Every finding on record at Fountainview Care Center

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illness.The deficient practice was evidenced by the following: On 7/9/26 at 10:47 AM, during the kitchen tour with the Food Service Director (FSD), the surveyor observed a utility rack with stacked pans on each shelf, all turned upside down. The FSD identified this as the dried pot and pan storage rack. The surveyor observed seven pans stacked together on the third shelf from the top. The FSD identified these as 4-inch deep full-size pans. The FSD separated all seven pans, and the 1st, 2nd, 3rd, and 4th pans in the stack revealed a clear, thin liquid dripping onto the floor. The pans were visibly wet on the inside and outside surfaces. The FSD acknowledged the pans should not be stacked together while wet, and acknowledged they were improperly wet-nested (the practice of stacking or storing recently washed dishes or kitchenware while still wet, creating a moist environment that promotes bacterial growth). The FSD also acknowledged that the wetness could cause bacterial growth. The FSD stated that staff should have stored the pans on the drying rack until completely dry before placing them on the clean storage rack.On 7/14/26 at 12:11 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged that wet nesting should not occur because bacteria could grow, and stated that it was not allowed. The LNHA further stated staff should have ensured that all pans were dry on the drying rack before placing them on the clean storage rack.On 7/15/26 at 2:05 PM, the survey team met with the Regional Licensed Nursing Home Administrator (RLNHA), the LNHA, and the Director of Nursing (DON). The surveyor made facility administration aware of the above-mentioned concerns.A review of the facility-provided FSD Job Description, under Purpose of Your Job Position, revealed: The primary purpose of your job position is planning, organizing, implementing, and directing the overall operation of the Dietary Department in accordance with current Federal, State, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner.Under Safety and Sanitation: Ensure that all food storage rooms, preparation areas etc., are maintained in a clean, safe, and sanitary manner.A review of an undated and unlabeled facility kitchen policy, provided by the DON, revealed under 5. Equipment:a.) All food service equipment should be cleaned, sanitized, dried and reassembled after each use. N.J.A.C. 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) a system to ensure discrepancies of controlled substances were documented and rectified for four controlled substances, Ambien, Klonopin, Percocet, and Ultram and, b.) accurately account for and document the administration of a controlled medication, liquid morphine sulfate. This deficient practice was identified for 4 medications stored in the Automated Dispensing System (ADS) and on 1of 4 medication carts reviewed and was evidenced by the following: 1. On 7/9/26 at 11:30 AM, the surveyor requested a copy of the discrepancy report for the ADS from the Assistant Director of Nursing (ADON). The report was provided and included Ambien, Klonopin, Percocet, and Ultram; however, no dates of when the discrepancies occurred or resident names were included. On 7/14/26 at 12:31 PM, the surveyor interviewed the Director of Nursing (DON) regarding the discrepancy report. She explained that any discrepancies flag on the screen when someone went to use the ADS. She stated that the report she provided was printed by the vendor of the machine, adding that she was unable to print the reports herself. The surveyor requested a report that included the dates of the discrepancies. On 7/15/26 at 8:20 AM, the DON provided a discrepancy report that included dates, which reflected the following discrepancies: Ambien 5 mg: 5/6/26 (minus 1) Ambien 5 mg: 5/7/26 (minus 1) Klonopin 0.25 mg: 5/8/26 (minus 1) Klonopin 0.5 mg: 5/8/26 (minus 19) Percocet 5 mg/325 mg: 5/24/26 (plus 4) Percocet 5 mg/325 mg: 5/27/26 (minus 4) Ultram 50 mg: 5/25/26 (plus 10) Ultram 50 mg: 5/26/26 (minus 1) Ultram 50 mg: 5/27/26 (minus 11) Ultram 50 mg: 5/28/26 (minus 1) Ultram 50 mg: 5/31/26 (minus 1) On 7/15/26 at 9:10 AM, the surveyor interviewed the DON, who stated she spoke with the nurses and determined the discrepancies were due to a misunderstanding regarding how count numbers were entered into the machine. She stated the actual counts were correct, but the nurses misunderstood how to input the numbers, putting them in twice. She further stated that she provided individual education as each incident occurred and then conducted widespread education on 6/2/26. The surveyor requested the records of the individual education as well as the investigation for each discrepancy to rule out diversion. On 7/15/26 at 10:17 AM, the DON explained that if a discrepancy occurred, it flagged in red at the top of the screen displaying the quantity, which must be addressed before anyone could access the machine. She further stated that it could not be bypassed. She explained that she educated and questioned the nurses involved in the discrepancies and noted that the machine requires two nurses to sign out a controlled substance. She also stated she reviewed which resident each medication was dispensed for, as every medication was signed out for a specific resident. On 7/15/26 at 10:24 AM, the surveyor interviewed the DON and asked if a daily count was completed for controlled substances. She repeated that education was completed for each nurse involved and that she would provide it to the surveyor. She stated that two nurses were involved in each discrepancy, and that she reviewed the medication and resident involved. She stated the machine does not provide a printout of discrepancies, re-emphasizing that nurses were entering incorrect numbers: It's silliness that they're doing. They're doing it backwards. They are punching in numbers and not doing it accurately. On 7/15/26 at 10:59 AM, the surveyor called the representative for the ADS. He stated that the discrepancies for May were resolved and that he would send the report to the DON. On 7/15/26 at 11:22 AM, the DON provided a report (Resolved Discrepancies, C3) sent to her from the ADS representative, which included (Date range: 4/15/26 – 7/15/26): Ambien 5 mg (5/6/26, minus 1): Resolved 5/8/26; reason: general typo during prior transaction. Ambien 5 mg (5/7/26, minus 1): Resolved 5/8/26; reason: general typo during prior transaction. Klonopin 0.25 mg (5/8/26, minus 1): Resolved 5/8/26; reason: prior user removed less than requested. Klonopin 0.5 mg (5/8/26, minus 19): Resolved 5/8/26; reason: count back error; pulled and replaced wrong bin. Percocet 5 mg/325 mg (5/24/26, plus 4): Resolved 6/4/26; reason: count back error. Percocet 5 mg/325 mg (5/27/26, minus 4): Resolved 6/4/26; reason: count back error. Ultram 50 mg (5/25/26, plus 10): Resolved 6/4/26; reason: count back error. Ultram 50 mg (5/26/26, minus 1): Resolved 6/4/26; reason: count back error. Ultram 50 mg (5/27/26, minus 11): Resolved 6/4/26; reason: count back error. Ultram 50 mg (5/28/26, minus 1): Resolved 6/4/26; reason: count back error. Ultram 50 mg (5/31/26, minus 1): Resolved 6/4/26; reason: count back error. On 7/15/26 at 1:08 PM, the ADON provided a Transaction by Patient report from the ADS. On 7/15/26 at 2:04 PM, the survey team met with the DON, Licensed Nursing Home Administrator (LNHA), and Regional LNHA to inform them of the above concerns. The DON stated she would print everything out that evening, adding that the printing process was very tedious. On 7/16/26 at 9:19 AM, the Consultant Pharmacist (CP) met with the survey team and stated he was unaware of any controlled substance discrepancies. The team shared the discrepancy report with the CP, who reiterated that he had not been notified of any ADS discrepancies. On 7/16/26 at 9:59 AM, the facility provided an undated policy titled Controlled Substances, which included: Policy: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 12. The Director of Nursing Services (DNS) shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a written report of such findings On 7/16/26 at 10:06 AM, the survey team met with the DON, LNHA, and Regional LNHA. The DON stated that she went through the discrepancies one by one, that there was no diversion, and that staff were printing the records out piece by piece, adding, the paperwork of it is tedious. She stated that education was completed, that she reviewed the system daily, and that education was given individually. She again stated these were clerical errors. The surveyor reviewed Item #12 of the Controlled Substances policy and requested the DON's written findings for the discrepancies in question. On 7/16/26 at 11:19 AM, the survey team again requested documentation regarding the discrepancy investigations. On 7/16/26 at 11:32 AM, the DON provided investigations, which included: Ambien 5 mg (5/4/26): Ambien was pulled for a resident and the ADS froze; staff were unable to enter the amount found. Klonopin (4/28/26): 20 tablets of Klonopin 0.25 mg were delivered. 4/29/26: Klonopin 0.25 mg was inaccurately placed in the bin assigned to Klonopin 0.5 mg. 5/7/26: Staff attempted to pull Klonopin 0.25 mg for a resident, but the box was empty. Staff noted the 0.25 mg tablets were in the 0.5 mg box. 5/8/26: The DON and ADON placed the Klonopin 0.25 mg tablets into the correct box. Ultram (5/25/26): Staff attempted to withdraw 1 Ultram and inadvertently documented that they placed 10 Ultram tablets into the bin. Percocet: Documentation provided without a written conclusion. On 7/16/26 at 11:53 AM, the DON stated the investigations were completed yesterday and today (following the surveyor's inquiry). 2. On 7/15/26 at 9:56 AM, the surveyor and Licensed Practical Nurse (LPN) #1 conducted a medication storage audit on the two medication carts located on the [NAME] Unit. The Low Side medication cart was checked, and no concerns were noted. During the High Side medication cart audit, the surveyor observed that a bottle of Morphine Sulphate liquid appeared to have been opened, but no administration record for Unsampled Resident #14 was noted. LPN #1 removed the twist-off lid from the Morphine Sulphate, and there was no foil observed, which was normally present to seal the bottle. At that time, LPN #1 stated that when the medication came from the pharmacy, the box was closed and two nurses would sign, which indicated that they had received the medication from the pharmacy. She then stated that the medication would only be opened when it was time to administer the medication to a resident. When asked if new bottles were delivered with a seal under the cap, LPN #1 stated she thought so but was unsure, and that an example of a new bottle would be in their locked medication storage room. LPN #1 stated that she would need another nurse to access the example. LPN #1 reviewed with the surveyor Unsampled Resident #14's Individual Patient's Controlled Drug Record (a form nurses use to track how much medicine is received, given, and left over during each work shift, commonly referred to as a 'declining sheet') showing that the medication was never given to the resident for whom it was prescribed. On 7/15/26 at 10:25 AM, the surveyor, accompanied by LPN #1 and the Assistant Director of Nursing (ADON), entered the medication storage room. LPN #1 and the ADON removed a new bottle of Morphine Sulphate liquid from the medication storage machine and, after removing it from its box, opened the lid. The surveyor, LPN #1, and ADON observed that the bottle was sealed with a silver-colored foil underneath the lid. On 7/15/26 at 11:01 AM, LPN #2 was interviewed by the surveyor. LPN #2 stated that if the declining sheet was blank, the medication had not been given and should not be opened. LPN #2 further stated that two nurses checked and counted the controlled medications at the beginning and end of every shift against the declining sheet to make sure they agreed. If there was a discrepancy, it would be reported to the Unit Manager (UM). On 7/15/26 at 11:20 AM, the UM/LPN was interviewed by the surveyor. She stated that medication bottles should be labeled with the date they were opened to ensure they would be used before their expiration date. The UM/LPN and LPN #2 checked the bottle again in the presence of the surveyor; no date indicating when it had been opened was noted on the bottle or the box containing it. On 7/16/26 at 9:19 AM, the Consultant Pharmacist (CP) for the facility spoke to the survey team. The CP stated to surveyors that the manufacturer of the morphine sulfate places a foil seal to cover the medication under the cap, and that it would not be broken unless the medication had been opened to be administered. He stated that the nursing rights of medication administration were meant to negate accidental opening and administering of medications meant for other residents. The CP stated that pharmacy consultants would be informed of any suspicion of diversion, and that they had not been contacted. Policy: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: The Director of Nursing Services (DNS) shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the Administrator a written report of such finding N.J.A.C. 8:39-29.7(c)

