Every finding on record at Grove Park Healthcare and Rehabilitation Center

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) all emergency equipment was readily available at bedside for residents with tracheostomies (a surgical opening in the neck to provide an airway and remove secretions from the lungs), b.) staff were trained to use the emergency tracheostomy equipment, and c.) the primary care nurses were aware of the residents' inner cannula sizes for their tracheostomies. This deficient practice was identified for 2 of 3 residents reviewed for tracheostomy (Resident #6 and Resident #174). 1.Resident #174 was admitted to the facility on [DATE], and had a tracheostomy (trach). Observations and interviews on 02/17/26, revealed that emergency trach supplies were not being kept at Resident #174's bedside and readily available for use. There was no obturator (a device that fits inside the trach tube to guide it during insertion) in Resident #174's room, and staff were unable to locate any extra ones in the storage area. During an interview with the Licensed Practical Nurse (LPN #1), who cared for Resident #174, had never heard of an Ambu bag (a handheld manual resuscitation device used to provide ventilation to a person who was not breathing adequately or stopped breathing) or obturator, so I really don't know where they are. 2.Resident #6 was admitted to the facility on [DATE], and had a trach. Observations and interviews on 02/17/26, revealed that there was no Ambu bag or obturator present in Resident #6's room, and there was no crash cart (cart containing emergency supplies) visualized on the floor. During an interview with LPN #2, who cared for Resident #6, the nurse was unsure what size inner cannula (removeable tube placed inside a trach tube to maintain airway patency and facilitate cleaning and secretion management) the resident used and confirmed there was only one size, a 5.0 millimeters (mm) inner cannula on the windowsill. The facility's failure to ensure there was emergency equipment readily available at the residents' bedside and ensure staff were trained to use emergency tracheostomy equipment placed Resident #6 and Resident #174 at risk, as well as all residents with tracheostomies at risk for respiratory distress. This posed the likelihood for serious harm, impairment, or death, and resulted in an Immediate Jeopardy (IJ) situation. The facility's Administration was notified of the IJ on 02/17/26 at 10:05 PM. The facility submitted an acceptable Removal Plan (RP) on 02/19/26 at 11:26 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 02/20/26, and determined that the immediacy was removed as of 02/20/26 at 1:05 PM. The facility further failed to d.) obtain a physician's order for the size of an inner cannula for a resident with a tracheostomy. This deficient practice was identified for 1 of 4 residents reviewed for tracheostomy (Resident #199). Findings include:Part A A review of the facility's policy Tracheostomy Care, dated January 2026, indicated . The following disposable equipment should be at the bedside:Spare trach tube - equal in size to the tube n placeBack-up trach - one size smaller for emergencies.Suction kits 14 Fr [French] (trach smaller than 6.0 require 12 Fr)Trach care kitsSplit drain sponges250 ml [milliliters] NSS [Normal Saline Solution]Trach tiesSuction cannister with lidSuction tubingThe following equipment should be in the room:Suction Canister5-liter concentratorOxygen tank in appropriate holder. A review of Lippincott Manual of Nursing Practice, dated 2018 page 544, revealed .Have available at the patient's bedside.a resuscitation bag, oxygen source, and a mask to ventilate the patient in the event of accidental tube removal. Anticipate your course of action in such an event.Tracheostomy-have extra tracheostomy tube, obturator.at the bedside. Be aware of reinsertion technique, if facility policy permits, or know how to contact someone immediately for reinserting the tube. 1.A review of Resident #174's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated Resident #174 was admitted to the facility with diagnoses that included but were not limited to; chronic respiratory failure, tracheostomy status, and persistent vegetative state. A review of Resident #174's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 01/27/26, indicated that Resident #174 was coded as comatose with persistent vegetative state/no discernible consciousness. The MDS further coded that the resident required oxygen therapy, suctioning, and tracheostomy care while a resident in the facility. A review of Resident #174's Physician Orders, located under the Orders tab in the EMR, included the following physician's orders (PO):A PO dated 02/09/26, to change inner cannula daily every day shift. The order did not specify the inner cannula size.A PO dated 02/09/26, to change trach collar ties weekly on the 11:00 PM to 7:00 AM (11-7) shift, on Sundays.A PO dated 02/09/26, to administer oxygen at 6 liters per minute (lpm), every 12 hours as needed.A PO dated 02/09/26, to suction every shift and as needed (prn), every 12 hours as needed, for increased secretions and a PO dated 02/09/26, to suction every shift, and prn every shift.A PO dated 02/09/26, for trach care every shift and prn, every 12 hours and a PO dated 02/09/26, for trach care every shift and prn every shift.A PO dated 02/11/26, for chest physiotherapy (a therapeutic technique aimed at improving respiratory function by mobilizing mucus in the lungs making it easier to breathe) and suction after therapy every six hours for prevention of mucous plug. A review of Resident #174's corresponding February 2026 Treatment Administration Record (TAR), located in the EMR under the Orders tab, included documentation of the physician's orders were being followed for changing the inner cannula daily every day shift, suctioning every shift and as needed every 12 hours for increased secretions, and trach care every shift and as needed every 12 hours as needed. There was no documentation of chest physiotherapy and suctioning every six hours after therapy for prevention of mucous plug being performed as ordered by the physician. A review of Resident #174's February 2026 Medication Administration Record (MAR), located in the EMR under the Orders tab, indicated on 02/12/26 and 02/13/26 at 12:00 AM and 6:00 AM, chest physiotherapy was not performed as ordered by the physician. There was no documentation that Resident #174 received oxygen at 6 lpm every 12 hours as needed on the February 2026 MAR. A review of Resident #174's Care Plan, located under the Care Plan tab in the EMR dated 11/14/25, included a Focus area that the resident was at risk for respiratory impairment related to chronic respiratory failure with tracheostomy and continuous oxygen therapy. Interventions included to evaluate lung sounds and vital signs as needed and report significant changes to the physician; if tracheostomy becomes dislodged, maintain patent airway and notify medical doctor immediately; and suction as ordered by the physician. A review of Resident #174's hospital records included a Progress Note from the Respiratory Therapist in the hospital dated 10/20/25, that Resident #174 had a trach collar with a size 8.0 mm inner cannula. During an observation on 02/17/26 at 1:50 PM, of Resident #174's bedside, there was a size 7.5 mm inner cannula and an Ambu bag, but there was no obturator at the bedside nor a size 8.0 mm inner cannula. During an interview on 02/17/26 at 2:06 PM, the surveyor asked LPN #1 what emergency equipment should be located at the bedside of a resident who had a trach. LPN #1 stated, suction machine, Yankauer suction (firm plastic suctioning tip), and a trach care kit. I don't remember what else needs to be in there. The surveyor then asked LPN #1 if she went into the resident's room and the resident's trach cannula was dislodged, what would she do? LPN #1 stated, I cannot remember but if you could help me out, I could use it. The surveyor asked LPN #1 if she had received any training at the facility regarding trach care, and LPN #1 stated that she had not received any additional training outside of nursing school. On 02/17/26 at 3:00 PM, LPN #1 accompanied the surveyor into Resident #174's room. The surveyor asked LPN #1 where the Ambu bag and obturator were in the resident's room, and LPN #1 stated, I have never heard of an Ambu bag or obturator, so I really don't know where they are. The surveyor and LPN #1 then walked out of Resident #174's room and there was a crash cart in the hallway across from Resident #174's room. During an interview on 02/17/26 at 8:10 PM, LPN #4 was asked if there were any trach cannulas located in the crash cart across from Resident #174's room. After reviewing what was in the crash cart, LPN #4 stated, No, there aren't any cannulas in here.During an observation on 02/17/26 at 8:20 PM, in the Clean Utility Room located on Resident #174's floor, LPN #4 confirmed there were no extra obturators located in the clean utility room. 2. A review of Resident #6's Face Sheet, located under the Profile tab in the EMR, indicated that Resident #6 was admitted to the facility with the diagnoses that included but were not limited to; malignant neoplasm of the larynx (cancer of the larynx/voice box), chronic obstructive pulmonary disease, and tracheostomy status. A review of Resident #6's comprehensive MDS, located under the MDS tab in the EMR, with an ARD of 01/05/26, included the resident had long and short-term memory problems with some difficulty in new situations for decision making. The MDS was also coded that Resident #6 required suctioning and tracheostomy care while a resident in the facility. A review of Resident #6's Physician Orders, located under the Orders tab in the EMR, included the following PO's: A PO dated 12/29/25, to change inner cannula daily every shift. The order did not indicate the size of the inner cannula.A PO dated 12/29/25, to change trach collar ties weekly in the 11-7 shift, Sundays.A PO dated 12/29/25, to suction every shift and prn, every 12 hours as needed for increased secretions and a PO dated 12/29/25, to suction every shift and prn, every shift.A PO dated 12/29/25, for trach care every shift and prn, every 12 hours as needed and a PO dated 12/29/25, for trach care every shift and prn, every shift.A PO dated 02/14/26, to transfer to the emergency department (ED) via 911 emergency services for tracheostomy decannulation (removal of the trach). A review of Resident #6's February 2026 TAR, included documentation that the physician's orders were being followed for changing the inner cannula every day shift except on 02/03/26, 02/05/26, 02/13/26, and 02/15/26, when it was documented Resident #6 refused. There was no documentation of suction every shift and as needed every 12 hours for increased secretions. There was documentation that indicated suctioning was being performed every shift and as needed every shift except on 02/03/26, 02/12/26, 02/13/26, 02/14/26, and 02/16/26 on day shift and 02/01/26, 02/04/26, 02/14/26, on night shift when Resident #6 either refused or was sent out to the hospital. Trach care was performed per physician's order except on 02/03/26, 02/12/26, 02/13/26, 02/15/26, and 02/16/26, on day shift and 02/01/26, 02/04/26, and 02/14/26, on night shift when either Resident #6 refused or was sent out to the hospital. A review of Resident #6's Nursing Progress Notes, located under the Progress Note tab in the EMR, indicated on 02/12/26 at 7:39 PM, . resident very combative and verbally abusive to staff during care, refused all [the resident's] due [sic] care. trach and personal care. A continued review of the progress notes on 02/14/26 at 3:07 PM, indicated sent to ER [emergency room] for trach dislodgement. A review of Resident #6's Hospital Record dated 12/22/25, in the EMR under the Misc tab, indicated Resident #6's inner cannula size was 6.0 mm. A review of Resident #6's Care Plan, located under the Care Plan tab in the EMR dated 12/30/25, included a Focus area that the resident was at risk for respiratory impairment related to chronic obstructive pulmonary disease (COPD), and the resident had a tracheostomy. Interventions included Administer