Every finding on record at Elmwood Hills Healthcare Center LLC

Complaint #: 2629258Based on interviews, review of medical records, and other pertinent facility documentation on 10/9/2025 and 10/10/25, it was determined that the facility failed to provide adequate supervision for a resident (Resident #2) who was cognitively impaired with documented history of exit seeking behaviors; and who eloped out of the facility building on 9/28/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2). A review of Facility Reportable Event (FRE) revealed that on 9/28/2025, a Licensed Practical Nurse (LPN #1) asked a Certified Nursing Assistant (CNA #1) to use her employee identification (ID) badge to swipe open the locked door on the second floor secured unit for Resident #2, which CNA #1 did provide. This allowed Resident #2 to exit the unit because both CNA #1 and LPN #1 thought the resident was a visitor. The FRE indicated that pictures of residents at risk for elopement, including Resident #2, were located by the same entrance door on the second-floor nursing unit to help staff identify at-risk residents and stop them from eloping out of the unit. The two staff members on the second floor from where the resident exited, (LPN # and CNA #1), stated they did not check the pictures by the exit door and did not recognize Resident #2. The FRE revealed that Resident #2, who was wearing an ID band on their wrist at the time they eloped, exited the second-floor unit, entered the elevator down to the first-floor lobby area and exited the building through the front door at approximately 9:47 AM. The security guard (SG) was seated at the front desk at the time and observed Resident #2 exit the building. The SG did not intervene to stop Resident #2, as the resident appeared to be a visitor. A visitor who was entering the facility saw Resident #2 outside on the sidewalk and alerted the SG. The SG then went outside where Resident #2 was in front of the building and escorted Resident #2 back into the building. Nursing staff was immediately notified. The facility's Safety Director stated during an interview on 10/10/25 at 9:12 AM, we rely on the unit to not let the residents off the unit. He further indicated that there is a book at the security desk and the reception area with pictures of all residents at risk for elopement. A review of Progress Note (PN) dated 9/24/2025 at 11:05 PM, revealed that Resident #2 repeatedly kept asking to go home and when they were leaving. Another PN dated 9/25/2025 at 9:37 PM, revealed that Resident #2 asked staff how they could get out so that they could go home. During interview on 10/10/25 at 8:37 AM with LPN #3, who wrote the 9/25/2025 PN, he confirmed that the resident's exit seeking behavior was documented in the progress note and it was also put on the 24-hour report sheet that was communicated among staff. LPN #3 further stated that he made the certified nursing assistants (CNAs) aware and verbally informed the incoming nurses during the shift report regarding the resident's repeated verbalizations about going home.LPN #1 stated during an interview on 10/9/25 at 1:25 PM, Resident #2 did not have a bracelet on and Resident #2 stated they were visiting their cousin and had laundry. LPN #1 further stated she genuinely did not know Resident #2, was never given report, and she was not educated that the pictures were residents at risk for elopement. During second floor unit tour on 10/9/2025 9:33 AM, the surveyor observed pictures posted on the wall by the exit door, which the facility stated was supposed to help staff to identify residents with elopement risks; to intervene if they see such resident try to leave the unit. The facility's failure to provide adequate supervision to ensure the safety of a cognitively impaired resident who was at risk for elopement, with documented history of exit seeking behaviors, posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy situation. The IJ began 9/28/2025 at 9:45 AM. The facility was notified 10/10/2025 at 5:10 PM. Facility submitted a Removal Plan on 10/15/2025 at 2:23 PM. The surveyor verified the implementation of the RP on-site visit on 10/16/2025 3:18 PM. The evidence was as follows:A review of the facility's policy titled Elopement, with an initiated date of November 2013, indicated: It is the policy of Elmwood Hills Care Center to implement all possible measures to protect our residents, minimize incident of elopement . Under Procedures: 2. indicated: Upon admission and whenever a resident exhibit exit seeking behavior, he/she will be assessed for risk of elopement 4. The nursing department will develop and maintain a list of all residents identified as Elopement/wandering risks (it is identified as a problem on the resident's care plan). Photograph will be posted near the main exit door of each floor for easy identification .The photographs will also be posted at the employee entrance security vestibule and in the binder at the front desk. According to the Facility Reportable Event Record (FRE) dated 09/28/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), on 9/28/2025 at approximately 9:45 AM, Resident #2 was observed in the front lobby by the receptionist with two bags full of clothes. The receptionist's statement in the FRE reflected that Resident #2 appeared to be a visitor carrying laundry. Resident #2 asked to use the bathroom, and receptionist showed them where the bathroom was. Security then arrived so that receptionist could take a break. Resident #2 returned to front lobby area from the bathroom and exited through the front lobby. Security was present and saw Resident #2 leave through the front door. As Resident #2 was walking out the front door a visitor was entering through the front door and alerted security that a resident was possibly out in the front of the building. Security then went outside where Resident #2 was in front of the building and escorted Resident #2 back into the building. Nursing staff was immediately notified.According to the facility provided document #7887 Elopement, Date 9/28/2025 10:00, Resident #2 indicated I was leaving to go home. Resident #2 was returned inside the building, was assessed, the facility placed Resident #2 on one-to-one (1:1) monitoring for safety, and psychiatric follow up was ordered.A review of LPN #1's statement revealed that she observed Resident #2 coming up the right hallway on the second floor secured unit with two bags of clothing, one in each hand. LPN #1 stated that she thought it was one of her residents and when she stopped Resident #2, Resident #2 stated that they were visiting their cousin and had their laundry. LPN #1 stated that she thought Resident #2 was a guest. LPN #1 stated that she used an Aide's badge and swiped the door to let Resident #2 off the secured unit. Resident #2 then went to the first floor.A review of the security guard (SG) statement revealed that he was at the front desk when Resident #2 came out of the bathroom with bags in hands and appeared to be a visitor. He stated that he watched Resident #2 leave, and it was a visitor that came in and alerted him that it was possibly a patient that went through the front door. The SG stated that he then went outside, saw Resident #2 in the front of the building on the property, and brought Resident #2 back inside.The surveyor reviewed the medical record for Resident #2.According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Dementia, Depression, Anxiety Disorder, and Altered Mental Status.According to the quarterly Minimum Data Set (MDS), an assessment tool dated 09/30/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired.A review of Resident #2's admission Observation V -13 (admission Assessment) received from the Director of Nursing (DON) on 10/9/2025, with an effective date of 09/23/2025 at 6:20 PM, revealed that Resident # 2 needed supervision for decision making abilities regarding Wander/Elopement risk, but was not at risk for elopement.A review of Resident #2's Care Plan (CP) with an initiated date of 9/25/2025, and a created-on date of 9/28/2025, revealed that Resident #2 was an elopement risk/wanderer related to (r/t) dementia, altered mental status, adjusting to new facility/surroundings.A review of the Progress Note (PN) dated 9/24/2025 at 11:05 PM, written by LPN #4, revealed that Resident #2 repeatedly kept asking to go home and when they were leaving.A review of another PN Dated 9/25/2025 at 9:37 PM, written by LPN #3, revealed that Resident #2 observed with belonging [SIC] in hand roaming on unit. resident [SIC] asking staff how can [they] get out so [they] can go home. pt. (patient) redirected multiple times.A review of PN dated 9/28/2025 at 1:27 PM, written by RN #1, revealed that at 9:45 AM, Resident #2 was observed by security at the front of the building in the parking lot. Security notified nursing and escorted the resident back inside the building .Full body assessment completed. Family and MD notified. The resident was placed on 1:1 monitoring. Consult placed for psych follow up. A review of the facility's video footage on 10/10/2025 at 12:41 PM in the presence of the Director of Public Safety (DPS) and DON, revealed that when Resident #2 came down the hallway after leaving the 2nd floor unit, Resident #2 was wearing an ID band on the left wrist.On 10/9/2025 at 12:55 PM, the surveyor conducted a telephone interview with Certified Nursing Assistant (CNA #1) who stated that she was on her way to dispose of trash when LPN #1 asked her to use her badge to allow a visitor to exit the secured unit. CNA #1 further stated that she had never seen this resident (Resident #2) before and that she did not look at the wall to confirm whether they were a resident or not.On 10/9/2025 at 1:25 PM, the surveyor conducted a telephone interview with Licensed Practical Nurse (LPN #1), who stated that she saw Resident #2 and told them to stop because she needed to verify them. LPN #1 stated that she initially thought it was one of her residents, but when she got closer, they were not the resident she thought it was. LPN #1 stated she did not see an ID bracelet, and when she asked Resident #2, they stated that they were visiting their cousin. LPN #1 stated that she saw a CNA (CNA #1) who was a regular aide on her unit. She asked CNA #1 if she recognized Resident #2 and the CNA said, no, Resident #2 was not one of their residents. LPN #1 stated that she could not recall who swiped Resident #2 off the floor and that everything was a blur. LPN #1 confirmed that she wrote her statement of the 9/28/2025, approximately 9:35 AM event, on 10/1/2025. A review of this statement revealed, I was at my medication cart out front of the main dining room. I observed [Resident #2] coming up the right hallway with two bags in each hand (clothing in bag.) I stopped [Resident #2] as [they were] going towards the door. [Resident #2] stated [they were] visiting [their] cousin, getting their laundry .at that point I thought [Resident #2] was a guest. I used the aide's badge to swipe the door. LPN #1 further stated that she was not familiar with Resident #2's care, that Resident #2 was not on her unit and that she had never seen Resident #2 before. LPN #2 stated she genuinely did not know this Resident #2, was never given report, and it was just an accident. LPN #2 stated that she could have held Resident #2 and called a supervisor.On 10/9/2025 at 1:54 PM, the surveyor conducted an interview with Maintenance Director (DM), who stated that doors are inspected quarterly or as needed. He stated that on 9/28/2025, he walked on the 2nd floor unit and the door was checked, and door was engaged properly along with all the other doors.On 10/9/2025 at 2:00 PM, the surveyor conducted an interview with the Assistant Directors of Nursing (ADON #1 and ADON #2). ADON #1 stated that Resident #2 should not have been off the unit without an employee, staff, or without supervision because Resident #2 was an elopement risk. ADON #1 stated that the Wall of Fame (the facility's process to identify residents as elopement risk) has been there for years, and staff are educated upon hire on the purpose of the wall and drills are completed throughout the year. On 10/9/2025 at 3:11 PM, the surveyor conducted an interview with the Director of Nursing (DON), who stated that the expectation is for all staff to be aware of all residents at risk for elopement based on the pictures on the walls.On 10/9/2025 at 3:38 PM, the surveyor conducted an interview with LPN #2, who was Resident #2's assigned nurse. LPN #2 stated that she last saw Resident #2 around 9:35 AM on 9/28/2025. She stated she gave Resident #2 their medication, checked vitals and asked them to eat their breakfast. LPN #2 stated that when she came in that morning, Resident #2 had their clothes on the bed and were rearranging the closet. LPN #2 stated that Resident #2 showed no indication that they wanted to leave.On 1010/2025 at 8:32 AM, the surveyor attempted to reach the receptionist who saw Resident #2 in the reception area via telephone and got no response.On 10/10/2025 at 8:37 AM, the surveyor conducted a telephone interview with LPN #3 who wrote the progress note on 9/25/2025 at 9:37 PM. LPN #3 stated that on 9/25/2025 he was passing medications and saw Resident #2 with belongings in hand, in a bag and dragging the bag on the floor. When Resident #2 was asked what they were doing, Resident #2 stated that they wanted to go home, they wanted to get out of there and wanted to leave. LPN #3 stated that he made the nursing aides on the floor aware, verbally updated the incoming nurse in the shift report, and documented it on the 24-hour report.On 10/10/2025 at 9:12 AM, the surveyor conducted an interview with the Director of Public Safety (DPS) who stated that they relied on the unit to not let the residents off the unit. He stated that if someone comes to the door to leave the facility, they called to verify me if they did not use the employee door and they came in. DPS further stated that the front doors are open from 8:00 AM to 8:00 PM, and after 8:00 PM all persons must go through the security entrance/exit.On 10/10/2025 at 10:30 AM, the surveyor conducted an interview with the SG, who stated that on 9/28/2025, he was in the back, in the boiler room, and the receptionist called him and asked him to come to cover for her. He stated he saw someone [Resident #2] going into the bathroom. The SG stated that when Resident #2 came out of the bathroom, they were carrying two bags, one in each hand, and they walked towards the front door. He stated that as Resident #2 was walking through the door, a visitor was coming in, and the visitor came to the counter to sign in and told him that he believed it was a resident that just went through the door. The SG ran outside, and Resident #2 was walking across the front lawn. He said he called to Resident #2 a couple times and Resident #2 kept walking, so he went behind and finally caught up to Resident #2. He stated that he asked Resident #2 what was going on. The SG said Resident #2 stated that they tried to get a hold of someone, and he asked Resident #2 to go back inside. He stated that Resident #2 agreed and walked back with him inside the building. The SG stated that Resident #2 was outside for about 3 to 4 minutes. He stated that he walked Resident #2 to the nursing supervisor's office on the 1st floor and made them aware that Resident #2 was outside. The SG stated that this happened quick and when he got there at the reception area, he did not have time to do anything. He stated that if he was there for a while he would have noticed when they came in. He stated that the receptionist did not say anything to him and that the receptionist was still in the bathroom when he ran outside to get Resident #2.On 10/10/2025 at 10:55 AM, the surveyor conducted an interview with the DON, who stated that the 24-hour shift report is a communication tool between the three shifts, 7-3, 3-11, and 11-7. The DON stated that after Resident #2 exhibited exit seeking behaviors Resident #2 should have been reassessed to see if any other interventions could be put in place. The nurse should have done an updated elopement assessment. The DON further stated that the expectation was that staff should have been able to identify residents at risk for elopement based on ID bracelet and picture posted on unit, and that the expectation for the Receptionist and Security Guard was to use the binder.An acceptable Removal plan was received on 10/15/2025 at 2:23 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include:IJ Removal PlanResident #2 was assessed post incident by Nursing Supervisor, placed on 1:1 monitoring for safety. A call was placed to the primary physician by the nursing supervisor. The nursing supervisor updated Resident #2's care plan.On 10/10/2025 resident #2 remains in the facility for long term care placement on 1:1 monitoring without any negative effects from this incident.On 10/10/2025 all staff were re-educated on the Elopement Policy.On 9/29/2025 the Elopement Policy was reviewed and determined no updates to the Elopement Policy was required at this time.A new system was implemented on 9/29/2025 that all visitors must sign out upon leaving the building.Security staff and receptionist staff were educated on the Elmwood Hills Elopement Policy and the new process for visitors signing out.All Elmwood hills nursing staff were re-educated 10/10/2025 on identifying elopement behaviors and initiating and completing a new Elopement Assessment, updating the resident's care plan and placing the resident picture at the entrance of the unit, receptionist desk, and security console.Elmwood Hills completed an audit on 9/28/2025 on all residents who are an elopement risk to ensure they have an appropriate Care Plan, Elopement Assessment and resident picture at receptionist binder and security console.On 10/10/2025 an audit was completed on all new admissions from 9/28/2025 through 10/10/2025 by the Infection Preventionist (IP) nurse and Nursing Supervisor to assure that residents identified at risk of elopement had an elopement care plan in place, ID band and picture on the wall of exit door and front reception desk and security desk.On 10/10/2025 on the 3-11 shift at 6:00 PM an audit was completed by the 3-11 Nursing Supervisor on resident ID bands to ensure all residents had an ID band in place and that all resident pictures were present in Point Click Care (PCC) as a form of identification. Refusal of pictures and/or ID band were indicated on the resident's care plan.On 10/10/2025 the DON, ADON and ICP re-reviewed the Elmwood Hills Elopement Policy, and no changes were indicated.On 10/11/2025 and 10/12/2025 the Nursing Supervisor and the ADONs completed the re-education on the Elopement Policy for Elmwood Hills staff.All the Elmwood Hills unit doors continue to remain locked and continue to require a swipe ID card to get off all the Elmwood Hills Nursing Units, this includes L1W, L2W, S1, and S2. The surveyor verified the implementation of the RP on-site during the continuation of the survey and determined that the IJ for F 689 was removed as of 10/16/2025 at 3:18 PM. NJAC 8:39-27.1 (a)

Complaint #: NJ176228 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) follow a physician's order to apply a urinary catheter stabilization device, b.) accurately identify a resident's urinary stabilization device was applied in the electronic medical record (EMR), c.) properly identify a resident's incontinence status in the EMR, and d.) monitor urinary output according to the physician's orders in the EMR. This deficient practice was identified for 2 of 2 Residents (Resident #104 and #196) reviewed for urinary catheters and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1). On 4/30/25 at 10:24 AM, during the initial tour of the facility, the surveyor observed Resident #104 sleeping in bed with a urinary catheter hanging at the bedside by the provided hook and was contained within a privacy bag. The surveyor reviewed the medical record for Resident #104. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Peripheral Vascular Disease (a progressive disorder that causes narrowing or blocking of the blood vessels outside the heart) and Palliative Care. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS identified under Section H indicated that the resident had an indwelling catheter. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 3/11/25, that the resident was at risk for a urinary tract infection (UTI) related to catheter use. Interventions included: Monitor for signs/symptoms of UTI (change in color, increased output, change in odor, presence of sediment, etc), notify physician of abnormalities, provide catheter care every shift as ordered and as needed, monitor for decrease in output, and secure catheter tubing to prevent trauma. A review of the Order Summary Report (OSR), dated as of 4/30/2025, included the following physician orders (PO): A PO, dated 3/26/25, to apply urinary catheter stabilization device, check skin integrity and placement every shift. A PO, dated 3/26/25, to monitor and document urinary catheter output every shift. If no output in eight hours, notify physician every shift. A review of Resident #104's March and April 2025 Treatment Administration Record (TAR) revealed that on the following dates and shifts there was no documentation to indicate that the resident had urinary output: -3/27/25 Day Shift -4/11/25 Night Shift -4/13/25 Day Shift A review of the Certified Nursing Assistant (CNA) Plan of Care (POC) Response History for Resident #104's Bladder Continence, of the 30 days look back period (through multiple shifts on each day), only 27 responses correctly identified Continence Not Rated due to Indwelling Catheter. Other selections that were checked off included: Incontinent and Continence Not Rated due to Condom Catheter. 2.) On 4/30/25 at 10:16 AM, during the initial tour of the facility, the surveyor observed Resident #196 sleeping in bed with a urinary catheter hanging at the bedside by the provided hook and was contained within a privacy bag. On 5/2/25 at 11:52 AM, the surveyor interviewed Resident #196 who stated that they did not have a urinary stabilization device applied to their leg. When asked if the facility emptied the urinary bag every shift Resident #196 responded, sometimes they do and sometimes they don't. The surveyor reviewed the medical record for Resident #196. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: chronic embolism (a piece of a blood clot or other substance travels and obstructs blood flow elsewhere) and thrombosis (blood clot) of unspecified deep veins of lower extremities and Type 2 Diabetes Mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy). A review of the resident's most recent Quarterly MDS, dated [DATE], included the resident had Brief Interview for Mental Status Score (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS identified under Section H that the resident had an indwelling catheter. A review of the resident's Individual Comprehensive Care Plan (ICCP) included a focus area, dated 3/11/25, that the resident was at risk for UTI related to catheter use. Interventions included: Monitor for signs/symptoms of UTI (change in color, increased output, change in odor, presence of sediment, etc), notify physician of abnormalities, provide catheter care every shift as ordered and as needed, monitor for decrease in output, and secure catheter tubing to prevent trauma. A review of the OSR, dated as of 4/30/25, included the following PO: A PO, dated 7/1/24, to apply urinary catheter stabilization device, check skin integrity and placement every shift. A PO, dated 7/1/24, to monitor and document urinary catheter output every shift. If no output in eight hours, notify physician every shift. A review of Resident #196's March and April 2025 TAR revealed that on the following dates and times, there was no documentation to indicate that the resident had urinary output: -3/17/25 Night Shift -4/8/25 Day Shift -4/11/25 Night Shift -4/22/25 Day Shift -4/25/25 Night Shift A review of the CNA (Certified Nursing Assistant) POC (Plan of Care) Response History for Resident #196 included: Bladder Continence, of the 30 days look back period (through multiple shifts on each day), only 10 responses correctly identified Continence Not Rated due to Indwelling Catheter. Other selections that were checked off included: Continent; Incontinent; and Continence Not Rated due to Condom Catheter. On 5/2/25 at 11:22 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that the urine of residents who had an urinary catheter should be monitored, including the resident's output. When asked what should be monitored, the IP indicated that the CNA was to empty the urinary bag and report the amount to the nurse for documentation. The IP further confirmed that a resident's Medication Administration Record (MAR) and TAR should not have any blanks because it could allow for the possibility of missing an infection. On 5/5/25 at 10:58 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who acknowledged that resident's urine output should be documented by the nurse to monitor for possible urine retention and that there should not be any blanks on the MAR and TAR. When asked about the CNA POC, LPN/UM #1 confirmed that the CNA should not document a urinary catheter resident as incontinent. The surveyor questioned what precautions were put into place to prevent catheter dislodgement, LPN/UM #1 indicated that a stabilization device should be applied to resident's leg as per physician order and facility policy. On 5/5/25 at 11:15 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #1 who reported that CNAs were to empty the resident's catheter bag but the nurses should be documenting the output. When asked if there should be any blanks in the MAR and TAR, RN/UM #1 stated no because it could mean a possible infection. The surveyor reviewed Resident #104 and #196's CNA POC with RN/UM #1 who confirmed that the CNAs should have identified both residents as Continence Not Rated due to Indwelling Catheter. Upon review of Resident #104 and #196's MAR and TAR, RN/UM #1 confirmed that there were blanks in the MAR and TAR for urinary output. On the same date at 11:27 AM, the surveyor requested RN/UM #1 to accompany the surveyor to Resident #196's room to see if the stabilization device was present on the resident's leg. With permission from the resident, RN/UM #1 checked and confirmed that the stabilization device was not present. On the same date at 11:34 AM, the surveyor requested RN/UM #1 to accompany the surveyor to Resident #104's room to see if the stabilization device was present on the resident's leg. With permission from the resident, RN/UM #1 checked and confirmed that the stabilization device was not present. The surveyor reviewed both Resident #104 and #196's MAR and TAR with RN/UM #1 confirmed that resident's orders were checked off as being applied. On 5/6/25 at 12:07 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and Quality Assurance (QA), who acknowledged that residents with a urinary catheter should be monitored and documented in the MAR and TAR, there should not be any blanks in the MAR and TAR, stabilization devices should be applied to prevent dislodgement of the urinary catheter and documented accordingly, and CNAs should not have identified residents with urinary catheters as incontinent. A review of the facility's Physician Orders policy, last updated 8/2024, included the following under Policy: The licensed nurse confirm and carried out all given orders timely. The following was included under Procedure: The licensed nurse will administer medications and treatment and care as ordered by the physician. A review of the facility's Urinary Catheters policy, last revised 1/23/24, included the following under Standards of Care For the Patient With an Indwelling Urinary Catheter: Catheters should be properly secured with the appropriate device after insertion to prevent movement and urethral traction. A review of the facility's Integrated Medication Management (IMM) in [name redacted] policy, last revised January 2025, included the following under Policy: To provide a centralized Electronic Health Record (EHR) and a full medication and treatment administration system that is accurate and dependable. The following was identified under Procedure: [name redacted] is securely accessed over the Internet for real-time accuracy and dependability, and the eMAR (Electronic Medication Administration Record)/eTAR (Electronic Treatment Administration Record) modules provide accurate and complete documentation of the resident and their medication and treatment information. A review of the facility's Job Description Certified Nursing Assistant, last revised November 2017, included the following under Responsibilities: Skin Checks Daily. The following was included under Adherence to Facility Procedures: All procedures in performing tasks of the job are performed following facility policy. The following was included under Documentation: Intake and output are accurately recorded on the proper form. A review of the facility's Job Description Licensed Practical Nurse, last revised November 2017, included the following under Responsibilities: Accurate and Timely Documentation, and Accurate and timely evaluation of residents. The following was identified under Documentation: Intake and output are accurately recorded on the proper form, and MARS/TARS are filled in properly with no GAPS. The following was identified under Adherence to Facility Procedures: All procedures in performing tasks of the job are performed following facility policy. The following were identified under Documentation: Intake and output are accurately recorded on the proper form. The following was identified under Adherence to Facility Procedures: All procedures in performing tasks of the job are performed following facility policy. A review of the facility's Job Description Unit Manager, last revised November 2017, included the following under Documentation: Ensures MARS/TARS/ADL sheets and BMS are filled in properly with no GAPS. The following was identified under Adherence to Facility Procedures: All procedures in performing tasks of the job are performed following facility policy. The following were identified under Documentation: Intake and output are accurately recorded on the proper form. A review of the facility's untitled policy included the following under Purpose: (facility name redacted) provides accurate nursing documentation supportive of the skilled nursing/extended care services received by our residents. The following was identified under Procedure: 1. the compliance in the following guidelines throughout the documentation process includes the following: . Entries are to be factual, complete and accurate, contain clinical observations. NJAC 8:39-27.1(a)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 resident (Resident #275) system selected for MDS over 120 days. This deficient practice was evidenced by the following: The MDS is a comprehensive federally mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must complete the assessment at discharge and electronically transmit the MDS no later than 14 days after completing the assessment. The surveyor reviewed the electronic medical record (EMR) for Resident #275. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, spinal stenosis (a condition where the spaces within the spine narrow, putting pressure on the spinal cord and nerve roots), difficulty walking, and muscle weakness. Further review of Resident #275's EMR revealed that the resident was discharged from the facility, but the discharge MDS was not completed. On 5/6/25 at 11:48 AM, the surveyor interviewed the MDS Coordinator, who stated that she oversees and completed the MDS assessments. She further stated that assessments should be completed upon admission to the facility, quarterly, annually, with any significant changes, and at discharge. At that time, the MDS Coordinator checked Resident #275's EMR and confirmed that the discharge MDS had not been completed, and she stated that the assessment should have been initiated the day the resident was discharged and submitted within 14 days. The MDS Coordinator then completed Resident #275's discharge assessment after surveyor inquiry. On 5/7/25 at 9:33 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that the discharge MDS was not completed and transmitted timely. A review of the facility's Resident Assessment Instrument (RAI) Process MDS/ Care Area Assessment (CAA)/Plan of Care Guidelines, guide, revised January 2025 included, Guidelines: The Resident Assessment Instrument (RAI) provides a tool for an interdisciplinary approach to develop a plan of care for the resident. Purpose 3. It is the responsibility of the Registered Nurse Assessment Coordinator (RNAC) to coordinate the RAI process.Procedure 4. The RNAC is responsible for overseeing an MDS assessment schedule for all residents and for creating and coordinating completion of the assessments in a timely manner. NJAC 8:39-11.1