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure contracted hospice staff utilized proper personal protective equipment (PPE: clothing or gear worn to protect both those providing and receiving care from potential harm) during care of a resident on enhanced barrier precautions (EBP: infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms). The deficient practice was identified for 1 of 1 resident (Resident #22) reviewed for infection control and was evidenced by the following:On 7/9/26 at 10:05 AM, the surveyor observed an EBP sign on the resident's door with the letter B written in black ink on it and a PPE bin outside of the room. The resident was observed in Bed B receiving care from an individual who was not wearing a gown.The electronic medical record was reviewed for Resident #22.A review of the admission Record, an admission summary, revealed diagnoses that included, but were not limited to: Alzheimer's disease (a progressive disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and right heart failure, unspecified (the right side of the heart cannot pump blood effectively to the lungs, causing blood to back up into the body's veins and leading to fluid accumulation).A review of the resident's most recent Minimum Data Set (MDS), an assessment tool dated 7/5/26, revealed the resident had a Brief Interview for Mental Status score of 2 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was dependent on staff for most self-care and mobility tasks, and the resident had an indwelling urinary catheter (a tube is inserted into the bladder to drain urine).A review of the Individual Comprehensive Care Plan (ICCP) revealed a focus area dated 7/6/26: Enhanced barrier precautions related to a suprapubic catheter, with interventions including: apply isolation equipment when providing direct care, maintain contact precautions during direct care, isolation cart outside of room, and place precaution signage at the resident's room entrance.A review of the Order Summary Report (OSR) revealed the following physician's orders (PO):A PO dated 7/6/26: Hospice.A PO dated 7/6/26: Enhanced barrier precautions every shift for infection related to suprapubic catheter.On 7/10/26 at 10:36 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated a hospice aide came daily for about an hour to wash, change, and support the resident. The LPN/UM also stated the resident was on EBP because of the suprapubic catheter, and the hospice aides were educated on EBP.On 7/14/26 at 9:32 AM, the surveyor interviewed a Certified Nursing Assistant (CNA), who stated she was not assigned to the resident that day and was not sure if there were precautions, but she could check the sign on the door. The CNA confirmed the resident was on EBP and that staff should gown and glove when giving care.On 7/14/26 at 10:12 AM, the surveyor conducted a telephone interview with the clinical director of the hospice provider, who stated the hospice aides were educated on EBP yearly and were notified by facility staff when a resident was on EBP. The clinical director stated that the expectation of hospice staff when caring for a resident on EBP was to maintain proper facility protocols, wear PPE, use proper hand hygiene, practice infection prevention, and notify the nurse of changes.On 7/15/26 at 9:34 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of EBP was to keep the resident safe with no spread of infection or harm to the patient. The DON confirmed that if a resident was on EBP, signage was posted on the door and everyone should follow the signage, not just in-house staff. The DON stated that if a hospice aide was not following EBP, it was the expectation of the entire building staff, not just nursing, to address it immediately.On 7/15/26, the above concerns were presented to the Licensed Nursing Home Administrator, the DON, and the Regional Administrator.A review of the facility-provided Isolation policy, updated 12/2/25, revealed:Policy Interpretation and Implementation . 2 . Enhanced Barrier Precautions-In addition to Standard Precautions, implement EBP during high-contact resident care activities: such as dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, for residents with indwelling devices . A. Examples of when EBP will be required: 4. Residents with a urinary catheter . C. Gown (1) . wear a gown (clean, nonsterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment.N.J.A.C. 8:39-27.1(a)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility Medical Director (MD) failed to attend mandatory quarterly Quality Assurance and Performance Improvement (QAPI) meetings for two out of five quarterly meetings. This deficient practice was evidenced by the following: On 07/09/26 at 10:05 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) during the Entrance Conference. The surveyor requested a copy of all quarterly QAPI sign-in sheets since the last survey, a list of QAPI Committee Members, and the QAPI policies and procedures.A review of the list of QAPI Committee Members revealed that the Medical Director was listed as a member.A review of the facility-provided QAPI sign-in sheets revealed the following:QAPI 2025 4th Quarter (dated 12/31/25): Did not include a signature for the Medical Director.QAPI 2026 2nd Quarter (dated 06/30/26): Did not include a signature for the Medical Director.On 07/16/26 at 11:00 AM, the surveyor interviewed the LNHA, who acknowledged that there was no Medical Director signature on either the 2025 4th quarter QAPI meeting sign-in sheet (dated 12/31/25) or the 2026 2nd quarter QAPI meeting sign-in sheet (dated 06/30/26). The LNHA was unable to provide evidence that the Medical Director attended either meeting, and acknowledged that the Medical Director was a key member of the QAPI committee.A review of the facility's undated QAPI policy, provided by the LNHA, revealed the following:Under the QAPI Committee members they included each Department Head, but Medical Director was not listed as a QAPI Committee member.N.J.A.C. 8:39-23.1, 2, 3

