Every finding on record at Embassy Manor at Edison Nursing and Rehabilitation

Complaint #: 3009338 Based on interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to conduct and document a thorough investigation of an allegation of resident neglect. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #3). The deficient practice was evidenced by the following:A Facility Reportable Event (FRE) form, submitted by the facility to the New Jersey Department of Health (NJDOH), was reviewed. The FRE revealed that on 05/06/2026 at 11:30 AM, a Nurse Investigator (RN #1) from [a state agency] conducted an investigation at the facility in response to allegations of neglect and weight loss made by Resident #3's visitor. The FRE revealed that the resident's medical records were reviewed by RN #1 and the resident's weight was noted to be stable. The FRE further revealed that RN #1 noted the resident was well groomed and was assisted with feeding. An undated Investigation Summary and Conclusion regarding Care Issues (ISC) was reviewed. The ISC revealed On 5/6//26 [sic], nurse investigator [RN #1] from [the state agency] conducted an investigation regarding allegations of care/neglect and weight loss involving the resident [Resident #3]. The ISC revealed that all assigned staff members were interviewed regarding care and consistently described the routine care which was consistent with documentation. The ISC revealed other residents and roommates were not interviewed due to cognitive impairment. The ISC revealed that RN #1 stated that based on her observations and findings, there was no evidence of care neglect or weight loss. The ISC further revealed that based on the findings of the investigation, the allegations were determined to be unsubstantiated. Resident #3 was no longer at the facility; a closed record review was conducted. Review of the admission Record for Resident #3 revealed that the resident was admitted to the facility with diagnoses including but not limited to: unspecified dementia, severe, with psychotic disturbance (cognitive decline affecting memory, thinking and social abilities affecting how a person perceives reality); moderate protein-calorie malnutrition (undernutrition with significant but not extreme deficiency of protein and calories); dysphagia (difficulty swallowing), unspecified; and need for assistance with personal care. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 03/10/2026, revealed that Resident #3 had severely impaired cognitive skills for daily decision making. Further review of the MDS revealed that Resident #3 required a helper to provide verbal cues, touching/steadying, or contact guard assistance with eating. The Care Plan (CP) for Resident #3 was reviewed. The CP revealed a Focus, initiated on 03/05/2026 that Resident #3 was at risk of malnutrition and/or dehydration related to their diagnosis of dementia. Interventions related to this Focus, included but were not limited to monitoring, recording, and reporting to the physician any signs and symptoms of malnutrition. On 07/28/2026 at 1:50 PM, a telephone interview was conducted with RN #1. RN #1 stated that she did an onsite visit to the facility on [DATE] and informed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) that she was at the facility for an allegation of neglect related to Resident #3's dietary and environmental needs, weight loss, and incontinence care. RN #1 further stated that on 05/11/2026, she notified the DON that her investigation was closed but did not report the findings to the DON. On 07/28/2026 at 2:41 PM, an interview was conducted with the DON. The DON stated that the DON was responsible for facility investigation of allegations. The DON stated that when RN #1 arrived at the facility, RN #1 informed the DON that RN #1 was investigating an allegation related to weight loss. The DON stated she also investigated the allegation being investigated by RN #1. The DON stated her investigation included checking resident weights, care plans, and observing residents for grooming and signs of neglect. The DON stated that her investigation did not include obtaining staff statements. On 07/28/2026 at 4:16 PM, a follow up interview was conducted with the DON. The DON stated that there was no documentation of her observations of other residents or her assessment of Resident #3 related to the allegation. On 07/28/2026 at 4:37 PM, an interview was conducted with the LNHA. The LNHA stated that on 05/06/2026, RN #1 informed him and the DON that she was investigating an allegation of care neglect. The LNHA stated no specifics were provided on the allegations. The LNHA further stated that he did not know if the allegation being investigated by RN #1 was warranted following the facility abuse policy, but the allegation was reported to the NJDOH because it was a general allegation of neglect that the state agency informed the facility of. The LNHA stated that the purpose of the facility's abuse policy was to ensure the safety and wellbeing of the residents. The undated facility policy ABUSE PREVENTION PROGRAM was reviewed. Under POLICY INTERPRETATION AND IMPLEMENTATION the policy revealed, 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: [.] c. Identification of occurrences and patterns of potential mistreatment/abuse [.] f. Timely and thorough investigations of all reports and allegations of abuse [.]. This section of the policy further revealed 6. The Facility assigned investigator must [.] obtain written signed and dated statements from person(s) reporting the incident, resident involved and any witnesses. The policy revealed under POLICY STATEMENT, Abuse includes but is not limited to emotional, financial, neglect, physical, psychological, sexual, or verbal. NJAC 8:39-13.4(c)2i-2ii

Complaint # NJ182121 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure residents were protected from physical abuse after a cognitively intact resident (Resident #381) made an allegation of staff-to-resident physical abuse on 12/28/24. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising (age undetermined) around the area and that she administered the prescribed pain medication. RN #1 made the Registered Nurse Supervisor (RNS #1) aware of the resident's complaints and endorsed the resident's care and further follow-up of the allegation of physical abuse to RNS #1, because RN #1 was being sent home early. An interview on 5/1/25, with RN #1, confirmed the allegation of abuse was made, and she reported it to RNS #1. Interviews on 5/1/25, with RNS #1 and the Director of Nursing (DON), revealed that they both denied having knowledge of the allegation and the allegation was never investigated. The facility's failure to implement their abuse policy including investigating all allegations of abuse and protecting all resident from abuse during an investigation, placed all residents at risk for abuse. This posed the likelihood of serious physical and emotional harm, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began 12/28/24 at 9:16 AM, after Resident #381 made the allegation of physical abuse to RN #1. The facility was notified of the IJ on 5/6/25 at 3:45 PM. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 5/7/25 at 3:40 PM. The evidence was as follows: Refer F 609, F 610 A review of the facility's Abuse policy dated 4/9/24, included that abuse and neglect exist in many forms and to varying degrees. Abuse includes verbal, sexual, physical, mental, involuntary seclusion, exploitation, misappropriation, mistreatment, neglect, intimidation and injury of unknown origin. The objective of the abuse policy is to comply with a seven-step approach to abuse and neglect detection and prevention .The seven steps include: 1.) Screening and verification of references, certification and verification of license and a criminal background check. 2.) Training of staff through orientation and on-going abuse and prohibition practices. 3.) Prevention: the facility is to prevent abuse by providing residents, family and staff with education on how and to whom to report concerns, incidences and grievances. 4.) Identification: All staff were to monitor residents and would know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse would be investigated. 5.) Investigation is the process used to try to determine what happened and the designated personnel would begin the investigation immediately and a root cause analysis would be completed. When an incident or suspected incident of abuse is reported, the Administrator or designee would investigate the incident with the assistance of appropriate personal to include who was involved, resident statement, roommate statements, involved staff and witness statements, a description of the residents behavior and environment at the time of the incident, any injuries and a resident assessment, and interview other residents who were cared for by the accused. All staff must cooperate during the investigation to assure the resident is fully protected. 6.) Protection procedure would include immediately upon receiving a report of alleged abuse, the Administrator or designee would deliver appropriate medical and psychological care and attention, ensuring safety and wellbeing of vulnerable individuals. The alleged perpetrator would be immediately removed, and the resident would be protected. 7.) Reporting: the facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin would be reported immediately to Administrator and state agencies to include the New Jersey Department of Health [NJDOH] and Ombudsman. The surveyor reviewed the closed medical record for Resident #381. A review of the Admission Record face sheet (admission summary), reflected that Resident #381 was admitted to the facility with diagnoses that included but were not limited to; unspecified fracture of the left femur and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the individual comprehensive care plan (ICCP) included a focus of area dated 12/30/24, for alteration in comfort due to pain evidenced by verbalizing due to status post surgical site knee intensity level (1-10). Interventions included; to adjust pain medication administration time to coincide with treatments, rehabilitation, and/or care, to administer analgesic (pain) medication as ordered, and to maintain in the most comfortable position which is per my request. A review of a Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381 was awake, alert, oriented and able to make their needs known. Resident #381 reported to RN #1 that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a CNA (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising around the area and that she administered the resident's prescribed pain medication. The resident reported some relief from the pain medication. RN #1 made RNS #1 aware of the resident's complaints and endorsed the resident's care and further follow-up to RNS #1 because RN #1 was being sent home early. A review of the December 2024, Medication Administration Record (MAR) between the dates the allegation of physical abuse took place (12/25/24 through 12/28/24) included a physician's order dated 12/25/24, for oxycodone hydrochloride (HCL) 5 milligram (mg); give one tablet by mouth every six hours as needed for complaints of severe pain. Resident #381 received oxycodone HCL on the following dates and times; 12/25/24 at 8:00 PM, 12/26/24 at 4:58 AM, 12/26/24 at 8:04 PM, 12/27/24 at 6:23 AM, 12/28/24 at 8:23 AM, 12/28/24 at 2:53 PM, and 12/28/25 at 9:05 PM. On 5/1/25 at 9:16 AM, the surveyor conducted a telephone interview with RN #1, who had documented the allegation of physical abuse for Resident #381 on 12/28/24 at 9:16 AM. RN #1 identified herself as an Agency nurse, and stated that on 12/28/24, Resident #381 reported that they were handled roughly by a CNA a couple days ago, during the 3:00 PM to 11:00 PM (3-11) shift around 9:00 PM. RN #1 stated that the resident requested to have their incontinence brief changed, and the CNA, without introducing herself and without explaining what she was going to do, turned the resident so roughly that the resident almost fell out of the bed. RN #1 stated that the resident used the word assaulted when describing how it happened. RN #1 stated that the resident had complained of severe pain in the left hip area due to being handled so roughly. RN #1 explained that she had administered the resident an as needed [prn] pain medication at that time. RN #1 stated that she was going to call the physician to notify and to get a left hip x-ray, however she was told by RNS #1 that she was being sent home. RN #1 stated that she had reported the allegation of abuse to RNS #1, and RNS #1 told RN #1 that she would follow-up with the resident's allegation of abuse. RN #1 stated that Resident #381 provided her with the name of the alleged CNA (CNA #1), as well as the first names of the staff members the resident had notified about the alleged physical abuse. RN #1 identified the staff as the DON and the Staffing Coordinator (SC) who still worked at the facility. On 5/1/25 at 9:51 AM, the surveyor interviewed the SC, who stated that he worked in Central Supply in December 2024, and did not remember any resident reporting an allegation of abuse to him. The SC stated that he would have taken the allegation very seriously and would have reported it to the administration because it would have required a full investigation. The SC identified the alleged CNA reported to RN #1 by Resident #381 as CNA #1. On 5/1/25 at 9:59 AM, the surveyor conducted a telephone interview with RNS #1, who confirmed that she had worked the weekend of 12/28/24, when the resident reported an allegation of abuse. RNS #1 stated that she did not remember the event occurring or being told about the resident's complaints of physical abuse. RNS #1 stated that if the allegation was reported to her, then she would have reported it to the administration and an investigation would have started. RNS #1 then instructed the surveyor to ask the DON for more information. On 5/1/25 at 10:50 AM, the surveyor interviewed CNA #1, who stated she might have worked the 3-11 shift on 12/26/24, but did not remember any resident complaining about a CNA being rough or abusive with Resident #381. On 5/1/25 at 11:01 AM, the surveyor interviewed the DON, who stated that she was in constant communication with Resident #381 when the resident was in the facility and did not remember the resident or any nurse informing her that a CNA was being rough with Resident #381. At that time, the DON reviewed the PN dated 12/28/24 at 9:16 AM, and confirmed that an allegation of physical abuse was documented and it should have been reported to the administration and have been immediately investigated. The DON stated that if it was reported to her at the time the event occurred, she would have interviewed the nurse and the resident, and removed the CNA from all resident care until an investigation was thoroughly completed. The DON stated that the physician and family would have been notified and that the resident's pain would have been monitored to assure that their pain was being managed. The DON also explained that she would have in-serviced all staff on repositioning and the handling of residents as well as abuse training. The DON stated that if she had known, she would have reported the allegation to the New Jersey Department of Health (NJDOH). On 5/1/25 at 11:09 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) in the presence of the DON, who explained that prior to completing any comprehensive admission assessment, she reviewed the resident's progress notes, interviewed the resident and staff, and looked at any documentation that was pertinent to the MDS assessment. The RN/MDSC stated that it would be important to review progress notes and extract pertinent information to develop a comprehensive assessment of the resident, and she reviewed the nursing progress notes going back seven days from the assessment reference date (ARD). The RN/MDSC explained that if Resident #381's MDS assessment's ARD was 12/31/24, she would have reviewed the progress notes from 12/25/24 until 12/31/24. The RN/MDSC stated that she remembered reading the documentation regarding the resident's allegation of abuse, and remembered that it was discussed at clinical morning meeting, however she did not remember who was there, but remembered there was enough management there to know that it needed to be followed-up with. On 5/5/25 at 11:38 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the nurse that cared for Resident #381 on 12/28/24, did not report any incident related to abuse to the administration. The LNHA stated that he reviewed the documentation minutes of the clinical morning meeting dated 12/30/24, and there were no minutes pertaining to any resident alleging abuse. The LNHA stated that the allegation of abuse should have been reported by the RN/MDSC who read the PN dated 12/28/24, regarding the resident's allegation of abuse during Resident #381's admission assessment with the ARD of 12/31/24. The LNHA stated the nurse should have reported it to the LNHA immediately. The LNHA continued to explain that the psychologist came into see Resident #381 on 1/2/25, and the resident did not report abuse and did not express any fears concerning their stay at the facility. The LNHA stated that he immediately started an investigation when he became aware of the allegation and reported the incident to the NJDOH on 5/1/25 at 11:16 AM. On 5/6/25 at 11:20 AM, the surveyor interviewed the DON, who reviewed the PN dated 12/28/24, after surveyor inquiry. The DON stated that the RN/MDSC who read the note during the resident's assessment period, should have reported the allegation to administration after reading the allegation of abuse in the progress notes. The DON stated that based on the timesheets, CNA #2 worked the 3-11 shift on 12/26/24, (alleged day of abuse) and cared for the resident. The DON reported that CNA #2 had not worked at the facility since January of 2025. At that time, the surveyor informed the DON that RN #1 identified the alleged CNA as CNA #1, and the DON was unsure of who that CNA was. A review of CNA #1's Timecard Report revealed that CNA #1 was working in the facility at the time of the allegation (12/26/24 during the 3-11 shift). On 5/7/25 at 11:17 AM, the surveyor interviewed the LNHA, who stated that CNA #1 was suspended on 5/6/25, pending outcome of the completed investigation and he had attempted to call RN #1, but received no answer. The LNHA alleged that he interviewed Resident #381 via telephone (no longer a resident in the facility) and the resident did not state that they were abused during stay and felt safe when they resided in the facility. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM, indicating that 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; CNA #1 was immediately suspended, CNA #2 was terminated and last day of work was 1/3/25, and RNS #1 was educated on the abuse policy that included the seven components; screening, training, prevention, identification, investigation, protection, reporting and response. All cognitively intact residents or representatives were interviewed to verify that there were no allegations of abuse that were not investigated or reported. The abuse policy was reviewed by the DON, Medical Director, Interdisciplinary team, Unit Managers, Infection Preventionist, Social Workers, Activities, and LNHA with no revisions made. All employees at the facility were educated on the abuse policy by the DON, Medical Director, Interdisciplinary team, Unit Managers, Infection Preventionist, Social Workers, Activities, and LNHA. The survey team verified the implementation of the RP on-site during the continuation of the survey on 5/7/25 at 3:40 PM. NJAC 8:39-4.1(a)(5)

Complaint #NJ182121 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) protecting all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident physical abuse; b.) thoroughly investigating an allegation of staff-to-resident physical abuse; and c.) reporting an allegation of staff-to-resident physical abuse to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). Resident #381, a cognitively intact resident who had diagnoses that included but were not limited to; unspecified fracture of the left femur and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both), reported to the Registered Nurse (RN #1) an allegation of staff-to-resident physical abuse on 12/28/24. RN #1 documented in a progress note that the resident reported they were fearful of staff and the facility, and RN #1 endorsed it to the Registered Nurse Supervisor (RNS #1) to follow-up. The allegation was not investigated, the identified perpetrator was not suspended pending a thorough investigation, and was not reported to the NJDOH per the facility's abuse policies. The facility's failure to ensure all staff, including the LNHA, implemented their facility policies to ensure all residents were free from abuse by not protecting residents from abuse, not investigating or reporting an allegation of staff-to-resident physical abuse posed the likelihood of serious physical and emotional harm or impairment. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began 12/28/24 at 9:16 AM, after Resident #381 made the allegation of physical abuse to RN #1. The facility was notified of the IJ on 5/6/25 at 3:45 PM. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 5/7/25 at 3:40 PM. The evidence was as follows: Refer to F 600, F 609, F 610. A review of the job description Administrator provided by the facility revealed the following: Position Summary: Direct day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality of care can be always provided to residents. -Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. -Develop and maintain written policies and procedures that govern the operation of the facility. -Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. -Ensure that the resident rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including wage complaints are well established and always maintained. -Serve on various committees of the facility (i.e., Infection Control, Quality Assurance and Assessment, ect) and provide written/oral reports of such committee meetings to the governing board as directed. -Ensure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. -Maintains a liaison with the residents, their families, support personnel, ect., to assure that the residents' needs are continually met. A review of the facility's Abuse policy dated 4/9/24, included that abuse and neglect exist in many forms and to varying degrees. Abuse includes verbal, sexual, physical, mental, involuntary seclusion, exploitation, misappropriation, mistreatment, neglect, intimidation and injury of unknown origin. The objective of the abuse policy is to comply with a seven-step approach to abuse and neglect detection and prevention .The seven steps include: 1.) Screening and verification of references, certification and verification of license and a criminal background check. 2.) Training of staff through orientation and on-going abuse and prohibition practices. 3.) Prevention: the facility is to prevent abuse by providing residents, family and staff with education on how and to whom to report concerns, incidences and grievances. 4.) Identification: All staff were to monitor residents and would know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse would be investigated. 5.) Investigation is the process used to try to determine what happened and the designated personnel would begin the investigation immediately and a root cause analysis would be completed. When an incident or suspected incident of abuse is reported, the Administrator or designee would investigate the incident with the assistance of appropriate personal to include who was involved, resident statement, roommate statements, involved staff and witness statements, a description of the residents behavior and environment at the time of the incident, any injuries and a resident assessment, and interview other residents who were cared for by the accused. All staff must cooperate during the investigation to assure the resident is fully protected. 6.) Protection procedure would include immediately upon receiving a report of alleged abuse, the Administrator or designee would deliver appropriate medical and psychological care and attention, ensuring safety and wellbeing of vulnerable individuals. The alleged perpetrator would be immediately removed, and the resident would be protected. 7.) Reporting: the facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin would be reported immediately to Administrator and state agencies to include the New Jersey Department of Health [NJDOH] and Ombudsman. The surveyor reviewed the closed medical record for Resident #381. A review of a Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381 was awake, alert, oriented and able to make their needs known. Resident #381 reported to RN #1 that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising around the area and that she administered the resident's prescribed pain medication. The resident reported some relief from the pain medication. RN #1 made RNS #1 aware of the resident's complaints and endorsed the resident's care and further follow-up to RNS #1 because RN #1 was being sent home early. On 5/1/25 at 9:16 AM, the surveyor conducted a telephone interview with RN #1, who had documented the allegation of physical abuse for Resident #381 on 12/28/24 at 9:16 AM. RN #1 identified herself as an Agency nurse, and stated that on 12/28/24, Resident #381 reported that they were handled roughly by a CNA a couple days ago, during the 3:00 PM to 11:00 PM (3-11) shift around 9:00 PM. RN #1 stated that the resident requested to have their incontinence brief changed, and the CNA, without introducing herself and without explaining what she was going to do, turned the resident so roughly that the resident almost fell out of the bed. RN #1 stated that the resident used the word assaulted when describing how it happened. RN #1 stated that the resident had complained of severe pain in the left hip area due to being handled so roughly. RN #1 explained that she had administered the resident an as needed [prn] pain medication at that time. RN #1 stated that she was going to call the physician to notify and to get a left hip x-ray, however she was told by RNS #1 that she was being sent home. RN #1 stated that she had reported the allegation of abuse to RNS #1, and RNS #1 told RN #1 that she would follow-up with the resident's allegation of abuse. RN #1 stated that Resident #381 provided her with the name of the alleged CNA (CNA #1), as well as the first names of the staff members the resident had notified about the alleged physical abuse. RN #1 identified the staff as the DON and the Staffing Coordinator (SC) who still worked at the facility. On 5/1/25 at 9:51 AM, the surveyor interviewed the SC, who stated that he worked in Central Supply in December 2024, and did not remember any resident reporting an allegation of abuse to him. The SC stated that he would have taken the allegation very seriously and would have reported it to the administration because it would have required a full investigation. The SC identified the alleged CNA reported to RN #1 by Resident #381 as CNA #1. On 5/1/25 at 9:59 AM, the surveyor conducted a telephone interview with RNS #1, who confirmed that she had worked the weekend of 12/28/24, when the resident reported an allegation of abuse. RNS #1 stated that she did not remember the event occurring or being told about the resident's complaints of physical abuse. RNS #1 stated that if the allegation was reported to her, then she would have reported it to the administration and an investigation would have started. RNS #1 then instructed the surveyor to ask the DON for more information. On 5/1/25 at 11:01 AM, the surveyor interviewed the DON, who stated that she was in constant communication with Resident #381 when the resident was in the facility and did not remember the resident or any nurse informing her that a CNA was being rough with Resident #381. At that time, the DON reviewed the PN dated 12/28/24 at 9:16 AM, and confirmed that an allegation of physical abuse was documented and it should have been reported to the administration and have been immediately investigated. The DON stated that the allegation should have been reported to the NJDOH. On 5/1/25 at 11:09 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) in the presence of the DON, who stated when doing Resident #381's admission assessment, she remembered reading the documentation regarding the resident's allegation of abuse, and remembered that it was discussed at clinical morning meeting. The RN/MDSC did not remember who was there, but remembered there was enough management there to know that it needed to be followed-up with. On 5/5/25 at 11:38 AM, the surveyor interviewed the LNHA, who stated that the nurse that cared for Resident #381 on 12/28/24, did not report any incident related to abuse to the administration. The LNHA stated that he reviewed the documentation minutes of the clinical morning meeting dated 12/30/24, and there were no minutes pertaining to any resident alleging abuse. The LNHA stated that the allegation of abuse should have been reported by the RN/MDSC who read the PN dated 12/28/24, regarding the resident's allegation of abuse during Resident #381's admission assessment with the assessment reference date (ARD) of 12/31/24. The LNHA stated the nurse should have reported it to the LNHA immediately. The LNHA continued to explain that the psychologist came into see Resident #381 on 1/2/25, and the resident did not report abuse and did not express any fears concerning their stay at the facility. The LNHA stated that he immediately started an investigation when he became aware of the allegation and reported the incident to the NJDOH on 5/1/25 at 11:16 AM. On 5/6/25 at 11:20 AM, the surveyor interviewed the DON, who stated that the RN/MDSC who read the note during the resident's assessment period, should have reported the allegation to administration after reading the allegation of abuse in the progress notes. The DON stated that based on the timesheets, CNA #2 worked the 3-11 shift on 12/26/24, (alleged day of abuse) and cared for the resident. The DON reported that CNA #2 had not worked at the facility since January of 2025. At that time, the surveyor informed the DON that RN #1 identified the alleged CNA as CNA #1, and the DON was unsure of who that CNA was. A review of CNA #1's Timecard Report revealed that CNA #1 was working in the facility at the time of the allegation (12/26/24 during the 3-11 shift). On 5/7/25 at 11:17 AM, the surveyor interviewed the LNHA who stated that CNA #1 was suspended on 5/6/25, pending outcome of the completed investigation and he had attempted to call RN #1, but received no answer. The LNHA alleged that he interviewed Resident #381 via telephone (no longer a resident in the facility) and the resident did not state that they were abused during stay and felt safe when they resided in the facility. The LNHA acknowledged that he was responsible to ensure allegations of abuse were reported and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance with the facility's abuse policy. An acceptable Removal Plan was received on 5/7/25 at 3:08 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 including: the Regional Administrator educated the LNHA regarding role and responsibilities of the administrator and on the facility's abuse policy which included screening, training, prevention, identification, investigation, protection, reporting and response. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey and determined the IJ for F 835 was removed on 5/7/25 at 3:40 PM. NJAC 8:39-9.2(a) NJAC 8:39-9.3(a) NJAC 8:39-27.1(a)