Complaint #: NJ165862, NJ184181 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 4 residents (Resident #247) reviewed for Activities of Daily Living (ADL) care and was evidenced by the following: On 4/30/25 at 10:16 AM, during the initial tour of the 2 East Unit, the surveyor observed Resident #247 awake and alert lying in bed, the bed sheets were wet and there was a strong odor of urine in the room. At that time, the surveyor requested Licensed Practical Nurse/Unit Manager (LPN/UM #3) to check the resident for incontinence care. The resident stated, I am sure I am wet. LPN/UM #3 checked the resident's incontinence brief which was saturated with urine and the bed sheet underneath was wet. LPN/UM #3 then stated, I will get the aide, and that the resident should have been changed in the morning during the Certified Nursing Assistant (CNA) morning rounds. On 4/30/25 at 10:28 AM, CNA #1 entered the resident's room and checked the resident's incontinence brief. The surveyor observed that the incontinence brief was saturated with urine and the resident's gown and bedsheets were wet. The resident stated, My gown is soaking wet. CNA #1 then stated I am just getting to [him/her] now. CNA#1 further stated that the resident was sleeping that morning, and she did not want to bother him/her. On 5/1/25 at 12:54 PM, the surveyor reviewed the medical record for Resident #247. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: chronic bronchitis, dementia, and heart failure. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/16/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was dependent for toileting and always incontinent of bladder. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 4/24/24, that the resident was at risk for skin breakdown related to impaired mobility, incontinence, prediabetes, and chronic pain. Interventions included: Provide prompt incontinence care and apply moisture barrier cream as needed. The ICCP also included a focus area, dated 5/1/24, the resident required up to moderate/maximum to total amount of assist with ADLs. Interventions included: maximal assistance with toileting/hygiene. On 5/1/25 at 12:32 PM, the surveyor interviewed CNA #2 who stated that incontinence rounds would be completed first thing in the morning, again before lunch, and last rounds would be completed around 2:00 PM. On 5/1/25 at 12:42 PM, the surveyor interviewed CNA #3 who stated that incontinence rounds would be completed when the CNA first came in the morning, then after lunch around 1:00 PM, then again before end of shift around 2:30-3:00 PM. On 5/1/25 at 12:55 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #3 who stated that incontinence rounds were completed two times a shift - at the beginning of the shift and any time after lunch. On 05/1/25 at 1:06 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) #1 who stated incontinence rounds should be completed every two hours on every resident. On 05/2/25 at 12:17 PM, the surveyor interviewed the Director of Nursing (DON) who stated that she would expect the CNAs to complete incontinence rounds every two hours. The CNAs would usually start their rounds after they clock in at 7:00 AM and night shift typically completed their last incontinence rounds between 5:00 and 5:30 AM. The DON further stated that it was important to complete timely incontinence care to prevent any skin breakdown or irritation to the resident. On 5/7/25 at 1:51 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the [NAME] President of Clinical Services (VPCS) and the Quality Assurance (QA) nurse, the surveyor reviewed the concern with incontinence care. A review of the facility's Incontinence Management policy, updated February 2025, included that all incontinent residents would be checked frequently during the shift to keep them dry and comfortable. NJAC 8:39-27.1(a) NJAC 8:39-27.2(h)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that treatment to prevent or reduce range of motion limitations were provided for 1 of 1 resident (Resident #11) reviewed for limited range of motion. This deficient practice was evidenced by the following: On 5/6/25 at 10:30 AM, the surveyor observed Resident #11 lying in bed in watching television. The resident's left hand was resting on the bed without a hand roll in place (which is used to prevent the fingers from contracting tightly into the palm). On 5/7/25 at 11:22 AM, the surveyor observed Resident #11 lying in bed watching television. The resident's left hand was resting on the bed without a hand roll in place. The surveyor reviewed the electronic medical record (EMR) for Resident #11. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: osteoarthritis. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/1/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cogntion was severely impaired. Further review of the MDS revealed the resident had a functional limitation in range of motion of the upper extremity on one side of the body. A review of the resident's individual comprehensive care plan (ICCP), dated 3/26/25, included a focus area indicating that the third, fourth, and fifth fingers of the resident's left hand were contracted. Interventions included: Applying rolled gauze (medical gauze rolled into a cylindrical form) to the left hand as tolerated, reapplying as needed, and removing for bathing and skin protection. A review of the May 2025 Treatment Administration Record (TAR) revealed a physician's order dated 3/18/24 for the application of a hand roll to the resident's left hand. The order directed that the hand roll be worn at all times, removed for hygiene, and that the skin be checked every shift. Further review of the TAR indicated that facility day shift nurses documented the application of the resident's left-hand roll on 5/6/25 and 5/7/25. However, the surveyor did not observe Resident #11 wearing the left-hand roll on either date, and there was no documentation in the EMR to show that the resident had refused the device. On 5/7/25 at 1:56 PM, the surveyor interviewed the Director of Nursing (DON) who stated that nurses should not have documented the application of a resident's left-hand roll if it was not applied. On 5/7/25 at 2:16 PM, the surveyor interviewed the Occupational Therapist/Director of Rehabilitation (OT/DOR) who stated that the resident was discharged from therapy in March 2024 and no staff training had been completed for the resident's left-hand roll because the hand roll was not considered a specialized device. The OT/DOR further stated if there was a physician's order and a care plan for the resident's left-hand roll, the facility staff were expected to apply the device as directed. A review of the facility's undated and unnamed policy revealed, under the procedure section, that the following elements will be in place to achieve maximum potential: range of motion: passive or active to maintain flexibility and useful motion in the joints of the body. 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 ensure that oxygen was administered in accordance with a physician's order for 1 of 1 resident (Resident #146) reviewed for respiratory care. This deficient practice was evidenced by the following: On 4/30/25 at 10:23 AM, the surveyor observed Resident #146 who was seated in a wheelchair at the bedside. The resident was receiving 3.5 liters of oxygen from an oxygen concentrator (a medical device) via a nasal cannula (two prongs inserted into the nostrils with a tube that connects to an oxygen source). When interviewed, the resident stated that he/she was ordered two liters of oxygen but the oxygen concentrator was weak and they needed to turn it up. On 5/1/25 at 11:59 AM, the surveyor observed Resident #146 seated on the side of the bed with noted shortness of breath. The resident stated that he/she had been exercising and was trying to catch their breath. The resident's oxygen concentrator was set at 3.5 liters via nasal cannula. On 5/2/25 at 10:48 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated that she thought that Resident #146 was on 2.5 liters of oxygen, but she would have to look at the physician's order to be certain. LPN #2 accompanied the surveyor into the resident's room and looked at the resident's oxygen concentrator settings. The LPN then stated that the oxygen was set at nearly four liters of oxygen. The resident stated that he/she thought that the oxygen concentrator was acting up and the nurse turned it up because it felt like nothing was coming out through the oxygen tubing. LPN #2 stated that she was off for the past couple of days and needed to see if the physician's order was changed. On 5/2/25 at 10:56 AM, LPN #2 reported to the nurse's station and asked Licensed Practical Nurse/Unit Manager (LPN/UM) #2 if Resident #146's oxygen order was changed. LPN/UM #2 reviewed the resident's electronic health record (EHR) and stated that the resident was ordered two liters of oxygen on 1/24/25. When interviewed, LPN #2 stated that she would have called the doctor to see what the doctor recommended because it was not her place to adjust the oxygen concentrator setting without a physician's order. At that time, the surveyor interviewed LPN/UM #2 who stated that nursing should have first assessed the resident, checked the oxygen concentrator to make sure that it functioned properly, and then called the doctor for recommendations. LPN/UM #2 further stated that you could not just increase the oxygen concentrator setting without a physician's order. The surveyor reviewed the medical record for Resident #146. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe), emphysema (a chronic lung disease that progressively damages the alveoli, or tiny air sacs, in the lungs). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/8/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS included the resident required oxygen therapy. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 11/14/24, that the resident had a potential for impaired respiratory status related to respiratory failure. Interventions included: Provide oxygen as ordered. A review of the Order Summary Report (OSR) included the following physician's orders (PO): A PO, dated 1/24/25, for oxygen via nasal cannula (n/c) at two liters per minute (LPM) as needed for shortness of breath (SOB) every shift. A review of the April 2025 Treatment Administration Record (TAR) included an order for Oxygen via N/C at 2 LPM as needed for SOB, dated 1/24/25, that was signed out as administered on the 4/30/25 day shift. A review of the May 2025 TAR included an order for Oxygen via N/C at 2 LPM as needed for SOB, dated 1/24/25, that was signed out as administered on 5/1/25 for the day, evening, and night shifts. Further review of the TAR revealed that the order was also signed out on 5/2/25 during the day shift. A review of the Progress Notes (PN) included a PN that was written by the Nurse Practitioner (NP), dated 4/29/25 at 11:23 AM, and included, pulse oximetry (Pulse Ox - a probe placed on the index finger to determine the amount of oxygen in the blood) 97 oxygen (O2) three (3) liters. Further review of the PN included a PN, dated 5/5/25 at 12:22 PM, which revealed, the resident was seen today (5/5/25) to follow up oxygen and chest x-ray (cxr), 3 liters nasal cannula (L/nc), attempted to wean to two (2) L n/c on Friday, but was not successful. Resident stated breathing was unchanged, unlabored, without distress. A cxr was ordered which revealed no acute process .pulse ox 96% on 3L. On 5/2/25 at 12:35 PM, the surveyor interviewed the Director of Nursing (DON) who stated that an oxygen order that was given by the physician should have been followed. The DON stated that the oxygen order was on the Treatment Administration Record (TAR) and the nurses were required to look at the concentrator each shift to ensure that the order was followed and document their findings accordingly. The DON stated that it was not appropriate to increase the oxygen rate because the nurses wanted to follow the physician's orders. On 5/8/25 at 9:34 AM, in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA), the DON stated that the nurses must ensure that the oxygen was set at the correct setting per the physician's order. A review of the facility's Oxygen tubing and Respiratory products policy, revised January 2025, included, Oxygen will be administered as ordered by the physician . The Licensed nurse must sign the ETAR (electronic treatment administration record) during the shift ensuring the correct amount of Oxygen is administered as ordered. NJAC 8:39-27.1(a)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer pain medication according to the physician's order for 1 of 5 residents (Resident #155) reviewed for unnecessary medications. This deficient practice was evidenced by: On 5/7/25 at 9:21 AM, the surveyor observed Resident #155 sitting in their room. When asked about pain, the resident stated he/she had chronic pain in his/her lower back from an old injury. The resident further stated that their pain was typically a level 7 out of 10, but that they received as needed pain medication that brought the pain level down to a level three (3) which was effective for the resident. The surveyor reviewed the medical record for Resident #155. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, lumbar spondylopathies (arthritis of the spine), spinal stenosis, chronic pain, and low back pain. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/7/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had frequent pain that he/she described as moderate intensity. A review of the individual comprehensive care plan (ICCP) included a focus area, revised 4/1/25, that the resident received opioid (pain) medication related to chronic pain. Interventions included: Monthly medication regimen review conducted by consultant pharmacist and assess pain using numeric scale if able. A review of the Order Summary Report (OSR), dated as of 5/7/25, included the following physician order (PO): A PO, dated 4/25/25, for Oxycodone 10 milligrams (mg) give one tablet by mouth every four hours as needed for moderate to severe pain. A review of the Consultant Pharmacist's Monthly Report (CPMR), dated 12/9/24, included the following recommendation: Medication error(s) noted. Documented pain level of 0's does not match as needed Oxycodone indication of moderate to severe pain. Please review. Further review of the CPMR revealed the section Action Taken, to be filled out by the facility, was blank. A review of the December 2024 Medication Administration Record (MAR) revealed a PO for Oxycodone 10 mg give one tablet by mouth every six hours as needed for severe pain, dated 12/12/24 to 1/8/25. The PO was signed out as administered for a documented pain level of 0 (zero) on the following date(s): -12/12/24 at 9:36 AM A review of the January 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every six hours as needed for severe pain, dated 12/12/24 to 1/8/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -1/4/25 at 11:01 AM Further review of the January 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for chronic pain, dated 1/8/25 to 3/21/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -1/8/25 at 12:10 AM -1/13/25 at 11:00 PM -1/22/25 at 10:20 AM -1/25/25 at 12:43 PM A review of the February 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for chronic pain, dated 1/8/25 to 3/21/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -2/6/25 at 10:28 AM -2/16/25 at 10:53 AM -2/28/25 at 9:08 AM A review of the March 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for chronic pain, dated 1/8/25 - 3/21/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -3/11/25 at 11:13 AM Further review of the March 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for chronic pain, dated 3/23/25 to 4/1/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -3/31/25 at 9:45 PM A review of the April 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for chronic pain, dated 3/23/25 to 4/1/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -4/1/25 at 8:29 AM Further review of the April 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for pain, dated 4/1/25 to 4/22/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -4/4/25 at 4:56 PM and 9:07 PM Further review of the April 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for moderate to severe pain, dated 4/25/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -4/28/25 at 9:06 PM -4/29/25 at 5:18 PM A review of the May 2025 MAR revealed a PO for Oxycodone 10 mg give one tablet by mouth every four hours as needed for moderate to severe pain, dated 4/25/25. The PO was signed out as administered for a documented pain level of 0 on the following date(s): -5/4/25 at 5:13 PM On 5/7/25 at 9:24 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated the numerical pain scale was as follows: mild pain 1-3; moderate pain 4-5; severe pain 6-10. The LPN further stated that as needed pain medication should never be administered for a pain level of 0 (zero) and that it was important to administer pain medication according to the PO in order to keep the resident's pain manageable and prevent excessive pain. On 5/7/25 at 9:28 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the numerical pain scale was as follows: mild pain 1-3; moderate pain 4-6; severe pain 7-10. The LPN/UM further stated that as needed pain medication should only be administered for a pain level of 1-10, not for a level of 0. The LPN/UM further stated that when the Consultant Pharmacist made a recommendation, it should be addressed as soon as possible to ensure the accuracy of medications. On 5/7/25 at 9:40 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated the nurses should not administer as needed Oxycodone for a pain level of 0. The CP further stated the nurses should follow the PO as a part of professional standards. On 5/7/25 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated the numerical pain scale was as follows: mild pain 1-3; moderate pain 4-6; severe pain 7-10. The DON further stated that as needed pain medication should not be administered for a pain level of 0 and that the nurse was required to administer as needed pain medication according to the PO. When asked about the CPMR, the DON stated recommendations were reviewed with the physician within one week in order to provide comprehensive care of the resident. The DON further stated that nurses should not have continued to document a pain level of 0 for the as needed Oxycodone after the CP identified the error on the CPMR. A review of the facility's Consultant Recommendations Policy, dated 11/25/24, included, Consultant recommendations will be reviewed by the licensed nurse. The attending physician will be notified as soon as possible. Nurse will document the date, time, and reason for call in the medical record. A review of the facility's Pain Assessment/Management and Documentation Policy and Procedure, revised 1/22/25, included, Pain and pain relief will be documented using the most appropriate pain scale based on the resident's cognition status. An appropriate medication will be administered based on that pain scale and assessment/observation of each resident. A review of the facility's 0-10 Scale of Pain Severity chart revealed the following: 0 - No Pain 1 - Minimal 2 - Mild 3 - Uncomfortable 4 - Moderate 5 - Distracting 6 - Distressing 7 - Unmanageable 8 - Intense 9 - Severe 10 - Unable to Move NJAC 8:39-27.1(a)

Complaint # NJ00176228 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable standards of practice. The facility failed to ensure a.) weekly skin assessments were accurately documented in the Treatment Administration Record (TAR) and b.) the physician's orders were followed and accurately documented the medication administration on the Medication Administration Record (MAR). This deficient practice was identified in 1of 2 residents (Resident #82) reviewed for pressure ulcer and 1of 1 resident (Resident #60) reviewed for communication and sensory problems and was evidenced by the following: 1.) On 4/30/25 at 10:34 AM, the surveyor observed Resident #82 awake and alert, lying in bed with a pressure relieving mattress on the bed. The surveyor reviewed the medical record for Resident #82. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, Parkinson's Disease (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement), dementia, malnutrition, pressure ulcer of left buttock, and incontinence without sensory awareness. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/6/25, included that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had a stage three pressure ulcer, with treatments including pressure ulcer/injury care and pressure relieving devices for bed and chair. A review of the individual comprehensive care plan (ICCP) included a focus area that the resident was at risk for skin breakdown related to impaired mobility, incontinence, dementia, depression, risk for malnutrition and use of high-risk medications. Interventions included: Weekly skin assessment completed by nurse, provide prompt incontinence care, and utilization of pressure relieving cushion to chair and mattress to bed. A review of the Order Summary Report (OSR), dated as of 5/7/25, included the following physician orders (PO): A PO, dated 12/3/24, for Weekly skin assessment: 1 = No Skin Injury, 2 = New Skin Injury/Wound, 3 = Previously Noted Skin Injury/Wound. Every day shift every Tuesday. A PO, dated 1/31/25, for wound care: Medihoney Wound/Burn Dressing Gel (Wound Dressings) Apply to sacrum to Left (Lt) Buttock topically every day shift for Incontinence Associated Dermatitis (IAD) Cleanse affected area with normal saline solution (NSS), pat dry, apply Medihoney cover with Bordered gauze, with a discontinuation date of 2/11/25. A PO, dated 2/11/25, for wound care: Collagenase Ointment 250 unit/gram, Apply to Sacrum to Left (L) buttock topically every day shift for pressure ulcer, with a discontinuation date of 3/31/25. A PO, dated 4/1/25, Cleanse sacrum to L Buttock with NSS, pat dry, apply Mesalt gauze, cover with bordered gauze every day and evening shift for wound care The surveyor reviewed the Progress Notes (PN) which included the following: A Nurses Note (NN), dated 1/16/25 at 3:46 PM, revealed the nurse observed a skin tear on the resident's sacrum. A Physician Progress Note (PPN), dated 1/22/25 at 10:30 AM, revealed the resident complained that their butt hurts and that the Certified Nursing Assistant (CNA) reported a sacral wound that morning to the nurse. A Nurse Practitioner (NP) Wound Progress Note, dated 1/30/25 at 4:44 PM, included, consulted for wound of the buttock and a wound gel treatment initiated. A NP Wound Progress Note, dated 2/11/25 at 3:21 PM, included that the sacral wound was reclassified as an unstageable (a type of bed sore that is covered by dead tissue) pressure ulcer with updates to wound care recommendations. A NP Wound Progress Note, dated 2/18/25 at 4:06 PM, included that the sacral wound was reclassified as a stage three pressure ulcer (has broken completely through the top two layers of the skin and into the fatty tissue below) with updates to wound care recommendations noted. A further review of the weekly NP Wound Progress Notes, dated 2/25/25, 3/4/25, 3/11/25, 3/18/25, 3/27/25, 4/1/25, 4/9/25, 4/15/25, and 4/23/25, included the sacral wound continued as a stage three pressure ulcer and recommended wound care treatments were ordered by the physician as indicated above. A review of the December 2024 Treatment Administration Record (TAR), included the 12/3/24 physician's order for weekly skin assessments were coded as: 1 = No Skin Injury, 2 = New Skin Injury/Wound, and 3 = Previously Noted Skin Injury/Wound. A review of the January 2025 through April 2025 TAR showed a code of 1 = No Skin Injury entered for the following dates: 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/25/25, 3/25/25 and 4/22/25. On 5/7/25 at 10:51 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #4 who stated that when a new skin issue was found it would be reported to the nurse. On 5/7/25 at 10:54 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #6 who stated that weekly skin assessments would be done on the resident's shower day, which included a head-to-toe assessment by the nurse, and documented in the TAR using the coding of 1= no skin injury, 2= new skin injury or 3= previously noted skin injury. The LPN further stated: a 2 should be documented for a new injury and 3 should be documented for a previously noted injury. On 5/7/25 at 11:01 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) #3 who stated that weekly skin assessments would populate in the TAR, the nurse would complete a head-to-toe skin assessment and document in the TAR using the 1/2/3 coding. When asked what should be documented for a skin injury that already exists, the LPN replied, a 3 for a previous skin injury. On 5/7/25 at 11:10 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses complete skin checks weekly and document on the TAR using the code. The DON further stated that a previously noted injury should be coded with a 3 (previously noted injury/wound). When asked about the documentation of 1s from January through April 2025, the DON stated the nurses inadvertently put in the wrong number and that it should be '3' for a previous injury. On 5/7/25 at 1:51 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON, the [NAME] President of Clinical Services (VPCS), the Quality Assurance (QA) nurse, and the survey team, the surveyor reviewed the above concern. A review of the Skin Inspection policy, revised and updated 8/24, included 1. Skin inspections will be conducted on admission, readmission, and weekly thereafter for all residents as scheduled by the licensed nurse. 2. The licensed nurse will observe all body surfaces of the resident and document in ETAR record of PCC (Electronic Medical Record) A review of the facility's Wound policy, revised January 2025, included (3) Weekly skin observation/assessment will be conducted by the licensed nurse and (15) All wounds will be assessed weekly. Documentation will be maintained in the resident's medical record. 51232 2.) On 4/30/25 at 10:46 AM, the surveyor observed Resident #60 seated in their wheelchair in the hallway on the 2-West Unit. At that time, the surveyor observed the resident was not wearing their bilateral hearing aids. On 5/1/25 at 9:06 AM, the surveyor reviewed the electronic medical records (EMR) for Resident #60. A review of the Admission Record, an admission summary, revealed the resident had diagnoses, which included, sensorineural hearing loss (a type of hearing loss). A review of the comprehensive Minimum Data Set (MDS) an assessment tool used to faciltitate the management of care, dated 4/14/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had moderate hearing loss. A review of the Medication Administration Record (MAR) revealed a physician's order (PO) dated 9/2/22 to check the placement of bilateral hearing aids six times daily at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 8:00 PM while the resident was up. An additional (PO) dated 2/20/24 instructed nursing staff to apply the bilateral hearing aids in the morning and to remove and place them on the charger in the medication room every evening. A review of the individual comprehensive care plan (ICCP), dated 4/9/25, included a focus area indicating that the resident has impaired communication related to hearing loss and used bilateral hearing aids. Interventions included: Nursing will apply and store bilateral hearing aids daily and ensure hearing aids are place. A review of the MAR indicated that day and evening shift nurses documented the resident's bilateral hearing aids were applied each morning, removed each evening, and placed on the charger in the medication room every day, and that the hearing aids were checked for placement while the resident was upon the following days: On 04/29/25 at 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 8:00 PM, On 04/30/25 at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 8:00 PM. There was no documentation in the EMR indicating that the resident's bilateral hearing aids were missing or that he/she had refused to wear them on either date. On 5/1/25 at 11:14 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 who stated that on the morning of 4/29/25, she noticed the resident's hearing aids were not on the charger in the medication room. LPN #4 admitted that she did not document that the hearing aids were missing on that date. On 5/6/25 at 10:22 AM, the surveyor interviewed LPN/Unit Manager (LPN/UM) #5 who stated that she was notified on 4/30/25 during the day that the resident's bilateral hearing aids were missing and initiated an investigation. LPN/UM #5 stated that she spoke with both the evening Certified Nurse Aide (CNA) and the nurse who had provided care for the resident during the shift prior to the discovery of the missing hearing aids and both staff members reported that they did not recall seeing the hearing aids. On 5/7/25 at 1:55 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses should not have documented that the resident's hearing aids were being applied and removed if they were not. A review of a facility's Personal Care policy, dated February 2025, revealed, Hearing aides are to be placed in appropriate ear by resident or nursing staff as needed in the a.m. They are to be removed in the p.m. at hour of sleep by resident or staff, as needed, and stored in a labeled container. NJAC 8:39-27.1(a) NJAC 8:39-35.2(d)(g)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the pneumococcal vaccination was administered to a resident upon admission to the facility. This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for immunizations and was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Pneumococcal Vaccine for Adults Aged >[AGE] years: Recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2023 Recommendations and Reports / September 8, 2023 / 72(3);1-39 Adults aged >[AGE] years who have received PCV13 only are recommended to receive a single dose of PCV20 at an interval >1 year after receipt of the PCV13 dose or to receive >1 dose of PPSV23 to complete their pneumococcal vaccine series. -When PPSV23 is used instead of PCV20, the minimum recommended interval between PCV13 and PPSV23 administration is >8 weeks for adults with an immunocompromising condition, a CSF leak, or a cochlear implant and >1 year for adults without these conditions. Either PCV20 or a second PPSV23 dose is recommended >5 years after the first PPSV23 dose for adults aged 19-[AGE] years with specified immunocompromising conditions but not for adults with a CSF leak or a cochlear implant. In addition, those who received both PCV13 (at any age) and PPSV23 (no PCV20) but have not received a dose of PPSV23 at age >[AGE] years are recommended to receive either PCV20 or a single and final dose of PPSV23 at age >[AGE] years and >5 years since the previous PPSV23 dose. On 4/30/25 at 10:57 AM, the surveyor requested Resident #72's signed consent form for receipt of the pneumococcal vaccine. On 5/1/25 at 9:00 AM, the facility provided Resident #72's Pneumonia/Vaccine/Consent/Declination & Education form, dated 9/23/24, which revealed the consent was signed by the resident's spouse for the resident to receive the pneumococcal vaccine. On 5/1/25 at 9:09 AM, the surveyor reviewed the medical record for Resident #72. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, dementia, senile degeneration of the brain, and palliative care. A review of the resident's Immunization Audit Report, as of 5/1/25, did not include any documentation related to the pneumococcal vaccine. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/30/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident was not offered the pneumococcal vaccine. A review of the Order Summary Report (OSR), with a date range of 4/30/25 to 5/31/25, included the following physician order (PO): A PO, dated 4/30/25, for Prevnar 20 Suspension Prefilled Syringe 0.5 milliliters (ml) (pneumococcal 20-[NAME] Conj. Vacc) inject 0.5 ml intramuscularly one time only for Pneumonia Vaccine for 1 (one) day [after surveyor requested consent forms]. A review of the May 2025 Medication Administration Record (MAR) revealed that the Pneumococcal vaccine was administered on 5/1/25 at 12:35 PM. On 5/2/25 at 11:01 AM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist (IP) who stated that upon admission, residents were given education and screened for the pneumococcal vaccine and then consent was obtained. The charge nurse then administered the pneumococcal vaccine and documented the administration of the vaccine in the Electronic Medical Record (EMR) under the immunizations tab. The IP further stated that it was important to administer the pneumococcal vaccine, if indicated, to prevent pneumonia. At that time, the surveyor reviewed Resident #72's signed consent form dated 9/24/24 with the IP. The IP stated that Resident #72's pneumococcal vaccine was missed and should have been administered by the admitting nurse when the consent was obtained. On 5/7/25 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident should have been assessed for the pneumococcal vaccine upon admission, and obtained consent from the resident or family if indicated, and the admitting nurse should administer the vaccine upon admission. On 5/7/25 at 1:51 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON, the [NAME] President of Clinical Services (VPCS), and the Quality Assurance (QA) nurse, the surveyor reviewed the concern that the Pneumococcal vaccine was not administered upon admission and was administered on 5/1/25 after surveyor inquiry. On 5/7/25 at 2:08 PM, the DON obtained Resident #72's New Jersey Immunization Information System form from the resident's family physician, which revealed that Resident#72 had received the PCV13 vaccine on 8/14/2017. On 5/8/25 at 9:27 AM, the DON, in the presence of the LNHA, and the QA Nurse, confirmed that the resident had received the PCV 13 on 8/14/2017 and received the PCV 20 on 5/1/25 and she stated that, according to the CDC pneumococcal Vaccine timing form for adults, the PVC 20 vaccine can be administered starting one year after receiving the PCV 13 vaccine. A review of the facility's Pneumococcal vaccine policy, revised January 2025, included to offer pneumococcal immunizations to all residents (unless contraindicated) as per CDC recommendations. Upon admission, review the resident's medical record including hospital records if available be to determine whether any pneumococcal vaccines have been received. The licensed nurse to educate resident/responsible party/legal guardian regarding Pneumonia vaccine and obtain a consent. The licensed nurse will administer Pneumonia vaccine as requested by the resident/responsible party and ordered by the physician/nurse practitioner. NJAC 8:39-19.4 (i)

