Every finding on record at Forest Hills Center for Rehabilitation and Healing

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and observed the following: 1. In the bread storage area, the surveyor observed one loaf of sliced white bread, one loaf of sliced whole wheat bread, one bag of 12 hotdog buns, and one loaf of rye bread all opened and without open/use by labels. The FSD stated they use the manufacturers use by dates.2. On a dry storage shelf the surveyor observed an open bag of penne pasta with an open date of 3/26/25 without a use by label. The FSD stated open pasta can be used for 90 days after opening and further acknowledged the pasta was past the 90 days from opening.3. On the Chef preparatory table, the surveyor observed three opened containers of seasoning: 16 ounce (oz) granulated garlic, 5 oz Italian seasoning, and 16 oz red pepper flakes. All seasonings had been opened and were missing open/use-by labels. The FSD stated the seasoning should have been labeled and were discarded.4. The surveyor observed a dietary aide (DA#1) without their hair fully restrained under a hairnet. DA#1 stated they had not realized some of their hair was no longer restrained and put on a new hairnet.5. The dual ovens were observed with a black colored burnt debris on the bottom area. The FSD stated the ovens are cleaned weekly but could not stated why the debris was present. 6. The surveyor observed on the top of the standing steamer a sticky grease like substance was present. The FSD stated the steamer is cleaned weekly but could not state why the grease like substance was present. 7. On the ice machine vent the surveyor observed a dust like debris. Per the FSD the ice machine vent is cleaned weekly but could not state why the debris was present.8. In the walk-in refrigerator the surveyor observed a dust like debris on the interior fans and wrapped sliced America cheese without an open/use-by label. The FSD stated all items should be labeled and the cheese was On 7/30/25 at 11:15 AM, during the follow up kitchen the surveyor observed the following.9. As the chef was taking food temperatures of the tray line the surveyor observed, the chef place the food thermometer into a full tray of broccoli past the metal probe where the broccoli was touching the plastic portion, thereby contaminating the broccoli. Per interview the chef stated they had not realized the plastic had touched the broccoli. Per the FSD the broccoli would need to be disposed of. During further observation the chef contaminated a full tray of roasted potatoes and a 1/4 tray of mashed potatoes by place the plastic portion of the food thermometer into the food. All food was disposed of by the FSD. The FSD stated all staff would be re-in-serviced on taking food temperatures.On 7/30/25 the Licensed Nursing Home Administrator (LNHA) provided the surveyor with multiple facility kitchen policies. The facility policy titled Storage of non-Perishable Goods with a reviewed date of 5/2025 revealed under the policy interpretation and implementation section, 6. Dry goods (i.e. cereal, grains_ shall be stored for a period not to exceed three months. The Kitchen Cleaning Equipment policy with a reviewed date of 5/2025 revealed under the policy interpretation and implementation section, 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions. The Employee Hygiene policy with a reviewed date of 5/2025 revealed under the policy interpretation and implementation section, 10. Hairnets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Policy for labeling and dating of food items not provided after surveyor request.On 7/31/25 at 12:36 PM, the surveyor met with the LNHA and acting Director of Nursing (DON) to review areas of concern found during the survey. The LNHA stated all kitchen concerns will immediately be addressed.On 8/5/25 at 12:27 PM, the surveyor team met with the LNHA and DON for the exit conference. No further information provided by the facility staffNJAC 8:39-17.2(g)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 6 of 6 residents (Resident #2, #8, #25, #69, #94, and #116) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 7/30/25 at 12:17 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #69's tray, per the tray ticket, Resident #69 was supposed to receive coffee, strawberry short cake and health shake supplement, all three items were missing from the tray. 2. On 7/30/25 at 12:23 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #25's tray, per the tray ticket, Resident #25 was supposed to receive sour cream and diet health shake supplement, both items were missing from the tray. 3. On 7/30/25 at 12:29 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #116's tray, per the tray ticket, Resident #116 was supposed to receive coffee and strawberry short cake, both items were missing from the tray.4. On 7/30/25 at 12:33 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #94's tray, per the tray ticket, Resident #94 was supposed to receive pot roast, bread and health shake supplement, all three items were missing from the tray.5. On 7/30/25 at 12:39 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #2's tray, per the tray ticket, Resident #2 was supposed to receive coffee and sour cream, both items were missing from the tray. 6. On 7/30/25 at 12:45 PM, the surveyor was observing the lunch meal on 5th floor unit. The surveyor observed Resident #8's tray, per the tray ticket, Resident #8 was supposed to receive double portions protein, tea, sour cream, and gravy, all four items were missing from the tray.1. On 7/30/25 at 12:50 PM, the surveyor reviewed the electronic medical record (E-mar) for Resident #69. A review of Resident #69's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to encephalopathy, hypothyroidism, and acute kidney failure.A review of the Quarterly MDS, (an assessment tool used to facilitate care management) dated 7/15/25, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition is intact.A review of the Physician Order (PO) summary revealed a PO dated 1/22/24, Health Shake three times a day for malnutrition.A review of Resident #69's care plan (CP) revealed a nutrition CP with an initiation date of 10/25/24, the intervention portion of the CP revealed two nutrition interventions, Provide, serve diet as ordered with an initiation date of 3/1/25 and Provide and serve supplements as ordered: Health Shakes as ordered, with an initiation date of 3/1/25.2. On 7/30/25 at 12:55 PM, the surveyor reviewed the E-mar for Resident #25. A review of Resident #25's FS was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease, hypothyroidism, and type 2 diabetes mellitus.A review of the annual MDS, dated [DATE], reflected a BIMS score of 6 out of 15, indicating Resident #25 had severe cognitive impairment.A review of the PO summary dated 7/16/25, identified an order with an original date of 7/16/25, Regular diet, Easy to chew texture, and Thin liquid consistency.A review of Resident #25's CP revealed a nutrition CP with an initiation date of 1/17/25, the intervention portion of the CP revealed three nutrition interventions all with 2/11/25 initiation dates, Provide, serve diet as ordered, Provide fortified foods as indicated, and Provide supplements per orders.3. On 7/30/25 at 1:00 PM, the surveyor reviewed the E-mar for Resident #116. A review of Resident #116's FS was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia, atrial fibrillation, and essential hypertension.A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 14 out of 15, indicating Resident #116 had intact cognition.A review of the PO summary dated 12/2/24, identified an order with an original date of 3/3/24, No Added Salt (NAS), Regular texture, and Thin liquid consistency.A review of Resident #116's CP revealed a nutrition CP with an initiation date of 12/9/24, the intervention portion of the CP revealed two nutrition interventions first with an initiation date of 3/25/24, Honor food preferences and a second with an initiation date of 3/6/25 Provide, serve diet as ordered.4. On 7/30/25 at 1:05 PM, the surveyor reviewed the E-mar for Resident #94. A review of Resident #94's FS was admitted to the facility with diagnoses that included but were not limited to subacute osteomyelitis left femur, encephalopathy, and essential hypertension.A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 6 out of 15, indicating Resident #94 had severely impaired cognition.A review of the PO summary dated 4/25/25, identified two orders, one with an original date of 4/24/25, Regular diet, Easy to Chew texture, and Thin liquid consistency, and a second order with an original date of 5/29/24, Health Shake two times a day for supplement. A review of Resident #94's CP revealed a nutrition CP with an initiation date of 1/22/24, the intervention portion of the CP revealed two nutrition interventions both with initiation dates of 1/22/25, Provide, serve diet as ordered and Provide supplements of Health shake 4 ounce twice per day.)5. On 7/30/25 at 1:10 PM, the surveyor reviewed the E-mar for Resident #2. A review of Resident #2's FS was admitted to the facility with diagnoses that included but were not limited to iron deficiency anemia, type 2 diabetes mellitus, and major depressive disorder.A review of the quarterly MDS, dated [DATE], reflected a BIMS score of 9 out of 15, indicating Resident #2 had moderate cognitive impairment.A review of the PO summary dated 6/25/25, identified an order, original date of 3/5/25, Regular diet, Regular texture, and Thin liquid consistency. A review of Resident #2's CP revealed a nutrition CP with an initiation date of 12/2/24, the intervention portion of the CP revealed a nutrition intervention with initiation date of 3/5/25, Provide, serve diet as ordered.6. On 7/30/25 at 1:15 PM, the surveyor reviewed the E-mar for Resident #8. A review of Resident #8's FS was admitted to the facility with diagnoses that included but were not limited to sepsis, peripheral vascular disease and acute kidney failure.A review of the admission MDS, dated [DATE], reflected a BIMS score of 14 out of 15, indicating Resident #8 cognition is intact.A review of the PO summary dated 6/1/25, identified an order, with an original date of 4/24/25, LCS (Low Concentrated Sweets) diet, Regular texture, Thin consistency, Double portion. A review of Resident #8's CP revealed a nutrition CP with an initiation date of 5/22/25, the intervention portion of the CP revealed two nutrition interventions both with initiation dates of 5/22/25, Provide double portion protein at all meals, and Provide, serve diet as ordered.On 7/30/25 at 1:30 PM, the surveyor conducted an interview with the Registered Dietitian (RD) who stated they have not completed tray accuracy audits, but agreed they need to be done to ensure tray accuracy.On 7/30/25 at 1:40 PM, the surveyor conducted an interview with the Food Service Director (FSD) who stated, the kitchen staff needs to have the tray double checked before going up to the units and he needs to perform more tray accuracy audits.On 7/31/25 at 12:36 PM, the surveyor met with the LNHA and acting Director of Nursing (DON) to review areas of concern found during the survey. The LNHA stated the tray accuracy concerns will immediately be addressed.On 8/4/25 at 11 AM, the DON provided the surveyor a facility policy titled, Meal Pass with a reviewed dated of 5/2025. Under the description portion of the policy it states, Meal Services .3. Staff must check the meal ticket upon removing tray from food truck and ensure that items on the meal ticket are present on the tray.On 8/5/25 at 12:27 PM, the survey team met with the LNHA and DON for the exit conference. No further information provided by the facility staffNJAC - 17.4(a)1, (e)

Based on observations and interviews and review of pertinent facility documents, it was determined that the facility failed to provide food at a safe and appetizing temperature. The deficient practice was identified for 6 of 6 residents (Residents #1, #19, #20, #29, #69 and #78) that participated in the Resident Council Meeting and was evidenced by the following:On 7/31/25 at 10:30 AM, while participating in Resident council meeting 6 of 6 residents verbalized, they receive food that is cold at meals. On 8/5/25 at 10:15 AM, the surveyor interviewed Unit Manager (UM) for 5th floor. The UM confirmed occasionally residents ask for their food to be heated because it arrived cold. The UM further stated cold food gets heated up on the unit in a microwave. UM stated staff starts passing trays as soon as they are on the floor and acknowledged there are some delays at times getting trays to floor caused by elevators. On 8/5/25 at 10:20AM, the surveyor interviewed CNA #1. CNA#1 verbalized that residents complain of cold food sometimes and stated the elevators slow down the food arrival time and sometimes we are busy and food gets passed out slowly. On 8/5/2025 at 10:25 AM, the surveyor interviewed CNA #2. CNA#2 stated that residents get cold food a lot. CNA#2 verbalized she heats trays up for residents almost every day and stated the elevator causes big delays and we only have one working elevator for a long time now. On 8/5/2025 at 10:40AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Acting Director of Nursing (DON) to discuss concerns including food temperature and both acknowledged food temperature and tray delivery delay issues. Both acknowledged residents should receive foods at appropriate temperatures. NJAC 8:39-17.4(a)2, (e)

Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area; and found the following. There was garbage debris that included food wrappers, food containers, cups, gloves, paper products, and plastic utensil around the dumpster and surrounding areas. The FSD stated that the area should have been cleaned by the maintenance and dietary departments.On 7/30/25 at 1:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Disposal of Refuge with a reviewed date of 5/2025. Under the interpretation and implementation section of the policy revealed, 4. Outside dumpsters or compactors provided by waste management services will be kept closed and free of surrounding debris.On 7/31/25 at 12:36 PM, the surveyor met with the LNHA and acting Director of Nursing (DON). The LNHA stated the garbage area concerns would immediately be addressed.On 8/5/25 at 12:27 PM, the surveyor met with the LNHA and DON for exit conference, no further pertinent information provided.NJAC 8:39-19.7

Based on observation, interview, record review and review of facility policies it was determined that the facility failed to a.) ensure residents with significant weight changes (a weight change of 5% in 30 days and/or 10% in 180 days) were addressed by the Registered Dietitian (RD#1) in a timely fashion and b.) ensure that a resident was weighed weekly in accordance with physician's orders and facility policy. This deficient practice was identified for 2 of 2 residents (Resident #8 and #64) reviewed for significant weights changes. The deficient practice was evidence by the following:1. On 7/29/25 at 11:18 AM, the surveyor interviewed Resident #64 in their room. Resident #64 stated they are on a pureed diet and had lost weight over the past year, but unable to state how much. A review of Resident #64 Face Sheet ((FS) an admission record) revealed that the resident had diagnosis that included but were not limited to unspecified protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), type 2 diabetes mellitus (a condition in which the body cannot use insulin correctly and sugar builds up in the blood), and anxiety disorder Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/15/25 reflected a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating Resident #64 had moderate cognitive impairment. Review of the weights from the electronic medical record (EMR) revealed:7/24/24: 86.7 pounds (Lbs.) 7/7/25: 86.0 Lbs.7/3/25: 84.7 Lbs.6/26/25: 84.2 Lbs.6/17/25: 84.0 Lbs.4/11/25: 102.2 Lbs. A review of the RD#1's nutrition progress notes (NPN) for Residents #64 in the electronic medical record revealed the following had two LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicates the notes were not written on the effective date (Date of service): 1. NPN with an effective date of 6/19/2025, but with a created date of 7/22/2025. Per the RD#1's NPN, dated 6/19/2025, the RD recommended Mighty Shakes 4 ounce (oz) twice per day. 2. NPN with an effective date of 6/23/2025, but with a created date of 7/22/2025. On 7/30/25 at 11:45 AM, the surveyor interviewed RD, who stated they are the Regional RD and has been covering the building until the facility is able to hire a part-time RD, currently she is in the building 3 times per week. Per the RD, residents are weighed upon admission, re-admitted , monthly, and weekly weights are completed for residents per RD discretion. RD acknowledged Resident #64's June weight loss note was backdated from 7/22/25, and the recommended intervention of Mighty Shakes could not have been entered at that time, but Resident #64 had those supplements already in place. On 7/31/25 at 12:36 PM, the surveyor met with the Licensed nursing Home Administrator (LNHA) and acting Director of Nursing (DON) to review areas of concern found during the survey. The LNHA stated they would look into the RD#1's documentation. On 8/4/25 at 11:35 AM, the acting DON provided the surveyor with a facility policy titled, Nutritional Assessment/ Documentation, with a reviewed date of 5/2025. Under the description portion of the policy it revealed, 1. The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change on condition that places the resident at risk for impaired nutrition. 2. A review of Resident #8 FS revealed that the resident had diagnosis that included but were not limited to Diabetes, Cellulitis of left lower extremity (an infection of tissue) and stage II pressure ulcer (a wound with partial thickness loss of skin affecting the epidermis and the dermis) of the left heel. Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated A review of the Physician Order Summary (POS) revealed an order dated 7/1/25 with a start date of 7/7/25 to weigh resident weekly on Mondays for four weeks. The dates for the four weekly orders were: 7/7/25, 7/14/25, 7/21/25 and 7/28/25. A review of the weight Review of the weights from the electronic medical record (EMR) revealed the recorded weight was 169.2 pounds on Thursday 7/24/25. On 8/5/25 at 9:15 AM the surveyor interviewed the 5th floor Unit Manage (UM), who stated that on Monday's the RD would provide a list of residents who had orders to be weighed. The UM further stated that the Certified Nursing Assistants (CNA) and the nurses on the unit would obtain the weights and would return the list to the RD. The UM also stated that the weights are then recorded by the RD into the medical records. On 8/5/25 at 9:40 AM, the surveyor interviewed the RD who stated Resident #8 had an order for weekly weight to start on 7/725 for four weeks. The RD acknowledged that one weight was documented for the four-week period. She further stated that she does not document on every weight and acknowledged that the weekly weighs should be entered in the residents' medical records. The RD acknowledged that the weekly weights should have been obtained and documented weekly as ordered for the entire four-weeks ordered by the physician. The RD confirmed there was no documentation of the weights stating, I don't document follow up on every weight. the RD further stated that weekly weights should be entered every week if the weekly weight data and review documentation should be entered for every week. RD confirmed that the floor nurses and staff do not enter the weights before she reviews them to prevent inaccurate weights from being entered in health records and she does not enter them or follow up to see they are entered into the residents' records. On 8/5/25 at 12:27 PM, the survey team met with the LNHA and DON for the exit conference. No further information provided by the facility staff NJAC 8:39-27(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to provide appropriate incontinence care to dependent residents. This deficient practice occurred for 3 of 4 residents reviewed for sufficient staffing (Resident # 47, #63, and #64) and was evidenced by the following:Refer to F677Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/1/21: (1) One Certified Nurse Aide (CNA) to every eight residents for the day shift. (2) One direct staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and (3) One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 7/13/25 through 7/26/25 prior to the standard survey of 8/5/2025 revealed the facility was deficient in staffing hours as evidenced by the following: For the 2 weeks of staffing prior to the survey from 07/13/2025 to 07/26/2025, the facility was deficient in CNA staffing for residents on 2 of 14 day shifts as follows:-07/17/25 had 13 CNAs for 109 residents on the day shift, required at least 14 CNAs.-07/20/25 had 12 CNAs for 106 residents on the day shift, required at least 13 CNAs. For the week of Complaint staffing from 08/25/2024 to 08/31/2024, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: -08/25/24 had 10 CNAs for 109 residents on the day shift, required at least 14 CNAs.-08/26/24 had 4 CNAs for 107 residents on the day shift, required at least 13 CNAs.-08/27/24 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs.-08/30/24 had 12 CNAs for 107 residents on the day shift, required at least 13 CNAs.-08/31/24 had 12 CNAs for 106 residents on the day shift, required at least 13 CNAs.On 7/31/25 at 8:15 AM, the surveyor completed an incontinence tour on the 4th floor Nursing Unit and observed the following:1. On 7/31/25 at 8:25 AM, the surveyor, accompanied by the Licensed Practical Nurse/ Unit Manager (LPN/UM) observed Resident #64 in bed. The LPN/UM exposed Resident #64's incontinence brief, and the surveyor observed that it was saturated with urine. The LPN/UM confirmed that the brief was saturated with urine.A review of the 11-7:00 AM, Certified Nursing Assistant (CNA) assignment sheet revealed that the 4th-floor nursing unit had a census of 60 Residents with 4 assigned CNAs. The CNA had an assignment of 15 residents on that 11-7 AM shift.2. On 7/31/25 at 8:30 AM, the surveyor, accompanied by the LPN/UM, observed Resident #63 in bed. The LPN/UM exposed Resident #63's incontinence brief, which was saturated with urine and feces. The LPN/UM confirmed that the brief was saturated with urine and feces. The CNA had an assignment of 15 residents on that 11-7 AM shift.3. On 7/31/25 at 8:40 AM, the surveyor, accompanied by the LPN/UM observed Resident #47 in bed. The LPN/UM exposed Resident #47's incontinence brief, which was saturated with urine and feces. The LPN/UM confirmed that the brief was saturated with urine and feces. The CNA had an assignment of 15 residents on that 11-7 AM shift. On 7/31/25 at 8:50 AM, during an interview with the surveyor, the LPN/UM was not sure what the facility policy was on providing incontinence care but confirmed that the 11-7 AM shift should provide incontinence care before the end of the shift between 5 AM-7AM. The LPN/UM was not sure what the CNA to resident ratio was on the 11-7 AM shift.The CNA assigned to the above residents on the 11- 7:00 AM shift were unavailable for interviews. On 8/5/25 at 10:25 AM, during an interview with the surveyor, the staffing coordinator confirmed that on 7/30/25, during the 11:00 PM-7:00 AM shift the census on the 4th floor nursing unit was 60 and that the CNAs had 15 residents on each of their assignments. The staffing coordinator stated that she was aware of the 1 CNA to 14 resident ratio for the night shift. On 8/5/25 at 10:38 AM, the survey team discussed the above observations and concerns with the MDS coordinator and Licensed Nursing Home Administrator (LNHA).A review of the facility's Activities of Daily Living (ADL) policy, revised July 2024, reflected that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility's Staffing Policy reviewed 5/2025 reflected .To ensure the facility complies with New Jersey state law regarding minimum staffing levels and maintains appropriate direct care staff ratios to ensure quality care and resident safety .NJAC 8:39-5.1 (a), 27.1 (a), 27.2 (h)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 7/30/25 and 7/31/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 25 opportunities, and six (6) errors were observed which calculated to a medication administration error rate of 24%. The deficient practice was identified for two (2) of six (6) residents, (Resident #16 and #89), that were administered medications by two (2) of three (3) nurses that were observed.The deficient practices were evidenced by the following:1). On 7/30/25 at 8:48 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #16. The surveyor observed LPN#1 informing Resident #16 that she would be administering the resident's medications. The surveyor observed the resident who was in their bed and just finished eating breakfast.On 07/30/25 at 8:52 AM, the surveyor observed LPN#1 preparing to administer nine (9) medications to Resident #16 which included one (1) tablet Carvedilol 6.25 mg (medication for lowering blood pressure), one (1) tablet of Levocarnitine 330 mg (to prevent and treat low blood levels of carnitine),one (1) tablet of Hydralazine 25 mg (medication for lowering blood pressure), one (1) Vitamin C 500 mg (supplement), two (2) chewable tablets of Aspirin 81 mg (coronary artery disease), Combigan eye drops (glaucoma), Dorzolamide eye drops (glaucoma), one tablet of [NAME]-Vite (supplement) and one tablet of Apixaban 5 mg (coronary artery disease). The surveyor observed LPN #1 entered the resident's room. LPN#1 one told the surveyor that the resident receives two eye drops and both drops are instilled into the resident's left eye. The surveyor observed LPN#1 instill one drop of Combigan into the resident's left eye (ERROR #1). She then told the surveyor she had to wait 15 minutes before administering Dorzolamide eye drops. LPN#1 was then observed to attempt to administer all of Resident #16's by mouth medications, and at that time the surveyor stopped LPN#1 and asked her to leave the room with all of the resident's medications. The surveyor and LPN#1 reviewed the resident's medications and at that time, LPN#1 acknowledge that she put two Aspirin 81 mg chewable tablets into the medication cup instead of one tablet (Error #3) . LPN#1 also acknowledge that she placed a Vitamin C 500 mg tablet into the medication cup instead of Vitamin C 250 mg (Error #4).The surveyor then observed LPN#1 disposing medication into a drug disposal system (drug buster) and then reprepared all the medications for administration. LPN #1 was then observed going back to Resident #16's room and administering the resident's medication. LPN #1 was then observed instilling 1 drop of Dorzolamide eye drops to the resident's left eye (error #2).After medication administration, the surveyor in the presence of LPN#1 reviewed Resident #16's Electronic Medication Administration Record (e-MAR) which revealed that Resident #16 had a physician's order for Combigan ophthalmic (eye) drops with a direction to instill 1 drop to both eyes twice daily and a physician's order for Dorzolamide ophthalmic drops with a direction to instill 1 drop in both eyes twice daily.At that time, LPN#1 acknowledge that she should have instill 1 drop in both eyes for both the Combigan and Dorzolamide eye drops.A review of the admission Record (an admission summary) reflected that Resident #16 was admitted to the facility with diagnoses that included but not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), type II diabetes(a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure).A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the of care, dated 05/08/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was cognitively intact.A review of the July 2025 Physician's Orders (PO) revealed a Physician's Order dated 11/05/24, for Combigan Ophthalmic solution 0.2%-0.5% (Brimonidine Tartrate-Timolol Maleate) Instill 1 drop both eyes two times a day for glaucoma (pressure in the eye) and a PO dated 06/18/25 for Dorzolamide HCL solution 2% Instill 1 drop in both eyes two times a day for glaucoma, a PO dated 11/5/24, for Aspirin 81 mg oral chewable, give 1 tablet by mouth in the morning for Coronary Artery Disease (CAD), and a PO dated 11/5/24, for Ascorbic Acid Oral tablet 250 mg (Vitamin C), give 1 tablet by mouth one time a day for supplement.A review of the July 2025 EMAR revealed a PO dated 11/05/24, for Combigan Ophthalmic Solution 0.2-0.5% (Brimonidine Tartrate-Timolol Maleate), Instill 1 drop in both eyes two times a day for glaucoma and PO dated 06/18/25 for Dorzolamide HCL 2%, Instill 1 drop in both eyes two times a day for glaucoma, a PO dated 11/5/24, for Aspirin 81 mg oral chewable, give 1 tablet by mouth in the morning for Coronary Artery Disease (CAD), and a PO dated 11/5/24, for Ascorbic Acid Oral tablet 250 mg (Vitamin C), give 1 tablet by mouth one time a day for supplement.2). On 07/31/25 at 8:30 AM, the surveyor while observing medication administration pass, observed a Registered Nurse (RN#1) entered Resident #89 who was eating breakfast, that she was going to take the resident's vitals and administer their medications.On 07/31/25 at 8:32 AM, the surveyor observed RN#1 preparing to administer five (5) medications to Resident #89 which included one (1) tablet of aspirin 81 mg chewable (coronary artery disease), one (1) tablet Januvia 50 mg (medication to lower blood sugar), Ferrous Sulfate 325 mg (anemia), Metformin 500 mg tablet( medication to lower blood sugar), and Metoprolol 25 mg tablet (blood pressure medication). The surveyor observed RN#1 preparing the resident's medications for administration. She told the surveyor that the resident is administered their medications crushed and in apple sauce. The surveyor observed RN#1 crush each medication including Januvia 50 mg and Ferrous Sulfate 325 mg and place each medication in a separate medication cup with apple sauce. The surveyor then observed RN#1 enter Resident #89's room and administered the resident their medications, which included Januvia 50 mg (Error #5) and Ferrous Sulfate 325 mg (Error #6).The surveyor reviewed Resident #89's medical records.A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; type II diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), syncope and collapse (fainting, or a sudden temporary loss of consciousness) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete painful blockage).A review of the Annual Minimum Data Set, an assessment tool used to facilitate the management of care dated 07/23/25, reflected that the resident's cognitive skills for daily decision-making score was 7 out of 15, which indicated that the resident' had severe cognitive impairment.A review of the July 2025 Order Summary Report (physician's order sheet) (OSR) revealed a physician's order (PO) dated 12/28/23, for Januvia 50 mg (Sitagliptin Phosphate) by mouth one time a day and an PO dated 02/27/25, for Ferrous Sulfate oral tablet 325 (65 Fe) MG (Ferrous Sulfate) give 1 tablet by mouth one time a day for supplement.A review of the July 2025 electronic medication administration record (eMAR) revealed a PO dated 12/28/223, for Januvia 50 mg (Sitagliptin Phosphate) by mouth one time a day and an PO dated 02/27/25, for Ferrous Sulfate oral tablet 325 (65 Fe) MG (Ferrous Sulfate) give 1 tablet by mouth one time a day for supplement with both medications having a plotted time of 9 AM.A review of the Manufacturer's Specifications for both Januvia and Ferrous Sulfate revealed the following:-Januvia should be swallowed whole. The tablets must not be split, crushed, or chewed before swallowing.-Ferrous Sulfate should not be crush, chew or break apart.On 07/31/25 at 09:00 AM, the surveyor in the presence of the RN#1 reviewed Resident#89's physician's orders and there were no instructions on the e-MAR instructing the nurse not to crush Januvia and Ferrous Sulfate. The surveyor in the presence of RN#1 reviewed Resident #89's Januvia medication card which contained no auxiliary label not to crush Januvia.At that time, the surveyor interviewed RN#1 who stated that she was not aware that both Ferrous Sulfate and Januvia couldn't be crush. She further stated if she was aware that both Januvia and Ferrous Sulfate couldn't be crush that she would not crush those two medications.On 7/31/25 at 1:15 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Minimum Data Set (MDS) coordinator who was covering for the Director of Nursing.No further information was provided.On 8/5/25 at 8:50 AM, the surveyor interviewed the CP via a telephone interview who acknowledge that both Ferrous Sulfate and Januvia should be taken whole and should not be crushed or split. She stated that crushing both medications won't affect the activity or the distribution of the medication or harm the resident. The CP stated that the recommendation not to crush both Januvia and Ferrous sulfate was due to bitter taste or causing discoloration of teeth. She felt it was not necessary to make this recommendation when it won't affect the way the medication works or harm a resident.A review of the facility's policy for Medication Administration that was dated 6/2025 and was provided by the LNHA revealed the following: 3. Reads medication order on electronic Medication Administration Record (e-MAR). 4. Removes medication from resident's drawer in the medication cart.Checks name of residentChecks name of drugChecks strength/dose of drugFrequency given. 5. Checks medication order again. Compares e-MAR to blister pack to ensure it reads the same. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, and other facility documentation, it was determined that the facility failed to a.) maintain a sanitary clean environment; b.) minimize the potential spread of infection to residents during medication administration for 1of 3 nurses observed during medication pass on 1 of 2 nursing units and c.) follow the Centers for Disease Control recommendations and guidelines for Hand Hygiene for 3 of 3 staff members.This deficient practice was evidenced by the following. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 07/30/25 at 8:52 AM, during medication administration observation the surveyor observed a Licensed Practical Nurse (LPN#1) preparing Resident #16's medications which included two (2) eye drops, Combigan and Dorzolamide Ophthalmic drops. After preparing all the medications, the nurse told the surveyor that she will be applying a pair of gloves to administer the resident's eye drops. The surveyor observed LPN#1 cleaning her hands with a hand sanitizer and then putting on her a pair of gloves. The surveyor then observed the LPN #1 while wearing the pair of gloves touching the lid of a trash bin that was attached to the medication cart. LPN#1 was then observed entering Resident #16's room and placing the resident's medications on the overbed table. The surveyor observed LPN#1 without performing hand hygiene and changing her gloves, touched the resident's bed and headrest. The surveyor observed LPN#1 with the same pair of gloves instilled 1 drop of Combigan eye drops to Resident #16's left eye and then wipe the eye with a tissue. At that time, the surveyor interviewed LPN#1 who acknowledge that after touching the trash bin and the resident's bed she should have removed her gloves, performed hand hygiene and then reapplied gloves before instilling an eye drop and then wiping the resident's eye with a tissue paper. 