Complaint #NJ182121 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident physical abuse for a cognitively intact resident (Resident #381) who reported being roughly handled by a Certified Nursing Assistant (CNA #1). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising (age undetermined) around the area and that she administered the prescribed pain medication. RN #1 made the Registered Nurse Supervisor (RNS #1) aware of the resident's complaints and endorsed the resident's care and further follow-up of the allegation of physical abuse to RNS #1, because RN #1 was being sent home early. An interview on 5/1/25, with RN #1, confirmed the allegation of abuse was made, and she reported it to RNS #1. Interviews on 5/1/25, with RNS #1 and the Director of Nursing (DON), revealed that they both denied having knowledge of the allegation and the allegation was never investigated or reported to the NJDOH. The facility's failure to implement their abuse policy including reporting all allegations of abuse to the NJDOH placed all residents at risk for abuse which posed the likelihood of serious physical and emotional harm, or impairment. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began 12/28/24 at 9:16 AM, after Resident #381 made the allegation of physical abuse to RN #1. The facility was notified of the IJ on 5/6/25 at 3:45 PM. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 5/7/25 at 3:40 PM. The evidence was as follows: Refer F 600, F 610 A review of the facility's Abuse policy dated 4/9/24, included that abuse and neglect exist in many forms and to varying degrees. Abuse includes verbal, sexual, physical, mental, involuntary seclusion, exploitation, misappropriation, mistreatment, neglect, intimidation and injury of unknown origin. The objective of the abuse policy is to comply with a seven-step approach to abuse and neglect detection and prevention .7.) Reporting: the facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin would be reported immediately to Administrator and state agencies to include the NJDOH and Ombudsman. The surveyor reviewed the closed medical record for Resident #381. A review of the Admission Record face sheet (admission summary), reflected that Resident #381 was admitted to the facility with diagnoses that included but were not limited to; unspecified fracture of the left femur and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the individual comprehensive care plan (ICCP) included a focus of area dated 12/30/24, for alteration in comfort due to pain evidenced by verbalizing due to status post surgical site knee intensity level (1-10). Interventions included; to adjust pain medication administration time to coincide with treatments, rehabilitation, and/or care, to administer analgesic (pain) medication as ordered, and to maintain in the most comfortable position which is per my request. A review of a Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381 was awake, alert, oriented and able to make their needs known. Resident #381 reported to RN #1 that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a CNA (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising around the area and that she administered the resident's prescribed pain medication. The resident reported some relief from the pain medication. RN #1 made RNS #1 aware of the resident's complaints and endorsed the resident's care and further follow-up to RNS #1 because RN #1 was being sent home early. On 5/1/25 at 9:16 AM, the surveyor conducted a telephone interview with RN #1, who had documented the allegation of physical abuse for Resident #381 on 12/28/24 at 9:16 AM. RN #1 identified herself as an Agency nurse, and stated that on 12/28/24, Resident #381 reported that they were handled roughly by a CNA a couple days ago, during the 3:00 PM to 11:00 PM (3-11) shift around 9:00 PM. RN #1 stated that the resident requested to have their incontinence brief changed, and the CNA, without introducing herself and without explaining what she was going to do, turned the resident so roughly that the resident almost fell out of the bed. RN #1 stated that the resident used the word assaulted when describing how it happened. RN #1 stated that the resident had complained of severe pain in the left hip area due to being handled so roughly. RN #1 explained that she had administered the resident an as needed [prn] pain medication at that time. RN #1 stated that she was going to call the physician to notify and to get a left hip x-ray, however she was told by RNS #1 that she was being sent home. RN #1 stated that she had reported the allegation of abuse to RNS #1, and RNS #1 told RN #1 that she would follow-up with the resident's allegation of abuse. RN #1 stated that Resident #381 provided her with the name of the alleged CNA (CNA #1), as well as the first names of the staff members the resident had notified about the alleged physical abuse. RN #1 identified the staff as the DON and the Staffing Coordinator (SC) who still worked at the facility. On 5/1/25 at 9:51 AM, the surveyor interviewed the SC, who stated that he worked in Central Supply in December 2024, and did not remember any resident reporting an allegation of abuse to him. The SC stated that he would have taken the allegation very seriously and would have reported it to the administration because it would have required a full investigation. The SC identified the alleged CNA reported to RN #1 by Resident #381 as CNA #1. On 5/1/25 at 9:59 AM, the surveyor conducted a telephone interview with RNS #1, who confirmed that she had worked the weekend of 12/28/24, when the resident reported an allegation of abuse. RNS #1 stated that she did not remember the event occurring or being told about the resident's complaints of physical abuse. RNS #1 stated that if the allegation was reported to her, then she would have reported it to the administration and an investigation would have started. RNS #1 then instructed the surveyor to ask the DON for more information. On 5/1/25 at 10:50 AM, the surveyor interviewed CNA #1, who stated she might have worked the 3-11 shift on 12/26/24, but did not remember any resident complaining about a CNA being rough or abusive with Resident #381. On 5/1/25 at 11:01 AM, the surveyor interviewed the DON, who stated that she was in constant communication with Resident #381 when the resident was in the facility and did not remember the resident or any nurse informing her that a CNA was being rough with Resident #381. At that time, the DON reviewed the PN dated 12/28/24 at 9:16 AM, and confirmed that an allegation of physical abuse was documented and it should have been reported to the administration and have been immediately investigated. The DON stated that if she had known, she would have reported the allegation to the NJDOH. On 5/1/25 at 11:09 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) in the presence of the DON, who explained that prior to completing any comprehensive admission assessment, she reviewed the resident's progress notes, interviewed the resident and staff, and looked at any documentation that was pertinent to the MDS assessment. The RN/MDSC stated that it would be important to review progress notes and extract pertinent information to develop a comprehensive assessment of the resident, and she reviewed the nursing progress notes going back seven days from the assessment reference date (ARD). The RN/MDSC explained that if Resident #381's MDS assessment's ARD was 12/31/24, she would have reviewed the progress notes from 12/25/24 until 12/31/24. The RN/MDSC stated that she remembered reading the documentation regarding the resident's allegation of abuse, and remembered that it was discussed at clinical morning meeting, however she did not remember who was there, but remembered there was enough management there to know that it needed to be followed-up with. On 5/5/25 at 11:38 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the nurse that cared for Resident #381 on 12/28/24, did not report any incident related to abuse to the administration. The LNHA stated that he reviewed the documentation minutes of the clinical morning meeting dated 12/30/24, and there were no minutes pertaining to any resident alleging abuse. The LNHA stated that the allegation of abuse should have been reported by the RN/MDSC who read the PN dated 12/28/24, regarding the resident's allegation of abuse during Resident #381's admission assessment with the ARD of 12/31/24. The LNHA stated the nurse should have reported it to the LNHA immediately. The LNHA stated that he immediately started an investigation when he became aware of the allegation and reported the incident to the NJDOH on 5/1/25 at 11:16 AM. On 5/6/25 at 11:20 AM, the surveyor interviewed the DON, who reviewed the PN dated 12/28/24, after surveyor inquiry. The DON stated that the RN/MDSC who read the note during the resident's assessment period, should have reported the allegation to administration after reading the allegation of abuse in the progress notes. The DON stated that based on the timesheets, CNA #2 worked the 3-11 shift on 12/26/24, (alleged day of abuse) and cared for the resident. The DON reported that CNA #2 had not worked at the facility since January of 2025. At that time, the surveyor informed the DON that RN #1 identified the alleged CNA as CNA #1, and the DON was unsure of who that CNA was. A review of CNA #1's Timecard Report revealed that CNA #1 was working in the facility at the time of the allegation (12/26/24 during the 3-11 shift). On 5/7/25 at 11:17 AM, the surveyor interviewed the LNHA, who stated that the RN/MDSC was disciplined because she did not report the resident's allegation of physical abuse after she read it in the progress note while performing the resident's admission assessment MDS. The LNHA acknowledged that he was responsible to ensure allegations of abuse were reported to the NJDOH and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance with the facility's abuse policy. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM, indicating that 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 which included; on 5/1/25 at 10:45 AM, the allegation of abuse was reported to the NJDOH, the LNHA and the DON were educated by the Regional Administrator on reporting allegations to the NJDOH on 5/6/25, all cognitively intact residents or representatives were interviewed to verify that there were no allegations of abuse that were not investigated or reported. The abuse policy was reviewed by the DON, Medical Director, Interdisciplinary team, Unit Managers, Infection Preventionist, Social Workers, Activities, and LNHA with no revisions made. All employees at the facility were educated on the abuse policy by the DON, Medical Director, Interdisciplinary team, Unit Managers, Infection Preventionist, Social Workers, Activities, and and LNHA that included the seven components screening, training, prevention, identification, investigation, protection, reporting and response. The survey team verified the implementation of the RP during the continuation on site survey on 5/7/25 at 3:40 PM. NJAC 8:39-9.4(f)

Complaint #NJ182121 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of staff-to-resident physical abuse to a cognitively intact resident (Resident #381) who reported the allegation to the Registered Nurse (RN #1) on 12/28/24. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff at the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising (age undetermined) around the area and that she administered the prescribed pain medication. RN #1 made the Registered Nurse Supervisor (RNS #1) aware of the resident's complaints and endorsed the resident's care and further follow-up of the allegation of physical abuse to RNS #1, because RN #1 was being sent home early. An interview on 5/1/25, with RN #1, confirmed the allegation of abuse was made, and she reported it to RNS #1. Interviews on 5/1/25, with RNS #1 and the Director of Nursing (DON), revealed that they both denied having knowledge of the allegation and the allegation was never investigated. The facility's failure to implement their abuse policy by investigating all allegations of abuse placed all residents at risk for abuse which posed the likelihood of serious physical and emotional harm, or impairment. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began 12/28/24 at 9:16 AM, after Resident #381 made the allegation of physical abuse to RN #1. The facility was notified of the IJ on 5/6/25 at 3:45 PM. The facility submitted an acceptable Removal Plan (RP) on 5/7/25 at 3:08 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 5/7/25 at 3:40 PM. The evidence was as follows: Refer F 600, F 610 The facility's Abuse policy dated 4/9/24, included that abuse and neglect exist in many forms and to varying degrees. Abuse includes verbal, sexual, physical, mental, involuntary seclusion, exploitation, misappropriation, mistreatment, neglect, intimidation and injury of unknown origin. The objective of the abuse policy is to comply with a seven-step approach to abuse and neglect detection and prevention . 4.) Identification: All staff were to monitor residents and would know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse would be investigated. 5.) Investigation is the process used to try to determine what happened and the designated personnel would begin the investigation immediately and a root cause analysis would be completed. When an incident or suspected incident of abuse is reported the Administrator or designee would investigate the incident with the assistance of appropriate personal to include who was involved, resident statement, roommate statements, involved staff and witness statements, a description of the residents behavior and environment at the time of the incident, any injuries and a resident assessment, and interview other residents who were cared for by the accused. All staff must cooperate during the investigation to assure the resident is fully protected . The surveyor reviewed the closed medical record for Resident #381. A review of the Admission Record face sheet (admission summary), reflected that Resident #381 was admitted to the facility with diagnoses that included but were not limited to; unspecified fracture of the left femur and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the individual comprehensive care plan (ICCP) included a focus of area dated 12/30/24, for alteration in comfort due to pain evidenced by verbalizing due to status post surgical site knee intensity level (1-10). Interventions included; to adjust pain medication administration time to coincide with treatments, rehabilitation, and/or care, to administer analgesic (pain) medication as ordered, and to maintain in the most comfortable position which is per my request. A review of a Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381 was awake, alert, oriented and able to make their needs known. Resident #381 reported to RN #1 that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a CNA (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising around the area and that she administered the resident's prescribed pain medication. The resident reported some relief from the pain medication. RN #1 made RNS #1 aware of the resident's complaints and endorsed the resident's care and further follow-up to RNS #1 because RN #1 was being sent home early. On 5/1/25 at 9:16 AM, the surveyor conducted a telephone interview with RN #1, who had documented the allegation of physical abuse for Resident #381 on 12/28/24 at 9:16 AM. RN #1 identified herself as an Agency nurse, and stated that on 12/28/24, Resident #381 reported that they were handled roughly by a CNA a couple days ago, during the 3:00 PM to 11:00 PM (3-11) shift around 9:00 PM. RN #1 stated that the resident requested to have their incontinence brief changed, and the CNA, without introducing herself and without explaining what she was going to do, turned the resident so roughly that the resident almost fell out of the bed. RN #1 stated that the resident used the word assaulted when describing how it happened. RN #1 stated that the resident had complained of severe pain in the left hip area due to being handled so roughly. RN #1 explained that she had administered the resident an as needed [prn] pain medication at that time. RN #1 stated that she was going to call the physician to notify and to get a left hip x-ray, however she was told by RNS #1 that she was being sent home. RN #1 stated that she had reported the allegation of abuse to RNS #1, and RNS #1 told RN #1 that she would follow-up with the resident's allegation of abuse. RN #1 stated that Resident #381 provided her with the name of the alleged CNA (CNA #1), as well as the first names of the staff members the resident had notified about the alleged physical abuse. RN #1 identified the staff as the DON and the Staffing Coordinator (SC) who still worked at the facility. On 5/1/25 at 9:51 AM, the surveyor interviewed the SC, who stated that he worked in Central Supply in December 2024, and did not remember any resident reporting an allegation of abuse to him. The SC stated that he would have taken the allegation very seriously and would have reported it to the administration because it would have required a full investigation. The SC identified the alleged CNA reported to RN #1 by Resident #381 as CNA #1. On 5/1/25 at 9:59 AM, the surveyor conducted a telephone interview with RNS #1, who confirmed that she had worked the weekend of 12/28/24, when the resident reported an allegation of abuse. RNS #1 stated that she did not remember the event occurring or being told about the resident's complaints of physical abuse. RNS #1 stated that if the allegation was reported to her, then she would have reported it to the administration and an investigation would have started. RNS #1 then instructed the surveyor to ask the DON for more information. On 5/1/25 at 10:50 AM, the surveyor interviewed CNA #1, who stated she might have worked the 3-11 shift on 12/26/24, but did not remember any resident complaining about a CNA being rough or abusive with Resident #381. On 5/1/25 at 11:01 AM, the surveyor interviewed the DON, who stated that she was in constant communication with Resident #381 when the resident was in the facility and did not remember the resident or any nurse informing her that a CNA was being rough with Resident #381. At that time, the DON reviewed the PN dated 12/28/24 at 9:16 AM, and confirmed that an allegation of physical abuse was documented and it should have been reported to the administration and have been immediately investigated. The DON stated that if it was reported to her at the time the event occurred, she would have interviewed the nurse and the resident, and removed the CNA from all resident care until an investigation was thoroughly completed. The DON stated that the physician and family would have been notified and that the resident's pain would have been monitored to assure that their pain was being managed. The DON also explained that she would have in-serviced all staff on repositioning and the handling of residents as well as abuse training. On 5/1/25 at 11:09 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) in the presence of the DON, who explained that prior to completing any comprehensive admission assessment, she reviewed the resident's progress notes, interviewed the resident and staff, and looked at any documentation that was pertinent to the MDS assessment. The RN/MDSC stated that it would be important to review progress notes and extract pertinent information to develop a comprehensive assessment of the resident, and she reviewed the nursing progress notes going back seven days from the assessment reference date (ARD). The RN/MDSC explained that if Resident #381's MDS assessment's ARD was 12/31/24, she would have reviewed the progress notes from 12/25/24 until 12/31/24. The RN/MDSC stated that she remembered reading the documentation regarding the resident's allegation of abuse, and remembered that it was discussed at clinical morning meeting, however she did not remember who was there, but remembered there was enough management there to know that it needed to be followed-up with. On 5/5/25 at 11:38 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the nurse that cared for Resident #381 on 12/28/24, did not report any incident related to abuse to the administration. The LNHA stated that he reviewed the documentation minutes of the clinical morning meeting dated 12/30/24, and there were no minutes pertaining to any resident alleging abuse. The LNHA stated that the allegation of abuse should have been reported by the RN/MDSC who read the PN dated 12/28/24, regarding the resident's allegation of abuse during Resident #381's admission assessment with the ARD of 12/31/24. The LNHA stated the nurse should have reported it to the LNHA immediately. The LNHA continued to explain that the psychologist came into see Resident #381 on 1/2/25, and the resident did not report abuse and did not express any fears concerning their stay at the facility. The LNHA stated that he immediately started an investigation when he became aware of the allegation. On 5/6/25 at 11:20 AM, the surveyor interviewed the DON, who reviewed the PN dated 12/28/24, after surveyor inquiry. The DON stated that the RN/MDSC who read the note during the resident's assessment period, should have reported the allegation to administration after reading the allegation of abuse in the progress notes. The DON stated that based on the timesheets, CNA #2 worked the 3-11 shift on 12/26/24, (alleged day of abuse) and cared for the resident. The DON reported that CNA #2 had not worked at the facility since January of 2025. At that time, the surveyor informed the DON that RN #1 identified the alleged CNA as CNA #1, and the DON was unsure of who that CNA was. A review of CNA #1's Timecard Report revealed that CNA #1 was working in the facility at the time of the allegation (12/26/24 during the 3-11 shift). On 5/7/25 at 10:45 AM, the surveyor interviewed the DON, who stated that the nurse did not report the allegation of abuse on 12/28/24 at 9:16 AM, to the administration when the incident occurred, however after surveyor inquiry, the DON started the investigation into the allegation of physical abuse. On 5/7/25 at 11:17 AM, the surveyor interviewed the LNHA, who stated that the RN/MDSC was disciplined because she did not report the resident's allegation of physical abuse after she read it in the progress note while performing the resident's admission assessment MDS. The LNHA acknowledged that he was responsible to ensure allegations of abuse were reported to the NJDOH and fully investigated. The LNHA stated he was responsible to oversee this process and that it was done in accordance with the facility's abuse policy. An acceptable Removal Plan was received on 5/7/25 at 3:08 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 including; the LNHA or designee immediately initiated an investigation; the allegation was reported to the NJDOH; the LNHA and DON were re-educated on Investigations/ Prevention/Correct Alleged Violations; and all staff were educated on the facility's abuse policies and procedures. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 5/7/25. NJAC 8:39-4.1(a)(5)

Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean and sanitary manner and b,) maintain 2 of 6 nourishment room refrigerators in a sanitary manner. The evidence was as follows: On 4/29/25 at 10:20 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following during kitchen tour: 1. The steamer unit floor drain was filled with debris and sediment. The FSD acknowledge it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. Two steamer units were drained into a floor trap and the trap screen had debris covering it. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The six-burner stove top and oven were covered with cooked on grease and sediment crusted around the burners. The oven had food sediment and debris on the interior and the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil. The FSD acknowledged and stated, it was not cleaned according to facility policy. On 5/6/25 at 1:31 PM, in the presence of the FSD, the surveyor observed the nourishment rooms as evidence with the following . 5. Both Unit 3A and 3B nourishment room refrigerators for resident use on the unit were observed to have discoloration and debris in the gaskets of the refrigerator door and freezer door. The FSD acknowledged and stated it was not cleaned according to facility policy, and it was his departments responsibility to maintain or report any issues in the nourishment rooms. 6. In the 3A (locked unit) nourishment room microwaves had crusted brown colored debris stuck to the roof of the microwave. The FSD acknowledged and stated, it was not cleaned according to facility policy, and it was his departments responsibility to maintain or report any issues in the nourishment rooms. 7. In all six nourishment rooms did not have properly documented temperatures for the freezer. The surveyor observed the temperatures to be in the correct range. The FSD acknowledged the logs his staff were documenting on only had a date column, AM temp column, and PM temp column for only the refrigerator. On 5/6/25 at 1:36 PM, the surveyor interviewed the FSD, who stated that he acknowledged that the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of our residents and staff. On 5/6/25 at 12:45 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's undated, Sanitation policy included food service area shall be maintained in a clean and sanitary manner .all kitchens and kitchen area, shall be kept clean .to protect from rodents, roaches, flies and other insects . A review of the facility's undated Resident Rights handout included the facility must provide a safe, clean, comfortable, homelike environment, allowing you the opportunity to use your personal belongings to the extent possible . NJAC 8:39-17.2(g)

Complaint #NJ182121, NJ183873 Based on interview, record review, and other pertinent facility documents, it was determined that facility to failed to ensure residents received the appropriate pain management by a.) administering pain medications according to the physician's ordered pain level parameters and b.) obtaining and administering pain medications as ordered by the physician. This deficient practice was identified for 2 of 2 residents reviewed for pain management (Residents #381 and Resident #531), and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #381. A review of the Admission Record face sheet (admission summary) reflected that Resident #381 was admitted to the facility with the diagnoses that included but were not limited to; unspecified fracture of the left femur (thigh bone) and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/31/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A further review of the MDS revealed the resident required extensive assistance with activities of daily living and mobility. A review of the individualized comprehensive care plan (ICCP) included a focus of area dated 12/30/24, for alteration in comfort due to pain evidenced by verbalizing due to status post surgical site to the knee with an intensity level (1-10). Interventions included: adjust pain medication administration time to coincide with treatments, rehabilitation, and/or care, analgesic medication (pain) as ordered, and maintain in most comfortable position which is per my request. A review of the physician's order (PO) dated 12/25/24, reflected an order for acetaminophen (Tylenol) tablet 325 milligrams (mg); administer two tablets by mouth every eight hours as needed for mild and moderate pain. A review of the PO dated 12/25/24, reflected on order for oxycodone hydrochloride (HCl) 5 mg oral tablet, a narcotic pain medication, administer one tablet by mouth every six hours as needed for severe. The numerical pain scale is as follows: 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain and 7-10 = severe pain. A review of the Medication Administration Record (MAR) dated 12/1/24-12/31/24, reflected that the following pain medications were administered out of physician ordered pain management levels: - On 12/25/24 at 10:53 PM, Resident #381 complained of pain at a numerical level pain scale of 10, which indicated severe pain and was administered Tylenol 325 mg two tablets. The resident should have been administered oxycodone HCl 5 mg for complaints of severe pain as ordered by the physician. - On 12/28/24 at 9:05 PM, the resident had complained of pain at a moderate level of five, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. - On 12/29/24 at 3:30 AM, the resident had complaints of pain at a mild level of three, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for mild pain as ordered by the physician. - On 12/29/24 at 11:19 AM, the resident had complaints of pain at a moderate level of four, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. - On 12/29/24 at 5:48 PM, the resident had complaints of pain at a moderate level of five, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tabs for moderate pain as ordered by the physician. - On 12/30/24 at 12:43 AM, the resident had complaints of pain at a mild level of two and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for mild pain as ordered by the physician. - On 12/30/24 at 10:58 AM, the resident had complaints of pain at a moderate level of four, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. - On 12/31/24 at 4:00 AM, the resident had complaints of pain at a moderate level of four, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. - On 12/31/24 at 10:06 AM, the resident had complaints of pain at a moderate level of four, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. - On 12/31/24 at 4:00 PM, the resident had complaints of pain at a moderate level of four, and was administered oxycodone HCl 5 mg. The resident should have received Tylenol 325 mg two tablets for moderate pain as ordered by the physician. On 5/1/25 at 11:41 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that when a resident verbally complained of pain, that the nurse asked the resident what their pain level was according to numerical pain scale ranging from 0-10 (0 indicating no pain and 10 indicating severe). The LPN stated that the numerical pain scale was 0= no pain; 1-3 = mild pain; 4-6 = moderate pain; and 7-10 = severe pain. At that time, the LPN reviewed Resident #381's physician's orders in the presence of the surveyor, and the LPN confirmed that Tylenol 325 mg two tablets should be administered every eight hours for mild or moderate pain, and oxycodone HCl 5 mg should be administered every six hours for severe pain [7-10]. The LPN stated that if the resident had complained of severe pain, then the resident should have been given the oxycodone HCl 5 mg and if the resident complained of mild to moderate pain [1-6], then the resident should have received Tylenol 325 mg two tablets. The LPN reviewed the MAR in the presence of the surveyor, and stated that when the resident complained of mild to moderate pain, the resident should not have been administered the oxycodone HCl and should have received the Tylenol as ordered by the physician. On 5/1/25 at 11:56 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that pain medications should be administered as per the physician ordered pain level parameters. The LPN/UM reviewed Resident #381's MAR and confirmed that the staff were not administering the pain medications according to the physician's pain level parameters. The LPN/UM stated that the oxycodone HCl was only to be administered if the resident complained of pain at a level of 7-10, not 1-6 which was mild to moderate pain. the LPN/UM stated that it would be the same for the Tylenol and that it should only be given for mild pain at pain level of 1-3 or moderate pain at a pain level of 4-6. On 5/7/25 at 11:17 AM, the surveyor interviewed the Director of Nursing (DON), who reviewed Resident #381's December 2024 MAR in the presence of the surveyor and confirmed that the nurses were administering pain medication out of the physician's ordered pain level parameters. A review of the facility's Pain-Clinical Protocol policy included that staff would use a standardized pain assessment instrument appropriate for the resident's cognitive level. The staff and provider may identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc ). 40744 2. The surveyor reviewed the closed medical record for Resident #531. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; fracture of the left femur, malignant neoplasm of the pancreas (cancer), and diabetes (high blood sugar). A review of the Minimum Data Set (MDS) list, a list of completed assessment tools, showed the resident had an entry MDS completed, and after a brief facility stay there was a discharge return not anticipated MDS completed. On the discharge MDS, Section J, Health Conditions, was marked as yes that the resident was receiving a scheduled pain medication regime. A review of the Electronic Medical Record (EMR) revealed that Resident #531 arrived to the facility on [DATE] at 8:57 PM. A review of the physician's orders reflected the following pain medication orders on admission to the facility: 1. Dilaudid (narcotic pain medication) 2 mg tablet; give one tablet every three hours as needed for moderate pain (pain between 4 and 6 on a numeric pain scale from 1 to 10) for five days. The order date was 2/12/25. 2. Dilaudid 4 mg tablet; give one tablet every three hours as needed for severe pain (pain between 7 and 10 on a numeric pain scale from 1 to 10) for five days. The order date was 2/12/25. 3. MS Contin (morphine, a narcotic pain medication) 30 mg tablet; give one tablet three times daily for chronic pain (to be given around the clock). The order date was 2/12/25. 4. Tylenol 650 mg every six hours for mild pain (pain between 1 and 3 on a numeric pain scale from 1 to 10). A review of the Medication Administration Record (MAR) revealed that Resident #531 did not receive any Dilaudid during their stay at the facility. The Dilaudid orders were pending confirmation. A further review of the MAR revealed that the MS Contin was scheduled to be given at 8:00 AM, 12:00 PM, and 8:00 PM. The resident did not receive the MS Contin the night of admission (2/12/25) at 8:00 PM as scheduled. On 2/13/25, the MS Contin was not administered at 8:00 AM or 12:00 PM, and it was documented to see progress notes. The surveyor reviewed the corresponding progress notes and there were no notes addressing the pain medication. On 2/13/25 at 8:00 PM, the medication was marked as not given and it was documented that the resident was sleeping. A review of the ICCP included a focus area for alteration in comfort due to pain evidenced by verbalizing due to my diagnosis with intensity level (1-10). Interventions included to: adjust pain medications as needed; administer analgesics as ordered; assess for continued need for analgesics; and monitor effectiveness of pain medications and side effects. A review of the Physician Progress Note dated 2/14/25, included that per the resident, they are comfortable with MS Contin. The physician's orders for Dilaudid were discontinued as resident's pain is tolerated at this time on current medications. On 5/6/25 at 1:35 PM, the surveyor interviewed LPN #2 regarding medication delivery, who stated that medications were delivered three times a day; morning, afternoon, and midnight. LPN #2 stated the facility did not have back-up medications, and You just keep calling the pharmacy until you get it. The surveyor asked how a resident's pain would be managed if the ordered medications were not available and she said, We would just give them Tylenol. On 5/6/25 at 1:43 PM, the surveyor reviewed the resident's MAR for the time the resident was at the facility. The resident did not receive any pain medications while waiting for the MS Contin delivery, and their pain level was documented as zero. On 5/7/25 at 12:20 PM, during an interview with the Licensed Nursing Home Administrator (LNHA) regarding the delay in the pain medications, the LNHA replied, Same as the other resident. We have requested a timeline from the pharmacy, but we have not received it. The surveyor was not provided any additional documentation from the facility. A review of the facility's undated Delivery of Medications from Satellite (Back-Up) Pharmacy policy included the purpose was to provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the facility's regularly scheduled delivery .the facility may call the pharmacy and request a STAT (immediate) delivery, and the pharmacy had a 3-to-4-hour window to deliver a medication from their main location . NJAC 8:39-27.1(a)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to administer ten doses of an anti-convalescent medication (clonazepam) prescribed for seizures according to physician's orders. This deficient practice was identified for 1 of 35 residents reviewed for quality of care (Resident #47), and was evidenced by the following: On 4/29/25 at 11:324 AM, during initial tour of the facility, the surveyor observed Resident #47 lying in their bed with the bed positioned low with a fall mat located at the side. On 4/30/25 at 10:49 AM, the surveyor reviewed the medical record for Resident #47. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; hypertension (high blood pressure), seizures (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior), and mood disorder (mental health condition that primarily affects your emotional state). A review of the most recent significant change Minimum Data Set (MDS), an assessment tool dated 4/1/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated a severely impaired cognition. A further review included the resident had an active diagnosis of seizure disorder or epilepsy. A review of the Order Summary Report included a physician's order (PO) dated 3/25/25, for clonazepam oral tablet 1 milligram (mg); administer one tablet by mouth one time a day for seizure. A further review revealed a PO dated 3/25/25, for lamotrigine (anti-convalescent medication) oral tablet 100 mg; administer one tablet by mouth two times a day for seizure. A review of the individualized comprehensive care plan (ICCP) included a focus area date initiated on 5/17/21, that the resident has a seizure disorder. Interventions included but were not limited to; give seizure medication as ordered by the doctor, seizure documentation, and seizure precautions. On 4/30/25 at 1:06 PM, the surveyor reviewed the March 2025 and April 2025 Medication Administration Records (MAR) which revealed the clonazepam 1 mg oral tablet was not administered on the following dates: 3/26/25, 3/27/25, 3/29/25, 3/30/25, 3/31/25, 4/1/25, 4/3/25, 4/4/25, 4/5/25, and 4/6/25. A further review of the March 2025 and April 2025 MAR revealed Resident #47 received the lamotrigine oral tablet 100 mg tablet by mouth two times a day for seizure as ordered by the physician. On 5/1/25 at 12:23 PM, the surveyor reviewed the Progress Notes in the electronic medical record (eMR) which revealed the resident did not have any seizure activity during March 2025 or April 2025. On 5/6/25 at 12:54 PM, the surveyor interviewed the Registered Nurse (RN #1), who stated medications were delivered three times a day. RN #1 further stated that the process when a medication was not delivered was to call the pharmacy, call the Nurse Practitioner (NP), complete a progress note and endorses it to the next shift. RN #1 acknowledged that the clonazepam was not administered as ordered. RN #1 also confirmed that the resident did not have any seizures during that time. On 5/6/25 at 1:00 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated medications delivery times vary but if a medication did not come in, the nurse should call the pharmacy to request it immediately (STAT). LPN #1 acknowledged that the resident did not receive the clonazepam as ordered on 3/26/25. LPN #1 further stated that the resident had not had any seizures during that time. On 5/6/25 at 2:35 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Nurse, and the survey team, acknowledged that the clonazepam was not administered as ordered. On 5/7/25 at 11:12 AM, the LNHA, in the presence of the Director of Nursing and survey team, could not provided any additional information. A review of the facility's Orders and Transcription policy undated, included 1. The nurse receiving the order must add it into [the electronic medical system] orders as a verbal order or telephone order. A review of the facility's Delivery of Medications from Satellite (Back-Up) Pharmacy, revised 9/6/19, included Purpose: To provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the facility's regularly scheduled delivery .1. The facility may call the pharmacy and request STAT delivery. Specialty Rx (prescription) has a 3-4-hour window to deliver a medication as a STAT from our main location. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed a.) to treat each resident with respect and dignity and b.) care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life recognizing each resident's individuality. This deficient practice was identified for 1 of 35 residents reviewed for dignity (Resident #206), and was evidenced by the following: On 4/29/25 at 11:09 AM, during initial tour of the facility, the surveyor observed a Certified Nurse Aide (CNA #1) walking alongside Resident #206 in the hallway towards the shower room. CNA #1 and Resident #206 entered the shower room, and the door closed. The surveyor then heard Resident #206 begin to yell inside the shower room. At that time, CNA #1 opened the door and asked for the facility's translator to assist with translating the resident's needs. The Translator entered the shower room, and the surveyor observed the resident, who was still fully dressed, speaking with the Translator who then informed CNA #1 that the resident did not want to be showered by him. At that time, CNA #2, who was a few doors down the hallway, came out of a resident's room and was laughing, approaching CNA #1. CNA #2 stated, I won the bet, I told you [the resident] wasn't going to shower. At that time, CNA #1, CNA #2, and Resident #206 left the vicinity of the shower room and escorted the resident back to their room. CNA #1 and CNA #2 then came out into the hallway, away from the resident's room, stood by the nurse's station and CNA #2 stated to CNA #1, I told you (the resident) only wants the son or daughter to shower. That was when CNA #1 began to imitate in a mocking manner the resident's yelling as the resident did in the shower room, both CNA #1 and CNA #2 laughed and walked away from the nurse's station and continued with other duties. On 4/29/25 at 11:13 AM, the surveyor interviewed the Chinese Program Manager (CPM), who stated Resident #206 refused showers and only wanted their son or daughter to provide showers to them. On 4/29/25 at 11:15 AM, the surveyor interviewed CNA #2, who stated that she usually was assigned to care for Resident #206, but today she was not. On 5/6/25 at 1:39 PM, the surveyor interviewed CNA #2, who stated that she was provided training and education by the facility upon hire regarding resident rights, dignity, and respect. CNA #2 stated Resident #206 was confused at times, but was consistent with wanting only family to provide their shower. CNA #2 stated that she informed CNA #1 that Resident #206 would refuse to be showered, but CNA #1 bet that he could give Resident #206 a shower. CNA #2 acknowledged that CNA #1 and CNA #2 laughed and stated it was because CNA #1 lost the bet and the resident refused to shower. On 5/6/25 at 1:51 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON), who both acknowledged that all residents were to be treated with respect and dignity and for all staff to always respect their preferences. The surveyor informed them of the observation made of CNA #1 and CNA #2 with Resident #206, and both the DON and LPN/UM stated that was absolutely not acceptable behavior and should not be tolerated. A review of the facility's Dignity policy with effective date of 2/1/24, included but was not limited to: a facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . NJAC 8:39-4.1(a)(12)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order to carry out a resident's wishes for code status. This deficient practice was identified for 2 of 38 residents reviewed for code status and advanced directives (Residents #167 and #230), and was evidenced by the following: 1. On 4/29/25 at 12:34 PM, the surveyor reviewed Resident #167's electronic medical record (EMR). A review of the Admission Record face sheet (an admission summary) indicated that the resident was readmitted to the facility with diagnosis which included but were not limited to; malignant neoplasm of colon (malignant colon cancer), malignant neoplasm of the liver (liver cancer), and malignant neoplasm of the lung (lung cancer). A review of the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) indicated the resident's wishes were to be a Do Not attempt resuscitation (DNR) and allow natural death and Do not intubate (DNI) in the event the resident had no pulse and/or was not breathing (code status), which was signed and dated 12/13/24. A review of the Physician Order Summary did not include a physician's order for the resident's code status to honor the resident's wish to be DNR and DNI. On 5/1/25 at 11:07 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated she was not aware of Resident #167'2 code status and that she would have to ask the nurse. On 5/1/25 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated a physician's order was required in the resident's medical record to indicate the code status of the resident so that the nursing staff knew what to do to honor the wishes of the resident in the event of an emergency. On 5/1/25 at 11:44 AM, the LPN approached the surveyor, and stated that Resident #167's DNR/DNI code status order was not in place previously, and she had since added it to the medical record after surveyor inquiry. The LPN stated whoever took the order did not enter it into the resident's EMR. On 5/1/25 at 11:47 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN), who stated that when the POLST form was completed with the resident's wishes for code status and signed by the physician, the code status should have been entered into the resident's EMR as a physician's order to be carried out. The RN/CN confirmed that there had not been an order for the resident's code status. On 5/5/25 at 9:03 AM, the surveyor interviewed the Director of Nursing (DON), who stated that when the POLST form was completed for a resident, then a physician's order should absolutely be put in place and entered into the resident's EMR for code status identification. 2. The surveyor reviewed the closed medical record for Resident #230. A review of the Admission Record face sheet indicated that Resident #230 was admitted to the facility with diagnosis which included but were not limited to; benign prostatic hyperplasia (benign prostate enlargement), dementia, and chronic kidney disease and was discharged due to death at the facility on 3/7/25. A review of the POLST which was completed and signed dated 9/29/19, indicated that Resident #230's code status wishes were to be a DNR, DNI, and no artificial nutrition. A review of the Physician Order Summary did not include a physician's order for code status to honor the resident's wish to be DNR, DNI, and no artificial nutrition. A review of the Progress Notes included a Health Note dated 3/7/25 at 4:56 PM, that while doing rounds, CNA #2 reported to this writer that the resident was not responding. The writer attended to the room and found the resident unconscious and non-responsive. The writer attempted to take vital signs, but was unable to obtain. The resident's code status was obtained, and the resident's status was DNR and DNI. The Nursing Supervisor was called to the unit, and they pronounced the resident at 4:05 PM. On 5/1/25 at 11:20 AM, the surveyor interviewed the LPN, who stated a physician's order was required in the resident's medical record to indicate the code status of the resident so that the nursing staff knew what to do to honor the wishes of the resident in the event of an emergency. On 5/1/25 at 11:47 AM, the surveyor interviewed the RN/CN, who stated that when the POLST form was completed with the resident's wishes for code status and signed by the physician, the code status should have been entered into the resident's EMR as a physician's order to be carried out. On 5/5/25 at 9:03 AM, the surveyor interviewed the DON, who stated that when the POLST form was completed for a resident, then a physician's order should absolutely be put in place and entered into the resident's EMR for code status identification. A review of the facility's undated Advance Directives policy included but was not limited to: the director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care . NJAC 8:39-4.1(a)