Based on observation, interview, record review and review facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy for 1 of 2 residents (Resident #5) reviewed for respiratory care. The deficient practice was evidenced by the following:On 7/9/26 at 10:40 AM, during the initial tour, the surveyor observed Resident #5 sitting in a wheelchair in their room. The surveyor observed an oxygen concentrator (a device that generates oxygen) located near the resident's bed, with a nasal cannula (tubing that delivers the oxygen from the concentrator to the nose) placed on the oxygen concentrator. The resident stated that they wear oxygen while in bed at night.The surveyor reviewed the electronic medical record (EMR) for Resident #5.A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to: chronic obstructive pulmonary disease, unspecified (COPD: incurable lung disease that causes restricted airflow and breathing difficulties) and morbid (severe) obesity due to excess calories (more of the calories consumed will be stored as fat).A review of the annual Minimum Data Set, an assessment tool dated 4/1/26, indicated the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating the resident was cognitively intact.A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 12/20/23, stating the resident was at risk for respiratory distress due to a diagnosis of COPD, pulmonary edema (too much fluid in the lungs), asthma (inflammatory disease of the airways), congestive heart failure (heart muscle doesn't pump blood as well as it should), history of sleep apnea (repeated stops and starts in breathing during sleep), and obesity. The ICCP interventions included: administer medications per physician orders, assist resident to a position of comfort when experiencing difficulty breathing, provide oxygen therapy as per physician order, and provide inhalation or nebulizer treatments per physician order. A further review of the ICCP included a focus area with a revision date of 3/13/25, stating the resident required the use of oxygen due to episodes of shortness of breath related to COPD and shortness of breath when lying flat. The ICCP interventions included providing oxygen as ordered by the physician and pulse oximetry (a test that measures blood oxygen saturation) as ordered by the physician, and reporting levels below normal limits to the physician.A review of the Order Summary Report included the following physician orders (PO):A PO dated 8/4/25: Oxygen: obtain SPO2 (oxygen saturation) every shift for shortness of breath (SOB).A review of the July 2026 PO did not include any orders for oxygen therapy.On 7/10/26 at 11:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident uses oxygen at 2 liters per minute (lpm) as needed (PRN) at nighttime. She further stated that there should be a physician's order for oxygen. The surveyor and LPN reviewed the physician's orders in the EMR, and the LPN confirmed there was no physician's order for PRN oxygen.On 7/10/26 at 11:47 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that Resident #5 wears oxygen PRN at night only. She further stated that there should be a physician's order for PRN oxygen. The UM/LPN confirmed that there were no physician orders for oxygen PRN at night. She stated that the importance of having a physician's order for oxygen was to ensure the resident received the oxygen as needed. She further stated, I do not see any current physician orders for oxygen.On 7/15/26 at 9:28 AM, the surveyor interviewed the Director of Nursing, who stated that if a resident used oxygen, there should be a physician's order. She stated that the purpose of having physician's orders was to ensure nurses are following physician directions.A review of the facility's Oxygen Administration Policy, revised 6/19/24, included, Purpose: the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .N.J.A.C. 8:39-27.1(a)

Based on observations, interviews, and review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits in the appropriate time frame. This deficient practice was identified for 1 of 2 residents reviewed for hospice (Resident # 11). This deficient practice was evidenced by the following:On 7/09/2026 at 10:23 AM, the surveyor observed Resident #11 in a wheelchair. The resident stated hospice was going well.The surveyor reviewed the resident's electronic medical record (EMR), which revealed an admission Record that reflected Resident #11 had medical diagnoses which included, but were not limited to, cancer.A review of the progress notes dated 2/20/26 indicated the resident was admitted on to hospice effective 2/20/26.A review of the resident's Minimum Data Set (MDS), an assessment tool, revealed that the SCSA dated 3/4/26 was completed on 3/10/26, which was not within 14 calendar days from the resident's hospice election as required (should have been completed by 3/6/26).On 7/14/2026 at 10:39 AM, the surveyor interviewed the MDS Coordinator (MDSC), who stated a significant change for hospice should be done within 14 days of going on hospice, and this resident's MDS was dated 3/4/26. She further stated that it was scheduled for 3/4/26, and she did not know it had to be completed within 14 days.On 7/14/2026 at 12:36 PM, the surveyor interviewed the Director of Nursing (DON), who stated she believed they had 2 weeks to complete a significant change for hospice.On 7/15/2026 at 2:04 PM, the survey team met with the DON, Licensed Nursing Home Administrator (LNHA), and Regional LNHA and notified them of the above concern.On 7/16/2026 at 10:06 AM, the survey team met with the DON, LNHA, and the Regional LNHA. The Regional LNHA stated the MDSC misinterpreted the guidelines for opening an MDS versus completion of the MDS.A review of the facility-provided, undated policy titled MDS Completion and Submission Timeframes included the MDS completion date as the 14th calendar day after determination of significant change in status. NJAC 8:39-11.2(i)

Complaint # 3091573Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to report an allegation of verbal abuse to the New Jersey Department of Health (NJDOH) within 2 hours for one of one resident (Resident # 19) reviewed for abuse. This deficient practice was evidenced by the following:A review of the admission Record (an admission summary) for Resident #19 revealed the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, recurrent, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities), anxiety disorder, unspecified (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and alcohol abuse with intoxication, uncomplicated.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 4/28/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact.A review of the Individual Comprehensive Care Plan (ICCP) revealed a focus area indicating the resident was at times verbally and physically aggressive toward staff related to poor impulse control and alcohol intoxication, and would make false statements against staff which would be immediately rescinded (Date Initiated: 09/11/2025; Revision Date: 07/10/2026). Further review of the ICCP revealed an intervention stating that when the resident became agitated, staff were to: intervene before agitation escalated; guide the resident away from the source of distress; engage calmly in conversation; and, if the response was aggressive, walk calmly away and approach later (Date Initiated: 09/11/2025).A review of the facility's Reportable Event Record/Report dated 7/13/2026 revealed the event occurred on 7/10/2026 at 11:00 AM and was reported to the NJDOH on 7/10/2026 at 4:20 PM. Further review revealed the resident told the Social Worker (SW) the Licensed Nursing Home Administrator (LNHA) had called them names.On 7/14/2026 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON), who stated Resident #19 emailed the SW on 7/9/2026 after 5:00 PM stating that something had happened with the administrator. The DON stated the SW had already left for the day but returned to the facility after seeing the email. The DON stated the SW made her aware of the event at that time. The DON stated the event occurred when the LNHA observed Resident #19 attempting to enter the nourishment room. She stated residents were not allowed in the nourishment room due to infection control concerns. The DON stated Resident #19 had previously been told that staff would assist them with whatever they needed from the nourishment room. She stated Resident #19 became irritated when the LNHA questioned them about attempting to enter the room. The DON stated she attempted to interview the resident on 7/9/2026, but the resident told her to leave them alone. The DON stated she did not report the incident to the NJDOH at that time because the resident was care planned for making false statements against staff. She stated that an allegation of verbal abuse should be reported to the NJDOH within two hours, adding that they did not report it initially because the resident rescinded what was said.On 7/14/2026 at 12:05 PM, the surveyor interviewed the SW, who stated she received an email on Thursday evening, 7/9/2026, after 5:00 PM from Resident #19 regarding an incident in which the LNHA allegedly called them names. The SW stated she immediately notified the LNHA, the DON, and the Assistant DON (ADON) about the allegations. She stated she returned to the facility and interviewed Resident #19. Resident #19 stated the event happened Wednesday morning (7/8/2026) when the LNHA questioned them about attempting to enter the nourishment room. She stated the resident alleged the LNHA pushed into their room and called them names. The SW asked the resident what names the LNHA had called them, at which point the resident stated it had not happened. The SW stated the LNHA was not in the building at the time of the interview. The SW stated she updated the DON, who then took over the investigation.On 7/14/2026 at 12:40 PM, during a follow-up interview with the DON, she stated she tried to interview the resident again on Friday morning (7/10/2026), but the resident did not want to speak to her. She stated she tried again Friday afternoon, but the resident asked to be left alone. Due to the resident's response, the DON stated she advised reporting it because the resident was not cooperating and it did not appear the matter was resolved. The DON provided the surveyor with a completed investigation which concluded the facility was unable to substantiate the allegation.On 7/14/2026 at 1:27 PM, the surveyor interviewed the LNHA, who stated that if an allegation of abuse was made, the first steps were to ensure the resident was safe and report the event to the NJDOH within two hours. The LNHA stated the DON advised him to report it when the SW first made him aware of the email, but he did not do so at that time.On 7/16/2026 at 10:06 AM, during a meeting with the survey team, the DON, and the regional administrator, the LNHA acknowledged that the allegation should have been reported within two hours.A review of the facility's policy Abuse Prevention initiated January 2018, revealed Policy: The facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members.The facility will have an abuse prevention program that protects residents from physical and mental abuse. in compliance with State and Federal regulations and the mission and philosophy of this facility.Verbal abuse: any use of oral, written, or gestured language which is threatening, profane, degrading, loud and/or using nicknames when the resident does not approve of them. 7. Report/Respond: The facility must assure that any incidents of substantiated abuse and neglect are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal Laws. NJAC 8:39-4.1(a)(5), 9.4(f)