medications/treatments per physician's orders. Collaborate with Hospice about respiratory symptoms and management. Encourage deep breathing exercises. During an observation on 02/17/26 at 2:36 PM, of Resident #6's bedside, the Ambu bag and obturator were not present in the room. There was a size 5.0 mm inner cannula noted on the windowsill and a suction machine was at the bedside. The surveyor did not visualize a crash cart on Resident #6's floor. During an interview on 02/17/26 at 2:45 PM, LPN #2 was asked what emergency equipment should be at the bedside of a resident with a trach. LPN #2 stated, sterile water, Ambu bag, split gauze and a trach care kit. The surveyor then asked LPN #2 what size inner cannula Resident #6 had in and she stated, Off the top of my head, I don't remember. I would have to look. LPN #2 accompanied the surveyor to Resident #6's room and confirmed there was no Ambu bag or obturator in the resident's room with only one size 5.0 mm cannula on the windowsill. During an interview on 02/17/26 at 4:40 PM, the Regional Director of Clinical Services (RDCS) confirmed that she would expect the resident with a trach to have the required emergency equipment at their bedside and in their room as outlined in the facility's policy. During an interview on 02/17/26 at 8:10 PM, LPN #4 was asked if she needed trach supplies that were not in the resident's room, where would she go to obtain these supplies. LPN #4 stated, I would have the supervisor who would go to the ground floor and get them out of the stock room and then bring them to me here on the fifth floor. During an observation on 02/17/26 at 9:00 PM, the Registered Nurse Supervisor (RNS #1) took the surveyor into the Central Supply Room on the ground level. There were trach inner cannulas sizes 6.0, 7.0, and 8.0 mm located in the storage room. RNS #1 was asked where the obturators were stored in this room, and RNS #1 stated, I know what they are, I just can't find them right now. I can call the person responsible for this room in the morning and find out where they are. RNS #1 was asked to describe the obturators to the surveyor and RNS #1 stated, It's hard to describe. RNS #1 walked around the storage room and picked up the blue oxygen tubing that would connect to the oxygen condenser and connect to the trach mask or collar and stated, It looks like this. (An obturator is a curved rod that fits in the tracheal cannula and not tubing.)During a telephone interview on 02/21/25 at 10:56 AM, the Medical Director was asked what his expectations were for residents with a trach. The Medical Director stated, I believe our current treatment and care is good. Replacement supplies are available in the residents' rooms or in the supply closets. I believe the staff is competent to provide trach care and if there are any immediate concerns, they are to contact 911. My expectations are that the staff follow the orders that have been written at any time and if there is any discomfort to the [resident], the staff should call 911. The Medical Director continued that supplies should be readily available for emergency purposes with the staff being trained, then retrained annually and as needed. An acceptable Removal Plan (RP) was received on 02/19/26 at 11:26 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the immediacy including: a size 8.0 mm replacement trach kit was immediately placed at Resident #174's bed, and the PO was updated to reflect the current size of the resident's inner cannula. A size 6.0 mm replacement trach kit was immediately placed at Resident #6's bed, and the PO was updated to reflect the current size of the resident's inner cannula. The Respiratory Therapy (RT) and Licensed Nursing Home Administrator (LNHA) reviewed the facility's Tracheostomy Care policy. The RT conducted education with all licensed nurses regarding necessary emergency supplies for residents with trachs in accordance with facility policy and the procedure to follow in the event of a trach dislodgement. The surveyor verified the implementation of the Removal Plan on-site on 02/20/26, and determined the immediacy was removed as of 02/20/26 at 1:05 PM. NJAC 8:39-27.1(a) PART B A review of Resident #199's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated that Resident #199 was admitted to the facility with diagnoses which included but were not limited to; chronic embolism and thrombosis of other specified veins (chronic blood clots in a deep vein), atrial fibrillation, and tracheostomy (trach) status. A review of Resident #199's JLMC - Admission/re-admission Evaluation - V13 dated 02/10/26 at 7:59 PM, in the EMR under the Evaluation tab, indicated Resident #199 was receiving oxygen therapy at 8 liters per minute (lpm) via trach. A review of Resident #199's Order Summary, located under the Orders tab in the EMR, included a physician's order (PO) dated 02/10/26, to change inner cannula every day shift. The PO did not include the size of the inner cannula. A review of Resident #199's Progress Note, documented by the hospital Registered Nurse (RN) in the EMR under the Misc tab, indicated Resident #199 had a tracheostomy size 7.0 mm XLT. A review of Resident #199's Care Plan, located under the Care Plan in the EMR dated 02/11/26, included a Focus area that the resident had a trach with supplemental oxygen with regards to Impaired [sic] breathing mechanics. Interventions were to . Keep obturator/spare trach/resuscitator bag/mask at bedside. If tube dislodges, maintain airway and notify respiratory/[physician] immediately. During an interview on 02/20/26 at 9:42 AM, the Licensed Practical Nurse (LPN #5) was asked where she could locate Resident #199's trach size and LPN #5 stated, I would look in the physician's orders for that. After reviewing Resident #199's PO in the EMR, LPN #5 confirmed Resident #199 did not have a PO which indicated their inner cannula size. During an interview on 02/20/26 at 9:47 AM, the Registered Nurse/Unit Manager (RN/UM) stated, There are no physician orders for the size of trach that [Resident #199] has. The RN/UM confirmed there should have been an order to reflect the size of Resident #199's inner cannula. During a telephone interview on 02/21/25 at 10:56 AM, the Medical Director was asked what his expectations were for residents with a trach. The Medical Director stated, I believe our current treatment and care is good. Replacement supplies are available in the residents' rooms or in the supply closets. I believe the staff is competent to provide trach care and if there are any immediate concerns, they are to contact 911. My expectations are that the staff follow the orders that have been written at any time and if there is any discomfort to the [resident], the staff should call 911. The Medical Director continued that supplies should be readily available for emergency purposes with the staff being trained, then retrained annually and as needed. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 119) out of five residents did not receive an unnecessary medication during medication pass. Findings include: Review of R119's admission Record located in the Electronic Medical Record (EMR) under the tab Census revealed readmitted to the facility on [DATE] with a diagnosis of chronic pain syndrome. Observation during medication pass on 02/17/26 at 8:34PM, Registered Nurse (RN) 1 administered to R119 Ibuprofen 800 milligrams (mg) by mouth (PO) because R119 had complained of pain. During review of R119's Order Summary Report located in the EMR under the tab Orders dated 02/18/26 indicated no evidence of an order for Ibuprofen 800 mg being ordered as of 02/17/26. Review of R119's Blister Package dated 01/07/26 indicated, Ibuprofen 800 mg one tablet by mouth (PO) every six hours (Q6H) when needed (PRN) for moderate to severe pain for 14 days.Interview on 02/18/26 at 3:45 PM, RN1 stated that he/she was unaware of R119 not having an order.Interview on 02/18/26 at 4:00 PM, Licensed Practical Nurse (LPN) 2 confirmed that R119 did not have a physician order for Ibuprofen. Interview on 02/19/26 at 2:45 PM, the Director of Nursing (DON) stated that he/she would have expected RN1 to call the physician and explained that R119 was having pain and get an order for the medication. The DON confirmed that there was no order for the Ibuprofen on 02/17/26. Review of the facility's policy titled, Administering Medications revised date 09/25 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. NJAC 8:39-29.3

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure that one resident (Resident (R) 142) out of five residents observed during medication administration received medication in a manner to prevent possible cross contamination in a sample of 36 residents. Findings include: Observation during medication pass on 02/17/26 at 8:34 PM, Registered Nurse (RN) 2 placed all of R142's medications into the medication cup except one medication, gabapentin (medication to treat neuropathic pain) 300 milligram (mg). RN2 placed the gabapentin in another medication cup. RN2 picked up the gabapentin with her bare right hand, opened the gabapentin capsule and with her bare hands, poured the contents on top of the other medication. RN2 then administered R142 his/her medications. Review of admission Record, located in the Electronic Medical Record (EMR) under the Census tab was admitted to the facility with diagnoses of type2 diabetes mellitus, and contracture of muscle-right upper arm, and right thigh. Review of R142's Order Summary Report dated 02/21/26, located in the EMR under the Orders tab indicated, gabapentin 300 mg PO [by mouth] three times a day [TID]. Interview on 02/19/26 at 4:15 PM, the Director of Nursing (DON) expects that the nurses do not pick up medication with their bare hands. They can use a spoon or gloves instead. Interview on 02/19/26 at 5:15 PM, RN2 stated that he/she should have put on gloves instead of using his/her bare hands. Review of the facility's policy titled, Administering Medications revised 09/25 indicated, .Policy Interpretation and Implementation .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable . NJAC 8:39-19.4

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure that three residents (R4, R62, and R175) out of a sample of 36 were treated with dignity and respect. Specifically, R4 was not permitted to go out on a pass without an escort even though the resident was their own responsible party. R62's Do Not Resuscitate (DNR) wristband was not removed at the time of admission and could be observed by residents and visitors. R175 was denied the ability to leave the facility due to a past positive drug test and was not informed that he/she could refuse to submit to a drug screening. In addition, facility staff entered R175's room without knocking or announcing themselves. These failures resulted in actual and potential impacts on residents' dignity, autonomy, and rights.Findings include:1. Review of R4's Face Sheet located in the Electronic Medical Record (EMR) revealed the most recent admission date of 08/09/25, with diagnoses of paraplegia and muscle weakness. The Face Sheet documented that R4 was his/her own responsible party. