described as half dark, non-blanchable with half raw epithelial skin. There were no recommendations indicated in the consultation. On 1/21/26 at 11:28 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #1), who explained that when the nurses signed the TAR, they were attesting that they performed the treatment as ordered. LPN/UM #1 stated that when a nurse performed a skin assessment, they were required to complete the skin observation tool (SOT) in the EMR which included the description of the wound and the measurement of the wound. At that time, LPN/UM #1 reviewed the SOT in Resident #2's EMR, and she did not have a response as to why there were so many skin observations that were not documented. LPN/UM #1 stated that at the time the nurse identified that a resident was developing a Stage 1 reddened area on the resident's sacrum, the nurses were required to call the physician to obtain a treatment order. LPN/UM #1 also stated that the nurse was responsible for obtaining a wound care consult so the wound care team could obtain an actual description and measurement of the wound, and possibly identify the cause of the wound. LPN/UM #1 stated that preventative skin care interventions should have been put in place on the ICP to prevent deterioration of the skin and to enhance healing, and that all the nurses were responsible for updating the ICP. At that time, LPN/UM #1 reviewed Resident #2's ICP in the presence of the surveyor, and she did not have a response as to why the ICP was not updated with preventative protective skin care interventions when the staff identified that the resident was at risk for pressure ulcer development and had started to develop a pressure ulcer in November of 2025. LPN/UM #1 further stated that the Hospice Nurse knew the resident had a wound and that the resident was never provided with an anti-pressure mattress. The surveyor then showed LPN/UM #1 a recommendation from hospice for a gel cushion to the resident's wheelchair and a foam mattress, and she did not have a response as to why these interventions were not obtained. LPN/UM #1 also did not have a response as to why an anti-pressure mattress was never provided for the resident when the Stage 1 wound was identified in November 2025 by the nursing staff. LPN/UM #1 stated that she reviewed the physician's orders, and an air mattress was ordered 1/20/26, but it should have been ordered when the resident developed the initial Stage 1 reddened area to prevent further deterioration. On 1/22/26 at 8:30 AM, the surveyor attempted to conduct a telephone interview with Resident #2's Responsible Party, but there was no answer. A message was left. On 1/22/26 at 8:50 AM, the surveyor observed LPN/UM #1 perform Resident #2's wound care on the sacrum with assistance from CNA #4. The surveyor observed the wound to encompass the entire sacral area and had yellow/black/brown tissue, a foul odor and a scant amount of brown exudate (drainage). The resident did not appear to be in any pain or discomfort. On 1/22/26 at 10:22 AM, the surveyor conducted a telephone interview with Resident #2's physician who was also identified as the facility's Medical Director (MD). The MD stated that when notified that a resident was developing skin breakdown, he would initiate a wound care follow-up because a Stage 1 wound could turn into a Stage 2 and so on and so forth. The MD was questioned concerning his visits with Resident #2, and he stated that he documented his notes on paper and not in the EMR. The MD then abruptly ended the call and stated that he would call the surveyor back. On 1/22/26 at 11:21 AM, the surveyor conducted a telephone interview with Resident #2's Hospice Service and interviewed the Executive Director (ED) and Clinical Director (CD). Both parties explained that the Hospice Nurses who had documented their visits in Resident #2's medical record on 11/28/25, 12/12/25, 12/15/25, 12/22/25, 1/2/26, and 1/9/26, were no longer employed by the hospice service. The CD stated that the Hospice Nurse's responsibilities included assessing the residents' skin and making recommendations accordingly. The CD stated that she would review Resident #2's records. The CD explained that if the Hospice Nurse made recommendations for skin protective devices on 11/28/25, then the facility's nurses were responsible to call the resident's primary care physician to obtain orders for those recommendations. On 1/22/26 at 11:34 AM, the surveyor conducted a telephone interview with the Wound Care Nurse Practitioner (Wound NP), who stated that Resident #2 was newly consulted by her on 1/18/26, for a new wound. The Wound NP stated that typically, the Wound NP staged the wounds, but when a resident was on hospice, the Wound NP usually did not stage the wounds. The Wound NP stated that the facility told her that the resident's wound was new, and they did not explain to her that the resident had an existing Stage 1 wound dating back to November 2025. The Wound NP stated that she did not have any information and could not say what happened to the resident's skin in November 2025. The Wound NP stated that Stage 1 wounds were not typically seen on wound rounds and that to this date, her impression was that the resident had a [NAME] wound which was a skin ulcer that appeared in people in the final weeks of their life. The Wound NP further stated that, At this point, the resident has no healing potential. On 1/22/26 at 12:10 PM, the surveyor interviewed CNA #4, who was present during Resident #2's wound treatment observation completed on 1/22/26 at 8:50 AM. CNA #4 stated that Resident #2 had an open wound on their sacral area for approximately one month that she was aware of. On 1/23/26 at 10:17 AM, the surveyor conducted a follow-up interview with the MD, who stated that he would have expected the staff to order a wound care consult when the resident was first identified as having a Stage 1 wound or excoriation on the sacral area. The MD stated that he did not know why the staff did not document the resident's skin condition on the skin observation tools (SOT). The MD further stated that if the hospice recommended anti-pressure devices for the resident, such as a gel cushion for the wheelchair or an anti-pressure mattress, he would have expected the Hospice Nurse to not just write the recommendations in their notes, but to verbally communicate the recommendation to the nurses to ensure that the nurse called the physician to get an order for the devices. The MD stated he was not aware that the resident's pressure ulcer was deteriorating, and the nurses did not tell him. The MD added that when he reviewed the resident's orders and there was an order for duoderm (hydrocolloid dressing), he assumed that the area stayed the same. The MD also stated that during his visit, he did not roll the resident over to observe the resident's skin, so therefore he did not know that the resident had an opening on the sacral area. The surveyor then questioned the MD regarding the treatment order dated 1/14/26, that indicated a silicone dressing should be applied to boney prominence during the day shift, and the MD confirmed that it was an incomplete treatment order. The MD stated that the order should have specified a site where the silicone dressing was to be applied, otherwise how would the nurse know where to apply it. On 1/27/26 at 1:16 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who confirmed that when hospice gave recommendations for anti-pressure devices for Resident #2, the MD should have been notified, and orders should have been obtained. The surveyor reviewed Resident #2's treatment orders with the ADON and she confirmed that a treatment order required a site of application so that the nurses knew where the treatment was to be performed. The ADON further stated that if Resident #2 was identified as a risk for skin breakdown, an ICP should have been developed and updated to include interventions to prevent skin breakdown. In addition, if skin redness or breakdown occurred, the care plan needed to be updated with additional interventions to prevent further deterioration of the skin. The ADON also stated that the skin observation tool (SOT) should be completed when ordered to get an accurate description of the resident's skin, to get a baseline, support early detection of pressure ulcers and allow staff to intervene before conditions worsen. NJAC 8:39-27.1(e)

Based on observation, interview, and documentation review, it was determined that the facility failed to follow proper sanitation practices for dishware and kitchen equipment to prevent microbial growth in accordance with professional standards for food service safety.The deficient practice was evidenced by the following:On 1/15/26 at 10:20 AM, the surveyor toured the kitchen with the Director of Service Director (FSD) and observed that the three-compartment sink quaternary chemical sanitization solution indicated 200 parts per million (ppm) concentration. The surveyor interviewed the FSD regarding proper sanitization using sanitizer, and stated that a quaternary ammonium compound required concentration levels between 150-200 ppm. The surveyor requested that the FSD verify the sanitizer concentration level using a test strip. However, the FSD was unable to conduct the test and admitted that test strips were not available. The FSD further indicated that he would obtain the test strips immediately. The FSD confirmed that the kitchen should never run out of the sanitizer strips as the chemical sanitization process destroys harmful bacteria and prevents foodborne illnesses. On 1/22/26 at 4:26 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that she expected kitchen staff to properly sanitize kitchen equipment and dishware. The LNHA further stated that sanitizing was important for infection prevention and safety.A review of the facility's Sanitization policy updated February 2025, included the following .3). All equipment, food contact surfaces and utensils shall . sanitized using hot water and/or chemical sanitizing solutions, 5). Sanitizing of utensils and removable parts of equipment., and 9). Manual washing and sanitizing .c). Chemical sanitizing solutions may consist of: (3). Quaternary ammonium compound 150-300 ppm.NJAC 8:39-17.2(g)

Based on observation, interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that staff, as well themselves, failed to ensure the facility's policies and procedures were implemented to ensure resident safety and well-being by failing: a.) protect residents who were previously identified to be at risk for self-harm and suicidal ideations b.) properly assess, monitor and implement the provision of a wound treatment c.) secure and maintain resident specific medications at all times e.) maintain an accurate accountability for controlled medications. The deficient practice had the potential to affect all residents who resided on 3 of 5 nursing units (nursing units 5, 6 and 7) and was evidenced by the following: A review of the undated facility Administrator job description revealed the following:The Long-Term Care Administrator oversees the daily operations of a specialized facility focused on behavior and mental health. This role is responsible for ensuring compliance with regulatory standards, maintaining a high standard of care, managing staff, and fostering a supportive environment for residents and employees. The Administrators is a strategic leader who balances operational efficiency, financial management, and compassionate care delivery.Duties and responsibilities included: plan, develop, organize, implement, evaluate and direct programs and activities. Review policies and procedures that govern the operations of the facility. Meet with department directors to discuss use of departmental policies and procedures and establish rapport in and among departments so that each can realize the importance of teamwork. Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc , as necessary. Review the facility's policies and procedures periodically at least annually and make changes as necessary to ensure continued compliance with current regulations. Assume the administrative authority, responsibility and accountability of directing the activities and programs in the facility. Refer to F686G; F689J; F755E and F761 D 1.)The facility failed to ensure that a cognitively impaired resident (Resident #2), who was dependent on staff for activities of daily living (ADLs) received appropriate interventions to prevent the development of a facility-acquired full thickness pressure injury; ensure ongoing skin assessments were completed and documented in accordance with a physician's order; ensure hospice recommendations for pressure reducing devices were communicated to the physician; and consistently follow-up documentation to monitor the progression or resolution of the skin breakdown. On 11/22/25, Resident #2 was identified as having a Stage 1 reddened area on their sacrum, that subsequently progressed to a full thickness wound and the wound measured on 1/18/26, as 10 centimeters by 7.5 centimeters by 7.5 centimeters (10 cm x 7.5 cm x 7.5 cm) by the Wound Care Nurse Practitioner (NP) during their initial assessment. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, dated revised April 2018, included that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers for example immobility, recent weight loss and history of pressure ulcers. In addition, the nurse shall describe and document/report the following: a.) Full assessment of pressure sore including location, stage, length width, depth, presence of exudate [fluid drainage] or necrotic [dead] tissue; b.) Pain assessment; c.) Resident's current mobility status; d.) Current treatments to include support surfaces and all active diagnoses; e.) The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches and dressings. A review of the facility's Prevention of Pressure Injuries policy, dated revised April 2020, included Risk Assessments.2. Use a standardized pressure injury screening tool to determine and document risk factors; 3. Supplement the use of a risk assessment tool with assessment of additional risk factors. Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge; 2. During the skin assessment, inspect: a. Presence of erythema; b. temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care ADLs: a. Identify any signs of developing pressure injuries (I.e., non-blanchable erythema).b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.).Prevention.Support Surfaces and Pressure Redistribution: 1. Select appropriate surfaces based the resident's risk factors, in accordance with current clinical practice. A review of the facility's undated Care Planning-Interdisciplinary Team policy indicated that comprehensive, person-centered care plans are based on resident assessments and developed by the interdisciplinary team. A review of the facility's Care Plans, Comprehensive Person-Centered policy, dated revised March 2022, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 2.) The facility failed to protect a resident from self-harm and provided adequate supervision for a resident (Resident #100) with a history of suicidal ideations with plans to cut their wrist prior to admission to the facility, who cut their wrist while residing in the facility. According to the progress notes, on 1/11/2026 at 10:30 PM, the resident was noted by facility staff with a two-inch laceration to their right wrist that was bleeding profusely. The resident stated, I thought that I was going home, but they said I was not. During an interview with the Licensed Practical Nurse (LPN #1) on 1/21/2026, LPN #1 stated that the Certified Nursing Aide (CNA #1) during their rounds observed that the resident was bleeding, and when LPN #1 went to the resident's room, the resident was holding their right wrist with toilet paper to reduce the bleeding. LPN #1 stated that Resident #100 disassembled a razor that they found in the shower, and that LPN #1 was unaware that the resident had a history of self-injurious behaviors. A review of the admitting facility's paperwork included on 8/27/2025, Resident #100 called 911 and informed the police officer that they were having suicidal ideations and wanted to cut themselves with a razor. A review of the resident's medical record at their current facility including, their care plan and physician's orders, did not include any safety interventions put in place to protect the resident from self-harm. The facility's failure to provide adequate supervision and protect Resident #100 from self-harm, who had a history of suicidal ideations, placed Resident #100, as well as all residents at risk of self-harm.A review of the facility's Safety and Supervision of Residents policy, dated revised July 2017, included our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents . Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions with all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions .Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . A review of the facility's admission Criteria policy, dated revised March 2019, included our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: 1. The objective of our admission criteria policy is to .b. admit residents who can be cared for adequately by the facility . A review of the facility's Sharps Disposal policy, dated revised January 2012, included the facility shall discard contaminated sharps into designated containers .Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers . 3.)The facility failed to provide pharmaceutical services in accordance with professional standards to ensure accountability of controlled substance medications were consistently conducted for prompt identification of loss or potential narcotic diversion; develop policy and procedures for the emergency electronic backup machines (electronic backup machine; EBM; ensure emergency medications were always available for administration; ensure consistent reconciliation of dispensed and administered controlled dangerous substances (narcotic medications) were accurately documented and discrepancies were immediately investigated.On 1/16/25 at 9:13 AM, during the observation of the EBM cycle count, conducted by the RN/IP and the DON, the surveyor observed two (2) house stock control countdown (declining) sheet for Morphine Sulfate 20 milligrams (mg)/1 milliliter (ml) with a quantity of 15 ml per bottle that were delivered, and signed received, on 12/17/25. At that time, the EBM machine did not reflect a drug listing for Morphine 20 mg/ml. Further observation of the cycle count revealed two (2) boxes were stored in the non-narcotic portion of the EBM. The RN/IP and the DON pulled the boxes from the EBM machine and discovered the two (2) boxes were empty and neither could find where the Morphine bottles were. The DON called the LPN/ UM who signed/received the two (2) Morphine bottles on 12/17/25. At that time, the LPN/UM stated she was present when the pharmacy provider removed the two (2) bottles of Morphine from the boxes and saw him place the Morphine bottles in one (1) of the top drawers but could not identify exactly where it was placed. At that time, the surveyor observed the RN/IP and the DON scrolled through the drug list inventory on the EBM for the Morphine 20mg/ml and did not find that Morphine 20 mg/ml was listed to locate the physical bottles of Morphine. On 1/16/25 at 10:07 AM, the surveyor discussed the concern with the DON that in the event a resident needed Morphine medication from the signed/delivered date of 12/17/25 the staff would not be able to administer the medication. The DON informed the surveyor that she would contact the pharmacy provider to locate the two (2) bottles of Morphine that were missing. On 1/16/25 at 1:20 PM, during a follow-up meeting with the surveyor, the DON stated that she had spoken with the pharmacy representative who confirmed he had placed the bottles in the top drawer. At that time, the DON could not explain why Morphine 20mg/ml was not included in the medication drug list of the EBM. The DON stated she could not show the Morphine bottles to the surveyor because she had no access to the top drawer. At that time, the DON was asked in the event of a power outage or an electrical failure, how would she access EBM to provide emergency medications to the resident(s) who needed the medication. At that time, the DON informed the surveyor that she could not locate her keys for the EBM, she did not know which keys it was and even if she found the keys, that she did not know how to use them. On 1/21/26 at 9:32 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON stated that the facility had no process to audit the cycle count and contributed to the delivered Morphine to be unidentified as inaccessible for administration from the time of signed/delivery on 12/17/25 to the time of surveyor inquiry. At that time, the DON stated that there was a software problem that caused the Morphine to not be included in the drug listing inventory of the EBM and that the pharmacy provider was researching the problem. On 1/21/26 at 9:32 AM, in the presence of the survey team, and the LNHA, the DON stated that the nurses who had filled out the Narcotic Controlled Count down sheet were in-serviced to ensure all lines were filled out. The DON confirmed and acknowledged that the facility did not have a process to audit the narcotic medication reconciliation process and contributed to the undetected discrepancies. On 1/23/26 at 3:34 PM, during a meeting with the survey team, the LNHA and the DON, no further information was provided. A review of the 2016 facility policy titled; [brand redacted] Implementation Guide included Discrepancy Handling included that discrepancy resolution should be clearly stated in the facility's policies and procedures. The department director should be notified of unresolved discrepancies. Unexplained losses should be reported to security, the Drug Enforcement Agency (DEA). 4.) The facility failed to properly store, and secure medication left at a resident's bedside (Resident #13).On 1/20/26 at 10:36 AM, the surveyor in the presence of another surveyor was making rounds on the fifth floor. The surveyors observed Resident #13 lying in bed, eyes closed, fully dressed with a blanket over their legs. On the bedside table was a clear plastic cup containing a clear liquid and a plastic medicine cup with two round pills, one pink-colored pill, and one slightly smaller light orange pill. The resident had their privacy curtain pulled to the side of their footboard on the bed, inhibiting access to the nightstand. Resident did not respond to surveyor inquiry.On 1/20/26 at 10:37 AM, surveyor #2 went to find the nurse and the Certified Nursing Aide (CNA) assigned to Resident #13, while surveyor #1 stayed with the resident. When CNA #2 arrived at the room and was shown the pills in the medicine cup on the nightstand she stated the medication should not be left there, that usually the resident was supposed to take their medication while the nurse was in the room.On 1/20/26 at 10:41 AM, the surveyor interviewed the Licensed Practical Nurse #5 (LPN #5) who acknowledged the medications found at the bedside and stated she had given Resident #13 their medications in the hallway and not in their room, that the medication in the cup was not from her morning medication pass. LPN #5 confirmed medications should not be left at the bedside and should be secured in a medication cart.On 1/20/26 at 11:01 AM, the surveyors interviewed the fifth floor Registered Nurse Unit Manager #2 (RN/UM #2) who acknowledged the medications on the bedside table, she was unable to identify the pills in the medicine cup. RN/UM #2 confirmed there should be no medications left unsecured at the resident's bedside. She stated the medication administration process was the nurse must observe the resident has taken the medication, to ensure the resident is therapeutic as well as medication was not left around for another resident to take. RN/UM #2 then took the medications to secure them.On 1/20/26 at 1:14 PM, the Director of Nursing (DON), RN/UM #2 and LPN #5 went to the medication cart to review the orders and identify the pills left in the medication cup. Upon review the DON determined the medications were Aspirin 81 mg (milligram) chewable tablet (a medication used to prevent blood clots) and Vitamin B12 100mcg (micrograms) tablet (a supplement used for vitamin deficiency). The DON confirmed medications should not be left at the bedside because they must be secured for the safety of all the residents.A review of the facility's undated Storage of Medications policy included. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe and sanitary manner.On 1/23/2026 at 10:14 AM, the surveyor interviewed the facility Medical Director (MD) who stated that he was not notified by the facility Licensed Nursing Home Administrator (LNHA) that there was Immediate Jeopardy (IJ) at the facility during survey. The MD stated that he was the attending physician for Resident #100, and he was not aware that the resident had been previously identified with suicidal tendencies prior to admission. The MD stated that a razor blade was not something that the resident should have been able to easily get a hold of. The MD further stated, especially with this population because you do not want to take a risk to be on the safe side., because the residents are all schizophrenic, but some are controlled.On 1/27/26 at 3:39 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the Assistant Director of Nursing (ADON) and the survey team. The LNHA stated that the Director of Nursing (DON) was responsible for the controlled medication back up inventory. The LNHA stated that she had just become aware that there was an issue with the accountability of controlled medications in the back up inventory. The LNHA stated that her role was to audit, monitor, and QAPI (Quality Assessment and Performance Improvement), which I have just become aware of the issue. The LNHA maintained that she was not made aware of any missing controlled medications by the clinical team.When the surveyor asked the LNHA what her role and responsibility was to ensure the safety of residents who were previously identified with suicidal ideas prior to admission she stated that it was a clinical and admissions process, and her role was to make corrective actions to that process. The LNHA further stated that her role was to now to make corrective actions to that process, and audit, monitor, and update trending information.When the surveyor asked the LNHA what her role and responsibility was to ensure that residents received appropriate skin interventions to prevent the development of pressure ulcers the LNHA stated she was responsible for identifying patient safety and quality of care that needed to be put into place. The LNHA further stated that we have clinical consultants who review the clinical information. The LNHA further stated we now have a new consultant.

Based on observation and interview, it was determined that the facility failed to provide a safe, clean, comfortable and home-like environment. This deficient practice was identified for 3 of 5 (three of five) nursing units, [the third (3rd), fifth (5th), sixth (6th)] inspected and was evidenced by the following: On 1/16/2026 at11:37 AM, during the initial tour of the facility, the surveyor observed the following on the third floor nursing unit: Room (RM) 306's rest room had a broken toilet paper holder. RM 309 C had a frayed protective mat wrapped with duct tape applied to the end of the bed. RM 313, the creases of the bathroom tiles had a brown substance on them, a broken toilet paper holder, and the toilet paper was located next to a soiled trash bin. RM 315 had a light switch box that was rusted and had flaked areas. The wall had areas of elevation that appeared to have been water damage. RM 316 had holes in the wall, a broken toilet paper holder, and a roll of toilet paper was located on a covered bathtub. RM 317 had a hole in the wall and there were other damaged areas on the walls. On 1/21/26 at 12:16 PM, the surveyor toured the sixth (6th) floor nourishment room with the Licensed Practical Nurse/Unit Manager (LPN/UM #1) and observed the right pantry side door was broken. On 1/22/26 at 12:21 PM, the surveyor observed chipped paint on the wooden bathroom organizer and a rusty metal shower room organizer was hanging on the pipe on the third (3rd) floor shower room. On 1/21/26 at 11:26 AM, the surveyor interviewed LPN #2, who stated that the residents' restrooms should have toilet paper holders and that the toilet paper should not be placed on the bathtub cover. LPN #2 further stated that rooms should be more presentable. On 1/21/26 at 12:22 PM, the surveyor interviewed LPN/UM #1, who stated that the pantry door should not be broken to prevent residents taking items and also for infection control purposes. On 1/21/26 at 2:00 PM, the surveyor interviewed the Director of Maintenance (DOM), who confirmed that all rooms should have functioning toilet paper holders, the toilet paper should never be placed anywhere else but on the toilet paper holder to avoid cross-contamination and prevent infection. The DOM further stated that all walls should be intact to help the residents' rooms appear home-like. On 1/22/26 at 4:26 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated staff were expected to report concerns to maintenance and housekeeping to ensure toilet paper holders were replaced and toilet paper was properly maintained in the holder. The LNHA also stated that chipped paint and water-damaged walls should be repaired or replaced to ensure resident safety, comfort, and a home-like environment. 2. On 1/23/2026 at 1:30 PM, the surveyor in the presence of Certified Nurse Aide #8 (CNA #8) inspected the fifth-floor south shower room and there was a chipped and cracked plastic shelf in the shower, a dark colored caked on substance in the shower drain and black colored substance on the walls of the shower, missing, chipped and cracked floor tiles and chipped white paint on the wooden shelf. There was also a black substance that was dotted along the grout and the shower drain. There was chipped white paint on a wooden shelf. At that time the surveyor interviewed CNA #8 and asked if the shower should have broken or damaged equipment, he stated it should not. When asked if he would want to shower in either of the fifth floor showers he responded definitely not. On 1//23/2026 at 2:38 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated she was aware of the condition of the showers in the facility and that the facility was in the process of updating all the shower rooms. The LNHA acknowledged the showers were not homelike. A review of the facility's Homelike Environment policy, revised 02/2021, included that residents are to be provided with a safe, clean, comfortable homelike environment . NJAC 8:39-31.4 (a)(f)