Complaint #: NJ186666 Based on interview and record review, it was determined that the facility failed to ensure physician's orders were obtained for a.) weekly cleaning and tubing changes for a resident's continuous positive airway pressure (CPAP) machine and b.) filling the chamber of the CPAP machine with distilled water daily from March 2025 through the resident's discharge from the facility in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1). 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. The evidence was as follows: The surveyor reviewed the closed medical record for Resident #1. According to the admission Record face sheet (an admission summary), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple fractures to the right-side rib, obstructive sleep apnea (a breathing disorder where the walls of the throat relax and narrow during sleep), depression, prosthetic heart valve, and history of falling. According to the Minimum Data Set (MDS), an assessment tool dated 02/25/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that the resident's cognition was moderately impaired. The MDS also indicated that Resident #1 required assistance with care for all activities of daily living (ADLs). A review of Resident #1's Order Summary Report (OSR) dated 02/01/2025 through 06/30/2025, included a physician's order dated 03/26/2025, for a CPAP machine (a machine used for sleep apnea disorders to send a flow of pressurized air into your nose and mouth as you sleep) every night applied at bedtime, set the pressure at 13 centimeters (cm) of water, and to remove in the morning. On 06/19/2025 at 1:27 PM, the surveyor interviewed the Infection Prevetionist/License Practical Nurse (IP/LPN), regarding the facility's policy for CPAP machine maintenance. The IP/LPN stated that all the tubing for the CPAP machine were changed by the 11:00 PM to 7:00 AM (11-7) shift nurses on Sunday nights, and the CPAP machines were washed and refilled with distilled water at that time. On 06/19/2025 at 1:50 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated the 11-7 shift nurses were assigned to change the CPAP tubing and clean the CPAP machines. The surveyor asked the UM/LPN if physician's orders were required to change the CPAP tubing, clean the CPAP machine, and change the distilled water, and the UM/LPN confirmed yes. At that time, the surveyor and the UM/LPN reviewed Resident #1's OSR, and the UM/LPN confirmed there were no orders. A review of the March, April, and May 2025 Medication Administration Records (MAR) revealed that the facility was signing for the administration of the CPAP machine daily, but not for the changing of the tubing, cleaning of the machine, or distilled water changes. On 06/19/2025 at 2:51 PM, the surveyor interviewed the Director of Nursing (DON), and asked if physician's orders were required to change the CPAP tubing, clean the CPAP machine, and change the distilled water, and the DON confirmed yes. At that time, the DON and the surveyor reviewed the physician's orders together, and the DON acknowledged there was no order for the tube changing, cleaning of the CPAP machine, and filling the water chamber of the CPAP machine daily with distilled water prior to use, and washing the resident's face to remove any oils prior to the use of the CPAP machine. The DON stated, if no order, no documentation means it not been done. A review of the facility's undated CPAP/BIPAP Support policy included Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplement oxygen. 2. To improve arterial oxygenation (PaO2) in resident with respiratory insufficiency, obstructive sleep apnea or restrictive/obstructive lung disease. 3. To promote resident comfort and safety . Preparation: 1. Only a Licensed Professional nurse or respiratory therapist should administer oxygen through a CPAP mask. 2. Review the resident's medical record to determine his/her baseline oxygen saturation. Respiratory circulation and gastrointestinal status. 3. Review the physician's order to determine the oxygen concentration and flow, and the [Positive End-Expiratory Pressure] pressure (CPAP, IPAP and EPAP) for the machine. 4. Review and follow manufactures instructions for CPAP machine setup and oxygen delivery . NJAC 8:39-27.1(a)

Complaint #: NJ162242 Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #239) was free from verbal abuse. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, Housekeeping Aide (HA #1), who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. Observation of the ENT's surveillance video showed the entrance to the ENT's office with HA #1 yelling and cursing at Resident #239 who was observed visibly upset and verbalized that they thought HA #1 was kidnapping them. HA #1 continued to record and yell at the resident; never once reassuring the resident of their safety. The ENT's office had to request that HA #1 leave their office and a new escort be brought from the facility for Resident #239. The facility's failure to implement their abuse policy to ensure all residents were free from verbal abuse and exploitation posed the likelihood of serious harm to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ was Past Non-Compliance (PNC). The IJ was identified from 3/7/23 at 1:38 PM, when HA #1 began verbally abusing Resident #239 and exploiting them by videotaping it. The facility's Administration were notified of the IJ on 3/6/25 at 4:50 PM. The facility submitted an acceptable Removal Plan (RP) on 3/6/25 at 10:41 PM. The facility was back in compliance when the facility addressed the situation by: HA #1 was terminated; Resident #239 received a psychosocial evaluation; and all staff were in-serviced on the facility's abuse prevention and reporting policies by the Assistant Director of Nursing (ADON). The survey team verified the completion of the RP was 3/7/23, during an on-site survey on 3/6/25 at 11:13 PM, and determined the IJ was PNC. Findings include: A review of the facility's Abuse Prevention policy initiated January 2018, included the facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitor, or family members or by another resident . The surveyor reviewed the closed medical record for Resident #239. A review of the Admission Record face sheet (admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/27/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated 1/22/23, that the resident had a cognitive deficit. Interventions included: to be able to verbalize safety rules for specific tasks; engage in appropriate social conversation with facility staff; and consistent caregivers. A review of a Social Progress Note dated 3/7/23, indicated that the Social Worker (SW) documented that they followed-up with Resident #239 upon their return from the doctor's office. The resident appeared calm and in no emotional distress. The resident reported they could not recall if there was an incident while they were at the doctors and does not know what may have happened . A review of the Individual Psychotherapy Progress Note dated 3/8/23, included that the resident was initially tense, worried, and irritated because [the resident] was going to attend a meeting with staff. [The resident] was able to speak calmly once [they] were settled and assured [they] would be alright . A review of the facility's undated Investigation included an overview that on 3/7/23, at approximately 1:40 PM, the Director of Nursing (DON) received a phone call from the ENT's office that Resident #239 was observed with their escort, HA #1, who was observed having inappropriate aggressive behaviors towards the resident which included yelling, cursing, and videotaping Resident #239. That caused Resident #239 to become more agitated, that they fear for the resident safety with staff member, that [HA #1's] were so disruptive to the office that they asked her to step out of the office. The DON advised the office to call the police, to have HA #1 removed, and the facility would immediately send a new staff member to assist the resident. The investigation further indicated that HA #1 returned to the facility, they were interviewed, and the facility reviewed HA #1's cell phone video and then had them delete the video. The facility concluded that based on their investigation, the alleged allegation of abuse was substantiated. HA #1 was witnessed yelling, cursing, and videotaping the resident; actual videos of the resident were taken without their consent. HA #1 was asked and deleted all videos, and HA #1 was terminated. On 3/4/25 at 3:10 PM, the surveyor observed the video recording taken and provided by the ENT's office on 3/7/23 at 1:38 PM. The video showed the outside entrance and reception area of the ENT's office with HA #1 yelling loudly and cursing towards Resident #239 while videotaping the resident with a cell phone. Resident #239 appeared upset and was confused and the resident stated that they believed they had been kidnapped by HA #1 who never reassured the resident of their safety, but only yelled at the resident. Further review revealed that at no time did the transport driver for the facility's contracted transportation company intervene on behalf of the resident, but instead assisted HA #1 with the videotaping of the resident on the same cell phone. During a telephone interview on 3/4/25 at 2:59 PM, ENT staff (ENT #1) stated that she was notified by her staff on 3/7/23, that HA #1 was inappropriate with Resident #239 and staff asked her to come to the reception area. ENT #1 also stated that she observed HA #1 yelling and belittling Resident #239. ENT #1 stated her staff asked HA #1 to step outside and they contacted the facility to make them aware and they requested that another staff member come to supervise Resident #239 for the remainder of the appointment. During a telephone interview on 3/4/25 at 3:05 PM, ENT #2 revealed that the aide [HA #1] was very nasty to Resident #239. ENT #2 stated HA #1 was yelling at the resident a lot and videotaping the resident who seemed agitated and confused. ENT #2 reported that Resident #239 thought they were being kidnapped, but the aide [HA #1] did not assure the resident that they were safe and just yelled at them. During an interview on 3/6/25 at 8:59 AM, the DON stated she was contacted by ENT #1 at the ENT's office on 3/7/23, who reported that she had witnessed HA #1 being abusive towards Resident #239. The DON stated HA #1 was terminated, and that the facility substantiated that abuse occurred. The DON stated when she reviewed the abuse video, she was visibly shocked and upset. The DON stated the abuse Resident #239 sustained was terrible. The acceptable Removal Plan (RR) on 3/6/25 at 10:41 PM, indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including; HA #1 was terminated, Resident #239 received a psychosocial evaluation, and all staff were in-serviced on the facility's abuse prevention and reporting policies by the ADON. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC); that the facility corrected their non-compliance on 3/7/23. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/6/25 at 11:13 PM. NJAC 8:39-4.1(5); 33.2(c)12