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was cognitively intact. During an interview on 02/19/26 at 5:43 PM, R4 stated that he/she wanted to become his/her own responsible party and be able to leave the facility on pass without his/her mother signing him/her out and escorting him/her. During an interview on 02/20/26 at 10:36 AM, the Social Services Director (SSD) stated that residents who are alert, oriented, and their own responsible party may request a pass to leave the facility. The SSD was informed that R4 had been unable to sign himself/herself out of the facility despite being his/her own responsible party. The SSD stated that even when a resident is documented as their own responsible party, the facility obtains a physician's order, therapy assessment, and requires accompaniment by a family member or escort. The SSD acknowledged that this process may violate residents' rights. Interview on 02/20/26 at 5:53 PM, the SSD confirmed that R4 had requested a pass to leave the facility and had a physician order permitting the pass but R4 required an escort. During an interview on 02/21/26 at 10:56 AM, the Medical Director (MD) stated that R4 has a history of substance abuse and alleged that R4 had overdosed on two occasions in the facility. The facility was unable to provide documentation supporting the MD's statements about the two occasions R62 overdosed in the facility. The MD stated, I am afraid for their life and obligated to take care of them. During an interview on 02/21/26 at 12:25PM, R4 reported a feeling of being helpless and there was no one that could help him/her. Review of the facility's policy titled Out on Pass revised 10/25 revealed, It is the policy of the Facility to meet residents' physical and psychological needs to go out on pass. The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights.When a resident requests to go out on pass, the Interdisciplinary Team (IDT) will assess the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The Attending Physician will review the IDT's assessment and evaluate the resident's ability to participate in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. If the Attending Physician determines that the resident may participate in activities outside the Facility, the Attending Physician will write/give an order for a pass on the physician order sheet.The Attending Physician's order should indicate whether the resident needs to be accompanied by a responsible person while out on pass. 2. Review of R62's Face Sheet located in the EMR indicated an admission date of 01/12/26 with diagnoses of hemiplegia and hemiparesis following cerebral infarction, dysphagia, cognitive communication deficit, and unspecified dementia. Review of R62's admission MDS with an ARD of 01/19/26 with a BIMS score of 00 indicating severe cognitive impairment. Observation on 02/19/26 at 12:16 PM and on 02/19/26 at 1:37PM, R62 had a purple wristband with white DNR on R62's left wrist, making R62's end of life code status visible to anyone present. During an observation on 02/21/26 at 12:50 PM, R62 was still wearing the DNR wristband even though the facility had already been made aware of the dignity concern. Interview with Certified Nurse Aide (CNA)5 on 02/19/26 at 1:53 PM, CNA5 confirmed that R62 was the only resident in the facility wearing a DNR wristband. During an interview on 02/19/26 at 4:58 PM, the Assistant Director of Nursing (ADON) stated code statuses are documented in two locations via a written order and on the Face sheet in the EMR. The ADON confirmed that the admitting nurse should have removed R62's wristband upon admission. Interview on 02/20/26 at 10:26 AM, the Regional Director of Clinical Services (RDCS) stated that the DNR wristband should have been removed at the time of admission. She stated that nursing staff are expected to follow facility procedures and remove all hospital identifiers as part of the admission process. During an interview on 02/20/26 at 1:06 PM, R62's Power of Attorney (POA) stated that the facility should follow its processes and ensure the wristband was removed. Interview on 02/21/26 at 12:15 PM, Licensed Practical Nurse (LPN) 3 stated that the use of code status wristbands is not part of the facility's practices and confirmed the band should have been removed at admission. Review of the facility's policy titled admission Process revised 08/25 indicated:.The facility will follow policies for the admission process for residents, and the Administrator will be responsible for the development of and adherence to procedures implementing the policies. Review of the facility's policy titled Quality of Life – Dignity revised 01/26 indicated, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. staff shall maintain an environment in which confidential clinical information is protected; for example, residents' clinical status or care needs shall not be openly posted. Treating all residents with dignity means the resident will be assisted in maintaining and enhancing their self esteem and self worth. 3.Interview on 02/17/26 at 11:20 AM, R175 stated that staff do not knock or announce themselves, they just come into your room. R175 stated that this makes them uncomfortable. At 11:36 AM, while interviewing R175, Administrator in Training (AIT) opened R175's bedroom door and walked in without knocking or announcing themselves. The surveyor redirected the AIT out the door. In addition, R175 stated that on 01/16/26, he/she went on an overnight weekend visit with his/her son, and when he/she returned, he/she was drug tested. R175 stated that he/she tested positive for fentanyl. R175 could not give a reason why he/she was randomly drug tested; however, he/she now cannot have visitors and/or go on any other overnight family visits. R175 denied using any illegal substance, has a history of using drugs but has not used in a long time. R175 stated that the facility staff did not want to hear this information. During a further interview on 02/20/26 at 12:00 PM, R175 stated that he/she consented for the drug screen and did not refuse the drug screen. On 02/21/26 at 2:00 PM, R175 stated that he/she did not know that he/she could refuse the drug screens. During an interview on 02/18/26 at 1:55 PM, the Ombudsman met with R175 on 02/06/26 and R175 complained to them about not being able to go anywhere. The Ombudsman said that R175 stated that when he/she returned he/she had a drug test which was positive for fentanyl, and that the facility would not let him/her go out anymore. R175 said it will be reevaluated in March 2026. The Ombudsman stated that he/she confirmed this information with the Administrator, who did not deny the information. Review of admission Record located under tab Census in the EMR indicated that R175 was re-admitted on [DATE], with a diagnosis of traumatic brain injury (TBI) and bipolar disorder. Review of Order Recap Report located under Orders dated 01/14/26, in the EMR indicated, May go out on overnight pass from 01/16/26 at 9:00 AM to 01/18/26 at 10:00 PM with responsible party. Review of Order Recap Report dated 01/14/26, located under the results tab in the EMR indicated, Lab on 01/18/26: Urine drug screen one time only for history of substance abuse for one day. Review of Lab Results Report dated 01/19/26 located under results tab in the EMR indicated, Positive for ethyl glucuronide and positive for fentanyl. During an interview on 02/20/26 at 2:23 PM, Physician1 stated they look at the history of substance abuse, any underlying psych history and drug tests to find out what to tell psych. Physician 1 stated that R175 refuses their drug screens. Physician1 could not give a reason for the drug screening after R175's overnight pass from 01/16/26 to 01/18/26. Interview on 02/20/26 at 3:30 PM, the RDCS confirmed that R175 does not refuse his/her drug screens. RDCS stated that the facility looks at physician orders, history of the resident, and signs and symptoms (S/S) that resident may be having from baseline prior to giving a resident a drug screen. RDCS could not confirm that R175 came back displaying any S/S from his/her baseline behavior. Review of facility's policy titled, Resident Substance (Drug and Alcohol) Abuse revised 01/26 indicated, To provide a safe and drug-free environment for residents while at the facility.Procedure: 4. A. Violations of this policy will result in notifications to the attending physician, responsible party, and law enforcement or state agencies as appropriate.D. If a resident violates this policy, the resident may be asked to voluntarily submit drug screening to test for the presence of any illegal substances if there are concerns that suspected drug us could adversely affect the resident's condition. I. If the drug screening is positive, the resident will be discharged to a more appropriate setting according to 'facility discharge procedures. Review of facility's policy titled, Quality of Life-Dignity revised 01/26 indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.Policy Interpretation and Implementation.6. Residents' private space and property shall be respected at all times. A. Staff will knock and request permission before entering resident's rooms. NJAC 8:39-4.1(a)(3)(18)(25)

Based on observation, record review, interview, and policy review, the facility failed to ensure a resident's rooms was clean and in good repair creating a homelike environment for one resident (Resident (R)83) of 175 residents in the facility. Failure to provide a homelike environment has the potential to affect the resident's quality of life.Findings include:Review of R83's admission Record located under the admission tab of the Electronic Medical Record (EMR) revealed R83 was admitted to the facility with diagnoses of dementia, major depressive disorder, and anxiety disorder. Review of R83's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 02/03/26, with a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R83's cognition was severely impaired. Review of R83's care plan initiated on 08/15/24, located under the Care plan tab revealed that R83 had a focus that R83 was at risk for changes in mood related to dementia with interventions in place, to assess for physical/environmental changes that may precipitate change in mood. During an observation on 02/17/26 at 1:26 PM and 02/18/26 at 10:37 AM, revealed R83's room to have old food and trash on the floor, no blinds or curtains on the window, and no personal items hung on the walls or displayed on the furniture. The baseboard near the right side of the door was chipped. R83 did not have a trash can. During an interview on 02/17/26 at 1:26 PM, R83's family member (FM83) stated, .I have been asking nursing staff for curtains for weeks, since they moved her to this room back in October last year. I don't know how they dress her in the mornings with the window wide open like that. You know she doesn't even have a trash can in here. I have been asking for a trash can for weeks .During an interview on 02/18/26 at 11:12 AM, Certified Nursing Aide (CNA) 3 stated when asked when R83 needs assistance with dressing, where does she assist R83. CNA 3 stated, .in his/her room. Sometimes I help him/her inside the bathroom.During an interview on 02/18/26 at 11:17 AM, Registered Nurse/Unit Manager (RN/UM) stated, I have not reported the issue of no blind or curtains on the window.During an interview on 02/18/26 at 11:24 AM, Housekeeping Aide (HA) 2 stated that she was not aware there was no trash can in the room. During an interview on 02/18/26 at 12:39 PM, Maintenance (MAIN) stated that he did not know that there was no blind or curtain on R83's window.Review of the facility's policy titled, Safe and Homelike Environment dated 12/2025 indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . NJAC 8:39-4.1(a)(11)

Based on record review, interview and policy review, the facility failed to ensure a written transfer notice that contained all required information and the bed hold notice was provided for one of four residents (Resident (R)174) and/or their resident representatives (RR) reviewed for hospital transfer out of 36 sample residents. This failure had the potential to result in the resident and their RR to not have the knowledge of where and why a resident was transferred, the bed hold policy and/or how to appeal the transfer, if desired.Findings include:Review of R174's undated Face Sheet in the electronic medical record (EMR) indicated R174 was originally admitted to the facility with diagnoses of chronic respiratory failure, tracheostomy status, and persistent vegetative state. Review of R174's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 02/07/26 at 1:10 PM, . Resident family member did ask the nurse that Resident responsible party [sic]. have instructed we send resident to [name of hospital] for further evaluation as they observed resident left side of his/her face is swollen from forehead to scalp. NP [nurse practitioner].gave order to send resident to [name of hospital] for further evaluation as requested by family. On 02/08/26 at 7:08 AM, the nursing progress note indicated, . patient is being admitted for facial swelling.Review of R174's EMR did not indicate documentation of the facility providing a written transfer and bed hold policy to the resident and RR when R174 was transferred to the hospital on [DATE].During an interview on 02/20/26 at 4:45 PM, the Social Service Director (SSD) stated, The resident went to the hospital on Friday and when I came back to work on Monday, I don't know why I did not send this information by email to the RR. The SSD also confirmed that the bed hold policy and the transfer notice should have been provided in writing to the resident and RR.During an interview on 02/21/26 at 5:00 PM, the Regional Director of Clinical Services stated, The expectation is for the social worker to follow the policy and procedures the facility has in place when a resident is transferred to the hospital.Review of the facility's policy titled, Transfer or Discharge Notice dated 04/2025 indicated, . The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged , d. A statement to the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email, and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed hold policy, f. The name, address, and telephone number of the Office of the State Long-term Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies), h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies), and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. NJAC 8:39-4.1(a)(32)