NJ Complaint #159807 Based on interviews, review of closed medical records, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate care was provided with no delay in treatment for a resident with an indwelling pleural chest catheter/tube who had a change in condition with respiratory distress on [DATE] received a chest x-ray on [DATE], and was hospitalized via emergency services prior to chest x-ray results. This deficient practice was identified for 1 of 45 residents (Resident #439) reviewed for quality of care, and was evidenced by the following: On [DATE] at 8:52 AM, the surveyor reviewed the closed medical records for Resident #439. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in November of 2022 with diagnoses which included chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes difficulty breathing), chronic respiratory failure with hypoxia (lungs cannot get enough oxygen into the blood), malignant neoplasm of lung (cancer of the lungs), secondary malignant neoplasm of liver, bone, adrenal gland (cancer that had spread to other areas in the body). A review of the admission Minimum Data Set (MDS), an assessment tool dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated an intact cognition. A further review in Section G Function Status revealed the resident required extensive assist of one person for bed mobility, transfer between surfaces, toilet use, personal hygiene and dressing. Further review revealed in Section J Health Conditions shortness of breath with exertion and when lying flat. Review of Section O Special Treatment, Procedures and Programs revealed oxygen therapy while at the facility. A review of the Progress Notes reflected the following notes: An Admission Summary dated [DATE] at 11:30 PM, included the resident was alert and oriented and able to make their needs known. The resident had oxygen at 4 liters per minute via nasal cannula. The resident had an indwelling chest tube, to the right flank area that was used to drain fluid from the pleural space (a thin layer of tissue that covers the lung and lines the interior wall of the chest cavity). An Admission History and Physical dated [DATE] at 8:00 PM, written by Physician #1, included the resident had a right chest catheter (tube) that was inserted on [DATE], due to resident's recurrent pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest). The chest tube was to be drained on Monday, Wednesday, and Friday. A Nurses Note dated [DATE] at 1:51 PM, included the catheter was drained of 500 milliliters (mL) and that vital signs were stable. A Nurses Note dated [DATE] at 10:24 AM, included the chest tube was drained with 550 mL output. The site had no signs of infection and the dressing, cap and clamp on the tube were changed. A Nurses Note dated [DATE] at 11:27 AM, included the chest tube was drained for a total of 250 mL, and there was slight redness around opening area and was cleansed and redressed. A Nurses Note dated [DATE] at 12:26 PM, included the resident's tube was drained, the sight was clean and dry with slight redness around tubing area and the total output was 125 mL. A Nurses Note written by Registered Nurse (RN #1) dated [DATE] at 12:11 PM, included the nurse was informed by the family member that the resident had respiratory issues. The assessment revealed the nurse heard crackles (indicated the small air sacs in the lungs are filled with fluid), rhonchi (indicated fluid or secretions in the larger airways) that was heard in the right lung. The pulse oxygenation (a method to monitor blood oxygen saturation) was 90% with the use of 4 liters per minute of oxygen received via nasal cannula. The resident was having respiratory difficulty and the chest tube was drained of 110 mL of yellow drainage at that time. The resident's [Physician #1] was called and the nurse was awaiting a call back. A Nurses Note written by RN #1 dated [DATE] at 10:00 PM, included a chest x-ray was ordered by Physician # 1. A Nurses Note written by the ,d+[DATE] Nursing Supervisor/RN dated [DATE] at 7:20 PM, included the resident's tubing catheter dressing was soiled with brownish drainage. The catheter was clamped, and the dressing was replaced with family at bedside. A Nurses Note written by RN # 2 dated [DATE] at 1:03 PM, included that the resident had shortness of breath with a pulse oxygenation level of 65 % with oxygen at 4 liters per minute with a nasal cannula. The nasal cannula was replaced with a non-rebreather mask (a device used to assist in the delivery of a higher concentration of oxygen) at 10 liters per minute. The physician was notified, and the resident was sent to the hospital via emergency response at 11:37 AM. A Nurses Note written by the ,d+[DATE] Nursing Supervisor/RN dated [DATE] 5:24 PM, included the resident was admitted to the hospital with diagnosis of pneumonia, hypoxia, and pulmonary embolism. A review of the [DATE] Medication Review Report revealed a verbal physician's order (PO) for a chest x-ray to rule out pneumonia one time only for one day dated [DATE]. A review of the Radiology Result Report with an examination date of [DATE], for an x-ray of the chest revealed a conclusion of moderate right and left infiltrates (substance denser than air) and possible right pleural effusion. Further review of the [DATE] Medication Review Report included a PO dated [DATE] with a start date of [DATE], to drain 500 mL to the right flank catheter daily on Monday, Wednesday; and Friday; call physician for bloody drainage or drainage of more than 1000 mL. A review of the corresponding [DATE] Treatment Administration Record (TAR) revealed the nurses signed the catheter to right flank was drained of 500 mL on [DATE] (Friday), [DATE] (Monday), [DATE] (Wednesday), [DATE] (Friday), and [DATE] (Monday). A review of the comprehensive care plan included a focus area initiated on [DATE], for a potential for complications related to the use of drainage system due to status post right pleural effusion and a diagnosis of lung cancer. Interventions included to assess lung sounds every shift and monitor for abnormal lung sounds during dressing changes and when draining; monitor site for signs and symptoms of infection and report abnormalities for prompt intervention; drain using [chest tube] kit as ordered limit drainage as ordered by physician to prevent re-expansion pulmonary edema; and monitor for respiratory changes in overall condition cyanosis (blue color of skin), change in capillary refill, skin temperature, change in mental status notify physician for instructions. On [DATE] at 10:17 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who confirmed she was one the nurses who cared for Resident #439. The LPN stated that she remembered the resident had a right sided chest tube, and when she administered the resident's medication, she checked vital signs and checked the dressing for wetness; if the dressing was wet, she notified the Unit Manger/Registered Nurse (UM/RN). The LPN continued on that weekend she recalled the dressing to the right chest was wet, and she called the ,d+[DATE] Nursing Supervisor/RN. The ,d+[DATE] Nursing Supervisor/RN reapplied the dressing, and she could not recall the color of the drainage on the dressing. On [DATE] at 10:54 AM, the surveyor interviewed RN #2, who stated she remembered Resident #439, and she had changed the dressing and drained the chest tube. She stated that on [DATE] at 1:13 PM, she sent the resident to the hospital. On [DATE] at 11:21 AM, the surveyor interviewed via telephone the ,d+[DATE] Nursing Supervisor/RN who stated on the evening of [DATE], the resident's chest tube catheter dressing was wet, and the family was at the bedside. She continued that she removed the dressing, and the area was fine and tender to touch. She stated the dressing was not that wet and if it was leaking at the site, she would have sent him to the hospital via emergency services. She stated the cap (closes the catheter the chest tube) was off the tube and she put a new one on. On [DATE] at 11:21 AM, the surveyor reviewed a grievance form dated [DATE], which included the [Resident Representative] had concerns and reported that the past weekend the [chest tube] was leaking and the nurse used the [internet to search chest tube]. The [Resident Representative] stated a chest x-ray was ordered on Saturday and was not done until Monday. The grievance was written up by the Director of Nursing (DON). On [DATE] at 9:31 AM, the surveyor interviewed the DON who stated the facility had a contract with a radiology company and the resident's chest x-ray was not ordered stat (immediately without delay), so it was completed on the next business day which was Monday. On [DATE] at 9:15 AM, the surveyor interviewed via telephone Physician #1 who stated that she was the resident's primary physician, and the resident had a chest tube that the nurses drained. Physician #1 stated she was away from the facility from [DATE] to [DATE], and she was not sure how the resident was. She continued that the Medical Director was on-call while she was away. Physician #1 stated if she was called for the resident's change in condition, she would have ordered the chest x-ray to have been completed stat. On [DATE] at 9:45 AM, the surveyor interviewed the DON who stated the RN #1 who received the chest x-ray order could not recall the physician that she spoke to and received the order from. The DON further stated that the Medical Director was on call for Physician #1. On [DATE] at 9:50 AM, the surveyor interviewed the Quality Assurance Director (QAD) who stated the nurse who took the order could not recall who the ordering physician she spoke to was. She documented Physician #1, but had not spoken to them. She also stated when she put the order in the electronic Medical Record (EMR), the primary physician's name automatically populated so that was why Physician # 1's name was associated with the order. The QAD further stated that the Medical Director was not on-call that weekend and she did not know who the on-call physician was. The QAD continued that Physician #1 filed a grievance that her name was on an order she did not give. On [DATE] at 10:58 AM, the surveyor via telephone interviewed RN #1 who stated that she was the nurse who received the chest x-ray order, and she was unable to recall which physician she spoke to. RN#1 stated the resident had a change in condition, and she remembered that the chest x-ray needed to be done immediately. She stated that when documenting a physician's order in the EMR, the orders automatically populated with a drop-down box that indicated prn (as needed) or one time order. RN #1 stated the nurses coming on for the next shift assisted her with the physician's order because the facility's staff had access to the x-ray company, and Agency nurses (like herself) did not have a pin number to order the x-ray. On [DATE] at 11:59 AM, the surveyor via telephone interviewed the Medical Director who stated that the resident's primary physician (Physician #1) asked her to cover her residents while she was away from facility. The Medical Director stated that she was not on-call that weekend, but her Physician Service was covering, and she pulled the phone records and there was no documented call to the Physician Service about Resident #439. The Medical Director continued that she could only give her medical opinion, but if she were ordering a chest x-ray for the resident with a change in condition, she would have ordered the chest x-ray stat because she ordered all x-rays stat to be done right away. On [DATE] at 12:36 PM, the surveyor via telephone interviewed RN #3 who stated she thought she was the oncoming nurse for the resident on [DATE], and it was change of shift. RN #3 stated that typically the Agency nurses put the physician's orders into the EMR, and the facility nurses would order x-rays so they would be done. On [DATE] at 1:31 PM, the surveyor interviewed the DON who stated that Agency staff and the facility staff have the same access when putting in physician's orders into the EMR and laboratory access. The DON continued that there was no reason for Agency staff to think that they do not have access, and that physician's orders could not be ordered stat in the EMR. On [DATE] at 2:30 PM, the surveyor interviewed the DON who stated that when she completed the grievance for the resident, the nurse who received the order for a chest x-ray did not order the x-ray stat. The DON continued she would try to find out who the ordering physician was. The DON stated that it would be up to the physician as to when a chest x-ray would be ordered for a resident in respiratory distress. On [DATE] at 10:33 AM, the surveyor re-interviewed via telephone RN#1 who stated she spoke to a physician, but did not recall who she spoke with, and she drained the resident's chest tube. The surveyor asked if she received a physician's order to drain the chest tube because it was a Saturday, and the order was for Monday, Wednesday, and Friday. RN #1 stated she could not recall, but to read her note. . On [DATE] at 1:32 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the DON of the concerns. On [DATE] at 9:47 AM, the DON in the presence of the LNHA and the survey team stated that Physician #1 was away from the facility at the time, and Physician #2 was covering her residents. The DON confirmed the resident's chest tube was drained on [DATE] without a physician's order because the resident was in distress. The DON stated typically the nurse needed a physician's order, but if you read the documentation, the resident was in distress with lower breath sounds, pulse oxygenation level of 90% on 4 liters per minute oxygen with respiratory difficulty. The DON continued the next shift administered a nebulizer (breathing treatment) and the pulse oxygenation level increased. The DON stated the resident expired at some point in the hospital. The DON confirmed Physician #2 had not spoken to RN#1, and the facility had no record of who or if RN #1 spoke to for a physician's order for a chest x-ray. A review of the facility's Physician Order policy dated updated [DATE], included licensed nurses will administer medication and treatments as ordered by the physician .the licensed nurse will write the order in the [electronic medical record] as prescribed by the medical professional and follow up to ensure timely completion . A review of the facility's Physician notification policy dated revised [DATE], included nurses should not hesitate to contact the attending physician at any time for a problem and changes in resident status are reported promptly and accurately to the physician to address any concerns. Including Laboratory results normal or abnormal which the physician requests on a stat or same day basis . NJAC 8:,d+[DATE].1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meals observed on 1 of 6 nursing units (1 East). This deficient practice was evidenced by the following: On 4/10/23 at 10:14 AM, the surveyor conducted a Resident Council meeting which included six residents (Residents #87, #118, #135, #208, #212, and #260). All six residents informed the surveyor that the food was served cold on all shifts to which they attributed to short staffing. On 4/14/23 at 8:35 AM, the surveyors informed the Assistant Food Service Director (AFSD) that they wanted to observe the lunch meal service for that day including food temperatures. The AFSD acknowledged the request and stated that lunch service began at 11:15 AM. On 4/14/23 at 11:20 AM, the surveyor observed the Chef Manager (CM) who had already began to serve food on the tray line. When interviewed, the CM stated that the food temperatures were already completed by the AM Cook. The CM stated that she obtained plates from the hot box to warm them prior to plating food on them, as the pellet warmer (heated plate liner) was not working. The CM utilized plastic insulated domes and bases and heated plates to maintain temperature. On 4/14/23 at 11:33 AM, the surveyors requested to have a regular tray and a pureed tray prepared and placed on the second food truck for 1 East nursing unit as a test tray. The surveyor requested that the CM record temperatures of the food in the presence of the surveyors on the nursing unit using a calibrated (procedure used to confirm accuracy) thermometer. On 4/14/23 at 12:07 PM, the CM calibrated a digital, thin probe thermometer in an ice bath to 32 degrees Fahrenheit (F). The CM and the surveyors then immediately proceeded to leave the kitchen and followed the food cart to the 1 East nursing unit. On 4/14/23 at 12:09 PM, the Dietary Aide (DA) arrived on the 1 East nursing unit with the food truck and the aides began to deliver meal trays to the residents. On 4/14/23 at 12:18 PM, the CM confirmed that the last resident's meal tray had been served. The surveyor asked the CM what temperature should hot foods and cold foods be served at, and the CM responded that hot food should be served at 135 F or above and cold food should be served at 40 F or below. At this time, the surveyor observed the CM obtain the following temperatures using the calibrated thermometer for the regular lunch meal tray: Fish 104.4 F Peas 106.6 F Sweet Potatoes 109 F Blueberries 37 F Apple Juice 45 F Milk 47 F Coffee 132 F At that time, the CM stated that the coffee was cold. She further stated that she received one to two resident complaints about cold coffee per day. On 4/14/23 at 12:27 PM, the CM obtained the following temperatures from the pureed texture lunch meal using a calibrated thermometer: Fish 123 F Peas 122 F Sweet potatoes 128 F Milk 48 F Apple Juice 48 F Yogurt 57 F Coffee 125 F At that time, the CM stated that the yogurt was not safe to eat and could make someone sick. On 4/14/23 at 12:41 PM, the surveyors returned to the kitchen with the CM and requested to review the food temperature logs from today's lunch meal. The CM reviewed the log and stated that the AM Cook failed to obtain both the breakfast and lunch temperatures today, which was contradictory to what the CM informed the surveyors earlier when they requested to observe the food temperatures taken. The CM stated that if temperatures were not completed prior to the meal service, the residents could get sick. On 4/14/23 at 1:53 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of the survey team, who acknowledged and expressed their shared concerns regarding the food temperatures. A review of the facility's undated Temperatures policy, included all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F. Take temperatures often to monitor for safe temperatures ranges of at or below 41 F for cold foods and at or above 135 F for hot foods . NJAC 8:39-17.4(a)(2)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, date and properly document and cool potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; c.) ensure that dented cans were removed from storage; d.) ensure that serving trays were dried in a safe and sanitary manner prior to meal service; e.) ensure that food was served in a safe and sanitary manner to prevent contamination; f.) ensure that the dish machine in use maintained the appropriate temperature and sanitizer levels according to the manufacturer's specifications; and g.) maintain multiuse food-contact surface cutting board and can opener in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 4/3/23 at 9:33 AM, the surveyors entered the kitchen and asked to tour with the Food Service Director (FSD). The surveyors met with the FSD who stated that both the hot water booster and chemical sanitizer were down on the dish machine and the repair technician was notified. At this time, the surveyors and the FSD toured the kitchen and observed the following: 1. In the walk-in refrigerator, there was an 84 count box of frozen omelettes that were stored in a plastic bag within a box that was opened to air and did not have an opened date or use by date. The FSD reached into the box with his bare hands and removed one omelette for demonstrative purposes. He stated, I will throw this one out. 2. In the milk-box, on the top shelf of a rolling cart there was a 50-pound pork roast (according to the FSD) that was loosely covered with aluminum foil and the meat was largely exposed to air on the right side and partially exposed to air on the top. The FSD stated, It should be kept open to air so that you do not get steam regeneration. The FSD stated that cooling process was to get the temperature to 135 degrees Fahrenheit (F) in two hours, then to 40 F in four hours. The FSD stated the pork roast was to be served on Wednesday. The FSD stated that the pork was 170 F when removed from the oven and cooled down to 135 F before it was placed in the refrigerator. The FSD agreed to furnish the cooling temperature logs. 3. In the deep freezer, there were two-pounds of cheese dated 8/22. The FSD stated that it should have been thrown out after six months. 4. In the dry storage room, on the can rack, there was a seven-pound can of beets that was dented. The FSD removed the can from the rack and placed it on the dented can rack. 5. In the dry storage room, on the can rack, there was a five-pound can of artichokes that was dented. The FSD removed the can from the rack and through it to the ground. He stated, It hit the floor, I have to throw it away. 6. In the dry storage room, on the rear can rack, a six-pound can of tropical fruit was dented. 7. In the dry storage room, on the rear can rack, a six-pound and twelve-ounce can of rice pudding both dented. The FSD stated, it was debatable, as there was a small dent on both the top and bottom of the can. 8. In the Unit #6 refrigerator, there was a staff member's lunch box and a bottle of soda. The FSD stated that it should not be in there. 9. The FSD stated that the dish machine was reportedly repaired according to the repair technician who was present in the kitchen. The FSD stated that it was a low temperature machine that operated on chemical sanitizer. A Dietary Aide (DA #1) was observed running dishes through the dish machine. She stated, It was not up to temperature and a lot of the plates were not coming clean all of the way. DA #1 stated they had to be sent back, sprayed with water, and ran back through the dish machine. At that time, the FSD ran a rack of dishes through the dish machine and tested some water that had pooled on a dish with a chlorine test paper strip. The FSD stated, No sanitizer level was detected. The FSD stated that the lunch meal service was to be served on paper products until the dish machine was repaired. The FSD reviewed the dish machine log and noted that it was not filled in on 4/3/23. The FSD stated that a maintenance request for assessment of the dish machine was placed at 8:30 AM. The FSD stated that with the booster, the wash cycle should have been 160 F and the final rinse cycle should have been between 180 F and 190 F. On 4/3/23 at 1:40 PM, the surveyors returned to the kitchen and the FSD confirmed that the dish machine had been repaired and agreed to furnish the surveyor with a work order from the repair technician. On 4/4/23 at 2:35 PM, the surveyor reviewed the Daily Cooling Log for Hot Potentially Hazardous Foods which specified: Remember to use ice bath and/or shallow pans to decrease cooling times and reviewed an entry dated 4/2/23 for a pork loin. The start time was 5:30 AM and the recorded temperature was 178 F and the end time was 11:50 AM. The surveyor requested to speak with the Cook who completed the entry on the log. At that time, the Cook stated that the Main Cook arrived at work at 4:00 AM, and she arrived at work at 6:15 AM. The Cook stated that when she arrived, she checked the pork loin temperature for doneness with a thermometer and it should be 165 F or higher. The Cook stated that she also slit the middle to ensure there was no pinkness or bleeding. The Cook stated that she returned it to the oven as it looked raw, and was more than a little pink. The Cook stated that there were eight pans total. The pork came out whole and we cut it in half. Then cut the pork to fit in little pans once done. Then we placed it into one large pan and split it three ways. The Cook stated that her process was to place the pan in the freezer to cool it at 178 F, then go back later and check again and pulled it out of the freezer and the temperature was 80 F to 90 F so it had to be put back in the freezer. The Cook stated that she did not want the meat to freeze. The Cook stated she thought at 11:50 AM, she put the meat back in the walk-in refrigerator. The Cook explained that even though the log indicated that the documented time was 11:50 AM, that was the last obtained temperature of the meat at 58 F when it went into the second walk-in refrigerator; otherwise known as the milk-box. The Cook stated that though she did not record the temperature, she checked the temperature again at 2:00 PM. The Cook stated that she had obtained the final temperature and covered it with foil before she left for the day. The Cook stated the meat was cooled down and she placed foil over it tightly. The Cook stated that the FSD informed her this morning that the meat was not fully covered. The Cook stated that no one ever said anything to her about having the meat exposed to air in the milk-box. The Cook stated that she assumed that it was okay because it was cold in there. The surveyors requested to go to the kitchen to see the pork loin and the Cook stated that the pork loin had already been sliced down to be served tomorrow. On 4/4/23 at 2:48 PM, the surveyor interviewed the FSD who stated, there was a remote possibility of air particles on the pork loin if it was not fully covered which could cause cross-contamination. The FSD then explained the cooling process of the pork loin. He stated that the pork loin came out of the oven in two or three pieces, then it was placed in a pan and then placed into the freezer to cool. The FSD stated that according to [Food Safety Course] cooling process, the meat was cut into smaller pieces and cooled to 130 F. The FSD stated that you could cool it in the refrigerator or freezer, dealer's choice. The FSD stated that no matter how he cooled it, the meat was exposed. At that time, the FSD clarified that there was eighty-pounds total of pork loin; twelve long pieces cut into six to eight pound loins. The Cook who was present stated, when she placed the meat in the freezer, it was not covered at all. The FSD stated the pork loin was then loosely covered to allow it to cool down. The Cook stated she covered it at 2:00 PM and placed it in the refrigerator and left at 2:30 PM. The Cook stated that she had to cool the pork loin from 135 F to 70 F in two hours then from 70 F to 40 F in two hours. Then the foil was removed, and the meat was put in sheet pans. The Cook stated that today the pork loin was likely reheated to between 165 F to 170 F. The Cook further stated that their process was to cook it twice. The Cook further stated, We do that with turkey and pot roast also. At that time, the FSD stated that if there was any cross-contamination of the pork loin roast it was still safe to serve as long as it was reheated to 170 F. The FSD stated that all food was exposed to air. The FSD stated that we should have taken a temperature of the pork loin yesterday while you were there so we could see. The FSD stated that what was missing from the log was: the starting point of 135 F when it was time to start the clock on the cooling process, and the final temperature taken when it was placed in the milk-box at 2:00 PM. The surveyor asked why the pork loin temperature was not monitored after the Cook left at 2:00 PM by the dietary staff? The FSD stated that the Night Cooks did not get involved with any roasting because they prepared food for residents. The FSD stated, I am going to eliminate the roasting process. I need staff to do it safely. The FSD stated that steam regeneration was worse than anything you could imagine, it was bacteria. The Cook stated, To avoid this, I put it in the freezer to cool it quicker. The FSD stated, I am going to speak with corporate because I did not have the staff [take the temperature] safely as it takes ten hours. The FSD stated to the Cook, when you left at 2:00 PM, the problem was that we did not know at what point the pork loin hit 135 F. The FSD maintained that the pork loin was still safe to serve, because the reheating process was everything. The FSD stated that every food was a potentially hazardous food. On 4/5/23 at 9:56 AM, the surveyor observed the FSD who calibrated a thermometer probe in an ice bath to 32 F. The FSD then obtained a temperature of sliced pork with sauerkraut which was 180 F. The FSD stated that the pork loin was held in a warmer at 170 F. On 4/5/23 at 11:31 AM, the surveyor interviewed the Registered Dietician (RD) who stated that the freezer stopped the growth of bacteria, the faster the better. The RD stated it would be appropriate in cooling. The RD stated that once the pork loin reached 135 F it was placed in the refrigerator. The RD stated that the threshold was to cool from 135 F to 70 F in two hours and from 70 F to 41 F in four hours for a total of a six hour process. The RD reviewed the, Daily Cooling Log for Hot Potentially Hazardous Foods and agreed that the form did not illustrate that the pork loin met the time and temperature required for proper cooling and did not illustrate the detailed cooling from 135 F to 70 F within two hours and then cooled from 70 F to 41 F within four hours. The RD stated that the form only showed the starting time and the end time. The RD stated that there was no one in the kitchen at 5:30 AM in the morning who could confirm the times. The RD stated that she had suggested that the cooling process was done correctly in the refrigerator. The RD confirmed that the cooling logs were incomplete and were not filled out to include the critical point. The RD stated that she did not dispute the 58 F that was recorded as the end temperature of the pork loin was a temperature in the danger zone and the bacteria could continue to grow at that temperature. The RD stated she did not like the log because they were confusing. The RD further stated that it was important to know the time and temperature for food safety. On 4/14/23 at 11:20 AM, during a follow-up visit to the kitchen, the surveyor observed the following in the presence of the Chef Manager (CM): 1. During the food line observation, the surveyor noted that the trays that were used to serve the residents' lunch meal were wet, and DA #2 used a disposable dish cloth to dry them. The CM stated that if the trays were not fully dried prior to service, that it could result in contamination. The Assistant Food Service Director (AFSD) was present and stated, The trays were not properly dried in the dish room. The AFSD stated that it was acceptable to wipe the trays down that were wet to dry them before they went out because the facility did not have enough trays to fully dry them between meal services. 