Based on observation, interviews, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice to ensure: a.) accountability of controlled substance medications were consistently conducted for prompt identification of loss or potential narcotic diversion, and develop a policy and procedure for the use of an emergency electronic backup machine (electronic backup machine; EBM, b.) emergency medications were always available for administration, c.) consistent reconciliation of dispensed and administered controlled dangerous substances (narcotic medications) were accurately documented and discrepancies were immediately investigated. This deficient practice was identified for one (1) of one (1) EBMs and was evidenced as follows: On 1/16/26 at 9:00 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the facility had one (1) EBM, and the inventory auditing procedure (cycle counts) were completed daily, during the day shift and were conducted by two nurses, a nurse unit manager with the Assistant Director of Nursing (ADON). The DON also stated that they had a written logbook where the nurses documented the cycle count, with the date, the time, the nurses' signatures and the residents' name for whom the narcotic medication was dispensed. On 1/16/26 at 9:09 AM, the surveyor observed the cycle count process which was conducted by the Registered Nurse/Infection Preventionist (RN/IP) and the DON. At that time, the surveyor did not observe a cycle count documentation for the daily cycle count. On 1/21/26 at 9:32 AM, in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA), the DON confirmed and acknowledged that the facility did not have a process to audit the narcotic medication reconciliation process. On 1/23/26 at 9:28 AM, the surveyor, RN/IP and DON together reviewed the 12/1/25 to 1/21/26 electronic Transaction by Item log from the pharmacy. At that time, the RN/IP and the DON acknowledged and confirmed the cycle counts had not been conducted daily. A review of the 2016 facility policy titled; [brand redacted] Implementation Guide reflected the guide should be used . to serve as a starting point for developing, documenting and enforcing best practices . b.) On 1/16/26 at 9:13 AM, during the observation of the EBM cycle count, conducted by the RN/IP and the DON, the surveyor observed two house stock declining inventory sheets (DIS) for morphine sulfate 20 milligrams (mg)/1 milliliter (ml) solution with a quantity of 15 ml per bottle that was delivered, and signed received, on 12/17/25 by the LPN/UM. A review of the corresponding EBM inventory list did not contain a listing for morphine sulfate 20 mg/ml, 15ml. Further observation of the cycle count revealed two empty morphine 20 mg/ml boxes which were being stored in the non-narcotic portion of the EBM. The RN/IP and the DON acknowledged the empty boxes of morphine but were unable to explain where the two bottles of morphine were. At that time, the DON called the LPN/UM who stated she was present when the pharmacy provider removed the two bottles of morphine from the boxes and placed the morphine bottles in one of the top drawers but she could not identify exactly where it was placed. The surveyor observed the RN/IP and the DON again reviewed the inventory list and again could not locate a compartment for the morphine 20 mg/ml, 15 ml. On 1/16/26 at 10:07 AM, the surveyor discussed the concern with the DON that in the event a resident needed morphine solution medication the staff would not be able to administer the medication. The DON informed the surveyor that she would contact the pharmacy provider to locate the two bottles of Morphine that were missing. On 1/16/26 at 1:20 PM, during a follow-up meeting with the surveyor, the DON stated that she had spoken with the pharmacy representative who confirmed he had placed the bottles in the top drawer. At that time, the DON could not explain why morphine 20 mg/ml was not included in the medication drug list of the EBM. The DON stated she could not show the Morphine bottles to the surveyor because she had no access to the top drawer. At that time, the DON was asked in the event of a power outage or an electrical failure, how would she access EBM to provide emergency medications to the resident(s) who needed the medication. The DON informed the surveyor that she could not locate her keys for the EBM, and she did not know which key it was and even if she found the keys, that she did not know how to use them. On 1/21/26 at 9:32 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON acknowledged that the facility had no process to audit the cycle count which contributed to the improper placement and storage of the morphine and the DON further stated that there was a software problem that caused the morphine to not be included in the drug listing inventory of the EBM and that the pharmacy provider was researching the problem. On 1/21/26 at 11:01 AM, during a re-inspection of the EBM, in the presence of the surveyor, the Assistant Director of Nursing (ADON), the DON showed the surveyor two bottles of morphine and stated that it was fixed by the pharmacy to be included in the drug listing of the EBM. On 1/22/26 at 11:38 AM, during an interview with the surveyor, the pharmacy provider representative (PPR) stated that he was in the facility sometime in December, assigned a drawer for the morphine and it should have populated in the drug list inventory of the EBM; the provider pharmacy was researching the software issue as to why it did not populate during inspection. The PPR further stated that he went into the facility sometime on 1/19/26 to locate the missing Morphine that was pointed out to him by the staff who knew exactly where the two bottles of Morphine were. At that time, the PPR stated that there was a way to force open and access the medication during a power outage or an electrical failure and the staff should have been oriented to the process. A review of the provided cycle count from 12/1/25 to 1/21/26, did not reveal morphine 20 mg/ml was part of the cycle count that required two nurses to physically count the inventory of medications. A review of the 2016 facility provided policy titled; [brand redacted] Implementation Guide, under Manual Override Access reflected that manual override keys must be assigned to at least one responsible person, per shift, per cabinet area and that keys must be kept in a secured area. c.) On 1/16/26 at 9:13 AM, during the observation of the EBM cycle count, conducted by the RN/IP and the DON, the surveyor observed a House Stock declining inventory sheet (DIS) for oxycodone 5 mg and noted the following: Line #30 of the DIS did not include the date and time for when the Oxycodone was removed for Unsampled Resident #149.Line #29 had the date, time of inventory removal, the nurses' signature and the resident's name.Line #28 reflected the date of 12/31/25, with no indication of the time of removal from inventory, and did not include the nurses' signatures and the resident's name.Line #27, #26, and #25 reflected on 12/31/25 at 6:00 PM, three tablets were removed for Resident #149. The inventory count matched the DIS that demonstrated a quantity of 24 tablets remained. At that time, the DON stated that she would investigate the dispensed oxycodone for Resident #149. On 1/21/26 at 9:32 AM, in the presence of the survey team, and the LNHA, the DON stated that the nurses who had filled out the oxycodone Controlled DIS were in-serviced to ensure all lines were filled out. At that time, the surveyor and the DON reviewed the investigation provided. The facility failed to provide the previously requested packing slips for Unsampled Resident #149 and the transaction by item report. On 1/22/26 at 11:21 AM, during an interview with the surveyor, the Regional Director (RD) of the pharmacy provider stated that they had a way to track who, when, and how many medications were removed from the EBM. At that time, the surveyor requested the report. A review of the provided transaction by item report reflected multiple discrepancies that were older than the date range requested from 12/1/25 to 1/21/26 and continued to be unresolved by the facility. On 1/23/26 at 9:28 AM, in the presence of the surveyor, and the RN/IP, the DON provided the investigation related to the oxycodone then stated that the medications removed were all for Unsampled Resident #149 and the nurses involved provided a statement. The surveyor, the RN/IP and the DON reviewed the investigation together and revealed the following discrepancies: Line #30 of the oxycodone was removed on 12/23/25 at 10:10 AM and was flagged discrepancy. The DON acknowledged that the medication was removed. Line #29 reflected one tablet was removed on 12/24/25 and the eMAR (electronic medication administration record) did not reveal an administration of the as needed (PRN) Oxycodone 5 mg to Unsampled Resident #149. An investigation of the discrepancy was not provided. Line #28 reflected one tablet was removed on 12/31/25 at 6:16 PM, and was flagged discrepancy, followed by Line #27, #26, and #25 reflected one tablet was removed each time per line on 12/31/25 from 6:16 PM and 6:17 PM. A review of the statements made by the two nurses who signed lines 27, 26 and #25 reflected that they removed three tablets of Oxycodone and skipped line #28 because of the discrepancy found on the EBM. The nurses also documented that Resident #149 had no remaining pills for their physician's ordered oxycodone 15 mg in the medication cart. A review of Unsampled Resident #149's eMAR for December 2025 did not reflect a physician's order for oxycodone 5 mg, to be given 3 tablets at one time to correspond to the dispensed medication by the nurses for lines #27, #26 and #25. Further review of Unsampled Resident #149's electronic Medication Administration Record (eMAR) included active medication orders for:-Oxycodone 15 mg, 1 tablet every 6 hours for pain, with a start date of 12/4/25.-Oxycodone 5 mg, 1 tablet every 8 hours as needed for severe breakthrough pain, with a start date of 12/4/25. A review of the packing slip (delivery invoice from the pharmacy) for Resident #149's physician ordered Oxycodone 15 mg reflected that a quantity of 90 was delivered and signed for on 12/10/25 [a supply for 22.5 days]. A review of the corresponding DIS for Resident #149's physician prescribed oxycodone 15 mg revealed that when the medication was received a recording was not made on the DIS, the initial pill was removed and was not recorded and the discrepancy remained unresolved. A review of the packing slip for Resident #149's physician ordered oxycodone 5mg reflected a quantity of 30 was delivered on 12/31/25. At that time, the DON stated that there were no prior orders for Oxycodone 5 mg and that was the reason the nurses utilized the EBM for Resident #149. On 1/16/26 at 9:13 AM, the during the observation of the EBM cycle count, conducted by the RN/IP and the DON, the surveyor also observed the following: A review of a House stock DIS for alprazolam (medications used to treat anxiety) 0.25 mgLine 30 reflected appropriate documentation of the date, time of inventory removal, the nurses' signature and the resident's name. Line 29 reflected a removal of a dose on 12/28/25 at 11:45 AM, by two nurses but did not reveal the resident's name. Line 26 reflected a removal of a dose on 12/22/25 at 4:30 PM, by two nurses but did not reveal the resident's name. A review of a House stock DIS for lorazepam (a medication used to treat anxiety) 0.5 mg Line 29 reflected a removal of a dose on 1/15/26 at 7:30 PM, by two nurses but did not reveal the resident's name. At that time, the surveyor discussed the concern with the process for the reconciliation of controlled medications that were dispensed and administered from the EBM. On 1/21/26 at 9:32 AM, in the presence of the survey team, and the LNHA, the DON confirmed and acknowledged that the facility did not have a process in place to audit the narcotic medication reconciliation process and that contributed to the undetected discrepancies. A review of the 2016 facility policy titled; [brand redacted] Implementation Guide included Discrepancy Handling included that discrepancy resolution should be clearly stated in the facility's policies and procedures. The department director should be notified of unresolved discrepancies. Unexplained losses should be reported to security, the Drug Enforcement Agency (DEA). NJAC 8:39-29.4(k), 29.7(c)

Based on observation, interviews, medical record review and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices a.) during medication pass observation b.) during wound care observation and c.) during dining observation specifically, performing appropriate hand hygiene during the meal service to prevent the spread of potential infectionThis deficient practice was identified for 1 of 3 nurses observed administering medications to 1 of 4 residents (Resident #88) during the medication pass observation task, and for 1 of 1 resident (Resident #2) observed for wound care and for 1 of 5 dining rooms (6th floor).This deficient practice was evidenced by the following:1.) On 1/16/26 at 9:22AM, the surveyor observed Registered Nurse (RN #1) prepare medications for Resident #88. RN #1 prepared five medications for the resident. One of the medications was Vitamin D3 50 mcg (microgram); give one tablet by mouth daily. The surveyor observed RN #1 open the bottle and pour the medication directly into her open palm and then proceeded to add the tablet into the prepared medicine cup. When the surveyor asked RN #1 if medication should be dispensed directly into the nurse's ungloved hand before placing the medication into the medicine cup? RN #1 stated she had cleaned her hands with alcohol-based hand rub prior to starting the medication pass, so she thought that it was okay. Then RN #1 stated, I guess there's a potential to contaminate the pills if your hands are dirty. RN #1 then donned a glove and removed the tablet from the medicine cup and discarded the pill in the designated medication eliminator solution and then re-poured all the oral medications. On 1/22/2026 at 4:42 PM, the survey team met with the facility Administration team to discuss concerns and Director of Nursing (DON) stated the nurse should not have poured any medications into their ungloved hands and acknowledged this would be an infection control issue. 2.) A review of the admission Record, an admission summary, indicated that Resident #2 was admitted to the facility with the diagnoses which included but were not limited to metabolic encephalopathy (broad term for brain dysfunction caused by systemic illness, such as diabetes, liver/renal failure, or infection, rather than a direct brain injury), acute respiratory failure, and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (psychosis) and a mood disorder, like bipolar disorder or depression). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 10/22/25, indicated that Resident #2 had short- and long-term memory deficits with severe impairment in decision making. The MDS further indicated that the resident was dependent on staff for all aspects of activities of daily living (ADLs) and was at risk for pressure ulcers; however, the resident did not have a pressure injury at that time. The MDS also indicated that the resident was receiving Hospice services. On 1/15/2026 at 11:36 AM, the surveyor observed Resident #2 sitting in a reclining chair in the dayroom. The surveyor did not observe the resident sitting on an anti-pressure device. The Certified Nursing Assistant (CNA) present in the dayroom stated that the resident had an excoriation on the buttocks area. The surveyor further observed that the resident's mattress was not an anti-pressure mattress. The surveyor reviewed Resident #2's Electronic Medical record (EMR) which revealed the following: Review of the Interdisciplinary Care Plan (ICP) contained a focus area dated 5/12/25, which indicated the resident had the potential for alteration in skin integrity related to scratching and picking the right temporal area and wound to sacrum measuring 10 x 7 x 5 (no date of initial development of wound). The goal documented indicated that the skin would heal by next review of 4/14/26. Interventions included: Dietician consult, keep nails short and clean, keep skin clean and dry, use skin barrier with each change and skin checks two times a week per policy. A review of the Treatment Administration Record (TAR) reflected a treatment dated 1/16/26, to cleanse the sacrum with normal saline solution (NSS) and apply medi-honey, calcium alginate and silicone foam dressing daily on the day shift for wound care. On 1/22/26 At 8:50 AM, the surveyor observed the Licensed Practical Nurse Unit Manager (LPN/UM #1) perform Resident #2's sacral wound care. The sequence was as follows: -The LPN/UM reviewed the treatment order with the surveyor which included cleansing the wound with NSS, application of Medi-honey and calcium alginate and cover silicone dressing. -The LPN/UM #1 then applied personal protective equipment (PPE) for enhanced barrier precautions (EBP), an infection control intervention in nursing homes and skilled nursing facilities that mandate the use of gowns and gloves during high-contact resident care to reduce the spread of multi-drug-resistant organisms (MDROs). -The LPN/UM #1 gathered the treatment supplies which included one small bottle of NSS, one covered calcium alginate dressing, one covered silicone dressing and one tube of medi-honey and put them on top of the resident's bedside table. The LPN/UM put all treatment supplies directly on the resident's bedside table without disinfecting the table or applying a protective barrier -The LPN/UM #1 then washed her hands according to Center for Disease Control (CDC) guidelines and applied gloves. -The LPN/UN #1 removed undated soiled dressing from the resident's sacral area and then washed her hands and applied clean gloves. -The LPN/UM #1 then proceeded to pour NSS on a clean 4x4 gauze dressing and cleansed the resident's wound. The wound was large, with light brown drainage, covered with yellow/black/brown eschar (dry, dark colored skin). -The LPN/UM #1 did not wash her hands or change her gloves after cleaning the wound and then proceeded to apply the medi-honey and calcium alginate and then covered the wound with the silicone dressing. -The LPN/UM did not date the new dressing that she applied to the resident's sacral area. -After the dressing change was complete and she washed her hands, LPN/UM #1, then attempted to put the contaminated wound supplies back into the treatment cart. The surveyor stopped the nurse before she did so, in an effort to avoid contaminated equipment. -The LPN/UM then signed the treatment out in the TAR. The surveyor interviewed the LPN/UM #1 at this time, and the LPN did not have a response as to why she did not decontaminate the bedside table or put down a clean barrier on the table before putting the treatment supplies down on the table. LPN/UM #1 did not have any response regarding breeches in infection control. She also stated that she did not think that dressings needed to be dated, because they signed them out in treatment Kardex. She stated that she would have to review the policy to see if dressings needed to be dated. On 1/22/2026 at 9:29 AM, the surveyor interviewed the Infection Preventionist (IP) who explained the process of dressing changes for residents with wounds. She stated that the nurse was responsible for checking physician treatment orders, ensuring it was the correct resident, wash hands, and apply gown, gloves and mask. The IP stated that when preparing for the treatment, the nurse should not bring the treatment equipment in the original containers into the resident's room. The nurse should put the NSS and ointments into a disposable medication cup, so that it could be disposed of after completing the treatment. She stated that this prevented any contaminated supplies from going back into the treatment cart. The nurse should disinfect the surface area they are working on and put a protective barrier down. Treatment supplies are then placed onto the protective barrier. She further stated that cleaning the table with a disinfectant and putting a clean barrier prevents contamination. She then added that the nurse should remove the soiled dressing, wash hands, change gloves, then proceed with wound cleansing. She stated that after cleaning the wound the nurse was to wash hands and change gloves, then proceed with the dressing change. She stated that she was not sure if dating dressings were within the dressing policy, however dating dressing ensured continuity of care and that dressing changes were being done. She continued to explain that after dressing change was completed, the nurse was to make sure the area was clean and the table they were working on was disinfected. The nurse should remove PPE and wash hands and sign the treatment out in the TAR. 3.) On 1/16/2026 at 12:39 PM, the surveyor observed staff on the 6th floor distributing lunch trays to the residents in the dining room. The surveyor observed three Certified Nursing Assistants (CNAs) retrieving trays from the lunch cart providing the trays to the resident. The aides delivered the tray to the resident and set the resident up, then went back to the food truck and retrieved another tray without first performing hand hygiene in between residents. On 1/16/2026 at 12:41 PM, the surveyor interviewed CNA #6 who stated that the process for passing food trays included looking at the resident's name on the tray ticket to verify that correct meal was provided. The surveyor asked the CNA what the staff should be performing before and after tray distribution to the residents and he did not know that he should be performing hand hygiene between the residents during tray pass to prevent the spread of infection. On 1/16/2026 at 12:46 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager for the 6th floor (LPN/UM #1) who confirmed that between residents and during food tray distribution, the CNA was supposed to perform hand hygiene to prevent the spread of infection. On 1/16/2026 12:57 PM, the surveyor interviewed an Activities Monitor (AM) who was observed assisting the CNAs distribute lunch trays to the residents on the 6th floor. The surveyor questioned the AM regarding hand hygiene in between tray distribution to the residents and the AM seemed to be unaware that she had to perform hand hygiene in between residents. She stated that she could not recall if she had received education regarding hand hygiene during meal tray distribution. On 1/22/26 at 8:12 AM, the surveyor interviewed the Infection Preventionist Registered Nurse (IP) who explained that when the CNAs passed out meal trays to the residents, they must perform hand hygiene in between residents. She stated that they must perform hand hygiene for standard precautions to prevent the spread of infection because they are in close contact with residents and touched objects while setting up resident trays. A review of the facility's Administering Medications policy updated 1/26 included. staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. A review of the facility policy dated 1/2026 and titled, Wound Care indicated the following steps: -Use disposable cloth or paper towel to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. -After removing soiled dressing, remove the dressing, discard and wash hands. -Use a no-touch technique and use sterile tongue blades and applicators to remove ointments and creams from their containers. A review of the facility policy dated August 2019 and titled, Handwashing/Hand Hygiene indicated that hand hygiene should be done before and after handling clean and soiled dressing or gauze, before moving from a contaminated body site to a clean body site during resident care, after handling contaminated equipment and used dressings, and before and after assisting residents during meals. NJAC 8:39-19.4 (a)(m)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to revise a resident's care plan with related goals and interventions each time the resident sustained a fall. This deficient practice was identified for 1 of 11 residents (Resident #135) reviewed for accidents and was evidenced by the following:On 1/16/26 at 12:52 PM, the surveyor observed Resident #135 ambulating independently in the hallway without an assistive device. At that time, the surveyor attempted to interview the resident who appeared to be confused and was unable to answer the surveyor's questions appropriately. On 1/20/26 at 11:54 AM, the surveyor reviewed the medical record for Resident #135.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: morbid (severe) obesity due to excess calories, schizophrenia, unspecified (a serious mental health condition), anxiety disorder, unspecified, depression, unspecified, and primary open-angle glaucoma, bilateral, mild stage (increased intraocular (eye) pressure).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/2/26, included the resident had both a short-term and a long-term memory problem and the resident's cognitive skills for daily decision-making ability was described as severely impaired. Further review of the MDS revealed that the resident had one fall since admission, entry, reentry, or prior assessment without injury.A review of the resident's facility provided individual comprehensive care plan (ICCP) included a focus area, dated 1/7/21, that the resident was at risk for falls or injury related to: Psychotropic Drug Use, Behaviors, Poor Safety Awareness (sits on floor) Hx (history): Decreased mobility r/t (related to) poor endurance associated with Dx (diagnosis) COPD (chronic obstructive pulmonary disease) and morbid obesity. Further review of the Focus Area included an Actual Fall on 11/15/25, with no documented evidence that any interventions were implemented to prevent the recurrence of resident falls.A review of the Order Summary Report (OSR), dated as of 1/28/26, included the following physician order (PO):A PO, dated 11/12/25, for DC (discharge) from skilled PT (physical therapy) services this last date of service due to patient met goals. Continue ambulation with rollator walker (a rolling walker with three or four wheels, a frame with handlebars, and a seat).A review of the facility provided fall investigation included a nursing progress note, dated 11/15/25, created at 4:03 PM by Registered Nurse (RN #2), included, At approximately 2:30 pm while passing resident's room in the hallway with other staff. Observed resident trying to get out of bed while doing so seen resident lost his/her balance and landed on his/her right shoulder and right upper arm against the dresser but did not hit his/her head on any object. Skin assessment done noted redness to right upper arm applied ice pack to affected area. This writer was not able to get to the resident in time to assist. MD (medical doctor) made aware no new order and POA (Power of Attorney).On 1/21/26 at 11:40 AM, the surveyor interviewed RN #2 who stated that when a resident fall occurred, either the supervisor or he was responsible for updating the resident's care plan. RN #2 further stated that if he updated the care plan, he only documented the date that the resident had fallen. RN #2 further stated the unit manager then reviewed the care plan and implemented interventions.On 1/21/26 at 12:09 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that she had worked at the facility for one week. LPN/UM #1 stated that new interventions were required to be put into place after each fall so that they know what they have done to help the resident and to determine the effectiveness of the interventions. LPN/UM #1 further stated they were supposed to update the interventions on the care plan with every fall. On 1/23/26 at 1:18 PM, the surveyor interviewed the Director of Nursing (DON) who stated that every new fall or event gets a new intervention on the resident's care plan. The DON further stated that the resident's care plan should have been updated immediately with new interventions after the resident fell. On 1/27/26 at 3:39 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the facility's failure to update the resident's care plan with new interventions after each resident fall.A review of the facility's Care Plans, Comprehensive Person-Centered policy, dated revised March 2022, included: .Care Plan interventions are chosen only after data gathering, proper sequence of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms or triggers.the interdisciplinary team reviews and updates the care plan.when the desired outcome is not met.A review of the facility's Safety and Supervision of Residents policy, dated revised July 2017, included: .Monitoring the effectiveness of interventions shall include the following: .Ensuring that interventions are implemented correctly and consistently; Evaluating the effectiveness of interventions; and documenting interventions.NJAC 8:39-11.2 (e) 2

Based on observation, interview and review of medical records, it was determined that the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not performing treatments as ordered by the physician. This deficient practice was identified for 1 (one) of 1 resident (Resident #194) reviewed for skin alterations and was evidenced by the following:Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist:Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist.A review of the admission Record (admission summary) reflected that Resident #194 was admitted to the facility with the diagnoses which included but was not limited to dementia, bipolar disorder and heart failure. A review of the quarterly Minimum Data Set, an assessment that facilitates a resident's care dated 3/5/26 indicated that Resident #194 scored a 3 out of 15 on the Basic Interview for Mental Status (BIMS). This score indicated that Resident #194 had severe impairment with cognition. The MDS also indicated that the resident was dependent on all aspects of activities of daily living (ADLs) and was at risk for developing pressure ulcers. On 3/16/26 at 12:14 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who indicated that he was caring for Resident #194. The LPN stated that the only treatment that was being performed for the resident was for a skin tear of the right forearm. On 3/16/26 at 12:17 PM, the surveyor interviewed the primary care Certified Nursing Assistant (CNA) who stated that Resident #194 required complete care with ADLs and was incontinent with bladder and bowel. She stated that the resident had a patch on the right side of the butt and has had the wound for a couple of weeks and had a dressing on the right forearm.On 3/16/26 at 12:25 PM, the surveyor accompanied the LPN and the CNA to Resident #194's room. The surveyor observed the LPN and CNA mechanical lift the resident back to bed. The surveyor observed an anti-pressure cushion on the resident's chair, an air mattress on the resident's bed and observed that the resident had a dressing on the right forearm dated 3/12/26. The LPN and CNA acknowledged that the dressing on the right forearm was dated 3/12/26.A review of the Treatment Administration Record (TAR) dated contained a physician's order dated 3/6/26 to cleanse the right forearm with normal saline solution (NSS) apply honey gel and a clean dry dressing (CCD) every day for wound healing. The TAR reflected nursing signatures dated 3/13/26 and 3/14/26 that the treatment was administered. The TAR dated 3/15/26 was blank.On 3/16/26 at 1:20 PM, the surveyor interviewed the LPN who reviewed the TAR in the presence of the surveyor and stated that he signed the TAR on 3/14/26 that he administered the right forearm wound treatment. The surveyor asked him if he completed the wound care as ordered that day, because the dressing was dated 3/12/26. He stated that he did not remember and that the treatment was probably overlooked. He stated that it was important to follow physician's orders to ensure that the residents got the care that they needed. He also stated that when the signature plot on the TAR was blank on 3/15/26, it meant that the treatment was not done as ordered.On 3/16/26 at 2:01 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Licensed Nursing Home Administrator simultaneously and informed them of the surveyors findings and they did not have a response as to why Resident #194's treatment dressing of the right forearm was dated 3/12/26 and the nursing staff were signing or not signing the TAR from 3/13/26 until 3/15/26 that a treatment was being performed.A review of the facility policy with a revised date of 1/2026 and titled, Wound Care indicated that the policy provided guidelines for the care of wounds to promote healing. The policy indicated that the staff were to verify that there was a physician order, review the care plan for any specific needs of the resident, mark date of dressing change with time, date and initials. The following documentation should be recorded in the resident's medical records: type of wound care given, date and time the wound care was given, position in which the resident was placed, the name and title of the individual performing the wound care and all assessment data obtained when inspecting the wound.NJAC 8:39-29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide urinary catheter (a tube used to drain urine), treatment and care, based upon current standards of practice specifically : a.) not documenting urinary outputs, and b.) failing to ensure the urinary catheter drainage bag was positioned off the floor and was not visible from the doorway, for 2 of 2 (two) residents (Resident #5 and Resident #8) reviewed for urinary catheter care. The deficient practice was evidenced by the following: On 1/15/26 at 12:22 PM, the surveyor observed Resident #5 lying in bed with the head of the bed elevated while being fed by staff. The surveyor observed the urinary catheter drainage bag contained within a privacy bag and positioned on the floor, visible from the hallway. On 1/16/26 at 9:31 AM, the surveyor observed Resident #5 lying in bed. The surveyor observed the urinary catheter drainage bag positioned on the floor and visible from the hallway. On 1/16/26 at 11:36 AM, the surveyor reviewed the medical record for Resident #5. A review of the admission Record, an admission summary indicated that the resident had diagnoses that included, but were not limited to, uninhibited neuropathic bladder (impaired bladder control resulting in involuntary, sudden urges to void, frequent urination, and urinary leakage). A review of the Resident's most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 12/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, reflecting severely impaired cognition. Further review of the MDS revealed that Resident #5 had an indwelling urinary catheter. A review of the Resident's Individual Comprehensive Care Plan (ICCP) included a focus area dated 8/20/25 that the Resident had an indwelling urinary catheter. Interventions included, but were not limited to, positioning the catheter bag and tubing below the level of the bladder and away from the room entrance. However, the Foley catheter drainage bag was observed positioned on the floor and visible from the resident's doorway. A review of the Order Summary Report (OSR) revealed an active order for foley catheter care every shift as of 8/19/25. On 1/16/26 at 1:51 PM, the surveyor interviewed Certified Nurse Assistant (CNA #7) and requested that she accompany the surveyor to Resident #5's room. When asked about the positioning of the Resident's Foley catheter drainage bag, CNA #7 acknowledged that the drainage bag should be kept off the floor and positioned away from the doorway for infection prevention and resident privacy. On 1/16/26 at 1:59 PM, the surveyor requested Licensed Practical Nurse (LPN #4) to accompany her to the Resident's room during an interview. LPN #4 stated that the Foley catheter drainage bag was on the floor and acknowledged that the drainage bag should not be placed on the floor to prevent infection. LPN #4 further stated that the drainage bag should be positioned away from the doorway to ensure resident privacy. On 1/21/26 at 11:28 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1), who confirmed that the privacy bag should be positioned below waist level, not on the floor. RN/UM #1 further stated that staff should follow the resident's care plan for proper positioning of the catheter drainage bag to prevent infection and maintain resident privacy. On 1/21/26 at 12:49 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the catheter drainage bag should be positioned for gravity drainage, placed in a privacy bag, and kept out of view to prevent infection and maintain resident privacy. A review of the facility policy titled, Catheter Care, Urinary updated 1/26 indicated that the purpose of this procedure is to prevent catheter-associated urinary tract infections, and under Infection Control included . 2. b.) be sure the catheter tubing and draining bag are kept off the floor . On 1/22/26 at 10:41 AM, the surveyor observed Resident #8 sitting in a wheelchair in the dayroom. The surveyor and Resident #8 went to the resident's room for an interview. Resident #8 stated they had been in the facility for a few months, confirmed they used a urinary catheter, had urinary tract infections in the past and that the Certified Nurse Aides (CNAs) would collect and measure the urine output from the urinary collection bag every shift. The surveyor reviewed the medical record for Resident #8. A review of the admission Record face sheet reflected that the resident was admitted to the facility in September of 2025 with diagnoses which included urinary tract infection, urinary retention, and neuropathic bladder (a dysfunction of the bladder, caused by nerve damage prevents the bladder from properly storing or emptying urine). A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 12/20/25, reflected that the resident had a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. It further included that the resident had an indwelling catheter. A review of the resident's individualized person-centered Care Plan (CP) included a focus area initiated on 9/22/25 for utilizing an indwelling catheter related to a diagnosis of neuropathic bladder. Interventions included to: position catheter bag and tubing below the level of the bladder; check tubing for kinks and patency every shift, every day; monitor and document intake and output as per facility policy; monitor/document for pain/discomfort due to catheter. A review of Resident # 8's Order Summary located in the Electronic Medical Record (EMR) revealed an order to, empty and measure foley catheter urine output every shift for health monitoring, initiated 9/19/25. A review of the December 2025 Treatment Administration Record (TAR) located in the EMR revealed blanks in the documentation portion for the following dates: 12/3/25-night-blank 12/14/25-day-blank 12/18/25-day-blank 12/19/25-day-blank 12/21/25-day-blank 12/23/25-day-blank 12/28/25-evening-blank 12/29/25-evening-blank A review of the January 2026 TAR located in the EMR revealed blanks in the documentation portion for the following dates: 1/2/26-evening-blank 1/3/26-day-blank 1/5/26-day-blank 1/8/26-day-blank On 1/22/26 at 11:31 AM, the surveyor interviewed the resident's Licensed Practical Nurse #1 (LPN/#1) who stated the CNAs (Certified Nursing Aides) were responsible for emptying the catheter bags and then reporting the amount of urine to the nurses who would record the urinary output amount in the EMR. At that time the surveyor reviewed with the LPN Resident #8's December 2025 TAR and January 2026 TAR. When asked what the blanks in the TAR meant she stated there should not be any boxes left blank, the empty box meant the nurse did not record the amount of urine output. On 1/22/26 at 4:26 PM, the survey team met with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the facility's Nursing Consultant (NC). The DON stated there should be no blanks left on the TAR, if there were blanks then the work was not done. A review of the facility policy titled, Catheter Care, Urinary updated 1/26 indicated that the purpose of this procedure is to prevent catheter-associated urinary tract infections, and under Infection Control included . 2. b.) be sure the catheter tubing and draining bag are kept off the floor . .the purpose of this procedure is to prevent catheter-associated urinary tract infections and included under Input/Output to observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident's daily output, per facility policy and procedure. NJAC: 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) assess a resident's oxygen setting to ensure that the resident was receiving the correct amount of oxygen as ordered by the physician and b.) properly store a Bi-level positive airway pressure (BiPAP), machine [helps breathing by delivering air through a face mask), in a bag when not in use, in accordance with professional standards of practice. This deficient practice was identified for 1 of 1 (one of one) resident (Resident #191) reviewed for respiratory care and was evidenced by the following: On 1/15/26 at 12:35 PM, during the initial facility tour, the surveyor observed Resident #191 lying in bed and the resident received three liters (3L) of humidified oxygen (O ) via an oxygen concentrator (a medical device that filters and delivers oxygen from the air). The surveyor also observed that the Resident's BiPAP machine was not stored in a plastic bag as ordered when not in use. On 1/16/26 at 9:29 AM, the surveyor observed Resident #191 lying in bed and the resident received 3.5 liters (3.5L) of humidified oxygen (O ) via an oxygen concentrator. The surveyor also observed several dated plastic bags in the room; however, the resident's BiPAP machine was not placed in a bag as ordered. On 1/16/26 at 11:42 AM, the surveyor reviewed the medical record for Resident #191. A review of the admission Record, an admission summary, indicated that Resident #191 was admitted to the facility with diagnoses that included, but were not limited to chronic obstructive pulmonary disease (COPD), [a chronic lung condition that makes breathing difficult]. A review of the quarterly Minimum Data Set (MDS), an assessment that guides a resident's care, dated 12/26/25, indicated that Resident #191 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which reflected severe cognitive impairment. A review of the Order Summary Report (OSR) dated as of 1/22/26, included the following physician orders (PO) for Resident #191:A PO dated 1/13/26, for O at 2L per minute (2L/min), as needed (PRN) every shift.A PO dated 1/13/26, to remove BiPAP machine and place it in a plastic bag, one time a day. A review of the Resident's Individual Comprehensive Care Plan (ICCP) included a focus area, dated 1/4/21, that Resident #191 had the potential for ineffective breathing related to COPD and a history of smoking. Interventions included:Administer oxygen therapy per medical doctor (MD) orders,Document respiratory status every shift as needed when not within resident baseline, andNotify the MD promptly as needed (PRN).However, the PO for O at 2L/min was not followed, and the MD was not notified for adjustments based on the Resident's respiratory status and care plan interventions. A review of Resident #191's O levels from 7/25/25 to 1/20/26, revealed that the resident received oxygen on multiple occasions despite O levels being greater than 94%. (Normal oxygen saturation levels in adults range from 95% to 100%). A review of Resident #191's Progress Notes (PN) from 12/28/25 to 1/2/26 revealed there were no nurse's notes indicating communication with the MD regarding the resident's oxygen (O ) levels and O settings, despite the ICCP specifying that the MD should be notified promptly. On 1/16/26 at 1:48 PM, the surveyor requested Certified Nursing Assistant (CNA #7) to accompany her to Resident #191's room. The surveyor asked CNA #7 to verify the resident's O setting. CNA #7 confirmed that the resident was receiving 3L of O . CNA #7 further stated that the BiPAP machine should be stored in a bag when not in use to prevent contamination. On 1/16/26 at 1:54 PM, the surveyor interviewed Licensed Practical Nurse (LPN #4) during a tour of Resident #191's room. LPN #4 confirmed that the resident's O concentrator was set to 3L of O . LPN #4 stated that the O level was set by the nurse and that nurses were responsible for carrying out the MD's orders. When asked to verify the physician's order for O , LPN #4 accessed the Resident's OSR and confirmed that O at 2L/min was ordered. The LPN further stated that it is important to follow the MD's orders and that staff should monitor the O setting to avoid the dangers of over-oxygenation. On 1/21/26 at 11:26 AM, the surveyor interviewed LPN #2, who stated the BiPAP machine should be stored in a labeled bag when not in use for infection control purposes. On 1/21/26 at 12:43 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that nurses are responsible for notifying the MD and resident's family of any changes in O settings and the resident's O levels, educating the Resident and the Resident's responsible party regarding O use. The DON emphasized that excess O can lead to negative health consequences. The DON also stated that the BiPAP machine should be cleaned and stored in a dated plastic bag to prevent contamination. The facility policy Oxygen Administration, updated 1/2026, indicated that the purpose of this procedure was to provide guidelines for safe oxygen administration. A review of the facility's CPAP/BiPAP Support policy, revised 3/2015, included that the purpose was . to promote resident comfort and safety. NJAC 8:39-27.1(a)