Based on, record review, interviews, policy review, the facility failed to provide training for three nurses (Licensed Practical Nurse (LPN)1, LPN2 and Registered Nurse (RN)3) to have the knowledge and competency to care for three of three residents (Resident (R)6, R174 and R199) with a tracheostomy. This failed practice had the potential to cause harm to the residents that had a tracheostomy. Findings include:During an interview on 02/17/26 at 2:06 PM, LPN11 was asked what emergency equipment needed to be at the bedside of a resident that has a tracheostomy. LPN1 stated, suction machine, Yankauer suction and a tracheostomy care kit. I don't remember what else needs to be in there. LPN1 was asked if he/she went into the resident's room and the tracheostomy cannula was dislodged, what would he/she do. LPN1 stated, I cannot remember but if you could help me out, I could use it. LPN1 stated that she could not remember receiving any in-service training regarding emergency tracheostomy care at the facility.During an interview on 02/17/26 at 2:45 PM, LPN 2 was asked what emergency equipment should be at the bedside of a resident with a tracheostomy. LPN2 stated, sterile water, Ambu bag, split gauze and a trach care kit. LPN2 was asked what size Shiley cannula did R6 have and he/she stated, Off the top of my head, I don't remember. I would have to look. LPN2 accompanied the surveyor to R6's room and confirmed there was no Ambu bag or obturator in the resident's room with only one size 5.0 inner cannula in the windowsill. During an interview on 02/17/26 at 3:00 PM, LPN1 accompanied the surveyor into R174's room. LPN1 was asked where the Ambu bag and obturator were in the resident's room. LPN1 stated, I have never heard of an Ambu bag or obturator, so I really don't know where they are. During an interview on 02/17/26 at 4:40 PM, the Regional Director of Clinical Services confirmed that he/she would expect the resident with a tracheostomy to have the required emergency equipment at the bedside and in the room as outlined in the policy.During an interview on 02/19/26 at 2:30 PM, RN3 was asked what emergency equipment was needed at the bedside of a resident with a trach. RN3 replied, An Ambu bag, inner cannulas, suction catheters and suction machine, trach care kit, and trach ties. RN3 was asked what size of trach did R6 have and he/she stated, I would have to google it to find out. RN3 accompanied the surveyor to R6's room and the surveyor asked where the obturator was located. RN3 stated, I really don't know. I didn't check my supplies this morning. RN3 stated that she had received emergency tracheostomy care training that morning but was unable to state the size of R6's cannula. RN3 stated that the in-service training indicated that she was to check for emergency equipment at the bedside of tracheostomy residents at the beginning of her shift however, she did not do this. Review of the facility's policy Tracheostomy Care dated January 2026 indicated, . The following disposable equipment should be at the bedside:Spare trach tube - equal in size to the tube in placeBack-up trach - one size smaller for emergencies.Suction kits 14 Fr [French] (trach smaller than 6.0 require 12 Fr)Trach care kitsSplit drain sponges250 ml [milliliters] NSS [Normal Saline Solution]Trach ties-Suction cannister with lid-Suction tubingThe following equipment should be in the room:Suction Canister5-liter concentratorOxygen tank in appropriate holder. NJAC 8:39-5.1(a)NJAC 8:39-27.1(a)

Based on interview, and record review, and review of pertinent documentation it was determined that the facility failed to fully investigate and implement measures to address an allegation that a visitor provided illegal, unapproved substance to a resident with history of substance abuse; which the resident ingested and reported it to the facility. This deficient practice was identified for 1 of 4 resident reviewed (Resident #1). The evident is as followed: A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but not limited to; opioid dependence, anxiety disorder, muscle wasting and atrophy. A review of Resident #1's quarterly Minimum Data Set (MDS), an assessment tool dated 11/4/25, revealed that the resident had a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. A review of Resdient#1's Medication Administration Record (MAR), revealed a physician order initiated on 11/14/25 for Buprenorphine HCL naloxone HCL dihydrate give 1 film sublingually every morning and at bedtime for opioid dependence. A review of the resident's care plan initiated on 10/21/25, revealed in the focus area that Resident #1 has a history of substance abuse and received suboxone for addiction treatment. On 12/4/25 at 10:21AM, the surveyor conducted an interview with Resident #1 who stated that a friend who worked for a transportation company, was in the facility to transport their roommate, and that the friend gave them a brownie that contained marijuana. On 12/4/25 at 2:07PM, the surveyor conducted an interview with the DON who stated that Resident #1 was given edible marijuana by a transportation driver. The DON further stated that the transportation company was contacted, and that the company indicated that no driver assigned to the facility had name that matched the name provided by the resident. The DON stated that since the transport company denied having a driver by the name Resident #1 provided, the facility ended the investigation. A review of the facility's policy Accident and Incident-Investigating and Reporting with a revised date of 1/2025, revealed in the Policy Interpretation and Implementation #1 the The Nurse Supervisor/ Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. NJAC 8:39-33.1(c)

Based on the interview and review of facility records, it was determined that the facility failed to consistently serve the residents a nourishing snack when there were more than 15 hours between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 5 residents (Residents #29, #61, #132, and #144) who attended during the resident council meeting and was evidenced by the following: On 10/11/24 at 10:00 AM, the surveyor conducted a group meeting with 5 alert and oriented residents selected by the facility to attend the group meeting. Four of the five residents stated they did not receive bedtime snacks. On 10/10/24 at 11:19 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the kitchen provided the five units in different floors with bedtime snacks. She could not provide an information if there was an accountability system the nursing staff used to document and ensure the residents were served their bedtime snacks. The FSD stated they do not keep a snack log to document and cannot provide accountability for the snacks that were delivered to the nursing units that showed the daily snack schedule. The surveyor reviewed the for form titled, Resident Council Meeting Minutes dated 7/29/24, 8/26/24, and 9/30/24 which did not address the food and bedtime snacks. A review of the undated facility's policy titled, Meal Delivery Times list reflected the following: First-floor dinner was scheduled to arrive at 4:30 PM and breakfast at 7:30 AM, yielded a 15-hour time gap. The second-floor dinner was scheduled to arrive at 4:45 PM and breakfast at 7:45 AM, which yielded a 15-hour time gap. Third-floor dinner was scheduled to arrive at 5:00 PM and breakfast at 8:00 AM, yielded a 15-hour time gap. The fourth-floor dinner was scheduled to arrive at 5:15 PM and breakfast at 8:15 AM, yielded a 15-hour time gap. Fifth-floor dinner was scheduled to arrive at 5:30 PM and breakfast at 8:30 AM, yielded a 15-hour time gap. On 10/16/24 at 10:15 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). Both LNHA and DON acknowledged that the facility should have a log to document or records the bedtime snacks provided to the residents. A review of the facility policy titled, Snacks, with a reviewed/revised date of December 2023, included the following: It is the center policy to provide: 3) bedtime (HS-hours of sleep) snacks to residents. NJAC 8:39-17.2 (f); 17.2 (f) 1

Based on observations, interviews, and review of facility policy, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to remove the weekly menus posted from resident's rooms who had a physician's order (PO) for NPO (nothing per orem (mouth)). This deficient practice was identified for 3 of 3 residents (Resident #40, #88, and #141) reviewed that had a PO for NPO. The deficient practice was evidenced by the following: 1. On 10/10/24 at 10:13 AM, the surveyor observed Resident #141 seated on a Geri-chair (geri-chair is a large, padded chair that is designed to help seniors with limited mobility) in their room awake with their ongoing tube feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine) machine. The surveyor further observed the facility's weekly menu posted on the wall next to Resident #141's bed. A review of Resident #141 medical records revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), Depression, and Muscle Weakness. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severely impaired cognition. A review of the October 2024 Physician Orders Sheet (POS) revealed a PO dated 9/21/23, NPO diet, NPO texture, NPO consistency. A review of Resident #141 care plan (CP) with a reviewed date of 9/25/24 revealed under the nutrition portion of the CP a Focus titled, Resident is at risk for malnutrition related problem secondary to diagnosis and past medical history of dysphagia, gastrostomy, reliance on TF/PEG to meet nutrition al and hydration need r/t (related to) NPO status. 2. On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed with their ongoing TF machine. The surveyor further observed the facility's weekly menu posted on the wall next to the resident's bed. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia, Gastrostomy, and Muscle Weakness. A review of the Quarterly MDS, an assessment tool used to facilitate management of care, dated 7/2/24, revealed the resident could not have a BIMS score due to cognitive impairment. A review of the October 2024 POS revealed a PO dated 10/5/23 for NPO diet, NPO texture, NPO consistency. A review of Resident #40 CP with a reviewed date of 9/27/24 revealed under the nutrition portion of the CP with a Focus statement titled, Resident is at risk for malnutrition related problem secondary to enteral feeding tube/PEG as their primary source of nutrition and hydration r/t NPO status. 