Complaint #NJ183871, NJ183873 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for a.) a resident who was receiving dialysis (a medical procedure that acts as an artificial kidney filtering waste and excess fluid from the blood) treatments and b.) a resident with a surgical wound. This deficient practice was identified for 2 of 35 residents reviewed for care plans (Resident #73 and Resident #531), and was evidenced by the following: 1. On 4/29/25 at 12:13 PM, the Resident #73 was observed in bed with a blanket pulled over their head. The resident did not want to be interviewed. The surveyor reviewed the medical record for Resident #73. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; end stage kidney disease, heart failure, difficulty in walking, and diabetes (high blood sugar). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/22/25, revealed that the resident had a Brief Interview of Mental Status score of 10 out of 15, meaning the resident had moderate cognitive impairment. A review of Section O, Special Procedures, indicated the resident was receiving dialysis treatments on admission to the facility. A review of the physician's orders included an active order dated 2/17/25, for dialysis treatments every Tuesday, Thursday, and Saturday. A review of the resident's dialysis communication book revealed that the facility completed the book every time Resident #73 went out to the dialysis facility. A review of the individualized comprehensive care plan (ICCP) did not include a focus area for dialysis treatments. On 5/6/25 at 1:22 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding care plans. The surveyor asked who was responsible for initiating and updating resident care plans, and the LPN stated it was the responsibility of the Unit Manager. On 5/6/25 at 3:30 PM, the surveyor met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) regarding care plans and who was responsible to initiate, revise, and update care plans on the sub-acute unit. The LNHA informed the surveyor that the Charge Nurse was responsible. The LNHA said the Charge Nurse shared the sub-acute unit and the second floor. 2. The surveyor reviewed the closed medical record for Resident #531. A review of the Face Sheet reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; fracture of the left femur (thigh bone), depression, and cancer of the pancreas. A review of the discharge MDS reflected under Section M, Skin Conditions, the resident had a surgical incision. A review of the physician's orders included order dated 2/13/25, for resident to follow-up with surgeon regarding left hip surgical site. A review of the ICCP did not include a focus area of skin or surgical incision. A review of the Progress Notes dated 2/12/25, revealed that the resident was admitted from an acute care facility and had a surgical incision on the left hip covered with gauze and transparent tape. On 5/6/25 at 1:22 PM, the surveyor interviewed the LPN regarding care plans. The surveyor asked who was responsible for initiating and updating resident care plans, and the LPN stated it was the responsibility of the Unit Manager. On 5/6/25 at 3:30 PM, the surveyor met with the DON and the LNHA regarding care plans and who was responsible to initiate, revise, and update care plans on the sub-acute unit. The LNHA informed the surveyor that the Charge Nurse was responsible. The LNHA said the Charge Nurse shared the sub-acute unit and the second floor. A review of the facility's undated Care Plans policy included that the resident's care plan was developed using the completed resident's comprehensive assessment using the Baseline Care Plan template and care plan were revised as changes in the resident's condition may dictate . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent worsening of a pressure ulcer. This deficient practice was identified in 1 of 4 residents reviewed for pressure ulcers (Resident #333), and was evidenced by the following: The surveyor reviewed the medical record for Resident #333. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; kidney failure, hypertension (high blood pressure), and pneumonia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 4/26/25, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of Section M, Skin Conditions, reflected that the resident had a pressure ulcer upon admission to the facility and used a pressure relieving device on the bed. A review of the Nursing Admission assessment dated [DATE], indicated that the resident had a sacral wound measuring 4.5 centimeters long (cm) by 2.5 cm wide by 0.1 cm deep. A review of the individualized comprehensive care plan dated initiated 4/19/25, had a focus area of actual alteration in skin integrity as evidenced by a sacral pressure wound. A review of the Wound Consultant Note dated 4/23/25, revealed the resident had an unhealed sacral pressure ulcer with recommendations that included a low air loss mattress to the resident's bed. On 4/30/25 12:16 PM, the surveyor observed Resident #333 in their room in a wheelchair visiting with family. The surveyor then asked the Licensed Practical Nurse (LPN) if the resident was on a low air loss mattress for the pressure ulcer. The nurse replied, No, just a regular mattress. On 5/6/25 at 1:14 PM, the surveyor interviewed the LPN regarding the residents with pressure ulcers or potential to develop them. The LPN informed the surveyor a Braden scale (tool used to assess and predict a patient risk of developing pressure ulcers) was done on admission which would indicate if a resident was at risk for a pressure ulcer. The surveyor asked who would need a low air loss mattress, and the LPN stated if the Braden scale classified them at risk for developing pressure ulcers or a resident had a pressure ulcer, then the resident needed one. The surveyor asked if a low air loss mattresses were available, and she stated that they came from the maintenance department and were in the facility all of the time. On 5/7/25 at 12:15 PM, during an interview with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) regarding Resident #333 and the low air loss mattress, the LNHA informed the surveyor, I can't speak to why there was no air mattress on the resident's bed. A review of the undated facility's Prevention of Pressure Ulcers policy included General Preventative Measures .2. determine if the resident needs a special mattress . NJAC 8:39-27.1(e)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) store all drugs and biologicals in locked compartments and b.) properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was identified in 1 of 1 observed treatment cart and 2 of 6 observed medication carts, and was evidenced by the following: 1. On 4/30/25 at 12:12 PM, the surveyor observed a wound treatment cart on the Second-floor nursing unit by the nurse's station in front of the elevators which was unattended and left unlocked. The surveyor remained near the treatment cart and observed two nursing staff members walk past the treatment cart and did not acknowledge or identify that the treatment cart was unsecured. On 4/30/25 at 12:29 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that treatment carts contained medications and should be treated as medication carts and should always be locked when unattended by the nurse. At that time, the surveyor asked the LPN/UM if the treatment cart was unsecured, and the LPN/UM acknowledged that the treatment cart was left unattended and unlocked and that it should have been locked since it contained medications used for wound treatments and other medications. On 5/1/25 at 12:51 PM, the surveyor interviewed the Director of Nursing (DON), who stated that treatment carts should be treated as medication carts as they contained medications. The DON further confirmed that treatment and medication carts should remain locked and secure when not attended to ensure residents cannot gain access to medications and potentially sharp objects that were stored in treatment carts. A review of the facility's undated Storage of Medications policy included compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if opened or otherwise potentially available to others . 2. On 5/1/25 at 11:30 AM, the surveyor, in the presence of the LPN, inspected the 2B nursing unit's medication cart labeled 2BC. The surveyor observed 17 unidentifiable loose medication pills of various shapes, colors, and sizes. At that time, the LPN confirmed that there should be no loose pills in the medication cart drawers, and all medications should be contained in the packaging as received from the pharmacy. On 5/1/25 at 12:17 PM, the surveyor, in the presence of the Registered Nurse (RN), inspected the 2B nursing unit's medication cart labeled 2B. The surveyor observed 11 unidentifiable loose medication pills of various shapes, colors, and sizes. At that time, the RN confirmed that there should be no loose pills in the medication cart drawers, and all medications should be contained in the packaging as received from the pharmacy. On 5/1/25 at 12:42 PM, the surveyor interviewed the LPN/UM, who confirmed that all medications in the medication carts should be kept in the pharmacy packaging and there should be no loose pills in the medication cart drawers. On 5/1/25 at 12:51 PM, the surveyor interviewed the DON, who stated that all nurses assigned to each medication cart were responsible to ensure the organization and cleanliness of the medication cart and that all medications should be stored in the pharmacy packaging and there should be no loose pills in the drawers. A review of the facility's undated Storage of Medications policy included drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . NJAC 8:39-29.4(h)

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 4 of 5 observed resident pantry rooms as evidence by the following: On 5/6/25 at 1:00 PM, the surveyor toured the 1st floor Subacute unit pantry room in the presence of the Food Service Director (FSD). The surveyor observed the following: the counter around the sink and backsplash had black discoloration. The caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:11 PM, the surveyor toured the 2nd floor, 2A, and Chinese unit pantry room, in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet, and worn-down laminate countertops exposing the wood type surface under the laminate. On 5/6/25 at 1:23 PM, the surveyor toured the 3rd floor 3B unit, pantry in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:36 PM, the surveyor toured the 3rd floor 3A Indian unit pantry room in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:07 PM, the surveyor interviewed 1A Registered Nurse (RN) charge nurse, who stated it was the nurse's responsibility to enter in electronic requisition system if they are told about an issue or notice an issue themselves. On 5/6/25 at 1:10 PM, the surveyor interviewed the Maintenance Director (MD), who stated, my staff and myself audit and make rounds daily to the pantry rooms. The MD proceeded to say that his expectations of his staff were to report any issues noted during the audit directly to him. If other staff identify a concern, they should be putting it into the electronic system to generate a ticket requisition. The MD confirmed he did not see any issues in the pantries, and there were not any request tickets for pantry room repairs. The MD further stated the issue was not verbalized either. On 5/6/25 at 1:27 PM, the surveyor interviewed the RN, who stated the staff were required to report any issues on the unit verbally to the unit manager and enter a requisition in the facility's electronic maintenance program. The RN further stated she had not entered a ticket for the black discoloration in the pantry. On 5/6/25 at 1:54 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Regional Chief Operating Officer (RCOO) and the Director of Nursing (DON), who explained that the facility had an electronic request system in place that was monitored by maintenance staff. The surveyor confirmed that all staff have access to the electronic maintenance reporting system. They acknowledged the concerns of the surveyor and pictures visually provided. They had nothing further to provide the survey team regarding their concerns. A review of the facility's undated Homelike Environment policy included the residents are provided with a safe, clean, comfortable and homelike environment .clean, sanitary, and orderly environment . NJAC 8:39 -31.2(e)