Complaint #: NJ162242 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse and exploitation by a Housekeeping Aide (HA #1) who was observed being verbally abusive and videotaping the incident. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, HA #1, who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. Observation of the ENT's surveillance video showed the entrance to the ENT's office with HA #1 yelling and cursing at Resident #239 who was observed visibly upset and verbalized that they thought HA #1 was kidnapping them. HA #1 continued to record and yell at the resident; never once reassuring the resident of their safety. The ENT's office had to request that HA #1 leave their office and a new escort be brought from the facility for Resident #239. During the facility's investigation, the facility failed to thoroughly investigate by obtaining statements from all witnesses including other residents who were escorted by HA #1 to their appointments. The facility's failure to implement their abuse policy by immediately conducting a thorough investigation to ensure all residents were free from abuse posed a likelihood of serious harm to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/7/23 at 1:38 PM, when HA #1 began verbally abusing Resident #239 and exploiting them by videotaping it. The facility's Administration were notified of the IJ on 3/6/25 at 4:50 PM. The facility submitted an acceptable Removal Plan (RP) on 3/6/25 at 10:41 PM. The survey team verified the implementation of the RP on-site 3/6/25 at 11:13 PM. Findings include: A review of the facility's Abuse Prevention policy initiated January 2018, included all reports of alleged or suspected abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the facility's Administrator. Immediate Investigation: the Nurse Supervisor will immediately initiate and investigation and will: .interview those staff members or other persons present to determine a cause/effect relationship for the injury/incident .the person conducting the interview will: .interview all witnesses and staff in the immediate area; interview the resident when appropriate . The surveyor reviewed the closed medical record for Resident #239. A review of the Admission Record face sheet (admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/27/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of a Social Progress Note dated 3/7/23, indicated that the Social Worker (SW) documented that they followed-up with Resident #239 upon their return from the doctor's office. The resident appeared calm and in no emotional distress. The resident reported they could not recall if there was an incident while they were at the doctors and does not know what may have happened . A review of the Individual Psychotherapy Progress Note dated 3/8/23, included that the resident was initially tense, worried, and irritated because [the resident] was going to attend a meeting with staff. [The resident] was able to speak calmly once [they] were settled and assured [they] would be alright . A review of the facility's undated Investigation signed by the Director of Nursing (DON), included an overview that on 3/7/23, at approximately 1:40 PM, the DON received a phone call from the ENT's office that Resident #239 was observed with their escort, HA #1, who was observed having inappropriate aggressive behaviors towards the resident which included yelling, cursing, and videotaping Resident #239. That caused Resident #239 to become more agitated, that they fear for the resident safety with staff member, that [HA #1's] was so disruptive to the office that they asked her to step out of the office. The DON advised the office to call the police, to have HA #1 removed, and the facility would immediately send a new staff member to assist the resident. The investigation further indicated that HA #1 returned to the facility, they were interviewed, and the facility reviewed HA #1's cell phone video and then had them delete the video. The resident returned to the facility and a skin assessment was conducted with no injuries found. The facility concluded that based on their investigation, the alleged allegation of abuse was substantiated. HA #1 was witnessed yelling, cursing, and videotaping the resident; actual videos of the resident were taken without their consent. HA #1 was asked and deleted all videos, and HA #1 was terminated. The statements obtained were from the Unit Manager, DON, and HA #1. There were no interviews with the driver of the contracted transportation company, the ENT staff, HA #1's supervisor, Resident #239, or other residents. There was no evidence during the course of the facility's investigation if any other residents were identified and interviewed who had been escorted to appointments by HA #1. On 3/4/25 at 3:10 PM, the surveyor observed the video recording taken provided by the ENT's office on 3/7/23 at 1:38 PM. The video showed the outside entrance and reception area of the ENT's office with HA #1 yelling loudly and cursing towards Resident #239 while videotaping the resident with a cell phone. Resident #239 appeared upset and was confused and the resident stated that they believed they had been kidnapped by HA #1 who never reassured the resident of their safety, but only yelled at the resident. Further review revealed that at no time did the transport driver for the facility's contracted transportation company intervene on behalf of the resident, but instead, he took HA #1's cell phone and continued to record the resident. During a telephone interview on 3/4/25 at 2:59 PM, ENT staff (ENT #1) stated that she reported the incident to the facility; however, there were no follow-up interviews conducted with her by the facility. During a telephone interview on 3/4/25 at 3:05 PM, ENT #2 stated that she was not interviewed by anyone from the facility about the incident. During an interview on 3/6/25 at 8:35 AM, the Social Services Director (SSD) stated during an abuse investigation, she interviewed the resident involved and other residents. The SSD stated during that investigation, she did not interview any residents. During an interview on 3/6/25 at 8:59 AM, the DON stated the ENT staff did not make her aware of the driver being involved in the incident, but she did not ask. The DON also stated that she did not interview all the ENT staff who witnessed the incident; she did not know that she could. The DON further stated that she did not interview the Scheduling Coordinator at that time or attempt to identify and interview other residents who had been escorted by HA #1 during appointments. The acceptable Removal Plan (RR) on 3/6/25 at 10:41 PM, indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including; a complete investigation was initiated; the Licensed Nursing Home Administrator (LNHA) and DON were educated by the Regional Administrator on the facility's abuse policy, customer service, professionalism, and complete and thorough investigations; the SSD was in-serviced on proper investigation of abuse including interviews of other residents; and all staff were in-serviced on abuse. The survey team verified the implementation of the Removal Plan on-site on 3/6/25 at 11:13 PM. NJAC 8:39-4.1(a)5

Based on record review, interview, and policy review, it was determined that the facility failed to ensure a physician ordered as needed (PRN) antianxiety medication had a stop date. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #141). Findings include: A review of Resident #141's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis of Alzheimer's with behaviors. A review of Resident #141's physician's Order Summary included an order dated 02/21/25, for alprazolam (an antianxiety medication) .25 milligrams (mg) daily PRN for anxiety. There was no documented evidence of a stop date. A review of Resident #141's corresponding February 2025 Medication Administration Record (MAR), revealed that the resident received alprazolam .25 mg PRN on 02/21/25, 02/26/25, and 02/28/25. A review of the March 2025 MAR, revealed that the resident received alprazolam .25 mg PRN on 03/01/25, 03/02/25, and 03/03/25. Interview with the Director of Nursing (DON) on 03/06/25 at 11:55 AM, confirmed that the PRN alprazolam should have had a stop date, and she confirmed the order did not. A review of the facility's undated Antipsychotic Medication Use included . Policy Interpretation and Implementation .7. All PRN orders for psychotropic medications must be ordered for 14 days. The physician will evaluate needs beyond 14 days for new orders. NJAC 8:39-29.3(a)