3. On 10/10/24 at 11:30 AM, the surveyor observed Resident #88 awake in bed with their ongoing TF machine. The surveyor observed the facility's weekly menu posted in resident's room on wall, within sight of the resident. A review of Resident #88's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Aphasia (a language disorder that affects your ability to speak and understand what others say), Gastrostomy, and Tracheostomy (hole that surgeons make through the front of the neck and into the windpipe (trachea) for breathing). A review of the Quarterly MDS, an assessment tool used to facilitate the management of care, dated 7/9/24, revealed the resident could not have a BIMS score due to cognitive impairment. A review of the October 2024 POS revealed an order dated 2/2/24, NPO diet, NPO texture, NPO consistency. A review of Resident #88's CP with a reviewed date of 7/10/24 revealed under the nutrition portion of the CP a Focus titled, Resident has enteral feeding tube/PEG as her primary source of nutrition and hydration r/t NPO status. On 10/15/24 at 9:46 AM, the surveyor interviewed the Recreation Director (RD), who stated their department placed the menus in the room, the recreation staff did not have a list of the resident's diets prior to placing the menus. The RD further stated they place a menu for every resident. The surveyor questioned the RD for any residents who had a PO for NPO/do not eat by mouth if it would be appropriate for those residents to have menus posted. The Recreation Director responded, No, it would not be appropriate for those residents to have menus On 10/15/24 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Quality of Life - Dignity with a revised date on 12/2023. The policy statement stated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Under the Policy interpretation and Implementation section of the policy it stated, 1. Resident shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .12. Shall treat cognitively impaired residents with dignity and sensitivity. On 10/15/24 at 12:02 PM, the survey team met with the LNHA, Director of Nursing, Chief Nursing Officer, and Regional Nurse Educator to discuss the above concerns. All agreed that residents who were currently with a PO for NPO should not have menus posted in their room as it is a dignity concern. No further information provided. NJAC 8:39-4.1(a)(12)(28), 17.3(c), 17.4(d)

Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: During the initial tour of the kitchen, the surveyor, together with the facility's Dietary Manager (DM) on 10/9/2024 at 10:15 AM, the surveyor observed the following: Upon entering the room where the dish machine was located, the surveyor observed 2 dietary staff inside cleaning the dishes that were used during breakfast. The surveyor asked the DM to turn on the dishwasher machine. When the DM turned on the dishwasher, the surveyor observed a significant amount of water splashing towards the drying rack where there were trays placed. The DM stated to the surveyor to step back because the dishwasher had water splash. The DM stated that the rack that was placed next to the dishwasher was a drying rack used to dry the meal trays. The surveyor observed the drying rack that was placed right next to the dishwasher machine exposing the trays of water splash from the dish machine. In the drying rack, there were several trays that was observed to be wet nesting and were stacked together in two and three. The DM stated to the surveyor, the trays were used to serve the resident's meals. The DM further stated that the trays were placed there after being washed to dry. The DSD acknowledged that the trays were not supposed to be stacked together to allow them to completely dry. On 10/15/24 at 12:02 PM, the surveyor discussed the above concern to the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Chief Nursing Officer, and the Regional Educator. On 10/16/24 at 10:05 AM, the LNHA stated to the surveyor that the facility does not have a policy and procedure regarding tray drying. The LNHA further stated to the surveyor that the DM agreed that the trays must not be stacked to allow for them to completely dry. No further information was provided. NJAC 8:39-17.1(a);17.2(g)

Based on observation, interview, record review, it was determined that the facility failed to monitor and document any potential side effects (SE) for a resident who was psychotropic medication as per Physician's Order (PO). This deficient practice was identified for 1 of 5 residents (Resident #94) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 10/9/24 at 11:28 AM, the surveyor observed Resident #94 in bed with eyes closed. On 10/10/24 at 11:38 AM, the surveyor reviewed the electronic medical record of Resident #94, which revealed the following: A review of Resident #94's Admission Record (an admission summary) reflected that Resident #94 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory), unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety (feeling of uneasiness). A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 9/26/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status score of 3 out of 15, which indicated that the resident had severe cognition impairment. Further review of the Q/MDS under Section N: High-Risk Drug Classes reflected that resident was on Anti-Psychotic medication. A review of Resident #94's September and October 2024 electronic Medication Administration Record (eMAR) included the following PO: Olanzapine (antipsychotic medication) tablet 5 mg (milligram) give 1 tablet by mouth at bedtime for dementia, with a start date of 7/11/2024. A review of the psychiatric progress note (PPN) dated 7/15/24 documented the resident's diagnosis which included but not limited to, Depression, Dementia, Insomnia (inability to sleep), Psychosis (loss of contact with reality) and Mood Disorder. Further review of the PPN revealed Resident #94 was on Zyprexa (antipsychotic medication) 5mg PO (by mouth) at bedtime for target symptoms including, anxiety, depression, hitting, kicking, and throwing. The surveyor did observe a PO to monitor Resident #94 for any psychotropic medication use SE. On 10/11/24, at 10:59 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the eMAR did not have a PO for monitoring or assessing the psychotropic medication use SE. On 10/16/24 at 10:20 AM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing (DON) regarding the above concern. The DON acknowledged that there was no PO for monitoring or assessing the psychotropic medication use SE. The surveyor reviewed the facility's policy titled Psychoactive Medication Use, with the reviewed/revised date of December 2023 stated under Policy Interpretation and Implementation, 14. Nursing staff shall monitor for and report side effects and adverse consequences of psychoactive medications to the Attending Physician. NJAC 8:39-27.1(a)

Based on observation, interview, record review and policy review it was determined the facility failed to document PO (by mouth) intake of a resident who is NPO (nothing by mouth). This deficient practice was observed for 1 of 9 residents reviewed for Nutrition, Resident #40, and was evidenced by the following: On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed and their ongoing Tube Feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device that is placed with its tip in the stomach or small intestine) machine. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Muscle Weakness. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate management of care, dated 7/2/24, revealed the resident's Brief Interview of Mental Status score could not be obtained due to cognitive impairment. A review of the October 2024 Physician's Order Summary revealed a physician's order dated 10/5/23 for, NPO diet, NPO texture, NPO consistency. A review of Resident #40 care plan (CP) with a reviewed date of 9/27/24 revealed under the nutrition portion of the CP with a Focus statement titled, Resident is at risk for malnutrition related problem secondary to enteral feeding tube/PEG as their primary source of nutrition and hydration r/t NPO status. A review of the most recent progress notes (PN) from the Registered Dietitian (RD) dated 9/27/24 at 6:58 AM stated, RD enteral/quarterly review: Diet order: NPO. Enteral Order: Glucerna 1.2 via G-tube at 75 milliliters per hour (ml/hr)., Total volume to infuse: 1500ml. Free water flush 160ml every 6 hours plus medication pass. This provides 1800 calories, 90 grams protein, and 1850 ml fluid plus medication pass. Recommendations: Continue current nutrition Plan of care (POC), Monitor tolerance to EN support. Goals: Maintain PO meal and snack intake >50% through next review date. See care plan for detailed goals and interventions. Will continue to monitor PO intake. On 10/11/24 at 12:07 PM, the surveyor interviewed the RD#1 via a phone call who stated, Resident #40 was NPO (nothing per orem (mouth) and does not take food or medication via mouth. The RD further stated that she made a mistake documenting to Maintain PO meal/snack intake >50% through next review date in her PN. The facility was unable to provide the surveyor with a policy regarding accuracy of documentation. On 10/15/24 at 12:02 PM, the survey team met with the Licensed Nursing Home Administrator , Director of Nursing, Chief Nursing Officer, and Regional Nurse Educator to discuss the above concerns. All agreed that the residents who had a physician's order for NPO should not have goals or recommendations regarding PO intake in the RD's notes. No further information provided. NJAC 8:39- 29.3 (a)

Based on observation, interview, record review, and review of other documentation, it was determined that the facility failed to: a.) consistently follow a physician's order (PO) for the application of a hand splint to the left arm, b.) consistently document accountability for the placement of heel booties, and c.) follow the residents individualized comprehensive care plan (ICCP). The deficient practice was identified for 3 of 3 residents (Resident #51, #45 and #96) reviewed for positioning and mobility. This deficient practice was evidenced by the following: 1. On 10/9/24 at 11:05 AM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. On 10/10/24 at 12:30 PM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. The surveyor reviewed Resident #51 electronic Medical Record (eMR). A review of the residents Admission Record (AR) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to Dysphagia (difficulty swallowing), Hypertension (elevated blood pressure) and Dementia (loss of memory). A review of the residents most recent Quarterly Minimum Data Set (Q/MDS), a tool used to facilitate the management of care, dated 7/16/24, revealed a Brief Interview for Mental Status (BIMS) score 00 out of 15, which indicated a severely impaired cognition. A review of the October 2024 Order Summary Report (OSR), revealed a PO dated 7/15/24 for bilateral heel booties with no time frame and accountability record for the application or removal for the heel booties. A review of the October 2024 electronic Medication Administration Record (eMAR) and the electronic Treatment Administration Record (eTAR) did not reflect the above PO. A review of the ICCP, revealed a care plan that the resident had the potential for skin breakdown related to total dependence for activities of daily living and incontinence, that included an intervention dated 2/26/24 for heel boots to bilateral feet. On 10/15/24 at 12:42 PM, the surveyor interviewed the Rehabilitation Director, who stated applying the heel boots to the resident are the responsibility of the nursing department. On 10/15/24 at 1:00 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1), who stated that when she cared for the resident she did not know where to document for the application of the heel boots. On 10/15/24 at 1:06 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that for residents who wear heel booties there would be an area on the eMAR or on the eTAR that the nurse would sign for and know what to do for the resident. LPN #1 and the surveyor reviewed the residents eMAR and eTAR and which did not reflect the documentation for the resident's heel booties. On 10/16/24 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) in the presence of the survey team and was informed that the booties were not observed on the resident for the two observation days and that there was no documentation on the eMAR/eTAR for the application for the heel boots. 