Based on interviews, record review, and review of facility documents, it was determined that the facility failed to act upon the recommendations made by the Consultant Pharmacist in a timely manner. This deficient practice was identified for 1 of 35 residents (Resident #135) reviewed for medications and was evidenced by the following:On 1/16/26 at 12:52 PM, the surveyor observed Resident #135 ambulating independently in the hallway without an assistive device. At that time, the surveyor attempted to interview the resident who appeared to be confused and was unable to answer the surveyor's questions appropriately. On 1/20/26 at 11:54 AM, the surveyor reviewed the medical record for Resident #135. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: morbid (severe) obesity due to excess calories, schizophrenia, unspecified (a serious mental health condition), anxiety disorder, unspecified, depression, Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia (deficiency in the amount of oxygen in the tissues) or Hypercapnia (an excess of carbon dioxide in the blood), and Chronic Obstructive Pulmonary Disease (a progressive, inflammatory lung disease that makes it difficult to breathe) (acute) exacerbation.A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/2/26, included the resident had both a short-term and a long-term memory problem and the resident's cognitive skills for daily decision-making ability was described as severely impaired. A review of the resident's facility provided individual comprehensive care plan (ICCP) included a focus area, dated 1/7/21, for Respiratory, resident has the potential for ineffective breathing related to: DX (diagnosis) COPD, morbid obesity, respiratory failure, smoker. Interventions included: .Observe respiratory status for: rate, depth, and ease, Presence of dyspnea (difficulty breathing), A review of the Order Summary Report (OSR), dated as of 1/27/26, included the following physician orders (PO): A PO, dated 10/20/25, for Fluticasone Furoate-Vilanterol. Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (micrograms per actuation) 1 (one) puff inhaled orally one time a day for nasal congestion.On 1/21/26 at 10:09 AM, the surveyor reviewed the Consultant Pharmacist Comments Report (CR) for Resident #135, which revealed that on 11/29/25, the Consultant Pharmacist (CP) made a recommendation to clarify and update the diagnosis for the Fluticasone-Vilanterol inhaler (used to treat chronic obstructive pulmonary disease (COPD) to improve breathing problems).Further review of the CR revealed that on 12/31/25, the CP recommended that Resident #135 should rinse their mouth after using Fluticasone-Vilanterol to decrease the risk of oral fungus infections. Please clarify and update the diagnosis.On 1/21/26 at 10:09 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated she had worked at the facility for one week. LPN/UM #1 stated the CP came into the facility and performed a Monthly Medication Review (MMR) and then sent their recommendations to the Director of Nursing (DON), who then provided the recommendations to the unit managers for review and implementation within a couple of days of receipt.At that time, LPN/UM #1 reviewed the order for Fluticasone Furoate-Vilanterol and stated they should have changed the diagnosis and updated the instructions for the resident to rinse their mouth in accordance with the CP recommendations.On 1/23/26 at 1:04 PM, the surveyor interviewed the DON, who stated that when she received the CP recommendations, she sent them to the unit managers via email and asked them to follow up. The DON stated that there had been a lot of turnover with the management staff. At that time, the DON confirmed that the CP recommendations were not acted upon effectively. The DON further stated that the nurse should have documented that the CP recommendations were conveyed to the physician and indicated if any physician orders were received.On 1/27/26 at 3:39 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON) were informed of the concerns related to the facility's failure to implement the CP recommendations in a timely manner.A review of the facility's Pharmacy Services-Role of the Consultant Pharmacist policy, revised April 2019, included: .The consultant pharmacist will provide specific activities related to medication regimen review including: a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines;. NJAC 8:39-29.3(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store and secure medication left at a resident's bedside (Resident #13). This deficient practice was identified on 1 of 5 nursing units (5th Floor) and was evidenced by the following:On 1/20/26 at 10:36 AM, the surveyor in the presence of another surveyor, observed Resident #13 lying in bed, with their eyes closed, fully dressed with a blanket over their legs. On the bedside table there was a clear plastic cup containing a clear liquid and a plastic medicine cup with two round pills, one pink-colored pill, and one slightly smaller light orange pill. The resident had their privacy curtain pulled to the side of their footboard on the bed, inhibiting access to the nightstand. The resident did not respond to surveyor inquiry.At that time, the surveyor did not observe any residents ambulating independently near the resident's room without staff present.On 1/20/26 at 10:37 AM, surveyor #2 went to find the nurse and the Certified Nursing Aide (CNA) assigned to Resident #13, while surveyor #1 stayed with the resident. When CNA #2 arrived at the room and was shown the pills in the medicine cup on the nightstand she stated the medication should not be left there, and that the resident was supposed to take their medication while the nurse was in the room. On 1/20/26 at 10:41 AM, the surveyor interviewed the Licensed Practical Nurse #5 (LPN #5) who acknowledged the medications found at the bedside and stated she had given Resident #13 their medications in the hallway and not in their room LPN #5 stated that the medication in the cup was not from her morning medication pass. LPN #5 confirmed that medications should not be left at the bedside, and should be secured in a medication cart. On 1/20/26 at 11:01 AM, the surveyors interviewed the fifth floor Registered Nurse Unit Manager #2 (RN/UM #2) who acknowledged the medications on the bedside table, she was unable to identify the pills in the medicine cup. RN/UM #2 confirmed there should be no medications left unsecured at the resident's bedside. RN/UM #2 explained the medication process and stated that the nurse must observe that the resident has taken the medication, to ensure the resident was therapeutic, and must ensure that no medication was left around for another resident to take. RN/UM #2 then took the medications to secure them.On 1/20/26 at 1:14 PM, the Director of Nursing (DON), RN/UM #2 and LPN #5 went to the medication cart to review the orders and identify the pills left in the medication cup. Upon review the DON determined the medications were Aspirin 81 mg (milligram) chewable tablet (a medication used to prevent blood clots) and Vitamin B12 100mcg (micrograms) tablet (a supplement used for vitamin deficiency). The DON confirmed medications should not be left at the bedside because they must be secured for the safety of all the residents.A review of the facility's undated Storage of Medications policy included. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe and sanitary manner.NJAC 8:39-29.4(h)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to properly dispose of garbage and refuse in one of one garbage disposal areas.This deficient practice was evidenced by:On 1/15/26 at 10:25 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's garbage disposal area. The surveyor observed container tops, food waste, plastic utensils, pieces of wood and cardboard boxes, as well as used gloves and face masks discarded on the ground adjacent to the garbage disposal containers. The surveyor also observed low-lying black tubing and additional black tubing running along the ground in the garbage disposal area. During the tour, the surveyor interviewed the FSD regarding the facility's garbage disposal practices and the presence of black tubing in the garbage disposal area. The FSD stated that maintenance of the facility's garbage disposal areas was a shared responsibility between the dietary and maintenance departments. The FSD confirmed that all trash and discarded items were expected to be placed inside the disposal containers and not discarded on the ground to maintain a safe and sanitary environment. The FSD further stated that the black tubing should not be located on the ground or hanging in a low position due to safety concerns. On 01/21/26 at 2:00 PM, the surveyor interviewed the Director of Maintenance (DOM), who stated that trash should be properly disposed of by placing it inside the disposal containers and not on the ground. The DOM further stated that the black tubing should always be maintained in a safe manner. The DOM explained that proper disposal and maintenance were important to prevent contamination and ensure a safe, sanitary environment. On 01/22/26 at 4:28 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that it was unacceptable for the garbage disposal area to be littered with trash, used items, or have tubing located on the ground. The LNHA further stated that she expected the garbage disposal area to be maintained in a sanitary condition, free of debris, to prevent infection and contamination. The surveyor reviewed the facility's Waste Disposal policy, updated February 2025, which included that all infectious and regulated waste . disposed of in a safe, controlled, and compliant manner to prevent exposure, environmental contamination and regulatory violations NJAC 8:39-19.7(c)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 2 of 4 meetings reviewed and was evidenced by the following:On 1/15/26 at 11:39 AM, the surveyor requested to view the last four quarters of the QAPI meeting sign-in sheets.On 1/20/26 at 10:13 AM, the surveyor was provided with the QAPI Committee Quarterly Meeting Sign-In Sheets that were dated 1/23/25, 4/24/25, July 2025, and October 2025. A review of the 4/24/25 Sign-In Sheet revealed that LOA (Leave of Absence) was documented in the signature panel of a mandatory participant, the Infection Control Preventionist (ICP). Further review of the July 2025 QAPI Meeting Sign-In Sheet revealed that the signature panel that was allotted for the ICP's signature was not filled in with any data to indicate the status of the ICP's attendance at the quarterly QAPI Meeting.On 1/23/2026 at 3:04 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. At that time, the surveyor asked the LNHA if the ICP was on leave of absence during two of the four quarterly QAPI Meetings reviewed that were dated 4/24/25 and July 2025? The LNHA stated that the QAPI Meetings were held before both she and the current Director of Nursing (DON) were hired. A Further review of the July 2025 QAPI Committee Meeting Sign-In sheet revealed that both the LNHA and the current DON had signed their names in the signature panel to indicate their attendance at the meeting.On 1/23/2026 at 3:39 PM, the surveyor interviewed the Director of Human Resources and Staffing who stated that the ICP was out on a leave of absence for two quarters, both April 24, 2025, and July 2025 and was not in attendance at the meetings. On 1/23/2026 at 3:50 PM, in a later interview with the LNHA, she stated the Medical Director, LNHA, DON, and the ICP were all required to be in attendance during the quarterly QAPI Committee Meetings. The LNHA stated that the ICP was required to be there, but she maintained that it was prior to her term as the LNHA.A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership policy, updated 1/2026, included: .the following individuals serve on the committee: Administrator, or a designee who is in a leadership role; Director of nursing services; Medical director; Infection preventionist; and Representatives of the following departments, as requested by the administrator:1. Pharmacy; 2. Social services; 3. Activity services; 4. Environmental services; 5. Human resources; and 6. Medical records.The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting.NJAC 8:39-33.1 (b)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the arbitration agreement and admission agreement specifically provides for the selection of a venue that is convenient to both parties, specifically by stating in the admission Agreement a specific location where binding arbitration will be settled. This deficient practice was identified for all residents in the facility. The deficient practice was evidenced by the following: Review of a copy of the facility's undated admission Agreement revealed in section 9. Miscellaneous Category G, Disputes, Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof including Facility's obligation thereof shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with then party to the extent that such affiliates joins in the arbitration, and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. A review of the facility policy titled, Arbitration Agreements Policy and Procedure with a date of 2025, revealed under Policy and Procedure at d. The agreement shall specifically provide for the selection of a venue that is agreed upon and convenient - - to both parties. On 5/08/2025 at 11:09 AM during an interview with the surveyor, the Licensed Nursing Home Administrator replied, No, and we will get that fixed. when the surveyor asked does the admission Agreement specifically provide for the selection of a venue that is agreed upon and convenient. NJAC 8:39-13.1(a)

Based on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 23 of 59 residents (Residents #2, #108, #69, #125, #90, #57, #111, #100, #60, #21, #165, #177, #136, #134, #132, #172, #83, #104, #174, #96 ,#54, and #19) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. The following residents were identified that the comprehensive MDS was not completed in a timely manner: 1. Resident # 2: The Annual MDS dated [DATE] which should have been completed by 03/22/2025 is in progress (44 days late as of 05/05/25). 2. Resident # 108: The Annual MDS dated [DATE] was completed on 01/17/2025 (34 days late). 3. Resident #69: The Annual MDS dated [DATE] was completed on 01/24/2025 (33 days late). 4. Resident #125: The Annual MDS dated [DATE] was completed on 01/17/2025 (31 days late). 5. Resident #90: The Annual MDS dated [DATE] was completed on 01/27/2025(33 days late). 6. Resident #57: The Annual MDS dated [DATE] should have been completed by 03/26/2025 (40 days late) as of 05/05/2025. 7. Resident #111: The Annual MDS dated [DATE] was completed on 02/04/2025 (36 days late). 8. Resident #100: The Annual MDS dated [DATE] was completed on 02/16/2025. (38 days late). 9. Resident #60: The Annual MDS 03/08/2025 which should have been completed by 3/22/25 is in progress (44 days late) as of 05/05/2025. 10. Resident #21: The Annual MDS dated [DATE] which should have been completed on 04/04/2025 is in progress. (31 days late) as of 05/05/2025. 11. Resident # 165: The Annual MDS dated [DATE] which should have been completed by 03/28/2025 is in progress (38 days late) as of 05/05/2025. 12. Resident # 177: The Annual MDS dated [DATE] which should have been completed by 04/07/2025 is in progress (28 days late) as of 05/05/2025. 13.Resident #136: The Annual MDS dated [DATE] which should have been completed by 03/27/2025 is in progress (39 days late) as of 5/5/25. 14.Resident # 47: The Annual MDS dated [DATE] was completed on 1/27/25. (25 days late). 15.Resident # 134: The Annual MDS dated [DATE] which should have been completed by 03/26/2025 is in progress (40 days late) as of 05/05/2025. 16.Resident # 132: The admission MDS dated [DATE] which should have been completed by 03/29/2025 is in progress. (38 days late) as of 05/05/2025. 17.Resident # 172: The Annual MDS dated [DATE] was completed on 2/16/25 (49 days late). 18.Resident # 83: The Annual MDS dated [DATE] which should have been completed by 3/21/25 is in progress (45 days late) as of 05/05/2025. 19.Resident # 104: The admission (annual) MDS dated [DATE] which should have been completed by 3/24/25 is in progress. (42 days late) as of 05/05/2025. 20.Resident # 174: Th Annual MDS dated [DATE] was completed on 4/20/25 (40 days late). 21.Resident # 96: The Annual MDS dated [DATE] which should have been completed by 3/29/25 is in progress (38 days late) as of 05/05/2025. 22.Resident # 54: The Annual MDS dated [DATE] was completed on 01/30/2025 (35 days late). 23.Resident # 19: The Annual MDS dated [DATE] was completed on 1/31/25. (33 days late). On 05/08/2025 at 08:40 AM, the surveyor interviewed the MDS Coordinator. She said she was aware that there are comprehensive assessments that have not been completed within the required time frame. She stated she is working on getting them completed. A review of facility provided policy titled, MDS 3.0 Completion, copyright 2023, reflected b. admission assessment-completed within 14 days of admission counting the day of admission as day #1.c. annual assessment-comprehensive assessment completed using an ARD no greater than 366 days from the most recent prior comprehensive assessment and no later than greater than 92 days from the most recent quarterly assessment (counting ARD to ARD). NJAC 8:39-11.2 (e)

Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (QMDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 54 of 59 residents (Residents # 129,#51, #42, #8, #2, #108, #69, #5, #1, #125, #58, #48, #111, #100, #3, #60, #21, #159, #46, #169, #75, #138, #71, #165, #107, #177, #67, #181, #176, #136, #147, #74, #134, #132, #126, #172, #18, #23, #83, #38, #104, #13, #96, #54, #78, #19, #105, #155, #116, #182, #135, #99, #39, and #52) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. The following residents were identified that the quarterly MDS was not completed in a timely manner as of 05/05/2025: 1.Resident # 129: The QMDS dated [DATE] which should have been completed by 3/16/25 is in progress. 2. Resident # 51: The QMDS dated [DATE] was completed on 1/30/25 (46 days late). The QMDS dated [DATE] which should be completed by 3/28/25 is in progress. 3. Resident #42: The QMDS dated [DATE] was completed on 1/19/24 (28 days late). The QMDS dated [DATE] which should have been completed by 3/21/25 is in progress. 4.Resident # 8: The QMDS dated [DATE] was completed on 0 2/10/2025(36 days late). 5.Resident # 2: The QMDS dated [DATE] was completed on 01/27/2025 (34 days late). 6.Resident #108: The QMDS dated [DATE] which should have been completed by 04/03/2025 is in progress. 7.Resident #69: The QMDS dated [DATE] which should have been completed by 03/21/2025 is in progress. 8.Resident #5: The QMDS dated [DATE] which should have been completed by 03/18/2025 is in progress. 9.Resident #1The QMDS dated [DATE] was completed on 01/05/2025 (18 days late). The QMDS dated [DATE] which should have been completed by 03/16/2025 is in progress. 10.Resident #125: The QMDS dated [DATE] which should have been completed by 03/16/2025 is in progress. 11.Resident # 58: The QMDS dated [DATE] which should have been completed by 03/17/2025 is in progress. 12.Resident #48: The QMDS dated [DATE] should have been completed as of 3/18/25 is in progress. 13.Resident #111: The QMDS dated [DATE] which should have been completed by 3/30/25 is in progress. 14.Resident #100: The QMDS dated [DATE] which should have been completed by 4/7/25 is in progress. 15.Resident #3: The QMDS dated [DATE] was completed on 02/07/2025 (38 days late). The QMDS dated [DATE] which should have been completed by 3/29/25 is in progress. 16.Resident #60: The QMDS dated [DATE] was completed on 01/24/2025 (31 days late). 17.Resident #21: The QMDS dated [DATE] was completed on 02/13/2025 (28 days late). 18. Resident #159: The 2/23/25 Q MDS was completed on 4/15/25. (37 days late). 19.Resident #46 :The QMDS dated [DATE] was completed on 2/13/25.(38 days late). The QMDS dated [DATE] which should have been completed by 4/5/25 is in progress. 20.Resident #169: The QMDS dated [DATE] was completed on 02/13/2025 (29 days late). The QMDS dated [DATE] which should have been completed by 04/04/2025 is in progress. 21.Resident #75: The QMDS dated [DATE] was completed on 2/15/2025. (35 days late). The QMDS dated [DATE] which should have been completed by 04/10/25 is in progress. 22.Resident #138: The QMDS dated which should have been completed on by 03/17/2025 is in progress. 23. Resident #71: The QMDS dated [DATE] was completed on 01/30/2025.(32 days late). The QMDS dated [DATE] which should have been completed by 03/28/2025 is in progress. 24.Resident # 165: The QMDS dated [DATE] was completed on 02/07/2025 (39 days late). 25.Resident # 107: The QMDS dated [DATE] was completed on 01/31/2025. (33 days late). The QMDS dated [DATE] which should be completed by 03/26/2025 is in progress. 26.Resident # 177: The QMDS dated [DATE] was completed on 02/16/2025 (38 days late). 27.Resident #67: The QMDS dated [DATE] was completed on 1/30/25 (34 days late). The QMDS dated [DATE] which should have been completed by 3/26/25 is in progress. 28.Resident # 181: The QMDS dated [DATE] was completed on 2/10/25. (40 days late). The QMDS dated [DATE] which should have been completed by 03/31/2025 is in progress. 29.Resident #176: The QMDS dated [DATE] was completed on 1/19/25. (29 days late). The QMDS dated [DATE] which should have been completed by 03/20/2025 is in progress. 30.Resident #136: The QMDS dated [DATE] was completed on 02/07/2025 (39 days late). 31.Resident # 47: The QMDS dated [DATE] which should have been completed by 3/23/25 is in progress. 32.Resident # 74: The QMDS dated [DATE] was completed on 2/10/25. (36 days late). The QMDS dated [DATE] which should have been completed by 4/3/25 is in progress. 33.Resident # 134: The QMDS dated [DATE] was completed on 1/30/25 (33 days late). 34.Resident # 132: The QMDS dated [DATE] was completed on 2/7/25. (38 days late). 35.Resident #126: The QMDS dated [DATE] which should have been completed by 03/16/2025 is in progress. 36.Resident # 172: The QMDS dated [DATE] which should have been completed by 04/11/2025 is in progress. 37.Resident # 18: The QMDS dated [DATE] was completed on 01/24/2025. (33 days late). The QMDS dated [DATE] which should have been completed by 03/21/2025 is in progress. 38. Resident # 23: The QMDS dated [DATE] which should have been completed by 3/16/25 is in progress. 39.Resident # 83: The QMDS dated [DATE] was completed on 01/24/2025 ( 32 days late). 40.Resident # 38: The QMDS dated [DATE] was completed on 02/16/2025. (50 days late). The QMDS dated [DATE] which should have been completed by 4/10/25 is in progress. 41.Resident # 104: The QMDS dated [DATE] was completed on 1/30/25 (35 days late). 42.Resident #13: The QMDS dated [DATE] Q which should have been completed by 3/15/25 is in progress. 43.Resident # 96: The QMDS dated [DATE] was completed on 02/07/2025. (38 days late). 44.Resident # 54: The QMDS dated [DATE] which should have been completed by 03/24/2025 is in progress. 45.Resident # 78: The QMDS dated [DATE] which should have been completed by 04/10/2025 is in progress. 46.Resident # 19: The QMDS dated [DATE] Q which should be completed by 03/28/2025 is in progress. 47.Resident # 105: The QMDS dated [DATE] which should have been completed by 03/15/2025 is in progress. 48.Resident # 155: The QMDS dated [DATE] was completed on 02/07/2025. (38 days late). The QMDS dated [DATE] which should have been completed by 03/30/2025 is in progress. 49.Resident # 116: The QMDS dated [DATE] Q MDS which should have been completed by 03/15/2025 is in progress. 50.Resident # 182: The QMDS dated [DATE] was completed on 02/10/2025 (38 days late). The QMDS dated [DATE] Q which should have been completed by 04/01/25 is in progress. 51.Resident # 135: The QMDS date 12/12/2024 was completed on 01/27/2025 ( 32 days late). The QMDS dated [DATE] Q MDS which should have been completed by 3/25/25 is in progress. 52.Resident # 99: The QMDS dated [DATE] was completed on 01/19/2025 (29 days late). The QMDS dated [DATE] which should be completed by 3/20/25 is in progress. 53.Resident # 39: The QMDS dated [DATE] was completed on 01/27/2025 (33 days late). The QMDS dated [DATE] which should have been completed by 3/24/25 is in progress. 54.Resident # 52: The QMDS dated [DATE] was completed on 2/10/25 (50 days late). The QMDS dated [DATE] which should have been completed by 04/03/2025 is in progress. On 05/08/25 at 08:40 AM, during an interview with the surveyor, the MDS Coordinator stated that is aware that there are Quarterly MDSs that are not completed within the required timeframe. She said she is trying her best. A review of facility provided policy titled, MDS 3.0 Completion, copyright 2023, which reflected e. quarterly assessment-completed using an ARD no greater than 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). N.J.A.C. 8:39-11.1

Based on interview and record review, it was determined the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines and that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 5 of 59 residents reviewed for resident assessment (Resident #34, #129, #58, #26 and #48 ). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after the assessment being completed. After transmission of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDSs were not transmitted timely: 1. Resident #34: the resident expired on [DATE]. There was no death in facility tracking record completed and the MDS was not transmitted as of [DATE]. 2. Resident #129: the Quarterly MDS was completed on [DATE] and was due to be transmitted no later than [DATE]. It was transmitted on [DATE] (23 days late). 3. Resident # 58: the Quarterly MDS was completed on [DATE] and due to be transmitted no later than [DATE]. It was transmitted on [DATE] (23 days late). 4. Resident # 26: the Quarterly MDS dated [DATE] was completed on [DATE] and was not transmitted as of [DATE] 5. Resident #48: the Quarterly MDS dated was completed on [DATE] and was due to be transmitted no later than [DATE]. It was transmitted [DATE] (23 days late). On [DATE] at 8:40 AM, during an interview with the surveyor, the MDS Coordinator stated that MDS's should be transmitted within 2 weeks of completion. The MDS Coordinator acknowledged that the MDSs are being transmitted late. A review of the facility provided policy titled, MDS 3.0 Completion, copyright 2023, which reflected 7. transmission requirements: all assessments shall be transmitted to the designated Center for Medicare and Medicaid Services within 14 days of completion. NJAC 8:39-11.1