2. The surveyor observed DA #2 who wiped the wet trays which had napkins and silverware on them. When interviewed, she stated that wet trays were placed in the food truck in stacks of nine. DA #3 who assisted on the food line, stated that she had loaded the trays onto the food truck in bundles of nine. When interviewed at that time, the CM confirmed that the trays were wetnested (a build up of bacteria caused by stacking wet dishes) while they were stacked wet in groups of nine inside of the food truck prior to use. 3. The surveyor observed the DM who placed a metal serving utensil on the stainless steel edge of the steam table. The CM then placed the serving utensil to a plate. The CM then picked up the plate and placed food on it and then passed it to DA #3 who placed it on a meal tray to be served to a resident. 4. The surveyor observed DA #3 who used her gloved hands and touched her face mask three times before she touched the lid of a tray and continued to work on the food line. On 4/14/23 at 12:32 PM, the CM stated that serving utensils should have been placed on a plate or in the food when food was served and should not have been laid on the stainless steel surface and then placed on a plate to be served to a resident due to a potential of contamination. The CM stated that the DA #2 and DA #3 should have washed their hands after they touched their masks and then touched plates and lids as it could lead to cross-contamination. The CM stated that the DA's have been told about that prior. On 4/14/23 at 12:48 PM, the surveyor returned to the kitchen with the CM to review temperature logs and dish machine function. At that time, the surveyor noted a can opener that was mounted to the surface of a prep station. The CM pulled the can opener out of the holder and showed the surveyor the blade which contained a thick black substance. When interviewed, the CM stated that the can opener blade was not clean and should have been cleaned once or twice per day. On 4/14/23 at 12:51 PM, the surveyor observed the Food Service Worker (FSW) who operated the dish machine. When interviewed, he stated that he had worked at the facility since 2006 as a pot washer. The surveyor requested that the FSW demonstrate use of the dish machine. The FSW took a test strip from the three compartment sink and attempted to use it to test the function of the dish machine. On 4/14/23 at 12:56 PM, the Night Operations Manager (NOM) who was present, stated that the FSW should not have used the test strip from the three compartment sink to test the dish machine as the results were not accurate. The surveyor requested to view the dish machine log at that time. The NOM stated that the dish machine function was not tested today, and was not recorded on the log. The NOM stated, We cannot guarantee that the dishes used to serve residents were effectively cleaned. The NOM stated that the log was supposed to be done first thing in the morning to ensure everything was rinsed, cleaned, and sanitized. He further stated, Otherwise, we could be serving dirty dishes to residents. On 4/14/23 at 1:12 PM, the NOM obtained a chlorine test strip to test the function of the dish machine and touched the test strip inside the entrance of the dish machine under the jet stream of water and held it there for one second and pulled it out. The NOM stated that the test strip did not yield a result because the bleach base liquid was empty. The surveyor noted an empty bottle that hung on the wall next to the dish machine. A new replacement bottle was available directly below it. The kitchen staff was unable to state how long the dispenser had been empty. On 4/14/23 at 1:17 PM, the AFSD stated that the staff were responsible to test the function of the dish machine in the morning, make sure there was chemical cleaner available to run the machine, test the sanitizer level, and complete the log. On 4/14/23 at 1:20 PM, the AFSD stated that the chlorine test strip should have been dipped after a load was run through the machine, not at the beginning of the cycle as the NOM had incorrectly demonstrated. The AFSD stated that the dish machine was required to meet a minimum wash temperature of 120 F and a rinse temperature of 140 F. The AFSD stated that the log was required to be documented at the time it was done. The AFSD stated the test strip should be held in the water for twenty seconds. The AFSD then proceeded to hold the test strip in the water that came out of the dish machine for twenty seconds. The AFSD repeated the test after holding the test strip in against a wet plate for ten seconds. On 4/14/23 at 1:27 PM, the surveyor reviewed the directions on the side of the chlorine test strips which directed to dip and remove the strip quickly, blot with a paper towel, compare to color chart (desired level was 50 to 200 parts per million). The surveyor asked the AFSD for a policy related to the test strips. The AFSD stated, we do not have a policy on everything. The AFSD stated that staff only needed to know how to scrape and wash the dishes. The AFSD stated that the FSD, AFSD and the NOM did the chemical sanitizer testing. The AFSD stated that staff were not in-serviced on dish machine function on low operating temperature settings and processes. On 4/14/23 at 1:36 PM, the surveyor noted plastic cutting boards that were on a drying rack. There were three large red cutting boards, seven large white cutting boards and four large green cutting boards that were pitted, and discolored. The AFSD stated that the cutting boards were not supposed to be used due to the potential for bacterial growth. The AFSD stated, We do not even use those. On 4/14/23 at 1:54 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss their concerns that were identified in the kitchen regarding dish machine function and food service. On 4/17/23 at 10:39 AM, the LNHA informed the surveyor that he called in the Regional Food Service Director (RFSD) on Friday (4/14/23) at 4:00 PM, and he had worked twelve hour shifts all weekend to ensure that the staff was in-serviced and the policies were reviewed. A review of the facility's Food Storage policy dated revised 1/22/21, included .dented, bulging or leaking cans will be discarded, or returned to vendors for appropriate credit .all food shall be protected from contamination and spoilage . A review of the facility's Food Preparation Standards policy dated revised 1/22/21, included .only nonabsorbent cutting boards are used .meat, fish, eggs, and milk products will be prepared as close to serving time as possible . A review of the facility's Food Preparation Standards policy dated revised 1/22/21, included .foods will be held below 40 F or above 140 F to prevent growth of micro-organisms .foods will be prepared and served in small batches to prevent long holding periods .all foods shall be covered, labeled and dated . A review of the facility's Dishwashing policy dated revised 1/22/21, included .supervisors will record dish machine temperatures daily. A dish machine temperature log is maintained to document that temperatures meet the established standards .employees will ensure dish washer temperatures are accurate according to standards before running items through the dish washer to be cleaned and ensure proper sanitation .if proper dish washing temperatures can not be maintained, management will not serve food on un-sanitized serving pieces. Paper and disposables will be used until dish machine is repaired and items are properly sanitized. A review of the facility's undated Dishwashing policy included .be sure the wash and rinse temperatures are appropriate for your dish machine. Document temperatures regularly on a temperature log. Use one staff to load dirty dishes and another to pull clean dishes. Air dry-use drying racks if needed; do not stack dishes immediately before or after washing. never dry with a towel . NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) appropriate personal protection equipment was worn for residents on transmission-based precautions; b.) appropriate hand hygiene including donning (put on) and doffing (removing) of gloves and hand washing; c.) appropriate disposal of resident's garbage in the room; d.) appropriate storage of respiratory equipment; and e.) sanitizing of reusable equipment in accordance with nationally accepted guidance and facility policy. This deficient practice was identified in 4 of 6 nursing units (S1, S2, 1 West, and 1 East) with multi-disciplinary staff and was evidenced by the following: 1. On 4/5/23 at 10:30 AM, the surveyor observed outside Resident room [ROOM NUMBER] a sign that indicated the resident was on transmission-based precautions (TBP) and prior to entering and exiting room you must perform hand hygiene; wear gloves when entering room; and wear a gown upon entering the room. The surveyor observed outside the door a plastic cart with drawers which contained personal protective equipment (PPE) of disposable gowns and gloves. At that time, the surveyor observed an Occupational Therapist ( OT) inside the room wearing a surgical mask, goggles, and gloves. The surveyor observed no gown. The OT assisted the resident out of the bathroom, and transferred the resident from the wheelchair to their bed. The OT picked up the walker, and left the room without removing her gloves or performing hand hygiene. The surveyor interviewed the OT who stated that she did not need to wear a gown in the room because it was the roommate that was on the TBP. The OT further stated that she did not need to disinfect the walker since the resident did not use it. The OT acknowledged that she should have removed her gloves and performed hand hygiene before she left the room. On 4/5/23 at 10:41 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) on the S2 nursing unit. LPN #1 stated that all staff entering a room on TBP were instructed to wear full PPE including mask, gown, eye protection, and gloves prior to entering the room even if providing care to the resident that was not on TBP. On 4/14/23 at 10:05 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) who stated that all staff and visitors entering a room with TBP must wear full PPE including mask, eye protection, gown, and gloves regardless of which resident they are seeing. The IP/RN further stated that all multiuse equipment that was brought into the room; whether or not it was used should be disinfected prior to leaving the room. On 4/18/23 at 1:32 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the above concerns. 2. On 4/5/23 at 10:43 AM, the surveyor observed the Certified Nursing Assistant (CNA #1) exit Resident Room #S235 wearing gloves and carrying two plastic bags; one with soiled linen and one with trash. The surveyor interviewed CNA #1 who stated that she should not wear gloves in the hallway and further stated that she should have removed them before leaving the room but stated she forgot. On 4/14/23 at 10:05 AM, the surveyor interviewed the IP/RN who stated that gloves should not be worn in the hallway; staff must remove gloves and perform hand hygiene prior to exiting room. On 4/18/23 at 1:32 PM, the surveyor informed the LNHA and DON the above concerns. 3. On 4/10/23 at 12:10 PM, the surveyor observed Housekeeper (HK #1) on the L2 nursing unit cleaning Resident Room #L230. The surveyor observed HK #1 leave the room without removing her gloves or performing hand hygiene. HK #1 removed the wet mop she had used in Resident Room #L230, removed her gloves, applied a new pair of gloves and without performing hand hygiene, proceeded to clean Resident Room #L228. On 4/10/23 at 12:15 PM, the surveyor interviewed HK #1 who stated, I forgot the sanitizer, I left it in my locker, I'm sorry. HK #1 removed a container of purple-top sanitizer wipes from the cart and stated, I sometimes use these to clean my hands. The surveyor and HK #1 observed that the label on the sanitizer wipes warned to avoid contact with skin. On 4/14/23 at 10:05 AM, the surveyor interviewed the IP/RN who stated that staff were expected to remove their gloves and perform hand hygiene prior to changing gloves or exiting a resident's room. The IP/RN further stated that staff should not use the purple-top sanitizing wipes to clean their hands; sanitizer was on the housekeeping carts and in resident rooms. On 4/18/23 at 1:32 PM, the surveyor informed the LNHA and DON the above concerns. 4. On 4/11/23 at 10:40 AM, the surveyor observed HK#2 on S2 nursing unit wet mopping Resident Room #S232 wearing a surgical mask, goggles and gloves. The surveyor observed HK #2 leave the room without removing her gloves or performing hand hygiene. HK#2 then removed the wet mop in the hallway, removed her gloves, applied a new pair of gloves, with no observed hand hygiene, and proceeded to clean Resident Room #S231 which had a TBP sign outside the door which indicated to wear gown and gloves inside room. The surveyor observed HK#2 enter the resident's room wearing a surgical mask, eye protection, gloves, and no gown. HK#2 brought in one bottle of cleaner and went into the bathroom, sprayed the chemical in the bathroom, then proceeded to bed B, sprayed the chemical, cleaned the room, then proceeded back to the hallway and placed the bottle on the housekeeping cart. There was no observed glove change or hand hygiene. HK #2 then grabbed the wet mop, mopped the bathroom floor and room floor. HK #2 removed her gloves, and donned a new pair of gloves without performing hand hygiene. HK #2 went back into the room and removed the garbage from bed A, then she removed and discarded her gloves and left the room without performing hand hygiene. On 4/11/23 at 11:00 AM, the surveyor asked HK #2 what PPE should be worn in Resident Room #S231 since the sign indicated that Resident Room #S231 was on TBP? HK #2 replied that she had not noticed the TBP sign until the surveyor pointed it out to her. HK #2 further stated that she should have cleaned that room after she was done cleaning all of the other rooms that were not on TBP. HK#2 further stated that she should have performed hand hygiene using soap or water or sanitized her hands with alcohol-based hand rub (ABHR) before leaving the resident's room and acknowledged she should not wear gloves in the hallway. On 4/11/23 at 11:10 AM, the surveyor interviewed the Director of Housekeeping (DH) who stated that HK #2 was expected to clean the TBP rooms last. The DH further stated that HK #2 should not enter a room on TBP without the proper PPE which included a surgical mask, goggles, gown, and gloves, and she should remove the gown and gloves in resident rooms, perform hand hygiene using soap and water for at least twenty seconds prior to exiting the room. On 4/14/23 at 10:05 AM, the surveyor interviewed the IP/RN who stated that all staff and visitors entering a room with TBP must wear full PPE including mask, eye protection, gown, and gloves. The IP/RN stated gowns and gloves should be removed prior to exiting the room, and hand hygiene performed. On 4/18/23 at 1:32 PM, the surveyor informed the LNHA and DON the above concerns. 37217 5. On 4/11/23 at 9:41 AM, the surveyor toured the S1 nursing unit and observed Resident #33 in their room sitting in a wheelchair. The surveyor observed the resident's nebulizer mask face down on top of the nebulizer machine. There was no storage bag observed in the resident's room for the face mask. The resident stated nebulizer treatments were given at 6:00 AM, 11:00 AM, 4:30 PM, and 10:00 PM. On 4/11/23 at 1:21 PM, the surveyor observed the resident's nebulizer mask on top of the nebulizer machine. There was no storage bag observed in the resident's room for the face mask. At that time, the surveyor interviewed the assigned LPN #2 who was outside the resident's room. LPN #2 stated she prepared the resident's nebulizer that day and stayed the entire duration of the nebulizer treatment. She stated after the nebulizer was finished, she washed it out, dried it and placed it on a holder. The surveyor brought LPN #2 into the resident's room. LPN #2 acknowledged that the mask was face down on the nebulizer machine and connected the mask to a holder on the machine. LPN #2 stated she was not aware the mask should not have been placed face down on the nebulizer machine, and she was not aware of any other way to store the mask. On 4/13/23 at 10:35 AM, the surveyor interviewed the IP/RN regarding storage of nebulizer masks. The IP/RN stated after the nebulizer was wiped down, the nurse should have stored it in a bag for infection control. On 4/19/23 at 10:23 AM, the DON and LNHA spoke about the above concerns. The DON stated that the nurse should have ensured Resident #'33's nebulizer mask was stored properly. 6. On 4/13/22 at 9:33 AM, the surveyor toured the 1 West nursing unit and observed signage outside of Resident room [ROOM NUMBER] that indicated, Stop Contact Precautions. The signage indicated TBP, and instructed the to perform hand hygiene before entering and before leaving the room; wear gloves when entering room or cubicle, and when touching patient's intact skin, surfaces, or articles in close proximity; wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces; and use patient dedicated or single use disposable shared equipment or clean and disinfect shared equipment (BP, Cuff, thermometers) between patients. At that time, the surveyor observed an open bag of garbage which included used isolation gowns inside the resident's room located directly on the resident's floor. HK #3 was inside the room wearing a mask, eyewear, gown, and gloves. HK #3 stated to the resident, I'm going to leave this here, if anyone asks, I'll be right back. HK #3 doffed (removed) her gown and gloves and exited the room. On 4/13/23 at 9:43 AM, HK #3 returned to the resident's room. At that time, the surveyor interviewed HK #3 who stated that the garbage should not have been opened and on the floor, and that she should have taken it directly to the soiled utility room. On 4/17/23 at 10:32 AM, the surveyor interviewed the IP on the resident rooms who were on contact precautions. The IP stated that all staff were educated on PPE and should be following the contact precaution instructions on the signage for both of the residents in the room for ESBL. She stated that garbage should not be on the floor and should be bagged in the resident's room and taken to soiled utility. On 4/19/23 at 10:23 AM, the DON and LNHA spoke about the above concerns. The DON stated that HK #3 should have removed the garbage when she left the room. 7. On 4/14/23 at 10:02 AM, the surveyor toured the 1 East unit and observed signage outside of Resident room [ROOM NUMBER] which revealed that the residents were on TBP. The surveyor observed a Social Worker (SW) inside the resident's room holding a pen and a clipboard. The SW was wearing eyewear and a surgical mask. The SW gave her pen and the clipboard to the resident to write on a piece of paper. The SW took the pen and clipboard from the resident and placed the clipboard on the resident's bedside table, picked it back up and exited the room without performing hand hygiene or sanitizing her pen and clipboard. At that time, the surveyor interviewed the SW about the signage outside the resident's room. The SW stated she was supposed to wear a gown and stated that she used hand sanitizer prior to exiting the resident's room. On 4/17/23 at 10:32 AM, the surveyor interviewed the IP on the resident rooms who were on contact precautions. The IP stated that all staff were educated on PPE and should be following the TBP instructions on the signage for both of the residents in the room for TBP. On 4/19/23 at 10:23 AM, the DON and LNHA spoke about the above concerns. The DON stated that the SW should have followed the signage for the required PPE for the rooms on TBP and sanitized their hands. She added that the SW should not have used her pen and clipboard for the resident to use. 37547 8. On 4/4/23 at 9:18 AM, during the initial tour of the facility, the surveyor observed signage for TBP outside of Resident room [ROOM NUMBER] which indicated that a gown and gloves were required to be worn when entering the room and when touching the resident's intact skin, surfaces, articles in close proximity or potentially contaminated environmental surfaces. The surveyor observed LPN #3 who wore a surgical mask and goggles, but failed to don a gown and gloves that were readily available outside of the room before she entered the room. The surveyor observed LPN #3 as she placed her ungloved hands on the foot board of the first bed inside the room. When interviewed, LPN #3 stated that she was an Agency nurse and did not see the TBP sign or PPE bin outside of the room. LPN #3 stated, I just walked in. LPN #3 stated that she did not know why the resident was on TBP as she was only assigned to check the dates on the resident's oxygen tubing today. LPN #3 stated that since she had not worn PPE into the room as required, there was a chance that she could spread disease. On 4/4/23 at 9:30 AM, the surveyor interviewed LPN #4 who stated that LPN #3 was an Agency nurse who had just begun her shift, and she did not know that Resident room [ROOM NUMBER] was on TBP for ESBL (Extended Spectrum Beta-Lactamase, enzymes produced by some bacteria that may make them resistant to some antibiotics) in the urine. On 4/11/23 at 11:13 AM, the surveyor interviewed the Unit Manger/LPN (UM/LPN) who stated that there were signs posted outside of Resident room [ROOM NUMBER], and we educated all staff to look at the signs before entering the room to observe the required precautions. The UM/LPN stated that no matter what, if a resident was on TBP, gloves were required to be worn and hand hygiene was required to be performed as you could not be sure if the resident had touched anything in the room. On 4/12/23 at 12:17 PM, the surveyor interviewed the IP/RN who stated that for contact isolation (TBP), gown and gloves were required to enter the room and for activities. The IP/RN further stated, The policy is to don a gown and gloves in case the foot board was contaminated. 9. On 4/12/23 at 10:09 AM, the surveyor observed signage for TBP outside of Resident #19's room, which indicated that a gown and gloves were required to be worn when entering the room and when touching the resident's intact skin, surfaces, articles in close proximity or potentially contaminated environmental surfaces. The surveyor observed HK #4 who wore a gown, mask, and goggles as she cleaned Resident #19's room. Resident #19 was present in the room and was seated in a wheelchair at the bedside. HK #4 exited the room with her gown and accessed the housekeeping cart and obtained a roll of trash bags. HK #4 went back into the room and placed her right ungloved hand on the foot board of the resident's bed while she conversed with the resident. HK #4 laid a roll of trash bags on the resident's bed and donned a pair of gloves. HK #4 then entered the bathroom with a mop and mopped the bathroom floor. HK #4 then proceeded to use the same microfiber cloth that covered the mop head to mop the bathroom to mop the floor in the hallway outside of the resident's room. HK #4 then doffed her gloves, and she untied the gown at her waist level posteriorly (behind) and left the ties secured around her neck posteriorly. HK #4 then proceeded to doff the gown by lifting the gown over her head and discarded both the gown and gloves in the trash receptacle on the housekeeping cart. At that time, Resident #19 called HK #4 back into the room to receive holy water that the resident had in a small bottle. HK #4 returned to the room without performing hand hygiene or donning any PPE. Resident #19 placed the holy water in HK #4's ungloved hands. HK #4 stated, I just realized that I was not supposed to come in here like this (without PPE on). HK #4 did not perform hand hygiene before she pushed her housekeeping cart across the hall to Resident room [ROOM NUMBER] (another resident's room), which did not have any signage or PPE outside of the room to indicate that it was an isolation (TBP) room. At that time, HK #4 proceeded to don a pair of gloves without first performing hand hygiene, before she entered Resident room [ROOM NUMBER]. HK #4 went into the resident's bathroom and proceeded to clean the bathroom. When finished, she bagged the microfiber cloths that she used to clean the bathroom and placed them on the housekeeping cart. HK #4 then proceeded to mop the floor. When finished, she moved the resident's cell phone, and a sealed pack of crackers from the television cart and placed it on the resident's bed with her gloved hand before she cleaned the top of the television cart. When finished, she returned both the cell phone and crackers to the television cart. HK #4 began to mop the area around the resident's bed when she noted the resident's urinal was full. With resident permission, she carried the urinal into the bathroom and proceeded to empty the urinal into the toilet. HK #4 informed the resident that she planned to hang the urine bottle in a plastic bag at the bottom of the bed until the resident received another. HK #4 then proceeded to clean the shelf of the television stand when she noted the resident's shoehorn, wiped it, and placed it on the resident's bed. HK #4 then exited the room, doffed her gloves and failed to perform hand hygiene as she prepared to clean the next room in the hall. On 4/12/23 at 10:44 AM, the surveyor interviewed HK#4 who stated that she worked on this hall today because the facility was short staffed. HK #4 stated that a gown, gloves, and mask were required to be worn in isolation (TBP) rooms to prevent staff from getting hurt and to provide protection from body fluids. HK #4 stated that she was not permitted to return to Resident #19's room after she had doffed her PPE. HK #4 stated that she had already doffed her gloves when she received holy water from Resident #19 in her ungloved hands and then touched her forehead and uniform to mark the sign of the cross on her body. HK #4 stated that she may have contaminated her uniform in the process. HK #4 stated that she should have washed her hands because there was hand sanitizer available in every room. On 4/12/23 at 10:58 AM, the surveyor interviewed the DH who stated that housekeeping staff were trained to pay attention to signage. The DH further stated that contact isolation (TBP) required gloves, gown, mask or goggles. He stated that staff were never permitted to go into the room without PPE in order to protect themselves and residents from spreading and passing germs from room to room, as there was a chance of contamination. The DH stated that housekeeping staff were trained to clean isolation (TBP) rooms last to prevent from spreading anything. The DH stated staff were not permitted to doff their gloves without performing hand hygiene. The DH stated that when HK #4 failed to perform hand hygiene after she doffed her gloves and went into another resident's room and touched personal effects like a cell phone, crackers, shoehorn and urinal there was a chance of contamination. The DH stated that if HK #4 did not wash her hands after surveyor inquiry there was a chance of contamination. The DH further stated, she should know, she has been here for a long time. On 4/12/23 at 12:17 PM, the surveyor interviewed the IP/RN who stated that HK #4 should have had gloves on regardless of isolation status. The IP/RN stated that PPE should be doffed and disposed of inside of resident rooms. The IP/RN stated that if HK #4 lifted the soiled gown over her head after she left Resident #19's room, she could spread ESBL, as there could be germs on her hair and face. The IP/RN stated that if HK #4 mopped the room of a resident who was positive for ESBL and then mopped the hallway with the same mop head there was a potential for contamination. IP/RN stated that HK #4 should have performed hand hygiene when she left the room. The IP/RN stated that HK #4 should not have emptied a urinal. The IP/RN stated that housekeeping was trained to clean from clean to dirty and isolation should have been cleaned last to stop the spread of infection. On 4/17/23 at 12:49 PM, the surveyor interviewed the DON who stated that all donning and doffing of PPE should have been done inside the room. The DON stated that HK #4 should have declined the holy water. The DON stated that HK #4 was required to round from clean to dirty to avoid cross contamination and prevent the spread of infection. The DON stated that when HK #4 emptied the urinal, there was a chance of contamination and spread of ESBL. A review of a facility's Oxygen Tubing and Respiratory Products policy dated revised in January 2023, included that all nebulizer tubing and equipment should be kept in a bag and dated . A review of a facility's Resident Room Cleaning -Occupied Isolation Room- Non C-diff dated revised August 2022, included .gather waste, place sealed plastic bags from waste containers into a second clearly tagged and/or labeled liner and seal that liner . A review of the facility's Isolation Precautions/COVID-19 policy dated revised January 2023, included facility will ensure that appropriate isolation precautions are maintained as advised by attending physician .remove gloves promptly before leaving resident's room and wash hands immediately to avoid transfer of microorganisms to other residents and environment .isolation precautions .transmission based precautions will be used for identified residents .contact precautions: contact measures that are intended to prevent transmission of infectious agents .gloves are to be worn if patients items in room are to be touched. gowns and gloves are worn if rendering personal care and contact with infected body fluids is expected A review of the facility's Hand Hygiene policy dated revised January 2023, included .wash hands or use alcohol-based hand sanitizer after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. wash hand or use an alcohol-based hand sanitizer after removing gloves . NJAC 8:39-19.3(b); 19.4(a)(b)(c)(k)(i)(n)

NJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) a.) an injury of unknown origin for an incident on 10/8/22; b.) an allegation of staff to resident abuse for an incident on 1/30/23; and c.) and allegation of staff to resident mistreatment on 9/24/22. This deficient practice was identified for 3 of 3 residents (Resident #15, #152, and #440) reviewed for abuse, and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The surveyor reviewed the medical record for Resident #15. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in August of 2020 with diagnoses which included dementia, major depressive disorder, persistent mood disorder, unspecified psychosis not known to a substance or known physiological condition, insomnia, and essential hypertension (high blood pressure). A review of the most recent quarterly Minimum Data Set (MDS), and assessment tool dated 2/16/23, reflected the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. A review of the Progress Notes included a Nurses Note dated 10/8/22 at 3:25 PM, that during morning medication administration, the resident was noted with discoloration around [his/her] right eye. The resident was unable to explain the discoloration. On 4/11/23 at 9:00 AM, the surveyor requested from the Director of Nursing (DON) all incident and accident investigations for Resident #15. On 4/11/23 at 11:06 AM, the surveyor observed Resident #15 sitting in their wheelchair in the dayroom. The resident was sitting at the table having a snack repeating the word please, and was unable to be interviewed. On 4/11/23 at 11:47 AM, the surveyor received the requested investigations from the DON. A review of an incident report dated 10/8/22 at 3:06 PM, included during medication administration, the resident was observed with discoloration right lower corner of right eye. (Nurse Note indicated discoloration around the eye) Resident was unable to explain the discoloration was noted on the side of the right eye and slightly under the eye. The resident was unable to explain what happened. The resident's mental status was confused. Staff was interviewed and surveillance video was watched. On 4/12/23 at 9:50 AM, the surveyor interviewed the DON regarding the facility's process for investigations who stated the facility investigates falls, skin tears, bruises, any event out of the normal for the resident, resident to resident abuse, any allegations of abuse, neglect, sexual abuse, misappropriation of funds, injuries of unknown origin. The DON continued that the facility reported to the NJDOH any allegations of abuse, neglect, misappropriation of funds. During a follow-up interview on 4/13/23 at 9:14 AM, the DON confirmed the facility had two hours to report to the NJDOH anything that involved abuse including allegations, and twenty-four hours to report anything non-abuse related. On 4/14/23 at 9:08 AM, the surveyor asked the DON if she reported the injury of unknown origin for Resident #15 to the NJDOH, and the DON responded no because after an extensive investigation and went through hours of video surveillance, it was determined that the incident was not caused from abuse so it did not have to be reported. The surveyor asked if the facility had to report the injury of unknown origin prior to the conclusion of the investigation, and the DON responded no because she immediately investigated the situation spending hours reviewing surveillance videos. The surveyor asked if discoloration of the eye was considered a suspicious area, and the DON responded not in this case because I completed a full investigation. The surveyor continued to review the medical record. A review of the Progress Notes revealed a Physician's Progress Note dated 10/10/22 at 11:44 PM, which included the resident was being seen for a black eye (right side) and right hand bruising. Resident was unable to provide information regarding injury to right eye or hand; no witnessed falls or injuries noted by staff. On 4/14/23 at 1:03 PM, the DON informed the surveyor that based on the total eye was not black she did not suspect abuse. The DON confirmed when the discoloration of the eye was reported, it was unwitnessed. On 4/19/23 at 10:46 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team confirmed this incident was noted reported to the NJDOH. 45209 2. On 4/3/23 at 11:18 AM, the surveyor observed Resident #152 laying on the bed requesting assistance from the nursing staff. The surveyor reviewed the medical record for Resident #152. A review of the Admission Record face sheet reflected the resident was readmitted to the facility in March of 2022 with diagnosis which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side. A review of the most recent quarterly MDS dated [DATE], had a BIMS score of 9 out of 15, which indicated a moderately impaired cognition. Further review of the MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). On 4/12/23 at 10:20 AM, the surveyor was informed by Resident#152 of a situation involving a Certified Nursing Assistant (CNA #1). With Resident #152's permission, this conversation was held in the presence of their roommate (Resident #113). Resident #152 advised that CNA #1 grabbed my arm [ .] shook me [ .] I was crying. Resident #152 further stated that CNA #1 pulled on my arm [to cover me up] because I had a rash from dialysis. I told her I got a rash and she said you don't have [breasts] hanging out like that. Resident #113 confirmed the entire event and stated that Resident #152 was crying after the event. When asked if CNA #1 had been assigned to Resident #152 or Resident #113, they both confirmed that they have not seen CNA #1 since that time. On 4/13/23 at 2:15 PM, the surveyor reviewed the facility's Grievance Form dated 1/30/23, which included it was reported that the Social Worker (SW) met with Resident #152 on 2/1/23. Resident #152 reported that on 1/30/23, the resident's CNA #1 attended to the resident for care. Resident #152 stated that CNA #1 started pulling on my arm [ .] I told her that you don't have to touch me [ .] she kept pulling on my arm [ .] I was crying and so shocked. Under the section identified as Actions Taken, the following was handwritten, Allegation is unfounded. A review of CNA #1's written statement dated 1/30/23, revealed that CNA #1 entered the room and asked Resident #152 if he/she could fix the resident's gown to protect [his/her] dignity. CNA #1 reported that he/she would never grab someone's arm. I always ask the residents first before I help them. On 4/14/23 at 1:02 PM, the surveyor reviewed Resident #152's grievance with the DON. The surveyor asked the DON if the incident was reported to the NJDOH, and the DON responded that based on their investigation, this did not rise to the level of reporting. The surveyor inquired that if their investigation took two days to complete, was that longer than the two hour reporting requirement? The DON responded, of course. 37217 3. The surveyor reviewed the closed medical record for Resident #440. A review of the Admission Record face sheet reflected the resident was admitted to the facility in August of 2015, and had diagnoses which included transient cerebral ischemic Attack (TIA, a temporary period of symptoms similar to a stroke). A review of the admission MDS dated [DATE], indicated the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. A review of the facility's Grievance Form dated 9/24/22, revealed that the SW met with Resident #440 on 9/26/22. Resident #440 reported that on 9/24/22, the resident's [CNA #2] attended to the resident for care. The resident was thirsty and had called for CNA #2 again at 1:00 PM and 2:00 AM. CNA #2 stated to the resident, why do you have your [profanity] lights on again, I am changing other people, you have been changed. Resident #440 reported that CNA #2 should not have spoken that way to the resident. Further review of the Grievance Form dated and signed by the DON on 9/26/22, revealed that an investigation was initiated, and the DON interviewed Resident #440. Resident #440 confirmed that CNA #2 used profanity when speaking to the resident. CNA #2 was held off work and CNA #2 denied using profanity toward the resident. A review of CNA #2's written statement dated 9/24/22, revealed that CNA #2 changed Resident #440 at 2:30 AM, and two hours later the resident had their light on to be changed. CNA #2 explained to the resident that she just changed the resident and had begun changing other residents and would be back soon. Resident #440 demanded to be change now and was told by CNA #2 that when she was finished with the other resident, she would be back. Further review of CNA #2's statement revealed that CNA #2 was frustrated at the time, but denied threatening or using profanity toward the resident. On 4/14/23 at 12:55 PM, the surveyor reviewed Resident #440's grievance with the DON. The DON stated that CNA #2 used an inappropriate comment, and that CNA #2 was not using profanity directly to the resident. The surveyor re-read the DON's written interview to the DON. The surveyor asked the DON if the incident was reported to the NJDOH. The DON stated that based on their (the facility's) assessment, it was not a reportable event. A review of the facility's Abuse and Neglect Policy and Procedure dated November 2022, included the purpose was to ensure prevention, protection, prompt reporting and intervention in response to alleged, suspected or witnessed abuse, neglect, mistreatment, misappropriation of property, or exploitation of any facility resident .Investigative and Reporting Procedure .The Department of Health and Senior Services, and the Office of the Ombudsman if the resident is over 60, will be notified immediately (as soon as possible but not to exceed two hours) of the incident, followed by a written report within five days of the incident and if the alleged violation is verified, the facility shall take all appropriate action . NJAC 8:39-9.4(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of enteral feeding formula and piston syringes. This deficient practice was identified for 2 of 3 residents (Resident #77 and #88) reviewed for tubing feeding, and was evidenced by the following: 1. On 4/3/23 at 10:50 AM, the surveyor observed Resident #88 in bed asleep with an enteral feeding tube pump (FT; a tube surgically inserted to the stomach to provide food and nutrients) administering Jevity 1.5 (nutritional formula) at a rate of 85 milliliters (mL) per hour. The surveyor observed the 1000 mL bottle of Jevity 1.5 had approximately 300 mL of formula remaining, and the label was not filled out with the resident's name, date, or rate of infusion (mL per hour). The surveyor also observed a piston syringe irrigation kit (used to flush the FT) dated 3/31/23. There was also no name labeled on the bag that contained the irrigation piston syringe kit. The surveyor reviewed the medical record for Resident #88. A review of the Admission Record face sheet (an admission summary) reflected the resident was readmitted to the facility in December 2022 and had diagnoses which included Alzheimer Disease (a disease that affects memory), unspecified protein calorie malnutrition, and gastrostomy tube (FT). . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/27/23, reflected that the resident had a brief interview for mental status (BIMS) score of 6 out of 15; which indicated a severely impaired cognition. A further review of Section K for Nutritional Status reflected that the resident received 51% or more of their nutrition through an enteral feeding tube and resident also received mechanically altered diet. A review of the Physician Order Summary Report dated as of 4/6/23, included the following physician's orders (PO): A PO dated 12/30/22, to provide 200 mL of water flushes every four hours via FT. A PO dated 1/4/23, for Jevity 1.5 administered 85 mL per hour for a total volume of 1000 mL. A PO dated 1/4/23, to change feeding every twenty-four hours. A PO dated 1/4/23, to change FT equipment (piston syringe irrigation kit) every twenty-four hours. A review of the corresponding April 2023 Enteral Administration Record (EAR) reflected that the nurses had signed the administration of the Jevity 1.5 daily. Further review revealed the nurses had signed that the equipment for the enteral feeding was hung every twenty-four hours since 4/1/23. A review of the comprehensive care plan dated 4/20/22, included a focus area that the resident received enteral feedings to meet nutrition and hydration needs. The goal of the care plan reflected that the resident would benefit enteral feeding without complications. The interventions included to administer feeding as ordered and to administer flushes as ordered. On 4/3/23 at 11:10 AM, the surveyor interviewed the Unit Manager/Registered Nurse UM/RN who stated that the nurses were responsible for the care of the resident's FT. On 4/3/23 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) in Resident #88's room, who acknowledged that the bottle of Jevity 1.5 was not dated, and she was not sure how much feeding the resident should have received. She stated that the 3:00 PM to 11:00 PM shift nurse hung a new bottle, and the bottle should be filled out. On 4/3/23 at 11:55 AM, the surveyor interviewed the UM/RN who stated that piston syringe irrigation kits were changed every shift, and the FT stopped at the total volume the pumps was set to. She stated that the Jevity 1.5 bottle should be filled out, so the nurses knew the time and date the bottle was hung because the formula was not good after twenty-four hours of being opened. The UM/RN also acknowledged that the irrigation set dated 3/31/23 for the resident was not acceptable. She further stated that during rounds, she noticed that the irrigation set for Resident #88 was dated 3/31/23, and discarded the irrigation set. On 4/10/23 at 12:13 PM, the surveyor interviewed the Staff Educator/LPN who stated all nursing staff were educated on FT. She stated that the piston syringe irrigation kits were changed at night, and should be labeled and dated with the resident's name, date, and room number. The Staff Educator/LPN stated that the formula bottles were expected to be labeled with the resident's name, date, the rate of infusion, and the time the bottle was hung. The Staff Educator/LPN stated that was the nurse's responsibility to make sure they were labeled and dated, and if they were not labeled, the nurse had to replace the formula and obtain a new irrigation set. The Staff Educator/LPN confirmed if the bottle was not labeled, the nurse would not know how long the bottle was up which would be an infection control issue and would not want the resident to get sick. On 4/17/23 at 9:41 AM, the surveyor interviewed the Director of Nursing (DON) who stated the formula bottles and the pistol syringe irrigation kits needed to be labeled and filled out because that was the facility's policy. The DON acknowledged that the formula should have been labeled and dated, and the piston syringe irrigation kits be changed daily. 2. On 4/3/23 at 11:25 AM, the surveyor observed Resident #77 in bed awake and alert, but non-responsive to surveyor questions. The surveyor observed on the resident's dresser a piston syringe irrigation kit dated 3/31/23. The resident had a FT that was not being administered and there was no formula hanging. The surveyor reviewed the medical records for Resident #77. A review of the Admission Record face sheet reflected that the resident was admitted to the facility in September of 2022 with diagnoses which included cerebrovascular infarction (disrupted blood flow to the brain), aphasia (a language disorder caused by damage in specific area of the brain), and dysphagia (difficulty swallowing). A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 0 out of 15; which indicated a severely impaired cognition. A further review in Section K Nutritional Status reflected that the resident received 51% or more of their nutrition through FT, and the resident also received a mechanically altered diet. A review of the April 2023 Physician Order Summary Report included a PO dated 12/16/22, for an enteral feeding order for water flushes of 200 mL every four hours. Further reviewed reflected a PO dated 9/1/23, for enteral feeding to change equipment (piston syringe irrigation kit) every twenty-four hours. A review of the corresponding April 2023 EAR reflected that the nurses were signing that the equipment was being changed daily at 2:00 PM. A review of the comprehensive care plan dated 9/1/22, included a focus area that the resident required an enteral feeding to meet nutritional and hydration needs. The goal was to benefit from the enteral feeding without complications. The interventions included to administer feeding as ordered and to administer flushes as ordered. On 4/3/23 at 11:10 AM, the surveyor interviewed the UM/RN who stated that the nurses were responsible for the care of the FT. On 4/3/23 at 11:50 AM, the surveyor interviewed the LPN who acknowledged that piston syringe irrigation kits were changed every shift and stated that she did not use the piston syringe irrigation kit that was dated 3/31/23. The LPN stated she did not leave the piston syringe irrigation that she used for Resident #77 in the room that day. She confirmed that the kit dated 3/31/23 should not have been available at the bed side. On 4/3/23 at 11:55 AM, the surveyor interviewed the UM/RN who stated that piston irrigation kits changed every shift. The UM/RN stated the piston syringe irrigation kits dated 3/31/23 for the resident was not acceptable. On 4/10/23 at 12:13 PM, the surveyor interviewed the Staff Educator/LPN who stated that all nursing staff were educated for FT. She stated that the piston syringe irrigation kits were changed at night, and they should be labeled and dated with the resident's name, the date, and the room number. The Staff Educator/LPN stated that she expected that they would be labeled, and it was the nurse's responsibility to make sure they were labeled and dated. The Staff Educator/LPN continued if they were not labeled, the nurse replaced the bottle and got a new piston syringe irrigation kit because it was an infection control issue and would not want the resident to get sick. On 4/17/23 at 9:41 AM, the surveyor interviewed the DON who stated the piston syringe irrigation kits needed to be labeled and filled out because that was the facility's policy. The DON acknowledged that the piston irrigation kit dated 3/31/23 should not have been used or in the resident's room on 4/3/23. A review of the facility's Gastric Tube Feeding Management policy and procedure dated revised 1/26/23 included, feeding sets are to be labeled and dated and are replaced every 24 hours . A review of the facility's Gastric Tube Feeding Management policy and procedure include .The nurse shall label the feeding container with the date and time the feeding was started . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 6 of 6 forms provided; and b.) to accurately document the administration of controlled medication for 2 sampled residents (Resident #19 and Resident #216) identified upon inspection of 1 of 6 medication carts (1 West right hall cart). The evidence was as follows: 1. On 4/17/23 at 1:37 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on six of the six provided forms Part 5, had not been completed upon receipt of the medications from the Provider Pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 221704808; 221704809; 221704810; 221704811; 221704812; and 221704816. On 4/17/23 at 2:13 PM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. The DON acknowledged she should have completed the Part 5 as instructed on the reverse of the DEA 222 form as required. A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item . 2. On 4/17/23 at 11:40 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the 1 West right hall medication cart. The surveyor and the LPN reviewed the narcotic medication located in a secured and locked narcotic box. When the narcotic inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns. Resident #19's oxycodone immediate release (IR) 5 milligram (mg) tablet, a medication used to relieve moderate to severe pain, did not match the physical inventory. The blister pack contained 24 tablets and the declining inventory sheet indicated there should be 25 tablets remaining. Resident #216's lorazepam 0.5 mg tablets also did not match. The blister pack contained 27 tablets and the declining inventory sheet indicated there should be 28 tablets remaining. At this time, the surveyor interviewed the LPN who stated he had administered the medications earlier to both residents, and he had forgotten to sign the declining inventory sheet for the doses he had administered. The LPN acknowledged the declining inventory sheet should be signed when the medication was removed from the packaging. On 4/17/23 at 12:24 PM, the surveyor interviewed the 1 West Unit Manager/LPN (UM/LPN) who acknowledged the LPN should have signed the declining inventory sheet immediately after removing the medication from the packaging. She further acknowledged this was the process to ensure the accurate inventory of all controlled medications. On 4/17/23 at 1:18 PM, the surveyor interviewed the DON who stated as soon as medication was removed from the packaging, the nurse must sign the declining inventory sheet. This was the process to ensure accountability and ensure the medication counts were correct. A review of the facility's provided Medication Administration General Guidelines for the Administration of Medications policy dated updated March 2023 included Administration of Controlled Dangerous Substances is also recorded on the Declining Inventory Form as soon as medication is removed . NJAC 8:39- 29.2(d), 29.7(c)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed a.) to ensure residents on transmission-based precautions (TBP) were treated in a dignified and respectful manner for their toileting needs and b.) ensuring the privacy curtain was closed during personal care. This deficient practice was identified for 2 of 35 residents (Residents #19 and #213) reviewed for dignity, and was evidenced by the following: 1. On 4/14/23 at 9:30 AM, during the initial tour of the facility, the surveyor observed cautionary signage and a personal protective equipment (PPE; clothing or equipment worn to protect the body from harm or infection) bin outside of Resident #19's room. A Stop Sign cautioned that TBP (precautions intended to prevent transmission of infectious agents) were in effect and directed to perform hand hygiene and don (put on) gloves and gown before entering the room. The surveyor observed Resident #19 who self-propelled themselves in a wheelchair within the room. When interviewed, the resident stated that he/she had a urinary tract infection (UTI), and was not permitted to use the bathroom because their roommate used it. The resident further stated staff instructed the resident to both defecate and urinate in their incontinence brief because there was a chance that their roommate could become infected if they used the bathroom. The resident stated that their roommate went to the hospital about a week ago and he/she was not happy about it, and preferred to use the bathroom; at least while the roommate was hospitalized . The resident confirmed that their skin was not affected. The resident reported occasional incontinence and stated that he/she was able to call for help to use the bathroom and knew when he/she had to go. The resident further stated that neither a bedside commode nor bed pan were offered in lieu of going to the bathroom in their brief. On 4/11/23 at 10:15 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #19 required total assistance for activities of daily living (ADLs), and used to go into the bathroom. CNA #1 explained that the resident no longer used the toilet because the resident could not stand for a long period of time. CNA #1 stated that the resident wore an incontinent brief and was able to tell her when they had to go to the bathroom or when they needed to be changed. CNA #1 stated that a gown, gloves, mask, and goggles were required to enter the resident's room due to the presence of ESBL in the resident's urine. The surveyor reviewed the medical record for Resident #19. A review of the Admission Record face sheet (an admission summary) revealed that the resident was readmitted to the facility in October of 2022 with diagnosis which included mixed incontinence (involuntary leakage of urine associated with urgency, exertion, sneezing or coughing), Type 2 diabetes mellitus (the body does not produce enough insulin, or is resistant to insulin), general anxiety disorder, constipation, and polyosteoarthritis (joint pain and stiffness). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/10/23, reflected the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. Further review of the MDS revealed that the resident required extensive assistance of one-person for bed mobility, transfers, toilet use, and personal hygiene. Further review of the MDS revealed that the resident was frequently incontinent of urine and frequently incontinent of bowel and a toileting program was not being used to manage the resident's urinary or bowel continence. On 4/12/23 at 11:13 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN #1) who stated that Resident #19 did not currently have a roommate. UM/LPN #1 stated that Resident #19 informed her that the resident did not use the bathroom, as he/she was incontinent, and the aides provided incontinence care in the resident's bed. The UM/LPN #1 further stated that Resident #19 requested to use the bathroom after they had spoken with the surveyor, and that Physical Therapy (PT) had since evaluated the resident, who was deemed able to use the toilet with assistance. UM/LPN #1 stated that the resident must be the only one who used the toilet due to their history of ESBL, and since the resident's prior roommate did not have ESBL, the resident's roommate was the only one who could use the bathroom. UM/LPN #1 further explained that Resident #19 declined to have their room changed when they tested positive for ESBL, and did not voice a desire to use the toilet. At that time, the surveyor asked UM/LPN #1 if she documented that Resident #19 was offered a room change and declined? UM/LPN #1 stated that she did not believe that she needed to document the conversation as the resident was incontinent at that time. UM/LPN #1 explained that the resident's urine tested positive for ESBL on 2/14/23, and was not treated with an antibiotic because the resident was determined to have been colonized (presence of a microorganism which does not cause harm or symptoms). UM/LPN #1 stated that she did not see it as a dignity issue. UM/LPN #1 further stated that if the resident's roommate returned from the hospital, she would change the resident's room or check with the family. On 4/12/23 at 12:17 PM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) who stated that if a resident were to test positive for ESBL and both residents used the same bathroom, then one of the residents must be moved to a different room. IP/RN stated, She would never tell a resident that they were not permitted to use the bathroom because it was a dignity issue to tell them to use the [incontinence brief] all the time for mixed incontinence. On 4/12/23 at 1:30 PM, the surveyor interviewed the Director of Rehab (DOR) who stated that as of 4/5/23, Resident #19 was currently receiving Occupational Therapy (OT, rehabilitation through performance of ADLs) for safety and transfer levels. The DOR confirmed that the resident previously received OT from 1/5/23-2/17/23 and was determined to have required moderate assistance overall at that time. The DOR stated that the resident was presently at baseline and was able to use the toilet with one-person moderate assistance. A review of a Certified Nursing Assistant (CNA) Assignment Sheets dated 4/3/23, 4/5/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, and 4/13/23, revealed that Resident #19 required complete care, transferred with stand and pivot technique, and was continent of bowel and bladder. On 4/13/23 at 11:13 AM, the surveyor observed that Resident #19's roommate returned from the hospital and shared a room with Resident #19 once more. On 4/13/23 at 12:02 PM, the surveyor interviewed LPN #1 who stated that Resident #19's roommate returned to the facility last evening, and did not use the bathroom at this time. On 4/13/23 at 12:17 PM, the surveyor interviewed the Medical Director (MD) in the presence of the survey team via speaker phone with permission. The MD stated that when a resident was colonized with ESBL (Extended Spectrum Beta-Lactamase; enzymes produced by bacteria that are resistant to antibiotics) and required TBP, the facility had to come up with a safe scenario for bathroom use which may include not letting one of the residents use the bathroom. The MD stated they may offer an alternative such as a bedside commode or bedpan. The MD further stated that an incontinence brief was not always the best choice, but would be better than using the same toilet or commode. The MD stated it was hard to say if telling the resident to go in their brief was a dignity issue; that you had to be thoughtful of the safety of the negative resident. On 4/17/23 at 12:40 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when a resident tested positive for ESBL and their roommate was negative, the facility determined whether the resident was incontinent and wore an incontinence brief, otherwise, a room change was implemented. The DON stated that UM/LPN #1 could have documented that Resident #19 had a positive urine culture and was offered a room change and declined. The DON stated that she was surprised that Resident #19 did not communicate a desire to go to the bathroom, instead of in their incontinent brief. On 4/18/23 at 10:45 AM, the surveyor observed Resident #19 seated their wheelchair at the bedside. When interviewed, the resident stated that he/she was now able to use the bathroom and wore an incontinent brief just in case. 38080 2. On 4/13/23 at 9:20 AM, the surveyor heard screaming coming from a resident's room with a closed door. The surveyor proceeded to knock on the door, announced themselves, and began to open the door. The surveyor was informed by CNA #2 that she was providing care for Resident #213. The surveyor observed Resident #213 lying in bed with an incontinent brief on with exposed legs, torso, and arms with the privacy curtain not closed as CNA #2 provided care with a washcloth to their torso. The resident's unsampled roommate was sitting in their bed facing Resident #213 and CNA #2 with their privacy curtain opened as well. At this time, CNA #2 immediately started closing the privacy curtain for Resident #213 to provide privacy for the resident. On 4/13/23 at 9:26 AM, CNA #2 exited Resident #213's room and the surveyor interviewed the aide who confirmed she was rendering care to Resident #213. The surveyor asked if the privacy curtain should be opened or closed when rendering care, and CNA #2 stated the curtain should be closed for the resident's privacy. CNA #2 confirmed she had not closed Resident #213's privacy curtain while rendering care which exposed the resident, she continued that the resident's unsampled roommate preferred the privacy curtain opened. The surveyor stated you were rendering care to Resident #213 and not their roommate, which CNA #2 acknowledged the curtain should have been closed. On 4/13/23 at 9:35 AM, the surveyor interviewed UM/LPN #2 who stated when staff was providing care to a resident, they were expected to pull the privacy curtain closed prior to rendering care to ensure resident privacy and dignity, as well as make sure the room door was closed. At this time, the surveyor informed UM/LPN #2 of their observation with CNA #2, and she confirmed that CNA #2 should not have rendered care on Resident #213 until their privacy curtain was closed. On 4/13/23 at 10:09 AM, the surveyor interviewed the DON who stated CNA #2 was an Agency staff aide who was oriented on facility policy and procedure prior to attending to the residents. The DON continued that staff was expected to close the privacy curtain prior to rendering resident care for privacy, which was a standard of practice. The surveyor reviewed the medical record for Resident #213. A review of the Admission Record face sheet reflected that the resident was admitted to the facility in September of 2021 with diagnoses which included Alzheimer's Disease, essential hypertension (high blood pressure), major depressive disorder, and generalized anxiety. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score undetermined, with short and long-term memory problems and a severely impaired cognition. On 4/19/23 at 10:46 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, acknowledged CNA #2 had not closed the resident's privacy curtain, and she stated that CNA #2 acknowledged she was aware that she should have closed Resident #213's privacy curtain prior to rendering care. A review of the facility's Resident Rights policy dated January 2023, included to be treated with courtesy, consideration, and respect for your dignity and individuality . A review of the facility's undated Nursing Assistant Skills Review Checklist included Interpersonal Skills/Communication .pulls curtains, drapes when giving care . A review of the facility's Isolation Precautions/COVID-19 policy dated revised January 2023, included isolation precautions .the resident will be placed in a private room, if possible. When a private room is not available, the resident will be placed with another resident who is colonized or infected with the same organism and isolation type (contact versus droplet) but does not have any other infection (cohorting) . NJAC 8:39-4.1(a)(12)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #152) reviewed for abuse. This deficient practice was evidenced by the following: On 4/3/23 at 11:18 AM, the surveyor observed Resident #152 laying on the bed requesting assistance from the nursing staff. On 4/12/23 at 10:20 AM, the surveyor was informed by Resident#152 of a situation involving a Certified Nursing Assistant (CNA). With Resident #152's permission, this conversation was held in the presence of their roommate (Resident #113). Resident #152 advised that the CNA grabbed my arm [ .] shook me [ .] I was crying. Resident #152 further stated that the CNA pulled on my arm [to cover me up] because I had a rash from dialysis. I told her i got a rash and she said you don't have [breasts] hanging out like that. Resident #113 confirmed the entire event and stated that Resident #152 was crying after the event. When asked if the CNA has been assigned to Resident #152 or Resident #113, they both confirmed that they have not seen the CNA since that time. A review of the Admission Record face sheet (an admission summary) reflected the resident was readmitted to the facility in March of 2022 with diagnosis which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side. A review of Resident #152's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/9/23, the resident had a brief interview for mental status (BIMS) score of 9 out of 15, which indicated a moderately impaired cognition. Further review of the MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). A review of Resident #113's the most recent quarterly MDS dated [DATE], the resident had a BIMS score of 15 out of 15, which indicated that the resident is cognitively intact. The surveyor reviewed the facility provided Grievance Packet, for 1/30/23 included the following: A review of the Grievance Form dated 1/30/23, which it was reported that the Social Worker (SW) met with Resident #152 on 2/1/23. Resident #152 reported that on 1/30/23, the resident's CNA attended to the resident to provide care. Resident #152 stated that the CNA started pulling on my arm [ .] I told her that you don't have to touch me [ .] she kept pulling on my arm [ .] I was crying and so shocked. A review of the Staff Statement form by the Nursing Supervisor, that identified the incident date of 1/31/23 at 2:10 PM. The reported allegation occurred on 1/30/23. The description of the incident identified that a call was received from [Resident #113] at about 6:30 PM. The documented statement did not address the concerns that were identified with the grievance including the remarks I was crying and so shocked I asked [Resident # 113] to call my sons and tell them. The documented statement identified actions that were taken and did not confirm the identity of the alleged CNA. A review of the section titled, Actions taken, included All appropriate departments made aware. Allegation is unfounded. A review of the section titled, Final Response, was blank. On 4/12/23 at 9:50 AM, the Director of Nursing (DON) was interviewed by the survey team. During the interview, the DON confirmed that a roommate could be identified as a witness and they would write or have phone interview with them. The DON further explained that upon conclusion of the investigation, the resident's care plan was updated with interventions. On 4/19/23 at 9:52 AM, the DON was interviewed by the survey team. When asked if the investigation was completed, the DON stated, There wasn't abuse. The DON was questioned why there was no statement from Resident #113 regarding the grievance. The DON responded that Resident #113 had his/her privacy curtain closed. When asked if the Nursing Supervisor followed-up with the claims that Resident #152 was crying or if the resident's family was contacted, the DON responded, I will have to double check. When asked if the resident was questioned if he/she would like the CNA to continue to care for the resident, the DON responded, that the [residents] preferred men. The DON confirmed that this was not documented on the grievance form. When the surveyor inquired if the care plan was updated to identify any interventions, the DON stated, I can double check. The survey team asked if there should be a summary or response on the second page of the grievance form? The DON acknowledged that there should be some type of summary completed. A review the facility's Abuse and Neglect Policy and Procedure, dated November 2022, included the definition of alleged violation: a situation nor occurrence that is observed or reported by staff, another health care provider, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source, and misappropriation of resident property .Investigative and Reporting .the following steps will be taken: Incident report will be completed; Interviews will be conducted- an statements obtained from all staff members, residents, family, volunteers and others that may have witnessed or have knowledge with the respect to the alleged events; All such statements will be in writing and place in the investigatory file related to the alleged incident; The employee file of any accused staff will be reviewed. All findings from such a review will be memorialized in writing and placed in the investigatory file related to the alleged incident; [ .] A written report, which among other things, provides an overview of the incident, pertinent medical data, and a summary of statements take, investigative findings, follow-up actions and a conclusion will be prepared; [ .] based on investigative findings may implement corrective action to prevent further potential abuse that may include, but are not limited to, staffing changes, etc . A review the facility's Social Services Policy and Procedure for Resident Grievances, dated November 2022, included .Grievance Officer responsibilities: ensuring that all written grievances decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued .Process .After reviewing the information and facts fathered during the investigation, the employee responsible for answering the grievance will put a report in writing and submit it to the Administrator/Grievance Officer (GO). The report is to include: the date the grievance was received; a summary of the grievance; record of who was interviewed; record of information/facts gathered; any conclusions/recommendations made regarding the grievance; the date the written decision was issued . NJAC 8:39-4.1(a)(5)

NJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) implement care plan interventions of a silent bed alarm for a resident with a history of falls; and b.) develop and implement a care plan for a resident with limited range of motion which included daily right hand splints and a bilateral knee pillow. This deficient practice was identified for 2 of 35 residents (Resident #15 and #152) reviewed for comprehensive care plans and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The resident was wearing non-skid socks. The surveyor reviewed the medical record for Resident #15. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in August of 2020 with diagnoses which included dementia, major depressive disorder, persistent mood disorder, unspecified psychosis not known to a substance or known physiological condition, insomnia, and essential hypertension (high blood pressure). A review of the most recent quarterly Minimum Data Set (MDS), and assessment tool dated 2/16/23, reflected the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. A further review in Section J. Heath Conditions, included the resident had two falls with no injury and one fall with injury (except major) which included skin tears, abrasions, lacerations, and superficial bruises since admission to the facility. A review of the Progress Notes included a Nurses Note dated 10/22/22 at 8:02 AM, that the resident was observed [scooting] on [his/her] buttock in the hallway around 7:10 AM. The resident was assessed with no injury or complaint of pain and was unable to state how he/she got to the floor. The resident's bed was noted on the lowest position, wheelchair was at bedside, and the resident wore non-skid socks. A further review of the Progress Notes included a Nurses Note written by Licensed Practical Nurse (LPN #1) dated 10/22/22 at 8:09 AM, that the resident was received in bed asleep upon my arrival on shift. The resident was redirected several times and assisted back to bed during the shift. Around 7:00 AM, staff noticed the resident on the floor at the entrance of his/her room and the Supervisor was made aware. Upon assessment, no injury was noted or pain. A review of the resident's comprehensive person-centered care plan included a focus area initiated on 8/20/2020, for the resident was at risk for falls with regards to impaired mobility, cognitive impairment/dementia with behaviors, poor safety awareness, history of falls, diagnosis of cataracts (clouding of a normally clear eye lens), pain, use of high-risk medications, depression, anxiety, insomnia, psychosis, incontinence, and hearing loss. Interventions included to silent bed alarm to bed, check placement/function every shift; bed against side of wall; and encourage to use call bell for assistance. A review of the Order Summary Report dated active orders as of 10/31/22, included a physician's order (PO) dated 10/11/22, for silent bed alarm connected to call bell; check placement and function every shift. On 4/11/23 at 9:00 AM, the surveyor requested from the Director of Nursing (DON) all incident and accident investigations for Resident #15. On 4/11/23 at 11:06 AM, the surveyor observed Resident #15 sitting in their wheelchair in the dayroom. The resident was sitting at the table having a snack repeating the word please, and was unable to be interviewed. On 4/11/23 at 11:47 AM, the surveyor received the requested investigations from the DON and the surveyor reviewed the unwitnessed incident report dated 10/22/22. The report included the resident was observed scooting on their buttocks in the hallway outside his/her room and was unable to give description; the resident was confused. The bed was noted in the lowest position, wheelchair was noted beside his/her bed, and he/she wore nonskid socks. Witness statements included from LPN #1 that the resident was received in bed and redirected several times back to bed. Around 7:00 AM, he/she was noticed on the floor by the entrance of their room and the Supervisor was made aware. An additional witness statement from Certified Nursing Aide (CNA #1) included I was about to walk down the hallway when I noticed Resident #15's feet out of the doorway on the floor; notified nurse and the resident's wheelchair was next to bed. Prior to the fall, CNA #1 indicated the resident was in bed asleep. The fall conclusion indicated probable causes of the fall unknown, fall interventions in place prior to fall were call light within reach, proper footwear, and bed against wall. Staff were at the Nurse's Station when they observed resident in the hallway scooting on their buttocks. Resident's bed was observed in lowest position, non-skid socks were on their feet, and wheelchair was noted next to bed. The investigation did not include the intervention of silent bed alarm. On 4/12/23 at 9:50 AM, the surveyor interviewed the DON regarding the facility's investigation process. The DON stated that for a fall, staff interviewed and collected statements from any witnesses or staff that cared for the resident. The team reviewed all statements, any video surveillance footage, reviewed interventions put in place at the time to determine the cause of the incident and if new interventions should be implemented. The care plan was reviewed and updated as necessary. On 4/17/23 at 10:50 AM, the surveyor interviewed CNA #1 who stated that Resident #15 had behaviors of screaming and yelling, and they were non-compliant with asking for assistance from staff. CNA #1 stated on the day of the incident on 10/22/22, she was standing at the Nurse's Station, and she recalled hearing the resident's screams which sounded closer. She continued that she observed the resident scooting themselves down the hallway on their buttock. CNA #1 stated the resident had a silent bed alarm currently, but did not recall if at the time the resident had the silent bed alarm. CNA #1 continued that the silent bed alarm rang only at the Nurse's Station and the resident's light outside their door turned on when triggered. CNA #1 stated she did not recall hearing a bed alarm ring; she only heard the resident's screams. On 4/17/23 at 11:50 AM, the surveyor interviewed LPN #1 who stated the resident did not sleep at night and spent most of the night self-propelling in their wheelchair down the hallway screaming. LPN #1 continued that the resident had medication to manage their behaviors, but he/she refused their medication at night. LPN #1 continued that the resident had a history of falling because he/she tried to get out of bed without assistance. She continued that the resident had a silent bed alarm that she had to check the placement and function during her shift that rang at the Nurse's Station, but she could not recall when the alarm was ordered. LPN #1 stated she recalled on 10/22/22, seeing the resident's legs or feet in the hallway as the resident dragged themselves out of the room. The surveyor asked if the resident had a silent bed alarm at this time, and LPN #1 stated she did not recall hearing an alarm, and staff would have run into the room and she would not have been able to drag [him/herself] on [his/her] buttocks into the hallway; staff would have made it to her room by then. On 4/17/23 at 12:36 PM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated Resident #15 was a high risk for falls. The UM/LPN continued that the resident's had a silent bed alarm that rang at the Nurse's Station if the resident got out of bed without assistance. The UM/LPN stated the resident's had the silent bed alarm she thought since October 2022, and the nurses checked for placement and function every shift. The UM/LPN stated she was not in the facility at the time the resident's fall on 10/22/22, so she was unable to speak to it. On 4/17/23 at 12:46 PM, the surveyor accompanied by the UM/LPN went into Resident #15's room, and the UM/LPN checked the function of the resident's silent bed alarm. The surveyor observed the light outside the resident's room illuminate and observed the call system activate at the Nurse's Station and the alarm sound. On 4/19/23 at 10:46 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team acknowledged that the resident had a silent bed alarm at the time of the fall, but she could not speak to if the alarm was activated that morning. 45209 2. On 4/3/23 at 11:18 AM, the surveyor observed Resident #152 lying on the bed requesting assistance from the nursing staff. A review of the Admission Record face sheet reflected the resident was readmitted to the facility in March of 2022 with diagnosis which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side. A review of the most recent quarterly MDS dated [DATE], had a BIMS score of 9 out of 15, which indicated a moderately impaired cognition. Further review of the MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). A review of the Ordered Summary Report dated 4/18/23, included a physician's order (PO) dated 11/9/22, to apply splint to right hand apply in AM and remove at HS (at bed) everyday and evening shift; worn six to eights hours and perform skin checks after removal. An additional PO dated 2/16/23, to apply pillow under bilateral (left and right) knee to ankle when in bed every shift. A review of the comprehensive care plan did not include the resident's need for right hand splint or pillow under both knees. On 4/12/23 at 10:58 AM, the surveyor observed Resident #152 lying in bed without a splint applied to the right hand. The resident was covered in a blanket and the surveyor was unable to observe if the pillow was placed under their knees at this time. On 4/13/23 at 1:30 PM, the surveyor observed Resident #152 lying in bed without a splint applied to the right and without a pillow under both knees. On 4/14/23 at 11:26 AM, the surveyor observed Resident #152 lying in bed without a splint applied to the right and without a pillow under both knees. On 4/14/23 at 11:26 AM, the surveyor observed Resident #152 lying in bed without a splint applied to the right and without a pillow under both knees. On 4/17/23 at 10:08 AM, the surveyor observed Resident #152 lying in bed without a splint applied to the right and without a pillow under both knees. On 4/17/23 at 11:30 AM, the surveyor interviewed LPN #2 regarding Resident #152 physician's orders. LPN #2 advised that the splint use was up to [him/her] if [he/she] wants it or not. The surveyor inquired if there was supposed to be documentation of the splint being offered and denied. LPN #2 responded, it can be. Upon review of the nursing documentation, LPN #2 stated, it isn't documented, so [cannot] say if it was done. The surveyor also inquired about the physician's orders regarding the pillow for under the knees. LPN #2 reviewed the nursing documentation and reported, I [do not] see any documentation of refusal or offering. When asked who was responsible for ensuring that physician's orders were followed, LPN #2 stated, everyone has the responsibility to review their orders and task sheets. On 4/17/23 at 01:39 PM, the surveyor interviewed CNA #2 if the resident was supposed to be wearing splint. CNA #2 responded, she [does not] always ask to put it on. I always ensure that it is on. The surveyor pointed out that the resident was not currently wearing the splint. CNA #2 asked Resident #152 if he/she would like the brace on and the resident responded, yes. On 4/17/23 at 01:39 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the expectation of staffing following physician's orders. The ADON responded that everyone was expected to follow the physician's orders as written. When asked regarding residents with range of motion deficits and their splints the ADON stated the nurses were responsible to communicate to the aides and document. When asked if the splint and pillow physician's order were identified on Resident #152's care plan the ADON responded that she had just updated the care plan to include it. A review of the facility's untitled policy dated November 2013, included it was the facility's policy that each resident would have a comprehensive care plan which will include possible intervention, measurable objectives and target time to meet a resident's medical, nursing, physical and psychosocial needs .the interdisciplinary team will review and revise the comprehensive care plan and all interventions thereafter during quarterly, annual and with any significant change care conference to ensure all interventions are appropriate and set up next target date .the unit manager/nursing supervisor or licensed nursing representative during the [interdisciplinary care] meeting will revise and update the care plan as necessary (Examples: incidents, infections, behaviors, new interventions, new medications, wounds . A review of the facility's Fall Prevention Investigating and Management Policy & Procedure dated revised January 2023, included if a resident is determined to be a fall risk, a care plan will be initiated to promote independence and safety. Individualized interventions will be initiated based on the fall risk score of each resident . A review of the facility's untitled policy dated revised January 2023, included it was the facility's policy to maintain optimum function for the residents. Splints and other assistive devices will be utilized to achieve this goal .the licensed nurse will document in the [Treatment Administration Record] regarding usage .the CNA staff can assist with applying the splint/brace. The CNA staff will monitor the splint usage on a daily basis, and they will document said usage in the task tab in [electronic medical record]. CNA staff will report to licensed nurses any issues or concerns with resident's splint/brace or change in status for appropriate evaluations and interventions . NJAC 8:39-27.1(a)

Based on observations, interviews, review of pertinent facility documents, it was determined that the facility failed to ensure that residents who required extensive assistance from staff with activities of daily living (ADL) were provided care consistent with their needs and preferences. This deficient practice was identified for 2 of 4 residents (Resident #223 and Resident #285) reviewed for activities of daily living, and was evidenced by the following: 1. On 4/4/23 at 10:10 AM, during the initial tour of the facility, the surveyor observed Resident #223 lying in bed awake. The resident stated that they had left sided weakness related to a cerebrovascular accident (CVA; a loss of blood flow to part of the brain, which damages brain tissue). Resident #223 held up his/her left hand and demonstrated an impaired ability to fully open and close their left hand. The surveyor observed that the resident's fingernails were long. The resident stated the staff did not offer to cut or trim his/her fingernails and the resident had tried to trim them by himself/herself. The surveyor reviewed the medical record for Resident #223. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in June of 2022 with diagnoses which included transient ischemic attack [TIA or mini stroke], cerebral infarction [stroke] without residual deficits; acquired absence of left leg below knee [amputation]; and unspecified dementia. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/5/23, indicated the resident had a brief interview for mental status (BIMS) score of 3 out of 15; which a severely impaired cognition. Further review of the MDS revealed that the resident required extensive assistance of one-person for personal hygiene. A review of the comprehensive care plan included a focus area for impaired functional status related to decline in mobility/generalized weakness status post recent hospitalization status post left below knee amputation. The resident's care plan did not include personal hygiene or nail care. A review of Certified Nurse Aide (CNA) ADL tracker, a communication tool used by CNAs with specific resident care needs and preferences, reflected the CNA's documentation from 4/1/23 to 4/18/23 reflected the resident only refused personal hygiene care on 4/14/23. The CNA ADL tracker did not include nail care. On 4/11/23 at 10:29 AM, the surveyor observed Resident #223 lying in bed awake watching television. The resident's teeth were observed with a buildup of a white-colored substance. Resident #223 stated that he/she had not had a toothbrush since being moved to the unit, and it bothered him/her to not have teeth brush. The resident's fingernails remained long and were not trimmed. The resident stated his/her left hand was weak, but he/she was going to peel his/her nails off. The resident stated that morning care was completed already. On 4/12/23 at 11:45 AM, the surveyor observed the resident and the resident's fingernails remained long and had not been trimmed. The resident stated his/her teeth had not been brushed. On 4/13/23 at 11:41 AM, the surveyor observed that the resident's fingernails had not been trimmed. The resident stated his/her teeth had not been brushed. On 4/13/23 at 11:46 AM, the surveyor interviewed CNA #1 who stated Resident #223 required complete care. CNA #1 stated that the care she provided to the resident included a complete bed bath, brief change, and linen change. The surveyor asked about the resident's mouth care and CNA #1 replied that the resident refused mouth care. The surveyor asked CNA #1 to show the surveyor where the resident's toothbrush was kept. CNA #1 responded, they may have thrown it away. She then proceeded to open the drawer and noted the toothbrush was not in the resident's basin. CNA #1 then found an opened multiple package container that contained one toothbrush and stated she did not see it that morning. The surveyor asked CNA #1 if she noted the length of the resident nails, to which CNA #1 replied, No, I did not. CNA #1 stated she would have reported it to the nurse and received permission to clip them if she did. On 4/13/23 at 11:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was assigned to Resident #223. He stated that the resident was totally dependent for ADLs. The surveyor accompanied the LPN to observe the resident's fingernails. The LPN stated that the resident's nails were uneven, the fingernails were longer on the right side than on the left. The LPN agreed that the residents' nails needed to be trimmed. The LPN stated he did not observe the resident's need for oral care or nail care when medications were administered. On 4/13/23 at 12:10 PM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated that oral care should be done twice daily and nail care should have been assessed daily to see if the fingernails needed to be trimmed. The UM/LPN stated that at approximately 10:00 AM, she directed an extra nurse on the unit to assist with nail care. The UM/LPN stated she noticed that the fingernails of Resident #223 were a little long that morning, and she did not believe that CNAs documented nail care. The UM/LPN acknowledged it was concern and that she would have an aide complete the resident's nail and oral care. On 4/13/23 at 12:44 PM, surveyor interviewed LPN #2 who stated that she was asked to trim the fingernails of Resident #223 and she had cut them. LPN #2 stated the nails on the resident's right hand were longer than the left because the resident stated that he/she bit their fingernails, and that some of the resident's fingernails looked like the resident had ripped them off. LPN #2 also stated that the resident was eating their meal and did not want mouth care at that time. On 4/17/23 at 1:06 PM, the surveyor interviewed the Director of Nursing (DON) who stated that staff assisted with resident ADLs based on care needs. The DON stated that both nail and mouth care should be offered daily as CNAs were taught this and know what was expected as a caregiver. On 4/19/23 at 9:48 AM, the surveyor asked the DON what the process was when a resident refused care. The DON stated that when a resident refused, the CNA should tell the nurse and the nurse should document the refusal. 36419 2. On 4/5/23 at 10:50 AM, the surveyor observed Resident #285 in his/her room awake in bed. The surveyor asked Resident #285 about the care he/she received with their ADLs. Resident #285 stated that they were offered showers, but preferred bed baths so staff assisted him/her with bed baths. Resident #285 stated that he/she wanted their fingernails cleaned, but staff never offered or provided nail care. The resident stated, I don't know how they got so dirty. On 4/11/23 at 10:25 AM, the surveyor observed Resident #285 in bed. The surveyor observed the resident's fingernails were long, jagged, and soiled with black substance caked under all ten fingernails. The resident stated they were never given nail care. The surveyor reviewed the medical record for Resident #285. A review of the Admission Record face sheet reflected the resident was admitted to the facility in March 2023 with diagnoses which included left closed hip fracture, diabetes mellitus, muscle wasting, sepsis and difficulty walking. A review of the admission MDS dated [DATE], reflected the resident had a BIMS score of 10 out of 15, which indicated moderately impaired cognition. A further review in Section G Functional Status reflected that the resident required one-person extensive physical assistance for personal hygiene. A review of the comprehensive care plan initiated on 3/13/23, included that the resident had impaired functional status with regards to a decline in mobility and generalized weakness due to left hip fracture post fall. Interventions included to assist with ambulation and bed mobility, and to encourage participation in ADLs as tolerated to increase independence. The comprehensive care plan did not include nail care or hygiene. A review of the resident's electronic CNA ADL tracker reflected the CNAs documented they provided a bath/shower or sponge bath for Resident #285 daily from 4/2/23 to 4/10/23. The document revealed that the resident refused their bath/shower/sponge bath one time on 4/3/23, during that time period. The ADL tracker did not include nail care. On 4/11/23 at 11:25 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) who stated that CNAs and nurses provide nail care to residents when needed. The UM/RN further stated the CNAs should check the residents' fingernails daily. The surveyor asked the UM/RN to observe Resident #285's fingernails and the UM/RN acknowledged that the resident's fingernails were long and soiled with black material caked under all ten nails. On 4/11/23 at 11:35 AM, the surveyor interviewed the CNA #2, the resident's aide, who stated that she had never assisted Resident #285 with their nail care because she had not noticed before this time how dirty his/her fingernails were. CNA #2 stated that Resident #285 usually refused their shower, but she never informed the UM/RN or any nurse when the resident refused his/her shower. At that time, the UM/RN asked Resident #285 if she could soak, clean, and clip their nails. Resident #285 replied, as long as you don't clip me, you can clean them but don't cut them too short. The surveyor observed the UM/RN cleaned the resident's nails with the resident's permission. On 4/11/23 at 12:05 PM, the surveyor interviewed the DON who stated it was the CNA's responsibility for providing nail care and all other ADL care and that if the resident refused any care, the CNA was responsible for informing the nurse and the nurse documented the refusal in their nursing progress note. On 4/12/23 at 12:25 PM, the surveyor interviewed Resident #285, who showed the surveyor his/her fingernails and stated that the nurse had cleaned and trimmed them. The resident smiled and stated, my nails are much better. On 4/18/23 at 1:32 PM, the surveyor informed the LNHA and DON the above observations and concerns. A review of the facility's Nursing Assistant Skills Review Checklist dated March 2023 included ADLs Care of Resident . nail care (no toenail clipping only clipping of fingernails.) .mouth Care . A review of the facility's Residents Hygiene policy dated revised October 2022 included residents will be offered shower/bath at least twice weekly . upon refusal of shower/bath from the resident, CNA will notify the nurse . NJ 8:39-27.1(a)

Complaint # NJ Based on interviews, review of the medical records and other facility documentation, it was determined that the facility failed to protect residents on 2 units from abuse and failed to develop/implement any additional interventions when previous interventions were not effective for 2 of 5 sampled residents (Residents #1 and #3). On 4/10/2013 Resident #1, who had a history of [REDACTED]. The incident/event was documented in the medical record, however current interventions were not reviewed and/or revised after this behavioral escalation in order to prevent another incident or protect all other residents on the unit from potential harm. The Immediate Jeopardy (IJ) for Resident #1 began on 4/10/2013, was identified on 4/15/2013, the first day of survey by the surveyor and relayed to the Director of Nursing (DON) and Administrator at approximately 1:00PM and was lifted that day at approximately 3:00PM when the facility implemented an acceptable plan of correction (POC). Resident #1 was the resident previously cited in F224 K during the annual survey of 3/5/2013. In addition, Resident #3, who had a previous history of physically abusing a resident, was witnessed hitting Resident #4 on 3/23/2013. Review of the CP showed the intervention added to prevent a recurrence for this resident, who was moderately cognitively impaired, was to remove her from the area, bring back to her room and give "education to keep hands to herself". Subsequently, on 3/25/2013, Resident #5 reported that Resident #3 hit her although Resident #3 denied the incident, she was removed from the area, became verbally abusive toward other residents in front of the nursing station and placed in her room. Resident #3's Care Plan interventions were not revised to include monitoring or prevention until 3/28/2013 which left all residents on the unit at risk for potential harm from Resident #3. The Director of Nursing (DON) and Administrator were notified at approximately 12:00PM on 4/18/2013 that the IJ was past non compliance (PNC) since the facility implemented interventions on 3/28/2013. The deficient practice is evidenced by the following; 1. According to the admission sheet, Resident #1 was admitted to the facility in April, 2012 with [DIAGNOSES REDACTED].A Minimum Data Set, (MDS), an assessment tool, dated 1/30/2013 showed Resident #1 was severely cognitively impaired and needed some assistance with activities of daily living. The MDS showed Resident #1 was ambulatory with the use of a cane as an assistive device. A CP, initiated 5/11/2012 and updated 4/1/2013 showed Resident #1 had behavioral symptoms with a target to decrease behaviors to less than one episode in 90 days. Interventions included but were not limited to; monitor for increased behaviors and notify the physician. The CP noted 2 episodes in February, 2013 of aggressive behavior with staff and/or another resident. Interventions included but were not limited to; monitor behaviors, update physician and Psychiatrist as needed, bed alarm for safety, private room close to nursing station was initiated 3/1/2013 and when agitated notify physician/psychiatry or S-COPE (a mental health services program) staff in a timely manner.Additionally, on 4/1/2013, the CP showed an incident of Resident #1 hitting another resident (#2) on the face. Interventions included; S-COPE and Psychiatry evaluations were scheduled, Resident #1 was sent to crisis, every (q)15 minute checks by staff were "ongoing", use 1:1 intervention and re-direction when agitated, remove and redirect when area is over stimulated, offer snack as diversion and Social Worker (SW) to assist family with discharge planning (d/c). Review of a Facility Reportable Event Form (AAS-45) sent by the facility to the N.J. Department of Health (DOH) on 4/11/2013 showed that on 4/1/2013 at 6:30PM, Resident #1 "punched (Resident #2) to the right side of her face". Resident #2 was removed from the area, ice applied to her face and she was noted with slight bruising in the area the next day.A Nursing "Event" Note, dated 4/1/2013 recorded at 7:51PM by the Registered Nurse (RN) Supervisor confirmed the AAS-45 and included that the event occurred in the main dining room (DR) and was witnessed by the RN Supervisor. A NN, dated 4/1/2013 at 7:46PM recorded by the Unit 3-11 shift Charge RN noted the incident and indicated Resident #1 had a history of [REDACTED]. The NN showed his behavior was monitored every 15 minutes and "he is ambulatory and paces on the unit." The physician was notified and an order to send to crisis was obtained. Resident #1 returned to the facility on [DATE] according to the NN, at 7:15AM and every (q) 15 minute monitoring continued.On 4/2/2013, a Social Service Note (SSN) recorded by the Social Worker (SW) at 5:41PM noted that due to the 4/1/2013 incident it was decided to move forward with discharge (d/c). The SW spoke with staff at S-COPE who explained "that dementia is a (an) exclusionary dx (diagnosis) and (Resident #1) should not go to crisis but rather call S-COPE 24/7 at (phone number)."Resident #1 was seen on 4/2/2013 by his primary physician and had a Psychiatry Evaluation. The Psychiatry Evaluation noted the [DIAGNOSES REDACTED]. Recommendations included an increase of medications, [MEDICATION NAME] and [MEDICATION NAME] and noted "pt (patient) would be best helped in behavior unit and behaviors are unprovoked, out of proportion and violent." There was no indication that the resident saw the Psychiatrist after 4/2/2013.A NN, dated 4/3/2013 at 9:09AM by the RN Unit Manager (UM) noted that staff from S-COPE would not be in for another evaluation for Resident #1, "do (due) to that they only assist with managing behaviors of dementia and at this time due (to) his unpredictable behaviors that he is to be referred to ...