Based on record review and interview, it was determined that the facility failed to ensure a resident's medical record was maintained complete, accurately documented, and readily accessible. This deficient practice was identified for 1 of 30 sampled residents (Resident #87). Findings include: A review of Resident #87's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included; atherosclerosis of native arteries of bilateral legs, restless leg syndrome (RLS), and nerve pain. A review of Resident's #87's Progress Notes included a Nurses Note dated [DATE], included .At 3:05 PM, [Resident #87] found in bed with eyes closed .no respirations/no pulse. 3:10 PM code blue called, cardiopulmonary resuscitation (CPR) initiated at 3:13 PM .3:30 PM call placed to power of attorney (POA) .During conversation, POA states that [Resident #87] should have been a do not resuscitate (DNR). She stated she had signed practitioner orders for life sustaining treatment (POLST) stating same. Explanations given that [name of the facility] did not have a copy of POLST and that with no POLST, [Resident #87] had to be considered a full code so CPR initiated. A review of the Progress Notes included no documented evidence from the Social Worker regarding talking to the resident POA about the POLST. During an interview on [DATE] at 9:15 AM, the Social Service Director (SSD) confirmed she kept a soft file on Resident #87 and had all the documentation in that file. The SSD confirmed that she educated the POA that either she would need to sign a new POLST, or the facility would need to get a copy of the existing POLST, and that Resident #87 would remain a full code until a POLST was obtained. The SSD stated that the only thing that she placed in the medical record was quarterly assessments and care conferences, otherwise she kept everything else in her office in a soft file. The SSD was not aware that the medical records were to remain complete, accurately documented, and readily accessible for each resident. A review of the facility's undated policy titled, Medical Records and Accuracy Policy, indicated, To ensure that all medical records are accurately maintained, easily accessible, and compliant with applicable laws and regulations, including those set by the State of [name of state], the Centers for Medicare and Medicaid Services (CMS), and the Health Insurance Portability and Accountability Act (HIPAA) .Policy: 1. Accurate Documentation: All medical records must reflect accurate, current, and complete information regarding the resident's medical condition, care plan, treatments, medications, and progress .2. Completeness of Records: Each medical record must contain, at a minimum, the following .treatment plans, care plan, and interdisciplinary progress notes .3. Timeliness of Documentation: Documentation should be completed in a timely manner, ideally immediately following a resident's visit or procedure. All entries should reflect the most up-to-date information.Review of the facility's undated policy titled, Medical Records and Accuracy Policy, indicated, To ensure that all medical records are accurately maintained, easily accessible, and compliant with applicable laws and regulations, including those set by the State of [name of state], the Centers for Medicare and Medicaid Services (CMS), and the Health Insurance Portability and Accountability Act (HIPAA) .Policy: 1. Accurate Documentation: All medical records must reflect accurate, current, and complete information regarding the resident's medical condition, care plan, treatments, medications, and progress .2. Completeness of Records: Each medical record must contain, at a minimum, the following .treatment plans, care plan, and interdisciplinary progress notes .3. Timeliness of Documentation: Documentation should be completed in a timely manner, ideally immediately following a resident's visit or procedure. All entries should reflect the most up-to-date information. NJAC 8:,d+[DATE].1(a)18 NJAC 8:,d+[DATE].2

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received alternative measures prior to installation of bedrails. This deficient practice was identified for 1 of 1 resident reviewed for bedrails (Resident 78). Findings include: A review of Resident #78's Admission Record face sheet (an admission summary) reflected the resident was readmitted to the facility with diagnoses which included but not limited to ; hemiplegia and hemiparesis. A review of Resident #78's quarterly Minimum Data Set (MDS), and assessment tool dated 12/01/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. A review of Resident #78's individualized comprehensive care plan dated 05/29/24, included the resident required left bedrail for mobility and safety. Interventions in place were left sided bedrails as ordered. A review of Resident #78's Bed Rail Evaluation dated 05/29/24, revealed no alternatives were attempted prior to the placement of the bedrails. During an observation on 03/04/25 at 11:18 AM, Resident #78 was lying in the bed with the head of the bed upright and a bedrail on the left side in place. During an interview on 03/05/25 at 5:01 PM, the Licensed Practical Nurse (LPN #3) stated that the nursing staff completed the bedrail assessment for Resident #78, but they did not explore alternative options prior implementing the use of the bedrail. During an interview on 03/06/25 at 6:09 PM, the Director of Nursing (DON) stated the facility did not explore alternative options prior to the use of bedrails, and the facility allowed a resident to use them when they requested to do so. NJAC 8:39-27.1(a)

Complaint #: NJ172235 Based on interviews, record review, and facility policy review, it was determined that the facility failed to implement policies and procedures to report an allegation of staff-to-resident sexual abuse to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #289). Findings include: A review of Resident #289's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; anxiety disorder, dementia with agitation, social phobia, and cognitive communication deficit. The resident expired on [DATE]. A review of Resident #289's BIMS Evaluation dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) score of 4 out of 15; which indicated a severely impaired cognition. A review of Resident #289's individualized comprehensive care plan (ICCP) revealed that the resident had impaired decision [making] and a diagnosis of cognitive communication deficit dated [DATE]. Further review of the ICCP revealed that the resident exhibited socially inappropriate behavior as evidenced by false accusations that included; yelled out was kicked, thrown to floor, pushed around with no specific details, nor timeframe then will forget saying those comments dated [DATE], with an intervention for a two-staff assistance with care, refer for psychiatric consult as needed, and social service evaluation and follow-up. The resident exhibited physically aggressive behavior toward staff/other dated [DATE]. The resident had a diagnosis of social anxiety disorder and social phobia dated [DATE]. The resident was at high risk for skin breakdown related to decreased mobility, anemia, history of wounds, actual wounds, incontinence or diabetes and bed bound status dated [DATE]. A review of the facility provided investigative documentation dated [DATE], revealed the facility was notified by the ombudsman on [DATE], that a complaint was received that Resident #289 was sexually assaulted by an unidentified staff member approximately two weeks before the resident's death on [DATE]. During a telephone interview on [DATE] at 3:22 PM, the Resident's Representative (RR #1) stated that they had not been notified of the allegation. During an interview on [DATE] at 4:05 PM, the Director of Nursing (DON) stated, No, it was not reported to the NJDOH or police. The DON stated that the ombudsman came in and investigated the allegation and closed the case. I didn't think I needed to report it, since the ombudsman came in. I just investigated the allegation and kept a soft file just in case and educated the staff on abuse. I'm responsible for reporting abuse allegations to the [NJDOH] and police. A review of the facility's Abuse Prevention policy revised [DATE], included The facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members, volunteers, visitors, or family members, or by another resident .All occurrences of abuse, neglect, mistreatment, exploitation, injuries of unknown origin, theft or misappropriation of resident's property, and other grievances or complaints will be reported .The facility has procedures to report all alleged violations and substantiated incidents to the [State Agency] and to all other agencies, as required, and to take actions depending on the results of the investigation .The Administrator or designee will notify the following agencies of the allegations: the office of the ombudsman .New Jersey Department of Health and Senior Services must be called immediately .the secretary of the US Department of Health and Human Services must be notified immediately and in no event later than 2 hours after forming the suspicion of a crime resulting in serious bodily injury to a resident .If the suspected crime does not result in serious bodily injury, the report must be made no later than 24 hours after forming the suspicion .the local police department will be notified of any suspected crime resulting but not limited to theft, physical abuse, sexual abuse or extreme verbal abuse threatening bodily harm. NJAC 8:,d+[DATE].4(f)

Complaint #: NJ162242 Based on observation, interview, record review, and review of the facility's policy, it was determined that the facility failed to ensure residents were free from physical restraints. This deficient practice was identified for 1 of 1 resident reviewed for restraints (Resident #239). Findings include: A review of Resident #239's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of Resident #239's comprehensive Minimum Data Set (MDS), an assessment tool dated 01/27/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15; which indicated a severely impaired cognition. A review of Resident #239's individualized comprehensive care plan 02/13/23, did not include the resident had a restraint or used a wheelchair seatbelt. A review of Resident #239's Physician Orders dated 03/05/23, did not include an order for restraints. Observation on 03/04/25 at 3:10 PM, of video recording taken on 03/07/23 at 1:38 PM, of the outside entrance and reception area of an Ear, Nose, and Throat (ENT) doctor's office, revealed Resident #239 was seated in their wheelchair with a lap seatbelt applied. Several times in the video, Resident #239 was observed grabbing the front of the reception desk and attempting to stand up from their wheelchair, but the wheelchair's lap seatbelt prevented the resident from independently standing up from their wheelchair. During a telephone interview on 03/04/25 at 2:59 PM, ENT staff (ENT #1) stated that she observed Resident #239 in the reception area of their office in a wheelchair. ENT #1 stated Resident #239 was strapped in their wheelchair and they were unable to release the seatbelt and stand up. During an interview on 03/05/25 at 2:29 PM, the Staffing Coordinator (SC) stated she was the staff who went to the ENT office on 03/07/23, to remain with Resident #239 and she accompanied the resident back to the facility. The SC stated she believed Resident #239 had a seatbelt on. The SC also stated that when residents were transported, the transport driver put a seat belt on the residents. The SC stated if a resident had a strap or lap seatbelt on while they were in their wheelchair, and it restricted their freedom of movement and it would be a restraint. During an interview on 03/06/25 at 8:59 AM, the Director of Nursing (DON) stated that she reviewed the abuse video and observed Resident #239 in a wheelchair with a lap seatbelt in use. The DON stated that the use of the wheelchair's lap seatbelt was a restraint. The DON stated that the transport driver was the person who put the strap on the resident and was the one who should have released it; it was not her staff that did that. A review of the facility's undated Restraints Policy and Procedure policy included restraints can only be applied with a physician's written order specifying type, medical justification, duration, and condition for use . NJAC 8:39-4.1(a)5, 6 NJAC 8:39-27.1(a)