46889 2. On 10/9/24 at 10:05 AM and 10/16/24 at 11:50 AM, the surveyor observed Resident #45 seated in a wheelchair in the dining room, unable to respond to the surveyor's questions. Resident #45 did not observe the resident wearing a hand splint to the left hand on both days. On 10/16/24 at 9:45 AM, the surveyor reviewed the eMR of Resident #45, which revealed the following: A review of the AR reflected that Resident #45 was admitted to the facility with diagnoses that included but were not limited to Hemiplegia (complete loss of strength on one side of the body) and Hemiparesis (partial weakness on one side of the body) following non-traumatic subarachnoid hemorrhage (bleeding in the brain) affecting left non-dominant side. A review of the most recent Q/MDS, dated [DATE], reflected that Resident #45 had a BIMS score of 7 out of 15, indicating severely impaired cognition. Further review of the Q/MDS under Section GG titled, Functional Limitation in Range of Motion reflected that the resident had impairment on one side of the upper extremity (shoulder, elbow, wrist or hand). A review of the resident's October 2024 OSR reflected a PO dated 4/2/24 for Left palm Splint: Apply after breakfast, remove before dinner check skin integrity to left hand before applying and after removal of the splint in the morning for Splint and remove per schedule. On 10/16/24 at 11:50 AM, the surveyor interviewed CNA #2, who stated that the resident was supposed to wear a carrot splint (a type of orthotic device that is used to position the finger away from the palm to protect the skin from moisture, pressure and nail puncture). CNA #2 went to the resident's room to look for a splint and found the splint on the bedside table. CNA #2 stated that she was unaware Resident #45 had to wear the splint in the morning. On 10/16/24 at 12:01 PM, the surveyor interviewed the LPN#2, who stated that the resident was supposed to wear a splint and added that the CNA's were supposed to put it on the resident and the nurses will document it to reflect that the resident's splint was applied. On 10/16/24 at 12:05 PM, the surveyor interviewed the Director of Rehab/Occupational Therapy (DOR/OT), who stated that Resident #45 had an order for the carrot splint for the left hand; she stated that all the staff, including nurses and the CNAs on the morning shift, was in service of how to put on the splint. On 10/16/24 at 1:15 PM, the survey team met with the LNHA, DON, Chief Nursing Officer (CNO), and Regional Nurse Educator (RNE) to discuss the concern. The staff agreed that if there's an order for devices, the resident should be wearing them. A review of the facility policy titled Splinting Procedure with a reviewed/revised date of December 2023 stated under 8. Nursing staff in-serviced on appropriate application techniques and monitoring requirements specifically associated with equipment . 3. On 10/9/24 at 11:49 AM and 10/17/24 at 10:05 AM, the surveyor observed Resident #96 in bed with eyes closed. On both observation days, Resident #96 was not observed wearing their heel boots on both feet. On 10/16/24 at 1:12 PM, the surveyor reviewed the eMR of Resident #96, which revealed the following: A review of the AR reflected that Resident #96 was admitted to the facility with diagnoses that included but were not limited to Bipolar (a mental illness that causes extreme mood swings) Disorder. A review of the recent Q/MDS, dated [DATE], reflected that Resident #96 had a BIMS score of 10 out of 15, indicating moderately impaired cognition. A review of the resident's October 2024 OSR reflected a PO dated 7/8/24 to Apply heel booties to b/l (bilateral) feet daily while in bed every shift for preventative care. On 10/17/24 at 10:05 AM, the surveyor interviewed CNA#3 regarding the heel boots. CNA #3 went to the resident's bedside table to get them and apply the heel boots to the resident. On 10/17/24 at 10:10 AM, the surveyor interviewed CNA #4 who stated that the resident had their blanket on and CNA#4 did not see whether the resident were wearing the heel booties. On 10/17/24 at 10:20 AM, the surveyor interviewed LPN #3, who confirmed that Resident #96 had a PO for heel booties to both feet while in bed after checking the eMR. On 10/17/24 at 11:00 AM, the surveyor interviewed the DON regarding the above concern. The DON acknowledged that if the resident had a PO for heel boots, it should be followed as stated in the PO. A review of the Facility policy's Medication and Treatment reviewed/revised date of January 2024, Pressure Ulcer/Skin Breakdown-Clinical Protocol reviewed/revised date of December 2023, and Splinting Procedure reviewed/revised date of December 2023, did not address complete orders and accountability documentation for heel boots. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to ensure nutritional evaluation for a resident on a 3-day calorie count were addressed in a timely fashion. This deficient practice was identified for 1 of 8 residents reviewed for Nutrition (Resident #20), and was evidenced by the following: On 10/10/24 at 10:07 AM, the surveyor observed Resident #20 awake in their room. During the surveyor's interview, Resident #20 stated, the food was horrible and were lacking flavor. The resident further added they have not seen the Registered Dietitian (RD) to address these concerns and believed they may have lost weight. A review of Resident #20 Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Gastritis. A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 8/6/24 reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. A review of the resident's Physician's Orders (POs) from the electronic medical record (EMR) for September 2024 included a PO dated 9/11/24, Calorie Count x 3 days Observe at each meal, fluids, po, and snack acceptance. With meals for calorie count, hold TF document percentage (%) consumed. A review of the Nutrition Progress Note dated 9/11/2024 at 10:11 AM stated, . Plan/Recommendations: Initiate a three-day calorie count to assess their nutritional intake. Reassess the appropriateness of continuing tube feedings based on calorie count and weight data. Further review of Resident #20's progress notes revealed no evaluation of the 3-day calorie count was observed until 10 days later following the completion. On 10/11/24 at 9:50AM, the Assistant Director of Nursing (ADON) provided the surveyor with a paper copy of Resident #20's 3-day calorie from 9/12-9/14/24. The surveyor observed there was no meal percentage recording for lunch and dinner on 9/14/24. On 10/11/24 at 10:08 AM, the surveyor interviewed the RD, who stated they work 100% remotely and do not come into the facility. The RD stated, following completion of the calorie count, the RD will assess the resident's meal intake and document a progress note discussing the results and further recommendations for the resident, if any are needed. The RD further stated following the completion of the calorie count, the progress note must be written within a day or two after completion of the 3-day calorie count. The RD added that 10 days between the completion of Resident #20's calorie and progress note was an oversight and should have been completed in a timely manner. No further information was provided. On 10/15/24 at 8:30 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Calorie Counts with a revised date of February 2024. Under the policy interpretation and implementation section, 8. The completed form will be returned to the Dietitian. The Dietitian will review daily caloric intake and average the caloric intake over the three-day period .11. The Dietitian will assess adequacy of caloric intake. If necessary, interventions will be initiated in accordance with current Standards of practice. On 10/15/24 at 12:02 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Chief Nursing Officer, and Regional Nurse Educator to review the above concern. The LHNA stated, they were aware of the late RD evaluation note. No further information was provided. NJAC 8:39 - 11.2(e)(1)(f), 17.1(c), 17.2(c)(d), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's routine pain level assessment was being completed and documented according to the facility's policy and standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #16) reviewed for pain management. This deficient practice was evidenced by the following: On 10/9/24 at 9:45 AM, the surveyor observed Resident #16 awake in bed. The resident reported they had pain to their wound on the back. The resident further stated that they request to take pain medication frequently. On 10/9/24 at 12:17 PM, the surveyor reviewed Resident #16's electronic medical record and revealed the following information: 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 Chronic Osteomyelitis (inflammation of the bone), Open Wound Left Lower Leg, Pressure ulcer of sacral region unstageable, Pressure ulcer of left heel stage 3, and Paraplegia (inability to voluntarily move the lower parts of the body). A review of the most recent Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 8/27/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS reflected under Section J. Pain Management, reflected that Resident #16 was on pain medication regimen. A review of the October 2024 Order Summary Report (OSR) reflected the following pain management which included but were not limited to the following Physician's Orders (PO): Morphine Sulfate ER (extended-release) tablet 15 mg (milligram), give 1 tablet by mouth every 12 hours for pain. with an order date of 3/8/24. Oxycodone Hydrochloride (HCl) oral tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. with an order date of 6/27/24. Acetaminophen tablet 325 mg: give 2 tablets by mouth every 6 hours as needed for mild pain. with an order date of 8/23/24. There were no PO to document the resident's pain assessment and/or pain monitoring. On 10/15/24 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated the resident was alert and oriented, and was able to verbalize if they were in pain. The LPN further added that the resident would request for the pain medication almost every day. The LPN stated they don't complete a pain assessment every shift. On 10/15/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and discussed the above concern. All acknowledged that there was no pain assessment and/or pain monitoring. A review of the facility policy titled Pain Assessment and Management with a reviewed/revised date of January 2024 under General Guidelines 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to accurately complete the resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 33 residents (Resident #45) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 10/9/24 at 10:05 AM, the surveyor observed Resident #45 seated in their wheelchair in the dining room. The resident was unable to respond to the surveyor's questions. On 10/16/24 at 9:45 AM, the surveyor reviewed the electronic Medical Record of Resident #45, which revealed the following: A review of the Admission Record (AR) (an admission summary) reflected that Resident #45 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory), unspecified severity with agitation. A review of the most recent Quarterly Minimum Data Set (Q/MDS), dated [DATE], reflected that Resident #45 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severely impaired cognition. Further review of the Q/MDS reflected in Section N for High-Risk Drug Classes: Use and Indication under the Antipsychotic medication reflected that Resident #45 was taking anti-psychotic medication. A review of the same Q/MDS under Section N, titled Anti-Psychotic Medication Review reflected that Resident #45 did not receive antipsychotics. A review of the resident's October 2024 Order Summary Report reflected a Physician's Order (PO) dated 5/7/24 for Risperidone tablet 0.25 mg (milligram) Give 1 (one) tablet by mouth one time a day for depression with psychosis. A review of Resident #45's electronic Medication Administration Record (eMAR) revealed that the nurses signed the PO for Risperdone from July 17 to 23, 2024 indicating the resident received the medication. On 10/16/24 at 12:01 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #45, who confirmed that the resident was taking Risperdone, an antipsychotic medication of classification. On 10/16/24 at 1:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Chief Nursing Officer, and Regional Nurse Educator to discuss the