(a) behavioral unit. ...she (S-COPE staff) requests that...we (the facility) pursue other placement for this resident".The following NNs showed behavior documentation; 4/8/2013 at 5:54AM "some aggression noted... pt. got OOB (out of bed) and urinated on floor of his room when CNA (certified nurses aide) tried to redirect him to the bathroom he became verbally abusive and threatening...", 4/9/2013 at 6:29AM, observed wandering on unit. CNA able to escort him to his room...", at 3:31PM, "OOB wandering on unit" with no behavior issues, at 9:54PM, "ambulated in the hallway and was assisted to his room." A monitoring log sheet documented q 15 minute monitoring for Resident #1 was completed and signed by nursing staff from 4/1/2013 through 4/15/2013.A "Behavior Note" on 4/10/2013, recorded by the Charge 11-7AM Licensed Practical Nurse (LPN) at 3:08AM showed; "...about 1:30AM resident's (#1) alarm sounded and staff went to check on resident. He was observed trying to squeeze himself between the headboard and the wall. Staff cued him to the right direction but he was resistance (resistant). He climbed over the bed and got in the bathroom where he stayed for 30 minutes undoing and lifting the commode placed on top of his toilet seat...monitored for safety...When staff offered resident snack/assistance resident stated 'It looks like somebody is gonna get a punch' as he made a fist. While the nurse is still documenting on this note a shatter of glasses (glass) was heard in the residents room...He was observed with broken pieces of glasses from the picture frame. When staff tried to cue resident out from the scene for safety, he wanted to attack staff with a piece of glass. Supervisor notified at this time. She brought some staff over for help, Residents room cleaned of shattered glasses (glass) at this time. Resident had no injury and he is sitting on his bed at this time."A "Supervisor's Note" recorded on 4/10/2013 by the 11PM-7AM Registered Nurse (RN) Supervisor at 6:29AM, showed the following; "I was called to assist (Resident #1) as he had been in the bathroom for about half and hour...Staff reported that he made a fist and a gesture and stated that somebody is gonna get a punch...I advised staff to leave him alone for now but continue to keep a close watch on him... I was called again for a second time...staff went to check immediately and observed pieces of broken glass on the floor from a picture frame. Staff attempt to remove him from the area. He refused to move. He had a piece of glass in his hand and gestured that he's going the (to) attack... The male CNA re-assuringly explained to (Resident #1) that he was there to help him. (Resident #1) attempted to throw a punch at the CNA... (Resident #1) sat on the bed. No injury noted... Observed very closely." When interviewed, the RN Supervisor stated that "closely" meant q 15 minutes.Review of NNs after the incident/event on 4/10/2013 through 4/15/2013 showed no indication of any change in monitoring or any further reference to the incident. There was no documentation in the medical record to indicate that a physician, family member, S-COPE center, Administrator, Director of Nursing (DON) or Assistant DON was notified of the 4/10/2013 incident. Additionally, there was no indication that the room was checked for any additional items that would be potentially harmful to the resident and others. NNs, documented under SOAP notes for "objective" showed; on 4/11/2013 and 4/14/2013, Resident #1 was "alert" and "wandering". A NN, dated 4/15/2013, recorded at 9:37AM by the DON showed a "summarization of the following "Event" of 4/1/2013 reviewed on 4/2/2013 with the team..." The note summarized the incident of 4/1/2013 noting Resident #1 who punched Resident #2 was a witnessed event with immediate staff intervention, the resident was sent to crisis center and the team is seeking alternative placement in a behavioral facility. There was no mention of the incident/event that occurred on 4/10/2013.Review of the CP showed no indication of the incident/event of 4/10/2013 or that when the resident broke a picture frame and "wanted to attack staff with a piece of glass" or that the team met to discuss this incident, any additional interventions were put in to place after the event.During a post survey telephone interview with the surveyor on 4/19/2013 at 9:30AM, the 11PM-7AM unit LPN who worked on 4/10/2013 confirmed most of her statement in the NN. She added that she observed the broken picture frame and stated Resident #1 was holding onto a piece of the glass which was the size of her hand and confirmed that it was approximately 6 inches by 4 inches. She stated he was holding it out but she did not think he was threatening staff. She was unsure why she had documented that he was threatening to staff. She added that she did not notify the physician as Resident #1 was calm after the incident and there was no increase in monitoring as he was already on q 15 min. checks. She confirmed that he was able to ambulate freely on the unit.During a telephone interview with the surveyor on 4/17/2013 at 3:00PM, the 11PM-7AM RN Supervisor confirmed her documentation in the NN. She stated that she did not notify the physician as the resident had settled down after the incident. She stated that it was not until after the incident that she saw the note at the nursing station to call S-COPE if there was a change in behavior but Resident #1 had already calmed down. She stated that she did not increase monitoring as Resident #1 was already on q 15 min. checks. She confirmed that Resident #1 was fully ambulatory. She noted that she informed the RN Unit Manager (UM) in the morning report and "assumed that the UM would follow up" regarding notification of the physician. When asked by the surveyor if the room was checked for additional items of glass on 4/10/2013, the RN Supervisor responded that she had checked the room and found no other items.In addition, the the 11PM-7AM RN Supervisor stated that she noted the 11PM-7AM LPN had documented the incident in the NN under a "behavior" note. She stated she did not notice it at the time of the event but after she was inserviced by the ADON that the incident should have been documented as an "event" instead of "behavior" which would have triggered a sequence of events including documenting notification of physician, family and printing a copy for the DON for review. She confirmed that anything out of the ordinary is considered an "event" and is documented as such in the NN. She stated she was inserviced by the ADON on 4/17/2013. During an interview with the surveyor on 4/15/2013 at 11:45AM, the RN UM stated she was aware of the incident after she returned to work on 4/11/2013. When she was made aware she stated she did verbally notify the primary physician but did not document it. She also added that she questioned the 11PM-7AM Supervisor as to why Resident #1 was not sent out for a crisis intervention and was told that there was no injury and he had calmed down. The RN UM stated she was unaware if a team meeting was held to discuss the incident and also confirmed that she was aware that S-COPE was to be called with any behavior changes. During an interview with the surveyor on 4/15/2013 at approximately 12:00PM, the ADON stated that he had spoken with the 11PM-7AM RN Supervisor regarding the event on 4/10/2013 and asked why the physician had not been notified. He stated the Supervisor noted that since the resident had calmed down, she felt it did not rise to a level of notification at that time. The ADON stated the facility protocol is to notify a physician and at least notify the DON or himself and documenting an "Event" would have triggered it. He also noted that there is no specific policy but the supervisor can make the decision to send out to crisis and at least she should have notified the physician. He confirmed that the CP is updated "for every incident".During an interview with the surveyor on 4/15/2013 at 12:30PM, the primary physician (Medical Director of the facility) stated he did not recall being notified of the event on 4/10/2013 as he would have remembered it. He stated that it was a "significant" event and would have expected to be notified. Resident #1 was observed by the surveyor accompanied by the RN UM at 9:20AM in the DR sitting in a chair. The UM stated Resident #1 ambulated independently on the unit and was on q 15 minute checks. She stated at that time, he had no behavior issues since the incident on 4/10/2013. Again, Resident #1 was observed on the unit at approximately 12PM ambulating independently in the hall. The surveyor found no glass items in his room but observed glass picture frames and other items which could be broken and used as a weapon in rooms adjacent to Resident #1's room and on the unit. The RN UM confirmed that Resident #1 was not constantly monitored and could ambulate freely on the unit.During an interview with the surveyor on 4/15/2013 at approximately 12:30PM, the DON stated that she was not notified of the incident initially but it was reported in the 24 hour nursing report which is reviewed each morning. She stated the ADON spoke with the RN Supervisor regarding notification and confirmed that the physician should have been notified, however, "it is up to her (RN Supervisor) discretion to call the physician" noting that Resident #1 "did calm down". She stated that Resident #1 was already being monitored on q 15 minute checks and it was the "first time he had touched a picture" so no additional monitoring was added. She confirmed that Resident #1 was independently ambulatory and ambulated around the unit.The IJ was identified for Resident #1 on 4/15/2013 at 1:00PM and lifted the first day of survey 4/15/2013 based on the following plan of correction. 1. Resident #1 was placed on 1:1 staff observation until transfer to a behavioral facility.2. The Physician, Psychiatrist, Family and S-COPE were all notified of the incident.3. The behavioral CP was updated to include additional activities.4. The Medical Director and DON are to be notified if there are any future behaviors for Resident #3.5. Staff were inserviced on "Behavioral Escalation Continuum model on Responding to Persons with Dementia" and review of the following; Any event where a supervisor is notified requires an "event" note, notification of physician and Supervisor, Supervisor is to call the DON, ADON and/or Administrator for events of injury, behaviors or anything abnormal. Review of a policy and procedure (P &P) for "Behavior Management in Long-term Care-Residents/Patients" dated January, 2013 included but was not limited to the following; The Center acknowledges that there will be times when some residents may have behavioral disturbances that make them a potential danger to themselves or others. It is at these times that we must initiate procedures that protect the resident as well as the other residents of the facility and the staff as well from potential harm or injury ... Ensure resident is not a danger to himself or others ... 2. All residents with a change in their behavior especially those with behaviors that are potentially a danger to themselves or others, shall be assessed for underlying causes including but not limited to [MEDICAL CONDITION], pain, illness injury medication changes, etc, Such underlying causes will be assessed and treated under the direction of the attending physician if at all able prior to sending out to the ER or Crisis Center ... 4. Based on the above assessments, evaluations and outcomes of interventions, the patient's care plan will be appropriately updated. Ongoing assessments and re-assessments will follow as the resident ' s response and condition dictate.Review of a P & P for "Incident/Event Reporting", effective July 25, 2012 showed; all incidents involving resident/patient, employees and /or visitors are reported as outlined in this policy. All reportable events are investigated and reviewed. Resident reportable events include but are not limited to the following; ...Altercations-between residents, families, employees, or visitors ...Physical assault or aggression. Procedure: Upon identifying a reportable event the staff member notifies a licensed nursing staff member, after initial assessments ...the event is reported in the Meditech (computer) system. The system allows for nurses note entries and identifies the proper steps the staff members must take to ensure complete care notification of physician, family and supervisor ...The completed event is printed to the LTC (long term care) Administration for review by the DON/ADON. Any investigation is initiated by the DON or designee. The event form is then routed in turn to the following and appropriate documentation is completed; Medical Director, Administrator and Risk Management.Review of a P & P titled Nursing staff Roles and Responsibilities of Resident/Patient with acute change in status or condition. The staff nurse recognizes and communicates to the RN UM changes in a resident status or condition in a time manner. The RN UM prior to physician notification, assesses the resident to establish a baseline condition and then communicates to the physician for his determination of a medical intervention.Review of a facility policy titled "Resident Abuse" dated 3/20/06 showed under "Investigation", "All reports of resident abuse...and injury of unknown source shall be promptly and thoroughly investigated. Investigations are conducted according to our policy: "Resident Abuse Investigation". When the investigation of resident abuse has been completed record of that investigation, including all documentation and final action will be maintained in the LTC Administration office. Review of a facility policy titled "Comprehensive Care Plans" (CCP) dated 12/20/2011, showed; "the interdisciplinary team reviews and revises the CCP after each assessment, change in condition or upon change in preference or decision making by resident or surrogate decision maker". There was no documented evidence that these policies were followed. 2. According to the facility Admission Information, Resident #3 was admitted to the facility in August, 2012 with [DIAGNOSES REDACTED].An MDS dated [DATE], showed Resident #3 was cognitively impaired and needed extensive assistance with transfers, activities of daily living and limited assistance with use of the wheel chair (w/c).A CP, initiated 10/18/2012, showed Resident #3 had Behavior problems r/t mental [MEDICAL CONDITION] (MR) with [MEDICAL CONDITION] such as; calling other residents names and using profanity, yelling and screaming when she wants attention. Interventions included but were not limited to; reduce stimulation when agitated by reducing volume on TV or place in quiet area, give a time out by removing from the dining room until calm by sitting at the nurses station (NS) or take to her room and follow up with psychiatrist. Additionally the CP noted that Resident #3 had a history of [REDACTED]. She was removed from the area and placed at the nursing station. The CP also noted two additional Resident-Resident altercations; on 3/23/2013, Resident #3 hit Resident #4 on her left arm; interventions showed Resident #3 was removed from the area to her room and educated to "keep her hands to herself"; on 3/25/2013 it was reported by Resident #5 that Resident #3 hit her and interventions at that time showed; Resident #3 was placed in her room with call light, TV remote and water with reach. A Geriatric Psychiatry Evaluation, dated 3/22/2013, showed Resident #3's long and short term memory was limited with decreased judgment and insight. "Resident #3 can be abusive (verbally) to staff and at times residents. Staff able to redirect. Pt. calm, co-operative, enjoys activities". Recommendations included a Gradual Dose Reduction (GDR) of Risperadal from 3mg to 2mg and to call if behavior worsens or psychotic.Review of NNs showed the following; NN dated 3/4/2013 at 5:31PM by the DON showed the incident on 2/23/2013 and CP was reviewed with specific interventions such as reducing stimulation, offering juice, snacks, and magazines.NN dated 3/23/2013 recorded at 12:12PM by the RN showed under "Event"; (Resident #3 was) "Observed by other residents in DR (Dining Room) hitting (Resident #4)" at 11:25AM with no injuries to either resident". Resident #3 was redirected to a different location in the DR. The "condition of resident before event" noted Resident #3 was awake, alert and oriented to self and surroundings with confusion at times and noted behavior issues due to cognitive status and ambulates with w/c. The narrative description showed; "LPN reported to me (RN) that she heard yelling in DR and went in to observe the problem and observed (Resident #3) with hand raised about to hit (Resident #4) and she redirected both residents to different locations in DR. Residents that sit at dining table against the window reported to LPN that Resident #3 hit Resident #4) on her left arm". A "7-3 Follow-up" NN on 3/23/2013 recorded at 4:35PM by an RN confirmed the altercation and noted "It was reported that resident (#3) was out of bed to her w/c self propelling in the hall and entered into the DR and began yelling and hitting another resident (#4) on her left arm". The NN showed Resident #4 was sitting in her w/c at the table. "It was reported from other residents who were in the room at the time to the (LPN) who was in the hall." "Resident with dx: MR/[MEDICAL CONDITION] and was just seen by physch (psychiatrist) on 3/20. All parties were notified and res. (Resident #3) was verbally educated on keeping hands to herself. The DON made aware and altercation was reported to state today and message left on hotline answering service. CP in place for behaviors". Review of the CP documented the incident of 3/23/2013 with the intervention of education, however, there was no indication that the facility had implemented any prevention of a recurrence or increased monitoring to protect other residents on the unit. NN on 3/23/2013 recorded at 11:14PM showed "heard cursing other resident, reprimanded resident, made aware that cursing not acceptable, easily redirected and said sorry, stationed resident in front of the NS (nursing station)". NN on 3/24/2013 recorded at 2:19PM; "Observed yelling out and waving arms towards other residents. She was telling other resident to 'shut up'. Redirected to sit in front of NS and provided a snack with (positive) effect of decreased aggression and agitation". NN on 3/24/2013 recorded at 10:34PM; "In MDR (DR) heard resident (#3) cursing other two resident (s) and staff during and after dinner, stated 'shut up you B...' Easily redirected but forgetful, did say shut up again. Assisted back to bed".NN on 3/25/2013 recorded at 1:52PM and 1:56PM under "Event" showed "hit another resident..." in DR with the time documented as "unknown" and the event "unwitnessed". The description noted; "It was reported by another resident (#5) that she was hit by (Resident #3). (Resident #3) denied that she hit anyone." The physician and family were notified. Resident (#3) was removed from the MDR after altercation; "resident became verbally abusive toward other resident in front of NS. Resident placed in her room". Review of the CP documented the incident of 3/25/2013 and noted that the resident was removed from the immediate situation, however, there was no indication that the facility had implemented any prevention of a recurrence or increased monitoring to protect other residents on the unit.NNs showed "behavior" documentation after the incident of 3/25/2013 which included the following; 3/26/2013 at 11:49PM-"Heard resident (#3) screamed at (unsampled resident #6)"redirected".3/27/2013 at 3:29AM- "will continue to monitor".3/27/2013 at 7:20AM- "seen by staff during lunch service".3/27/2013 at 2:13PM- "...observed yelling at another (resident unnamed) after lunch while seated in MDR (DR). Nurse intervened and removed resident from the MDR (DR). When resident (#3) was being removed from MDR (DR) she passed the same resident she (#3) was yelling at and raised her hand as if she (#3) was trying to hit her...Placed in front of NS for close observation where she (#3) remains ....Will continue to monitor behavior".3/28/2013 at 2:47PM- No behavior issues. Resident #3 was evaluated by S-COPE representative for recent behavior issues "All recommendations placed in resident chart for MD review... Will continue to monitor behavior".A NN dated 3/29/2013 recorded by the RN UM at 6:39PM showed that recommendations from S-COPE were reviewed and entered into the CP as well as the 24 hour nursing report. The recommendations included; 1. Having resident in DR for structured activity only and then set aside after activity and during change of shift for relaxation periods at this time put on cooking shows as she enjoys them. 2. If resident is having behaviors of cursing or aggression, she is to be removed from group and taken to her room as this reinforces negative behavior.3. Staff to provide (positive) attention to resident in order to decrease her negative attention-seeking behaviors, also use 1:1, decreasing stimulation and soft touch to aid with behaviors.Review of the S-COPE Evaluation dated 3/28/2013 included the above recommendations and one additional recommendation, 15 minute checks which the facility chose not to implement.Review of a "Team Note" dated 4/04/2012, 10 days after the last incident on 3/25/2013, recorded at 10:58AM by the RN UM showed; "Special care conference held today with DDD (Department of Developmental Disabilities) nurse ..., (family), SW, Activity (representative), Resident #3 and RN UM. The purpose of this meeting is to discuss the physical aggression that occurred on 3/23/13 and 3/25/13 wherein she hit 2 residents. Resident has MR with [MEDICAL CONDITION] and (psychiatrist) has been following her and psyche (psychiatric) medications and on 3/22/2013 he decreased the [MEDICATION NAME] from 3mg to 2mg daily. And on 3/23/13 resident started the physical aggression. Staff assessment revealed she focused on residents that are cognitively impaired and docile and does not retaliate." The RN UM noted that since interventions recommended by S-COPE were initiated, such as removing her from group environment when cursing, arguing or hitting, there has been no more episodes of physical aggression. [MEDICATION NAME] was increased back to 3mg from 2mg by the physician. The SW "emphasized other residents safety and that if resident continues to hit despite meds and behavior modifications an alternative behavioral placement will be discussed ..." Resident #3 was observed by the surveyor on 4/18/2013 at approximately 9:15AM sitting in a wheelchair across from the nursing station. She was awake and alert and spoke to staff or residents passing by in a pleasant manor. During an interview with the surveyor Resident #3's Power of Attorney (POA), who noted she visited daily, stated Resident #3 seemed not to have remembered the incidents when she (POA) asked her about them. When interviewed by the surveyor, Resident #3 denied any incidents with other residents. During an interview with the surveyor on 4/18/2013 at 9:40AM, the RN UM for Resident #3 stated she was made aware of the incidents after she returned from vacation on 3/28/2013 and focused mainly on the interventions recommended by S-COPE. She stated that an investigation is completed on all "events" and should have been done for both incidents. She added "especially after our recent state (annual) survey". She further stated that the investigation would have been completed by the DON or ADON. The surveyor asked the RN UM what would be included in the investigation and she stated that any staff or resident who witnessed the event would be asked to document it. During the same interview, the RN UM stated monitoring of Resident #3 was increased after the incident on 3/25/2013 but could not be specific regarding how it was increased. She did note that prior to the incidents, staff on the unit were assigned to the DR during the 7AM-3PM shift in intervals of 15 minutes to monitor residents so someone is always in the room during that shift. She produced "CNA Assignment" Sheets, dated 3/23 and 3/25/2013 with a list of CNAs assigned to an "every 15 minute DR rotation". She stated if a CNA would have to leave the room, they are aware to notify the charge nurse. She stated she was unaware if the CNAs (CNA#1 for incident on 3/23/2013 and CNA #2 for the incident on 3/25/2013) had given statements. She stated she had no "information" regarding an investigation for the events on 3/23 and 3/25/2013. During an interview with the surveyor on 4/18/2013 at 10:40AM, the DON stated she did not have any additional investigation/information/statements related to (r/t) the incidents on 3/23 and 3/25/2013. She stated no statements were warranted as no staff were present for either incident. When the surveyor questioned the DON regarding the Unit "CNA DR rotation" schedule and asked if any of the CNAs who were scheduled to be in the DR at that time were interviewed, to confirm that the DR was being monitored per the protocol on the unit, the DON responded that "maybe the CNA was assisting another resident in the bathroom", but the DON didn't pursue why staff wasn't in the DR as per protocol. The DON also noted that she would/did not interview the resident who witnessed the event of 3/23/2013 as "this is their home" and she would not "interrogate" them. She confirmed that the resident who witnessed the 3/23/2013 incident was alert and oriented, however, was no longer at the facility. The IJ was identified for Resident #3 was past non compliance and lifted on 3/28/2013 when an effective plan was implemented; 1. A [MEDICAL CONDITION] medication was decreased on 3/22/2013 and reinstated to the previous dose on 3/26/2013.2. Have resident in DR for structured activity onl

C#: NJ Cross Reference F 224 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility failed to thoroughly investigate allegations of resident to resident and/or staff abuse/mistreatment for 2 of 5 sampled residents (Resident #1 and #3). The Immediate Jeopardy (IJ) for Resident #1 was identified on 4/15/2013, the first day of survey and relayed by the surveyor to the Director of Nursing (DON) and Administrator at approximately 1:00PM and was lifted that day at approximately 3:00PM when the facility implemented an acceptable plan of correction (POC). Resident #1 was the resident previously cited in F224 K during the annual survey of 3/5/2013. The Director of Nursing (DON) and Administrator were notified at approximately 12:00PM on 4/18/2013 that the IJ for Resident #3 was past non compliance (PNC) since the facility implemented interventions on 3/28/2013. This deficient practice is evidenced by the following; 1. See Example #1 2. See Example #2 The IJ was identified for Resident #1 on 4/15/2013 and lifted the same day based on an acceptable plan of correction (POC); 1. Resident #1 was placed on 1:1 staff observation until transfer to a behavioral facility.2. The Physician, Psychiatrist, Family and S-COPE were all notified of the incident.3. The behavioral CP was updated to include additional activities.4. The Medical Director and DON are to be notified if there are any future behaviors for Resident #3.5. Staff were inserviced on "Behavioral Escalation Continuum model on Responding to Persons with Dementia" and review of the following; Any event where a supervisor is notified requires an "event" note, notification of physician and Supervisor, Supervisor is to call the DON, ADON and/or Administrator for events of injury, behaviors or anything abnormal. The IJ identified for Resident #3 was past non compliance and lifted on 3/28/2013 when an effective plan was implemented; 1. A [MEDICAL CONDITION] medication was decreased on 3/22/2013 and reinstated to the previous dose on 3/26/2013.2. Have resident in DR for structured activity only and during change of shift relaxation periods in room. 3. If showing behaviors of cursing or aggression, remove from group and bring to room. 4. Staff to provide extra attention to decrease negative attention. 5. If Resident #3 shows additional behaviors, place on q 15 minute checks6. Residents exhibiting behaviors will be immediately removed form the situation, the physician and family notified. Statements will be taken from any witnesses and the resident will be placed on q 15 minute checks. The CP will be updated with interventions. All staff inserviced. 7. Additionally, a new investigative tool is to be implemented to capture all relevant details, interventions, statements related to the investigation to ensure proper and all inclusive documentation. Statements will be obtained from any witnesses to an event. Behaviors/interventions will be discussed at morning meetings with quarterly Quality Assurance meeting follow up by the DON, Administrator, Supervisors, CEO and Social Worker. NJAC 8:39-4.1 (a) (5)

C#: Cross Reference F 224 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility failed to review care plan (CP) interventions for 2 of 5 sampled residents (Residents #1 and #3). Resident #1 had previous resident to resident and/or staff altercations and exhibited a new behavior of threatening staff with a shard of broken glass. Resident #3 had one previous physical resident to resident altercation and the next month had 2 additional physical resident to resident altercations. Both residents' CPs lacked a specific plan for identified behavior triggers and/or considered additional intervention(s) to decrease/eliminate physical aggression. The Immediate Jeopardy (IJ) for Resident #1 was identified on 4/15/2013, the first day of survey and relayed by the surveyor to the Director of Nursing (DON) and Administrator at approximately 1:00PM and was lifted that day at approximately 3:00PM when the facility implemented an acceptable plan of correction (POC). Resident #1 was the resident previously cited in F224 K during the annual survey of 3/5/2013. The Director of Nursing (DON) and Administrator were notified at approximately 12:00PM on 4/18/2013 that the IJ for Resident #3 was past non compliance (PNC) since the facility implemented interventions on 3/28/2013. The deficient practice was evidenced by the following; 1. See Example #1 2. See Example #2 The IJ was identified for Resident #1 on 4/15/2013 and lifted the same day based on an acceptable plan of correction (POC); 1. Resident #1 was placed on 1:1 staff observation until transfer to a behavioral facility.2. The Physician, Psychiatrist, Family and S-COPE were all notified of the incident.3. The behavioral CP was updated to include additional activities.4. The Medical Director and DON are to be notified if there are any future behaviors for Resident #3.5. Staff were inserviced on "Behavioral Escalation Continuum model on Responding to Persons with Dementia" and review of the following; Any event where a supervisor is notified requires an "event" note, notification of physician and Supervisor, Supervisor is to call the DON, ADON and/or Administrator for events of injury, behaviors or anything abnormal. The IJ identified for Resident #3 was past non compliance and lifted on 3/28/2013 when an effective plan was implemented; 1. A [MEDICAL CONDITION] medication was decreased on 3/22/2013 and reinstated to the previous dose on 3/26/2013.2. Have resident in DR for structured activity only and during change of shift relaxation periods in room. 3. If showing behaviors of cursing or aggression, remove from group and bring to room. 4. Staff to provide extra attention to decrease negative attention. 5. If Resident #3 shows additional behaviors, place on q 15 minute checks6. Residents exhibiting behaviors will be immediately removed form the situation, the physician and family notified. Statements will be taken from any witnesses and the resident will be placed on q 15 minute checks. The CP will be updated with interventions. All staff inserviced. Additionally, a new investigative tool is to be implemented to capture all relevant details, interventions, statements related to the investigation to ensure proper and all inclusive documentation. Statements will be obtained from any witnesses to an event and CPs will be updated with interventions. Behaviors/interventions will be discussed at morning meetings with quarterly Quality Assurance meeting follow up by the DON, Administrator, Supervisors, CEO and Social Worker. NJAC 8:39-11.2(e) 2