Complaint # NJ160740, NJ166295, NJ167271, NJ169912 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/24/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #3) . The facility also failed to follow its policy titled Administering Medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. 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 regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. According to the Admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to, Essential Hypertension (high blood pressure), Hyperlipidemia (elevated cholesterol), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Diabetes (high blood sugar levels). A review of the 05/08/2024 Quarterly Minimum Data Set (MDS), an assessment tool reflected that the Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was cognitively intact. A review of the Order Summary Report (OSR) Active Orders as of 07/24/2024 included the following Physician's Orders (Pos): Clopidogrel Bisulfate Tablet 75 mg Give 1 tablet by mouth one time a day. Escitalopram Oxalate Tablet 20mg Give 1 tablet by mouth one time a day. Amlodipine Besylate Tablet 5mg Give 1 tablet by mouth two times a day. Eliquis 2.5mg Tablet Give 1 tablet by mouth two times a day. Metformin HCL Tablet 1000mgs Give 1 tablet by mouth two times a day. Vitamin D3 5000 Unit Tablet Give 1 tablet by mouth one time a day. During an interview with Resident #3 on 07/24/2024 at 10:13 A.M., the Surveyor observed six pills in a medicine cup on Resident # 3's bedside table. Resident #3 stated the nurse left the pills and never gave me water. On 07/24/2024 at 10:20 A.M., the Surveyor notified the Charge Nurse of pills in medicine cup on Resident #3's bedside table. The Charge Nurse removed the medicine cup with pills from Resident #3's bedside and notified the Registered Nurse (RN#1) assigned to Resident #3. The Surveyor attempted to interview RN #1 on 07/24/2024 at 10:23 A.M., but RN #1 was not available at that time. During an Interview with the Surveyor on 07/24/2024 at 10:23 A.M., the Charge Nurse stated, the expectation was not to leave medications unattended in a resident's room. The Charge Nurse further stated the expectation for nurses was to ensure residents took their medications before leaving the resident's room. During an interview with the Surveyor on 07/24/2024 at 1:02 P.M., RN #1 stated, this morning was a mistake. RN #1 further stated she became distracted with Resident #3's roommate and did not observe Resident #3 take their medications. RN #1 stated expectation was to make sure resident took medications prior to leaving room. RN #1 stated she should not leave room without ensuring medications are taken by resident. RN #1 was able to confirm that medications in the medicine cup found at Resident #3's bedside were Clopidogrel Bisulfate Tablet 75 mg, Escitalopram Oxalate Tablet 20mg, Amlodipine Besylate Tablet 5mg, Eliquis 2.5mg Tablet, Metformin 1000mg, and Vitamin D3 5000 Unit. During an interview with the Director of Nursing (DON) on 07/25/2024 at 4:45 P.M., the DON stated the expectation was the nurse should have ensured that the resident swallowed the pills with water or juice. The DON further stated, I would never expect the nurse to leave medications at the resident's bedside. The DON stated, it was important that the nurse ensures the resident swallows their medication to ensure they are getting the medication that they need. Review of the undated facility policy titled, Administering Medications revealed under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, 15. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to a.) provide privacy and promote dignity during podiatry care for 3 of 3 residents observed (Residents #180, #205 and #264) and b.) provide care and services in a dignified and respectful manner during dining in 1 of 4 dining rooms observed. This deficient practice was evidenced by the following: 1. During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #205 which revealed the following: Resident #205 was admitted in December 2022 with diagnoses which included but were not limited to: Type 2 diabetes mellitus and cognitive communication deficit. Review of Resident #205's Admission Minimum Data Set (MDS), an assessment tool, dated 12/6/22 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated that the resident's cognition was severely impaired. On 2/21/23 at 11:27 AM, the surveyor observed the podiatrist enter Resident #264's room. Resident #264 was awake and in bed. The podiatrist put gloves on and introduced himself to the resident as the foot doctor. The podiatrist removed a blue pad from his bag and placed it under the resident's feet on the bed. The door to the resident's room remained opened as the podiatrist stood at the end of the resident's bed and performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #264 which revealed the following: Resident #264 was admitted in June 2022 with diagnoses which included but were not limited to: Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #264's Quarterly MDS, dated [DATE], revealed that Resident #264 had short- and long-term memory impairments. On 2/21/23 at 11:31 AM, the surveyor observed the podiatrist enter Resident #180's room. Resident #180 was awake and seated in a wheelchair. The podiatrist sat on floor, put gloves on, unfolded a blue pad from his bag and put it down onto the floor under the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. The surveyor reviewed the medical records of Resident #180 which revealed the following: Resident #180 was admitted in July 2022 with diagnoses which included but were not limited to Type 2 diabetes mellitus, and dementia. Review of Resident #180's Quarterly MDS dated [DATE], revealed that Resident #180 had BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 2/21/23 at 11:36 AM, the podiatrist stated that he usually provided privacy during toenail care by pulling the curtain or sitting in front of the resident to block anyone from seeing, but acknowledged that he did not during those times. During an interview with the surveyor 3/2/23 at 9:40 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that the residents should be provided privacy during care, exams, and procedures for dignity of the resident. During an interview with the surveyor on 3/6/23 at 11:38 AM, the Director of Nursing (DON) stated the podiatrist should provide privacy during care. She stated that the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) had previously spoke to the podiatrist about privacy. 2. On 2/22/23 at 1:21 PM, the surveyor entered the 2A dining room. There were 10 residents present. The surveyor observed a certified nurses aide (CNA) #3 collect two unsampled resident's lunch trays (one after the other) and placed them on the food cart while talking on her cell phone. CNA #3 did not interact with the residents while approaching them to remove their lunch trays. CNA #3 saw the surveyor and put her phone down. At that time, the surveyor interviewed CNA #3 who stated she was on her phone because her son's daycare had called, and she had answered the phone in case it was an emergency. During an interview with the surveyor on 3/2/23 at 10:01 AM, the LPNUM #1 stated that CNAs should not be on their phones in the dining room. If there was an emergency, they should leave the resident area and come back after. During an interview with the surveyor on 3/6/23 at 11:50 AM, the DON stated that staff should not be on their cell phone in front of the resident because it was the resident's home. She added that the staff had been previously in serviced not to use cell phones during care or in the dining room. Review of a facility policy titled, Quality of life, dignity dated February 1, 2021, revised January 3, 2023, included but was not limited to; 1. Residents should be treated with dignity and respect at all times. 6. Resident's private space and property should be respected at all times. 10. Staff shall promote, maintain and protect resident privacy during assistance with personal care and during treatment procedures. Review of a facility policy titled, Cell Phone Usage (including texting, headsets, handsfree, IPADS, tablets, and any other electronic communication devices) dated February 1, 2021 and reviewed on January 26, 2023, included but was not limited to: 1. Employees are not permitted to use cell phones while on their individual work units. Incoming calls to employees should not be answered. If there is an emergency, the employee's family and friends should be instructed to call the main number to the facility. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to: a.) accurately transcribe a physician's order for enteral flushes for 1 of 2 residents reviewed for tube feeding (Resident #23), b.) accurately transcribe a physician's order for contractures for 1 of 3 residents reviewed for range of motion (Resident #77), c.) follow a physician's order for weekly weights for 1 of 5 residents reviewed for weights (Resident #183), d.) ensure urinary output was accurately documented in the medical record for 1 of 3 residents reviewed for foley catheters (Resident #199), and e.) ensure neurological assessments neuro checks were completed for 2 of 4 residents reviewed for accidents (Residents #130 and #264). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/24/23 at 9:33 AM, the surveyor observed Resident #23 in bed as staff entered room to perform morning care. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/8/22, identified Resident #23 as severely impaired and dependent on staff for all aspects of care. A review of the medical record indicated that Resident #23 was admitted to the facility with diagnosis which included, but not limited to: Severe Intellectual Disability, Dysphagia (difficulty in swallowing) and Gastronomy Status (a tube inserted through the abdomen that brings food directly to the stomach). A review of the Order Summary Report (OSR) revealed an order to Flush GT/PEG Tube with 500mL of water every six hours. Flush GT/PEG Tube with an additional 100mL every shift, with a start date of 10/1/2021. The order was implemented with the specific administration times of 0900, 1200, 1700, 2100. A review of the corresponding February and March 2023 Medication Administration Record (MAR) revealed the above order with a check mark and the administrating nurse's initials. During an interview with the surveyor on 03/06/23 at 10:45 AM, Licensed Practical Nurse (LPN) #2 confirmed that medication orders should not be combined into one order but separate. During an interview with the surveyor on 03/06/23 at 10:50 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that everyone had the responsibility of reviewing orders for accuracy when you give meds you review them. LPNUM #1 also confirmed that 24 hours chart checks were completed by the night shift. Upon reviewing the MAR, LPNUM #1 confirmed that the orders should be separated, and the identified hours were not spaced correctly to correlate every 6 hours. When asked what the dietitian's impression would be upon reviewing the MAR, LPNUM #1 stated, she would be under the impression that the nurses were giving all the hydration. When asked why having two separate orders for the flushes would be important LPNUM #1 responded, there is no way to determine if each flush was given. During an interview with the surveyor on 3/6/23 at 11:30 AM, the Registered Dietitian (RD) reported that she used the nurse's documentation in the progress notes and the MAR for her nutritional assessment. When asked how she determined if the residents received their hydration, the RD reported that she contacted the nurse and they confirm with the MAR. Upon reviewing Resident #23's MAR, the RD confirmed that she was under the impression that the resident was receiving both flushes. The RD also stated that hydration flushes are very specific, and this incorrect order was something that should have been brought to her attention. During an interview with the surveyor on 3/8/23 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that the night shift was responsible for completing 24-hour chart checks and the unit manager was responsible for completing chart reviews. Upon reviewing Resident #23's MAR, the ADON confirmed that the orders should be separated. The ADON also confirmed it was not possible to determine if the resident had received the ordered hydration based on how it was transcribed on the MAR. 2. On 2/21/23 at 11:52 AM, Resident #77 was observed in the wheelchair with right their hand contracted and bent at the wrist with downward flexion. The resident was unable to follow commands. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/22/23, identified the resident as severely impaired and with impairments on both sides of the upper and lower extremities. A review of the medical record indicated that Resident #77 was admitted to the facility with diagnosis which included, but not limited to: Hemiplegia (severe or complete loss of strength) and Hemiparesis (mild loss of strength) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting right dominant side. A review of the Order Summary Report (OSR) revealed an order to separate digits at all times with gauze, with an order date of 1/26/23. A review of the corresponding February and March 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect this order. On 2/24/23 at 9:54 AM, Resident #77 was observed without gauze between the fingers of either hand. On 2/28/23 at 10:25 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/2/23 at 10:07 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/6/23 at 11:44 AM, Resident #77 was observed without gauze between the fingers of either hand. On 3/8/23 at 11:16 AM, Resident #77 was observed without gauze between the fingers of either hand. During an interview with the surveyor on 3/6/23 at 10:45 AM, Licensed Practical Nurse (LPN) #1 confirmed that she did not have any orders for Resident #77 regarding contractures. During an interview with the surveyor on 3/2/23 at 12:09 PM, Registered Nurse Unit Manager (RNUM) #1 confirmed that the order was received to use gauze to separate the fingers. When asked if this order could be located on the MAR or TAR, the RNUM#1 responded, no. During an interview with the surveyor on 3/8/23 at 1:05 PM, the Assistant Director of Nursing (ADON) stated that the night shift was responsible for completing 24-hour chart checks and the unit manager was responsible for completing chart reviews. Upon reviewing Resident #77's MAR and TAR, the ADON reported that the orders were located on the OSR, so it will never transcribe over. When asked if this order should have been clarified, the ADON responded, yes, it should have. When asked if this order should have been transcribed to the MAR or TAR the ADON stated, yes . A review the facility Policy Titled Physician Orders, with Reviewed Date of 2/1/2023, revealed under Procedure that: 1.The discipline requesting the order will complete the appropriate request in its entirety in the electronic orders Portal and submit on behalf of the resident. 2.The nurse will notify the attending physician or physiatrist to ask for an order based on the disciplines request and then Confirm the orders in the Orders Pending Confirmation Tab. If the physician chooses not to give the order, the nurse must inform the discipline that requested the order. 4.Verbal telephone orders may only be received by licensed personnel (e.g RN, LPN, Physician, etc). Orders must be reduced to writing by the person receiving the order and recorded in the resident's medical electronic record. The entry must contain the instructions from the physician, date, time and the signatures and title of the person transcribing the information. 5.Upon receiving the telephone order, the nurse will transcribe the order in the electronic record, read the order back to the physician, sign with his/her name and document ordered by the physician's name, date, and time the order. 37217 3.On 2/22/2023 at 10:40 AM, Resident #183 was observed in bed sleeping. According to the Admission Record, Resident #183 was readmitted to the facility in 10/2022 with diagnoses which included but were not limited to; Type 2 diabetes mellitus and hypothyroidism. Review of the Quarterly MDS dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated that the resident's cognition was intact. The MDS also revealed that the resident had a weight loss and weighed 146 pounds (lbs). Review of Resident #183's care plan, created on 3/30/22, revised 2/22/23, included that the resident was at risk for altered nutrition/hydration status related to abnormal labs and significant weight loss. An intervention created on 3/30/22 and revised on 2/22/23, included to monitor weights monthly and that the resident had a history of refusing weights despite encouragement and education. Review of the Registered Dietician's (RD) progress notes (PN) dated 11/18/22 included, to initiate weekly weights for four weeks to monitor. Review of a physician's order dated 11/18/22 with a start date of 11/22/22, revealed weekly weight for four weeks, one time a day, every Tuesday, for monitoring. Review of the Resident's November and December MAR did not reflect the 11/18/22 order for weekly weights. Review of Resident #183's weight summary report revealed a weight of 146.2 lbs documented on 12/9/23. There were no weekly weights documented as ordered for 11/22/22, 11/29/22, 12/6/22, and 12/13/22. During an interview with the surveyor on 3/2/23 at 9:50 AM, the LPNUM #1 stated the RD would recommend weekly weights, and would put an order in the computer. She stated the Certified Nurses Aides (CNAs) would obtain the weight, document the weight on paper and the RD would enter the weight in the computer. During an interview with the surveyor on 3/2/23 at 10:43 AM, the RD stated she would put in the order for weekly weights and provided a list to the CNAs and the unit managers. In the presence of the surveyors, the RD reviewed Resident #183's weights and progress notes. She stated that the resident's appetite improved, and the resident's weights were trending up. She confirmed that she did not see the November 2022 ordered weekly weights documented and would follow up. During an interview with the surveyor on 3/3/23 at 10:59 AM the Director of Nursing (DON), in the presence of the RD, stated that there was a documentation error when the RD put the order for weekly weights in the computer. The RD selected no documentation required which was why the order was on the physician order sheet (POS) only and not on the MAR where the nurses would see the order. The DON and RD confirmed there was no documentation of weights based on the order. The DON stated that there should have been documentation if resident refused to be weighed, but the order was only on the POS, it was an error, and the RD clicked the wrong thing. Review of the facility's policy titled, Physicians Orders, revised on February 1, 2022, reviewed on February 1, 2023, included that it was the policy of Embassy Manor to receive requests/recommendations through electronic medical record, orders portal from dietary departments for patient/resident physician orders. Procedure: the discipline requesting the order will complete the appropriate request in it's entirety in the electronic Orders Portal and submit on behalf of the resident .A 24 hour check will be conducted so any transcription errors will be picked up, clarified and then corrected. Upon receiving the telephone order, the nurse will transcribe the order on the electronic record .It is the responsibility of the discipline requesting the order to assure that the order they have requested has been obtained in a timely manner. Review of a facility policy titled, Weights/Weight loss revised January 3, 2023, included Policy: In order to ensure an ongoing and accurate record of a resident's weight as part of the medical record .Procedure: 2. A monthly weight shall be obtained by the assigned certified nurses aide, under the supervision of the licensed nurse or RD. The certified nurses aide shall record the weight on the units monthly tracking sheet. The dietician shall then transcribe the weight on the electronic medical record. 3. A resident may be reweighed for various reasons, i.e significant changes in weight. This shall be recorded in the same manner as procedure #2. 4. On 2/28/23 at 10:35 AM, Resident #199 was observed sleeping in bed. The resident's foley catheter was draining amber colored urine. According to the Admission Record, Resident #199 was admitted to the facility in December 2022 with diagnosis which included but were not limited to: urinary tract infection. Review of the resident's Admission MDS dated [DATE], revealed that the resident had short and long term memory impairments, and had an indwelling catheter. Review of the resident's care plan dated 12/8/22, revealed that the resident had an indwelling catheter related to obstructive uropathy due to benign prostatic hyperplasia (enlarged prostate). Interventions included to monitor and document intake and output per facility policy. Review of the resident's Order Summary report included an order dated 12/15/22 to monitor urine output every shift for foley catheter. Review of the resident's February 2023 Medication Administration Record (MAR) included the aforementioned order. Additional review of the MAR revealed that 0 was coded as the output for the shift on the following dates and times: 2/6/23 night shift, 2/7/23 day and evening shift, 2/15/23 evening and night shift, 2/17/23 evening and night shift, 2/23/23 evening shift, 2/25/23 night shift, and 2/27/23 night shift. During an interview with the surveyor on 2/28/23 at 10:44 AM, Licensed Practical Nurse (LPN) #4 stated that the nurses entered the resident's output every shift in the Treatment Administration Record (TAR), and Resident #199 had urine output every shift. During an interview with the surveyor on 3/7/23 at 12:17 PM, Registered Nurse (RN) #2 stated nurses monitored and assessed foley catheters, and the urine in the urine bag. The CNAs emptied the urine from the foley bags and notified the nurses of the resident's output. The nurses then documented the output on the MAR. If there was 0 output, the nurse would notify the physician and obtain an order. During an interview with the surveyor on 3/7/23 at 01:03 PM, LPNUM #1 stated nurses observed the resident's foley catheter to make sure it was patent, flowing and there was a certain amount of urine each shift. She stated the CNA's emptied the urine and report the output to the nurse who would document the output on the MAR. The surveyor reviewed Resident #199's February 2023 MAR with LPNUM #1. LPNUM #1 stated, that no one should have a 0 documented, and that she would ask the nurse if the foley was already emptied prior to the documentation on the MAR or if the foley catheter was flushed. During an interview with the surveyor on 3/8/23 at 10:41 AM, the DON stated that nurses should monitor foley catheter output and document the output every shift. She stated the CNAs emptied the foley catheter, measured the output and notified the nurse who would document on the MAR. The DON stated Resident #199 always had urine output and was disappointed that the nurses did not document correctly. The DON stated LPNUM #1 was contacting the nurses for clarification. During an interview with the surveyor on 3/9/23 at 11:30 AM, LPN #5 stated Resident #199 always had urine output on the days she worked, but she inadvertently clicked 0 on the MAR. She stated it was a human error and if there was no output, she would have called the physician. Review of an employee statement form written by LPN #6, dated 3/8/23, revealed that LPN#6 was the assigned nurse for Resident #199 on 2/6/23 and that the resident's foley catheter was patent and draining urine. LPN #6 wrote that the resident had an output of 300 milliliters at the end of the shift, and LPN #6 mistakenly entered 0. Review of a facility's policy titled, Intake and output, effective February 1, 2021, with a reviewed date of January 26, 2023, included but was not limited to; Policy: Accurate intake and output shall be documented, when indicated by a resident's medical condition .Measure and record the amount of each voiding. If the resident has a catheter or other drainage collection device, empty at the end of each shift and record the amount. 5. a. On 2/21/23 at 11:22 AM, Resident #130 was observed sleeping in bed. According to the Admission Record, Resident #130 was admitted to the facility in July 2022 with diagnoses which included but were not limited to: unspecified dementia. Review of the Quarterly MDS, an assessment tool, dated 2/13/22, revealed that the resident had a BIMS of 5 out of 15 which indicated that the resident had severely impaired cognition. Additional review revealed that the resident had a diagnosis of dementia, required extensive assist of one staff with transfers, and had two falls since the prior assessment. Review of the resident's CP included a focus dated 5/19/22, that the resident was at risk for falls due to confusion, gait/balance problems, incontinence, poor comprehension, unaware of safety needs and a history of falls Review of an incident report (IR) dated 11/26/22 at 4:00 PM, revealed that Resident #130 was observed lying on the floor on their right side, and the resident had a bump on their forehead. A cold compress was applied, vital signs were checked, neurological checks were initiated. The resident was assisted back to bed. Review of an IR dated, 1/11/23 at 8:25 AM, revealed that Resident #130 was observed lying on the floor next to their bed. The resident was unable to provide a description of the fall. Neurological checks were initiated, the resident denied pain and there were no visible injuries. Review the Neurological Flow Sheet indicated the following: Note: This checklist should be completed at the following intervals for follow up for all unwitnessed falls or falls in which head is struck, initial assessment followed by every 15 minutes x 4, every 30 minutes x2, every hour x2, once per shift for 72 hour[s]. Review of Resident #130's neurological assessment flow sheet's dated 11/26/23 and 1/11/23 revealed neurological assessments were completed for the first four hours after each fall, however there was no documented neurological assessments on the flow sheet for the interval of once per shift for 72 hours. b. On 2/21/2023 at 11:27 AM, Resident #264 was observed awake and in bed. According to the Admission Record, Resident #264 was admitted to the facility in 6/2022 with diagnosis which included but were not limited to: Alzheimer's disease. Review of the resident's Quarterly MDS dated [DATE], revealed that the resident had short and long term memory impairments, required extensive assist of one staff for bed mobility and transfers. Further review revealed that the resident did not have any falls since the last assessment. Review of Resident #264's CP revealed a focus dated 6/3/22 that the resident was at risk for falls related to weakness of bilateral lower extremities. Review of an IR dated 1/28/23 at 2:15 PM, revealed that the resident was observed sitting on the floor in front of their wheelchair in the dining room. The resident was unable to provide a description of the fall. Neuro checks were initiated and there were no injuries. The resident was assisted back to the wheelchair. Review of an IR dated 1/28/23 at 10:43 PM, revealed that the resident was observed sitting on the floor by the side of the wheelchair in the activity room. The resident was unable to provide a description of the fall. Neuro checks were initiated and there were no injuries. The resident was assisted to their wheelchair and to their bed. Review of Resident #264's Neurological Assessment Flowsheet dated 1/28/23, revealed that neurological assessments were completed from 2:15 PM though 8:15 PM. There was no further assessments documented on the flow sheet for the interval of once per shift 72 hours. During an interview with the surveyor on 3/2/23 at 10:12 AM, LPNUM #1 stated neurological assessment should be in the resident's chart. The surveyor reviewed Resident #130's and Resident #264's neurological flow sheets with LPNUM #1. The LPNUM #1 was unable to provide additional information. During an interview with the surveyor on 3/7/23 at 11:03 AM, the ADON stated neuro checks would be completed for unwitnessed falls and would be completed to identify any deficits. LPNUM #1 would be responsible to ensure completion. The surveyor reviewed Resident #130 and Resident #264's IRs and neurological assessments with the ADON. The ADON confirmed the assessments were incomplete. Review of a facility policy titled, Fall prevention and post fall management, revised February 1, 2021 included, if an unwitnessed fall occurs or there is a suspected head injury, or if ordered by a physician, a neurological evaluation status post fall will be completed. Documentation for neurological evaluation starts with the time of the fall. The neurological form must be completed. Neurological evaluation will be completed by a nurse only and documented as follows: Initial neurological evaluation includes: Vital signs, level of consciousness, orientation, pupillary reflexes, motor and sensory function. NJAC 8:39-11.2(b), 27.1(a)

Based on interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 2 residents (Resident #71) reviewed for dialysis. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/21/23 at 11:22 AM, the Licensed Practical Nurse (LPN) #3 informed the surveyor that Resident #71 had begun dialysis (the process of removal of excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) approximately one month ago and was presently out of the facility for dialysis treatment. According to the Admission Record (an admission summary), Resident #71 was admitted to the facility in January of 2023 with diagnoses which included but were not limited to: End stage renal (kidney) disease, dependence on renal dialysis, anemia (a deficiency of red blood cells or of hemoglobin in the blood that results in pallor (pale appearance) and weariness, essential hypertension (high blood pressure), artherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls), and a nondisplaced fracture of the greater trochanter (located at the top of thigh bone, the widest part of the hip) of the left femur. Review of Resident #71's Admission Minimum Data Set (MDS), an assessment tool dated 01/10/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed that Resident #71 received dialysis treatments while a resident at the facility. Review of the Order Summary Report revealed a physician's order dated 01/06/23 for Dialysis three times per week on Tuesdays, Thursdays, and Saturdays at 10:25 AM, transport at 9:25 AM. Review of a Consultant Pharmacist (CP) Evaluation contained within Resident #71's paper chart revealed an entry dated 02/17/23, in which the CP recommended that the facility adjust the resident's medications for dialysis. Review of Resident #71's Medication Administration Record (MAR) dated 01/01/23-01/31/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth one time a day for Neuropathy (dysfunction of peripheral nerves causing numbness or weakness) for 1 (one) month with a start date of 01/25/23 and D/C (discontinue) date of 02/08/23. The medication was plotted on the MAR for administration at 9:00 AM, and all doses were charted as administered. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date 01/23/22 and D/C date 02/23/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Saturday 01/28/23 at 1300 the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1300, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 3. Tylenol PM Extra Strength Tablet 500-25 mg (Diphenhydramine-Acetaminophen) (Sleep) Give 2 tablets by mouth four times a day for pain management Max-3 (three) grams acetaminophen/day from all sources. Start date 01/23/23 and D/C date 02/20/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Saturday 01/28/23 at 1200 the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1200, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 4. Heparin Sodium (Porcine, of a pig) Solution 5000 Units/ML Inject 5000 units subcutaneously every 8 (eight) hours for clotting prevention. The start date of the medication was on 01/25/23 and the D/C Date was on 02/20/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Saturday 01/28/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1400, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. 5. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN (hypertension). Hold SBP (systolic blood pressure) less than 125. Start date 01/23/23 and D/C date 02/28/23. The medication was plotted on the MAR for administration at 0400 (4 AM), 1200 (12 PM) and 2000 (8 PM). On Saturday 01/28/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. On Tuesday 01/31/23 at 1200, the status of the medication administration for this medication was not documented as evidenced by a blank space on the MAR. Review of Resident #71's Medication Administration Record (MAR) dated 02/01/23-02/28/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth three times a day for Neuropathy for 1 (one) month until 03/08/23 at 07:43. Start date of 02/08/23 and D/C date of 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23 Tuesday 02/21/23, Thursday 02/23/23, and Saturday 02/25/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date 01/23/22 and D/C date 02/23/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23, Tuesday 02/21/23, and Thursday 02/23/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 3. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. Start date was 02/24/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM), and 1700 (5 PM). On Saturday 02/25/23 at 1300, the medication was charted as OO which indicated that the resident was Out on Pass. 4. Heparin Sodium (Porcine, of a pig) Solution 5000 Units/ML Inject 5000 units subcutaneously every 8 (eight) hours for clotting prevention. Start date of the medication was on 01/25/23 and the D/C Date was on 02/20/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, and Saturday 02/18/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. 5. Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 1 ml subcutaneously every 8 (eight) hours for clotting prevention. The start date of the medication was on 02/20/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Tuesday 02/21/23, Thursday 02/23/23 and Saturday 02/25/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. 6. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN. Hold SBP (systolic blood pressure) less than 125. Start date 01/23/23 and D/C date 02/28/23. The medication was plotted on the MAR for administration at 0400 (4 AM), 1200 (12 PM) and 2000 (8 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, Saturday 02/18/23, Tuesday 02/21/23, Thursday 02/23/23, and Saturday 02/25/23 at 1200, the medication was charted as OO which indicated the resident was Out on Pass. 7. Tobramycin Solution 0.3% Instill 2 (two) drop in left eye four times a day for Conjunctivitis (inflammation or infection of the conjunctiva of the eye) for 7 (seven) days. Start date 02/12/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Thursday 02/16/23 and Saturday 02/18/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. 8. Tylenol PM Extra Strength Tablet 500-25 mg (Diphenhydramine-Acetaminophen) (Sleep) Give 2 tablets by mouth four times a day for pain management Max-3 (three) grams acetaminophen/day from all sources. Start date 01/23/23 and D/C date 02/20/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1200 (12 PM), 1700 (5 PM) and 2100 (9 PM). On Thursday 02/02/23, Saturday 02/04/23, Tuesday 02/07/23, Thursday 02/09/23, Saturday 02/11/23, Thursday 02/16/23, and Saturday 02/18/23 at 1200, the medication was charted as OO which indicated that the resident was Out on Pass. Review of Resident #71's Medication Administration Record (MAR) dated 03/01/23-03/31/23 revealed the following: 1. Gabapentin Capsule 100 mg. Give 1 (one) capsule by mouth three times a day for Neuropathy for 1 (one) month until 03/08/23 at 07:43. Start date of 02/08/23 and D/C date of 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM) and 1700 (5 PM). On Thursday 03/02/23 at 1300, the medication was charted as OO which indicated the resident was Out on Pass. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate, Iron) Give 1 (one) capsule by mouth three times a day for anemia. The start date was 02/24/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0900 (9 AM), 1300 (1 PM), and 1700 (5 PM). On Thursday 03/02/23 at 1300, the medication was charted as OO which indicated the resident was Out on Pass. 3. Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 1 ml subcutaneously every 8 (eight) hours for clotting prevention. Start date of the medication was on 02/20/23 and the D/C date was 03/06/23. The medication was plotted on the MAR for administration at 0600 (6 AM), 1400 (2 PM) and 2200 (10 PM). On Thursday 03/02/23 at 1400, the medication was charted as OO which indicated that the resident was Out on Pass. Review of Resident #71's Order Summary Report provided by the Administrator on 03/07/23, which contained active orders as of 02/01/23, revealed the following Pharmacy Orders: 1. Gabapentin Capsule 100 mg Give 1 (one) capsule by mouth one time a day for Neuropathy. For 1 (one) month. 2. Auryxia Oral Tablet 1 (one) gm 210 mg (Fe) (Ferric Citrate) Give 1 (one) tablet by mouth three times a day for anemia. 3. Heparin Sodium (Porcine) Solution 5000 Unit/ML. Inject 5000 unit subcutaneously every 8 (eight) hours for clotting prevention. 4. Clonidine HCL Tablet 0.3 mg Give 1 (one) tablet by mouth every 8 (eight) hours for HTN (hypertension). Hold SBP <125 Monitor B/P per policy. 5. Tylenol PM Extra Strength Oral Tablet 500-25 mg Diphenhydramine-Acetaminophen (sleep) Give 2 tablets by mouth four times a day for pain management. Review of Resident #71's Care Plan revealed that the resident was ordered antibiotic therapy Tobramycin Solution 0.3% Instill 2 (two) drops in left eye four times a day for Conjunctivitis for 7 (seven) days on 02/13/23. Interventions included administer medications as ordered. During an interview with the surveyor on 03/02/23 at 1:01 PM, LPN #3 stated that Resident #71's medications were adjusted to correlate with the resident's dialysis schedule on Tuesday, Thursday, and Saturday as the resident was scheduled for transport at 9:25 AM and received dialysis treatment at 10:25 AM. LPN #3 further stated that the physician discontinued the resident's scheduled dose of Clonidine (medication used to treat high blood pressure) last week as the resident was out of the facility to dialysis when the medication was scheduled. LPN #3 further stated that the resident's blood pressure medications were administered at dialysis. During an interview with the surveyor on 03/06/23 at 10:58 AM, Registered Nurse Unit Manager (RNUM) #1 stated that the CP reviewed the resident's medications on a monthly basis and provided the Director of Nursing (DON) with the recommendations. RNUM #1 further stated that the DON then distributed the CP's recommendations to the unit managers. RNUM #1 stated that, A recommendation to adjust medications for dialysis indicated that the orders needed to be changed right away. RNUM #1 stated that oral medications scheduled for 9:00 AM were administered to Resident #71 at 8:00 AM before the resident left for dialysis. RNUM #1 stated that she spoke with the resident's primary physician during rounds regarding the resident's medication scheduling. RNUM #1 further stated that the DON had the documentation that directly related to the interventions that were implemented to the resident's medications in response to the CP recommendations. On 03/07/23 at 8:44 AM, the Administrator provided the surveyor with Resident #71's Consultant Pharmacist's Monthly Report which was dated 02/17/23 and revealed the following entry: A review of the Medication Administration Record indicated medication doses are being held due to the resident Out to dialysis. The times of administration should be modified to accommodate the needs of the resident. Please obtain a physicians order for changes in administration times. Review: Clonidine, Auryxia (medication that can lower the amount of phosphate in the blood for adults with chronic kidney disease who are on dialysis), gabapentin (nerve pain medication), heparin (anticoagulant used to prevent blood clotting), tobramycin (antibiotic), Tylenol PM (pain reliever, sleep aid). Further review of the Consultant Pharmacist's Monthly Report revealed a handwritten entry next to the recommendations which specified, Changed to accommodate dialysis days. During an interview with the surveyor on 03/07/23 at 11:01 AM, the CP stated that she visited the facility monthly and made recommendations based off review of the resident's Medication Administration Record (MAR). The CP stated that once the unit review was complete the office sent the report to the DON and Administrator to distribute to the unit managers. The CP stated that she reviewed the medical record on her next scheduled monthly visit to ensure the recommendations were addressed. The CP stated that she made recommendations for Resident #71 to ensure that the doses were given as ordered, rather than to reflect that they were going to be dialyzed out of the resident. During an interview with the surveyor on 03/08/23 at 11:25 AM, RNUM #1 stated that she first learned of the issue with Resident #71 who had not received his/her medications on dialysis days from the CP in February. During an interview with the surveyor on 03/09/23 at 11:33 AM, the DON stated that any resident who was on hemodialysis had to have their medications changed to match the dialysis days and times. The DON stated that if a medication was scheduled when the resident was out of the facility to dialysis, then the nurse had to call the doctor to obtain an order to change the time of administration to accommodate the resident's dialysis schedule. The DON stated that all nurses were trained to ensure that if a medication was missed, then they were required to call the doctor who would provide orders and instructions on how to proceed. The DON stated that the facility did not wait for the CP to review the resident's orders before they reviewed medications that were required to be administered on scheduled dialysis days. The DON stated the unit manager should have reviewed the medications when she initiated and prepared the resident's dialysis communication binder to ensure that the binder was complete and contained all related dialysis information. The DON stated that the nurses had a one-hour window of time to administer medications and if the medication was not administered within that time frame, then the nurse was required to notify the doctor. The DON further stated, If a medication was not administered, then you have to handle it immediately and ensure that the medications were given at alternate times when the residents are in the facility. Review of the facility policy titled, Dialysis-Care of the Patient Receiving (Reviewed 05/11/22) revealed the following: .Re-arrange medication and treatment times as needed to accommodate resident/patient being out of the building. NJAC 8:39-27.1(a)