2. On 7/30/25 at 9:41 AM, during medication administration observation, the surveyor observed LPN#1 cleaning her hands with a hand sanitizer and then putting on a pair of gloves. The surveyor observed LPN#1 cleaning a blood pressure monitor, a pulse ox, and a thermometer with a disinfectant wipe. After allowing them to dry, the surveyor observed LPN#1 without removing her gloves and performing hand hygiene take Resident #54's vitals. At that time, the surveyor interview LPN#1 who acknowledge that after cleaning the blood pressure monitor, pulse ox, and the thermometer, she should have removed her gloves and perform hand hygiene. She further stated that after performing hand hygiene she should have reapply her gloves and then took Resident #54's vitals. On 07/31/25 at 1:00 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Minimum Data Set (MDS) coordinator who was the acting Director of Nursing for this survey. A review of the facility's policy titled Handwashing/Hand Hygiene with a review date of 5/2025 and was provided by the LNHA revealed the following: 6. In most situations, the preferred method of hand hygiene is an alcohol-based rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: Before and after direct contact with residents Before donning sterile gloves Before performing any non-invasive procedures Before preparing or handling medications Before handling clean or soiled dressing, gauze pads, etc Before moving a contaminated body site to a clean body site during resident care After contact with a resident's intact skin After handling used dressing, contaminated equipment, etc After contact with objects (e.g medical equipment) in the immediate vicinity of the resident After removing gloves 2. On 7/30/25 at 8:54 AM, Surveyor #1 (S#1) toured the laundry area in the presence of the Director of Maintenance and Housekeeping (DMH). Both S#1 and the DMH observed the following: -Next to the dirty area of the laundry room was the washer area and the DMH stated that it was considered a clean area. Upon entry, there were three folding tables, the 1st two tables with folded clean residents' clothes and towels uncovered, at the end of the 3rd table was the big electric fan blowing air towards uncovered clothes and towels. The electric fan observed with heavy accumulation of blackish substances, which the DMH stated they were heavy accumulation of dust. Below the table was a small electric fan blowing air with accumulations of dust. -At the back of the big electric fan were metal racks with folded clean towels, linens, and blankets, and they were all uncovered. The other back side were rehabilitation (rehab) supplies and equipment (wheelchair, walkers, positioning equipment) heavily covered with dust (grayish substances). Above were pipes with heavy accumulation of grayish substances and the DMH stated should have been cleaned. At that same time, the DMH was unable to state when the last time was it was cleaned and there was no accountability log. He stated it was the responsibility of the maintenance people to clean the area. He also stated that the clean supplies should have been covered. The laundry area at that time was left unattended. On 7/30/25 at 9:14 AM, both S#1 and the DMH toured the 4th floor unit shower room. Both S#1 and the DMH observed the door was left open, the Certified Nursing Aide (CNA) entered the room, and performed handwashing in the sink. The CNA, while washing her hands stated that there were no soap and paper towels, and the water accumulated in the sink. The DMH stated that the sink was clogged and should have been fixed. He further stated that he would ask Housekeeper to put soap and paper towels. At that same time, both S#1 and the DMH observed the left side of the shower room, there were two big plastic bags of garbage on the floor next to the three compartment bins, and the lids were left open. The DMH stated that the bags of garbage should have been disposed properly in one of the three compartment bins and the lids should have been closed. On 7/30/25 at 10:09 AM, S#1 in the presence of the Minimum Data Set Coordinator/Registered Nurse (MDSC/RN) interviewed the Infection Preventionist/RN (IP/RN). The IP/RN informed S#1 that she was responsible for infection control, ensuring hand hygiene, infection control protocols were followed, education of staff, immunizations of residents and staff, and antibiotic stewardship. She stated that part of her responsibility also was to do daily rounds in the unit, including shower rooms, and residents' room, and monthly rounds for the laundry area. She further stated that she ensure that all areas were clean and with enough supplies. At that same time, S#1 notified the IP/RN and the MDSC/RN of the above findings and concerns with laundry area, shower room on the 4th floor, and hand hygiene of the CNA. The IP/RN stated that the garbage should not be on the floor, it should be inside the three compartment bins, and lids should be down to cover the bins. She further stated that there should be soap and paper towels for the staff to be able to perform appropriate hand hygiene. A review of the facility's Laundry and Linen Policy with a reviewed date of 5/2025, that was provided by the MDSC/RN, revealed, under purpose.this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. A review of the facility's Handling of Linens Policy with a reviewed date of 5/2025, that was provided by the MDSC/RN, revealed, under purpose.the facility will ensure that all linens are handled, stored, processed and transported so as to prevent the spread of infection. A review of the facility's Cleaning a Resident's Room Policy with a reviewed date of 5/2025, that was provided by the MDSC/RN, revealed, under Important things to remember.2. Never: d. Place soiled items (example garbage) directly on the floor. On 7/31/25 at 1:30 PM, the survey team met with the MDSC/RN and the LNHA, and S#2 notified them of the above findings and concerns. 3. On 7/31/25 at 8:25 AM, during the incontinence tour on the 4th floor nursing unit, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) enter Resident 64's room and perform hand hygiene. The LPN/UM applied soap and immediately placed his hands under the stream of running water without first lathering and applying friction. The LPN/UM used the same paper towel he dried his hands with to turn off the faucet. The LPN/UM put on gloves and exposed Resident #63's brief, which was saturated with urine. The LPN/UM removed his gloves, applied soap, and immediately placed his hands under the stream of running water without first lathering or applying friction. The LPN/UM dried his hands and used the same paper towel to turn off the faucet. On 7/31/25 at 8:30 AM, the LPN/UM entered Resident #63's room and performed hand hygiene. The LPN/UM applied soap and immediately placed his hands under the stream of running water without lathering and applying friction. The LPN/UM dried his hands and used the same paper towel to turn off the faucet. The LPN/UM put on gloves and exposed Resident #63's brief, which was saturated with feces and urine. The LPN/UM removed his gloves, applied soap, and immediately placed his hands under the stream of running water without first lathering or applying friction. The LPN/UM dried his hands and turned off the faucet with the same paper towel. On 7/31/25 at 8:32 AM, the Certified Nursing Assistant (CNA #1) assigned to Resident #63's care entered the room and performed hand hygiene. The surveyor observed the CNA applied soap and lathered her hands for 6 seconds outside the stream of running water, then placed her hands under water. On 7/31/25 at 8:40 AM, the LPN/UM entered Resident #47's room. The LPN/UM applied soap and immediately placed his hands under the stream of running water without lathering or applying friction. The LPN/UM dried his hands and with the same paper towel turned off the faucet. The LPN/UM put on gloves and exposed Resident #47's brief, which was saturated with feces and urine. The LPN/UM removed his gloves, applied soap, and immediately placed his hands under the stream of running water without first lathering and applying friction. The LPN/UM dried his hands and turned off the faucet with the same paper towel. On 7/31/25 at 8:45 AM, during an interview with the surveyor, the LPN/UM stated he thought that as long as he washed his hands for 20 seconds, it didn't matter whether it was outside or under the stream of water. On 7/31/25 at 8:55 AM, during an interview with the surveyor, CNA #1 stated that she was educated by the Assistant Director of Nursing (ADON) to wash and lather her hands outside the stream of water for 20 seconds. CNA #1 could not speak to why she only lathered for 6 seconds outside the stream of water. On 7/31/25 at 8:58 AM, during an interview with the surveyor, the ADON stated she was the facility's educator and that she instructed all staff on how to perform hand hygiene properly, which included applying soap and lathering their hands outside the stream of water for a minimum of 20 seconds. On 8/4/25 at 10:00 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and MDS coordinator, who confirmed that hand hygiene included lathering and applying friction for at least 20 seconds out of the stream of water. NJAC 8:39-19.4(a)(1),(m)

Based on observations, interviews, and a review of pertinent facility documents, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes their quality of life. The deficient practice and violation of privacy were identified for 3 of 28 residents (Resident #70, #71 and Resident #123) reviewed for residents' rights and was evidenced by the following: On 7/30/25 at 11:30 AM, the surveyor was interviewing Resident #70. At that time, the surveyor observed a maintenance worker enter the room without knocking or announcing themselves. The maintenance worker opened a step ladder and inspected the privacy curtain and then exited the room.On 7/30/25 at 11:40 AM, the surveyor observed the same maintenance worker enter the room of Resident #71, without knocking, waiting for permission or introducing themselves before entering the room.At that time, the surveyor interviewed the maintenance worker who stated that they should have knocked, announced themselves and attempted to get permission before entering the room. On 7/30/25 at 11:45 AM, the surveyor interviewed the 5th floor Registered Nurse/Unit Manager (RN/UM) who stated that all staff should knock, announce themselves, and state the purpose for entry into any resident's room. On 7/30/25 at 12:13 PM, the surveyor observed two transport ambulance personnel pushing a stretcher, enter Resident #123's room. Neither person was observed to knock, announce themselves, or state their purpose upon entering the room. At that time, the surveyor interviewed the ambulance personnel, who stated that they did not knock or announce themselves before entering the room, and both acknowledged that they should have.On 7/30/25 at 12:25 PM, the surveyor interviewed the 5th floor UM, who stated that outside contractors should respect the policies of the facilities, knock and announce themselves before entering a resident's room.On 7/30/25 at 12:37 PM, the surveyor interviewed the Director of Maintenance (DOM), who stated that all staff are expected to knock before entering a resident's room and then wait to receive permission from the resident before entering.On 7/30/25 at 1:45 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that all employees and contractors must knock and announce themselves before entering a resident's room. No further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for a.) 1 of 2 Nursing Units reviewed for environment; b.) ensure clean linens were provided daily for 6 of 6 residents who attended the resident group meeting (Resident #1, 19, 20, 29, 69 and 78); c.) ensure equipment was kept in a clean, sanitary manner for 2 of 2 residents, (Resident #113 and #70) and e). ensure privacy curtains were clean and in working order for 2 of 2 Residents (Resident #47 and #13)). This deficient practice was evidenced by the following: 1. On 7/30/25 at 9:14 AM, Surveyor #1 (S#1) and the Director of Maintenance and Housekeeping (DMH) toured the 4th floor unit and observed the following: The clean linen room was observed with the door closed, upon entry there was a metal rack uncovered with clean folded towels. On top was a vent with heavy accumulation of grayish substance and the ceiling tile with dried brownish discoloration. The DMH stated that the heavy accumulation of grayish substance was dust and the last time it was cleaned was beginning of March this year. He further stated that there was no specific timeframe when to clean the vent but when it was dirty it should have been reported to the Maintenance department and to be cleaned. On that same date and time, the DMH informed S#1 that it was not cleaned because they were doing some projects. He also stated that the ceiling tile where the vent had a dried brownish discoloration was from the condensation from the vent. The shower room door was left open, upon entry there were 6 and 1/2 missing tiles and broken tiles on the floor. The DMH stated he was aware of concerns with missing and broken tiles in the 4th floor unit shower room a month ago and had not had a chance to fix it. The shower curtain with missing hooks, the exhaust on the ceiling, and vent with accumulation of blackish substances. The DMH stated they were accumulations of dust. At that same time, the Certified Nursing Aide (CNA) entered the shower room and performed handwashing in the sink. Both S#1 and the DMH observed water accumulation in the sink, and the DMH stated that the sink was clogged and should be fixed. The two shower cubicles vents were heavily covered with dust and the DMH stated that they should have been cleaned daily. The DMH was unable to state the last time it was cleaned, there was no accountability log. The DMH stated that the housekeepers knew it should be cleaned daily. On 7/30/25 at 9:25 AM, both S#1 and the 4th floor Licensed Practical Nurse/Unit Manager (LPN/UM) went to Resident room [ROOM NUMBER] (RR#416) and observed privacy curtains with missing hooks. The resident's closet in the 1st bed observed the 1st drawer with chipped wood and the light was busted. The LPN/UM stated it should have been fixed. The toilet room vent with heavy accumulation of grayish substances, which the LPN/UM claimed it was dust, and should have been cleaned. At that same time, both S#1 and LPN/UM observed the shade blind was broken and the windowsill with accumulation of blackish substances, which the LPN/UM claimed should have been cleaned. The air-conditioning (aircon) system was blowing air, inside was observed individual packets of handwipes, dust accumulations, and dried brownish items. The LPN/UM stated that those brownish items were dried leaves. On 7/30/25 at 9:35 AM, both S#1 and the LPN/UM went to RR#431, observed privacy curtains with missing hooks, the floor with brownish discoloration, and dust. Both S#1 and LPN/UM also observed the aircon with dried brownish discoloration on top and accumulation of dust. The LPN/UM stated that the floor and aircon should have been cleaned. On that same date and time, outside RR#431, in the hallway, both S#1 and the LPN/UM observed the vent with heavy accumulation of dust, and LPN/UM stated it should have been cleaned. On 7/30/25 at 9:39 AM, S#1 interviewed the Housekeeping Staff (HS) assigned in the 4th floor unit in the presence of the DMH. The HS informed S#1 that it was her responsibility to maintain the cleanliness of the unit, that included mopping the floor, cleaning the tables, resident's toilet rooms, and shower room daily. At that same time, the HS informed S#1 that she did not have a chance to check the shower room yet today. She further stated that she was aware of the privacy curtains in resident rooms with missing hooks but did not report it to anyone. On 7/30/25 at 10:09 AM, S#1 in the presence of the Minimum Data Set Coordinator/Registered Nurse (MDSC/RN) interviewed the Infection Preventionist/RN (IP/RN). The IP/RN informed S#1 that part of her responsibility also was to do daily rounds in the unit, including shower rooms, resident rooms, and monthly rounds for the laundry area. She further stated that she ensured that all areas were clean and with enough supplies. At that same time, S#1 notified the MDSC/RN who was covering for the Director of Nursing (DON), in the presence of the IP/RN the above findings and concerns. The IP/RN had no answer as to why the above concerns were not identified during her routine rounds. A review of the facility's Cleaning a Resident's Room Policy with a reviewed date of 5/2025, that was provided by the MDSC/RN, revealed, under policy: to ensure that all residents' rooms are cleaned on a regular basis. Under procedure, daily cleaning, 1. Using a clean cloth treated with an appropriate disinfectant or dusting utensil: a. [NAME]/high dust all appropriate surfaces including, but not limited to: i. vents,.windowsills.c. clean floors.e. inspect privacy curtains. Replace curtains that are soiled or damaged. On 7/31/25 at 1:30 PM, the survey team met with the MDSC/RN and the Licensed Nursing Home Administrator (LNHA), and Surveyor #2 notified them of the above findings and concerns. 2. On 7/30/25 at 9:00 AM, during a tour of the 5th floor Nursing unit, two alert and oriented unsampled residents (who wished to remain anonymous) stated that they were not provided clean towels or wash cloths daily and that the Certified Nursing Assistants (CNAs) often used their top sheets to dry them after bathing. They both stated that they received clean gowns daily. On 7/31/25 at 9:05 AM, during an interview with the surveyor, the CNA (CNA #1), who was assigned to the 4th floor nursing unit, stated that 5 out of 7 days, she was unable to provide fresh clean towels or wash clothes to her residents. CNA #1 stated that she had brought it to the attention of the Director of Nursing (DON) and the nurses on the 4th floor. On 7/31/25 at 9:10 AM, during an interview with the surveyor, CNA #2 stated that there were not enough towels or washcloths for the residents, and that when towels were unavailable, she used the top sheets to dry the residents after their showers and bed baths. On 7/31/25 at 9:12 AM, during an interview with the surveyor, CNA #3 stated that she did not have enough towels or washcloths for the residents on her assignment and sometimes needed to use their top sheets to dry them. On 7/31/25 at 9:15 AM, during an interview with the surveyor, CNA #4 stated she often was unable to provide fresh, clean linens to the residents on her assignment. She stated that she had notified DHK with no resolution. On 7/31/25 at 9:30 AM, during an interview with the surveyor, the CNA (CNA #5) stated that when she notified the Housekeeping staff that she needed more linens, the response was that there were no clean towels or washcloths available. CNA #5 further stated that the facility was always running out of paper towels. On 7/31/25 at 10:30 AM, during the resident council meeting, 6 out of 6 alert and oriented residents (#1, #19, #20, #29, #69, #78) chosen by the facility to attend the meeting stated that they did not receive clean towels and or washcloths daily. They further stated that the top sheets were not changed often. On 7/31/25 at 11:00 AM, during an interview with the surveyor, the Director of Housekeeping/ Maintenance (DHK) stated that he did not keep a record of PAR levels or the number of linens ordered and had no idea of how much linen the facility had. The DHK stated that every resident should be provided with 3 towels per shift. He further confirmed that the CNAs often told him that they were short and needed more, but he stated that the CNAs hoarded the linens and more were not always available. The DHK showed the surveyor the emergency linen supply closet. DHK confirmed that there should be enough emergency supplies for 3 days .Facility Census was 106. The surveyor and DHK observed that there were no fitted sheets and no top sheets. There were three boxes of towels, each containing 60 towels. The facility had a total of 180 towels for 106 residents. Additionally, there was one box with 10 dozen (120) washclothes. The surveyor observed 3 boxes of disposable wipes, which the DHK stated that the facility no longer used. The DHK acknowledged that he did not have 3 days' supplies of emergency linens. On 7/31/25 at 11:15 AM, during an interview with the surveyor, the Housekeeper/porter stated that the CNAs would notify him a few times a week that they were short and needed more linens, but they were not always available. They would be in the washer and dryer. He further stated that he would be unable to provide additional linens. The surveyor asked the porter if he had notified the DHK that there were not enough linens. The [NAME] replied that the DHK was aware. On 7/31/25 at 12:35 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Minimum Data Set (MDS) coordinator/Acting Director of Nursing. (ADON) [NAME] Sanguan. The ADON stated that he would get back to me regarding facility policy on linens provided to the residents and PAR levels. On 8/4/25 at 2:30 PM, during an interview with the surveyor, Resident #1 stated that she only received one towel for the entire week. 3. On 7/31/25 at 8:45 AM, the surveyor and the LPN/UM entered room [ROOM NUMBER] and observed that the privacy curtain for Resident #47 was heavily soiled with a brown substance across the bottom section of the curtain. The LPN/UM confirmed that the curtain should have been replaced as the residents should be provided a clean environment. On 7/31/25 at 8:52 AM, during an interview with the surveyor, the Housekeeping aide stated that when she saw a soiled curtain, she would report it to the Director of Housekeeping (DHK), but had not realized the curtain was soiled. On 8/4/25 at 10:00 AM, the survey team met with the LNHA and MDS coordinator to discuss the above observations and concerns. A review of the facility's Linen policy reviewed 5/2025 reflected .The purpose of this policy is to ensure that all residents in the facility receive adequate, clean, and well-maintained linens. Establishing proper linen par levels will help maintain a consistent and efficient supply of linen for daily use while minimizing waste and shortages .Policy .The facility will maintain an appropriate par level of linens to ensure that each resident has access to sufficient and appropriate clean linens (e.g., bed sheets, towels, pillowcases, incontinence products) at all times. Linen par levels will be established based on resident census, facility needs, and infection control protocols . Linen Par Level: The ideal quantity of linen items needed to meet daily demand and allow for turnover without running short .This includes the standard linens provided for each resident, as well as an additional inventory to account for laundry processing time, emergencies, or high usage. Par Level Calculation: The quantity of linen required for daily usage, factoring in the number of residents, laundry processing time, and anticipated fluctuations (e.g., seasonal changes, special needs) . A review of the facility's Terminal Cleaning policy reviewed 5/2025 reflected .It is the policy to ensure that all resident rooms, treatment areas, and common areas are thoroughly and effectively cleaned and disinfected . Medical Equipment Cleaning: Clean and disinfect all non-disposable resident care equipment such as .PEG tube feeding stands . 