Complaint #: NJ162242 Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's rights were protected when a staff member video recorded the resident without the resident or their representative's consent. This deficient practice was identified for 1 of 1 resident reviewed for resident rights (Resident #239). Findings include: A review of Resident #239's Admission Record face sheet (an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but not limited to; bipolar disorder, schizoaffective disorder, and anxiety disorder. A review of Resident #239's comprehensive Minimum Data Set (MDS), an assessment tool dated 01/27/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15; which indicated a severely impaired cognition. The surveyor observed on 03/04/25 at 3:10 PM, a video recording taken on 03/07/23 at 1:38 PM, of the outside entrance and reception area of the Ear, Nose, and Throat (ENT) doctor's office, revealed that Housekeeping Aide (HA #1) was video recording Resident #239 with a cell phone. Resident #239 appeared upset and was confused and the resident stated that they believed they had been kidnapped by HA #1. Further review revealed that the transport driver from the transportation company took HA #1's cell phone and assisted HA #1 with continuing to video recording the resident on the same cell phone. During a telephone interview on 03/04/25 at 2:59 PM, with the ENT staff (ENT #1), who stated that she was notified by her staff on 03/07/23, that HA #1 was inappropriate with Resident #239 and they asked her to come to the reception area. ENT #1 stated that she observed HA #1 yelling and belittling Resident #239 while video recording the resident. During a telephone interview on 03/04/25 at 3:05 PM, ENT #2 stated that HA #1 was video recording Resident #239 who seemed agitated and confused. ENT #2 stated the staff were videotaping the resident during the incident. During an interview on 03/06/25 at 8:59 AM, the Director of Nursing (DON) stated that she was contacted by ENT #1 who reported that HA #1 was videotaping Resident #239 who upset and then she passed the phone to the transport driver who continued to video tape Resident #239. The DON stated that staff were prohibited from recoding residents, and they had been trained regarding that expectation. NJAC 8:39-4.1(a)12

Based on observation and interview, it was determined that the facility failed to properly store medications safely and securely during medication administration. The deficient practice was identified for 2 of 8 residents observed during medication pass. Findings include: Observation on 03/05/25 at 11:27 AM, of Resident #290's medication administration, the Registered Nurse (RN #1) left the medication cart unlocked in the hallway outside of the dining room and left a vial of insulin on top of the medication cart unsecured. The cart was not visualized by RN #1 during medication administration. During an interview on 03/05/25 at 11:40 AM, RN #1 stated, I'm nervous, I don't normally leave the cart unlocked or leave insulin on top of the cart. Observation on 03/05/25 at 1:02 PM, of Resident 38's medication administration, the Licensed Practical Nurse (LPN #1) left the medication cart unlocked in the hallway. The cart was not visualized by LPN #1 during medication administration. During an interview on 03/05/25 at 1:05 PM, LPN #1 stated, someone could get into the medications if the cart is left unlocked. During an interview on 03/06/25 12:09 PM, the Director of Nursing (DON) stated it was expected that if the medication cart was not within eyesight during medication administration, the nurse was required to lock the cart. The DON continued if the medication cart was left unlocked, someone could have gotten into the cart and took medications. The DON confirmed insulin vials were expected to be secured in the cart when the nurse was not present. A review of the facility's Medication Administration policy dated March 2017, included During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. NJAC 8:39-29.4(h)

Based on observation, interview, and policy review, it was determined that the facility failed to respect the right to confidentiality of medical records during medication pass. This deficient practice was identified for 2 of 8 residents observed during medication pass (Resident #38 and Resident #290). Findings include: Observation on 03/05/25 at 11:27 AM, Registered Nurse (RN #1) administered medications to resident Resident #290 in the resident's room. RN #1 left Resident #290's electronic medical records (EMR) open which contained confidential and private medical information visible to any resident or visitor in the hallway outside of the dining room. During an interview on 03/05/25 at 11:40 AM, RN #1 stated, I'm nervous, I don't normally leave the computer screen open. Observation on 03/05/25 at 1:02 PM, Licensed Practical Nurse (LPN #1) administered medications to Resident #38 in the resident's room. LPN #1 left Resident #38's EMR open which contained confidential and private medical information visible to any resident or visitor in the hallway outside of the dining room. During an interview on 03/05/25 at 1:05 PM, LPN #1 stated, someone could see the resident's information if the screen of the computer is left open. During an interview on 03/06/25 12:09 PM, the Director of Nursing (DON) stated, It's expected for the computer screen to be closed so that people cannot see resident information. It would be a HIPPA [Health Insurance Portability and Accountability Act] violation and a violation of resident rights to privacy and confidentiality. A review of the facility's undated Resident Rights policy includedFederal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: . t. privacy and confidentiality. NJAC 8:39-4.1(a); 35.2(i)

Complaint# NJ00174037 Based on interviews, record review, and review of other pertinent facility documentation on 05/30/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out for an emergent hospitalization . This deficient practice was identified for Resident #4, 1 of 5 sampled residents, and was evidenced by the following: According to the Admission Record, Resident #4 was admitted to the facility with diagnoses which included but were not limited to: Benign Neoplasm of Cerebral Meninges, Hypertension, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus type 2. A review of the Resident #4's Progress Notes (PN) revealed that on 05/13/2024 at 09:45, Licensed Practical Nurse (LPN) #1 documented Resident was noted yelling I can't breathe, I can't breathe. Bp-126/78, R-18, T-97.5, SpO2- 75% on 2L of O2, wheezing noted to bilateral lungs upon auscultation. Call place to [physician] n/o [new order] received to send resident to ER [emergency room ] for eval [evaluation] and treat [treatment] .Call place to 911 EMTs [emergency medical technicians] arrived stat [immediately] resident transported to MMSC [hospital] . A further review of the Resident #4's PN, dated 05/13/2024 at 14:20 and documented by LPN #1, revealed as follows: Call place to MMSC-ER [hospital-ER] for status on resident .spoke with RN [nurse] made aware resident being admitted dx: Pneumonia. Call place to [physician] and wife [resident's wife] to make aware . A review of Resident #4's MR revealed no NJUTF for the 05/13/2024 transfer to the hospital. During an interview with the surveyor on 05/30/24 at 2:57 p.m. and at 4:57 p.m., the Director of Nursing (DON) stated she was unable to locate the 05/13/2024 NJUTF for Resident #4. The DON further stated she/he did not see the Resident when he was transferred out. At which point, the DON affirmed that Resident #4's NJUTF was not made. A review of the facility policy titled, Transfer or Discharge, Emergency, revealed under the Policy Interpretation and Implementation #2 Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident . NJAC 8:39-35.2 (d) 12