A. Based on observation, interview and record review, it was determined that the facility failed to protect residents from abuse/mistreatment due to inadequate monitoring and supervision of a cognitively impaired resident. The resident was identified with unpredictable behaviors of unsupervised wandering, which impacted the safety and well-being of residents on the units. The resident wandered freely into the rooms of other residents, refused to leave, and posed verbal and physical mistreatment of [REDACTED]. The resident also defecated and urinated in areas frequented by other residents. The incidents were documented in the medical record from 8/2012 to the present and interventions were not revised to protect both the identified resident and the residents residing on two units in the facility. The incidents documented in the medical record included, but were not limited to; consistent notations of wandering in and out of residents rooms and common areas, and multiple documented incidents of maladaptive behavior that impacted on the emotional and physical health and safety of residents in the facility. This deficient practice constituted an Immediate Jeopardy situation for Resident #12, who was 1 of 12 residents reviewed for abuse/mistreatment, as well as residents who resided on the L-1 and S-2 units. The Immediate Jeopardy was identified on 2/27/13. An acceptable plan of correction was submitted on 2/27/13, identifying that the jeopardy situation was corrected on that date based upon actions taken by the facility. These actions included every 15 minute observations by staff and revision of the care plan behavior interventions. The following evidenced the deficient practice: During the initial tour of the facility on 2/25/13 at 11:00 a.m., the unit manager told the surveyor that Resident #12 had wandering behavior in and out of other residents' rooms and was difficult to redirect. The surveyor observed the resident at that time ambulating independently in the hall with the use of a wooden cane. The surveyor reviewed the medical record of Resident #12 on 2/26/13 at 9:30 a.m., which revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the List Patient Notes on the above mentioned date and time revealed that from 4/30/12 to 8/08/12, the resident exhibited wandering behaviors, but was easily redirected by staff. On 5/11/12, a psychiatrist note indicated "wandering is normal in dementia and not amenable to treatment." Documented evidence of increased behaviors in the List Patient Notes was evidenced by the following: On 8/9/12 at 2:42 p.m., "Reported by other residents that Resident has been entering their room multiple times and standing over their beds. Stop signs in place to rooms. Resident observed by nurse removing stop signs and entering resident's rooms. When nurse approached resident face to face and spoke to him about entering the ladies room and he is not supposed to enter the rooms he stated, "I will do what I want and you can't do nothing about it." He then came to close to nurse and pushed me. Stated "you can't make me leave the room I will leave when I want." I stood in the doorway until he was ready to come out because it was a frightened lady in the room. He raised his cane like he was going to hit me, I grabbed his cane and lowered it to the floor. Resident left the room and began to walk in and out of other resident's rooms. Nurse did not follow and instead tried to approach resident later." On 8/10/12 at 2:39 p.m., "Resident continues to wander in and out of other resident's rooms." On 8/14/12, at 9:14 a.m., the Social Worker documented in an "Annual Assessment" note, "... being short-tempered several of the last 14 days." "... had several episodes of being combative." "... ambulates around L-1 units much of the day and often goes in and out of other resident's rooms." On 8/19/12 at 12:32 a.m., a List Patient Note revealed "Supervisor told by CNA that resident was redirected out of female room, came down to nurses' station proceeded into supply room with oxygen tanks in room." "...Patient swung a punch at me and told me not to touch him. Supervisor called security and 3 nurses assist pt. into wheelchair, pt. rolled w/c on supervisor's left great toe." On 8/20/12 at 10:27 a.m., a "Unit Manager followup review of 8/19/12" revealed "...resident combative and difficult to re-direct when staff noted him going into the clean utility room. He punched 2 staff CNA's as they attempted to re-direct him." "Staff observed and documented several incidences of combative/fighting, also other alert residents reported being "afraid" since he comes and wanders in their rooms and when redirected out he insisted "this is my room." A psychiatrist note dated 8/21/12 indicated "single episode of aggression-had been doing well previously." Documentation in the List Patient Notes continued as follows: On 9/3/12 at 9:33 p.m., "Resident observed wandering about the unit for the remainder of the shift. Redirection is not effective. He was noted wandering in and out of other residents' rooms and also noted to have misplaced his cane." On 9/29/12 at 10:22 p.m., a List Patient Note revealed "CNA reported to me that resident was combative during care. CNA states resident 'attacked me.'" On 10/1/12 at 2 :47 p.m., "resident observed swinging his cane while speaking to nurse this shift." On 10/5/12 at 3:15 p.m., "...he is observed to be trying to open doors." On 10/1/12 at 6:35 a.m., "...began wandering in and out of every resident's room on the unit." On 10/14/12 , "supervisor notified around 11:45 p.m., on 10/13/12 to come up to 1 West due to pt. wandering in and out of pt's rooms, pulling covers off some residents, attempt to lift TV, became combative as nurses tried to redirect pt and pt tried to swing his hand at me." On 10/17/12 at 2:30 p.m., "Resident spent most of the morning ambulating about the unit and wandering in and out of other residents' rooms." On 10/22/13 at 2:47 p.m., "Called from 1 West to "come and get the resident." As per social worker she witnessed resident making a fist to CNA and social worker when they tried to assist him to sit since he was unsteady on his feet." "Resident immediately swung his cane around towards them, he almost hit CNA, however he hit the nameplate of room [ROOM NUMBER] and smashed and broken." On 10/24/12 at 2:30 p.m., the social worker wrote a note for 10/22/12, which stated "Summoned to Room L-162 by resident (initials), to help redirect (resident) out of females room." "When social worker reached out to try to steady (resident) he made a fist and gestured punching at social worker." "As (resident) sat in the wheelchair he brought up his cane and swung it at social worker and CNA hitting the number sign on room L-176 breaking the sign with the cane impact." On 10/29/12 at 2:43 p.m., a List Patient Note indicated "wandering into other residents' rooms this morning until his medication was given." A psychiatrist note dated 10/31/12 indicated "Pt. has instances of threatening to hit staff (especially when touched). He also swung cane at staff nearly hitting CNA." On 12/06/12 at 12:32 p.m., the Social Worker note revealed "(name) is reported to have had a BM in an L-1 West resident's garbage can- previous reports claim (name) has urinated in several locations other than toilet, i.e.. sunroom plants and garbage cans. Social worker informed by another resident that he is walking around L-1 West poking at with a fork- Social Worker did find (name) carrying a fork but no poking was observed." "Residents frequently c/o (name) in their room and bathrooms despite stop signs in place." On 12/7/12 at 4:51 p.m., a List Patient Note revealed "Resident transferred to S2 unit today due to requiring smaller unit. Resident has progression in dementia and wandering around unit and going in and out of room of other residents has becoming worst (sic). He was also urinating and defecating at inappropriate places i.e.: using trash can of other residents in their rooms. Last incident this past few days he defecated at other resident's room on 1 West unit using garbage container. Several alert residents verbalized being afraid at night when he just enters the room and sat at the edge of bed. Stop sign across room not helping since he removes it or get in from under (sic)." On 12/8/12 at 7:33 p.m., "initially refused meds this a.m., stated "you better get the hell away from me" and balled up his fist to hit this nurse." On 12/10/12 at 1:45 p.m., "...resident is ambulatory. He goes into other resident's rooms." On 12/12/12 at 2:55 p.m., "Resident awake and ambulating ad lib with no distress noted with cane. Resident roaming in and out of room including trying doors that are lock and close (sic). Also voided x 1 in Dining Room trash can." On 12/13/12 at 9:33 p.m., "Resident walking the unit going into other resident's rooms and checking locks on doors. I asked him to come out of one resident's room and he puts his fist up and says " Don't touch me or I'll break your face." Review of a Physician's Progress Note dated 12/19/12, revealed "The patient is now up on S2. He was moved back on 12/7 since he has had some issues with wandering in and out of patient's rooms and urinating and defecating inappropriate places. Up here on S2, a smaller unit. He seems to be doing much better." List Patient Notes con't: On 12/22/12 at 12:03 a.m., "(Name) wandered into a female resident's room and sat in the chair in her room. Numerous attempts were made to ask him to leave without success. As I entered the room he jumped up from the chair and stood in the doorway preventing myself and the other resident from exiting the room, saying "Go out the way you came," and "Come on I will knock you out," as he raised both fists and swung at me. I attempted to exit the door and he raised his hands and punched and scratched at me. He remained in the doorway of the room unwilling to move." On 12/23/12 at 7:50 a.m., "observed wandering in the hallway and other resident's rooms." A Physician's Progress Note dated 12/27/12, revealed "the patient has been up on the S2 Unit for the past several weeks. He continues to wander in and out of rooms, sometimes claiming that these are his rooms. He, at times, is difficult to redirect. He can be very threatening, raising his fists and cane and saying threatening things." "He was moved to the S2 Unit where it was hoped that in a smaller unit he would be more easily redirectable and less likely to get agitated. In spite of that, he does continue with these episodes. He is often not able to be redirected and certainly cannot be rationalized with." List Patient Notes con't: On 1/2/13 at 11:51 a.m., "Patient wandering in and out of other resident rooms." A psychiatrist note dated 1/11/13, indicated "Pt has been wandering and had relieved himself in another's room. He is sometimes combative but can usually be redirected." "Continue non-pharm aides (ie.signs) to help pt. recognize and decrease episodes of inappropriate toileting." Review of Physician's Progress Notes dated 1/18/13, revealed "He is very happy and pleasant today. He did have some disruptive behaviors and agitation a couple of weeks ago." "The staff put up a sign with large, easy to read letters indicating which is his room and which is the bathroom for him." List Patient Notes con't: On 1/24/13 at 7:32 a.m., "His water pitcher also observed with urine. Resident was carrying his water pitcher to the adjacent room at the time it was noted." On 2/5/13 at 10:44 a.m., the Social Worker wrote an "Annual Note" which stated "Staff is learning what triggers some of (Name) behaviors. (Name) is a very nice man who does not enjoy being startled or touched without consenting and knowing what is happening first. Stop signs appear to be successful in keeping (Name) from wandering in other's rooms." On 2/6/13 at 3:01 p.m., a Nursing Supervisor note revealed " Continues to have episodes of relieving himself in non-bathroom areas. Continues to wander around the unit in and out of others room, he is difficult to re-direct at times. There have been noted aggressive and combative behavior episodes since his transfer." On 2/16/13 at 10:27 p.m., "Resident was walking up the hall and I observed him with my coat and car keys. I went to him and asked him for the keys . He says "I don't have it." A CNA came to the doorway. He became agitated. He became upset again and with fist raised said "Look little girl, stay out of grown folks business." As he swung a fist toward her, I attempted to prevent him from hitting me. He turned again to hit her, I went in front and he punched my shoulder." On 2/17/13 at 7:36 a.m., "Observed at intervals wandering in the hallway and other resident's rooms. He tends to urinate in the trash cans." On 2/19/13 at 6:45 p.m., the 3-11 supervisor documented "I was on unit during rounds and I observed (staff) run into the dining room. I also went to the dining room and observed Resident standing next to a table holding his cane in his hands. This table had another resident sitting at it in her wheelchair. As I approached the dining room and (name) the nurse stated that she observed resident hit another resident who was sitting at the table across the hands and chest with his cane. (Name) had placed both her hands across her chest as resident approached her. Resident was yelling "She shouldn't have ran into me and I wouldn't have hit her!" Review of the medical record of the resident who was struck revealed that the resident was "observed to be crying and her left hand pointer finger/knuckle area was observed to be red with a small purple hematoma that had small amount of blood over it. Resident is awake, alert and oriented to self and when asked if she was hit she said "yes." A psychiatrist note dated 2/20/13, indicated "Pt. had incident where he struck CNA and another resident (2/19). He is liable to get agitated when someone comes too close. He wanders and has urinated in inappropriate places. On 2/16 he threatened to hit staff." The resident's medication was adjusted and non-pharmacological interventions included "Attempt to prevent residents entering his personal space." Review of the physician's progress notes dated 2/20/13, revealed "He did have a couple of agitation episodes over the past couple of days." "His behaviors have been pretty good up on the S2 unit." A List Patient Note dated 2/21/12 at 1:51 p.m., (resident) was ambulating in hallway, a female resident came up to him and attempted to ambulate with him and he said "If you don't make her leave me alone I will knock her out." On 2/26/13 at 1:00 p.m., the unit manger of the S2 unit told the surveyor that "we do not believe his behaviors are such that he requires a behavioral unit at this time." She also stated that the resident had not been sent out to a crises center or evaluated by S-COPE. The surveyor also asked the unit manager if the resident was ever assessed for a toileting program to manage his urinating/defecating in inappropriate places and she responded "we do not consider him to be incontinent. That is just his behavior." On that same day at 2:00 p.m., a nursing supervisor told the surveyor "we do not report the incidents involving altercations with other residents, we do our own internal investigation." The supervisor could not provide evidence of the investigations regarding the above mentioned incidents to the surveyor. Review of the care plan on the above mentioned date and time revealed that the Interdisciplinary Team identified and documented the following: the Resident "will decrease behaviors to less than one episode x 90 days" dated 5/11/12, with interventions that included "Staff will ensure close supervision, provide a structured daily routine to maintain trust and familiarity, if (name) becomes combative stop task and or leave room." An interview with the Unit Manager on 2/26/13 at 2:00 p.m. revealed that she was unable to tell the surveyor how the staff was providing close supervision and what the resident's structured daily routine entailed. There was no documented evidence or information offered by the staff that indicated that interventions were implemented or re-assessed as the behaviors continued. On 2/26/13, (during the survey), the psychiatrist saw the resident and documented "Pt. has tolerated [MEDICATION NAME] and has not had further incidents." "He is being effectively redirected by staff and is being allowed to have personal space. He doesn't require behavioral unit but will get S-cope involved to assess situation." The resident was seen by S-COPE on 2/27/13. Review of documentation by the S-COPE nurse revealed, "Client's behavioral symptoms of verbal and physical aggression are occurring within the context of dementia." "Client would not benefit from psychiatric hospitalization or crises evaluation at this time and his behavior is dementia related. Client does not appear to meet criteria for behavioral unit at this time." The S-COPE nurse recommended "1. Physical Therapy evaluation re: replacing the cane with a walker to increase safety of client and other residents. 2. Consider moving his room closer to nurses' station for increased supervision. 3. Try increased physical activity during the day either via restorative exercise program or activities. This may decrease agitation during the 3-11 shift where behaviors appear most frequently. Provide preferred music during this time. 4. Utilize ABC chart to identify triggers/early warning signs. 5. Schedule S-cope training in-service for staff re: managing resident to resident aggression. 6. Consider involving wandering female residents in a group/activity during pm shift to decrease conflict with client." Review of the facility policy titled "Resident Abuse Investigation," dated June 16, 2008, revealed "all reports of resident abuse, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated." Review of the facility policy titled "Resident Abuse," dated 3-20-06, revealed under Section 5., Investigation "all reports of resident abuse, neglect, misappropriation of resident property, and injury of unknown source shall be promptly and thoroughly investigated." Under Section 7., Reporting "When the investigation of resident abuse/exploitation has been completed, record of that investigation, including all documentation and final action will be maintained in a confidential file located in the Long-Term Care Administration office. All investigation results will be forwarded to the Department of Health, Ombudsman's Office and appropriate licensing agencies according to regulations." The Immediate Jeopardy was identified on 2/27/13 at 2:00 p.m. Facility Administration was notified and a Plan of Correction was submitted to the survey team and accepted on 2/27/13 at 4:30 p.m., which indicated that the jeopardy was corrected at that time, based on actions by the facility which included the following: 1. On 2/26/13 seen by head of S-COPE program physician. S-COPE representative evaluation as of 2/27/13. 2. Educate the residents who are oriented of (Resident) personal space and the need to call for assistance from staff. 3. On 2/27/13 behavioral care plan revised to include moving (Resident) to a private room closer to the nursing station on 3/1/13. 4. Recreational activity to provide extended hours of structured activity. When (Resident) becomes agitated, get staff who is familiar with him to intervene. 5. Monitor whereabouts every 15 minutes with documentation. 6. Stop signs on doors. 7. Bed alarm to alert staff. 8. Every 15 minutes checks effective immediately with sign-off sheet. 9. Initiate voiding pattern for seven days every hour and bedtime. Toileting program. 10. Physical Therapy evaluation of assistive device use. 11. Staff education for behavioral escalation continuum model as recommended by S-COPE representative, beginning 2/27/13 on 3-11 shift and continuing on all units starting 2/28/13. F224 remains a deficiency at a scope and severity of D, based on the evidence in Part B. Part B. Based on observation, interview and medical record review, it was determined that the facility failed to protect residents from abuse/mistreatment by other residents. This deficient practice was identified for 2 of 12 residents reviewed for abuse/mistreatment, Resident #7 and #11, as evidenced by the following: 1. During a tour of the nursing unit on 2/25/13 at 10:00 a.m., the Unit Manager (UM) told the surveyor that Resident #7 was a "wanderer" who was receiving psychoactive medications. Throughout the survey the resident was observed either in bed or in a wheelchair. The resident was not observed self-propelling the wheelchair. On 2/25/13 at 12:56 p.m., the surveyor observed Resident #7 in a wheelchair in the dining room eating a sandwich. The resident attempted to eat the plastic beverage lid and was observed tapping/banging the left hand on the table repeatedly. The resident had a tearful, distressed look on his/her face. On 2/26/13 at 8:44 a.m., the surveyor observed Resident #7 during the medication pass. The resident was in bed and visibly distressed; his/her legs were trembling, the resident was constantly fussing with the bed covers, was exhibiting shallow breathing and pounding the left hand on the bed, repeatedly. According to the medication nurse, this was the resident's usual behavior, due to significant dementia. The nurse stated that the resident's agitated behaviors had recently increased and the previous day the physician had added a morning dose of the resident's anti-psychotic medication, in an effort to reduce the distress. On 2/26/13 at 12:12 p.m. the resident was observed in the dining room with a family member, who had his arm around the resident. The resident appeared much less distressed than observed in the morning. On 2/27/13 at 8:27 a.m., the surveyor observed Resident #7 in bed, awaiting breakfast. The resident was slightly less anxious than the previous morning. At 11:57 a.m., the resident was observed in the dining room by the surveyor. The resident was noted to be in constant motion with his/her legs shaking, intermittently pounding on the table with the left hand, and playing with a straw wrapper. On 2/28/13 at 12:12 p.m., the surveyor observed Resident #7 in the dining room fidgeting with the paper placemat which he/she eventually ripped in half. The resident was intermittently banging on the table with the left hand. Another resident was observed to be seated to the left of Resident #7. The surveyor observed that on 3 occasions this resident mocked the behavior of Resident #7 when banging on the table. The surveyor reviewed the medical record of Resident #7 on 2/26/13 at 9 a.m., which revealed that the resident was admitted to the facility on [DATE]. On 7/6/12, the resident was evaluated by the psychiatrist who identified at that time that the resident was wandering and at times became agitated when re-directed, with some episodes of crying. The psychiatrist diagnosed the resident with moderate dementia. On 11/21/12 the dietitian stated the resident had increased agitation at meals and seemed to be overstimulated in the dining room. According to the 2/25/13 monthly summary, Resident #7 had increased dementia symptoms, was anxious most of the time, banged on tables and was restless. The note stated the resident had a history of [REDACTED]. Review of the resident's plan of care for "Behavior Problems," revealed that Resident #7 had the behavior of banging on the table since admission. On 10/22/12 a new intervention was added to the care plan, to remove Resident #7 from over stimulating areas when agitated and to take the resident to a quiet area with supervision, until calmed. The title of the resident's care plan was "Resident will remain safe in his/her environment when anxious and agitated." Review of the List Patient Notes revealed that Resident #7 was hit in the arm several times and slapped in the face on 2/23/13 at 11:10 a.m., by another resident. According to the List Patient Notes, this occurred in the dining room and was witnessed by an activities staff member, who stated Resident #7 had been banging on the table. The description of the event stated Resident #7 was "very upset and continued to bang on the table" after the 2 residents were separated. According to the 2/28/13 UM follow-up nursing note, Resident #7 had been banging on the table and this was what precipitated the other resident to hit and slap Resident #7. Further review of the List Patient Notes revealed that Resident #7 was punched in the face by a different resident on 2/24/13 at 11 a.m., in the dining room. According to the note, prior to the incident the resident had been "tearful and banging on the table at times." The incident was not witnessed by staff, but was witnessed and reported by another resident. According to the witness, Resident #7 had been sitting at the table and "began crying and banging on the table." The other resident yelled at Resident #7 to stop, but the resident continued the behavior. The other resident then punched Resident #7 in the face. According to the UM follow-up review of these incidents, Resident #7 "has severe dementia with behavior disorder, he/she had a recent increase in anxiety, restlessness, and banging on the table." Review of the medical record revealed that the resident did not sustain any injuries at either incident. During an interview with the UM and the resident's regular medication nurse on 3/1/13 at 10:06 a.m., they stated that both of the residents who hit Resident #7 did not have a history of striking this resident in the past. They also stated that no other residents had a history of [REDACTED]. The UM told the surveyor that the staff was aware of increased behavioral issues with Resident #7, which included the issue of banging on the table in the dining room. 2. The surveyor reviewed the medical record of Resident #11 on 2/27/12 at 11:30 a.m., which revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] and 11/13/12 revealed that the resident was alert and oriented, required assistance from staff for ADL's and was wheelchair bound. On 2/28/13 at 11:30 a.m., the surveyor reviewed a List Patient Note dated 8/7/12, which revealed that the resident was slapped on the face by another resident. The nurse documented " The resident will be monitored for any ill effect from the incident." There was no evidence that statements were obtained from staff or the resident, who was slapped. There was no evidence that statements were obtained from other residents who witnessed the incident in the dining room. On 2/28/13 at 1:15 p.m., the resident told the surveyor that the incident occurred a long time ago, and the resident did not want to comment further on it. On 2/28/13 at 1:30 p.m., the Unit Manager (UM) told the surveyor that the other resident was transferred to another facility because of his/her behavior of being assaultive toward other residents. The UM stated at that time that statements were not obtained from the residents involved as part of the investigation on the incidents. NJAC 8:39-4.1 (a) (5)

Based on observation, interview and record review, it was determined that the facility failed to develop and revise care plan interventions to manage the behavior of a resident who a.) wandered unsupervised in and out of resident's rooms, causing residents to be fearful, and urinating and defecating in resident rooms and public areas, and b). exhibited difficult to redirect behavior that was unpredictable and included verbal and physical intimidation of residents and staff. Care Plan interventions were non-specific and were not revised as the resident's behaviors continued to escalate. Interventions were standardized in nature and lacked a specific plan for increased supervision, identified behavior triggers and emphasis on protecting Resident #12 as well as other residents in the facility. Failure to identify and develop interventions to manage the behavior of Resident #12 resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was identified on 2/27/13 during survey and a plan of correction was submitted by the facility and accepted on 2/27/13, by providing every 15 minute observation of the resident and developing specific behavioral interventions. This deficient practice was identified for 1 of 12 residents reviewed for behavior symptoms and care plan interventions, Resident #12, who according to the medical record, had multiple instances of maladaptive behavior. This deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #12 on 2/26/13 at 10:00 a.m. Review of the medical record revealed that the resident had [DIAGNOSES REDACTED]. Further review of the List Patient Notes revealed that from 8/2012 until present, the resident had exhibited behaviors of unsupervised wandering in other resident's rooms, causing residents to be fearful, urinating and defecating in public areas, and engaging in verbal and physical altercations with staff with behaviors that were difficult to redirect. Review of the care plan on the above date and time revealed that on 5/11/12, behaviors were identified as punching the CNA, wandering into other resident's rooms, was difficult to re-direct, and was combative with care. It further indicated that the resident will decrease behaviors to less than one episode x 90 days. Interventions for the above included a) Staff will ensure close supervision, b) provide a structured daily routine to maintain trust and familiarity, c) if (Resident) becomes combative stop task and or leave room. Interventions were not specific as to how close supervision and structured daily routine would occur, as documentation in the List Patient Notes repeatedly showed that the resident wandered unsupervised and staff only intervened when behavior escalated. The care plan lacked interventions to address the resident's behavior of public urination/defecation. The Immediate Jeopardy was identified on 2/27/13 at 2:00 p.m. An Acceptable Plan of Correction was received on 2/27/13 at 4:30 p.m., which indicated that the jeopardy was corrected with specific action that included; a) Revision of behavioral plan to include moving (Resident) to a private room on 3/1/13, b) Recreational activity to provide extended hours of structured activity when the resident becomes agitated and to get staff who is familiar with him to intervene c) Monitor the residents whereabouts every 15 minutes with documentation d) Stop signs on doors e) Bed alarm to alert staff f) Every 15 minute checks effective immediately with sign-off sheet g) Initiate voiding pattern for seven days every hour and bedtime. Toileting program h) Physical Therapy evaluation for assistive device use. Refer to F224, Part A NJAC 8:39-11.2, (e) 2

Based on observation, interview and record review, it was determined that the facility failed to provide care in a manner that minimized the painful effects of impaired range of motion. As a result, a resident experienced avoidable pain during dressing. This deficient practice was identified in Resident #22, 1 of 6 residents reviewed for activities of daily living concerns, and was evidenced by the following: During the initial tour of 2/7/12 the accompanying nurse told the surveyor that Resident #22 was able to be interviewed. On 2/8/12 at noon, the surveyor observed Resident #22 sitting in a wheelchair. The resident's left arm was pulled up and pressed against the chest. In addition, the resident's left hand was closed into a tight fist. When interviewed that day at 1:55 p.m., the resident voiced having had a stroke in the past, with residual paralysis of the left arm and leg. The resident also voiced being unable to straighten the left arm or open the left hand (These limitations are known as contractures). The resident then said that the left arm was painful to straighten, and that a Certified Nursing Assistant (CNA) had not used the proper dressing technique the night before to minimize the pain. The resident said that the CNA had not dressed the contracted arm first, followed by the unaffected arm as per the resident's request. According to the 12/27/11 Resident Assessment Instrument (RAI), the resident had [DIAGNOSES REDACTED]. The RAI further identified that the resident experienced pain frequently which affected the resident's ability to sleep. This RAI also noted that Resident #22 scored 14 out of 15 on the BIMS test which indicated that this resident is very alert and oriented. The resident had a physician's orders [REDACTED]. The corresponding "Patient's Plan of Care" contained interventions to manage the resident's chronic pain from arthritis, but failed to include interventions necessary to minimize pain in the resident's contracted left arm when assisting with donning or removing clothing. In a follow-up interview on 2/13/12 at 11 a.m., the resident said that the same CNA had used the same improper dressing technique over the weekend. The resident said that despite repeated requests that the contracted arm be dressed first, and repeated verbalizations made to the CNA that "You're hurting me!" the CNA "ignored" the situation, resulting in the resident experiencing continued, unnecessary left arm pain during dressing. When interviewed on 2/13/12 at 10:45 a.m., the acting unit manager said that dressing the affected side first when a person had impaired functional range of motion was part of basic CNA training and all CNAs should be aware of this when caring for residents with contractures. NJAC 8:39 - 27.1(a)