4. On 7/30/25 at 9:30 AM, during medication administration the surveyor observed a Certified Nursing Assistant (CNA#1) in the process of starting morning care for Resident #13. The surveyor observed CNA #1 attempting to close the privacy curtain which could only close halfway. The surveyor observed the curtain not attached to multiple rings which connects the privacy curtain to the rail . The surveyor interviewed CNA #1 after she completed morning care. CNA#1 told the surveyor that she's been working at the facility for around one month and the curtain has been that way since she started. On 7/30/25 at 9:45 AM, the surveyor interviewed the resident's nurse, Licensed Practical Nurse (LPN#1). LPN#1 stated that the resident's curtain has been broken for a long time and the facility were aware that the curtain was broken. She was unable to tell the surveyor why the privacy curtain was not fixed. On 7/31/25 at 1:15 PM, the surveyor presented the above concern to the Licensed Nursing Home Administrator (LNHA) and the Minimum Data Set (MDS) coordinator who was the acting Director of Nursing. 5. On 7/30/25 at 9:00 AM, during a tour of the 5th floor nursing unit, two unsampled residents (who wished to remain anonymous) stated that they didn't receive clean towels or wash cloths daily. The residents further stated that the Certified Nursing Assistants (CNAs) often used their top sheets to dry them after bathing. On 7//31/25 at 10:30 AM, the surveyor conducted the Resident group meeting with 6 residents. All 6 of 6 residents stated that they were not provided with clean towels or washcloths daily and further stated that their sheets were not changed very often. On 8/4/25 at 2:30 PM, during an interview with the surveyor, Resident #1 stated that they only received one towel for the entire week and that their sheets were not changed often. 6. On 7/29/25 at 11:39 AM, the surveyor observed in the room of Resident #113, a Tube Feeding Pump (delivers liquid nutrition through a flexible tube into the stomach). The surveyor observed that the pump and the pole was soiled with yellow and brown substances. The surveyor further observed the floor behind the head of the bed was heavily soiled with yellow brown substance. The oxygen concentrator (a medical device that provides supplemental oxygen) that was also in the room was observed to have had splatters of a substance and a layer of dust. On 7/30/25 at 8:45 AM, the surveyor observed in Resident #113's room a Tube Feeding Pump (delivers liquid nutrition through a flexible tube into the stomach). The surveyor observed that the pump was soiled with yellow and brown substances, and the pole was heavily soiled with dark brown and yellow substances. there was a NC oxygen tubing connected to the concentrator not in use and not stored in a plastic bag. On 7/31/25 at 9:30 AM, the surveyor showed the Registered Nurse (RN) assigned to Resident #113 the soiled Tube Feeding Pump and Pole. The RN stated that Resident #113 no longer used the pump and that it should have been removed from their room. The RN acknowledged that the pump and pole were soiled. The surveyor asked the RN who was responsible for cleaning the pump and pole. The RN replied that she was not sure. 7. On 7/29/2025 at 10:30 AM, the surveyor observed the enteral feeding pump and pole of Resident #70's were splattered with light brown dried substance. The legs of the pole were also heavily crusted with thick reddish-brown substance. On 7/30/2025 at 12:30 PM The Surveyor made a second observation of Resident #70's enteral feeding pump and the pole the pump was mounted to remained splattered with light brown dried substance. The legs of the pole remained heavily crusted with thick reddish-brown substance. On 8/4/2025 at 1:40 PM, the survey team met with the LHNA and DON for the exit conference. No further pertinent information provided. NJAC 8:39-31.4(a)(b)(f) NJAC 27.1 (a)

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 4 residents (Resident #47, 63 and 64) observed for incontinence care on 1 of 2 units (4th-floor Nursing Unit).This deficient practice was evidenced by the following:On 7/31/25 at 8:15 AM, the surveyor completed an incontinence tour on the 4th floor Nursing Unit and observed the following:1. On 7/31/25 at 8:25 AM, the surveyor, accompanied by the Licensed Practical Nurse/ Unit Manager, observed Resident #64 in bed. The LPN/UM exposed Resident #64's incontinence brief, and the surveyor observed that it was saturated with urine. The LPN/UM confirmed that the brief was saturated with urine.A review of Resident #64's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to, diabetes mellitus and dementia. A review of Resident #64's Quarterly Minimum Data Set (MDS), an assessment tool dated 7/15/25, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated Resident #64 had a moderate cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder.A review of Resident #64's Individualized Care Plan (CP) initiated on 1/22/23 and revised on 4/16/25 had a focus area that included the resident was at risk for development of a pressure ulcer due to decreased mobility and incontinence with interventions that included but were not limited to; provide incontinent care every 2 hours.2. On 7/31/25 at 8:30 AM, the surveyor, accompanied by LPN/UM, observed Resident #63 in bed. The LPN/UM exposed Resident #63's incontinence brief, which was saturated with urine and feces. The surveyor observed that the sheets were soiled with a brown substance. The LPN/UM confirmed that the brief was saturated with urine and feces and that the sheets were soiled. A review of Resident #63's admission Record revealed Resident #63 was admitted to the facility with diagnoses which included but were not limited to, diabetes mellitus and dementia.A review of Resident #63's quarterly MDS, dated [DATE], revealed Resident #63 had a BIMS score of 0 out of 15, which indicated a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for toileting and was always incontinent of bowel and bladder. A review of Resident #63 CP initiated on 12/21/22 and revised on 4/15/25 had a focus area that included the resident was at risk for the development of a pressure ulcer due to decrease mobility and incontinence with interventions that included but were not limited to; provide routine incontinent care.3. On 7/31/25 at 8:40 AM, the surveyor, accompanied by the LPN/UM, observed Resident #47 in bed. The LPN/UM exposed Resident #47's incontinence brief, which was saturated with urine and feces. The LPN/UM confirmed that the brief was saturated with urine and feces.A review of Resident #47's admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus and a urinary tract infection.A review of Resident #47's Quarterly MDS dated [DATE] revealed Resident #47 had a BIMS score of 6 out of 15, which indicated Resident #47 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was always incontinent of bowel and bladder.A review of Resident #47's CP initiated on 1/22/23 and revised on 2/25/25, had a focus area that included that the resident was at risk for a pressure ulcer development related to immobility and incontinence with interventions that included to always keep skin dry by providing incontinent care every shift and as needed. On 7/31/25 at 8:50 AM, during an interview with the surveyor, the LPN/UM was not sure what the facility policy was on providing incontinence care but confirmed that the CNAs on the 11-7AM shift should provide incontinence care before the end of the shift between 5 AM-7 AM. On 7/31/25 at 8:58 AM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) stated that she was not sure of the facility's policy on incontinence care but confirmed that best practice would be to provide incontinence care every two hours and when needed.The CNAs assigned to the above residents on the 11-7 AM shift were unavailable for interviews.On 8/4/2025 at 10:00 AM, the survey team discussed the above observations and concerns with the MDS coordinator/ Acting DON. The Acting DON confirmed that incontinence care should be provided every 2-3 hours. A review of the facility's Activities of Daily Living (ADL) policy dated as reviewed 5/2025 reflected.the purpose of this policy is to establish guidelines for providing comprehensive assistance with ADLs to residents or patients. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort.monitor for signs of incontinence and ensure the use of appropriate hygiene products. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a safe smoking environment for 2 of 2 residents (Resident #3 and #72). This deficient practice was identified in the smoking area by the entrance to the facility, and was identified by the following:On 7/29/25 at 9:15 AM, the surveyor observed that the area near the facility's covered entryway had extinguished cigarettes on the ground in several areas. The surveyor observed that there were no receptacles or ashtrays in the area to safely extinguish cigarettes. The surveyor also observed that there were no fire extinguishers or fire blankets.1. On 7/29/25 at 10:50 AM, the surveyor observed Resident #3 in their room. The alert and oriented Resident stated that he/she was an independent smoker, and the facility staff permitted him/her to keep their cigarettes and lighters locked in their top drawer.On 7/30/25 at 11:00 AM, the surveyors observed Resident #3 in the portico near the front entrance smoking a cigarette. The surveyors observed extinguished cigarettes on the ground in several areas. The surveyor asked Resident #3 if this area was designated for smoking. The Resident replied that the staff told him/her that this was where she/he was permitted to smoke. The surveyor asked the resident where he/she extinguished and discarded the leftover portion of the cigarette (butt). The resident replied that he/she extinguished it on the outside of the trash can and then threw the butt into the trash can.The surveyor reviewed the medical record for Resident #3.A review of the admission Record reflected Resident #3 was admitted to the facility with diagnoses that included but were not limited to; seizures and hemiplegia (partial paralysis on one side of the body) and hemiparesis (weakness) following cerebrovascular disease (stroke).A review of the admission Minimum Data Set, an assessment tool dated 6/21/25, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS further assessed under section J that the resident was not currently using tobacco. A review of Resident #3's Care Plan Report had a focus area that included: the resident is a known smoker with the goal that the resident will smoke safely within the designated smoking area x 90 days initiated on 6/18/25 and revised on 7/2/25 with interventions that included but were not limited to; review the smoking policy with the resident as needed. A review of the Smoking Regulation Agreement signed and dated 6/15/25 reflected.[Resident #3] is aware of the smoking rules and has been informed and accompanied to the designated smoking area. residents who smoke are permitted to smoke, must do so off premises in a public domain.I understand that it is my responsibility to keep all matches/lighters secured in a locked drawer in my room or secured on my person. A review of Resident #3's Smoking assessment dated [DATE] reflected. Resident demonstrates an accurate understanding of smoking policy and guidelines.2. On 08/5/2025 at 9:15 AM, the surveyor observed Resident #72 smoking in the area by the facility entrance. During an interview with the surveyor, Resident #72 stated that he/she was admitted to the facility about a year ago. Resident #72 stated that he/she was informed at that time that this was the designated smoking area and that he/she had been smoking in this space since admission. He/she further stated that there used to be a bucket with sand to extinguish the cigarette butts, and now there is an ashtray. The resident further stated that when there was no bucket or ashtray, he/she extinguished them on the ground. The surveyor observed that there were no fire extinguishers or fire blankets in the area. The surveyor reviewed the medical record for Resident #72.A review of the admission Record reflected Resident #72 was admitted to the facility with diagnoses that included but were not limited to; depression, anxiety, and chronic obstructive pulmonary disease (a lung disease).A review of the most recent Minimum Data Set, dated [DATE], revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS further assessed under section J that the resident was currently using tobacco. A review of Resident #72's Care Plan Report had a focus area that included: resident is a known smoker and smokes daily initiated 11/7/24 with the goal that the resident will smoke safely within the designated smoking area x 90 days initiated on 12/2/24 and revised on 3/21/25 with interventions that included but were not limited to review smoking policy with resident as needed and allow resident to smoke in designated smoking area with supervision as needed. A review of Resident #72's Smoking assessment dated [DATE] reflected.Resident demonstrates an accurate understanding of smoking policy and guidelines.On 8/5/25 at 9:30 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the Smoking Regulation Agreement for Resident #72. No Smoking Regulation Agreement was provided for Resident #72.On 7/30/25 at 11:10 AM, during an interview with the surveyors, the receptionist confirmed that there was no fire extinguisher in the front lobby. On 7/30/25 at 12:00 PM, during an interview with the surveyor, the LNHA stated that the designated smoking area was located off to the side near the building's entrance. The surveyor asked the LNHA where the residents were supposed to extinguish their cigarette butts. The LNHA replied, In the ashtray. The surveyor informed the LNHA that no ashtrays were observed on 7/29/25 or 7/30/25. The LNHA replied, Someone must have stolen it. The surveyor asked the LNHA if there was a fire extinguisher in the area. The LNHA replied that she would have to get back to the surveyor. On 7/31/25 at 12:35 PM, the surveyor discussed the above observation and concerns with the LNHA and MDS coordinator. The LNHA stated that the facility was smoke-free and that residents needed to go off the premises if they wanted to smoke.On 7/31/25 at 1:15 PM, the surveyor observed two unsampled residents smoking in the area near the facility entrance. The surveyor observed there were no receptacles or ashtrays for the residents to safely extinguish their cigarette butts, and there were no fire extinguishers.On 8/4/25 at 8:10 AM, the surveyor observed by the facility entrance a large bucket filled with sand and several cigarette butts. At that time, the surveyor observed the Director of Housekeeping (DHK) /maintenance used a dolly to remove the large bucket and replace it with a green ashtray.On 8/4/25 at 8:20 AM, during an interview with the surveyor, the DHK stated that he had gone to the Home Depot to get the bucket and sand this weekend. He just got the ashtray today, so he was replaced it with the sand bucket. The DHK further stated that the area where he placed the ashtray was, in fact, the designated smoking area. The DHK acknowledged that the facility was responsible for providing a safe smoking environment. Specifically, it should have had an ashtray receptacle so that residents could safely extinguish and dispose of their cigarettes, and a fire extinguisher in the designated smoking area. A review of the facility's undated Smoking Policy reflected.In accordance with New Jersey state law, this center shall maintain a smoke-free environment. Residents, visitors, and employees are prohibited from smoking within the building, including the center's parking area, delivery area, and portico covered entryway. Residents and visitors wishing to smoke shall be directed to do so off premises on the public domain.such as a sidewalk.NJAC 8:39-31.6(e)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a urinary drainage bag was secured in a manner to prevent contamination, infection control, and to enhance dignity for 1 of 1 resident reviewed for urinary catheter care.The deficient practice was evidenced by the following: On 8/4/25, at 9:45 AM, the surveyor observed Resident #113's urinary drainage bag not in a privacy bag and visible from the hallway. A review of Resident #113's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; urinary retention, chronic obstructive pulmonary disease, and gastrostomy status (a feeding tube inserted through the abdominal wall into the stomach to deliver nutrition). A review of the current Order Summary Report and transcribed onto the Treatment Administration Record (TAR) reflected a physician order to check urinary catheter (a flexible, plastic tube inserted into the bladder to drain urine) for proper placement, provide urinary care, record urine output at the end of each shift and maintain in privacy bag every 8 hours. A review of Resident #113's admission Minimum Data Set (MDS), an assessment tool, dated 7/24/25 reflected the resident had a severely impaired cognition. Section H of the assessment revealed the resident had an indwelling catheter. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, initiated on 7/18/25, that the resident has a foley catheter for urinary retention with interventions that included but were not limited to; cover drainage bag with privacy cover at all times. On 8/4/25 at 9:45 AM, during an interview with the surveyor, the Registered Nurse (RN) stated that she was unsure whether the urinary drainage bag should be secured in a privacy bag for infection control prevention and dignity. On 8/4/25 at 10:00 AM, the survey team discussed the above observations and concerns with the MDS coordinator and the Licensed Nursing Home Administrator (LNHA). The MDS coordinator confirmed that the urinary drainage bag should be stored in a privacy bag for infection control and dignity. A review of a facility policy, Catheter Care, Urinary dated as reviewed 5/2025, revealed.cover urinary drainage bags with privacy covers. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure oxygen nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 residents (Resident #113) reviewed for Oxygen Therapy. The 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 case-finding, 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 case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/29/25 at 11:39 AM, the surveyor observed in Resident #113's room an oxygen concentrator, not in use, soiled with a brown and yellow substance and covered with dust.On 7/30/25 at 8:45 AM, the surveyor observed in Resident #113's room an oxygen concentrator soiled with a brown and yellow substance covered with dust and a Nasal Cannula Oxygen tubing connected to the concentrator, not in use, not stored in a plastic bag. A review of Resident #113's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and gastrostomy status (a feeding tube inserted through the abdominal wall into the stomach to deliver nutrition). A review of the current Order Summary Report revealed a Physician Order (PO) dated 7/17/25 and transcribed onto the Treatment Administration Record (TAR) to give 3 liters per minute (lpm) of oxygen via nasal cannula, check saturation (the amount of oxygen in the blood) every shift. A review of Resident #113's admission Minimum Data Set (MDS), an assessment tool, dated 7/24/25, reflected that the resident had severely impaired cognition. Section O of the assessment revealed the resident received respiratory treatments, which included oxygen therapy. A review of the resident's individual comprehensive care plans (CP) revealed that no care plan had been initiated for oxygen therapy. On 7/31/25 at 9:30 AM, during an interview with the surveyor, the Registered Nurse assigned to Resident #113's care stated that the oxygen tubing should be stored in a plastic bag for infection control prevention. On 8/4/25 at 10:00 AM, the survey team discussed the above observations and concerns with the MDS coordinator and the Licensed Nursing Home Administrator (LNHA). The MDS coordinator confirmed that when the oxygen tubing was not in use, it should be stored in a plastic bag for infection control measures. A review of a facility policy, Oxygen Administration dated as reviewed 5/2025, revealed.the purpose of this procedure is to provide guidelines for safe oxygen administration.review the resident's care plan to assess for any special needs of the resident.store tubing that is not in use in plastic bags. NJAC 8:39-19.4(a); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medication was administered according to the physician's order (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of six (6) residents (Resident #16) during medication observation pass. The 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 case-finding, 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 case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 7/30/25 at 8:48 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #16. The surveyor observed LPN#1 informing Resident #16 that she would be administering the resident's medications. The surveyor observed the resident in bed eating breakfast.On 07/30/25 at 8:52 AM, the surveyor observed LPN#1 preparing to administer nine (9) medications for Resident #16 which included Carvedilol 6.25 mg (medication for lowering blood pressure), Levocarnitine 330 mg tablet (to prevent and treat low blood levels of carnitine), Hydralazine 25 mg tablet (medication for lowering blood pressure), Vitamin C 250 mg tablet (supplement), Aspirin 81 mg (coronary artery disease), Combigan Ophthalmic (eye) drops (glaucoma), Dorzolamide Ophthalmic (eye) drops (glaucoma), [NAME]-Vite (supplement) and Apixaban 5 mg (coronary artery disease). The surveyor observed LPN #1 during medication administration observation instilling 1 drop of Combigan eye drops and 1 drop of Dorzolamide eye drops into the resident's left eye.After LPN#1 administered Resident #16's medications the surveyor reviewed the physician orders for both the Dorzolamide and Combigan eye drops with LPN#1. The surveyor in the presence of LPN#1 inspected the pharmacy packaging for both Combigan and Dorzolamide Ophthalmic drops. The surveyor observed a label with administration directions for Dorzolamide Ophthalmic drops to instill 1 drop to the left eye twice daily. The pharmacy label was dated 6/10/25. A review of the Combigan Ophthalmic drops revealed a label with administration directions to instill 1 drop to both eyes twice daily. After reviewing the packaging for both eye drops the surveyor in the presence of LPN#1 reviewed Resident #16's Electronic Medication Administration Record (e-MAR) which contained a physician's order for Combigan Ophthalmic drops to instill 1 drop to both eyes twice daily and a physician's order for Dorzolamide Ophthalmic drops to instill 1 drop in both eyes twice daily.At that time, the surveyor interviewed LPN #1 who acknowledge that both Dorzolamide and Combigan Ophthalmic drops should have been instill into both eyes. LPN#1 acknowledge that she was following the instructions of the pharmacy label and should have follow the instructions on the EMAR. LPN#1 further stated that the incorrect directions on the pharmacy label was confusing and had a potential to cause an error. She stated that whenever the instructions on the pharmacy label are different from the order on the EMAR, she should verify the order with the physician. A review of the admission Record (an admission summary) reflected that Resident #16 was admitted to the facility with diagnoses that included, but were not limited to; hypertension (a condition in which the force of the blood against the artery walls is too high), type II diabetes(a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of the quarterly Minimum Data Set, an assessment tool, dated 05/08/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was intact.A review of the July 2025 Physician's Orders (PO) revealed a PO dated 11/05/24, for Combigan Ophthalmic solution 0.2%-0.5% (Brimonidine Tartrate-Timolol Maleate) Instill 1 drop both eyes two times a day for glaucoma (pressure in the eye) and a PO dated 06/18/25 for Dorzolamide HCL solution 2% Instill 1 drop in both eyes two times a day for glaucoma.A review of the July 2025 EMAR revealed a PO dated 11/05/24, for Combigan Ophthalmic Solution 0.2-0.5% (Brimonidine Tartrate-Timolol Maleate), Instill 1 drop in both eyes two times a day for glaucoma, and a PO dated 06/18/25 for Dorzolamide HCL 2%, Instill 1 drop in both eyes two times a day for glaucoma. On 07/31/25 at 1:00 PM, the surveyor discussed the above concerns with the facility administration team that consisted of the Licensed Nursing Home Administrator (LNHA) and the Minimum Data Set (MDS) coordinator, who was the acting Director of Nursing.There was no additional information provided.A review of the facility's policy for Medication Administration dated 6/2025, which was provided by the LNHA revealed the following: 3. Reads medication order on electronic Medication Administration Record (e-MAR). 4. Removes medication from resident's drawer in the medication cart.Checks name of residentChecks name of drugChecks strength/dose of drugFrequency given. 5. Checks medication order again. Compares e-MAR to blister pack to ensure it reads the same.NJAC 8:39-11.2 (b), 29.2 (d)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of six (6) residents observed during medication administration pass, (Resident #89) for medication management and was evidenced by the following: On 07/31/25 at 8:30 AM, during medication administration pass the surveyor observed a Registered Nurse (RN#1) entered into Resident #89 room. The resident was observed sitting up in bed and eating breakfast.RN #1 informed the resident that she would be taking their vitals and then would be administering their medications.On 7/31/25 at 8:32 AM, the surveyor observed RN#1 preparing to administer five (5) medications for Resident #89 which included aspirin 81 milligram (mg) chewable tablet (coronary artery disease), Januvia 50 mg (medication to lower blood sugar), Ferrous Sulfate 325 mg (anemia), Metformin 500 mg tablet (medication to lower blood sugar), and Metoprolol 25 mg tablet (blood pressure medication). The surveyor observed RN#1 preparing the resident's medications for administration. She told the surveyor that the resident is administered their medications crushed and in apple sauce. The surveyor observed RN#1 crush each medication including Januvia and Ferrous Sulfate and place each medication in a separate medication cup with apple sauce. The surveyor then observed RN#1 enter Resident #89's room and administered the resident their medications which included Januvia 50 mg and Ferrous Sulfate 325mg.The surveyor reviewed Resident #89's medical records.A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; type II diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), syncope and collapse (fainting, or a sudden temporary loss of consciousness) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete painful blockage).A review of the Annual Minimum Data Set, an assessment tool used to facilitate the management of care dated 07/23/25, reflected that the resident's cognitive skills for daily decision-making score was 7 out of 15, which indicated that the resident' had severe cognitive impairment.A review of the July 2025 Order Summary Report (physician's order sheet) (OSR) revealed a physician's order (PO) dated 12/28/23, for Januvia 50 mg (Sitagliptin Phosphate) by mouth one time a day and an PO dated 2/27/25, for Ferrous Sulfate oral tablet 325 (65 Fe) MG (Ferrous Sulfate) give 1 tablet by mouth one time a day for supplement. A review of the July 2025 electronic medication administration record (eMAR) revealed a PO dated 12/28/2023, for Januvia 50 mg (Sitagliptin Phosphate) by mouth one time a day and an PO dated 2/27/25, for Ferrous Sulfate oral tablet 325 (65 Fe) MG (Ferrous Sulfate) give 1 tablet by mouth one time a day for supplement with both medications having a plotted time of 9 AM.A review of the Manufacturer's Specifications for both Januvia and Ferrous Sulfate revealed the following:-Januvia should be swallowed whole. The tablets must not be split, crushed, or chewed before swallowing.-Ferrous Sulfate should not be crush, chew or break apart.A review of the Consultant Pharmacist (CP) Monthly Reports from dated 5/1/25 through 7/31/25 indicated that the CP reviewed the medication regimen for Resident #89 with no recommendation that both Ferrous Sulfate and Januvia can't be crush. They were also no recommendation making the physician or nurses aware that these two medications were not recommended to be crushed by the manufacture.On 7/31/25 at 9:00 AM, the surveyor in the presence of the RN#1 reviewed Resident#89's physician's orders and they were no instructions on the e-MAR instructing the nurse not to crush Januvia and Ferrous Sulfate. The surveyor in the presence of RN#1 reviewed Resident #89's Januvia medication card which contained no auxiliary label not to crush Januvia.At that time, the surveyor interviewed RN#1 who stated that she was not aware that both Ferrous Sulfate and Januvia couldn't be crush. She further stated if she was aware that both Januvia and Ferrous Sulfate couldn't be crush that she would not crush those two medications.On 7/31/25 at 1:15 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Minimum Data Set (MDS) coordinator who was covering for the Director of Nursing. No further information was provided.On 8/5/25 at 8:50 AM, the surveyor interviewed the CP via a telephone interview who acknowledge that both Ferrous Sulfate and Januvia should be taken whole and should not be crushed or split. She stated that crushing both medications won't affect the activity or the distribution of the medication or harm the resident. The CP stated that the recommendation not to crush both Januvia and Ferrous sulfate was due to bitter taste or causing discoloration of teeth. She felt it was not necessary to make this recommendation when it won't affect the way the medication works or harm a resident.A review of the facility's policy for Medication Administration Guidelines undated, which was provided by the MDS coordinator included the following: 17. Observe for medications suitable and unsuitable for crushing. Stickers on blister packs will state Do Not Crush to indicate that the medication cannot be crushed. A review of the Consultant Pharmacist responsibilities that was undated and provided by the MDS coordinator revealed the following: Consultant Pharmacist would assure duration of therapy (adequate therapy) and Manufacturer's Recommendations.On 8/4/25 at 1:40 PM, the survey team met with the LNHA and DON for exit conference, no further pertinent information provided. NJAC 8:39-29.3

Based on observation, interview, and record review, it was determined that the facility failed to properly dispose of medications which was observed for one (1) of three (3) nurses during medication administration pass. This deficient practice was evidenced by the following:On 7/30/25 at 8:48 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #16. The surveyor observed LPN#1 informing Resident #16 that she would be administering the resident's medications. The surveyor observed the resident in bed and eating breakfast.On 07/30/25 at 8:52 AM, the surveyor observed LPN#1 preparing to administer nine (9) medications to Resident #16 which included Carvedilol 6.25 mg (medication for lowering blood pressure), Levocarnitine 330 mg tablet (to prevent and treat low blood levels of carnitine), Hydralazine 25 mg tablet (medication for lowering blood pressure), Vitamin C 250 mg tablet (supplement), Aspirin 81 mg (coronary artery disease), Combigan eye drops (glaucoma), Dorzolamide eye drops (glaucoma), [NAME]-Vite (supplement) and Apixaban 5 mg (coronary artery disease). The surveyor observed LPN#1 during medication preparation added two (2) Aspirin 81 mg chewable tablets instead of one tablet into the medication cup. The surveyor also observed LPN #1 adding a Vitamin C 500 mg tablet instead of a Vitamin C 250 mg tablet into the medication cup.The surveyor stopped LPN#1 just before she was going to administer the medications to Resident #16. The surveyor asked LPN#1 to leave the resident's room with all of the resident's medications. The surveyor informed LPN#1 of the observations and asked for her to take out a bottle of Vitamin C 500 mg and a bottle of Aspirin 81 mg chewable tablets from the medication cart, so that she could identified the tablets. The surveyor observed LPN#1 pour two tablets of Aspirin 81 mg chewable tablets from a stock bottle and put them on a tissue paper. LPN#1 was observed handling these two tablets while reviewing the medications. LPN#1 acknowledge that she accidently added two Aspirin 81 mg chewable tablets to the medication cup. At that time, the surveyor observed LPN#1 pick up the tissue paper that contained the two Aspirin tablets and was going to throw them into the trash bin that was attached to the medication cart. At that time, the surveyor stopped LPN#1 and asked her if that was the proper way to dispose medications. LPN#1 stated that all medications should be dispose in a Drug Buster (medication disposal system) and that medication should not be dispose in a trash bin. The surveyor then observed LPN#1 remove a Drug Buster from her medication cart and dispose the two Aspirin tablets and all the medications that were in the medication cup. The surveyor then observed the nurse re-prepared all of the resident's medications for medication administration.On 7/31/25 at 1:00 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator and the Minimum Date Set (MDS) Coordinator who was covering for the Director of Nursing who was on vacation.No further information was provided by the facility.A review of the facility's policy titled Medication Return and Disposal of Medications Non-Controlled that was dated 05/2025 and was provided by the LNHA indicated the following: Policy: Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed If a dose of a non-controlled prescription medication is refused, spit out and/or dropped during medication pass, the facility will utilized Drug Buster to dispose of said medication. When container is filled per manufacturer's instructions, it will be disposed of in a med room trash and replaced with a new Drug Buster container.NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview, record review, and review of other pertinent facility documents on 12/4/2023, it was determined that the facility failed to provide four of ten residents with a prescribed pureed diet, which should have been smooth, soft, and homogenous in consistency. The pureed mashed potatoes served to the residents from the kitchen on 12/4/23, were served with several chunks of potato mixed into the mashed potatoes. The facility's failure to prepare and provide the proper pureed food consistency and, failure of the nursing staff to report the improper food consistency, placed Resident #61, #28, #31 and #69, as well as all other residents, at risk of aspiration and choking which could cause serious harm, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/4/23. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 12/4/23 at 4:18 PM. An acceptable written Removal Plan was received on 12/5/23 at 10:00 AM. The Removal Plan was verified by the survey team onsite on 12/5/23 at 1:10 PM, lifting the immediacy, and the survey team continued verification of the Removal Plan onsite throughout the survey while onsite for the dates of 12/6/23, 12/7/23, 12/8/23, and 12/11/23. The evidence was as follows: On 12/4/23 at 12:15 PM, during the lunch meal, Resident #61's family member, who was feeding the resident, asked the surveyor to look at the resident's meal, specifically the mashed potatoes. The resident was prescribed a Pureed diet and that was indicated on the resident's tray ticket which was provided with the meal. Resident #61's tray ticket also indicated an alternate required starch and the resident had received pureed mashed potatoes as part of their meal which was served by the facility's kitchen. The surveyor observed 14 1/4- 1/2 inched sized chunks of potatoes in the pureed mashed potatoes. On 12/4/23 at 12:20 PM, the surveyor observed the pureed lunch meal, which was served by the facility's kitchen, for all of the residents who were prescribed a pureed diet. The surveyor observed that the lunch tray tickets for Resident #28, which indicated that the residents were to receive boiled rice (pureed) but the resident actually received pureed mashed potatoes on their trays instead. The surveyor observed Resident #28 lunch meal and also identified several 1/4- 1/2 sized chunks of potatoes within the pureed mashed potatoes served to those residents. At 12:20 PM, the surveyor observed the pureed lunch meal, which was served by the facility's kitchen, for all of the residents who were prescribed a pureed diet. The surveyor observed that the lunch tray tickets for Resident #31, which indicated that the residents were to receive boiled rice (pureed) but the resident actually received pureed mashed potatoes on their trays instead. The surveyor observed Resident #31 lunch meal and also identified several 1/4- 1/2 sized chunks of potatoes within the pureed mashed potatoes served to those residents. At 12:21 PM, the surveyor interviewed the Food Service Worker (FSW) who prepared the pureed mashed potatoes, he stated that he had used fresh, boiled mashed potatoes without the skin and he used the commercial puree machine to puree it, then, he checked the smoothness with a rubber spatula. He stated that he did not see any chunks in the pureed mashed potato. He stated that he did not use the dried potato product for the pureed potatoes because when he uses that for puree, the consistency comes out like glue. The FSW provided the ingredients and procedure for pureed mashed potato which revealed to whip the potatoes on low speed until smooth, add hot milk, margarine and salt. Then, whip until creamy. At 12:31 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) #2 and #3. Both the CNA #2 and #3, who were feeding Resident #31 and Resident #28 stated that they observed chunks in the pureed mashed potato and mashed the chunks before feeding it to Resident #31 and #28. The CNA #2 and #3 did not report this to anyone else. At 12:40 PM, the surveyor observed the pureed lunch meal, which was served by the facility's kitchen, for all of the residents who were prescribed a pureed diet. The surveyor observed that the lunch tray tickets for Resident #69, which indicated that the residents were to receive boiled rice (pureed) but the resident actually received pureed mashed potatoes on their trays instead. The surveyor observed Resident #69 lunch meal and also identified several 1/4- 1/2 sized chunks of potatoes within the pureed mashed potatoes served to those residents. The CNA #1, who was feeding Resident #69, stated that she did not give the pureed mashed potato to Resident #69 because it did not look like a pureed consistency. The CNA #1 did not report this to anyone else. At 12:45 PM, the surveyor interviewed the Director of Dietary (DD), who stated that the commercial puree machine used in the kitchen for making pureed foods smooth had dull blades from wear and tear and he just ordered a new blade recently. The DD stated that they should have used the immersion blender if there was a problem with the commercial puree machine. The FSD was not aware of the pureed mashed potatoes containing chunks. The DD stated that the staff should never puree freshly cooked raw potato and the staff should have used a dried potato product sfor puree. The DD stated that the lunch tray tickets did indicate that all the residents who received a puree diet were supposed to receive boiled rice (pureed) but all the residents actually received pureed mashed potato and he was not sure why that occurred. At 12:50 PM, the surveyor interviewed the Speech Language Pathologist (SLP), who observed the plate of pureed mashed potatoes and stated that there should not be any chunks and that the pureed item should be smooth. The SLP stated that all four of the residents are at risk of aspiration and choking. The SLP stated that Resident #28's muscles could freeze up and then cannot finish the chewing the food, and it could build up and cause pocketing which could lead to choking and aspiration. The SLP stated that Resident #69 had a risk of aspiration and choking due to decreased cognition. The SLP stated that Resident #31 had severely impaired cognition and needed to be fed by staff. The resident did not have awareness of the bolus in the resident's mouth which could lead to aspiration and choking. The SLP stated that Resident #61 had impaired cognition with poor dentition and cannot chew chunks of food, which could lead to aspiration and choking. The SLP stated that the CNAs cannot alter food consistency to meet the needs of the resident, however a licensed professional can. At 1:01 PM, the Director of Nursing (DON) stated that a CNA should inform the staff if the consistency is not correct but can mash the food or add a liquid. The surveyor reviewed the records for Resident #61, which revealed the following: The Order Summary Report (OSR) revealed an order for a Regular, Puree texture, thin consistency diet. The Speech therapy Evaluation and Plan of Treatment (SLP EPT) dated 3/9/23, revealed that the resident exhibits a primarily oral stage dysphagia with solids i.e. difficult chewing and recommendation of puree, thin liquids. According to the residents' Quarterly Minimum Data Set (MDS), an assessment tool dated 10/20/23, revealed the resident scored 6 of possible 15 on the Brief Interview for Mental Status, which indicated moderate cognitive impairment. The surveyor reviewed the records for Resident #31, which revealed the following: The Admission Record (AR) revealed Diagnoses which included but were not limited to altered mental status, dementia, and encephalopathy. The resident's OSR revealed an order for a Regular, Puree texture, thin consistency diet. The nurse progress note (PN) dated 11/20/23, revealed that the resident did not swallow during feeding, needed cuing to swallow and also pocketed food in the mouth. The Rehabilitation order from the SLP dated 6/11/2020 revealed that the resident need SLP treatment for Dysphagia and recommended a pureed diet. According to the residents' Quarterly MDS, an assessment tool dated 10/15/23, revealed the resident scored 0 of possible 15 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. The surveyor reviewed the records for Resident #28, which revealed the following: The AR revealed Diagnoses which included but were not limited to Parkinson's Disease. The OSR revealed an order for a Regular, Puree texture, nectar liquid consistency diet. The SLP EPT dated 6/12/23, revealed that the resident required treatment of swallowing dysfunction and/or oral function for feeding and needs treatment based on dysphagia, oropharyngeal phase. According to the residents' Comprehensive MDS, an assessment tool dated 10/18/23, revealed the resident scored 3 of possible 15 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. The surveyor reviewed the records for Resident #69, which revealed the following: The AR revealed Diagnoses which included but were not limited to Dementia. The OSR revealed an order for a Regular, Puree texture, thin consistency diet. The SLP Diagnoses dated 1/27/22, revealed that the resident had a Diagnosis of dementia and oropharyngeal dysphagia and needed puree consistency. The Rehabilitation Orders by the SLP dated 1/13/22, revealed the resident had safety precautions due to risk of aspiration. According to the residents' Quarterly MDS, an assessment tool dated 11/2/23, revealed the resident scored that he/she was never or rarely understood for the Brief Interview for Mental Status. This indicated the resident had severe cognitive impairment. The Administrator provided the surveyor with the Food and Nutrition Services policy dated 8/2023, which revealed If an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that new food tray can issued. The DON provided the surveyor with the Puree Diet Consistency policy dated 9/20/23, which revealed Puree foods should be prepared in such a manner to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency. On 12/5/23 at 10:00 AM, the LNHA submitted the removal plan. The surveyor verified the plan which included the following interventions. The facility removed the commercial puree machine and replaced it with a new one, the FSW who served the rice instead of potatoes was immediately in serviced to follow the menu and to use dried potato product instead of raw boiled potato for pureed diet, the CNAs #1, #2, #3 were immediately in-serviced regarding diet consistency and were educated to report concerns immediately to food service staff for replacement, the CNAs were educated not to alter food consistency by mashing food and food types for pureed diet, the dietary staff were immediately in-serviced about checking consistency of food and diet accuracy during prep and prior to serving. An audit tool was developed to ensure compliance with revised policy on food tray accuracy, nursing will audit 10 trays each day for 1 week, and then monthly for 3 months, and then as needed. Any concerns identified will be immediately referred to administration for review and corrective action. An audit of findings will be presented to the QA Committee for evaluation and follow up as indicated. The DD/designee will monitor diet accuracy during prep and prior to serving. The noncompliance for F689 remained at a lower scope and severity after the immediacy was removed. NJAC 8:39-31.7 (h)

Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 20 of 22 residents (Resident #86, 14, 31, 34, 48, 54, 152, 22, 28, 49, 1, 4, 12, 56, 58, 16, 40, 61, 69, and #73) reviewed. Some of the residents had not had physician signed orders since December 2022. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents' primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition, there were no electronic signatures under the physician's orders in the electronic medical record for the following residents: 1. Resident #86's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for October 2023 and November 2023. 34033 2. Resident #14's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from May 2022 to November 2023. 3. Resident # 31's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from May 2022 to November 2023. 4. Resident #34's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from September 2023 to November 2023. 5. Resident #48's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from October 2022 to November 2023. 6. Resident #54's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from May 2022 to November 2023. 7. Resident #152's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023. 49078 8. Resident #22's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from October 2023 to November of 2023. 9. Resident #28's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 10. Resident #49's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from September 2023 to November of 2023. 46889 11. Resident #1's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 12. Resident #4's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 13. Resident #12's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 14. Resident #56's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 15. Resident #58's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 34421 16. The surveyor reviewed Resident #16's hybrid medical records, which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from June 2023 to November of 2023. 17. The surveyor reviewed Resident #40's hybrid medical records, which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 18. The surveyor reviewed Resident #61's hybrid medical records,, which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from February 2023 to November of 2023. 19. The surveyor reviewed Resident #69's hybrid medical records, which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. 20. The surveyor reviewed Resident #73's hybrid medical records, which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders from January 2023 to November of 2023. On 12/6/23 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the physician's should have been signing monthly for each of the resident's orders in the Electronic Health Record (EHR). The DON stated that the facility did not realize that the monthly orders had not been signed as there was no access in their EHR for the physician to do so. The monthly orders had not been printed into a paper format since December of 2022. The physician's were expected to sign their monthly orders electronically starting in January 2023, which did not occur. The surveyor reviewed the Physician Services policy and procedure dated 9/2023, which revealed review of orders are provided during monthly physician's visits and documentation in Physicians noted and update and needed. NJAC 8:39-35.2,7

Based on observation, interview, and record review, it was determined that the facility failed to follow Professional Standards of Practice by failing to assess a weight change for 2 of 3 residents reviewed for nutritional status which did not contribute to harm, Resident #73 and #58. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 11/29/23 at 11:11 AM, the surveyor interviewed Resident #73, who stated that he/she had not lost weight and that he/she looks the same. The resident stated that he/she had no issues with appetite and is happy with his/her weight. On 12/1/23 at 12:25 PM, the surveyor observed Resident #73 who was eating lunch, the resident received a diet consisting of regular chopped texture and thin liquids as ordered by the Physician. The resident consumed about 50-75% of the meal. A review of the Admission Record revealed that Resident #73 had diagnoses which included but were not limited to cholecystitis, hyperlipidemia and gastro-esophageal reflux disease (GERD). A review of the resident's Order Summary Report (OSR) revealed a current order for monthly weights to be obtained with a start date of 3/7/23. A review of Resident #73's weights revealed that on 6/7/23, the resident weighed 180 pounds (lbs) and on 7/7/23, the resident weighed 148 lbs, which indicated a significant weight loss of 17.7% weight loss in one month. There was no monthly weight recorded for the month of August 2023. The resident's current weight was recorded at 150.4 lbs on 11/2/23 and 154.2 lbs on 12/7/23. The Registered Dietitian (RD) had documented nutritional assessments/progress notes on the dates of 6/30/23, 9/13/23, 9/28/23, 10/16/23 and 11/16/23. The RD did not have a documented nutrition assessment or progress note written after the resident had lost weight in the month of July 2023. Review of the Medical Professional Note (MPN) dated 9/6/23, revealed Assessment: Patient reported with 10% weight loss since June. Patient noted with fair/good appetite consuming about 50-75% of meals. Although weight loss was not planned, it is stabilized and still within an ideal BMI weight at 23.2. A MPN dated 10/3/23, revealed Assessment: Patient reported with 10% weight. Patient noted with fair/good appetite consuming about 50% of meals. Although weight loss was not planned, it is stabilized and still within an ideal BMI weight at 23. A MPN dated 11/3/23, revealed Assessment: Patient reported with a 10% weight loss. Patient noted with fair/good appetite and consumption of meals varies. Although weight loss was not planned, it is stabilized and still within an ideal BMI weight of 23.9. A MPN dated 7/14/23, revealed Vitals: Reviewed. Weight/BMI reviewed. A review of the comprehensive Minimum Data Set, an assessment tool used to facilitate care management dated 9/30/23, revealed a Brief Interview for Mental Status score of 6, which indicated moderately impaired cognition. The resident was able to answer all questions asked by the surveyor. On 12/5/23 at 12:39 PM, the surveyor observed Resident #73 who was eating lunch, the resident received a diet consisting of regular chopped texture and thin liquids as ordered by the Physician, The resident consumed about 50-75% of the meal. On 12/5/23 at 1:15 PM, the surveyor interviewed the RD who stated that she was aware of Resident #73's documented weight loss which occurred between the months of June 2023 and July 2023. The RD stated that the resident had an order for monthly weights and they should be done every month. The CNA weighs the resident and then she will document the weights in the Electronic Health Record (EHR). The RD stated that she did not document about the weight loss occurrence which happened in July as she was waiting for a reweigh to be done. The RD stated that she asked the nursing staff multiple times to do the re-weight but did not document about the situation since she was not sure if the weight loss was accurate. The RD also stated that the resident's appearance did not change around that time of the weight discrepancy, and she has not had to buy any news clothes. The RD stated that she interviewed the resident, who did not indicate lost weight or changes in appetite or food intake either. The RD stated that the scales are calibrated on occasion and brought the surveyor calibration information from the month of June 2023. She stated that maybe the calibration in June fixed a problem with the scale. The RD did not document this interview with the resident either. The RD stated that the reweigh should be done by 10th of the month and that she should have continued to follow up on the need for the re-weigh in July 2023. The RD also stated that she did not realize that the weight was not recorded in August 2023 as well. The RD stated that the resident is actually at a desirable weight at this time and that the resident is happy with his/her weight. The RD stated that she also did add a supplement when the weight loss was noticed in September 2023 to ensure no further weight loss would occur. On 12/8/23 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who cared for Resident #73. The CNA stated that she weighed the residents each month If there was a weight discrepancy then the weight would be re-taken, the weights were recorded on a piece of paper and the RD checked those weights and would ask for re-weights as needed. The CNA stated that the RD also imported the weights into the EHR each month. The CNA could not remember if a re-weight was requested for Resident #73 during the time of the weight discrepancy. The CNA stated that Resident #73 had a good appetite and ate about 50-75% of most meals. She did not appear to have any weight loss or gain. The CNA stated that the resident was weighed yesterday and was also