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/16/2023 from 9:30 AM to 10:18 AM the surveyor, accompanied by the Director of Nutrition Services (DONS), observed the following in the kitchen: 1. In the dry storage room on an upper shelf 3 individual, opened cardboard boxes, contained plastic knives, forks, and spoons. The boxes were open to the air and the utensils were exposed to contamination. 2. On an upper rack of a wheeled and multi-tiered can storage rack, a can of applesauce unsweetened had a significant dent on the upper seam. The DONS removed the can to the designated dented can area. 3. Prior to observing the high temperature dish machine the surveyor requested that the DONS provide the surveyor the high temperature dish machine temperature log for review. The log revealed the following recorded temperatures for the breakfast period on 2/16/2023: Wash: 160 F (Fahrenheit) Rinse: 180 F. According to the Dish Machine Temperature Documentation sheet, dated February 2023, the following minimum temperature standards were Wash Temp> 160 degrees and Rinse Temp>180 degrees. The document further revealed, Any out-of-range temps/ppm (parts per million) must be reported to supervisor. The surveyor and DONS then went to observe the wash and rinse temperatures on the dish machine while facility staff were actively washing dishes after the breakfast meal service. On the first observation the surveyor and DONS observed a wash temperature of 120 F and a rinse temperature of 196 F. The surveyor then questioned the dishwasher at what time the dish machine temperatures were recorded. The dishwasher responded, I had 160 F this morning when I recorded the temperature. The surveyor then questioned the dishwasher at what time did he record the wash and rinse temperature of the dish machine. The dishwasher responded, I wrote on the log around 7 AM. The surveyor further questioned the dishwasher if he monitored the dish machine wash and rinse temperatures throughout the dishwashing process. The dishwasher replied, I monitor the temperatures periodically, but I didn't today. At this point the DONS instructed the dishwasher to shut the high temperature dish machine down and was placing a call to have the dish machine serviced. 4. On an upper shelf of the walk-in refrigerator, a plastic milk crate contained 3 lemons in a plastic bag dated 1/19/2022. An orange was also in the crate, open to the air and uncovered. The orange was wilted and was covered in a white fungus like growth on the outer surface. The DONS removed the orange to the trash. On another upper shelf, an opened bag of Low Moisture Mozzarella Cheeses was not completely sealed and was exposed to the air. The bag also had no open or use by date, as per facility policy. The DONS threw the cheese in the trash. On 2/22/2023 from 10:27 to 10:39 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #2), observed the following on the [NAME] unit pantry/nourishment room: 1. On an upper shelf of a snack storage cabinet the surveyor observed a face shield that was used by staff for PPE (personal protective equipment). The face shield was stored in the same cabinet that is used to store snacks for the facility residents. 2. In a drawer next to the refrigerator, the surveyor observed (2) empty portion control packages of breakfast cereal. The packages were opened and only crumbs were visible in the containers. 3. The surveyor observed a white plastic bag in the pantry refrigerator. A paper bag was within the white plastic bag and appeared to contain Asian style takeout food. The bag was labeled with a name and room number. The bag did not have a date. According to LPN #2, I will take out the food. LPN #2 further stated, Yes, all food should be dated and discarded after 72 hours. I will remove everything, when asked by the surveyor if foods are to be dated when placed in the refrigerator. On 2/23/2023 from 10:43 to 11:04 AM, the surveyor, accompanied by the DONS, observed the following in the kitchen: 1. In the walk-in refrigerator, on a lower rack of a multi-tiered wheeled cart, a 1/2 pan placed on top of a sheet pan contained 2 white plastic bags of ground turkey to be defrosted. The bags had a pull date of 2/20/23 and a discard/use by date of 2/22/2023. The DONS stated, That should have been used yesterday. The ground turkey was discarded. 2. In the cook's prep area a cleaned and sanitized meat slicer was on top of the cook's prep table. The slicer had no cover and was exposed. The surveyor asked the cook and DONS if the meat slicer had been used since the beginning of operations that day. The cook nodded no, and the DONS stated that the meat slicer was cleaned and sanitized and should be covered when not in use. The surveyor and DONS observed unidentified food debris on the base of the slicer under the slicing wheel. The surveyor reviewed the facility policy titled Dented Can Policy, Rev 8.2021. The following was revealed under POLICY: Kitchen will receive quality acceptable canned goods. Unacceptable, dented canned goods will be reported and returned/discarded in a timely manner. The following was revealed under the heading PROCEDURE: 1. Identify an acceptable/unacceptable dented can. Unacceptable: Any dent, crease, bulge, swelling, or rust. 2. Upon discovery, place dented can in the designated Dented Can area. The surveyor reviewed that facility policy titled RECEIVABLE AND STORAGE POLICY, Revised 7.2022. The following was revealed under the heading PROCEDURE: 8. Ensure that all foods are securely covered, dated, and labeled. The surveyor reviewed the facility policy titled DISWASHING POLICY, Revised 7.2020. The following was revealed under the heading PROCEDURE: 9. Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitation. 10. High Temp (Wash 150 degrees F (Fahrenheit), Rinse 180 degrees F). 12. FSD (Food Service Director) or designee will spot check clean dishes and dish machine log temperature and PPM (part per million) reading prior to each usage. The surveyor reviewed the facility policy titled RECEIVING and STORAGE, dated 2.2020. The following was revealed under the heading Purpose: To receive, store, and issue efficiently foods, nonfood items, and supplies; to establish receiving methods that assure that all items ordered are received, and to control issue so that no items are lost, stolen, or allowed to deteriorate. The policy further revealed the following: vii Produce that shows insect infestation, mold, cuts, wilting, discoloration, or unpleasant odor. The surveyor reviewed the facility policy regarding food brought in by family and visitors, undated. The following was revealed under the heading Policy Interpretation and Implementation: 6. Once food is delivered to the resident, the food or any leftover food that the resident did not finish, will be bagged, labeled, dated and placed in resident's own fridge or nourishment room fridge on the unit for the resident. 7. Leftover food is only allowed to stay in the nourishment fridge for up to 72 hours only. 11. After 72 hours kitchen staff upon their daily inspection of the nourishment fridge, will discard any food left in the fridge. The surveyor reviewed the facility policy titled Food Service Equipment Sanitation Policy; date reviewed/revised: 5/08/21. The following was revealed under the heading POLICY: All slicers, Buffalo Choppers, Blenders and Mixers will be cleaned and sanitized before and after every use. In addition, the following was revealed under PROCEDURE: Only bag clean equipment once completely cleaned, sanitized, air dried and not in use. N.J.A.C. 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to provide fall safety interventions to a resident, at risk for falls, while in bed. Resident #4 fell and sustained a fractured nose and thumb and received sutures to a lacerated forehead. This deficient practice was evident for 1 of 9 residents, Resident #4, reviewed for falls and was evidenced by the following: During the initial tour on 6/21/11 at 10 a.m. the Unit Nurse Manager (UNM) told the surveyor that Resident #4 was dependent for all areas of care and was currently receiving Hospice care. The UNM further stated that the resident had a history of [REDACTED]. The UNM stated that the Hospice Aide had left the resident in bed with the side rails down and went to the bathroom to get the resident's wheelchair. The surveyor reviewed Resident #4's medical record on 6/22/11 which revealed that the resident had a fall from bed on 4/22/11. At that time the resident had a fall care plan in place related to "decreased mobility and impulsive behavior" which included the use of a bed and wheelchair alarm. After the 4/22/11 fall a DPM (defined perimeter) mattress was added to the care plan. The Hospice care plan also included "fall precautions" and was signed by the Hospice Aide on 5/1/11. The resident had another fall from bed on 5/24/11 at 8:15 a.m. According to the fall investigation report, the Hospice Aide had provided morning care to the resident, left the resident in bed with the side rail down and went to the bathroom to get the resident's wheelchair. While in the bathroom the Aide heard the bed alarm sound and found the resident lying on her left side on the floor at the bedside. The resident had a laceration on the forehead and swelling and bleeding at the nose. According to the fall investigation, first aid was administered and the resident was sent to the hospital for evaluation. The resident was returned to the facility later that day with a fractured nose, fractured left thumb and sutures to a laceration on the right forehead. The fall investigation included a statement from the Assistant Director of Nurses (ADON) who interviewed the Hospice Aide. According to the statement, the resident was left unattended while the Aide went to the bathroom to get the resident's wheelchair. The ADON confirmed that the side rail was down and "even" with the edge of the DPM mattress with "nothing to prevent the resident from rolling out" of the bed. As a result, the resident fell out of bed and sustained injuries to her nose, forehead and thumb. The surveyor interviewed the ADON and DON on 6/28/11 at 9:45 a.m. The ADON stated that while getting the wheelchair from the bathroom, the aide noticed that the wheelchair was dirty and started to clean the wheelchair in the bathroom before returning to the bedroom. Both the ADON and DON stated that the side rails should have been up as a "standard of practice." The ADON further stated that the aide knew she "did something wrong" and the aide no longer provided care to the resident. NJAC 8:39-27.1(a)