Based on observation, interview and policy review it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 9:43 AM, the surveyor, in the presence of the Dietary Director (DD), observed the following during the kitchen tour: 1. In the food preparation area, Dietary Aide #1 and Dietary Aide #2 were observed wearing baseball caps with their hair at the back of the head exposed and were not wearing hairnets. The DD acknowledged the dietary aides should have been wearing hairnets. 2. In the food preparation area, Dietary Aide #2 was observed wearing a surgical mask above his chin area and his facial hair was exposed. The DD stated Dietary Aide #2 should have facial hair covered and provided a facial hair restraint to the dietary aide. 3. On a shelf in the walk-in refrigerator, the surveyor observed an 8-lb container of macaroni salad, which had a manufacturer's label that had a best used by date of [DATE]. The DD confirmed the date and stated the food item would be disposed. 4. On a shelf in the walk-in refrigerator, in a box containing cabbage, a half-cut head of cabbage wrapped in plastic, was observed undated and had an area that was grey in color to the cut side of the cabbage. The DD inspected the cabbage and stated it should be thrown away. On [DATE] at 10:25 AM, the Administrator provided the surveyor with the policy for expired foods and dietary personnel standards. The Administrator stated the macaroni salad was not being used as their menu had previously changed, and that the macaroni salad had not been thrown out at the time. The surveyor asked the Administrator how often and who was responsible for checking the refrigerated food items. The Administrator stated it was indicated in the policies provided. On [DATE] at 11:00 AM, the surveyor interviewed the DD about refrigerator storage being checked for expired items. The DD stated that himself or an assigned dietary staff would check for expired food items. The DD further stated they used a FIFO [First In, First Out] policy for food items stored. On [DATE] at 1:15 PM, the surveyor informed the Administrator, and the Director of Nursing of the above concerns. The surveyor reviewed the facility's policy titled, Personnel Standards with an effective date of February 2021. Under Procedure, it read All staff members will have their hair off the shoulders, confined in a hairnet or cap, and facial hair properly restrained. The surveyor reviewed the facility's policy titled, Food Service with an effective date of [DATE]. The policy read Maintain a clean, safe, and sanitary storage for all items. Under Procedures, it read F-I-F-O (First In First Out) rule will be followed at all times and Put a date, label as necessary, all foods stored in walk-in refrigerators and freezers that are out of its original packaging from the time it was opened. The surveyor reviewed the facility's policy titled, Expired Foods with a revised date of [DATE]. The policy indicated The Dietary aide/designee will ensure proper dating for all food upon delivery and All expired food will be discarded immediately. The policy did not further address checking food item expiration dates. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, and record review, it was determined that the facility failed to a.) perform hand hygiene before and after podiatry care for 3 of 3 residents (Residents #180, #205 and #264). This deficient practice was evidenced by the following: 1.During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad, stood up off the floor, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #205 which revealed the following: Resident #205 was admitted in 12/2022 with diagnoses which included but were not limited to; Type 2 diabetes mellitus and cognitive communication deficit. Review of Resident #205's Admission Minimum Data Set (MDS), an assessment tool, dated 12/6/22 revealed that the resident had a brief interview for mental status (BIMS) of 3 which indicated that the resident's cognition was severely impaired. On 02/21/23 at 11:27 AM, the surveyor observed the podiatrist enter Resident #264's room. Resident #264 was awake and in bed. The podiatrist put gloves on and introduced himself to the resident as the foot doctor. The podiatrist removed a blue pad from his bag and placed it under the resident's feet on the bed. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad and placed it back into his bag, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #264 which revealed the following: Resident #264 was admitted in 6/2022 with diagnoses which included but were not limited to, Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #264's Quarterly MDS, dated [DATE], revealed that Resident #264 had short- and long-term memory impairments. On 02/21/23 at 11:31 AM, the surveyor observed the podiatrist enter Resident #180's room. Resident #180 was awake and seated in a wheelchair. The Podiatrist touched resident's hand to greet the resident and explained to the resident that he would look at their feet. The podiatrist sat on floor, put gloves on, unfolded a blue pad from his bag and put it down onto the floor under the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad, discarded it, removed his gloves and left the resident's room. There was no hand hygiene observed. The surveyor reviewed the medical records of Resident #180 which revealed the following: Resident #180 was admitted in 7/2022 with diagnoses which included but were not limited to Type 2 diabetes mellitus, and dementia. Review of Resident #180's Quarterly MDS dated , 1/4/23, revealed that Resident #180 had a BIMS of 3 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 2/21/23 at 11:36 AM, the podiatrist stated he kept hand sanitizer in his bag and would do hand hygiene after care. The podiatrist acknowledged that he did not perform hand hygiene in between the three residents. During an interview with the surveyor 3/2/23 at 9:40 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that hand hygiene should be performed before and after resident care for infection control. During an interview with the surveyor on 03/06/23 at 11:38 AM the Director of Nursing (DON) stated the podiatrist should perform hand hygiene because of infection control. She stated that the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) had previously spoke to the podiatrist about hand hygiene. During an interview with the surveyor on 03/08/23 at 01:19 PM, the IP stated that she and the ADON had previously went over hand hygiene, use of the blue pad (chux), with the podiatrist. She stated between each resident the podiatrist should perform hand hygiene for infection control because he touched toes, and the blue pad (chux) should be individualized for infection control. Review of a facility policy titled, Handwashing and hand hygiene purposes, dated 2/2021, revised on 2/2022, included but was not limited to; It is the policy of Embassy Manor that hand washing and hand hygiene will be performed in accordance with the Center of Disease Control (CDC) Guidelines. Definitions: Hand hygiene cleansing the hands with facility-approved alcohol- based antimicrobial hand cleanser. Procedure: Hand washing and hand hygiene indications. 1. The use of gloves does not eliminate the use of hand hygiene. 2. Indications for hand washing and hand hygiene include, but are not limited to the following: After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes blood or body fluid secretions or excretions .Before and after performing invasive procedures .After removing gloves. Handwashing Method: Scrub the hands for at least 20 seconds. NJAC 8:39-19.4(a)

C# NJ Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to adequately supervise and monitor a resident with a known history of smoking while receiving oxygen via nasal cannula (tubing that delivers oxygen directly into the nose/nares) for 1 of 31 sampled residents (Resident #3), which resulted in facial burns. In addition the facility failed to re-assess/evaluate Resident #3 for safe smoking practices after the resident was discovered smoking with oxygen in place on 2/5/15 in the facility lobby, a designated non-smoking area. The facility failed to monitor the effectiveness of the interventions for Resident #3 after the the first incident on 2/5/15 and subsequently on 5/28/15 Resident #3 was found in the laundry area, a designated non-smoking area with facial burns from smoking with oxygen on and sustained second degree burn injuries requiring hospitalization . This deficient practice was evidenced by: 1. The medical records were reviewed on 6/19/15 and 6/23/15. According to Resident #3's Admission Record, the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 2/19/15 and 5/14/15 indicated the resident had no cognitive deficits and was non-ambulatory. The MDS's both reflected in the area of Range of Motion (ROM) that the resident had no impairment to the upper extremities, but had bilateral impairment to the lower extremities. A review of Resident #3's physician's orders [REDACTED]. A Resident Safety Smoking assessment dated [DATE] indicated Resident #3 was deemed an independent smoker and reflected a care plan was initiated on 9/16/14. A review of Resident #3's Interdisciplinary Plan of Care (IPC) for smoking initiated on 3/21/14 and last reviewed/updated on 5/14/15, reflected the resident had a potential for injury related to smoking. Interventions included but were not limited to; assess resident's ability to smoke safely, instruct resident about the facility policy on smoking, locations, times, safety concerns, notify charge nurse immediately if it is suspected resident has violated facility smoking policy and observe clothing and skin for signs of cigarette burns. A review of a Resident Smoking Agreement signed by Resident #3 and by the Assistant Administrator on 4/18/14, reflected that in order to insure the safety of all persons within the facility, I hereby agree to follow the facility protocol of cigarettes, matches, and lighters being held securely by the nursing staff. I understand that upon my request, I will be given cigarette/matches/lighter when I go outside to smoke. In addition, I will adhere to the smoking designated areas in the outside of the building. Smoking is not permitted within the facility. Furthermore, failure to comply with protocol will result in the following: 1st violation-warning notice of non-compliance with smoking policy, 2nd violation-loss of smoking privileges for 7 days, 3rd violation-30 day discharge notice and permanent loss of privileges while resident at Edison Estates. A review of a Safety Report (facility incident report) dated 2/5/15 at 1 am documented that Resident# 3 stated that while smoking in the lobby, oxygen tank was just put off by resident. Resident with nasal cannula on, just burst on (his/her) face and nose. The resident was assessed with [REDACTED]. A Daily Security Report dated 2/4-5/15 during the 11 pm-7 am shift timed 2300 (11:00 pm), reflected at 0200 (2:00 am) the nursing supervisor informed him that Resident #3 lit a cigarette outside and nearly blew up (his/her) face. A review of Nursing Narrative Notes (NNN) dated 2/5/15 at 1 am reflected that Resident #3 stated that while smoking in the lobby, the oxygen tank was just put off by Resident #3. The resident with a nasal cannula on just burst on (his/her) face and nose. The resident was assessed with [REDACTED]. A review of the Universal Transfer Form from the facility to the hospital dated 2/4/15 (no time indicated), reflected Resident #3 stated that while smoking in the lobby with nasal cannula on and O2 (oxygen) tank off, it burst onto his face. During an interview with the surveyor on 6/19/15 at 4:00 pm via telephone from the facility, Registered Nurse (RN) #1 assigned to care for Resident #3 on 2/4/15, stated that it was okay for Resident #3 to go outside at 1am to smoke. RN# 1 stated that he/she did not give Resident #3 a lighter. During an interview with the surveyor on 6/19/15 at 10:45 am the Administrator stated that the resident must have lit the cigarette in the lobby on the way outside. The surveyor asked the Administrator for Resident #3's smoking re-assessment after the 2/5/15 incident. At 10:55 am, the Administrator returned and stated that the Director of Social Services (DOSS) will be in to discuss the assessments. In addition she stated that a post-burn (2/5/15) smoking re-assessment may not have been completed because the agreement that the resident signed would indicate he/she was given a violation. The surveyor requested the violation and none was provided. When the Administrator was interviewed on 6/19/15 at 11:15 am the Administrator revealed only smokers who are independent can smoke, any resident that needs assistance was not allowed to smoke, the family must come in and assist. Residents are allowed to go outside all night to smoke. During an interview with the surveyor on 6/19/15 at 11:05 am the DOSS stated that resident smoking assessments are completed yearly. The surveyor asked if there was any instance that a smoking re-assessment would be completed prior to the yearly assessment. The DOSS revealed If we notice a major change, we would do as needed. Such as a change in condition. The surveyor asked if a resident burning themselves while smoking would be considered a change in condition. She stated only if it's a cognitive change. She revealed (His/Her) cognition and ROM didn't change that's why a re-assessment wasn't done. There was no documentation provided to the surveyor of the annual Resident Smoking Assessment since 4/18/14. During a telephone interview with the surveyor on 6/22/15 at 1:30 pm the Director of Nursing (DON) stated that on 2/4/15 as Resident# 3 leaned into a car window with his/her oxygen on and he/she singed his/her face. The surveyor asked the DON if the 2 burn incidents were reported to the New Jersey Department of Health (NJDOH). She stated they were not required to report because we are not required to report every time they send someone to the hospital. A review of the Emergency Medical Transport report dated 2/5/15 for Resident #3 reflected that Resident #3 stated that he/she went outside to smoke a cigarette and turned his/her oxygen tank off, but did not remove the cannula from his/her nose before lighting a cigarette at which time the cigarette flared up and caused burns to his/her face. Resident #3 sustained face-burn, blistering, burn charring, burn redness and pain. In addition reflected that Resident #3 had partial thickness burns to upper lip, nose, and cheeks and had soot around nostrils and on face. A review of Resident #3's Medication Administration Record (MAR) for February 2015 showed a physician's orders [REDACTED]. The order was discontinued on 2/9/15. A review of a Physician's Progress Notes (PPN) dated 2/9/15 reflected Resident #3 was seen to follow up on burn wounds sustained last week in smoking incident. Resident #3 complained of pain in back as well as nose region, he/she continues to use nasal cannula for supplemental oxygen but reports his/her breathing is more difficult than usual. Wounds are scabbing and crusting over. On inspection of nares they appear blackened with charring. Oral cavity free of lesions, lungs with poor aeration. Will refer to the burn center (name redacted) increase Percocet (a narcotic analgesic) to one tab 5/325 every 6 hours. In addition reflected the resident had burned nares and the nares were charred, hard to assess depth of burn, will increase Percocet and refer to the Burn Center for wound care and assessment. A review of Resident #3's February 2015 MAR confirmed the physician's orders [REDACTED]. A review of the physician's Discharge Summary dated 2/5/15 for Resident #3 reflected a [DIAGNOSES REDACTED]. A review of hospital records dated 2/5/15 reflected superficial burns to face after smoking cigarette while on oxygen, Resident #3's beard and lower mouth were burned. Resident #3 reported pain and irritation in the areas of the burn. The hospital discharge [DIAGNOSES REDACTED]. A review of a consultation with a Otolaryngology (ear, nose and throat) Physician dated 3/18/15, reflected Resident #3 had sustained a burn injury to the nose about 3 weeks ago where his/her nasal oxygen combusted when a friend lit a lighter near him/her. Resident #3 has crusting in the nasal cavity. Resident #3 continues to use nasal oxygen and has some moderate nasal obstruction both at baseline and now after the injury. A review of an untitled agreement signed by Resident #3 on 2/9/15 reflected that Resident #3 agreed to the following; -not to smoke while within a near proximity to oxygen. -not to have my oxygen tank on my wheelchair when smoking. -only have my oxygen on my wheelchair when I'm going long distances; for example:going to the store. On 2/9/15 an IPC was initiated for smoking precautions that included but was not limited to the following interventions; educate on the dangers of smoking near oxygen, resident will not smoke within or near proximity to oxygen, resident will remove oxygen from (his/her) wheelchair prior to smoking. There was no documentation that reflected the facility re-assessed Resident #3 for safe smoking practices/procedures upon readmission to the facility and/or the resident's ability to safely remove the oxygen from his/her wheelchair prior to smoking. An annual Care Conference Note dated 5/26/15 documented Resident #3 is unable to reach toward (his/her) back and movement is limited 2 (degree) (secondary to) lumbar/thoracic pain and obesity. In addition, the resident is independent in other activities of daily living and was out of bed to an electric wheelchair. There was no documentation that reflected Resident #3's IPC was updated to reflect new interventions to address the resident's limited upper extremity movement. A review of a Safety Report (facility incident report) dated 5/28/15 at 6:00 pm reflected that Resident #3 was found by a housekeeper in the laundry room with burned nostrils, burned right face and a burned nasal cannula. The physician was notified and the resident was transported to the hospital. Resident #3 was not available for an interview with the surveyor, secondary to Resident #3's hospitalization of 5/28/15. Review of a undated facility collected statement from the Director of Environmental Services (DOES) reflected that while the DOES was doing paper work the DOES heard someone outside the office door and came out and found Resident #3 facing the wall with the arm of his/her motorized wheelchair caught on the door, the DOES immediately noticed that Resident #3's face was burnt and the oxygen tube was burnt hanging to side of chair. The DOES asked Resident #3 if he/she was okay but the resident didn't respond. The DOES then shook the resident and the resident moaned and opened his/her eyes. The DOES notified the nurse. During an interview with the surveyor on 6/19/15 at 12:15 pm the Director of Environmental Services (DOES) confirmed that on 5/28/15 he found Resident #3 in his/her motorized wheelchair, the arm of the wheelchair was stuck on the door, Resident #3's face was black and red and the resident was going in and out of consciousness. The DOES revealed the oxygen tank was on the back of the wheelchair and the nasal cannula was charred and was on the floor. He revealed that The oxygen was still on and the nurse turned it off. A review of the Narrative Nurses Notes (NNN) dated 5/28 (no year indicated) at 7 pm reflected that at 6 pm Resident #3 was found in the back laundry room area by housekeeping staff with a facial burn. Upon assessment Resident #3 was found with a facial burn, around the nares and mouth. The residents clothing was also observed with burned holes. Resident #3 was transferred to the hospital, admitted with facial burns and inhalation injury. A review of the Universal Transfer Form from the facility to the hospital dated 5/28/15 (no time indicated) reflected that the resident was status [REDACTED]. A review of the Emergency Medical Services Transport record dated 5/28/15 for Resident #3 reflected the resident presents with blistering to both cheeks, nose and left orbit. There is singed facial hair with soot in bilateral nares. Resident #3 had obvious shoot burns to face, nose, bilateral cheeks with both eye brows and mustache singed. The resident arrived at the hospital without incident. A review of the hospital admission records dated 5/28/15 reflected that Resident #3 sustained a burn to the face while smoking with oxygen. On physical examination, the resident had less than 1% total body surface area deep second degree flame burn involving the central face area including the nose, the area around the nares, and spotty areas of the upper lip and medial cheeks. The resident was intubated (a tube to maintain the airway) by anesthesia in the ER prior to transport to the burn unit. A review of the hospital discharge note dated 6/5/15 reflected that Resident #3's discharge [DIAGNOSES REDACTED]. According to the Resident Smoking Agreement dated 4/18/14 Resident #3 was not to have cigarettes, lighters or matches in his/her possession and was to obtain them from nursing staff. There was no indication in the facility's investigations of Resident #3's unsafe smoking on 2/5/15 and 5/28/15 of where Resident #3 obtained the cigarettes and lighting materials. In addition, there was no documentation that indicated the facility notified the New Jersey Department of Health of the 2/5/15 and 5/28/15 burn incidents for Resident #3. During an interview on 6/19/15 at 9:20 am the DON stated that on 2/5/15 Resident #3 did not smoke in the lobby. The resident went outside at 1 am to meet a friend who pulled up in a car. Resident #3 stuck his/her head into the car and puff (his/her) face was ignited. There was no documentation contained in the facility's investigation of 2/5/15 that reflected Resident #3 was burned while leaning into a friend's car. A review of the facility's Administration of Oxygen by Mask or Cannula policy dated 1/1/93, revised 10/2007 and last reviewed on 10/2009 reflected that the purpose was the Administration of oxygen by mask or cannula shall be performed under physician's orders [REDACTED]. To prevent or reverse hypoxia and improve tissue oxygenation. In addition, reflected explain oxygen procedures to resident and visitors. Explain no smoking or use of an improperly grounded radio, TV (television) or electric razor. A review of the facility's Smoking policy dated 10/1/13 reflected that the purpose was Smoking is prohibited for residents, staff and visitors in the facility. In addition Residents deemed unsafe may not keep cigarettes, lighters, or matches in their room or on their person at any time during their stay at the facility. Assessments will be done by nursing and will be re-evaluated yearly unless change in condition occurs prior to the annual date. A review of the facility's Safety/Incident Report policy dated 9/26/01, revised 5/1/05 reflected the purpose was All incidents or accidents to a resident, employee or visitor must be reported immediately on the safety report form. In addition Procedure is to evaluate and provide emergency care prn (as needed). Assess area of injury of resident as to make a decision to the seriousness of injury. Ask witness for explanation of incident, and have report done within 24 hours of the incident. The incident should be documented on the 24 hour report and nurses notes. Obtain statements from resident, staff on shift, prior shifts, evaluate environment and equipment. NJAC 8:39-27.1 (a)