weighed a few days before as well. On 12/8/23 at 10:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that Resident #73 has not had an appearance of weight loss She stated the resident ate approximately 50-75% at most meals and was prescribed a nutritional supplement as well. The LPN stated that Resident #73's family was here often and did not report a change in the resident's appearance which would indicate weight loss either. The LPN stated that the scale may have been calibrated which could cause a discrepancy, but did not recall any other residents having weight loss around that time. The LPN stated that the CNAs weigh the resident and it gets recorded into the EHR by the RD. The LPN stated that there was no skin breakdown or physical harm to the resident, the resident's clothing is still tight on the resident and no other clothes have been purchased which would have indicated weight change. On 12/8/23 at 11:10 AM, the surveyor conducted a phone call to Resident #73's representative/family member, who stated that he comes to visit his family member almost every day since admission and there has not been any weight loss or gain. He stated that he resident has not had any new clothing purchased and the resident has not needed any new clothes which would indicate a weight change. He stated that the resident has always eaten about 50 to 75% of the meal and had no concerns about the food provided here. He also stated that the resident had no skin breakdown and no health issues that would suggest a weight loss or gain. He stated that the resident is happy with the current weight and care here. 46889 2. On 12/8/23 at 11:00 AM, the surveyor observed Resident #58 lying in bed asleep inside the room. A review of the admission record for Resident #58 reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hyperlipidemia (increased cholesterol level in the blood). The resident's most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 9/8/23, reflected that Resident #58 had a Brief Interview for Mental Status (BIMS) score of 7out of 15, which indicated that the resident had severe cognitive impairment. A review of the November 2023 OSR did not show an order for monthly weights. A review of Resident #58's weight revealed that on 11/29/22, the resident's admission weight was 152 lbs. on 12/1/22, the resident weighed 158 lbs. Resident #58's weight on 12/29/22 was 126 lbs., which indicated a significant weight loss of 17.11% in one month in 2022. No weight was documented in June and August 2023. The resident did not lose any further weight, with a registered weight of 135 lbs. on 11/15/23. The Nutrition and Dietary Note dated 1/24/23 indicated there was 17.2% significant unplanned weight loss for one month. The care plan initiated on 12/3/22 revealed that [resident name] is at risk for malnutrition r/t low BMI, variable PO intake. H/o sig unplanned wt. loss. On 12/8/23 at 11:10 AM, the surveyor interviewed the CNA who worked with the resident, who stated the monthly weight was done every first week of the month, and the re-weigh should be done within a week. On 12/8/23 at 11:13 AM, the surveyor interviewed the LPN on the unit, who stated he would document the weight that the CNA reported to him. On 12/8/23 at 11:52 AM, the surveyor interviewed the RD, who works in the facility 2-3 days per week. She stated that Resident #58's admission weights of 152 lbs. and 158 lbs. on 12/1/22 were inaccurate. However, she did not address the cause of the weight discrepancy. On 12/08/23 at 01:45 PM, the surveyor interviewed the Director of Nursing (DON) regarding the order for weights in POs and the weight discrepancy. The DON stated that the weight should be done monthly. The DON provided no further information. On 12/6/23 at 2:09 PM, the surveyor discussed the above concerns with the DON and the Administrator. The facility's Policy and Procedure titled Weights, with a revised date of 9/20/23, revealed under the procedure, If there is a discrepancy of plus or minus 5 pounds, the resident will be reweighed with the nurse supervising. The nurse will document the reweigh and the date. When a weight change of 5 pounds plus or minus occurs, the physician will be notified, and a dietary alert sheet filled out for notification of the dietitian. NJAC 8:39-27.2(a)

Based on observation, interview and record review of documentation provided by the facility, it was determined that the facility failed to ensure resident safety and supervision for a resident identified as a high risk for falls. The resident fell and sustained a left [MEDICAL CONDITION] requiring hospitalization and repair. The deficient practice was identified for 1 of 3 residents, Resident #12, reviewed for falls and was evdenced by the following: On 10/6/18 at 10:30 AM, the surveyor observed Resident #12 in bed watching television with the bed was in a low position and close to the floor. On 10/6/18 at 1:00 PM the surveyor interviewed Resident #12 regarding the fall. Resident #12 stated during morning care they fell out of bed and injured his/her hip. The resident added they went to the hospital and had a [MEDICAL CONDITION]. The surveyor reviewed the resident's medical record. According to the admission sheet Resident #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #12's Quarterly Minimum Data Set (MDS), an asssessment tool dated 7/15/18, indicated the resident had moderate cognitive impairment, could usually be understood and was able to understand clearly. The resident required total dependence of two staff for bed mobility and transfers. A review of Resident #12's Fall Risk assessment dated [DATE], indicated the resident had a total score of 15, which indicated a score of 10 or above was a high risk for falls. The surveyor reviewed the Notes Report under nursing daily notes dated 8/7/18 which revealed the CNA (Certified Nursing Assistant) reported that Resident #12 was found sitting on the floor next to their bed, awake, alert, and verbally responsive, and complained of left hip pain. The nurse indicated in the note that the resident stated they fell off the bed. The resident was transferred back to bed using a hoyer lift, the physician was called and an order for [REDACTED]. A review of the Incident/Accident Report dated 8/7/18 inicated the CNA was in the process of doing morning care for Resident #12 when she left the resident lying in bed on their left side. The CNA stated that she went to the bathroom to get water and when she returned she found Resident #12 sitting on the floor. The License Practical Nurse (LPN) indicated in the report that when he was called into the resident's room he found the resident's bed in the highest position and the resident was sitting on the floor facing the wall and was awake and alert complaining of left hip pain. The surveyor reviewed the Fall Incident Investigation dated 8/13/18 which was the final summary of the investigation conducted by the facility. The facility conclusion indicated that the [MEDICAL CONDITION] was the result of the CNA raising the resident's bed to the highest position, placing the resident on their side and positioned the resident too close to the edge of the bed, and left the resident unsupervised when the fall occurred. The Director of Nursing (DON) conducted an interview with the CNA who stated that the fall was caused by having Resident #12 turned and positioned too close to the edge of the bed with the bed up high. The surveyor reviewed the resident's care plan dated 1/3/18 which indicated under the focus/problem area; potential for falls related to Anti-Hypertensive medications, Impaired Cognition, Weakness and Impaired Mobility, and [MEDICAL CONDITION] Diagnosis. The intervention included to maintain the bed in the lowest position, skid socks, observe and address changes with cognition, and have items within reach at bedside. On 10/10/18 at 12:30 PM, the surveyor attempted to interview the CNA that was involved in the incident but was notified that she was no longer at the facility. On 10/12/18 at 9:15 AM, the surveyor interviewed the DON. The DON stated that after Resident #12's fall that resulted in a left [MEDICAL CONDITION], the facility conducted an investigation. The investigation determined that the CNA involved in the incident was responsible for the resident's fall and subsequent fracture to the left hip. NJAC 8:39-27.1

Based on interview and closed record review, it was determined that the facility failed to protect cognitively impaired residents from physical and mental abuse by another resident. The resident exhibited multiple episodes of verbal and physically aggressive behavior toward residents and staff before becoming physically threatening and abusive toward his/her room mates. The facility was aware of the resident's behavior escalating and threats made to other residents, yet did not develop interventions to manage the behavior and abuse. The facility also failed to investigate the incidents and report them to the state agency. During an altercation with the first room mate, (Resident # 24) Resident #22 pushed him/her to the floor. A new room mate (Resident #25) was placed in the room and the next day Resident #22 threatened to hit him/her with a towel because he/she was moaning. Two days later, Resident #22 was observed standing over the room mate with a pillow over his/her face and the resident was hitting the room mate's legs with a blanket. Staff intervened and Resident #22 was heard screaming that he/she wanted to kill the room mate. Three months later, Resident #22 punched another resident in the face. This deficient practice constituted an Immediate Jeopardy situation due to the abusive behavior of Resident #22 that was directed toward both room mates, Residents #24 and #25, as well as the other residents who resided on the unit and were subject to Resident #22's unpredictable behavior and facility failure to address. This deficient practice was identified for 3 of 5 residents reviewed for abuse/mistreatment, Resident #22, #24, and #25. The Immediate Jeopardy was identified on [DATE] at 1:30 p.m. An acceptable plan of correction was submitted by the facility at 2:30 p.m. identifying that the jeopardy situation was corrected on that date, based upon actions taken by the facility. These actions included, but were not limited to: 1. Resident #22 expired on [DATE]. The facility's nursing administration reviewed the medical records of residents with behaviors who participated in activities or who shared a room with other residents, to determine if residents were subject to abuse. 2. Education and in-service training of all staff regarding the proper reporting and investigation of any incidents that occur between residents. 3. The facility's Director of Nursing and Assistant Director of Nursing shall, weekly for three months, review the medical records of residents with behavior [DIAGNOSES REDACTED]. The following evidenced the deficient practice: On [DATE] at 11:30 a.m., the surveyor reviewed the closed record of Resident #22 which revealed that the resident had [DIAGNOSES REDACTED]. The resident resided in the facility since 2010. Further review of the electronic progress notes from ,[DATE] to [DATE] revealed the following: On [DATE] at 11:04, the resident was yelling and screaming at other residents. On [DATE] 10:40 p.m., the resident was yelling and screaming at residents and staff. On [DATE] at 10:57 p.m., the resident was combative, tried to hit staff and other residents with shoes. On [DATE] at 12:35 p.m., Resident #22 pushed the roommate (Resident #24) out of the bathroom because "She needs to use it." The roommate sustained a fall without injury. On [DATE] 9:00 p.m., the resident was screaming at his/her new roommate (Resident #25), threatening the roommate that she was noisy, and she was unable to sleep. On [DATE] 10:23 p.m., the resident threatened to hit the roommate with a towel. On [DATE] at 9:00 p.m., the resident was verbally and physically aggressive toward the roommate. Staff saw her (referring to Resident #22) putting a pillow on the roommate's face and hitting his/her legs with a blanket. On [DATE] at 2:30 p.m., Resident #22 was coming out of the bathroom and found another resident in his/her bed. Resident #22 screamed, went after the resident and hit he/her in the face with her fist. On [DATE] at 11:04 a.m., the resident was noted yelling at staff and other residents inside the main dining room, prior to dinner. On [DATE] at 12:15 p.m., the surveyor requested the investigative reports for the above incidents. The Director of Nursing (DON) told the surveyor there were no investigative reports for the above mentioned incidents. The DON further stated, "When we know what happened, we do not investigate." There were no statements from staff or other residents to indicate what had happened and no evidence of remedial action to manage the behavior. There was no documented evidence to indicate that the Interdisciplinary Team identified interventions to prevent Resident #22 from abusing other residents. During an interview with the Social Worker (SW) on [DATE] at 12:15 p.m., the SW revealed that he/she was aware of the behavior and he/she discussed the behavior with the resident and the resident's family. The SW could not provide any documentation or actions taken to indicate that she had intervened or what steps were taken to address the behaviors. A review of the facility's policy for abuse submitted by the facility on [DATE] at 11:00 a.m., revealed the following: "It is the policy of the facility to prohibit the mistreatment, neglect, and abuse of residents by staff, family members or other residents. Each resident has the right to freedom from mental, verbal, sexual, or physical abuse or neglect, including corporal punishment or involuntary seclusion. Any abuse will be reported and thoroughly investigated. Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. " Under the title " Resident to Resident Abuse " the policy indicated "All incidents or inappropriate behavior or actions of abuse between residents should be reported by all employees to either their immediate supervisor or the Nursing Home Administrator." Under" Documentation" the following was noted " The medical record will reflect notification of suspected abuse or neglect to both the Department of Health and the Office of the Ombudsman for the Institutionalized Elderly, as appropriate. " On [DATE] at 12:30 p.m., the Administrator and DON confirmed to the team that the above incidents were not investigated or reported to the State Agency. The Immediate Jeopardy was identified on [DATE] at 1:30 p.m. Facility administration was notified and a Plan of Correction was submitted to the survey team and accepted on [DATE] at 2:30 p.m., which indicated that the jeopardy was corrected at that time, based on actions by the facility which included the following: 1. Resident #22 expired [DATE]. 2. Residents with behavior [DIAGNOSES REDACTED]. The facility's nursing administration shall review the medical records of these residents to ascertain if these residents were subject to any resident to resident abuse. Corrective action plans shall be developed immediately for any resident who is affected by the deficient practice. 3. All staff shall receive in-service training regarding the proper reporting and investigation of any incidents that occur between residents. The in-service will address the identification of incidents; the proper reporting of incidents to appropriate staff members; NJ Department of Health Reportable Events; the investigation process of incidents and formation of conclusions. The in-services shall be presented by the administrator and shall commence with the ,[DATE] shift [DATE]. 4. The facility's Director of Nursing and Assistant Director of Nursing shall, weekly for three months, review the medical records of residents with behavior [DIAGNOSES REDACTED]. Findings shall be reported to the Administrator, who shall take immediate corrective action. An investigation will be initiated immediately for any findings, and appropriate actions shall be taken to the failure of reporting. Upon the completion of the three months, the review of the reporting process shall be part of the facility's continuing quality assurance program. The continuing reviews will be conducted on a quarterly basis and shall be the responsibility of the administrator. On [DATE] at 11:00 a.m., the survey team reviewed documentation submitted by the administrator which revealed that all staff had been inserviced regarding the investigation and reporting of abuse. Interviews with random staff members on the units at that time revealed that staff had attended the in-services. NJAC 8:,[DATE].1 (a) 5