Complaint #: NJ185153 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure: a) a staff member immediately reported an observed sexual encounter between a resident (Resident #1) who had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment) from a resident (Resident #2) who had a BIMS score of 8 (moderate cognitive impairment) and b) both residents were immediately separated, safe, and no other residents were placed in immediate danger. The facility also failed to follow its policy titled Resident Abuse/Neglect Policy. On 4/3/25 at approximately 12:00 P.M., the Housekeeper (HK) stated she went to Resident #1 and Resident #2's room and knocked on the door. The HK entered the room and observed Resident #1 on the bed performing oral sex on Resident #2. The HK finished collecting hangers from out of the room and then went on her lunch break for approximately 30 minutes. When the HK returned from lunch, she reported it to her co-worker. The co-worker then reported the sexual encounter that the HK observed to the Central Supply Coordinator (CSC). The CSC reported it to the 5th floor nurse, the Abuse Coordinator, the Licensed Nursing Home Administrator (LNHA), and the Assistant Director of Nursing (ADON). The facility failed to follow its policies and procedures and protect facility residents when the HK failed to immediately report the observed sexual encounter between both residents (Resident #1 and Resident #2) and ensure both residents were immediately separated. The facility also failed to ensure the safety of all other residents within the facility. This placed all residents in an immediate jeopardy (IJ) situation. The IJ began on 4/3/25, was identified on 4/10/25 at 5:32 P.M., and was reported to the LNHA. The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 4/14/25 at 9:19 A.M., indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The Housekeeper and facility staff were educated on the facility's policy on sexual abuse, the ability for residents to consent to sexual interactions with each other, and to immediately report any sexual activity between residents and ensure the residents were safe. The LNHA conducted audits to monitor compliance with education and conducted staff assessment and testing to ensure staff had a true understanding of education. The surveyor verified the removal plan on site on 4/16/25 and determined the IJ for F600 was removed as of 4/16/25. After the IJ removal, the non-compliance continued from 4/16/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2. According to the facility's Summary of Investigation with an event date of 4/3/25 revealed under Summary, Staff knocked on the door and entered the room to complete her work assignment. The staff member observed Resident #1 and #2 involved in a sexual act between each other. The staff member exited the room and reported what she witnessed to the nurse. The residents were immediately separated and placed on 1:1. The residents expressed consent to their actions without anyone being taken advantage of by the other. Abuse is unsubstantiated as both residents were consenting to their sexual action. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in April 2021 with diagnoses which included but were not limited to: major depressive disorder, alcohol abuse, and toxic encephalopathy (a neurologic disorder caused by exposure to toxins). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/26/25, Resident #1 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. 2. According to the AR, Resident #2 was admitted to the facility in September 2020 with diagnoses which included but were not limited to: schizoaffective disorder (a mental health condition with hallucinations, delusions, and mood disorder symptoms), bipolar disorder, and major depressive disorder. According to the Quarterly MDS, an assessment tool dated 2/21/25, Resident #2 had a BIMS score of 8, which indicated the resident's cognition was moderately impaired. A review of Resident #2's care plan (CP) revealed under Focus, Resident #2 has an alteration in thought process related to cognitive loss associated with mental illness. History of asking for pornography and fixating on females. Under Interventions, Monitor for sexually inappropriate behaviors. On 4/10/25 at 11:03 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN#1), who stated that on 4/3/25 she was informed by the CSC that the HK walked into the room and witnessed both residents in a sexual act. LPN #1 stated she immediately reported the incident to the ADON and the LNHA. LPN #1 stated Resident #2 told me he had been involved with another guy before, but I never seen [sic] anything. LPN #1 further stated that even though both residents were able to make their own decisions, she did not know if they were able to have sex. On 4/10/25 at 11:46 A.M., the surveyor interviewed the HK, who stated last week she was collecting hangers, and she went to both residents' room and knocked on the door. She further stated when she entered the room, she observed Resident #1 on the bed performing oral sex on Resident #2, who had his/her pants partially down. The HK stated that both residents stopped when they saw her. She stated she finished collecting the hangers, then left the room and observed Resident #2 come out of the room behind her. The HK indicated she could not remember the exact date and time the incident had occurred. The HK further stated she went to lunch for 30 minutes and when she returned, she told her co-worker who reported it to the CSC. The HK stated I did not tell my supervisor because he was off. I was scared to report it to a supervisor because my English is not always understood. The HK indicated Yes, I should have reported it sooner. I knew I had to report it, but I did not at that moment. The surveyor asked the HK why she wrote in her statement that she immediately told a staff member. The HK did not respond to the surveyor's question. On 4/10/25 at 12:20 P.M., the surveyor interviewed the CSC who stated she could not remember the actual date and time of the incident, but her daughter, who was the HK's co-worker reported to her that the HK told her she witnessed two residents on the fifth floor having sexual intercourse. The CSC further stated she immediately reported what was told to her to the fifth-floor nurse, the abuse coordinator, the LNHA, and the ADON. The CSC stated after she reported the incident, she called the HK to find out what she had observed. The CSC stated, The HK should have went [sic] straight to a department head and reported it. On 4/10/25 at 2:23 P.M., the surveyor interviewed the Social Worker (SW), who stated she was made aware by the LNHA that both residents were involved in a sexual interaction with each other. The SW stated she interviewed both residents and that Resident #2 told her that he had oral sex with Resident #1. The SW stated that the facility residents were allowed to engage in sexual activity under certain circumstances such as having the capacity to give consent. The SW stated that capacity to consent meant that the residents understood the consequences of their actions. The SW stated the BIMS score determined the resident's ability to give consent. The SW further stated No, I would not consider a resident having a BIMs score of 3, that they have the capacity to make a decision regarding having sex. The SW further indicated I think a BIMS score of 8 is too low for giving consent as well. On 4/10/25 at 3:20 P.M., the surveyor interviewed the ADON who stated that the CSC reported to her that her daughter informed her that the HK stated Resident #1 was lying on the side of the bed, Resident #2 had his/her pants partially down and Resident #1 was performing oral sex on Resident #2. She further stated that once she was made aware by the CSC she immediately placed both residents on 1:1 and conducted an investigation. The ADON stated the local police came to the facility and Resident #1 denied what occurred but Resident #2 confirmed what the HK stated she observed. The ADON stated Yes, I wrote that both residents were consenting to their sexual action. Neither of them said they were raped in front of the police. The ADON further stated Every resident has a right to make a decision, whether good, bad, or indifferent. They all have rights. I don't have the right to tell them not to do it. The ADON further indicated she did not have the right to tell the residents not to have sex. She further stated, I don't think they can consent to sexual acts with a BIMS score of 3 and 8. The ADON stated that if the staff had seen any residents having sex, they must immediately report it to the abuse coordinator and separate both residents to ensure their safety. She further indicated that any sexual activity should be reported immediately because it could be abuse. The ADON further indicated she was not aware of any sexually inappropriate behaviors from Resident #1 and Resident #2 prior to the incident. On 4/10/25 at 4:10 P.M., the surveyor interviewed the LNHA in the presence of the Director of Nursing (DON). The LNHA stated that the CSC reported the sexual act between Resident #1 and #2 to the abuse coordinator and the abuse coordinator reported it to her. The LNHA stated Yes, correct it was unsubstantiated because both residents said in front of the police that they consented to having sex. The LNHA stated the HK told her that she reported the incident to her co-worker who reported it immediately to the CSC. The LNHA indicated she was not aware that the HK went to lunch prior to reporting the incident. The LNHA stated Yes, she (HK) should have reported it immediately to the nurse and the abuse coordinator, so it could have been addressed and the safety of all residents could have been assured. A review of the undated facility policy titled Sexual Intimacy revealed It is the policy of [NAME] Lake Health Care and Rehabilitation Center that residents who wish to engage in sexual intimacy with one another, are permitted to do so, contingent upon they are both consenting adults and have been deemed capable to make decisions according to guidelines of the MDS. A review of the undated facility policy titled Resident Abuse/Neglect' revealed under Policy, An employee witnessing any form of abuse or neglect is also required to report the incident promptly to the charge nurse. NJAC 8:39-4.1 (a) (5)

Complaint # NJ185153 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/10/25 and 4/23/2025, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to a) ensure that the staff implemented the facility's policies and procedures for a witnessed sexual abuse that occurred between two residents, and b) ensure that residents were provided with the care and services to achieve their highest practical wellbeing. On 4/3/25 at approximately 12:00 P.M., the Housekeeper (HK) stated she went to Resident #1 and Resident #2's room and knocked on the door. The HK entered the room and observed Resident #1 on the bed performing oral sex on Resident #2. The HK finished collecting hangers from out of the room and then went on her lunch break for approximately 30 minutes. When the HK returned from lunch, she reported it to her co-worker. Her co-worker then reported the sexual encounter that the HK observed to the Central Supply Coordinator (CSC). The CSC reported it to the 5th floor nurse, the abuse coordinator, the LNHA, and the Assistant Director of Nursing (ADON). The LNHA's failure to ensure that the facility staff implemented the facility's policies and procedures for a witnessed sexual abuse that occurred between two residents placed all residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 4/23/2025 at 1:37 P.M. and was reported to the LNHA. The LNHA was presented with the IJ template. The IJ began on 4/3/25. An acceptable removal plan was electronically mailed to the surveyor on 4/24/2025 at 4:26 P.M., indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The co-founder/ Chief Executive Officer (CEO) educated the LNHA on the Administrator's job description. The CEO educated the LNHA and the facility's department heads on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident. The Corporate Consultant/designee educated the governing body on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident. The surveyor verified the removal plan on site on 4/29/2025 and determined the IJ for F835 J was removed as of 4/29/2025. After the IJ removal, the non-compliance continued from 4/29/2025 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2. According to the facility's Summary of Investigation with an event date of 4/3/25 revealed under Summary, Staff knocked on the door and entered the room to complete her work assignment. The staff member observed Resident #1 and #2 involved in a sexual act between each other. The staff member exited the room and reported what she witnessed to the nurse. The residents were immediately separated and placed on 1:1. The residents expressed consent to their actions without anyone being taken advantage of by the other. Abuse is unsubstantiated as both residents were consenting to their sexual action. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility in April 2021 with diagnoses which included but were not limited to: major depressive disorder, alcohol abuse, and toxic encephalopathy (a neurological disorder caused by exposure to toxins). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/26/25, Resident #1 had a BIMS score of 3, which indicated the resident's cognition was severely impaired. 2. According to the AR, Resident #2 was admitted to the facility in September 2020 with diagnoses which included but were not limited to: Schizoaffective disorder (a mental health condition with hallucinations, delusions, and mood disorder symptoms), bipolar disorder, and major depressive disorder. According to the Quarterly MDS, an assessment tool dated 2/21/25, Resident #2 had a BIMS score of 8, which indicated the resident's cognition was moderately impaired. A review of Resident #2's care plan (CP) revealed under Focus, Resident #2 has an alteration in thought process related to cognitive loss associated with mental illness. History of asking for pornography and fixating on females. Under Interventions, Monitor for sexually inappropriate behaviors. On 4/10/25 at 11:46 A.M., the surveyor interviewed the HK, who stated last week she was collecting hangers, and she went to both residents' room and knocked on the door. She further stated when she entered the room, she observed Resident #1 on the bed performing oral sex on Resident #2, who had his/her pants partially down. The HK stated that both residents stopped when they saw her. She stated she finished collecting the hangers, then left the room and observed Resident #2 come out of the room behind her. The HK indicated she could not remember the exact date and time the incident had occurred. The HK further stated she went to lunch for 30 minutes and when she returned, she told her co-worker who reported it to the CSC. The HK stated I did not tell my supervisor because he was off. I was scared to report it to a supervisor because my English is not always understood. The HK indicated Yes, I should have reported it sooner. I knew I had to report it, but I did not at that moment. The surveyor asked the HK why she wrote in her statement that she immediately told a staff member. The HK did not respond to the surveyor's question. On 4/10/25 at 2:23 P.M., the surveyor interviewed the Social Worker (SW), who stated that the facility residents were allowed to engage in sexual activity under certain circumstances such as having the capacity to give consent. The SW stated that capacity to consent meant that the residents understood the consequences of their actions. The SW stated the BIMS score determined the resident's ability to give consent. The SW further stated No, I would not consider a resident having a BIMs score of 3, that they have the capacity to make a decision regarding having sex. The SW further indicated I think a BIMS score of 8 is too low for giving consent as well. On 4/10/25 at 3:20 P.M., the surveyor interviewed the ADON who stated that the local police came to the facility and Resident #1 denied what occurred but Resident #2 confirmed what the HK stated she observed. The ADON stated Yes, I wrote that both residents were consenting to their sexual action. Neither of them said they were raped in front of the police. The ADON further stated Every resident has a right to make a decision, whether good, bad, or indifferent. They all have rights. I don't have the right to tell them not to do it. The ADON further indicated she did not have the right to tell the residents not to have sex. She further stated, I don't think they can consent to sexual acts with a BIMS score of 3 and 8. The ADON stated that if the staff had seen any residents having sex, they must immediately report it to the abuse coordinator and separate both residents to ensure their safety. She further indicated that any sexual activity should be reported immediately because it could be abuse. On 4/10/25 at 4:10 P.M., the surveyor interviewed the LNHA in the presence of the Director of Nursing (DON). The LNHA stated that the CSC reported the sexual act between Resident #1 and #2 to the abuse coordinator and the abuse coordinator reported it to her. The LNHA stated Yes, correct it was unsubstantiated because both residents said in front of the police that they consented to having sex. The LNHA stated the HK told her that she reported the incident to her co-worker who reported it immediately to the CSC. The LNHA indicated she was not aware that the HK went to lunch prior to reporting the incident. The LNHA stated Yes, she (HK) should have reported it immediately to the nurse and the abuse coordinator, so it could have been addressed and the safety of all residents could have been assured. On 4/23/25 at 12:06 P.M., the surveyor conducted a follow up interview with the LNHA who stated, I oversee everything in the building as the Administrator. The LNHA further indicated she reviewed the completed investigation for the incident between the two residents. She stated, Based on everything in the investigation, I agreed abuse was unsubstantiated. The LNHA indicated that she did not know why the HK did not report the incident immediately. A review of the facility's undated job description titled Facility Administrator revealed This role is responsible for ensuring compliance with regulatory standards, maintaining a high standard of care, managing staff, and fostering a supportive environment for residents and employees. Under Miscellaneous, Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of the residents. Assure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. NJAC 8:39-9.2 (a)

Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024 and 12/30/2024, it was determined that the facility failed to a.) prevent physical and verbal abuse towards a resident (Resident #1) from a staff member and b.) staff members that witnessed the abuse failed to intervene and report the incident. The facility also failed to follow its policy titled Abuse Policy and Procedure. During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. On 12/21/2024, the local police went to the facility to investigate an abuse allegation after receiving notification that the video was circulating online. The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. found on a social media website, that revealed a staff member hitting at a resident with a broom. Several other staff members observed the incident and did not intervene. The ADON identified the resident in the video as Resident #1. The ADON identified the staff member holding the broom throughout the video as the DON. The DON was heard asking the staff that were present during the incident to go get another staff member. The DON then stated, before I kill this man. The other staff members seen in the video that did not intervene when the incident occurred were identified by the ADON as LPN #2, Certified Nursing Assistant (CNA #2), and the Housekeeper (HK). The ADON stated that according to the Facility Reportable Event (FRE) completed by the DON, the incident occurred on 06/20/2023. Review of the FRE dated 06/20/2023 revealed the DON conducted the investigation. The DON never reported the incident to the Department of Health. There was only one witness statement from the staff of the incident. In addition, the incident of alleged staff to resident abuse occurred on 06/20/2023 and the DON remained employed at the facility until she was suspended on 12/21/2024. This placed Resident #1 and all other residents at risk for an Immediate Jeopardy (IJ) situation. The IJ began on 06/20/2023 and was identified on 12/23/2024 at 5:40 P.M. and was reported to the ADON. The ADON was presented with the IJ template. An acceptable removal plan was electronically mailed to the surveyors on 12/26/2024 at 2:37 P.M. indicating the action the facility will take to prevent serious harm from occurring or recurring. On 12/30/2024, a revisit to verify the Removal Plan was conducted. The facility implemented the Removal Plan, which included education to all staff on abuse, neglect, and exploitation. The facility also provided education on intervening and calling the police if abuse was witnessed, what to do when abuse was reported, and the process for reporting abuse. A third-party consultant company completed an audit that reviewed all incident and accident reports from 06/20/2023 to 12/24/2024 to ensure that each incident included a thorough investigation and appropriate follow-up. The third-party consultant company provided the facility with recommendations based on the audits. The staff within the video that witnessed the incident between the DON and Resident #1 were no longer working at the facility. The Human Resources Director (HRD) received education from the ADON on the proper reporting process when an abuse allegation was reported to her. CNA #1 and CNA #3 who witnessed the incident but were not in the video, continue to work at the facility and education was provided to both staff on intervening and calling the police if abuse was witnessed. The surveyors determined the IJ was removed as of 12/26/2024. The noncompliance remained on 12/30/2024 as a level I for actual harm that is not an IJ based on the following: The DON has been suspended since 12/21/2024 and the facility confirmed they were terminating her employment and reporting the DON to the Board of Nursing (BON). All staff have been educated on abuse, neglect, and to intervene and call the police if abuse was witnessed. This deficient practice was identified for 1 of 3 residents (Resident #1) who were reviewed for abuse and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with a date of event of 06/20/2023 and the DON identified as the person reporting, revealed that Resident #1 attempted to scratch LPN #1 with something that looked blue, plastic, and shiny in the resident's hand. The DON came to the unit and was told by LPN #1 that the resident was chasing her down the hallway. The DON approached Resident #1 and he/she attempted to claw at her with what appeared to be a blue disposable razor. The DON took a broom and tried to swat the razor out of Resident #1's hand. The resident could not be redirected, and the DON snatched the razor from Resident #1's hand. The nurse called the police. The FRE did not specify the nurse that called the police. According to the FRE, Resident #1 was sent to the hospital. A review of the video footage that was found on a social media website on 12/21/2024 revealed the DON standing in front of Resident #1 holding a broom. Resident #1 appeared to have his/her back towards the corner of the wall. The DON and Resident #1 had a verbal altercation between each other. Resident #1 then moved towards the DON, and the DON hit the resident with the broom. The DON asked the staff that were present during the incident to go get another staff member. The DON then stated, before I kill this man. The video further revealed LPN #2, CNA #3, and the HK that were present during the incident but did not intervene. The video did not reveal that the DON snatched a razor from Resident #1's hand. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder, Dementia, and Epilepsy (seizures). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/02/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 had experienced hallucinations but had no physical or verbal behaviors towards others. A review of Resident #1's Care Plan (CP) initiated on 11/01/2022 revealed that the resident could be verbally and physically aggressive. Interventions initiated on 11/01/2022 included: Allow to verbalize frustrations, redirect as needed, and provide diversional activities. A review of Resident #1's June 2023 Progress Notes (PNs) revealed no documentation related to the incident that occurred on 06/20/2023. The PNs further revealed no documentation that the police were notified of the incident or that the resident was transferred to the hospital. A review of the DON's personnel file revealed that she received training on abuse on 04/13/2023. During an interview with the surveyors on 12/23/2024 at 10:41 A.M., the ADON stated the Receptionist, and the Licensed Nursing Home Administrator (LNHA) called her on 12/21/2024 and made her aware that the local police were at the facility to investigate an abuse allegation involving Resident #1. The ADON stated she notified the NJDOH of the abuse allegation on 12/21/2024. The ADON stated she was not aware of what occurred during the incident prior to seeing the video. The ADON stated that according to the FRE and an investigation conducted by the DON, the incident on the video occurred on 06/20/2023. The ADON stated she was off the day the incident occurred. The ADON stated she was not aware that the DON hit Resident #1 with a broom and that the other staff members did not intervene until she watched the video. The ADON stated the staff members who observed the incident should have not stood there but got the resident help. The ADON stated it was not the facility's protocol to hit a resident with a broom. The ADON stated the DON had been suspended since 12/21/2024 pending the outcome of the investigation being conducted by a third-party consultant company. The ADON stated that according to the FRE from 06/20/2023, the police and the NJDOH were notified of the incident. The ADON was unable to provide the surveyor evidence that the FRE was reported to the NJDOH and that the police were called on 06/20/2023. During an interview with the surveyors on 12/23/2024 at 11:52 A.M., the Housekeeping Director (HD) stated one of his co-workers sent him a video over the weekend of the incident involving Resident #1 and the DON. The HD stated that he identified one of the staff members in the video was his former HK and that she had retired. The HD stated that no staff should let another staff member hit a resident with a broom and the other staff members should have intervened. The HD further stated that his former HK did not report the incident to him. The HD stated the expectation was that the HK should have reported what happened in the video to him immediately. During an interview with the surveyors on 12/23/2024 at 12:44 P.M., CNA #1 stated she had seen the video involving the incident between the DON and Resident #1 on social media. CNA #1 identified the person recording the video as LPN #1. CNA #1 stated she was present when the incident occurred involving the DON and Resident #1. CNA #1 stated Resident #1 was upset about his/her clothing prior to the incident. The DON was called to the unit due to Resident #1 having aggressive behaviors. CNA #1 stated the DON came to the unit and went to Resident #1's room and the resident threw a chair at the DON. The DON then ran to the nursing station where CNA #1, CNA #2, and the HK were standing. CNA #1 stated the DON grabbed a broom and hit Resident #1 with the broom. CNA #1 stated she did not remember Resident #1 having any items in his/her hand. CNA #1 further stated she remembered Resident #1 was bleeding after the DON hit him/her with the broom. CNA #1 stated she did not intervene when the incident occurred because the DON had threatened her job if she had intervened. CNA #1 further stated if the DON had not threatened her job she would have called the police. CNA #1 stated the DON was aggressive towards the residents at times. During an interview with the surveyors on 12/23/2024 at 2:22 P.M., the Social Worker (SW) stated she had seen the video involving the DON and Resident #1 that had been circulating on social media. The SW stated she was not aware of the incident until she had seen the video on 12/21/2024. The SW stated if a resident was aggressive, the facility policy was to try to de-escalate the resident, address the resident's needs, and ensure the safety of all residents. The SW stated it was not acceptable for a staff member to hit a resident with a broom and considered this a form of abuse. The SW stated if she witnessed abuse, she would ensure the safety of the resident involved and immediately notify the abuse coordinator, the NJDOH, and the police. During a telephone interview with the surveyor on 12/23/2024 at 3:08 P.M., LPN #1 stated she was present when the incident occurred and recorded it on her cellphone. LPN #1 stated she observed a walker fly past the charting room after the DON came to the unit. LPN #1 further stated she observed Resident #1 chasing the DON. LPN #1 stated she yelled out for someone to call the police, but no one called them. She further stated that the DON hit Resident #1 with a broom and then the resident walked away. LPN #1 stated she observed cuts to Resident #1's hands and that he/she was bleeding. LPN #1 stated she reported the incident to the Human Resources Director (HRD) which resulted in her not being allowed to return to the facility since she was agency staff. LPN #1 stated she sent the video of the incident to her friend who posted the video to a social media website. During a telephone interview with the surveyor on 12/23/2024 at 3:20 P.M., CNA #3 stated she was present when the incident occurred but could not remember the exact date. CNA #3 stated It happened a long time ago. CNA #3 stated Resident #1 was agitated and threw a chair at the DON. CNA #3 further stated Resident #1 started to go after the DON and the DON hit the resident with a broom. CNA #3 stated she believed the DON was trying to defend herself against the resident. CNA #3 stated We are given education on how to de-escalate the residents when they are aggressive. We are not taught to hit a resident with a broom. CNA #3 stated she did not report the incident because the DON was in charge and that she had threatened the staff member's jobs. CNA #3 stated she thought someone called the police after the incident occurred. During a follow up telephone interview with the surveyor on 12/30/2024 at 10:21 A.M., CNA #3 stated she did not remember if the police came to the facility after the incident occurred. CNA #3 stated she did not remember if Resident #1 had anything in his/her hand when the incident occurred. During an interview with the surveyor on 12/23/2024 at 3:34 P.M., the HRD stated she was made aware of the video that was circulating on social media on 12/21/2024. She further stated she was not aware of the incident that occurred prior to watching the video on 12/21/2024. The HRD stated that no staff came to her to report the incident prior to her watching the video. The HRD stated that it was not the facility's protocol to hit a resident with a broom. The HRD further stated that the staff that had witnessed the event should have reported the incident immediately. The HRD confirmed that the DON has been suspended since 12/21/2024. During a telephone interview with the surveyors on 12/30/2024 at 1:30 P.M., the DON stated she could not remember the date the incident occurred with Resident #1. The DON stated that a code was called due to Resident #1 having combative behaviors, and she went up to the unit. The DON stated when she arrived on the unit, Resident #1 was running down the hallway. Resident #1 then grabbed a chair and threw it at the DON. The DON further stated she observed a blue object in Resident #1's hand. The DON stated that Resident #1 attempted to hit her with what was in his/her hand. The DON stated she got a broom from the HK and then told all the other staff in the area to move away. The DON further stated Resident #1 started coming towards her and she hit him/her with the broom in attempt to swat what was in the resident's hand. The DON stated that after she hit the resident with the broom, Resident #1 walked away. The DON further stated when the resident walked away, she snatched a blue razor from his/her hand. The DON stated, I apologize, we are never supposed to hit a resident even if they are aggressive. The DON stated she overreacted when she hit Resident #1 with a broom because she thought the resident had a weapon in his/her hand. The DON further stated she though the local police were notified but that was the unit nurses' responsibility to call the police. During an interview with the surveyors on 12/30/2024 at 2:12 P.M., the Licensed Nursing Home Administrator (LNHA) stated she was off when the incident occurred between the DON and Resident #1. The LNHA stated the DON was suspended and the Corporate Human Resources was sending the DON a termination letter in the mail. The LNHA stated that it was not acceptable to hit a resident with a broom. The LNHA stated she would consider hitting a resident with a broom a form of abuse. The LNHA stated she was not aware at the time of the incident that Resident #1 was hit with a broom by the DON and that other staff members watched and did not intervene. The LNHA stated the expectation was that if staff witnessed abuse, they were to intervene and notify the local police immediately. The surveyors were unable to reach LPN #2, CNA#2, and the HK for an interview regarding the incident that occurred on 06/20/2023 with Resident #1. Review of the facility policy titled Abuse Policy and Procedure updated 8/2014, revealed under Policy that This facility requires that any allegations of abuse be addressed immediately in accordance with all federal and state regulations. All allegations will be evaluated in a prompt and thorough manner. Under Procedure, 6. Any employee alleged to have participated in abusive activity will be removed from care of the involved resident immediately. 9. The RN supervisor will contact the Director of Nursing immediately upon suspicion or confirmation of abuse. If the Director of Nursing is unable to be contacted, the Administrator will be contacted. 10. The Administrator will be contacted regarding all cases of physical and verbal abuse. 22. Employees who have had allegations of physical abusive treatment will be removed from direct resident care. Review of the undated facility job description titled Director of Nursing revealed, This leadership role ensures the highest standards of care and compliance with regulatory requirements while fostering a collaborative environment for residents and staff. Revealed under Key Responsibilities, Resident Advocacy: Ensure residents' rights are respected and upheld. N.J.A.C:8:39-4.1 (a) (5)

Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024, it was determined that the facility failed to conduct a timely and thorough investigation for an allegation of witnessed staff to resident physical abuse toward a resident (Resident #1). During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. found on a social media website, that revealed a staff member hitting at a resident with a broom. Several other staff members observed the incident and did not intervene. The ADON identified the resident in the video as Resident #1. The ADON identified the staff member holding the broom throughout the video as the DON. The DON was heard asking the staff that were present during the incident to go get another staff member. The DON then stated, before I kill this man. The other staff members seen in the video that did not intervene when the incident occurred were identified by the ADON as LPN #2, Certified Nursing Assistant (CNA #2), and the Housekeeper (HK). The ADON stated that according to the Facility Reportable Event (FRE) form completed by the DON, the incident occurred on 06/20/2023. On 12/21/2024, the local police went to the facility to investigate an abuse allegation after receiving notification that the video was circulating online. Review of the FRE dated 06/20/2023 revealed the DON conducted the investigation. The DON never reported the incident to the Department of Health. There was only one witness statement from the staff of the incident. In addition, the incident of alleged staff to resident abuse occurred on 06/20/2023 and the DON remained employed at the facility until she was suspended on 12/21/2024. This placed Resident #1 and all other residents at risk for an Immediate Jeopardy (IJ) situation. The IJ began on 06/20/2023 and was identified on 12/23/2024 at 5:40 P.M. and was reported to the ADON. The ADON was presented with the IJ template. An acceptable removal plan was electronically mailed to the surveyors on 12/26/2024 at 2:37 P.M. indicating the action the facility will take to prevent serious harm from occurring or recurring. On 12/30/2024, a revisit to verify the Removal Plan was conducted. The facility implemented the Removal Plan, which included education to all staff on conducting a thorough investigation related to an abuse allegation. A third-party consultant company completed an independent investigation of the abuse allegation which was comprised of a documentation review, review of the resident's medical records, staff interviews, resident observations, and a review of the reportable event from 06/20/2023. The third-party consultant company conducted an audit of all incident and accident reports from 06/20/2023 to ensure that each incident included a thorough investigation. The Licensed Nursing Home Administrator (LNHA) implemented a daily audit to assure abuse allegations were addressed and investigated according to the facility's policy. The surveyors determined the IJ was removed as of 12/26/2024. The noncompliance remained on 12/30/2024 as a level I for actual harm that is not an IJ based on the following: The DON has been suspended since 12/21/2024 and the facility confirmed they were terminating her employment and reporting the DON to the Board of Nursing (BON). All facilty staff were educated on conducting a thorough investigation related to an abuse allegation and a third-party consultant company conducted an investigation of the abuse allegation. This deficient practice was identified for 1 of 3 residents (Resident #1) who were reviewed for abuse and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 06/20/2023 and the DON identified as the person reporting, revealed that Resident #1 attempted to scratch LPN #1 with something that looked blue, plastic, and shiny in the resident's hand. The DON came to the unit and was told by LPN #1 that the resident was chasing her down the hallway. The DON approached Resident #1 and he/she attempted to claw at her with what appeared to be a blue disposable razor. The DON took a broom and tried to swat the razor out of Resident #1's hand. The resident could not be redirected, and the DON snatched the razor from Resident #1's hand. The nurse called the police and Resident #1 was sent to the hospital. A review of the video footage that was found on a social media website on 12/21/2024 revealed the DON standing in front of Resident #1 holding a broom. Resident #1 appeared to have his/her back towards the corner of the wall. The DON and Resident #1 had a verbal altercation between each other. Resident #1 then moved towards the DON, and the DON hit the resident with the broom. The DON asked the staff that were present during the incident to go get another staff member. The DON then stated, before I kill this man. The video further revealed LPN #2, CNA #3, and the HK that were present during the incident but did not intervene. The video did not reveal that the DON snatched a razor from Resident #1's hand. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder, Dementia, and Epilepsy (seizures). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/02/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 had experienced hallucinations but had no physical or verbal behaviors towards others. A review of Resident #1's Care Plan (CP) initiated on 11/01/2022 revealed that the resident could be verbally and physically aggressive. Interventions initiated on 11/01/2022 included: Allow to verbalize frustrations, redirect as needed, and provide diversional activities. A review of Resident #1's June 2023 Progress Notes (PNs) revealed no documentation related to the incident that occurred on 06/20/2023. The PNs further revealed no documentation that the police were notified of the incident or that the resident was transferred to the hospital. During an interview with the surveyors on 12/23/2024 at 10:41 A.M., the ADON stated the Receptionist, and the Licensed Nursing Home Administrator (LNHA) called her on 12/21/2024 and made her aware that the local police were at the facility to investigate an abuse allegation involving Resident #1. The ADON stated she notified the NJDOH of the abuse allegation on 12/21/2024. The ADON stated she was not aware of what occurred during the incident prior to seeing the video. The ADON stated that according to the FRE and an investigation conducted by the DON, the incident on the video occurred on 06/20/2023. The ADON stated she was off the day the incident occurred. The ADON stated she was not aware that the DON hit Resident #1 with a broom and that the other staff members did not intervene until she watched the video. The ADON stated the staff members who observed the incident should have not stood there but got the resident help. The ADON stated it was not the facility's protocol to hit a resident with a broom. The ADON stated the DON had been suspended since 12/21/2024 pending the outcome of the investigation being conducted by a third-party consultant company. The ADON stated that according to the FRE from 06/20/2023, the police and the NJDOH were notified of the incident. According to the local police department's report dated 12/21/2024, the police were never dispatched to the facility on the date of the incident regarding Resident #1. During a telephone interview with the surveyors on 12/30/2024 at 1:30 P.M., the DON stated she could not remember the date the incident occurred with Resident #1. The DON stated that a code was called due to Resident #1 having combative behaviors, and she went up to the unit. The DON stated when she arrived on the unit, Resident #1 was running down the hallway. Resident #1 then grabbed a chair and threw it at the DON. The DON further stated she observed a blue object in Resident #1's hand. The DON stated that Resident #1 attempted to hit her with what was in his/her hand. The DON stated she got a broom from the HK and then told all the other staff in the area to move away. The DON further stated Resident #1 started coming towards her and she hit him/her with the broom in attempt to swat what was in the resident's hand. The DON stated that after she hit the resident with the broom, Resident #1 walked away. The DON further stated when the resident walked away, she snatched a blue razor from his/her hand. The DON further stated she thought the local police were notified but that was the unit nurses' responsibility to call the police. During an interview with the surveyors on 12/30/2024 at 2:12 P.M., the Licensed Nursing Home Administrator (LNHA) stated she was off when the incident occurred between the DON and Resident #1. The LNHA stated the DON was suspended and the Corporate Human Resources was sending the DON a termination letter in the mail. The LNHA stated that it was not acceptable to hit a resident with a broom. The LNHA stated she would consider hitting a resident with a broom a form of abuse. The LNHA stated she was not aware at the time of the incident that Resident #1 was hit with a broom by the DON and that other staff members watched and did not intervene. The LNHA stated the expectation was that if staff witnessed abuse, they were to intervene and notify the local police immediately. Review of the facility policy titled Abuse Policy and Procedure updated 8/2014, revealed under Policy that This facility requires that any allegations of abuse be addressed immediately in accordance with all federal and state regulations. All allegations will be evaluated in a prompt and thorough manner. Under Procedure, 6. Any employee alleged to have participated in abusive activity will be removed from care of the involved resident immediately. 9. The RN supervisor will contact the Director of Nursing immediately upon suspicion or confirmation of abuse. If the Director of Nursing is unable to be contacted, the Administrator will be contacted. 10. The Administrator will be contacted regarding all cases of physical and verbal abuse. 22. Employees who have had allegations of physical abusive treatment will be removed from direct resident care. Review of the facility policy titled Investigation, Recording & Reporting of Accidents/Incidents dated 12/22/2024 revealed under Policy, It is the policy of this Center to investigate all accidents and incidents. Under Purpose, the purpose of investigating an accident/incident is to find out what actually happened, why it happened, what needs to be done to prevent a recurrence. A comprehensive investigation of all Accidents/Incidents must be completed, and documentation must be maintained in a secure location. All accident and incidents must be investigated for possible abuse. Under Investigation Basics, 8. Statements and an accident/incident report should be completed by the end of the shift during which the event occurred or as close to the time of the even as possible. 9. Notify the Director of Nursing and/or Administrator of any significant events. 10. Collect statements from ALL staff on the unit. Under Responsibility Nurse, 1. Safety is priority. Assess the situation and take the necessary steps to ensure the safety of residents, visitors, and staff. 2. Conduct and document a full head to toe assessment of all residents involved. Under Director of Nursing/Designee, 3. If the Accident/Incident is reportable, ensure that all necessary entities have been notified. Document the date and time and name of individual notified. NJAC 8:39-4.1(a) 5

Complaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024 and 10/29/2024, it was determined that the facility: a) failed to provide services necessary to prevent physical abuse for a resident (Resident #1), b) used a physical hold restraint for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. LPN #1 stated she heard a loud bang and yelling in the hallway. LPN #1 responded to the hallway and saw Resident #1 laying on the floor in the hallway yelling please stop, get them off of me. LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM hitting Resident #1 with his fist. LPN #1 told both staff members (CNA #2 and SM) to stop and to get off the resident. LPN#1 stated CNA #2 and the SM did not immediately stop and get off the resident. She had to repeat the request. LPN#1 stated the SM said, Its ok we are told to do this. LPN #1 stated she assisted Resident #1 off the floor to the nursing station and immediately reported the incident to the Assistant Director of Nursing (ADON). CNA #2 and the SM went down to the other side of the hallway and passed the lunch trays. The Social Worker (SW#1) stated the ADON got her to come to the unit. SW #1 stated Resident #1 was yelling They just beat the [profanity] out of me. SW#1 stated while at the nursing station, she observed the resident's back when Resident #1 lifted his/her tee shirt. SW #1 reported the observation to the ADON. SW#1 stated she was asked by LPN#1 to take Resident #1 to her office on the first floor. SW #1 stated Resident #1 complained of back pain. During an interview with SW#1, she stated while Resident #1 stated oh my back while attempting to pick up food from off the floor. The ADON stated Resident #1 told her that he/she fell , and an order was obtained from the Medical Director to send Resident #1 to the hospital for a fall. On 10/14/2024, Resident #1 was admitted to the hospital with diagnoses of splenic laceration, subcapsular hematoma, and an active bleed. The facility failed to follow its policy titled Abuse Policy and Procedure and the facility job description titled Certified Nursing Assistant Job Description. This placed Resident #1 and all other residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 10/22/2024 at 8:50 PM and was reported to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and ADON. The LNHA, DON, and ADON were presented with the IJ template. The IJ began on 10/14/2024 and continued through 10/29/2024 when the facility submitted an acceptable Removal Plan. On 10/29/2024, a revisit to verify the Removal Plan was conducted. The facility implemented the Removal Plan, which included re-educating all facility staff on the importance of preventing abuse, ensuring resident safety, and the importance of following the facility's abuse policy. The facility also provided re-education on incident investigations, importance of collecting all written statements, utilizing the SW to assist in obtaining the resident statements, assuring the original signed statements are turned into the abuse coordinator, and reporting all incidents to the abuse coordinator immediately. The facility initiated an audit to monitor compliance with the education and conducted a staff assessment and testing to ensure true understanding of the facility's abuse policy. The noncompliance remained on 10/29/24 as a level G for actual harm that is not an IJ based on the following: Resident #1 is no longer at the facility, CNA #2 and the SM no longer work at the facility, and all facility staff have been re-educated on the facility's abuse policy. This deficient practice was identified for 1 of 7 residents (Resident #1) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with a report date of 10/15/2024, Resident #1 was upset while in his/her room and threw an overbed tray table at a staff member outside of Resident #1's room on 10/14/2024. While throwing the overbed tray table, Resident #1 lost balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff and others. Staff attempted to subdue Resident #1 by using gentle resistance while on the floor. Resident #1 was sent to the hospital for further evaluation. While at the hospital, Resident #1 stated to hospital staff that he/she had been beaten up by two staff members. The police department notified the facility on 10/15/2024 of Resident #1's allegation. According to the FRE, a full investigation was initiated on 10/15/2024. Both staff members were suspended pending an investigation on 10/15/2024. According to the facility's document titled Summary of Investigation with a date reported of 10/15/2024 under Summary, Resident #1 sustained injuries when he/she fell on top of the overbed tray table while trying to continue an attack on the staff member. Resident #1 had a history of aggression towards others and staff were protecting residents and themselves while trying to keep Resident #1 from continuing aggression. The staff were concerned for everyone's safety and tried to keep Resident #1 down on the floor to avoid Resident #1 from hurting others. They were too aggressive while trying to keep Resident #1 down to prevent further aggression from Resident #1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). According to the Admission Minimum Data Set (MDS), an assessment tool dated 08/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 was on antipsychotic medications and had no behaviors that were exhibited towards others. According to the Discharge MDS dated [DATE], Section A, a discharge assessment indicated return anticipated. Section E revealed that Resident #1 had physical and behavioral symptoms directed toward others. A review of Resident #1's Care Plan (CP) initiated on 8/25/2024 revealed under Focus: Resident #1 is the aggressor in a physical altercation with peer related to poor impulse control. The Goal included Resident #1 will not harm others through the review date. Interventions initiated on 8/25/2024 included: When Resident #1 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. A review of Resident #1's Progress notes (PNs) dated 10/14/2024 at 2:24 PM written by the ADON revealed Resident #1 became upset while in the room and threw an overbed table at a staff member outside the room door. During the throwing of the overbed tray table, Resident #1 lost his/her balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff. Staff attempted to subdue Resident #1 using gentle resistance while on the floor. Resident #1 was given time to calm down before being assisted to a standing position. Resident #1 was taken off the unit with Social Services (SS) to further calm down. The Physician was informed of Resident #1's behaviors. An order was secured to send Resident #1 to the hospital for a behavioral evaluation and x-ray of the right hip and ribs. A review of Resident #1's PNs dated 10/14/2024 at 9:35 PM revealed at 5:30 PM, Resident #1 was picked up by transport via stretcher and taken to the emergency room (ER). A review of CNA#2 and the SM's personnel files revealed that both staff had training on abuse and how to deal with aggressive residents. During an interview with the surveyors on 10/22/2024 at 1:04 PM, CNA #1 stated that on 10/14/2024 at 11:58 AM, she walked out of the dayroom, heard a commotion, and observed Resident #1 on the floor in the hallway between Resident #1's room and the dayroom on his/her back. She observed CNA#2 and the SM hitting resident with their fists. CNA #1 stated the camera could show you better. CNA #1 further stated she ran to get LPN#1, who responded to the incident. CNA #1 stated that CNA# 2 and the SM continued to work the rest of the shift on another unit. She stated that Resident #1 went to the hospital the same day the incident occurred but was unsure of the time. CNA #1 stated that Resident #1 can be aggressive at times but re-directable with a calm approach. CNA #1 stated she heard both CNA #2 and the SM tell LPN #1 that Resident #1 got upset because resident was told to wait to go out to smoke. During an interview with the surveyors on 10/22/2024 at 1:27 PM, LPN #1 stated she worked on 10/14/2024 and was assigned Resident #1. LPN #1 stated she was in the charting room speaking with the Speech therapist (ST) and heard a loud bang and yelling. LPN #1 stated the ST and herself immediately got up and as she was coming out of the charting room door, she was met by CNA #1 who was coming to get her. LPN #1 stated she looked down the hallway where the yelling was coming from and observed Resident #1 laying in the hallway in front of his/her room. LPN #1 stated she heard Resident #1 yelling please stop, get them off of me. LPN #1 further stated that the ST was behind her and stated, Oh my God, what are they doing to him? LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM punching Resident #1. LPN #1 stated Resident #1 was laying on his/her side. LPN #1 stated she told CNA #2 and the SM to stop and get off the resident. CNA #2 and the SM did not immediately stop. She had to repeat the request to CNA#2 and the SM to stop hitting the resident. CNA #2 and the SM then stopped hitting the resident. LPN #1 further stated that the SM said, its ok, we are told to do this. LPN #1 did not state who told the SM that it was okay to hit and punch the resident. LPN #1 stated she assisted the resident off the floor to the nursing station and immediately reported the incident to the ADON. She stated that CNA #2 and the SM went down the other hallway and passed out the lunch trays. LPN #1 further stated I don't know what time, but CNA #2 and the SM were moved off the floor to the other units. LPN #1 stated SW#1 and the ADON came to the unit after the incident. SW#1 stayed with her and the resident at the nursing station. LPN #1 stated, I don't know where the ADON went. LPN #1 further stated Resident #1 complained of pain all over and asked her to call the police because he/she wanted to press charges. LPN #1 stated SW#1 lifted Resident #1's tee shirt, and they both observed red marks on the resident's back. She stated that SW#1 told the ADON that the resident had red marks on their back. LPN #1 stated she asked the ADON what are we doing with the resident. LPN #1 stated SW#1 took Resident #1 downstairs to her office. LPN #1 heard an overhead page for CNA#2 and the SM to report to the first floor, was unsure how long it was after the incident occurred, but it was not immediate. LPN#1 stated CNA #2 and the SM left the unit after the overhead page. LPN #1 stated she received a call from the DON asking her and CNA#1 to write a witness statement. LPN #1 stated she wrote her witness statement and brought both her and CNA #1's original witness statements to the DON's office. Upon her return to the unit, she received a phone call from the ADON stating that Resident #1 was going to the hospital. LPN#1 further stated that the ADON told her that Resident #1 and their roommate (Resident #4) were being moved to the seventh-floor unit. Resident #1 was not moved to the seventh floor unit because he/she was transferred to the hospital. She stated she received Resident #1's universal transfer form (UTF) already completed by the ADON. She took Resident #1's chart and the UTF to the seventh-floor unit and observed CNA #2 on that unit. LPN #1 stated she did not observe Resident #1 on the seventh-floor unit. She stated CNA #2 came to work on 10/15/2024, but the SM had called out. LPN #1 further stated that CNA #2 did not work on her unit on 10/15/2024. LPN #1 stated no administrative staff came to talk to me after the incident had occurred. During an interview with the surveyors on 10/22/2024 at 2:48 PM, CNA #3 stated that she was watching the residents in the dayroom around 12:00 PM on 10/14/2024 when she heard a commotion in the hallway. She came out from the dayroom and observed Resident #1 on the floor laying on his/her side. CNA #3 stated she observed the SM pinning down the resident on the floor and CNA #2 was standing there. CNA #3 further stated SW#1 and the ADON came and took Resident #1 downstairs. She stated that when the lunch tray came to the unit, all the CNAs including CNA #2 and the SM passed out the lunch trays. CNA #3 stated she did not see CNA #2 and the SM on the unit after lunch but saw CNA #2 and the SM when she clocked out at the end of her shift at 3:00 PM. CNA #3 stated CNA #2 was assigned as the monitor for Resident #1 on the day of the incident. She stated on the morning of 10/15/2024 she saw CNA #2 on the fifth floor. During an interview with the surveyors on 10/22/2024 at 4:06 PM, SW #1 stated she met the ADON by the elevators on 10/14/2024, and the ADON told her that Resident #1 was upset and wanted her to go to talk with the resident. She stated when she got upstairs, she observed LPN #1 and Resident #1 at the nursing station. She further stated that the resident was yelling they just beat the [profanity] out of me. SW #1 stated Resident #1 pulled his/her tee shirt up and she observed red marks to the resident's back. She told the ADON about the red marks on the resident's back. SW #1 stated she was asked by LPN #1 to take the resident off the unit. SW#1 stated she took the resident to her office on the first floor, and LPN #1 brought the resident's lunch tray. She stated the resident appeared anxious, had excessive speech, and was agitated. SW #1 stated while Resident #1 was eating he/she dropped a piece of mashed potato on the floor, the resident attempted to pick up the mashed potato and stated, oh my back. She stated the resident was still in her office for approximately 45 minutes when she texted the LNHA to let her know the resident was still in her office. During an interview with the surveyors on 10/22/2024 at 4:47 PM, the ADON stated on 10/14/2024, I was told that Resident #1 was having some behaviors and took the over bed table and tried to hit the CNA. The ADON stated she did not know where the resident got the overbed tray table from and was unsure of the staff involved in the incident. She further stated that she was called to the unit by LPN #1. She stated LPN #1 told her that Resident #1 tried to throw the overbed tray table at the aide and the resident and the overbed table went down. The surveyor asked the ADON if LPN#1 made her aware of the abuse allegation and she stated, LPN#1 did not say anything else. The ADON stated that when she got to the unit, she did not see anyone on the floor but saw the overbed tray table broken in half. The ADON further stated she saw Resident #1 and he appeared angry, and she tried to get the resident somewhere quiet. She asked Resident #1 what happened with the overbed tray table, and the resident stated he/she fell . According to the ADON the resident refused an assessment. The ADON called the doctor and got an order to send Resident #1 to the hospital because the resident was on the floor. The ADON stated the reason for Resident #1's transfer to the hospital was because the resident complained of right leg pain, had agitation, and an x-ray was requested. The ADON was unsure of what time Resident #1 went to the hospital. During an interview with the surveyors on 10/22/2024 at 5:01 PM, the DON stated that LPN #1 told her Resident #1 was acting out. The DON stated that when she came to work on 10/15/2024 there were two police officers and a detective at the facility. The DON stated she was asked if she knew what happened to the resident. The DON stated she was asked by the police if she had heard that Resident #1 had been beaten up the day before and the DON stated she told them No. During an interview with the surveyors on 10/22/2024 at 5:03 PM, the LNHA stated on 10/15/2024 the police asked her if she knew Resident #1 had been beaten up. The LNHA stated she knew that the resident had thrown an overbed tray table, the overbed tray table got broken, and the resident had a fall. The LNHA stated she did not call the police because she thought it was a resident to staff incident. The LNHA further stated she normally would have called the police for a resident to resident, staff to resident, and resident to staff incident but did not for this incident. The LNHA further stated she would have called the police if the resident hit the staff or if the resident was a harm to self and others. The LNHA stated she would have considered a resident throwing an overbed tray table a danger to a resident's self and others. The LNHA stated the police should have been notified. The LNHA stated the police came to the facility on [DATE] and talked to the staff and were trying to determine if abuse had occurred. The LNHA further stated she reviewed the camera surveillance on 10/15/2024 in the presence of the police and observed the overbed tray table come out of the resident's room. She also observed CNA#2 and the SM holding Resident #1 on the floor. When asked by the surveyor if the camera surveillance was reviewed on 10/14/2024, the LNHA stated no, I was told the resident threw an overbed tray table and had a fall. I didn't think to review the camera because it was reported as a regular fall. The LNHA stated after reviewing the camera surveillance with the police, she was informed by them that they were taking CNA #2. The LNHA further stated the SM was not at the facility on 10/15/2024. The LNHA determined through the investigation CNA #2 and the SM were trying to hold Resident #1 after the resident threw the overbed tray table. The LNHA stated a physical hold was not a part of how to deal with aggressive residents and a physical hold would be considered a restraint. The LNHA stated the facility did not have a policy on restraints. The surveyors requested a copy of surveillance footage from the LNHA throughout the complaint survey. During exit conference on 10/29/2024 at 3:24 PM, the LNHA stated that the facility was not able to access the footage because 14 days had passed since the incident occurred on 10/14/2024. During a post survey telephone interview with the surveyors on 10/30/2024 at 2:52 PM, the ST stated she was on the third-floor unit to use the bathroom and did not witness the incident with Resident #1 that occurred on 10/14/2024. Review of the facility policy titled Abuse Policy and Procedure updated 8/2014, revealed under Policy that This facility requires that any allegations of abuse be addressed immediately in accordance with all federal and state regulations. All allegations will be evaluated in a prompt and thorough manner. Under Procedure, 6. Any employee alleged to have participated in abusive activity will be removed from care of the involved resident immediately. 9. The RN supervisor will contact the Director of Nursing immediately upon suspicion or confirmation of abuse. If the Director of Nursing is unable to be contacted, the Administrator will be contacted. 10. The Administrator will be contacted regarding all cases of physical and verbal abuse .11. The supervisor/Nurse Manager/Director of Nursing/designee will interview all staff who have provided care. 13. Confused residents will be interviewed with a witness present. 16. Employee statement forms and an incident form will be filled out completely. An Incident Report form will include the following information: a. The name of the involved resident, b. the date and time the incident occurred, c. the circumstances surrounding the incident, d. where the incident took place, e. the name(s) of those participating in the act, f. physician and family notification, g. treatment rendered. 22. Employees who have had allegations of physical abusive treatment will be removed from direct resident care. Review of the facility job description titled Certified Nursing Assistant Job Description updated 10/4/2016 revealed under Patient Care, Treat residents with respect and dignity at all times. Observes and reports unusual symptoms, changes, accidents, and injuries to the charge nurse. N.J.A.C:8:39-4.1(a)(5)

Complaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to conduct a timely and thorough investigation for an allegation of witnessed and reported staff to resident physical abuse toward a resident (Resident #1). On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. LPN #1 stated she heard a loud bang and yelling in the hallway. LPN #1 responded to the hallway and saw Resident #1 laying on the floor in the hallway yelling please stop, get them off of me. LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM hitting Resident #1 with his fist. LPN #1 told both staff members (CNA #2 and SM) to stop and to get off the resident. LPN#1 stated CNA #2 and the SM did not immediately stop and get off the resident. She had to repeat the request. LPN#1 stated the SM said, Its ok we are told to do this. LPN #1 stated she assisted Resident #1 off the floor to the nursing station and immediately reported the incident to the Assistant Director of Nursing (ADON). CNA #2 and the SM went down to the other side of the hallway and passed the lunch trays. The Social Worker (SW#1) stated the ADON got her to come to the unit. SW#1 stated Resident #1 was yelling They just beat the [profanity] out of me. SW#1 stated while at the nursing station, she observed the resident's back when Resident #1 lifted his/her tee shirt. SW#1 reported the observation to the ADON. SW#1 stated she was asked by LPN#1 to take Resident #1 to her office on the first floor. SW#1 stated Resident #1 complained of back pain. During an interview with SW#1, she stated Resident #1 stated oh my back when he/she attempted to pick food up off the floor. The ADON stated Resident #1 told her that he/she fell , and an order was obtained from the Medical Doctor to send Resident #1 to the hospital for a fall. On 10/14/2024, Resident #1 was admitted to the hospital with diagnoses of splenic laceration, subcapsular hematoma, and an active bleed. The facility also failed to follow its policy titled Conducting an Investigation of all Incidents/Accidents and Abuse Policy and Procedure. This placed Resident #1 and all other residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 10/22/2024 at 8:50 PM and was reported to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and ADON. The LNHA, DON, and ADON were presented with the IJ template. The IJ began on 10/14/2024 and continued through 10/29/2024 when the facility submitted an acceptable Removal Plan. On 10/29/2024, an onsite revisit was conducted to verify the facility implemented the Removal Plan. The facility re-educated all staff on incident investigations, the importance of collecting all written statements, utilizing the social worker to assist in obtaining the resident statements, assuring the original signed statements are turned into the abuse coordinator, and reporting all incidents to the abuse coordinator immediately. The noncompliance remained on 10/29/24 as a level G for actual harm that is not an IJ based on the following: Resident #1 is no longer at the facility, CNA #2 and the SM no longer work at the facility, and all facility staff have been re-educated on incident investigations, importance of collecting all written statements, utilizing the social worker to assist in obtaining the resident statements, assuring the original signed statements are turned in to the abuse coordinator, and reporting all incidents to the abuse coordinator immediately. This deficient practice was identified for 1 of 7 residents (Resident #1) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 10/15/2024, Resident #1 was upset while in his/her room and threw an overbed tray table at a staff member outside Resident #1's room on 10/14/2024. While throwing the overbed tray table, Resident #1 lost balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff and others. Staff attempted to subdue Resident #1 by using gentle resistance while on the floor. Resident #1 was sent to the hospital for further evaluation. While at the hospital, Resident #1 stated to hospital staff that he/she had been beaten up by two staff members. The police department notified the facility on 10/15/2024 of Resident #1's allegation. According to the FRE, a full investigation was initiated on 10/15/2024. Both staff members were suspended pending an investigation on 10/15/2024. According to the facility's document titled Summary of Investigation with a date reported of 10/15/2024 under Summary, Resident #1 sustained injuries when he/she fell on top of the overbed tray table while trying to continue an attack on the staff member. Resident #1 had a history of aggression towards others and staff were protecting residents and themselves while trying to keep Resident #1 from continuing aggression. The staff were concerned for everyone's safety and tried to keep Resident #1 down on the floor to avoid Resident #1 from hurting others. They were too aggressive while trying to keep Resident #1 down to prevent further aggression from Resident #1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). According to the Admission Minimum Data Set (MDS), an assessment tool dated 08/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 was on antipsychotic medications and had no behaviors that were exhibited towards others. According to the Discharge MDS dated [DATE], Section A, a discharge assessment indicated return anticipated. The MDS further indicated that Resident #1 had physical and behavioral symptoms directed towards others. A review of Resident #1's Care Plan (CP) initiated on 08/25/2024 revealed under Focus: Resident #1 is the aggressor in a physically altercation with peer related to poor impulse control. The Goal included Resident #1 will not harm others through the review date. Interventions initiated on 08/25/2024 included: When Resident #1 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. A review of Resident #1's Progress notes (PNs) dated 10/14/2024 at 2:24 PM written by the ADON revealed Resident #1 became upset while in the room and threw an overbed tray table at a staff member outside the room door. During the throwing of the overbed tray table, Resident #1 lost his/her balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff. Staff attempted to subdue Resident #1 using gentle resistance while on the floor. Resident #1 was given time to calm down before being assisted to a standing position. Resident #1 was taken off the unit with Social Services (SS) to further calm down. The physician was informed of Resident #1's behaviors. An order was secured to send Resident #1 to the hospital for a behavioral evaluation and x-ray of the right hip and ribs. A review of Resident #1's PNs dated 10/14/2024 at 9:35 PM revealed at 5:30 PM, Resident #1 was picked up by transport via stretcher to the emergency room (ER). A review of CNA #2 and the SM's personnel files revealed that both staff had training on abuse and how to deal with aggressive residents. During an interview with the surveyors on 10/22/2024 at 1:04 PM, CNA #1 stated that on 10/14/2024 at 11:58 AM, she walked out of the dayroom, she heard a commotion and observed Resident #1 on the floor in the hallway between Resident #1's room and the dayroom on his/her back with CNA#2 and the SM hitting resident with their fists. CNA #1 stated the camera could show you better. CNA #1 further stated she ran to get LPN#1 who responded to the incident. CNA #1 stated that CNA# 2 and the SM continued to work the rest of the shift on another unit. She stated that Resident #1 went to the hospital the same day the incident occurred but was unsure of the time. CNA #1 stated that Resident #1 can be aggressive at times but re-directable with a calm approach. CNA #1 stated she heard both CNA #2 and the SM tell LPN #1 that Resident #1 got upset because resident was told to wait to go out to smoke. During a subsequent interview with the surveyors on 10/23/2024 at 3:23 PM, CNA #1 stated I wrote my statement on 10/14/2024 and gave the original copy to LPN#1. During an interview with the surveyors on 10/22/2024 at 1:27 PM, LPN #1 stated she worked on 10/14/2024 and was assigned Resident #1. LPN #1 stated she was in the charting room speaking with the Speech therapist (ST) and heard a loud bang and yelling. LPN #1 stated the ST and herself immediately got up and as she was coming out of the charting room door, she was met by CNA #1 who was coming to get her. LPN #1 stated she looked down the hallway where the yelling was coming from and observed Resident #1 laying in the hallway in front of his/her room. LPN #1 stated she heard Resident #1 yelling please stop, get them off of me. LPN #1 further stated that the ST was behind her and stated, Oh my God, what are they doing to him? LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM punching Resident #1. LPN #1 stated Resident #1 was laying on his/her side. LPN #1 stated she told CNA #2 and the SM to stop and get off the resident. CNA #2 and the SM did not immediately stop. She had to repeat the request. CNA#2 and the SM stopped hitting the resident. LPN #1 further stated that the SM said, its ok, we are told to do this. LPN#1 was unsure of who told both staff they could hit and punch the resident. LPN #1 stated she assisted the resident off the floor to the nursing station and immediately reported the incident to the ADON. She stated that CNA #2 and the SM went down the other hallway and passed out the lunch trays. LPN #1 further stated I don't know what time, but CNA #2 and the SM were moved off the floor to the other units. LPN #1 stated Social Worker (SW#1) and the ADON came to the unit after the incident. SW#1 stayed with her and the resident at the nursing station. LPN#1 stated, I don't know where the ADON went. LPN #1 further stated Resident #1 complained of pain all over and asked her to call the police because he/she wanted to press charges. LPN #1 stated SW#1 lifted Resident #1's tee shirt, and they both observed red marks on the resident's back. She stated that SW#1 told the ADON that the resident had red marks on his/her back. LPN #1 stated she asked the ADON what are we doing with the resident. LPN #1 stated SW#1 took Resident #1 downstairs to her office. LPN #1 heard an overhead page for CNA#2 and the SM to report to the first floor, was unsure how long it was after the incident occurred, but it was not immediate. LPN#1 stated CNA #2 and the SM left the unit after the overhead page. LPN #1 stated she received a call from the DON asking her and CNA#1 to write a witness statement. LPN #1 stated she wrote her witness statement and brought both her and CNA #1's original witness statement to the DON's office. Upon her return to the unit, LPN #1 received a phone call from the ADON stating that Resident #1 was going to the hospital. LPN#1 further stated that the ADON told her that Resident #1 and their roommate (Resident #4) were being moved to the seventh-floor unit. Resident #1 was not moved to the seventh-floor unit and was transported to the hospital. She stated she received Resident #1's universal transfer form (UTF) already completed by the ADON. She took Resident #1's chart and the UTF to the seventh-floor unit and observed CNA #2 on that unit. LPN #1 stated she did not observe Resident #1 on the seventh-floor unit. She stated CNA #2 came to work on 10/15/2024, but the SM had called out. LPN #1 further stated that CNA #2 did not work on her unit on 10/15/2024. LPN #1 stated no administrative staff came to talk to me after the incident had occurred, but LPN #1 wrote a statement for the incident that occurred on 10/14/2024. LPN#1 stated the process after an incident was for the nurse on the unit to complete the incident report, obtain witness statements from all staff on the unit, and complete an assessment of the resident(s) involved. She stated they (Administration) did not make me fill it out (incident report). During an interview with the surveyors on 10/22/2024 at 3:22 PM, the DON stated when an incident occurs the nurse assigned the resident is responsible for completing an incident report. The DON stated, I guess that day it was not filled out. The DON confirmed that no incident report was completed for Resident #1 on 10/14/2024. The DON stated the expectation was that the charge nurse should have filled out an incident report and gathered witness statements after the incident occurred. The DON further stated the next day either the ADON or herself would review the incident report and were responsible to ensure there was an incident report with witness statements. The DON further stated, We did not ask the nurse why an incident report was not completed. The DON confirmed there was no incident report or witness statements regarding 10/14/2024 incident involving Resident #1. The DON stated the expectation was to have an incident report and witness statements completed after an incident occurred. During an interview with the surveyors on 10/22/2024 at 3:22PM, the ADON stated as a team, we go over the incident reports in morning meeting. This has not happened in this case with Resident #1. During an interview with the surveyors on 10/22/2024 at 4:06 PM, SW #1 stated she met the ADON by the elevators on 10/14/2024, and the ADON told her that Resident #1 was upset and wanted her to go to talk with the resident. She stated when she got upstairs, she observed LPN #1 and Resident #1 at the nursing station. SW #1 stated Resident #1 pulled his/her tee shirt up and she observed red marks to the resident's back. She told the ADON about the red marks on the resident's back. SW #1 stated she was asked by LPN #1 to take the resident off the unit. SW#1 stated she took the resident to her office on the first floor, and LPN #1 brought the resident's lunch tray. SW #1 stated she believed Resident #1 said to call the cops. She stated the resident appeared anxious, had excessive speech, and was agitated. SW #1 stated while Resident #1 was eating he/she dropped a piece of mashed potato on the floor, the resident attempted to pick up the mashed potato and stated, oh my back. She stated the resident was still in her office for approximately 45 minutes when she texted the LNHA to let her know the resident was still in her office. SW #1 stated she came to work the next day and the police were at the facility. SW#1 stated she did not speak with the police. SW #1 stated she did not recall why the police were at the facility. SW#1 stated she did not know anything until she read an article online about two staff members at the facility that were detained, and a resident was in the hospital in critical condition. SW #1 further stated she was not asked to write a statement. SW #1 stated she did not speak to any staff or residents about the incident that occurred. SW #1 stated if an abuse allegation occurred, it was to be reported to the LNHA who was the abuse coordinator. SW #1 stated that if the LNHA was not there she would report the allegation to the DON or ADON. SW #1 further stated that she would await instruction from the LNHA. SW #1 stated the LNHA would tell her to interview the resident. SW #1 stated she would report the abuse allegation and then await further instruction from the LNHA. SW #1 stated she did not ask Resident #1 who beat him/her up. SW #1 stated that Resident #1 pointed to the two staff members in the hallway after the incident occurred and the resident stated, they just beat the [profanity] out of me. SW #1 stated she assumed the two staff members were CNA #2 and the SM because she had seen their pictures on the internet after the incident occurred. SW #1 further stated she had not spoken to any residents on CNA #2 and the SM's assignments. SW#1 stated the LNHA did not ask her to speak to any of the residents cared for on 10/14/2024 by CNA #2 and the SM as of 10/22/2024. SW#1 stated she did not speak to Resident #1 about the incident. During an interview with the surveyors on 10/22/2024 at 5:01 PM, the DON stated that LPN #1 told her Resident #1 was acting out. The DON stated that when she came to work on 10/15/2024 there were two police officers and a detective at the facility. The DON stated she was asked if she knew what happened to the resident. The DON stated she was asked by the police if she had heard that Resident #1 had been beaten up the day before and the DON stated she told them No. During an interview with the surveyors on 10/22/2024 at 5:03 PM, the LNHA stated on 10/15/2024 the police asked her if she knew Resident #1 had been beaten up on 10/14/2024. The LNHA stated she knew that the resident had thrown an overbed tray table, the overbed tray table got broken, and the resident had a fall. The LNHA stated she did not call the police because she thought it was a resident to staff incident. The LNHA further stated she normally would have called the police for a resident to resident, staff to resident, and resident to staff incident but did not for this incident. The LNHA further stated she would have called the police if the resident hit the staff or if the resident was a harm to self and others. The LNHA stated she would have considered a resident throwing an overbed tray table, a danger to resident's self and others. The LNHA stated the police should have been notified. The LNHA stated the police came to the facility on [DATE] and talked to the staff and were trying to determine if abuse had occurred. The LNHA stated she reviewed the camera surveillance on 10/15/2024 in the presence of the police and observed the overbed tray table come out of the resident's room. She also observed CNA#2 and the SM holding Resident #1 on the floor. When asked by the surveyor if the camera surveillance was reviewed on 10/14/2024, the LNHA stated no, I was told the resident threw an overbed tray table and had a fall. I didn't think to review the camera because it was reported as a regular fall. The LNHA further stated an incident report should have been completed for the fall and the incident that occurred on 10/14/2024. During an interview with the surveyors on 10/23/2024 at 12:48 PM, the LNHA stated she was the abuse coordinator. The LNHA stated once an abuse allegation was made, the staff was to report it to the SW and herself and they would start the investigation. She stated the nurse on the floor would collect the witness statements and the SW would interview and gather statements from the resident(s) involved. The LNHA stated there were no instances where the SW would not have collected resident statements when an abuse allegation occurred. She further stated, I cannot speak to why there were no statements gathered for the other residents for the incident on 10/14/2024. The LNHA stated, I know the SW talked to the other residents after the incident. The LNHA further stated the expectation was that the SW should have talked to Resident #1 and other residents on CNA #2 and the SM's assignments after the incident occurred. The LNHA stated that she agreed that some of the steps of the abuse and investigation policies were not followed for the incident on 10/14/2024. The LNHA confirmed that SW#1 should have started an investigation and reported the incident to her on 10/14/2024. The LNHA stated I was not made aware of the marks seen by SW#1 and the ADON on 10/14/2024. All I knew was the resident fell . The LNHA stated the witness statements were written and collected on 10/15/2024. During a third interview with the surveyors on 10/23/2024 at 3:05 PM, the LNHA stated she was told the employees' written statements were left in the DON's mailbox. The LNHA stated I think the employees have the original statements and left the copies in the DON's mailbox. The LNHA stated the nurse would collect the statements and put them in the mailbox. The LNHA stated The DON would be the first person to collect and look at the statements if they are put in her mailbox. The LNHA further stated, Yes, for the 10/14/2024 incident the witness statements were all put in the DON's mailbox. During an interview with the surveyors on 10/23/2024 at 3:23 PM, CNA #1 stated I wrote my statement on 10/14/2024 and gave the original copy to LPN #1. During an interview with the surveyors on 10/23/2024 at 3:27 PM, the DON stated copies of the written statements were in her mailbox on 10/15/2024. The DON further stated, I don't remember off the top of my head, who the statements were from. The DON stated she does not review the witness statements and the final investigation. The DON stated she has not reviewed the witness statements for the incident that occurred on 10/14/2024. The DON confirmed she took the witness statements regarding the 10/14/2024 incident out of her mailbox on 10/15/2024. The DON stated, I don't know who would read the witness statements. The facility was unable to provide written statements from CNA #2 and the SM. The surveyors requested a copy of the surveillance footage from the LNHA throughout the complaint survey. During exit conference on 10/29/2024 at 3:24 PM, the LNHA stated that the facility was not able to access the footage because 14 days had passed since the incident occurred on 10/14/2024. Review of the facility policy titled Abuse Policy and Procedure updated 8/2014, revealed under Policy that This facility requires that any allegations of abuse be addressed immediately in accordance with all federal and state regulations. All allegations will be evaluated in a prompt and thorough manner. Under Procedure, 9. The RN supervisor will contact the Director of Nursing immediately upon suspicion or confirmation of abuse. If the Director of Nursing is unable to be contacted, the Administrator will be contacted. 10. The Administrator will be contacted regarding all cases of physical and verbal abuse .11. The Supervisor/Nurse Manager/Director of Nursing/designee will interview all staff who have provided care. 13. Confused residents will be interviewed with a witness present. 16. Employee statement forms and an incident form will be filled out completely. An Incident Report form will include the following information: a. The name of the involved resident, b. the date and time the incident occurred, c. the circumstances surrounding the incident, d. where the incident took place, e. the name(s) of those participating in the act, f. physician and family notification, g. treatment rendered. Review of the undated facility policy titled Conducting an Investigation of all Incidents/Accidents revealed under Policy Statement, It is the policy of this Center to make every effort to investigate any/all incidents/accidents of residents. Under Purpose, to provide appropriate action that can be taken to correct the situation and prevent reoccurrence by gathering all pertinent information about the incident that is reported through a complaint or other report. Under Policy Interpretation and Implementation, A. Initial Investigation: 4. If there appears to be a possibility of abuse, mistreatment, or neglect, the RN supervisor or designee: a. Completes the Resident Incident report, b. Notifies the DON and Administrator. 5. If the incident involves an allegation of abuse, neglect, or mistreatment against an employee, the RN supervisor or designee interviews the employee, gets a written statement, and suspends the employee pending an investigation. The employee is removed from duty for the protection of the residents during the investigation. 7. The Director of Nursing Services or designee reviews the investigation to determine if the incident should be reported as suspected abuse. B. Organizing and conducting the investigation: 1. The RN supervisor or designee starts the investigation immediately. 4. The police should be notified in cases of assault. D. Taking Statements: 1. Never take a statement until you have interviewed them. 3. Remain with the witness as they write the statement. NJAC 8:39-4.1(a)5

Complaint #: NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to a.) implement care plan (CP) interventions for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. LPN #1 stated she heard a loud bang and yelling in the hallway. LPN #1 responded to the hallway and saw Resident #1 laying on the floor in the hallway yelling please stop, get them off of me. LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM hitting Resident #1 with his fist. LPN #1 told both staff members (CNA #2 and SM) to stop and to get off the resident. LPN#1 stated CNA #2 and the SM did not immediately stop and get off the resident. She had to repeat the request. LPN#1 stated the SM said, Its ok we are told to do this. LPN #1 stated she assisted Resident #1 off the floor to the nursing station and immediately reported the incident to the Assistant Director of Nursing (ADON). CNA #2 and the SM went down to the other side of the hallway and passed the lunch trays. The Social Worker (SW#1) stated the ADON got her to come to the unit. SW #1 stated Resident #1 was yelling They just beat the [profanity] out of me. SW#1 stated while at the nursing station, she observed the resident's back when Resident #1 lifted his/her tee shirt. SW #1 reported the observation to the ADON. SW#1 stated she was asked by LPN#1 to take Resident #1 to her office on the first floor. SW #1 stated Resident #1 complained of back pain. During an interview with the SW, the SW stated while Resident #1 stated oh my back while attempting to pick up food from off the floor. The ADON stated Resident #1 told her that he/she fell and an order was obtained from the Medical Director to send Resident #1 to the hospital for a fall. On 10/14/2024, Resident #1 was admitted to the hospital with diagnoses of splenic laceration, subcapsular hematoma, and an active bleed. The facility also failed to follow its policy titled Care Plan. This placed Resident #1 and all other residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 10/22/2024 at 8:50 PM and was reported to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and ADON. The LNHA, DON, and ADON were presented with the IJ template. The IJ began on 10/14/2024 and continued through 10/29/2024 when the facility submitted an acceptable Removal Plan. On 10/29/2024, a revisit to verify the Removal Plan was conducted. The facility implemented the Removal Plan, which included education on ensuring CP interventions were implemented, the location of the CPs, how to read the CPs, the importance of following the CPs, and how to update the CPs. Audits were conducted that monitor compliance with the implementation and following of the CP interventions or if updates to the CP were required. The noncompliance remained on 10/29/24 as a level G for actual harm that is not an IJ based on that the facility staff have been educated on how to ensure CP interventions were implemented, the location of the CPs, how to read the CPs, the importance of following the CPs, and how to update the CPs. Audits were conducted that monitor compliance with the implementation and following of the CP interventions and if updates to the CP were required. This deficient practice was identified for 1 of 7 residents (Resident #1) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 10/15/2024, Resident #1 was upset while in his/her room and threw an overbed tray table at a staff member outside of Resident #1's room on 10/14/2024. While throwing the overbed tray table, Resident #1 lost balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff and others. Staff attempted to subdue Resident #1 by using gentle resistance while on the floor. Resident #1 was sent to the hospital for further evaluation. While at the hospital, Resident #1 stated to hospital staff that he/she had been beaten up by two staff members. The police department notified the facility on 10/15/2024 of Resident #1's allegation. According to the FRE, a full investigation was initiated on 10/15/2024. Both staff members were suspended pending an investigation on 10/15/2024. According to the facility's document titled Summary of Investigation with a date reported of 10/15/2024 under Summary, Resident #1 sustained injuries when he/she fell on top of the overbed tray table while trying to continue an attack on the staff member. Resident #1 had a history of aggression towards others and staff were protecting residents and themselves while trying to keep Resident #1 from continuing aggression. The staff were concerned for everyone's safety and tried to keep Resident #1 down on the floor to avoid Resident #1 from hurting others. They were too aggressive while trying to keep Resident #1 down to prevent further aggression from Resident #1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. According to the Admission Minimum Data Set (MDS), an assessment tool dated 08/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 was on antipsychotic medications and had no behaviors that were exhibited towards others. According to the Discharge MDS dated [DATE], Section A, a discharge assessment indicated return anticipated. Section E revealed that Resident #1 had physical and behavioral symptoms directed toward others. A review of Resident #1's CP initiated on 8/25/2024 revealed under Focus: Resident #1 is the aggressor in a physically altercation with peer related to poor impulse control. Under Goal revealed Resident #1 will not harm others through the review date. Under Interventions initiated on 8/25/2024 revealed the following: When Resident #1 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Resident #1 was sent to ER for behavioral evaluation. A review of Resident #1's Progress notes (PNs) dated 10/14/2024 at 2:24 PM written by the ADON revealed Resident #1 became upset while in the room and threw an overbed table at a staff member outside the room door. During the throwing of the overbed table, Resident #1 lost their balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff. Staff attempted to subdue Resident #1 using gentle resistance while on the floor. Resident #1 was given time to calm down before being assisted to a standing position. Resident #1 was taken off the unit with Social Services (SS) to further calm down. The Physician was informed of Resident #1's behaviors. An order was secured to send Resident #1 to the hospital for a behavioral evaluation and x-ray of the right hip and ribs. A review of Resident #1's PNs dated 10/14/2024 at 9:35 PM revealed at 5:30 PM, Resident #1 was picked up by transport via stretcher to the ER. During an interview with the surveyors on 10/22/2024 at 5:01 PM, the DON stated the expectation was that the staff should follow a resident's CP. The DON further stated that a resident could be in danger if the CP was not followed. The DON confirmed that Resident #1's CP was not followed for the incident that occurred on 10/14/2024. During an interview with the surveyors on 10/22/2024 at 5:03 PM, the LNHA stated she was told by the staff that Resident #1 was on the floor and CNA#3 and the SM held Resident #1 down to prevent any further aggression. The LNHA further stated the expectation was to remove either the aggressor or other people from the situation which ever was safer. The LNHA agreed that Resident #1's CP intervention was not followed for the incident that occurred on 10/14/2024. During an interview with the surveyors on 10/24/2024 at 3:11 PM, the ADON stated the importance of the CPs were for staff to know how to care for the residents. The ADON stated the expectation was that CP interventions should be implemented by the staff. The ADON further stated if the care plan interventions were not implemented, it could cause harm to the resident. The ADON stated the interdisciplinary team (IDT) was responsible for implementing interventions on a resident's CP. A review of the facility's undated policy titled Care Plan revealed under Policy Interpretation and Implementation .2. The comprehensive care plan has been designed to: d. reflects treatment goals and objectives in measurable outcomes., e. identifies the professional services that are responsible for each element of care., f. prevent declines in the resident's functional status and/or functional levels. NJAC 8:39-11.2 (b)

Complaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to: a.) provide services necessary to prevent physical abuse for a resident (Resident #1), b.) follow the facility's abuse policy by allowing staff members to continue to work with other residents after an abuse allegation occurred, c.) conduct a timely and thorough investigation for a reported witnessed allegation of staff to resident physical abuse, d.) provide accurate and original witness statements to the surveyors for an abuse investigation e.) implement care plan (CP) interventions for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. LPN #1 stated she heard a loud bang and yelling in the hallway. LPN #1 responded to the hallway and saw Resident #1 laying on the floor in the hallway yelling please stop, get them off of me. LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM hitting Resident #1 with his fist. LPN #1 told both staff members (CNA #2 and SM) to stop and to get off the resident. LPN#1 stated CNA #2 and the SM did not immediately stop and get off the resident. She had to repeat the request. LPN#1 stated the SM said, Its ok we are told to do this. LPN #1 stated she assisted Resident #1 off the floor to the nursing station and immediately reported the incident to the Assistant Director of Nursing (ADON). CNA #2 and the SM went down to the other side of the hallway and passed the lunch trays. The Social Worker (SW#1) stated the ADON got her to come to the unit. SW#1 stated Resident #1 was yelling They just beat the [profanity] out of me. SW#1 stated while at the nursing station, she observed the resident's back when Resident #1 lifted his/her tee shirt. SW #1 reported the observation to the ADON. SW#1 stated she was asked by LPN#1 to take Resident #1 to her office on the first floor. SW #1 stated Resident #1 complained of back pain. During an interview with the SW#1, she stated Resident #1 stated oh my back while attempting to pick up food from off the floor. The ADON stated Resident #1 told her that he/she fell , and an order was obtained from the Medical Director to send Resident #1 to the hospital for a fall. On 10/14/2024, Resident #1 was admitted to the hospital with diagnoses of splenic laceration, subcapsular hematoma, and an active bleed. The facility also failed to follow its job description titled Administrator. This placed all residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified on 10/22/2024 at 8:50 PM and was reported to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the ADON. The LNHA, DON, and the ADON were presented with the IJ template. The IJ began on 10/14/2024 and continued through 10/29/2024 when the facility submitted an acceptable Removal Plan. On 10/29/2024, the surveyors conducted an onsite revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included the two staff members identified (CNA #2 and the SM) were terminated from the facility. Disciplinary action was initiated for the three employees (CNA #1, LPN#1, and SW#1) who witnessed the incident on 10/14/2024 and did not report it to the Abuse Coordinator. Education was provided to all administrative staff about the facility's abuse and investigation policy which included immediate steps taken when an abuse allegation was made and ensuring the safety of all residents. Education was provided to all staff on the importance of preventing abuse, ensuring resident safety, and the importance of following the facility's abuse policy to protect all residents. Education was provided to all staff on the importance of collecting all truthful statements in their original form, utilizing the SW to assist in obtaining resident statements, and assuring the original signed statements were all submitted to the Abuse Coordinator. Education on ensuring implementation of care plan interventions was provided to all the staff. This education included the location of care plans, how to read the care plans, the importance of following the care plans, and how to update the care plans. Audits were conducted that monitor compliance with the implementation, following of care plan interventions, and if updates to the care plan were required. Audits were initiated by the DON that monitor compliance with all staff education. The DON conducted staff assessments and testing to ensure that staff have a true understanding of the facility's abuse policy. The noncompliance remained on 10/29/24 as a level G for actual harm that is not an IJ based on the following: Resident #1 is no longer at the facility, CNA #2 and the SM no longer work at the facility, and all facility staff have been re-educated on the facility's abuse and investigation policy, importance of preventing abuse and ensuring resident safety, importance of collecting all truthful statements in their original form, utilizing the SW to assist in obtaining resident statements, and assuring the original signed statements were all submitted to the abuse coordinator. All facility staff have also been re-educated on ensuring implementation of care plan interventions. The facility began audits on compliance with all staff education and conducted staff assessments and testing to ensure that staff have a true understanding of the facility's abuse policy. This deficient practice was identified for 1 of 7 residents (Resident #1) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 10/15/2024, Resident #1 was upset while in his/her room and threw an overbed tray table at a staff member outside of Resident #1's room on 10/14/2024. While throwing of the overbed tray table, Resident #1 lost balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff and others. Staff attempted to subdue Resident #1 by using gentle resistance while on the floor. Resident #1 was sent to the hospital for further evaluation. While at the hospital, Resident #1 stated to hospital staff that he/she had been beaten up by two staff members. The police department notified the facility on 10/15/2024 of Resident #1's allegations. According to the FRE, a full investigation was initiated on 10/15/2024. Both staff members were suspended pending an investigation on 10/15/2024. According to the facility's document titled Summary of Investigation with a date reported of 10/15/2024 under Summary, Resident #1 sustained injuries when he/she fell on top of the overbed tray table while trying to continue an attack on the staff member. Resident #1 had a history of aggression towards others and staff were protecting residents and themselves while trying to keep Resident #1 from continuing aggression. The staff were concerned for everyone's safety and tried to keep Resident #1 down on the floor to avoid Resident #1 from hurting others. They were too aggressive while trying to keep Resident #1 down to prevent further aggression from Resident #1. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). According to the Admission Minimum Data Set (MDS), an assessment tool dated 08/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 was on antipsychotic medications and had no behaviors that were exhibited towards others. According to the Discharge MDS dated [DATE], Section A, a discharge assessment indicated return anticipated. Section E revealed that Resident #1 had physical and behavioral symptoms directed toward others. A review of Resident #1's Care Plan (CP) initiated on 8/25/2024 revealed under Focus: Resident #1 is the aggressor in a physical altercation with peer related to poor impulse control. Under Goal revealed Resident #1 will not harm others through the review date. Under Interventions initiated on 8/25/2024 revealed the following: When Resident #1 becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. A review of Resident #1's Progress notes (PNs) dated 10/14/2024 at 2:24 PM written by the ADON revealed Resident #1 became upset while in the room and threw an overbed tray table at a staff member outside the room door. During the throwing of the overbed tray table, Resident #1 lost his/her balance and fell to the floor. While on the floor, Resident #1 continued to be a danger to the staff. Staff attempted to subdue Resident #1 using gentle resistance while on the floor. Resident #1 was given time to calm down before being assisted to a standing position. Resident #1 was taken off the unit with Social Services (SS) to further calm down. The Physician was informed of Resident #1's behaviors. An order was secured to send Resident #1 to the hospital for a behavioral evaluation and x-ray of the right hip and ribs. A review of Resident #1's PNs dated 10/14/2024 at 9:35 PM revealed at 5:30 PM, Resident #1 was picked up by transport via stretcher and taken to the emergency room (ER). During an interview with the surveyors on 10/22/2024 at 1:04 PM, CNA #1 stated that on 10/14/2024 at 11:58 AM, she walked out of the dayroom, heard a commotion, and observed Resident #1 on the floor in the hallway between Resident #1's room and the dayroom on his/her back. She observed CNA#2 and the SM hitting resident with their fists. CNA #1 stated the camera could show you better. CNA #1 further stated she ran to get LPN#1, who responded to the incident. CNA #1 stated that CNA# 2 and the SM continued to work the rest of the shift on another unit. She stated that Resident #1 went to the hospital the same day the incident occurred but was unsure of the time. CNA #1 stated that Resident #1 can be aggressive at times but re-directable with a calm approach. CNA #1 stated she heard both CNA #2 and the SM tell LPN #1 that Resident #1 got upset because resident was told to wait to go out to smoke. During an interview with the surveyors on 10/22/2024 at 1:27 PM, LPN #1 stated she worked on 10/14/2024 and was assigned Resident #1. LPN #1 stated she was in the charting room speaking with the Speech Therapist (ST) and heard a loud bang and yelling. LPN #1 stated the ST and herself immediately got up and as she was coming out of the charting room door, she was met by CNA #1 who was coming to get her. LPN #1 stated she looked down the hallway where the yelling was coming from and observed Resident #1 laying in the hallway in front of his/her room. LPN #1 stated she heard Resident #1 yelling please stop, get them off of me. LPN #1 further stated that the ST was behind her and stated, Oh my God, what are they doing to him? LPN #1 stated she observed CNA #2 kicking Resident #1 and the SM punching Resident #1. LPN #1 stated Resident #1 was laying on his/her. LPN #1 stated she told CNA #2 and the SM to stop and get off the resident. CNA #2 and the SM did not immediately stop. She had to repeat the request. CNA #2 and the SM then stopped hitting the resident. LPN #1 further stated that the SM said, its ok, we are told to do this. When asked by the surveyor if the SM said who told him to this, the LPN said, No, he did not say who told him to do this. LPN #1 stated she assisted the resident off the floor to the nursing station and immediately reported the incident to the ADON. She stated that CNA #2 and the SM went down the other hallway and passed out the lunch trays. LPN #1 further stated I don't know what time, but CNA #2 and the SM were moved off the floor to the other units. LPN #1 stated Social Worker (SW#1) and the ADON came to the unit after the incident. SW#1 stayed with her and the resident at the nursing station. LPN#1 stated, I don't know where the ADON went. LPN #1 further stated Resident #1 complained of pain all over and asked her to call the police because he/she wanted to press charges. LPN #1 stated SW#1 lifted Resident #1's tee shirt, and they both observed red marks on the resident's back. She stated that SW#1 told the ADON that the resident had red marks on their back. LPN #1 stated she asked the ADON what are we doing with the resident. LPN#1 stated SW#1 took Resident #1 downstairs to her office. LPN #1 heard an overhead page for CNA #2 and the SM to report to the first floor, was unsure how long it was after the incident occurred, but it was not immediate. LPN#1 stated CNA #2 and the SM left the unit after the overhead page. LPN#1 stated she received a call from the DON asking her and CNA#1 to write a witness statement. LPN #1 stated she wrote her witness statement and brought both her and CNA #1's original witness statements to the DON's office. Upon her return to the unit, she received a phone call from the ADON stating that Resident #1 was going to the hospital. LPN#1 further stated that the ADON told her that Resident #1 and his/her roommate (Resident #4) were being moved to the seventh-floor unit. Resident #1 was not moved the seventh-floor unit because he/she was transferred to the hospital. She stated she received Resident #1's universal transfer form (UTF) already completed by the ADON. She took Resident #1's chart and the UTF to the seventh-floor unit and observed CNA #2 on that unit. LPN #1 stated she did not observe Resident #1 on the seventh-floor unit. She stated CNA #2 came to work on 10/15/2024, but the SM had called out. LPN #1 further stated that CNA #2 did not work on her unit on 10/15/2024. LPN #1 stated no administrative staff came to talk to me after the incident had occurred. She stated the process after an incident was for the nurse on the unit to complete the incident report, obtain witness statements from all staff on the unit, and complete an assessment of the resident(s) involved. She stated, they [Administration] did not make me fill it out [incident report]. During an interview with the surveyors on 10/22/2024 at 2:48 PM, CNA #3 stated that she was watching the residents in the dayroom around 12:00 PM on 10/14/2024 when she heard a commotion in the hallway. She came out from the dayroom and observed Resident #1 on the floor laying on his/her side. CNA #3 stated she observed the SM pinning down the resident on the floor and CNA #2 was standing there. CNA #3 further stated SW#1 and the ADON came and brought Resident #1 downstairs. She stated that when the lunch tray came to the unit, all the CNAs including CNA #2 and the SM passed out the lunch trays. CNA #3 stated she did not see CNA #2 and the SM on the unit after lunch but however, she saw CNA #2 and the SM when she clocked out at the end of her shift at 3:00 PM. CNA #3 stated CNA #2 was assigned as the monitor for Resident #1 on the day of the incident. She stated on the morning of 10/15/2024 she saw CNA #2 on the fifth-floor unit. During an interview with the surveyors on 10/22/2024 at 3:22 PM, the DON stated when an incident occurs the nurse assigned the resident is responsible for completing an incident report. The DON stated, I guess that day it was not filled out. The DON confirmed that no incident report was completed for Resident #1 on 10/14/2024. The DON stated the expectation was that the charge nurse should have filled out an incident report and gathered witness statements after the incident occurred. The DON further stated the next day either the ADON or herself would review the incident report and were responsible to ensure there was an incident report with witness statements. The DON further stated, We did not ask the nurse why an incident report was not completed. The DON confirmed there was no incident report or witness statements regarding 10/14/2024 incident involving Resident #1. The DON stated the expectation was to have an incident report and witness statements completed after an incident occurred. During an interview with the surveyors on 10/22/2024 at 3:22PM, the ADON stated as a team, we go over the incident reports in morning meeting. This has not happened in this case with Resident #1. During an interview with the surveyors on 10/22/2024 at 4:06 PM, SW #1 stated she met the ADON by the elevators on 10/14/2024, and the ADON told her that Resident #1 was upset and wanted her to go to talk with the resident. She stated when she got upstairs, she observed LPN #1 and Resident #1 at the nursing station. She further stated that the resident was yelling they just beat the [profanity] out of me. SW #1 stated Resident #1 pulled his/her tee shirt up and she observed red marks to the resident's back. She told the ADON about the red marks on the resident's back. SW #1 stated she was asked by LPN #1 to take the resident off the unit. SW#1 stated she took the resident to her office on the first floor, and LPN #1 brought the resident's lunch tray. She stated the resident appeared anxious, had excessive speech, and was agitated. SW #1 stated while Resident #1 was eating he/she dropped a piece of mashed potato on the floor, the resident attempted to pick up the mashed potato and stated, oh my back. She stated the resident was still in her office for approximately 45 minutes when she texted the LNHA to let her know the resident was still in her office. SW #1 stated she came to work the next day and the police were at the facility. SW#1 stated she did not speak with the police. SW #1 stated she did not recall why police were at the facility. SW#1 stated she did not know anything until she read an article online about two staff members at the facility that were detained, and a resident was in the hospital in critical condition. SW #1 further stated she was not asked to write a statement. SW #1 stated she did not speak to any staff or residents about the incident that occurred. SW #1 stated if an abuse allegation occurred, it was to be reported to the LNHA who was the Abuse Coordinator. SW #1 stated that if the LNHA was not there she would report the allegation to the DON or ADON. SW #1 further stated that she would await instruction from the LNHA. SW #1 stated the LNHA would have told her to interview the resident. SW #1 stated she would report the abuse allegation and then await further instruction from the LNHA. SW #1 stated she did not ask Resident #1 who beat him/her up. SW #1 further stated she had not spoken to any residents on CNA #2 and the SM's assignments. SW#1 stated the LNHA did not ask her to speak to any of the residents cared for on 10/14/2024 by CNA #2 and the SM as of 10/22/2024. SW#1 stated she did not speak to Resident #1 about the incident. During an interview with the surveyors on 10/22/2024 at 4:47 PM, the ADON stated on 10/14/2024 that I was told that Resident #1 was having some behaviors and took the over bed tray table and tried to hit the CNA. The ADON stated she did not know where the resident got the overbed tray table from and was unsure of the staff involved in the incident. She further stated that she was called to the unit by LPN #1. She stated LPN #1 told her that the resident tried to throw the overbed tray table at the aide, the resident and the overbed tray table went down. The surveyor asked the ADON if LPN#1 made her aware of the abuse allegation and she stated, LPN#1 did not say anything else. The ADON stated that when she got to the unit, she did not see anyone on the floor but saw the overbed table broken in half. The ADON further stated she saw Resident #1 and he appeared angry and tried to get the resident somewhere quiet. The ADON stated she asked Resident #1 what happened with the overbed tray table, and the resident stated they fell . The ADON stated the resident refused an assessment. The ADON stated she called the doctor and got an order to send Resident #1 to the hospital because resident was on the floor. The ADON stated the reason for Resident #1's transfer to the hospital was because resident complained of right leg pain, had agitation, and an x-ray was requested. The ADON stated she was unsure of what time Resident #1 went to the hospital. During an interview with the surveyors on 10/22/2024 at 5:01 PM, the DON stated that LPN #1 told her Resident #1 was acting out. The DON stated that when she came to work on 10/15/2024 there were two police officers and a detective at the facility. The DON stated she was asked if she knew what happened to the resident. The DON stated she was asked by the police if she had heard that Resident #1 had been beaten up the day before and the DON stated she told them No. The DON further stated the expectation was that staff should follow a resident's care plan. The DON further stated that a resident could be in danger if the care plan was not followed. The DON confirmed that Resident #1's care plan was not followed during the incident that occurred on 10/14/2024. During an interview with the surveyors on 10/22/2024 at 5:03 PM, the LNHA stated on 10/15/2024 police asked her if she knew Resident #1 had been beaten up. The LNHA stated she knew that the resident had thrown an overbed tray table, the overbed tray table got broken, and the resident had a fall. The LNHA stated she did not call the police because she thought it was a resident to staff incident. The LNHA further stated she normally called the police for a resident to resident, staff to resident, and resident to staff incident but did not for this incident. The LNHA further stated she would have called the police if the resident hit the staff or if the resident was a harm to self and others. The LNHA stated she would have considered a resident throwing an overbed tray table, a danger to resident's self and others. The LNHA stated the police should have been notified. The LNHA stated the police came to the facility on [DATE] and talked to the staff and were trying to determine if abuse had occurred. The LNHA stated she reviewed the camera surveillance on 10/15/2024 in the presence of the police and observed the overbed tray table come out of the resident's room. She also observed CNA#2 and the SM holding Resident #1 on the floor. When asked by the surveyor if the camera surveillance was reviewed on 10/14/2024, the LNHA stated no, I was told the resident threw an overbed tray table and had a fall. I didn't think to review the camera because it was reported as a regular fall. The LNHA stated after reviewing the camera surveillance, with the police, she was informed by them that they were arresting CNA #2. The LNHA further stated the SM was not at the facility on 10/15/2024. The LNHA stated she finalized her investigation, and that CNA #2 and the SM were trying to hold Resident #1 after he/she threw the overbed tray table. She stated a physical hold was not a part of how to deal with aggressive residents. The LNHA stated she would consider a physical hold as a restraint. The LNHA stated the facility did not have a policy on restraints. The LNHA further stated an incident report should have been completed for the fall and the incident. The LNHA stated she was told by staff that Resident #1 was on the floor and CNA#3 and the SM held Resident #1 down to prevent any further aggression. The LNHA further stated the expectation was to remove either the aggressor or other people from the situation whatever was safer. The LNHA agreed that Resident #1's care plan intervention was not followed for this incident. During an interview with the surveyors on 10/23/2024 at 12:48 PM, the LNHA stated she was the Abuse Coordinator. The LNHA stated once an abuse allegation was made, the staff was to report it to the SW and herself and they would start the investigation. She stated the nurse on the floor would collect the witness statements and the SW would interview and gather statements from the resident(s) involved. The LNHA stated there were no instances where the SW would not have collected resident statements when an abuse allegation occurred. She further stated, I cannot speak to why there were no statements gathered for the other residents for the incident on 10/14/2024. The LNHA stated, I know the SW talked to other residents after the incident. The LNHA further stated the expectation was that the SW should have talked to Resident #1 and other residents on CNA #2 and SM's assignments after the incident occurred. The LNHA stated that she agreed that some of the steps of the abuse and investigation policies were not followed the incident on 10/14/2024. The LNHA confirmed that SW#1 should have started an investigation and reported the incident to her on 10/14/2024. The LNHA stated I was not made aware of the marks seen by SW#1 and the ADON on 10/14/2024. All I knew was the resident fell . The LNHA stated the witness statements were written and collected on 10/15/2024. During an interview with the surveyors on 10/23/2024 at 1:11 PM, CNA #1 was shown her witness statement that the facility provided to the surveyors. CNA #1 stated Yes, I am confirming that my statement was altered. CNA #1 stated in her original statement she wrote that she had seen her co-workers hit on Resident #1 while resident was on the floor. CNA #1 further stated Yes, I am confirming that the witness statement you are showing me, does not have all the information I put in my original statement. During an interview with the surveyors on 10/23/2024 at 3:05 PM, the LNHA stated she was told the employees' written statements were left in the DON's mailbox. The LNHA stated I think the employees have the original statements and left the copies in the DON's mailbox. The LNHA stated the nurse would collect the statements and would put them in the mailbox. The LNHA stated The DON would be the first person to collect and look at the statements if they are put in her mailbox. The LNHA further stated, Yes, for the 10/14/2024 incident the witness statements were all put in the DON's mailbox. During an interview with the surveyors on 10/23/2024 at 3:23 PM, CNA #1 stated I wrote my statement on 10/14/2024 and gave the original copy to LPN#1. During an interview with the surveyors on 10/23/2024 at 3:25 PM, LPN #1 stated I took my original statement and CNA #1's statement as requested by the DON. I was going to make copies, but the copier was down. I took a screenshot of the original statements. During an interview with the surveyors on 10/23/2024 at 3:27 PM, the DON stated copies of written statements were in her mailbox on 10/15/2024. The DON further stated, I don't remember off the top of my head, who the statements were from. The DON stated she does not review the witness statements and the final investigation. The DON stated she has not reviewed the witness statements for the incident that occurred on 10/14/2024. The DON confirmed she took the witness statements regarding 10/14/2024 incident out of her mailbox on 10/15/2024. The DON stated, I don't know who would read the witness statements. Review of the facility document titled Job Description revealed under Job Title, Administrator. Under Duties and Responsibilities revealed 2. Ensure the development of, implementing and enforcing all policies and procedures. 3. Exercise full and complete authority relative to the employment and placing of all staff within the facility. Review of the facility policy titled Abuse Policy and Procedure updated 8/2014, revealed under Policy that This facility requires that any allegations of abuse be addressed immediately in accordance with all federal and state regulations. All allegations will be evaluated in a prompt and thorough manner. Under Procedure, 6. Any employee alleged to have participated in abusive activity will be removed from care of the involved resident immediately. 9. The RN supervisor will contact the Director of Nursing immediately upon suspicion or confirmation of abuse. If the Director of Nursing is unable to be contacted, the Administrator will be contacted. 10. The Administrator will be contacted regarding all cases of physical and verbal abuse .11. The supervisor/Nurse Manager/Director of Nursing/designee will interview all staff who have provided care. 13. Confused residents will be interviewed with a witness present. 16. Employee statement forms and an incident form will be filled out completely. An Incident Report form will include the following information: a. The name of the involved resident, b. the date and time the incident occurred, c. the circumstances surrounding the incident, d. where the incident took place, e. the name(s) of those participating in the act, f. physician and family notification, g. treatment rendered. 22. Employees who have had allegations of physical abusive treatment will be removed from direct resident care. NJAC 8:39-9.2(a)

Complaint#: NJ176503, NJ178530 Based on interviews and medical record review on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to implement the recommendations from a resident's Pre-Admission Screening and Resident Review (PASARR) level II determination. This deficient practice was identified for 1 of 2 residents reviewed for the PASARR (Resident #1), and was evidenced by the following: According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). According to the Admission Minimum Data Set (MDS), an assessment tool dated 08/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated Resident #1 was on antipsychotic medications and had no behaviors that were exhibited towards others. A review of the PASARR Level II Determination Notification letter by the New Jersey Department of Human Services Division of Mental Health and Addiction Services dated 5/23/2024 revealed that Resident #1 had mental health treatment needs that could be met in a nursing facility. According to the notification, the recommendations made for the resident included the following: 1. Psychiatric consult upon admission to the nursing facility. 2. Routine follow up visits with the Primary Care Physician and Psychiatrist. 3. Medication Monitoring 4. Supportive Counseling 5. Routine Laboratory Testing 6. Formulate and implement a behavioral modification plan to address any behavioral disturbances. 7. Provide education to the client and family on mental illness and medication. 8. Develop a Crisis Intervention/Safety Plan with the client. A review of Resident #1's medical record revealed an initial assessment from the psychologist titled with a date of service of 08/27/2024 (25 days after resident's admission into the facility). Resident #1's medical record did not reveal any visits from the psychiatrist while in the facility. During an interview with the surveyors on 10/24/2024 at 1:32 PM, the Social Worker (SW#2) stated I put the PASARR results and recommendations on the resident's baseline care plan. SW#2 stated the interdisciplinary team (IDT) was responsible for ensuring the PASARR recommendations were implemented. SW#2 further stated, the resident's plan of care would not be comprehensive or complete if recommendations were not followed. During an interview with the surveyors on 10/24/2024 at 1:47 PM, SW#1 stated most of the PASARR recommendations such as a psychiatric consult was already a part of the admission process for a resident. SW #1 stated I think the psychiatric consults were scheduled when the psychiatrist comes to the building. SW #1 further stated she had seen the psychiatrist at least three times a month in the building. SW#1 stated she implemented a Performance Improvement Plan (PIP) for ensuring the PASARR recommendations were on a resident's chart and that recommendations were implemented. SW #1 further stated the PIP was started in March and ended in May. SW#1 further stated she was not aware of issues with the PASARR recommendations being implemented. SW#1 stated the IDT was responsible for implementing the PASARR recommendations. SW #1 further stated it could be a problem for all areas of a resident's care if the PASARR recommendations were not implemented. During an interview with the surveyors on 10/24/2024 at 3:37 PM in the presence of the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) stated Resident #1's PASARR recommendations were not followed because the resident was never seen by a psychiatrist since being admitted to the facility. The DON stated she could not speak to why Resident #1 was not seen by a psychiatrist. During an interview with the surveyors on 10/24/2024 at 3:37 PM in the presence of the DON, the LNHA stated the SW was responsible for putting the PASARR in the resident's electronic medical record. The LNHA stated the resident's care plan was updated based on the PASARR recommendations. The LNHA stated if the resident's care plans were not updated with the PASARR recommendations and were not implemented, the staff would be unable to properly care for the resident. The LNHA further stated she could not speak to why Resident #1 was not seen by a psychiatrist. The surveyors requested a facility policy on PASARR recommendations, and the facility was unable to provide a policy. NJAC 8:39-27.1 (a)

Based on record review, interview and policy review, the facility failed to ensure residents were free from physical abuse for two of seven residents (Resident (R) 191 and R79) reviewed for resident-to-resident abuse. R79 suffered a facial fracture due to physical abuse. The facility failed to ensure residents were free from sexual abuse for one of seven (R116) residents reviewed for sexual abuse. Findings include: 1. Review of R168's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and was readmitted on [DATE] with diagnoses including restlessness and agitation, schizoaffective disorder, bipolar disorder, schizophrenia, anxiety disorder and dementia with behavioral disturbance. Review of R168's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/10/23, revealed a Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated severe cognitive impairment. Review of R168's Care Plan, located under the Care Plan tab of the EMR and dated 01/06/23, revealed The resident was at risk for potential alteration in mood and behavior related to a diagnosis of schizophrenia and dementia with behavior disturbance. Resident had an aggressive altercation with a peer and was the alleged aggressor. Interventions in place were R168 will be kept separate from R79 while in the common room, psychiatrist and psychologist evaluation as needed, psychiatrist to review and change psychotropic medications as needed, resident will change rooms/units upon return to facility, and resident will be offered a facility change. Review of R191's Admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] and was readmitted on [DATE] with diagnosis of schizophrenia. Review of R191's discharge MDS assessment under the MDS tab of the EMR, with an ARD of 05/20/23, revealed BIMS score of three out of 15 which indicated severe cognitive impairment. Review of R191's Care Plan, located under the Care Plan tab of the EMR and dated 03/25/21, revealed The resident was at risk for mood and behavior due to long psychiatric history, periods of increased anxiety and aggression and physical and verbal aggression. Interventions in place were remind resident of 12 step meeting, attempt to build a trusting relationship with resident, attempt to identify situations that may trigger anxiety, encourage relaxation techniques, monitor for nonverbal signs and symptoms of anxiety, be alert to impending violent behaviors, and increase psychomotor activity. Review of a Nurse's Note, in the EMR under the Note tab written by Licensed Practical Nurse (LPN) 1 and dated 05/05/23 at 9:13 AM indicated, nurse was called to R168's room, R191 stated he punched me in the eye. R168 was observed sitting in a chair. The DON [Director of Nursing] and physician was made aware and 911 was called to report assault. An order was made to send resident to emergency room (ER) for evaluation. R 191 was removed from the room and R168 was placed on 1:1 [one to one] supervision until transport arrived. During an interview on 02/07/24 at 11:03 AM, LPN1 stated on 05/05/23 she heard something and went into R168's room and observed him sitting on the bed. R191, who was the roommate at the time told her This man was crazy and just punched me in my face. She said both residents were immediately separated, and the DON was made aware. 2. Review of R79's Admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder, secondary Parkinson's. Review of R79's quarterly MDS assessment under the MDS tab of the EMR, with an ARD of 11/11/23, revealed a BIMS score of nine out of 15 which indicated moderate cognitive impairment. Review of R79's Care Plan, located under the Care Plan tab of the EMR and dated 08/08/23, revealed, The resident was the receiver in an altercation with another peer. Further review revealed staff were to ensure that residents were kept separate from R168 while in common areas. Review of a Nurse's Note, in the EMR under the Notes tab by Registered Nurse (RN) 1 dated 08/07/23 at 3:37 PM indicated, R79 was punched in the back by R168. A skin assessment was completed with noted new bruising to his left mid back area. R79 stated the area was tender to touch but he refused any PRN (as needed) medication. The physician was made aware. 911 was called, R79 and R168 were separated and R168 was placed on 1:1 supervision until he was sent to the ER for evaluation. 3. Review of R53's Admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] and was readmitted on [DATE] with diagnoses including major depressive disorder and generalized anxiety disorder. Review of R53's quarterly MDS assessment under the MDS tab of the EMR, with an ARD of 12/03/23, revealed a BIMS, score of 10 out of 15 which indicated moderate cognitive impairment. Review of R53's Care Plan, located under the Care Plan tab of the EMR and dated 03/04/20, revealed The resident is at risk for mood and behavior due to log psych history, periods of increased agitation and anxiety, conflicts with roommates and verbal and physical aggression. Interventions in place were Caucasian caregiver when available, 2 people in room as needed, attempt to build a trusting relationship with resident, provide consistent caregiver routine, attempt to identify situations that may trigger anxiety, encourage relaxation techniques, monitor for nonverbal signs and symptoms of anxiety, be alert to impending violent behaviors, and increase psychomotor activity, decrease stimuli, and verbal de-escalation techniques. Review of a Nurse's Note, in the EMR under the Notes tab written by LPN8 dated 10/24/23 at 9:01 PM indicated, R79 came to nurses' station with an obvious injury to his face and stated that his roommate R53 hit him multiple times in his face. Spoke with R53 and asked him what happened and R53 stated R79 was making a lot of noise, and he could not sleep, so R53 hit R79. R53 was sent out for psychiatric evaluation and R79 was sent to ER. Review of a Nurse's Note, in the EMR under the Notes tab written by LPN8 dated 10/25/23 at 5:18 AM indicated, R79 returned to the facility around 5:00 am . New diagnosis of fracture of face bones and swelling in right upper eye orbital Review of a Nurse's Note, in the EMR under the Notes tab written by Social Services Director (SSD) dated 10/26/23 at 2:45 PM indicated, she spoke with R79 today about the incident he had with his roommate, R53. R79 said he was having trouble sleeping and does keep his overbed light on for reading. He had his curtain closed and did not mean to upset his former roommate. SSD explained to R79 he had every right to read at night. During an interview on 02/07/24 at 3:20 PM, RN1 stated that she was at the nurse's station on 10/24/23 when R79 walked up to her bleeding and told her R53 hit him but he did not know why. She said she walked back to the resident's room and spoke with R53 who told her I wanted to go sleep and I wanted to go to bed, and he wouldn't let me, so I hit him. RN1 did remember R79 had some facial injuries and some bleeding. Both residents were sent out to the emergency room and when they were readmitted , R53 was placed on another unit. 4. Review of the Investigative Report, provided by the facility, revealed, [R190] was alert and oriented time three and self ambulates with a wheelchair. [R116] was alert and oriented times one and to her immediate environment Summary/Conclusion: [R190] entered room [ROOM NUMBER] without permission and climbed into the bed of [R116]. [R190] was fully clothed at the time he entered her bed. [R116] demanded the resident get out of her bed and room. Review of the Admission Record found under the Profile tab of the EMR revealed R116 was admitted to the facility on [DATE] with a diagnosis of Schizoaffective, bipolar, depression, and anxiety. Review of the quarterly MDS found under the MDS tab of the EMR, with an ARD of 12/04/23 indicated the resident scored a 99 on her BIMS indicating severe cognitive impairment. Record review of the Admission Record in the EMR under the Profile tab revealed R190 was admitted to the facility on [DATE] and discharged immediately after the above incident on 01/30/24 with a diagnosis of dementia, diabetes, mood affective disorder, and low back pain. Review of the quarterly MDS found under the MDS tab of the EMR, with an ARD of 08/21/23 indicated the BIMS score of 11 out of 15 which indicated moderate cognitive impairment. Review of the Progress Note, in the EMR under the Notes tab documented by the SSD dated 01/30/24 at 8:55 AM, titled, Communication with Resident indicated, On 01/24/24, [R190] approached this SSD and asked .if he could visit any of the female residents at that end of the hall? SSD explained that he was not able to visit with any residents in their room as it was a resident's right to privacy issue. All visits must be in the common area dayroom. [R190] expressed an understanding and the conversation ended. Review of the Progress Note in the EMR under the Notes tab dated 01/30/24 at 10:04 AM, revealed the R190 was observed by staff to be in R116's room in her bed, fully clothed. The female resident did not want R190 in her room at the time he was in the room. Staff ensured the resident exited the female resident's room and back to his room. The resident was educated this behavior is not acceptable and immediately placed on 1:1 supervision. A call was placed to the doctor's office to inform of the resident's behavior and sent to hospital for evaluation and has not returned to the facility. Interview with Certified Nursing Assistant (CNA)7 on 02/07/24 at 12:05 PM, CNA7 stated that she saw R190 lying in the bed with R116. He had her in the bed like they were spooning. CNA7 stated she went to go get help and when she returned, R190 had rolled on the floor. Two CNAs helped R190 up and got him out of the room. CNA7 stated she had never seen R190 in R116's room prior to the incident. Interview with Assistant Director of Nursing (ADON) and the Administrator on 02/07/24 at 12:12 AM revealed she had to do a full investigation. The ADON and the Administrator stated they interviewed the CNA who found the resident. The SSD interviewed the residents, and the Administrator interviewed the staff. The Administrator stated they did not interview the SSD because she was not a part of the accusation. When asked about the SSD having knowledge of the resident wanting to visit female residents' rooms prior to the incident, the Administrator stated, every morning we have a morning meeting with all department, in which the SSD attends. The Administrator stated she did not recall anything prior that was brought to our attention about R190 wanting to visit resident's room during the morning meetings. During an interview on 02/08/24 at 11:53 AM, the DON stated that she did not know why there were no specific changes to interventions that were identified and implemented after each of the incidents that occurred. The DON agreed there should have been. The DON said she sees now there should have been something done after the residents were readmitted following the incidents to ensure continued safety for all the residents. During an interview on 02/08/24 at 3:21 PM, the Administrator stated how the facility handled preventing resident-to-resident abuse and identifying new interventions depending on the level of aggression during an incident. They would tell staff on that floor to just keep an eye on the resident but that was not documented and there was no 1:1 supervision. Review of the undated facility's policy titled [Name of Facility] /Abridged Abuse Policy for Annual Review revealed the goal was to keep all residents of [Name of Facility] free from abuse. 40902 NJAC 8:39-4.1(a)5 NJAC 8:39-33.2(c)12

Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to a.) identify all residents exposed to COVID-19 as persons under investigation (PUI), b.) implement mitigation strategies to prevent the transmission of COVID-19 and c.) appropriately implement their Pandemic Influenza/COVID-19 Preparedness & Readiness Plan (Outbreak Response Plan). This deficient practice was identified for 88 of 154 residents, (Residents #1 to #44 who resided on the 6th floor and Residents #45 to #88 who resided on the 7th floor) reviewed for a known exposure to COVID-19 on 2 of 5 nursing units during a focused infection control COVID-19 survey conducted on 1/14/21 and 1/15/21. Part A: On 1/8/21, and on 1/11/21, the facility became aware that two staff members, a Licensed Practical Nurse (LPN) and a Housekeeper (HK #1) were confirmed positive for COVID-19 in the facility. LPN #1 worked the 11 PM-7 AM shift on the 6th floor and was tested on [DATE] and confirmed positive on 1/8/21. LPN #1 had worked on 1/3/21, 1/4/21, 1/6/21, and 1/7/21 and was responsible for providing medications, treatments and needed care to the 44 residents on the 6th floor. HK #1, who was assigned to the 7th floor, tested positive on 1/11/21, and had worked on 1/5/21, 1/6/21, 1/7/21, 1/9/21, and 1/10/21. HK #1 had direct contact with the resident's environment and went room to room cleaning all resident rooms on the 7th floor. All the residents exposed to LPN #1 and the HK #1 on the 6th and 7th floor were considered by the facility to be well-non-exposed and were not placed on Transmission Based Precautions (TBP). The facility failed to identify these residents exposed to COVID-19 as Person Under Investigation (PUI) and the residents were not placed on contact and droplet TBP to mitigate the spread of the virus. During the survey conducted on 1/14/21 and 1/15/21, the surveyors observed that the exposed residents who resided on the 6th and 7th floor were not identified as PUI and were not placed on full TBP. There was no signage on the doors of the 6th and 7th floor units or on the individual resident rooms for the use of full PPE for droplet TBPs. There was no Personal Protective Equipment (PPE) bins such as gowns, face shields, goggles, KN95 masks, and N95 masks observed stocked throughout the 6th and 7th floor units. The surveyors further observed that staff caring for the residents on the 6th and 7th floors were wearing either a surgical mask or KN95 masks and no additional PPE. In addition, staff were unaware of the appropriate TBP or protocol that should have been implemented for exposure to the virus. The facility's failure to identify residents on the well non exposed nursing units as exposed to COVID-19 or implement strategies to prevent the spread of the COVID-19 virus, posed a serious and immediate threat to safety and wellbeing of all well non-exposed residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/8/21 when the facility was notified of the confirmed positive LPN#1. The facility's Administration was notified of the IJ on 1/15/2021 at 4:48 PM. The immediacy was removed on 1/29/21 based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site visit on 1/29/21. The evidence was as follows: On 1/14/2021 at 9:07 AM to 9:55 AM, the surveyors conducted entrance conference with the Administrator and Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP stated that as soon as they found out a staff member tested positive for COVID-19, the staff would be notified immediately, assessed for signs and symptoms of the virus, and be placed on quarantine. The ADON/IP further stated that he would ask the staff member that tested positive for COVID-19 who they had been in contact with and perform contact tracing for the residents who resided in the facility. The ADON/IP stated that the facility conducted contact tracing for the residents seven days prior to the positive COVID-19 test result and any residents who had contact with the staff would be PUI. The ADON/IP stated that PUI residents would be placed on quarantine for fourteen days. The ADON/IP stated that the PPE the staff utilized when caring for the PUI residents were a gown, KN95 mask or N95 mask, gloves, face shield or goggles, and hair or shoe coverings. During a follow-up interview on 1/19/21 at 1:54 PM, the ADON/IP stated the facility had all needed supplies for the staff to have N95 masks but there were problems getting the staff fit tested . On 1/14/21 at 11:06 AM, Surveyor #2 was on the 7th floor unit and observed LPN #2 in the hall wearing a KN95 mask. During an interview at that time, LPN #2 stated she was dedicated to the 7th floor unit and there were no COVID positive residents, new or readmissions or residents under PUI for COVID. LPN #2 stated if the unit had COVID positive, new or readmissions or PUI residents, the process would be to wear the KN95 masks with a surgical mask over it, PPE gown and gloves before entering the isolation room and to remove the surgical mask, gown and gloves prior to leaving the isolation room. LPN #2 stated that there would be a notification at the nurses' desk and the time clock, to alert the staff of any COVID in the facility. LPN #2 further stated she had been educated on isolation precautions, PPE and quarantining residents. On 1/14/21 at 11:15 AM, Surveyor #2 observed Certified Nursing Aide (CNA) #1 on the 7th floor unit in the hall wearing a surgical mask. During an interview at that time, CNA #1 stated there were no residents or isolation for COVID on the floor. CNA #1 stated the nurses would inform staff of COVID isolation and there would be a sign posted. At 11:37 AM, Surveyor #2 was on the 6th floor unit and observed two staff members and one resident by the nurses' desk, all wearing blue surgical masks. At 11:39 AM, the surveyor interviewed CNA #2. CNA #2 stated she was dedicated to the unit, there was plenty of PPE available and that if there were an isolation COVID resident, the nurses would inform her, there would be a sign on the door and a notice at the time clock. At 11:45 AM, Surveyor #2 observed signs around the 6th floor unit which included how to perform hand washing, instructing all to wear a mask, and reminding all to social distance. The signage did not indicate what type of mask was to be worn. On 1/15/21 at 8:56 AM, day 2 of survey, the surveyors entered the 7th floor. There was no signage posted that the residents were on TBP. There was no PPE observed to don or receptacles to doff PPE upon leaving the unit. At 8:57 AM, the surveyors observed the Housekeeping Director (HKD) exit the main elevator onto the 7th floor wearing a surgical mask. The surveyors further observed staff and multiple resident's walking around the unit wearing surgical masks and no other form of PPE. At 8:58 AM, Surveyor #1 interviewed CNA #1 who stated that she worked full-time at the facility and during the past few weeks, had only worked on the 6th or 7th floors. CNA #1 stated that there was one resident who resided on the 7th floor unit that was on TBP due to an infectious organism in his/her urine. CNA #1 stated that she wasn't sure if there was a recent exposure of COVID-19 for the residents on the unit from an infected staff member. CNA #1 further stated that if a resident was exposed to COVID-19, staff would have to wear a N95 mask or KN95 mask, surgical mask, gown, face shield, and gloves when providing direct care to the resident. CNA #1 told the surveyor that many of the residents who resided on the unit were ambulatory. She also stated that a lot of the residents smoked, and smoking was currently canceled so she felt that walking around the unit was a stress relief for the residents. At 9:05 AM, Surveyor #1 observed a sign that indicated, Stop Report to nurse before entering outside of one resident's room on the 7th floor. The surveyor further observed a plastic bin outside of the resident's room which was observed to be stocked with gloves, face shields, and surgical masks. There were no PPE gowns observed in the plastic bin. At 9:06 AM, Surveyor #2 observed HK #2 wheel the housekeeping cart into a resident room on the 7th floor. HK #2 was wearing a surgical mask and gloves. There were four resident names on the door and Surveyor #2 observed two residents inside the room. During an interview at 9:13 AM, HK #2 stated she would be able to recognize any type of isolation room by a sign on the door. HK #2 stated if there was an isolation room, she would have to wear the N95 mask, gown, gloves, and eye protection. At 9:08 AM, Surveyor #1 observed an Activities Aide (AA #1) working on the 7th floor wearing a surgical mask in the hallway. During an interview at that time, AA #1 stated that she worked on different units throughout the facility. AA #1 stated that she worked on the 6th floor the day before (1/14/21) and worked on the 5th floor on Monday (1/11/21) and Tuesday (1/12/21) that just passed. AA #1 stated that there were no residents on the unit on TBP. AA #1 stated that she would do a different activity with the residents every day in their rooms. AA #1 further stated that if a resident was considered a PUI, the staff would have to wear a gown, gloves, N95 mask, KN95 mask, surgical mask, and face shield prior to entering the resident's rooms. After conducting the interview, Surveyor #1 observed AA #1 enter a room occupied by four residents wearing a surgical mask and no additional PPE. Surveyor #1 observed the AA #1 stand in the middle of the room and sing and dance in front of the residents while playing music from her phone. At 9:12 AM, Surveyor #1 observed the Licensed Practical Nurse/Unit Manager (LPN/UM) on the 7th floor wearing a surgical mask. The LPN/UM stated that she was the unit manager for the 3rd and 7th floor and was back and forth between both units throughout her shift. The LPN/UM stated that there were many ambulatory residents who resided on the unit who needed to walk throughout the unit because, it was their nature. The LPN/UM further stated that a staff member who worked on the 7th floor recently tested positive for COVID-19, so due to that, smoking was canceled for the residents. The LPN/UM stated that after the staff member tested positive, all the residents who resided on the unit were re-tested for COVID-19 and monitored for signs and symptoms of the virus. The LPN/UM stated that one resident who resided on the unit was on TBP due to an infectious organism in his/her urine. Surveyor #1 asked the LPN/UM if TBP were implemented for the residents on the 7th floor after the known exposure to the positive staff member. The LPN/UM stated, no. At 9:21 AM, Surveyor #1 observed the Speech Language Pathologist (SLP) on the 7th floor wearing a surgical mask and face shield. The SLP stated that the PPE she wore when interacting with the residents was a surgical mask and face shield because she provided the residents with, feeding therapy. The SLP stated that she would have to wear full PPE if she worked on the 4th floor COVID-19 positive unit and would be able to tell which residents were on TBP by a sign on their door. The SLP stated that she worked on multiple floors throughout the facility and was providing treatment to two residents in the facility during her shift that day. One who resided on the 7th floor and one who resided on the 5th floor. The SLP stated that she was told by her director to provide treatment to the resident who resided on the 7th floor first. The SLP further stated that she was not given information on anyone or any staff member that recently tested positive for COVID-19. At 9:24 AM, Surveyor #2 observed an LPN #3 in the hall of the 7th floor unit, wearing a KN95 mask only. During an interview at that time, LPN #3 stated there was enough PPE available on the unit. LPN #3 stated there were no residents on the unit who were on isolation for COVID, PUI or observation. LPN #3 further stated that if there were, the staff would need to wear full PPE gowns, gloves, eye protection and KN95 mask in and out of the isolation rooms. At 9:37 AM, on the 7th floor unit, Surveyor #1 interviewed CNA #3 who stated that he worked for an agency and for the past week and a half, he had worked on all different units throughout the facility because his assignment was different every day. CNA #3 stated that only one resident on the unit was on TBP and if he knew a resident had exposure to COVID-19, he should wear a gown, face shield, N95 mask, gloves, and a surgical mask while providing care to the resident. CNA #3 further stated that today he was only wearing a surgical mask while providing care to the residents. At 9:47 AM, Surveyor #1 observed the Housekeeping Director (HKD) wearing a surgical mask and mopping the floor in the hallway on the 7th floor. The HKD stated that throughout his shift he went to all the units in the facility. The HKD further stated that if he were to go to the COVID-19 positive unit, he would wear full PPE. On 1/15/21 at 10:07 AM, the surveyors entered the 6th floor unit. There was no signage observed that residents were on TBP. There was no PPE observed to don or receptacles to doff PPE upon leaving the unit. Surveyor #2 observed three residents in the hall and only one resident was wearing a surgical mask while the other two were wearing no mask at all. Surveyor #1 observed a resident self-propelling in his/her wheelchair around the unit. Both surveyors observed a resident seated in his/her wheelchair in front of the nurses' station wearing a surgical mask pulled down under his/her chin, not covering their face. At 10:12 AM, Surveyor #1 observed CNA #4 wearing a surgical mask and standing in the hall to the right of the nurses' station. During an interview at that time, CNA #4 stated that he only worked on the 6th floor in the facility and was not aware of any staff that recently tested positive for COVID-19. CNA #4 further stated that there were no residents residing on the unit that were on TBP. At 10:16 AM, Surveyor #1 interviewed CNA #5, who was wearing a surgical mask in the hallway, who stated that she only worked on the 6th floor. CNA #5 further stated that the residents on the unit were not allowed to go outside to smoke for two weeks because a staff member who worked on the unit had tested positive for COVID-19. CNA #5 further stated that there were no residents on the unit on TBP. CNA #5 stated that if a resident was on TBP related to exposure of COVID-19, the staff should wear a N95 mask, surgical mask, gown, face shield, and gloves while providing care and perform hand hygiene in between everything. At 10:16 AM, Surveyor #2 observed CNA #6 in the hall wearing a surgical mask. During an interview at that time, CNA #6 stated that there was no isolation, PUI, observation or COVID positive resident on the 6th floor unit. CNA #6 stated he was dedicated to this unit and that the nurses would let the staff know and that there would be isolation carts by the door to distinguish isolation rooms if the residents were on TBP. At 10:21 AM, Surveyor #1 observed the Central Supply (CS) staff member in the hallway wearing a KN95 mask. The CS stated that she went onto all the units throughout the facility and was responsible for stocking supplies regularly throughout the facility. The CS stated that she heard that staff had tested positive for COVID-19 but didn't know who or where they had worked. The CS further stated that she was the person in the facility responsible for the set-up of TBP and explained to Surveyor #1 that if a resident was on TBP, a stop sign would be placed outside of their door, additional garbage cans would be set up in the room, and a plastic bin would be put outside the residents room which contained gowns, gloves, masks, and KN95 masks. The CS stated that there were no residents on the 6th floor on TBP. At 10:24 AM, Surveyor #2 observed CNA #7 wearing a surgical mask only and wheeling a bin to the laundry chute. During an interview at that time, CNA #7 stated there were no residents on isolation for COVID, PUI or observation on the unit. CNA #7 stated the staff would know if there were because there would be a sign and PPE by the door. CNA #7 stated she believed a staff member on the floor tested positive for COVID but that was over two weeks ago. At 10:38 AM, Surveyor #1 observed LPN #3 wearing a KN95 mask in the hallway. During an interview at that time, LPN #3 who stated that there were no residents on the 6th floor that were on TBP. LPN #3 stated that because a staff member who worked on the unit recently tested positive for COVID-19, to stop the spread of the virus the facility put all the resident's on, quarantine which meant the resident's weren't allowed to go outside and smoke or leave the unit. LPN #3 stated that if a resident was considered PUI or exposed to COVID-19 positive staff, they would have to wear full PPE which consisted of a N95 mask, surgical mask, gown, face shield, and gloves. LPN #3 further stated that all staff was currently wearing either a surgical mask or KN95 mask when they provided care to the residents on the unit. At 10:44 AM, Surveyor #1 interviewed the Registered Nurse/Unit Manager for the 6th and 5th floors who stated that she went from floor to floor throughout the day. The RN/UM stated that she would wear either a KN95 mask or surgical mask while working. The RN/UM stated that some of the residents that resided on the unit 6th floor walked around the unit throughout the day and used the telephone at the nurses' station. The RN/UM stated, Residents can't stay in their rooms. Have to walk around and move or their anxiety kicks in. The RN/UM further stated that a staff member who worked on the 6th floor recently tested positive for COVID-19 but the RN/UM could not recall the exact date. She further explained that to mitigate the spread of the virus, the facility re-tested all of the residents and staff and put the resident on, lock down which meant they couldn't leave the unit or go outside to smoke. The RN/UM stated that there were no residents on the unit on TBP. The RN/UM explained to the surveyor that if the facility had a new/re-admission, PUI, or COVID-19 positive resident then staff would have to wear a gown, face shield, N95 mask, and gloves. On 1/15/21 at 10:57 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated that if there were a new or readmission, they would be placed on the 3rd floor unit South and monitored for 14 days to see if any symptoms appear. The ADON/IP stated those residents would not be placed on any transmission-based precautions. On 1/15/21 at 12:18 PM, the ADON/IP stated the DON was the one who had contact with the local health department and that he was not aware of any guidance from the local health department that the facility should isolate any exposed residents. On 1/15/21 at 12:26 PM, the surveyors conducted an interview with the LNHA, ADON/IP, and the DON via telephone. The DON stated exposed residents would be quarantined on their unit meaning they would stay on that unit and not leave for smoking. The facility would try to keep the exposed residents in their rooms and away from each other and would implement environment source control such as maintaining a 6-foot distance and privacy curtains pulled, for two weeks. The DON further stated the staff would use basic mask precautions being a KN95 or N95 with or without a surgical mask over it. At 12:36 PM, the LNHA stated the COVID positive employee was not amongst the residents or staff so the staff do not have to wear gowns or full PPE because the employee was not by anyone for any length of time. At 12:37 PM, the ADON/IP stated the residents who were exposed to the positive employees were classified as observation. All residents were COVID tested and their vital signs monitored three times a day. The ADON/IP stated the facility Pandemic Influenza/COVID-19 Preparedness & Readiness Plan did not speak to putting the exposed residents on isolation precautions. On 1/15/21 at 1:11 PM, the surveyors conducted a telephone interview with the local health department facility representative. The LHD representative stated that the exposed residents were considered PUI and the facility was provided with all the guidelines regarding the exposed residents. The LHD representative also stated the PUI residents would be placed on transmission-based precautions. At 1:25 PM, the LNHA stated the DON communicated verbally with the LHD and could not provide written communication from the LHD. Review of the facility's Staff Outbreak Line List (a table of information recorded for staff and resident's that identifies dates of exposure and signs and symptoms of the virus which is used as a tool for infection control tracking) indicated that LPN #1 tested positive for COVID-19 on 1/8/21. Further review of the facility's Staff Outbreak Line List indicated that LPN #1 received a COVID-19 PCR test (a molecular test that looks for the genetic material of the virus itself in the nose, throat, or other areas of the respiratory tract to determine if there is an active infection with [CONDITION(S)]-CoV-2) on 1/5/21. Review of LPN #1's work schedule indicated the LPN #1 was the 11:00 PM to 7:00 AM nurse on the 6th floor on 1/3/21, 1/4/21, 1/6/21, and 1/7/21. The schedule indicated that LPN #1 was responsible for the care of all the residents on the 6th floor. Further review of LPN #1's schedule indicated that she worked on the COVID-19 positive unit on 1/5/21. LPN #1's assignment sheet revealed that on 1/3/21, 1/4/21, 1/6/21 and 1/7/21 she had been the only nurse for all 44 residents on the 6th floor. Review of the facility's contact tracing questionnaire for LPN #1 indicated that the staff member tested positive for COVID-19 on 1/5/21. The contact tracing questionnaire did not address the residents who had contact with LPN #1. Further review of the contact tracing questionnaire indicated that LPN #1 was to isolate until Monday, 1/18/21. Review of the Floor Nurse Job Description indicated the nurse's duties and responsibilities included providing direct nursing care and supervising of all nursing activities on the nursing unit and to assess the needs of each resident and develop and implement the resident's care plan and nursing care to meet the needs of the residents. The floor nurse job duties and responsibilities further included to provide direct resident care and coordinate the care with other services and to observe, evaluate and report resident symptoms and progress to the attending physician. Review of the facility's Staff Outbreak Line List indicated that HK #1 tested positive for COVID-19 on 1/11/21. Further review of the facility's Staff Outbreak Line List indicated that HK #1 received a COVID-19 PCR test on 1/7/21. Review of HK #1's work schedule indicated that HK #1 worked on the 7th floor on 1/5/21, 1/6/21, 1/7/21, 1/9/21, and 1/10/21. Review of the Housekeeper Job Description revealed day-to-day functions including dusting, moping, polishing, cleaning, and sanitizing all unit rooms, hallways and common areas including main dining room, dayroom, nurses' station, bathrooms, walls, counters, sinks, trash cans, and all other surfaces. In addition, the Housekeeper was responsible for cleaning all resident's rooms on the unit as needed throughout the day and that established infection control practices were maintained when performing duties throughout the unit. Review of the facility's contact tracing questionnaire for HK #1 did not reflect the date that HK #1 tested positive for COVID-19. The contact tracing questionnaire did not address the residents who had contact with HK #1. Further review of the contact tracing questionnaire did not indicate when HK #1 was cleared to return to work. Review of the facility's Pandemic Influenza/COVID-19 Preparedness & Readiness Plan (The Plan), revised on August 31, 2020, indicated that if a staff member tested positive for COVID-19, the staff member would be immediately excluded from work and the facility would consult with the local health department and follow the, CDC's Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19. The Plan further indicated, Facility will perform an investigation to identify other potentially exposed individuals: For any staff who had possible close contact with the confirmed case, in consultation with the local health department, facility will follow CDC's Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. Residents who had close contact with a confirmed case within 48 hours of the case's symptom onset will be moved to the observation/quarantine unit (if asymptomatic), or if available, a unit for persons under investigation for COVID-19 (if symptomatic). If such a unit is not available, isolate the resident in a private room. As part of outbreak investigation and in consultation with public health, the facility will consider additional interventions for residents with known exposure to the case that do not meet the strict definition of close contact, e.g.; Increase use of PPE by staff caring for these residents to include gloves, gown, N95 respirator. Quarantine these residents for 14 days after the last possible exposure, with increased monitoring of residents for new symptoms of COVID-19, dedicated staff, and dedicated equipment as possible. The facility's Pandemic Influenza/COVID-19 Preparedness & Readiness Plan indicated that the facility would consider universal eye protection for all staff. Review of the guidance of the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 included that cohort 2 COVID-19 negative, exposed consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. These individuals should be quarantined for fourteen days from the last exposure, regardless of test results. The guideline further included that residents in cohort 2 should be placed on TBP using the COVID-19 recommended PPE of a N95 mask, eye protection, gloves, and isolation gowns. On 1/15/2021 at 4:48 PM, the Administrator and ADON/IP were notified of the IJ and the IJ template was provided. An electronic mail (e-mail) removal plan was accepted on 1/18/2021 which included that all residents and staff had the potential to be affected and that immediately full TBP were implemented and all recommended COVID-19 PPE would be used for all the floors and all patients and residents in the building for 14 days after the last exposure. The removal plan specified that the PPE the staff were required to don included, N95 [masks], gown, gloves, face shield/goggles. Additionally, the removal plan indicated that the facility was in the process of educating all staff and would conduct audits on staff throughout the facility. Part B: On 1/19/21, the survey team returned to the facility to verify the implementation of the removal plan. During this visit, the facility failed to implement the use of N95 masks for all staff of all floors/units in accordance with the removal plan. This was observed by Surveyor #1 and Surveyor #2 throughout tour of the facility and was evidenced as follows: On 1/19/21 at 10:42 AM, the surveyors entered the 3rd floor unit and observed signs which revealed the floor was on droplet precautions and TBP for 14 days and how to don (apply) and doff (remove) PPE gowns, gloves, masks and eye protection. The sign did not specify which type of mask was to be worn when caring for residents on TBP. At 10:44 AM, the surveyors observed LPN #4 on the 3rd floor wearing a KN95 mask at the nurses' station. At 10:44 AM, Surveyor#1 interviewed LPN #4 who stated that the residents could not go off the unit because the unit was on lock down due to staff recently testing positive to COVID-19. LPN #4 further stated that prior to entry of the resident's room staff were to don full PPE which consisted of a N95 mask or KN95 mask, surgical mask over, face shield or goggles, gown, and gloves. LPN #4 stated that staff were also required to perform hand hygiene prior to entering and exiting resident's rooms on the unit. At 10:57 AM, the surveyors observed the CNA #1 on the 3rd floor in a non-occupied resident room wearing a KN95 mask. At 11:02 AM, the surveyors observed the central supply staff member in the hallway on the 3rd floor wearing a KN95 mask. At 11:07 AM, the surveyors observed the AA #2 in the hallway on the 3rd floor wearing a KN95 mask. At 11:10 AM, Surveyor #1 observed HK #3 enter a room on the third floor which was occupied by four residents' and observed the privacy curtains in the room were all open. Surveyor #1 observed HK #3 wearing a surgical mask only, start cleaning the resident's room. Surveyor #1 did not observe HK #3 don PPE prior to entry of the residents' room. Surveyor #1 observed HK #3 then walk out of the residents' room to her housekeeping cart that was left in the hallway outside of the residents' room. At this time, Surveyor #1 attempted to conduct an interview with HK #3. HK #3 stated that she did not speak English and was unable to communicate with Surveyor #1. At 11:15 AM, the surveyors observed CNA #8 in the hallway on the third floor wearing a KN95 mask. At 11:17 AM, the surveyors observed CNA #7 in the hallway on the third floor wearing a KN95 mask. At 11:19 AM, the surveyors observed LPN #5 in the hallway on the third floor wearing a KN95 mask. At 11:27 AM, the surveyors entered the 5th floor unit and observed a nurse standing in front of her medication cart and preparing medications, wearing a KN95 mask. The surveyors also observed signs which revealed the floor was on droplet precautions and TBP for 14 days and how to don and doff PPE gowns, gloves, masks, and eye protection. At 11:31 AM, Surveyor #2 observed HK #4 wearing a disposable PPE gown, gloves and a KN95 mask with a blue surgical mask covering it. HK #4 was standing inside the door of a resident room occupied with four residents. Surveyor #2 observed no privacy curtains pulled around resident beds. Surveyor #2 observed that HK #4 was not wearing any eye protection inside the resident room. During an interview at the same time, HK #4 stated she had worked over the weekend and received additional in-servicing on PPE donning and doffing. HK #4 stated she would be verbally informed of any resident rooms on precautions by her supervisors. HK #4 stated she would also be aware of precautions by the posted signs and PPE bins on the units. HK #4 stated she was educated to wear a PPE gown, gloves, KN95 mask, and surgical mask into resident rooms and that she would discard the PPE gown, gloves, and surgical mask prior to exiting the resident room. HK #4 stated she was not aware if she needed any type of eye protection and that she had PPE accessible in her housekeeping cart and the CNA closets on the units. At 11:33 AM, the surveyors interviewed LPN#6 in the hallway on the 5th floor wearing a KN95 mask and a face shield. At 11:38 AM, the surveyors entered the 6th floor unit and observed signs which revealed the floor was on droplet precautions and TBP for 14 days and how to don and doff PPE gowns, gloves, masks, and eye protection. At 11:43 AM, Surveyor #1 observed HK#5 on the 6th floor standing in the hallway outside of resident rooms wearing a KN95 mask, surgical mask, and gown. HK #5 stated that sometimes she wore a face shield or goggles when she entered the residents' rooms. HK #5 further stated that she was to utilize Alcohol Based Hand Rub (ABHR) prior to entry and after exiting the resident rooms and would always change out her surgical mask, gown, and gloves in between resident rooms while working on her designated unit. At 11:45 AM, Su [TRUNCATED]