Complaint# NJ and NJ Based on the review of the medical record, interview and other facility documentation, it was determined that the facility failed to provide the necessary treatment and services to prevent the development of a pressure ulcer, resulting in the development of an avoidable Stage III pressure ulcer for 1 of 4 sampled residents, (Resident #2). This deficient practice is evidenced by the following: According to a Facility Face Sheet, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/07/2013, documented that Resident #2's memory was severely impaired, incontinent of bowel and bladder and required extensive assistance with all activities of daily living. A review of the Nursing Narrative Note (NNN) dated 11/11/2013, 11-7 stated "order of x-ray right foot due to swollen right foot." An x-ray report dated 11/11/13 states, "...Impression: Fractures involving the neck of the third and fourth metatarsals ..." A review of the Physician order [REDACTED]." The Interdisciplinary Plan of Care (IPC), dated 3/8/2013, indicated a potential for altercations in skin integrity. A review of the IPC, updated on 11/13/13, for the Potential for Complications related to fracture of right 3rd and 4th metatarsals, interventions included but not limited to: "...monitor for circulation to affected area every shift and monitor skin integrity beneath splint/ace wraps for signs of breakdown every shift..." A review of the December 2013 Treatment Administration Record stated "Unwrap right foot to monitor skin integrity every shift and wrap back up". A review of the Treatment Administration Record (TAR) revealed that the skin integrity was not initialed as being monitored on the following opportunities, the 7-3 shift on 12/11/2013 and 12/12/2013, the 3-11 shift on 12/7/2013, 12/8/2013, and 12/11/2013. A review of the Nursing Narrative Note (NNN) dated 12/7/2013, at 3:00 AM, stated "skin check to right foot and right leg, splint re-wrapped positive pedal pulse intact skin." A review of the NNN dated 12/8/2013, at 3:00 AM, stated "right foot and right leg unwrapped and wrapped back for skin check. Skin intact, positive pedal pulse." A review of the NNN dated 12/9/2013, at 3:00 AM, stated "right foot and right leg unwrapped for skin check, skin intact and positive pedal pulse." A review of the NNN dated 12/9/2013, at 9:00 PM, stated "dressing to right foot removed to check skin integrity right heel intact right pedal pulse palpable." A review of the NNN dated 12/10/2013, at 9:00 PM, stated "Dressing to right foot removed to check skin integrity, right heel intact, right pedal pulse palpable." There were no NNN for the dates of 12/11/2013 and 12/12/2013. The NNN dated 12/13/2013, at 8:00 AM, stated "Removed right foot splint with ace wrap per Physician order, noted stage 3 with blister to lateral right lower extremity". The pressure ulcer weekly assessment sheet dated 12/13/2013, indicated a 3.0 by 2.0 stage 3 pressure ulcer with 90% eschar and 10% slough on the resident's right lateral ankle/calf. The following physician orders [REDACTED]. During an interview with the Licensed Practical Nurse on 3/13/2014, at 11:45 AM, she stated that to prevent pressure ulcers, skin assessments are done daily during the bed bath and treatments. NJAC 8:39-27.1 (e)

Based on observation, interview and record review, it was determined that the facility failed to; a.) protect a resident (Resident #7) from abuse/mistreatment from other residents due to inadequate monitoring and supervision of a cognitively impaired resident, and b.) failed to address consistent aggressive behaviors for 2 residents ( Resident #19 and #20). Resident #7 displayed unsupervised wandering behavior, which impacted on his/her safety and well-being and resulted in physical abuse/mistreatment of [REDACTED]. The incidents were documented in the medical record from 4/17/12 to 3/10/13, and interventions were not revised to protect the resident who was the victim of the abuse or to identify and modify the behaviors of the residents who were the abusers. The incidents documented in the medical record included, but were not limited to; notations that the abused resident was cognitively impaired and had a pattern of unsupervised wandering into one particular room that was occupied by two alert and oriented residents identified as "territorial," and who were repeatedly verbally and physically abusive to the confused resident. As a result, the confused resident suffered cuts, scratches, a punch in the head requiring a hospital evaluation, and was hit in the face sustaining a black eye. This deficient practice constituted an Immediate Jeopardy situation for Residents #7, #19 and #20, who were 3 of 5 residents reviewed for abuse/mistreatment. The Immediate Jeopardy was identified on 3/14/13. An acceptable plan of correction was submitted on 3/14/13 identifying that the jeopardy situation was corrected on that date based upon actions taken by the facility. These actions included: a.) 1:1 supervision of the confused resident, b.) revision of the care plan of the confused resident and the residents with territorial behavior, c.) education of staff to supervise and manage the behaviors of residents with agitation and wandering behavior. The following evidenced the deficient practice : 1. On 3/8/13 at 10:15 a.m., during the initial tour of the facility, the nurse told the surveyor that Resident #7 had wandering behavior. The surveyor observed the resident seated in a wheelchair in his/her room with a rear closing seatbelt applied. On that same day at 11:30 a.m., the surveyor reviewed the medical record of Resident #7, which revealed that the resident had [DIAGNOSES REDACTED]. On 3/11/13 at 10:15 a.m., the surveyor observed the resident seated in a wheelchair in the room, and a Certified Nursing Assistant (CNA) was at the bedside providing care. The CNA told the surveyor that the resident was confused, and totally dependent on staff for care. The CNA further stated that Resident #7 was known for wandering on the unit and into other resident's rooms. On that same day at 11:15 a.m., the charge nurse confirmed the behavior and described the resident to the surveyor as "a Sundowner." Further review of the medical record on 3/12/13 at 12:30 p.m., revealed that the resident's wandering behavior had been documented extensively in the medical record from 4/2012 to the present, as evidenced by the following: Review of a Nurses' Progress Note dated 4/17/12 at 5:45 p.m., "We heard commotion in room [ROOM NUMBER]. When we got there patients were both in wheelchair . (Resident #7) was in the wheelchair close to (Resident #20), we separated both of them. ((Resident #7)) was bleeding on the right arm due to a skin tear and scratch 2 centimeters ( cm) x 3cm., then one scratch on R (right) 2 inches and one in the L (left) face below the ear with measurement of 2 inches. Treatment done, help patient to go to bed early." A review of the Safety Report provided by the facility indicated that Resident #20 told the staff he "was defending himself." Resident #20 did not sustain any injury in the altercation. There was no statement from either resident to indicate what had happened and no evidence of remedial action taken to prevent Resident #7 from entering the other resident's room. A Nurse's Progress Note dated 7/28/12, revealed the following: "Resident #7 self propelled in room [ROOM NUMBER], Resident #20 got out of bed grabbed Resident #7 by the neck while in the wheelchair and tried to throw him out of the room. Sustained some scratch marks with some redness." Review of another Nurses' Progress Note dated 9/20/12, at 6:30 p.m., revealed " Patient (Resident #7) went to other patient's room and got scratched on his face, forehead and right arm. " Further review of the medical record revealed that on 11/29/12 at 2:45 p.m., Resident #20 grabbed Resident #7's right arm, while he/she was in the hallway. Resident #7 sustained a skin tear. A Nurse's Progress Note dated 1/23/13, revealed that Resident #7 reported to the staff that a male resident hit him. Later on the resident identified the aggressor as Resident #19. An interview with Resident #7's wife on 3/14/13 at 1:30 p.m., revealed the resident sustained [REDACTED]. The wife told the surveyor that she "was not too happy with (name) getting beat up all the time." The wife stated that other residents "wandered into the resident's room and never got assaulted." A review of the Skilled Nursing Narrative Notes dated 1/24/13, revealed the following "He denied any pain from the hit on his face on 1/23/13, now L (left) side of face at corner of the eye is black and blue." Further review of the medical record on 3/12/13 at 12:30 p.m., revealed a Nursing Progress Note dated 3/10/13, where an aide witnessed Resident #19 hit Resident #7 in the back of the head. Resident #7 complained of pain and was transferred to the hospital for evaluation. The resident returned to the facility the same day. There was no evidence of revision of interventions to indicate how Resident #7 would be protected from Resident #19. There was no documented evidence to indicate that the Interdisciplinary Team met and discussed what interventions would be implemented to prevent further incident. Review of the care plan revealed that a stop sign on the door to prevent Resident #7 from wandering to the other resident's room was not implemented until 3/11/13. 2. On 3/13/13 at 10:30 a.m., the surveyor observed Resident #19 standing at the nursing station. The resident was identified by the facility as being verbally abusive to staff and other residents. The charge nurse and the Certified Nursing Assistant (CNA) who cared for the resident told the surveyor that the resident used foul language with staff and other residents. The surveyor reviewed the medical record of the resident at that time which revealed [DIAGNOSES REDACTED]. On 3/13/13 at 11:15 a.m., the surveyor interviewed the resident who stated that he was sent to the hospital the previous day, following an incident. The resident told the surveyor that Resident #7 was in his room and rummaging through his drawer. The resident indicated the staff alleged that he punched Resident #7 in the head. The resident told the surveyor that Resident #7 was confused and wandered constantly in his room. Further review of the Nurses' Progress Notes dated 1/23/13 and 3/10/13, revealed that Resident #19 assaulted Resident #7 on two occasions. Resident #7 sustained a black eye as a result of the injury on 1/23/13. On 3/10/13 at 5:00 p.m., staff witnessed Resident #19 punch Resident #7 in the back of the head for wandering in his room. Further review of the Nurse's Progress Notes revealed that the resident had been verbally abusive to staff and other residents. 3. On 3/13/13 at 11:00 a.m., the surveyor reviewed the medical record of Resident # 20, which revealed in the Nurses' Progress Notes that the resident had the behavior of being physically abusive to another resident. An interview with the nurse on 3/13/13 at 10:50 a.m., confirmed the behavior. Review of a psychiatry consult dated 9/20/12, revealed that the resident was referred for agitation, hostility and attacking others. Thre resident's behavior was identified in the consult as follows: On 4/17/12, hit another patient, said he was defending himself. On 7/28/12, grabbed another resident by the neck trying to throw him out of the room. On 9/20/12 scratched another resident in the face and arms for entering his room. Review of the resident's care plan revealed that his abusive behavior toward other residents was not identified. On 3/14/13 at 10:30 a.m., the Social Worker (SW) described the resident to the surveyor as "very reactive." The SW told the surveyor that the resident got angry when his personal space was violated. There was no documentation in the clinical record to indicate how this behavior would be managed. A review of the facility policy for abuse dated 11/1/03 and revised 5/7/09 revealed "It is the policy of JFK Hartwyck Nursing, Convalescent,and Rehabilitation Center to ensure that the rights of each resident are respected and maintained, including each resident's right to be free from mistreatment, neglect and misappropriation of resident property. Each facility will provide an environment that does not condone resident abuse by anyone including staff members, physicians, consultants, volunteers, agency staff, family members, legal guardians, other residents, friends or other individuals." There was no documented evidence this policy was consistently followed. Under "Abuse Identification;" "A comprehensive interdisciplinary assessment will be completed on every resident upon admission and at intervals, in accordance with federal and state guidelines and as the resident's condition indicates, to ensure staff is alerted to any signs or symptoms that an individual resident may ? Have the potential for abusing other residents. ? Have the potential for being a victim of abuse. Under Section D titled "Abuse Reporting and Resident Protection Procedures" stated "Allegations of abuse are investigated and substantiated incidents are reported to state and federal agencies as appropriate, by facility Administration." On 3/14/13 at 11:30 a.m., the Administrator and Director of Nurses' confirmed to the surveyor that the above incidents were not thoroughly investigated or reported to the State Agency. The Immediate Jeopardy was identified on 3/14/13 at 12:45 p.m. Facility Administration was notified and a Plan Of Correction was submitted to the survey team and accepted on 3/14/13 at 2:15 p.m., which indicated that the jeopardy was corrected at that time, based on actions by the facility which included the following: - A nursing assistant will provide 1:1 supervision to Resident # 7 for 48 hours pending updated care plan. After which time the resident will be monitored every 15 minutes by the nurse and /or nursing assistant. The 1:1 staff person will gather data regarding his behaviors specific to description and number of attempts to wander as well as how easily and what methods were used to redirect him. Observations of the 15 minute monitoring will be documented on a tracking form. Residents #19 and #20 have territorial tendencies and their care plans will be updated to include checks every 15 minutes to be performed by the nurse and /or nursing assistant. The residents will be evaluated for possible room change in an effort to decrease their proximity to the most frequent wanderers. Observations of the 15 minute monitoring will be documented on a tracking form. - The IDC team will meet and with the use of a tool determine what other facility residents are at risk for physical altercations based partially on history of behaviors such as agitation and wandering, as well as diagnosis. Current interventions will be reviewed for appropriateness and updated as needed. - The facility staff will be educated by Administration on all shifts beginning 3/14/13, as well as future education by a Psychologist from Center for Behavioral Health regarding appropriate evaluation and management of residents with behaviors such as agitation and wandering. Additional refreshments will be offered after dinnertime with staff supervision to those residents identified for being at risk of the stated behaviors. Therapeutic modalities such as continual snoozelin use will occur on a daily basis in the evening on Unit 3A. Tactile therapeutic tools will be placed on Unit 3A for independent resident use. For residents identified as above a structured walking/wheeling physical activity will occur nightly. The current utilization of physical space within the resident lounges will be re-evaluated for most appropriate use of space on Unit 3A. The wife of Resident #7 will be encouraged to join Resident #7 for dinner and visit after dinner time when convenient for her. Residents #19 and #20 will be reminded twice a shift of appropriate responses when others enter their personal space. Their care plans will be updated to reflect this. - A representative from Nursing Administration, Social Work, Recreation, Dietary and Rehab will meet monthly and as needed to review all residents identified as at risk for above stated behaviors. Any updates and changes to the resident's plan of care will be made as needed. Results of these reviews will be reported monthly to Nursing Professional Practice and Administrator. 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.) a cognitively impaired resident who wandered unsupervised into the next door room of two residents who were alert and oriented, who exhibited territorial behavior and were physically abusive to the cognitively impaired resident. Care plan interventions were non-specific and were not revised as the cognitively impaired resident continued to wander into the room of the two residents who were physically abusive and was repeatedly assaulted and sustained injuries. Interventions were standardized in nature and lacked a specific approach for increased supervision, identified behavior triggers and emphasis on protecting the resident, as well as other residents in the facility. Failure to identify and develop interventions to manage the behavior of the residents who were involved in the altercations resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was identified on 3/14/13 during survey and a plan of correction was submitted by the facility and accepted on 3/14/13, by providing 1:1 supervision of Resident #7 and developing specific behavioral interventions for all three residents. This deficient practice was identified for 3 of 5 residents reviewed for behavior symptoms and care plan interventions, Resident#7, #19 and #20, as evidenced by the following: During the initial tour of the facility on 3/8/13 at 11:15 a.m., the nurse informed the surveyor that Resident #7 had the behavior of wandering into other resident's rooms. The surveyor observed the resident seated in a wheelchair in the room. On 3/11/13 at 9:30 a.m., the surveyor reviewed the medical record of Resident #7, which revealed that the resident had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE], revealed the resident was cognitively impaired for decision making skills. The Nursing Monthly Notes from May 2012 to present revealed the resident's behavioral symptoms as: wandering the unit in a wheelchair, and wandering from room to room. Further review of the medical record revealed the resident needed close monitoring and the behavior was not easily altered. Review of nurses' notes on the above date and time revealed that Resident #7 had been involved in several physical altercations with other residents due to the wandering behavior. Examples are as follows: On 4/17/12, Resident #20 scratched Resident #7 on the face and forearm for entering his room. On 7/28/12, Resident #20 grabbed Resident #7 by the neck in an attempt to throw him out of the room. On 9/20/12, Resident #20 scratched Resident #7 on the face, forehead and arm, when he/she attempted to enter his room. On 1/23/13, Resident #19 hit Resident #7 in the face in the hallway. Resident #7 sustained a black eye from the incident. On 3/10/13, Resident #19 punched Resident #7 in the back of the head. Resident #7 went to the emergency room for evaluation. Review of the care plan for Resident # 7 revealed that his/her wandering behavior was not addressed. Review of the care plans for Residents #19 and #20, revealed that their territorial, abusive behavior was not addressed. Immediate Jeopardy was identified at 12:45 p.m., on 3/14/13, based on the facility's failure to a.) protect Resident #7 from abuse by other residents, b.) develop behavior interventions to increase supervision of Resident #7, and c.) develop interventions to identify/modify the abusive behavior of Residents #19 and #20. An acceptable Plan of Correction was received on 3/14/13 at 2:15 p.m., which included; - 1:1 supervision of Resident #7 for 48 hours pending updated care plan, - every 15 minute monitoring by staff, - Residents #19 and #20 have territorial tendencies and their care plans will be updated to include checks every 15 minutes, and - the residents will be evaluated for possible room change. Refer to F 224 NJAC 8:39-11.2 (e)-2