Part A. Based on interview and record review, it was determined that the facility failed to investigate abuse/mistreatment between residents and failed to report the allegations to the state agency. This deficient practice constituted an Immediate Jeopardy situation for Residents #24 and #25, who were victims of abuse/mistreatment by Resident #22, as well as for any residents in the facility who were subject to abuse/mistreatment. This deficient practice was identified for 3 of 5 residents reviewed for investigation of abuse/mistreatment, Resident #22, #24, and #25. The Immediate Jeopardy was identified on [DATE] at 1:30 p.m. An acceptable plan of correction was submitted by the facility on [DATE] at 2:30 p.m., which identified that the jeopardy situation was corrected on that date based upon actions taken by the facility. These actions included but were not limited to a.) inservice education of all staff on the proper reporting to appropriate agencies and b.) investigation of all incidents that occur between residents. The In-services began on [DATE] on all shifts, and continued through [DATE]. The following evidenced the deficient practice: 1. On [DATE] at 10:30 a.m., the surveyor reviewed the closed record of Resident #22 which revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Verbal behavioral symptoms directed toward others were documented in the medical record as having occurred periodically. According to the MDS, the resident was an independent ambulator who moved freely throughout the facility. A review of the electronic progress notes from ,[DATE] to [DATE] revealed the resident was involved in several altercations with other residents, as revealed by the following incidents: On [DATE] at 11:04 a.m., Resident #22 was yelling and screaming at other residents. On [DATE] 10:40 p.m., the resident was yelling and screaming at residents and staff. On [DATE] at 10:57 p.m., the resident was combative, and tried to hit staff and other residents with shoes. On [DATE], Resident #22 pushed his/her roommate (Resident #24) out of the bathroom. The roommate sustained a fall. On [DATE] 9:00 p.m., Resident #22 was screaming at his/her new roommate, (Resident #25) threatening the roommate that he/ she is noisy, and he/she is unable to sleep. On [DATE] 10:23 p.m., the resident threatened to hit his/her roommate with a towel. On [DATE] at 9:00 p.m.,Resident #22 was verbally and physically aggressive toward the roommate. Staff saw him/her (referring to Resident #22) putting a pillow on the roommate's face and hitting his/her legs with a blanket. On [DATE] at 2:30 p.m., Resident #22 was coming out of the bathroom found another resident in his/her bed. Resident #22 screamed, went after the resident and hit he/her in the face with her fist. On [DATE] at 11:04 a.m., the resident was noted yelling at staff and other residents inside the main dining room prior to dinner. That same day at 12:30 p.m., the surveyor interviewed the DON who revealed that the above incidents were not investigated or reported to the State Agency. The DON further stated, "We do not investigate if we know what happened." Review of facility policy at that time titled "Incident/Accident Policy &Procedure" revealed under "Procedure:" 1. An incident/ accident sheet is initiated when an incident / accident occurs. 2. The physicians, family and unit managers are notified. 3. The incident/ accident are investigated using the "IA" Investigation Form. On [DATE] at 11:30 a.m., the Administrator and the Director of Nursing confirmed to the surveyor that the above incidents were not investigated or reported to the State Agency. Further review of the facility Policy and Procedure / Resident Abuse and Neglect Reporting and Investigating at that time revealed under "Reporting" that the facility was to report all alleged violations and all substantiated incidents to the N.J.S.D.O.H. and to the office of the Ombudsman. There was documented evidence these policies were not consistently followed. The Immediate Jeopardy was identified on [DATE] at 1:30 p.m. Facility administration was notified and a Plan of Correction was submitted to the survey team and accepted on [DATE] at 2:30 p.m., which indicated that the jeopardy was corrected at that time, based on actions by the facility which included the following: 1. Resident #22 expired [DATE]. 2. Residents with behavior [DIAGNOSES REDACTED]. The facility's nursing administration shall review the medical records of these residents to ascertain if these residents were subject to any resident to resident abuse. Corrective action plans shall be developed immediately for any resident who is affected by the deficient practice. 3. All staff shall receive in-service training regarding the proper reporting and investigation of any incidents that occur between residents. The in-service will address the identification of incidents; the proper reporting of incidents to appropriate staff members; NJ Department of Health Reportable Events; the investigation process of incidents and formation of conclusions. The in-services shall be presented by the administrator and shall commence with the ,[DATE] shift [DATE]. 4. The facility's Director of Nursing and Assistant Director of Nursing shall, weekly for three months, review the medical records of residents with behavior [DIAGNOSES REDACTED]. Findings shall be reported to the Administrator, who shall take immediate corrective action. An investigation will be initiated immediately for any findings, and appropriate actions shall be taken to the failure of reporting. Upon the completion of the three months, the review of the reporting process shall be part of the facility's continuing quality assurance program. The continuing reviews will be conducted on a quarterly basis and shall be the responsibility of the administrator. On [DATE] at 11:00 a.m., the survey team reviewed documentation submitted by the administrator which revealed that all staff had been inserviced regarding the investigation and reporting of abuse. Interviews with random staff members on the units at that time revealed that staff had attended the in-services. F226 remains a deficiency at a scope and severity of D, based on the evidence in part B as followes: Part B. Based on interview and record review, it was determined that the facility failed to a.) investigate incidents of resident to resident abuse/mistreatment, and b.) report incidents to the state agency. This deficient practice was identified for 1 of 5 residents reviewed for abuse, Resident #8, as evidenced by the following: On [DATE] at 1:00 p.m., the surveyor reviewed the medical record of Resident #8, which revealed that the resident was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of the progress notes for Resident #8 revealed the following documentation by nursing on [DATE] at 10:01 p.m.: At 8:15 pm while cleaning the hallway housekeeping staff observed resident standing by her roommate (sic) bed removing peg tube. On [DATE] at 9:30 a.m., the Director of Nurses' (DON) told the surveyor that she did not initiate an investigation because it was a "witnessed incident." The DON also stated that the incident was not reported to the state agency. Review of the Policy and Procedure for Resident Abuse and Neglect Reporting and Investigation, which was provided by the facility on [DATE], revealed the following: a. Any abuse will be reported and thoroughly investigated... Our facility will not permit residents to be subjected to abuse by anyone... b. All reports of abuse must be reported to the Administrator... within 24 hours...An immediate investigation must be conducted by the Social Services Director and D.O.N./Designee and the findings of such investigation must be reported to the Administrator upon completion. c. Should the investigation reveal that suspected abuse or actual abuse occurred, the Social Services Director must report such findings to the resident's representative (sponsor) as required by current state and federal laws, such as local Police Department, Ombudsman and the State License agency. There is no documented evidence this policy was consistently followed. NJAC 8:,[DATE].1 (a) 5 2. On [DATE] at 1:00 p.m., the surveyor reviewed the medical record of Resident #8 which revealed that the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Further review of the progress notes for Resident #8 revealed the following documentation by nursing on [DATE] at 10:01 p.m.: "8:15 pm while cleaning the hallway housekeeping staff observed resident standing by her roommate (sic) bed removing peg tube." On [DATE] at 9:30 a.m., the surveyor asked the Director of Nursing (DON) if an investigation had been initiated for the incident of [DATE]. The DON replied that they did not write a report because it was a "witnessed incident." When asked if the incident of pulling out another resident's peg tube was reported to the state agency, the DON stated that it was not reported. Review of the Policy and Procedure for Resident Abuse and Neglect Reporting and Investigation, which was provided by the facility, revealed the following: a. "Abuse" includes the deprivation of goods or services that are necessary to attain or maintain physical well-being. "Any abuse will be reported and thoroughly investigated... Our facility will not permit residents to be subjected to abuse by anyone..." b. "All reports of abuse must be reported to the Administrator... within 24 hours...An immediate investigation must be conducted by the Social Services Director and D.O.N./Designee and the findings of such investigation must be reported to the Administrator upon completion." c. "Should the investigation reveal that suspected abuse or actual abuse occurred, the Social Services Director must report such findings to the resident's representative (sponsor) as required by current state and federal laws, such as local Police Department, Ombudsman and the State License agency. The report must include, but is not limited to: 1) The name of the resident involved. 2) The date and time the incident occurred. 3) The circumstances surrounding the incident. 4) Where the incident took place. 5) The name of any witnesses." There was no evidence this policy was consistently followed. NJAC 8:,[DATE].1 (a) 5

Part A. Based on medical record review and interview, it was determined that the facility failed to develop care plan interventions for a resident who exhibited aggressive behavior toward other residents, that included verbal and physical intimidation. Care plan interventions were not developed as the resident's behavior continued to escalate. The care plan lacked specific interventions for increased supervision, and triggers were not identified to assist the Interdisciplinary Team (IDC) with a plan that could manage the resident's maladaptive behavior and protect other residents in the facility. This deficient practice was identified for 1 of 5 residents reviewed for behavioral symptoms and care plan interventions, Resident #22, who displayed multiple instances of aggressive behavior. Failure to identify and develop interventions to manage the behavior of Resident #22 resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was identified on [DATE] at 1:30 p.m., during the survey. The facility submitted a plan of correction which was accepted by the team on [DATE] at 2:30 p.m. The Plan of Correction included the following: 1. Residents with behavior [DIAGNOSES REDACTED]. 2. The facility's nursing administration shall review the medical records of these residents to ascertain if these residents were subject to any resident to resident abuse. Corrective action plans shall be developed immediately for any resident who is affected by the deficient practice. The following evidenced the deficient practice: The surveyor reviewed the closed medical record of Resident #22 on [DATE] at 11:30 a.m. Review of the medical record revealed that the resident had [DIAGNOSES REDACTED]. According to the Family Meeting Notes dated from ,[DATE] to [DATE] the resident had exhibited aggressive behaviors toward other residents and staff. The resident had engaged in verbal and physical altercations with staff and other residents that were difficult to redirect. Review of an annual MDS dated [DATE] and a Quarterly MDS dated [DATE], revealed that the resident was coded as having behavior symptoms directed toward others. A review of the care plan for Resident #22 revealed that the resident's abusive and territorial behavior was not addressed. Further review of Family Meeting Notes dated [DATE] revealed the following: "the resident's cognitive and physical function have remained stable, no significant changes have been noted ... In February 18, 2013 Resident #22 was sent to crisis for evaluation " There was no documented evidence that the facility identified the behavior and developed interventions to prevent the resident from abusing other residents. Further review of the electronic progress notes on [DATE] at 11:30 a.m., revealed the following behaviors: On [DATE] at 11:04 a.m., the resident was yelling and screaming at other residents. On [DATE] 10:40 p.m., the resident was yelling and screaming at residents and staff. On [DATE] at 10:57 p.m., the resident was combative, and tried to hit staff and other residents with shoes. On [DATE], Resident #22 pushed the roommate out of the bathroom. The roommate sustained a fall. On [DATE] at 9:00 p.m., the resident was screaming at his/her roommate, threatening the roommate that she is noisy, and she is unable to sleep. On [DATE] at 10:23 p.m., the resident threatened to hit his/her roommate with a towel. On [DATE] at 9:00 p.m., the resident was verbally and physically aggressive toward the roommate. Staff saw her (referring to Resident #22) putting a pillow on the roommate's face and hitting his/her legs with a blanket. On [DATE] at 2:30 p.m., Resident #22 was coming out of the bathroom and found another resident in his/her bed. Resident #22 screamed, went after the resident and punched the resident in the face with his/her fist. On [DATE] at 11:04 a.m., the resident was noted yelling at staff and other residents inside the main dining room, prior to dinner. Review of the care plan for behavior initiated on [DATE], revealed the following goal: (Resident #22) "will not have further episodes of aggressive and threatening behavior toward other residents x 90 days." There was no documented evidence of specific interventions to address the resident's abusive and territorial behavior. The immediate jeopardy was identified on [DATE] at 11:30 a.m. due to the facility's failure to address Resident #22's abusive and territorial behavior. An acceptable plan of correction was received on [DATE] at 2:30 p.m., which included the following actions: 1. Resident #22 expired [DATE]. 2. Residents with behavior [DIAGNOSES REDACTED]. The facility's nursing administration shall review the medical records of these residents to ascertain if these residents were subject to any resident to resident abuse. Corrective action plans shall be developed immediately for any resident who is affected by the deficient practice. 3. All staff shall receive in-service training regarding the proper reporting and investigation of any incidents that occur between residents. The in-service will address the identification of incidents; the proper reporting of incidents to appropriate staff members; NJ Department of Health Reportable Events; the investigation process of incidents and formation of conclusions. The in-services shall be presented by the administrator and shall commence with the ,[DATE] shift [DATE]. 4. The facility's Director of Nursing and Assistant Director of Nursing shall, weekly for three months, review the medical records of residents with behavior [DIAGNOSES REDACTED]. Findings shall be reported to the Administrator, who shall take immediate corrective action. An investigation will be initiated immediately for any findings, and appropriate actions shall be taken to the failure of reporting. Upon the completion of the three months, the review of the reporting process shall be part of the facility's continuing quality assurance program. The continuing reviews will be conducted on a quarterly basis and shall be the responsibility of the administrator. On [DATE] at 11:00 a.m., the survey team reviewed documentation submitted by the administrator which revealed that all staff had been inserviced regarding the investigation and reporting of abuse. Interviews with random staff members on the units at that time revealed that staff had attended the in-services. F279 remains a deficiency at a scope and severity of "D" based on the following example under Part B: Part B. Based on observation, interview and record review, it was determined that the facility failed to develop a plan of care based on individual assessment for a resident who exhibited aggressive behavior toward other residents. This deficient practice was identified for 1 of 5 residents reviewed for maladaptive behavior, Resident # 8, as evidenced by the following: On [DATE] at 11:00 a.m., the surveyor reviewed the medical record of Resident #8, which revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the care plan, Resident #8 had "episodes of temper tantrums by (sic) evidenced of refusing care, refused at times to eat, shouting/yelling and banging (his/her) hands on the table and banging the door." There were no other maladaptive behaviors noted on the care plan. The surveyor observed Resident #8 on ,[DATE], ,[DATE], ,[DATE] and [DATE] during lunch and activities. On all of these occasions, Resident #8 was calm and smiling and did not display any of the behaviors that were identified on the care plan. On [DATE] at 1:00 p.m., the surveyor reviewed the daily nursing progress notes for Resident #8, which revealed the following, on [DATE] at 10:01 p.m.: " At 8:15 pm while cleaning the hallway housekeeping staff observed resident standing by her roommate (sic) bed removing peg tube and she called the nurse." On [DATE] at 9:38 a.m, the surveyor also reviewed the progress notes for the roommate of Resident #8, who was Resident # 6 on the list of residents sampled during the survey. According to the nurses' note dated [DATE] at 10:34 p.m., Resident #8 was standing by the bed of Resident #6 "pulling the peg tube. Upon assessment moderate amount of blood noted from the stoma, peg tube lying by resident bed." The note also indicated that the nurse successfully reinserted the peg tube. On [DATE] at 1:30 p.m., the Director of Nursing (DON) told the surveyor that the resident's roommate was moved immediately after the incident. She further stated that it was a one time incident that had not recurred. On [DATE] at 9:50 a.m., the DON told the surveyor that she realized that they had not added the resident's behavior of pulling out the peg tube to the Resident's care plan. The DON stated at that time "We should have." NJAC 8:,[DATE].2 (e) 2. F-279 remains a deficiency at a scope and severity of "D" based on the following example: Based on observation, interview and medical record review, it was determined that the facility failed to develop a plan of care based on individual assessment for a resident who exhibited behaviors which could potentially harm other residents. This deficient practice was identified for 1 of 23 residents reviewed for care plans, Resident # 8, as evidenced by the following: On [DATE] at 11:00 a.m., the surveyor reviewed the medical record of Resident #8, which revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the care plan, Resident #8 had "episodes of temper tantrums by (sic) evidenced of refusing care, refused at times to eat, shouting/yelling and banging (his/her) hands on the table and banging the door." There were no other maladaptive behaviors noted on the care plan. The surveyor observed Resident #8 on ,[DATE], ,[DATE], ,[DATE] and [DATE] during meals and activities. On all of these occasions, Resident #8 was calm and smiling and did not display any of the behaviors listed on the resident's care plan. On [DATE] at 1:00 p.m., the surveyor reviewed the daily nursing progress notes for Resident #8. The note from [DATE] at 10:01 p.m. contained the following statement, "8:15 pm while cleaning the hallway housekeeping staff observed resident standing by her roommate (sic) bed removing peg tube and she called the nurse." On [DATE] at 9:38 a.m, the surveyor also reviewed the progress notes for the roommate of Resident #8, who happened to be Resident # 6 on the list of residents sampled during this survey. According to the nursing note from [DATE] at 10:34 p.m., Resident #8 was standing by the bed of Resident #6, "pulling the peg tube. Upon assessment moderate amount of blood noted from the stoma, peg tube lying by resident bed." The note also indicated that the nurse successfully reinserted the peg tube. On [DATE] at 1:30 p.m., the Director of Nursing (DON) copied the care plan for Resident #8 for the surveyor and stated that the resident's roommate was moved immedately after the incident. She further stated that this was a one time incident that had never happened prior to [DATE] and had not recurred. On [DATE] at 9:50 a.m., the DON told the surveyor that she realized that they had not added the resident's behavior of pulling out the peg tube to the Resident's care plan. "We should have," she added. NJAC 8:,[DATE].2 (e) 2.