Based on observation, interview and record review, it was determined that the facility failed to consistently implement care plan interventions for a.) a resident who was assessed to be at risk and had a history of [REDACTED].) a resident who required laboratory monitoring for [MEDICAL CONDITION] medications. This deficient practice was identified for 2 of 27 residents reviewed for care plan interventions, Residents #3 and #15, as evidenced by the following: 1. On 3/8/13 at 10:00 a.m., during the initial tour of the unit, the nurse told the surveyor that Resident #3 had fallen frequently and had sustained a fractured wrist in October, 2012. On 3/13/13 at 10:00 a.m., the surveyor reviewed the resident's medical record and care plan. These documents revealed that since admission on 7/15/12, the resident had fallen 5 times: 9/21/12, 10/3/12, 10/4/12, 12/5/12 and 12/14/12. Further review of the medical record revealed that the resident had a physician's orders [REDACTED]. The intervention of a bed alarm was also included on his/her care plan for falls. On 3/14/13 at 9:00 a.m. the surveyor reviewed the Safety Reports for these falls. A report dated 10/3/12, revealed that Resident #3 fell out of bed at 12:30 a.m. According to the report, the "bed alarm was not plugged in." The resident sustained [REDACTED]. The facility failed to consistently implement care plan interventions related to falls to ensure the safety of the resident. Refer to F323. 2. The surveyor reviewed the medical record of Resident # 15 on 3/11/13 at 10:15 a.m., which revealed that the resident had a [MEDICAL CONDITION] disorder and behavioral disturbances. Review of the medical record revealed a physician's orders [REDACTED]. When the surveyor reviewed the medical record, no [MEDICATION NAME] levels or [MEDICATION NAME] acid levels were found. Review of the resident's plan of care for "[MEDICAL CONDITION]", initiated in December 2009, reflected; "monitor anti-convulsant blood levels as ordered." Refer to F 502 NJAC 8:39-11.2(d)

Based on observation, interview and record review, it was determined that the facility failed to a.) provide adequate supervision for a resident who had a history of [REDACTED].) adequately investigate falls to determine causal factors and to prevent recurrence, and d.) properly close sharps containers to prevent accidents. The facility's failure to consistently apply safety devices related to falls resulted in a resident falling and sustaining a fractured wrist. This deficient practice was identified for 1 of 14 residents reviewed for falls and accidents, Resident #3, as evidenced by the following: 1. During the initial tour of the nursing unit on 3/8/13 at 10:00 a.m., the nurse told the surveyor that Resident #3 had fallen frequently and had sustained a fractured wrist in October 2012. The nurse also stated that the resident was alert and oriented, with periods of confusion. The nurse further stated that the resident utilized a rear closing seatbelt, a low bed and a bed alarm at night. On 3/8/13 at 12:45 p.m., the surveyor observed Resident #3 in his/her room. The resident was seated in a wheelchair with a rear closing seatbelt tied in the back of the chair. The resident was also wearing a wanderguard on his/her ankle. On 3/11/13 at 9:45 a.m and on 3/12/13 at 9:35a.m., the surveyor observed Resident #3 sleeping in bed with two half side rails up and a mat on the floor next to the bed, which was in the lowest position. There were no pads on the resident's side rails. On 3/13/13 at 10:00 a.m., the surveyor reviewed the resident's medical record. The physician's orders [REDACTED]." The POS dated 7/26/12 included an order for [REDACTED]." On 3/13/13 at 10:20 a.m., the surveyor questioned the nurse in charge of the unit about the orders, since the resident was observed on two occasions with only half rails up, without padding. The nurse responded that the staff had not been using the pads for the side rails and further stated that the resident "does take seizure medication." The nurse also stated that the resident had no recent seizure activity. The intervention of padding the resident's side rails was not included in the resident's care plan. After this conversation, the nurse obtained a physician's orders [REDACTED]." Further review of the resident's medical record and care plan on 3/13/13, revealed that Resident #3 had a history of [REDACTED]. The POS included orders for a low bed, and "bed/personal alarm on. Check (placement every) shift," since 7/26/12. Other orders for adding mats to the floor beside the low bed, a wheel chair alarm and a rear-closing seat belt were included in the POS since 10/27/12. The Care Plan identified a "Potential for Falls" and included all of the interventions listed in the POS. On 3/13/13 at 11:15 a.m., the charge nurse told the surveyor that Resident #3 could not walk. She further stated that the restorative aide would help the resident to exercise his/her legs, but Resident #3 would not ambulate with the aide. On 3/13/13 at 11:20 a.m., the surveyor reviewed the Skilled Nursing Narrative Notes. The notes indicated that the resident had five falls since admission on 7/15/12, which occurred on 9/21/12, 10/3/12, 10/4/12, 12/5/12 and 12/14/12. On 3/14/13 at 9:00 a.m. the surveyor reviewed the Safety Reports for these falls. The report dated 10/3/12 indicated that Resident #3 was "found sitting on the floor" in her room at 12:30 a.m. According to the report, the "...bed alarm was not plugged in." The resident was sent to the emergency room and was diagnosed with [REDACTED]. On 3/14/13 at 10:00 a.m., the surveyor reviewed the facility's Policy & Procedure regarding bed and chair alarms. The Policy revealed that "Each shift, nurses will sign the TAR (Treatment Administration Record) as evidence that the alarm(s) are properly placed and that both audible and visible alarms are functioning." The TAR for October 2012, indicated that the bed alarm was checked for functioning on all shifts on October 2 and 3, 2012. Review of the Safety Report dated 12/5/12 indicated Resident #3 was found on the floor at 11:45 a.m. The statements on this Safety Report contradicted the other and both statements conflicted with the report in the Skilled Nursing Narrative Notes. For example, the Safety Report indicated that the resident "fell while getting out of (his/her) wheelchair." The Employee Statement Form attached to the Safety Report, completed by the Certified Nursing Assistant (CNA) contained the following CNA statement: the resident "did not want to get out of the bed to sit in the wheelchair. So I leave (sic) her in bed." The account for the incident in the Nurse's Progress Notes included the following statement: "Social Worker call (sic) me that the pt. was found on the floor in the 2C hallway that ((he/she)) fell and might bump ((his/her)) head on the med cart." There is no documented evidence that the facility did any further investigation to determine what actually happened when Resident #3 was found on the floor at 11:45 a.m. on 12/5/12. Review of the Safety Report dated 12/14/12, indicated that the nurse found the resident sitting on the floor in the bathroom at 5:30 a.m. The report further revealed that the CNA toileted the resident at 4:00 a.m. The report did not indicate that a "restraint free alarm" was used at the time of the fall. The CNA's statement contained the following quotation: "I took care of other patients when the incident happened. The nurse notified me that she found ((him/her)) on the floor." In the section titled, "What is the opinion on how this fall occurred?" the responses were "Patient is confused" and "Unsteady gait." The conclusion of the report was to "Remind pt. to ask for assist." The facility's conclusion to this investigation did not address the residents mentation or causal factors surrounding the resident's incident on 12/14/12 at 5:30 a.m. 2. On 3/11/13 at 11:57 a.m., the surveyor was standing at the nurse's station on the 3 A unit, a locked unit of the facility, which housed residents with behavioral and/or elopement issues. To the right of the surveyor was the medication cart for this unit. The surveyor observed that the top of the sharps container on the cart was not closed and had been prevented from closing by tissues jammed into the lid. On top of the tissues was a lancet device used to obtain a blood sample from a resident. This lancet was accessible to anyone on the unit. At that time the surveyor questioned the medication nurse who said there was a resident on the unit who was known to attempt to discard tissues in the sharps container. The nurse confirmed that the lancet had been used on a resident and was in fact exposed in the container. NJAC 8:39-27.1 (a)

C# NJ Based on observation, interviews and a review of pertinent facility documentation, it was determined that the facility failed to provide a safe living environment, free of potential fire hazards, due to lit candles and cigarette smoking inside resident rooms. This practice posed a serious and immediate threat to all residents, staff and visitors and was identified as an Immediate Jeopardy situation on 12/21/11 at 10:00 a.m. The Immediate Jeopardy was corrected and lifted on day of survey based on an acceptable plan of correction. This deficient practice was identified for 3 of 4 sampled residents (Resident #1, #3 and #4) and was evidenced by the following: All interviews and observations were conducted by the surveyor on 12/21/11 unless otherwise specified. 1. Resident #4 was admitted to the facility in September 2011 with [DIAGNOSES REDACTED]. The admission minimum data set (MDS), an assessment tool dated 9/28/11, indicated that the resident was alert, oriented and required extensive assistance with activities of daily living (ADL). At 10:00 a.m., during a tour of the facility, the surveyor observed a candle burning on the tall bureau in Resident #4's two bedded room. The surveyor observed wall oxygen in the room, however, neither resident was utilizing oxygen at the time of the surveyor's observation. The resident immediately blew out the candle upon the surveyor's request. In an interview with the surveyor at 10:00 a.m., Resident #4 explained that the candle was purchased during a shopping trip "two days ago". During an interview with the surveyor at 12:50 p.m., the Certified Nurse Assistant (CNA), assigned to Resident #4, stated that she did not see the candle in the resident's room. 2. Resident #1 was originally admitted to the facility in August 2011 and readmitted in November 2011 with [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated that the resident was alert, oriented and independent with ADLs. Review of the Skilled Nursing Narrative Notes and a facility Safety Report, both dated 11/17/11, revealed that Resident #1 was found smoking a cigarette in bed. An Individual Statement Form, dated 11/18/11, indicated that the resident was educated about smoking safety at that time. The resident was sent to the hospital on [DATE] at 5:30 p.m. for aggressive behavior and readmitted to the facility on [DATE]. At the time of readmission, Resident #1 was placed on 30 minute observation and 1:1 smoking supervision. An Interdisciplinary Plan of Care for Behavior, dated 11/21/11, identified that Resident #1 was smoking in his room. Interventions included devise a smoking schedule and encourage adherence, check resident every 30 minutes, keep cigarettes and matches/lighter with the nurse and supervise smoking out of the unit/facility. During an interview conducted by the surveyor at 10:30 a.m. on 12/21/11, Resident #1 denied smoking in his bed. However, he explained that his roommate (Resident #3) smokes in the bathroom. At 10:30 a.m., the surveyor observed the smell of smoke in the bathroom of Resident #1 and Resident #3, ashes were observed on the toilet seat and the tub drain. The surveyor immediately notified the Nursing Supervisor. In an interview conducted by the surveyor at 12:00 p.m., the CNA, assigned to the care of Residents #1 and Resident #3, stated that she was not aware that both residents had to be monitored for smoking. 3. Resident #3 was originally admitted to the facility in September 2010 and readmitted in February 2011. Resident #3's [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated that the resident was alert, oriented but needed cueing with recall. In addition, he required minimum assistance with ADLs. At 10:30 a.m., the surveyor observed the smell of smoke in the bathroom of Resident #1 and Resident #3, ashes were observed on the toilet seat and the tub drain. The surveyor immediately notified the Nursing Supervisor. Nursing documentation in the 24 Hour Report, dated 11/30/11, included that Resident #3 was caught attempting to smoke during the 3-11 shift in his bathroom. A facility Safety Report concurred with the 24 hour report with the addition that the incident occurred at 7 p.m.. A facility Employee Statement of Resident Incident, dated 11/30/11, revealed that the CNA found Resident #3 with a cigarette and lighter "about to smoke" in the bathroom. The CNA asked the resident not to smoke and "reported to the supervisor". An Individual Statement Form, regarding the incident of 11/30/11, documented by the Nursing Staff Development Coordinator, indicated that the cigarettes and a lighter were confiscated from Resident #3. Education was provided to the resident regarding his safety as well as the safety of all the other residents and the resident was reminded of the scheduled times when smoking would be safe and supervised. In a post survey telephone interview with the surveyor on 12/23/11 at 9:30 a.m., the 3-11 Nursing Supervisor, who was on duty on 11/30/11, stated that Resident #3 attempted to smoke, security was called to check the resident for cigarettes and lighter and the resident's lighter was immediately confiscated. The incident was reported to the next shift. The Nursing Supervisor added that she was unsure if any monitoring of the resident was documented after the incident, as the nurses and CNAs are responsible for monitoring. The Interdisciplinary Plan of Care for Resident #3 dated 9/22/10 through 10/29/11, lacked any evidence or documentation that interventions were implemented to prevent unsafe smoking by Resident #3. Interviews were conducted by the surveyor at 10:55 a.m. and 12:16 p.m. with the Licensed Practical Nurse (LPN) assigned to Resident #3. The LPN explained that Resident #3 was moved from another unit because of his smoking on the unit. She further explained that staff monitored his room from "time to time" and that staff checked him for matches and cigarettes. The LPN also stated that there was no set time to monitor the resident and that he was checked "periodically". In addition, she explained that cigarettes and lighters are kept locked on the medication carts. She further explained that she did not know how he received the smoking paraphernalia. An interview was conducted by the surveyor on 12/21/11 at 11:15 a.m. with Resident #3. The resident admitted that he smoked a cigarette approximately three hours ago in the bathroom. He stated that he smokes in his room daily because he is not allowed to smoke outside due to being an elopement risk. Resident #3 further stated that he no longer had any matches or cigarettes at the time of the interview. During an interview with the surveyor, in the presence of the LPN on 12/21/11 at 12:30 p.m., Resident #3 denied smoking in his room that day. He then stated that he had not smoked in three months. In an interview conducted by the surveyor on 12/21/11 at 12:00 p.m., the CNA, assigned to both Resident #1 and #3, stated that she was not aware that both residents had to be monitored for smoking. During an interview with the surveyor on 12/21/11 at 12:56 p.m., the Maintenance Supervisor stated that all of the rooms were checked daily and he had not observed any evidence of smoking or candles burning. An interview was conducted by the surveyor on 12/21/11 at 3:30 p.m. with the Director of Nursing (DON). At that time, the DON stated that Resident #3 was not placed on close monitoring after attempting to smoke on 11/30/11. The Immediate Jeopardy was identified on 12/21/11 at 10:00 a.m. and was lifted on the day of survey with an acceptable plan of correction (POC). No further POC is required. The plan of correction submitted on day of survey included the following: 1. The lit candle was immediately extinguished. All of the resident rooms within the facility were searched for candles. Candles found in resident rooms were removed. 2. Resident #3 was counseled regarding the facility's no smoking policy and immediately placed on 30 minute observation. 3. All smoking residents were reminded of the facility policy regarding smoking, including the hazards. Residents were also reminded that all smoking paraphernalia is to be maintained by staff. 4. All facility staff was re-educated on the facility smoking policy. All facility staff was re-educated regarding potential hazards of candles in the facility and outside purchases made by residents on trips. 5. Random audits will be conducted monthly by Nursing Administration to assure there are no candles within the facility. Monthly audits on all smoking residents will be conducted to assure that the facility is free from evidence of smoking and that all smoking paraphernalia is maintained by staff. NJAC 8:39- 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to: (1) respond to signs and symptoms of pain prior to and during a pressure sore treatment for 1 resident, Resident #11; (2) administer a standing order for a pain medication prior to a treatment as ordered by the prescribing physician for Resident #3; and (3) administer standing order medications for 2 residents, Resident # 9 and #17. This deficient practice resulted in Resident #11 experiencing unnecessary pain during treatment. This deficient practice was identified for 4 of 27, Residents #11, 3, 9, and 17, reviewed and was evidenced by the following: 1. Resident #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the recent Minimum Data Set (MDS-a resident assessment document), dated 9/30/10, which indicated that Resident #11 was alert and able to make his/her needs known. On 1/13/11 at 11:05 a.m., the surveyor observed the Licensed Practical Nurse (LPN) render treatment to Resident #11's Stage 4 sacral pressure sore. The LPN entered the room, observed the resident and stated, "He is in pain." The surveyor observed Resident #11's facial expression which was tense and the fists, which were clenched. The LPN informed Resident #11 of the procedure but did not ask the resident if pain was present or if the pain medication received at 9:00 a.m. was effective. The LPN first turned Resident #11 to the left side. As the resident was being turned, the surveyor observed Resident #11's facial expression again. Resident #11 grimaced and started screaming. The LPN proceeded to remove the soiled dressing and the packing and Resident #11 kept screaming. The surveyor approached Resident #11 and asked him if he/she was having pain. The resident stated, "yes." At that point the surveyor informed the LPN that Resident #11 had pain and that the LPN had to stop the dressing change. The LPN told the surveyor that this was Resident #11's "usual behavior" and that the resident always screamed. The LPN informed the surveyor that Resident #11 received his regular dose of [MEDICATION NAME], an [MEDICATION NAME] medication, at 9 a.m. The LPN proceeded with the treatment despite the surveyor's request and the resident's continued expressions of pain. When the surveyor asked the LPN if Resident #11 had an order for [REDACTED]. On 1/13/11 at 12:45 p.m., the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for the resident. The CNA revealed that Resident #11 screamed when turned and when care was provided. The CNA added that sometimes she would inform the nurse of the resident's discomfort. That same day at 1:15 p.m., the surveyor interviewed the LPN regarding the failure to stop the wound treatment when requested by the surveyor. The LPN indicated that she did not stop the treatment because she knew the patient and the patient screamed all the time while care was provided. On 1/13/11 at 1:30 p.m., the surveyor reviewed Resident #11's record and noted a Physician order [REDACTED]. There was no documented evidence that Resident #11 was assessed for pain prior to the wound treatment. Further review of the MAR indicated [REDACTED]. Furthermore, Resident #11's Initial Pain Assessment, dated 6/10/10, read: "With standing order for pain prior to wound treatment. Plan: To remain pain free at all times." The surveyor reviewed Resident #11's Care Plan which was dated 11/19/09 and revised 12/15/10. The plan did not address any behavior of screaming (as a behavior vs pain) as indicated by the LPN. Nor was there evidence of this behavior in the nursing notes. Further review of Resident #11's record revealed a physician progress notes [REDACTED]. Patient was unable to identify the location of pain but was described to be screaming." Another physician progress notes [REDACTED]." A review of Resident #11's Care Plan for pain, dated 11/19/09 and revised 12/15/10, noted: " Resident will be kept pain free at all times and/or episodes of pain will be properly managed ." On 1/18/11 at 1 p.m., the surveyor observed the LPN again render treatment to Resident #11's pressure sore. The resident had been given pain medication prior to the treatment. When the nurse turned Resident #11, the resident was calm and exhibited no sign of pain. The resident started screaming as soon as the LPN started to remove the soiled dressing. The CNA who was assisting the LPN said there was nothing you can do when somebody is in pain; you have to stop." The LPN stopped the treatment immediately. 2. Resident #3 had a physician's orders [REDACTED]. The MAR indicated [REDACTED]. However, a review of the narcotic declining inventory for the month of November 2010 indicated that 4 doses were not administered prior to the treatments done on 11/9, 11/10, 11/13 and 11/14. During an interview with the Director of Nurses on 1/19/11 at approximately 10 a.m., she indicated that she did not have an explanation as to why this occurred nor for the discrepancy in the declining inventory. 3. Resident #9 had a physician's orders [REDACTED]. The December 2010 MAR indicated [REDACTED]. The surveyor observed a written explanation on the reverse of the MAR from the nurse which indicated the drug was not administered due to "not available, not given." Additionally, an order for [REDACTED]." There was no indication in the Medical Record that the physician or pharmacy were notified of the omissions. When interviewed on 1/19/11 at approximately 10 a.m., the Director of Nurses indicated to the surveyor that she did not have an explanation as to why this occurred. 4. During the initial tour on 1/11/11 at approximately 10 a.m., the nurse Unit Manager (UM) stated that Resident #17 was alert but confused and went to [MEDICAL TREATMENT] 3 times weekly. The nurse UM stated that Resident #17 left the facility at "about 3:15 p.m." but was unsure of when the resident returned from [MEDICAL TREATMENT]. The surveyor reviewed Resident #17's medical record and observed a physician's orders [REDACTED]. The surveyor reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 1/18/11 at 11:30 a.m., the surveyor asked the UM when the resident arrived back to the facility from [MEDICAL TREATMENT]. She replied that the resident returned after 6 p.m. and usually by 7 p.m. At 12:05 p.m. the surveyor interviewed the medication nurse and showed the nurse Resident #17's Nepro order on the MAR. The nurse stated, "Oh, we have a 5 p.m. order when he's not here. I see they circled them. I'll call the doctor and see if we can hold it until he gets back." (Circling indicated a medication was not given.) N.J.A.C. 8:39-27.1(a)

Based on staff interview and record review, it was determined that the facility failed to administer medications in accordance with the [MEDICAL TREATMENT] schedule for Resident #11, 1 of 2 residents reviewed for [MEDICAL TREATMENT]. The harm level deficiency cited at the Standard Survey was corrected although the following deficient practice remained, as evidenced by the following: The surveyor reviewed Resident #11's medical record on 3/7/11. The resident received [MEDICAL TREATMENT] outside of the facility 3 times per week. According to the schedule, the resident left the facility at 8 a.m. and returned to the facility at approximately 1 p.m. every Tuesday, Thursday and Saturday. On 2/23/11 a physician order [REDACTED]. The medication was scheduled to be administered at 6:45 a.m., 10:45 a.m. and 4:45 p.m. The surveyor reviewed the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The surveyor interviewed the unit nurse on 3/8 at 10:20 a.m. The nurse stated that on the days that the resident was at [MEDICAL TREATMENT] the 10:45 a.m. dose of [MEDICATION NAME] was not administered. The nurse was unable to provide an explanation for why the MAR indicated [REDACTED]. NJAC 9:39-29.2(d)