above concern. All agreed that if there's an order for psychotropic medication, it should reflect yes in the Q/MDS assessment. According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual of October 2024, the RAI manual was revealed under Version 3.0 Manual, pages N-14. Steps for Assessment 1. Review the resident's medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent. On 10/15/24 at 9:32 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) over the phone. The MDSC/RN stated that the psychotropic medication was an error and should be coded as yes. The MDSC/RN added that the facility followed the RAI (Resident Assessment Instrument) manual. On 10/15/24 at 12:02 PM, the survey team met with the LNHA and DON regarding the above concern. All acknowledged that the A/MDS did not reflect the accurate information for the resident. NJAC 8:39-33.2(c)2, (d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) that the Infection Preventionist Nurse (IPN) was aware and involved in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread, this deficient practice has a potential to affect the 172 residents in the facility and b.) that the linens were handled in accordance to standards in order to maintain hygienically clean laundry and prevent the spread of infection for one (1) of five (5) units, (4th-floor unit). This deficient practice was evidenced by the following: 45449 1. On 5/22/23 at 9:53 AM, during an Entrance Conference, the Licensed Nursing Home Administrator (LNHA) in the presence of the Assistant Administrator (AA), and the Director of Nursing (DON) stated that the facility census was 172. On 5/24/23 at 9:19 AM, the surveyor interviewed the LNHA. The LNHA stated that the Legionella Water Management Program was under the task of the Facility Maintenance Director (FMD). He further stated that the testing was conducted by an outside vendor and the results were reported to the LNHA. At that time, the LNHA provided the vendor laboratory certificate result, and the Cleaning Log for the First-floor shower room to the surveyor. A review of the Laboratory Certificate Result from the facility's vendor reflected that the First-floor shower room, 1 (one) of 6 (six) sample point was collected on 02/21/2023 at 12:01 PM. The analyte/test method was for L. pneumophila (Legionella; a bacteria that can cause a serious type of pneumonia, transmitted through small droplets of water in the air) that resulted in 30 MPN (most probable number)/100 ml with a comment of PR. The comment table revealed PR - any numerical result is a cause for concern. A review of the First-floor cleaning log did not indicate what was being cleaned or flushed. At that time, the concern regarding the detection of Legionella pneumophila was communicated to the LNHA. On 5/25/23 at 12:50 PM, during an interview with two surveyors, the LNHA stated the laboratory report that indicated 30 MPN/100 ml of Legionella was found in the first-floor shower room, maybe on the shower head. The LNHA stated the policy indicated that the Water Management Program will be reviewed at least once a year, or sooner if any of the following occurs. The LNHA confirmed the testing samples were delivered on 02/22/23, and he deferred to the vendor's recommendation. On that same date and time, the LNHA stated that he was advised that the location of the result was found in a specific area and not in other areas. The LNHA further stated that he was advised by corporate to clean the area with bleach and to continue with cleaning and flushing. He also stated he was instructed by corporate not to re-test. The LNHA stated that he felt after 3 (three) months of cleaning would be the time to re-test. The LNHA stated he had no basis for the 3 (three) months and that was the advise he received from corporate. At that time, in the presence of two surveyors, the LNHA stated he did not report the result to the local department because the issue was local to that device. He further stated he was not sure if he had consulted with the facility's IPN. Furthermore, the LNHA stated that the Legionella was discussed in the Quality Assurance Performance Improvement (QAPI) meeting on April 27, 2023. The LNHA informed the surveyors that the QAPI was ran by the Assistant Administrator (AA) and he had no knowledge as to who prepared the QAPI action plan for Legionella. When the surveyor asked the LNHA if the IPN should have been involved in the QAPI plan for Legionella, the LNHA had no response. A review of the facility provided QAPI plan, under action plan, reflected, Test conducted in February 2023. Result at 1st floor shower showed strains of Legionella. Total numbers do not exceed acceptable level of 30%. Shower head was removed, bleached, water flushed. Will be repeated and test repeated in May. A review of the facility provided communication from the vendor dated 5/24/23, included: [name redacted] advises our customer [name redacted] to flush the line and retest the site of positive detection and proper flushing should remediate the isolated issue. If after the next test, we see positive still lingering we will come to the facility and preform [perform] a complete facility remediation. No further retest information or result was provided. On 5/25/23 at 01:32 PM, two surveyors interviewed the IPN. The IPN informed the surveyors that she worked in the facility as the infection Preventionist since February of 2023. The IPN stated she heard something from the LNHA and corporate about the Legionella but was not involved in the planning and surveillance. The IPN confirmed she did not receive information back in February 2023. She further stated that she signed her job description. On that same date and time, the IPN stated that she was out of the country during the April 2023, QAPI meeting. The IPN stated that Legionella was part of the infection control and that she should have been involved in the QAPI plan. The IPN reiterated that she did not prepare the QAPI action plan for Legionella for the meeting held on 4/27/23. She acknowledged that part of infection control task of the IP is to follow through the surveillance. On 5/25/23 at 01:45 PM, in the presence of two surveyors, the IPN stated she did not inform the Medical Director and the local public health authorities about the results of Legionella. She further stated that there were no resident who tested positive for Legionella because we did not test the residents. On 5/25/23 at 01:51 PM, the surveyor interviewed the AA in the presence of another surveyor. The AA stated she did not know who prepared the report. She further stated, it was not a significant concern and if it was, we would have notified the IPN. At that same time, the AA stated that generally infection control was directed by the IPN. The AA also stated that Legionella was part of infection control. The AA confirmed that the IPN should have been aware of all infection control information in the building. A review of the facility provided policy, Legionella Water Management Program, reviewed/revised 01/2023, included: Policy Statement; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation, section 2. The water management team will consist of at least the following personnel: a) The infection Preventionist . 5. The water management program includes the following elements: a. An interdisciplinary water management team . A review of the facility provided job description of the Infection Preventionist, responsibilities included the following: -Coordinating the infection control program which includes surveillance, analysis of data, developing reports, educating staff, and implementing policies and procedures. -Use epidemiological principles and statistical methods to design, implement and evaluate infection prevention and control strategies. -Provides consultation and education to staff, physician, and community leaders in respect to Infection Prevention and Control. -Notifies the County and/or State Health Department of any reportable diseases, adhering to all internal county and state procedures. -Ensures the infection prevention and control procedures meet CMS, state, local and CDC regulations, standards or guidelines. 2. On 5/26/23 at 7:57 AM, the surveyor observed that the [NAME] transported the linens to the 4th-floor unit and the bedsheet fell off the floor while transferring it from his clean cart to the unit's clean linen cart. Immediately, the [NAME] picked up the bedsheet from the floor and directly placed it in between clean linens and bedsheets in the unit's clean linen cart and continued transferring the remaining linen sheets. The 4th-floor clean linen cart was between room [ROOM NUMBER] and the exit door. During an interview, the [NAME] informed the surveyor that he works in the Housekeeping department for [AGE] years. He stated that if the linens fell off the floor, they should be discarded into the dirty linen supply and should not be mixed with clean linens. The surveyor then asked [NAME] why he put back into the unit clean linen cart the sheet that fell off the floor. The [NAME] stated that it was the bedsheet that fell off the floor. At that time, the [NAME] took the bedsheet that fell off the floor from the unit's clean linen cart and put it in the clean linen cart that he brought into the unit where there were a few clean linens left. The [NAME] further stated I'm probably rushing, that was why he put back the dirty bedsheet that fell off the floor into the unit's clean cart. The surveyor asked the [NAME] what he will do now. The [NAME] did not respond and continued to finish transferring linens from his cart to the 4th-floor linen cart. Afterward, the surveyor did not find an available nurse in the unit except for the DON. The surveyor approached the DON who was currently observing the dining area on the 4th floor with residents inside the dining area. The surveyor notified the DON of the findings and observation. The DON stated that the [NAME] should not put back the dirty bedsheet that fell off the floor back into the clean linen cart and all the linens that the [NAME] put the dirty sheet should be discarded and considered dirty. At that same time, the surveyor and the DON observed the [NAME] pushing his linen cart to another end of the unit and did not remove the remaining linens in the unit's linen cart. In addition, both the surveyor and the DON observed a face towel fell on the floor while the [NAME] pushed his linen cart, and the [NAME] picked up the face towel off the floor and placed it on top of his linen cart. The DON instructed the [NAME] to remove all linen supplies that the [NAME] transferred to the unit's clean linen cart and discard them since it was contaminated with a bedsheet that fell off the floor. The DON further stated to the surveyor that he will talk to the Housekeeping Director and make sure to re-educate the staff about the proper handling of linens. 05/26/23 at 8:57 AM, the surveyor asked the Regional Director of Clinical Compliance (RDCC) for a copy of the facility's policy with regard to Handling of Linen and she stated that she will get back to the surveyor. On 6/01/23 at 9:42 AM, the surveyor interviewed the IPN regarding the [NAME] who handled the linens on the 4th floor on 5/26/23. The IPN informed the surveyor that she was notified on the same date it happened and education was provided immediately to the [NAME]. The IPN stated that the [NAME] acknowledged that he should have not put the contaminated bed sheet that fell on the floor with the rest of the clean linens and bedsheets in the linen cart of the 4th-floor unit. The IPN further stated that the [NAME] should have placed the contaminated bed sheets from the floor in a bag, disinfect the linen cart, and discarded the other linens and bedsheets because they got into contact with a contaminated bed sheet that fell on the floor according to the facility practice to prevent infection. On 6/01/23 at 12:53 PM, the survey team met with the LNHA, DON, Regional Administrator (RA), and AA and made them aware of the above findings. A review of the facility's Laundry and Bedding, Soiled Policy with a review/revised date of 01/2023 and included that soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen and that soiled laundry and bedding should be placed in a contaminated laundry bag or container. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, RDCC, and AA. There was no additional information provided by the facility management and did not refute the findings. NJAC 8:39-19.1, 19.4(a)(e), 21.1(b)(d)(e)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure certified nurse aide (CNA) credentials were verified upon hire. This deficient practice was identified for 4 (four) of 5 (five) newly hired staff reviewed, (CNA #1, CNA #2, CNA #3 and CNA #4) and was evidenced by the following: On 6/07/23 at 01:48 PM, the surveyor reviewed the facility provided employee files of five randomly selected newly hired employees. The review included the following: CNA #1 with a date of hire (doh) of 3/21/23 had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. CNA #2 with a doh of 3/27/23 had a NJDOH online Public Registry license verification printout which was dated 4/21/23 which was after the doh. CNA #3 with a doh of 5/15/23 had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. CNA #4 with a doh of 5/8/23 did not have a NJDOH online Public Registry license verification printout. There was no documented evidence that the status of the four newly hired CNA's licenses were verified prior to the staff having direct contact with residents of the facility. On 6/08/23 at 9:27 AM, the surveyor interviewed the Director of Human Resources (DHR) regarding the process for hiring new employees. The DHR stated that for nursing staff, she would check their credentials, licenses and vaccinations. She then stated that all employees receive a background check before they start working. She added that she uses another system that monitors their license but it does not show if the license is active. She then stated that she would verify if their license was active and print out the verification sheet and keep it in their file. The surveyor asked if the date was on the verification sheet. The DHR stated that when you print out the license verification, it had the date on it to show the date you did it. On 6/08/23 at 10:22 AM, the surveyor showed the DHR the CNA's files. The DHR stated that she did not know why CNA #2 had a date that was after the doh. She then stated she did not know why the other CNA's did not have a date. The DHR did not know why CNA #4 did not have a printout. On 6/08/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) the concern that there was no documented evidence that the 4 (four) CNA's had their license verification done prior to their doh. The LNHA stated that he did not think it was required to have a date on the them [printouts] but that he would check. On 6/08/23 at 11:00 AM, in the presence of the survey team, the Assistant Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Compliance and Chief Nursing Officer, the LNHA stated that the DHR checks the newly hired staff's license before they start work and that she printed it but that she did not print it with a date. He then stated that CNA #2's printout must have been an updated copy. The LNHA then added that he did not think it was required to have dates on the printouts. The facility did not have a policy for the new hire process. A review of the facility provided policy titled, Policy for Resident Abuse Investigation with a reviewed/revised date of 10/2022 included the following: SCREENING: Employees are screened via Department of Health License Verification Line and are in-serviced on facility's abuse policies as part of orientation and thereafter as part of regular in-service program. Background check is conducted by outside service of all employees prior to hire . [Facility] does not employ individuals who have been Found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment of residents by a court of law; or Have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of property; or Have a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriation of resident property. N.J.A.C. 8:39-43.15(a)

NJ#00163298 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate, a.) timely report, (Resident#372 and #117) and b.) a hematoma of unknown origin on 4/07/23 of Resident#95. This deficient practice was identified for three (3) of seven (7) residents reviewed for abuse and was evidenced by the following: 1. A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 4/10/23 at 9:00 PM, with an event date of 4/07/23 at 11:56 PM. The incident was reported as an allegation of resident-to-resident abuse. The event was described as follows: While Resident #372 was transferring from bed to wheelchair, Resident #117 allegedly pulled Resident #372's wheelchair from underneath him/her. This resulted in Resident #372's fall with no injury. The FRE showed there was no plan of care or planned interventions prior to the event. Further review of the event reflected that Resident #117 was sent to the hospital for psychiatric evaluation, psychology and psychiatric consults were ordered. The residents were moved to separate unit and would remain in separate units. The report also reflected the prescriber, responsible parties, and Ombudsman were notified. The surveyor reviewed the medical record for Resident #372. The Admission Record (AR; or face sheet; an admission summary) reflected that the resident had been admitted with diagnoses which included venous insufficiency (chronic; peripheral), thrombocytosis (increased platelet), muscle weakness, acquired absence of the right leg, above the knee, muscle weakness and unsteadiness on feet. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 4/25/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Further review of the qMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident #372 required extensive assistance (resident involved in activity; staff provide weight-bearing support) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) with 1 (one) person physical assist from staff. The individualized Care Plan (CP) revealed a focus that included, Resident #372 with a high risk for falls related to amputation and muscle spasms. The interventions included: anticipate and meet the resident's needs, the resident's call light is within reach and the resident needed prompt responses to all requests that were initiated on 10/20/22. Psych consult and Psychology consults were added to the interventions after the resident-to-resident abuse that was initiated on 4/11/23. The facility provided PN for Resident #372, dated 4/07/23 at 02:24 AM by Registered Nurse#1 (RN#1), documented the following: At 11:50 PM [4/06/23], the patient reported to the nurse . At 12:00 AM, the supervisor arrived on the unit At 12:30 AM, the police arrived At 12:40 AM, telehealth with doctor conducted patient reported pain [scale of] 6 (six) out of 10, Tylenol was given by nurse. Doctor told patient he/she does not need to go to the ER (emergency room ), she will order x-rays . At 01:00 AM, transport arrived to bring resident to the hospital, resident declined. Patient was sitting on the wheelchair resting, non-labored breathing. The facility provided PN by the Registered Nurse/Supervisor (RN/S) on 4/07/23 at 12:55 AM, reflected Late Entry The resident stated his/her roommate pulled his/her wheelchair from underneath him/her while he/she was transferring causing him/her to fall on the floor; An assessment was conducted and rendered no redness, or alteration in skin integrity; The assessment indicated the resident was able to flex and extend bilateral upper/lower extremities. Emergency Response arrived on the unit. Further review of the PN by the RN/S reflected telehealth was conducted via dual video Conference/Assessment was completed, and new orders of x-Rays were provided for the resident. Neurological Assessments were also ordered. The PN revealed that Neurological screens were provided on 4/08, 4/09 and 4/10. The documentation of Neurological Monitoring sheets by the nurses were not provided. The PN also reflected that on 4/10/23 Nurse Practitioner#1 (NP#1) reviewed the x-rays with results of no fracture/dislocation on bilateral ribs, left shoulder, right shoulder; the lumbar spine did not indicate a fracture. The bilateral hip result showed no dislocation or obvious fracture, CT/MRI (computed tomography/ computed tomography; medical imaging methods that creates images of the internal body that includes bones and soft tissue) is recommended if occult (hidden) fracture is suspected. A review of the risk assessment dated [DATE] at 6:19 AM, indicated that Resident #372 had a predisposed physiological factor of gait imbalance and a predisposed situation of above the right knee amputation. 2. The surveyor reviewed the medical record for Resident #117. The AR reflected that the resident had been admitted with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertension, other seizures, other abnormalities in gait and mobility, muscle weakness, need for assistance with personal care, anxiety disorder, depression, vitreous opacities, unspecified eye (floaters that blocks light from reaching retina which may cause mild to severe vision loss), other symptoms and signs appearance and behaviors. The qMDS dated [DATE], reflected that the resident had a BIMS of 8 (eight) out of 15, which indicated the resident had a moderately impaired cognition. Further review of the qMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident # 117 required supervision (oversight, encouragement, or cueing) for walk in room (how resident walks between locations in his/her room) and walk in corridor (how resident walks in corridor on unit with setup help from staff). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) (excludes to/from bath/toilet)) reflected limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) required 1-person physical assistance from staff. The individualized CP revealed a focus that included, Resident #117 had limited physical mobility related to neurological deficits. The interventions included, Resident #117 required extensive assist by staff to walk using a walker, date initiated 11/01/21. A review of the PN reflected the following: -4/04/23 at 5:40 PM, pacing back and forth on the unit, combative with staff, verbally abusive with staff, hitting staff, fall precautions maintained. Very difficult to redirect, refer to psych for evaluation. -4/05/23 at 12:20 PM, combative, verbally abusive to staff, very difficult to be redirected, refused nursing care and treatment, wandering on the unit, continue to be redirected, referred to psych for evaluation. -4/06/23 at 7:15 AM, behavior monitoring in progress. Redirected multiple times -4/06/23 at 16:03 resident alert and verbal. Observed with anxiety and agitation. Constant redirection required and provided. Resident refused to follow verbal redirection . -4/06/23 at 7:49 PM, patient continues to be on behavior monitoring, As needed Ativan (antianxiety medication) given . -4/06/23 at 12 AM, reflected Late Entry, RN/S documented she was called to the unit by assigned nurse to assess the resident within the room for aggressive behavior towards roommate .Resident #117 was asked to leave in [dialect redacted]. The resident refused and became aggressive with staff, Ativan 1 (one) mg (milligram) was administered at 11 PM, which rendered ineffective by behavior. [redacted] notified dual /video conference assessment completed. - 4/07/23 at 00:31 AM, the telehealth assessment and plan included the NP sent Resident #117 to the Emergency Department (ED). -4/07/23 at 01:30, RN#1 authored a PN that included the following: At 9 PM, all due meds [medications] given and tolerated At 10 PM, wandering hallway going into resident's rooms, redirected . At 11 PM, pt [patient] anxious, wandering the hallway going into other resident's room, Ativan 1 (one) mg given. At 12 AM, supervisor arrived to the unit, patient laying in bed refusing to get up and leave the room to be placed in another room At 12:30 AM, the police arrived, pt remained non compliant At 12:50 AM, ems took patient to hospital breathing non labored. Responsible party and Medical Doctor notified by supervisor A review of the electronic Administration Record, reflected Resident #117 received Ativan 1 (one) mg on 4/06/23 at 4:20 PM, documented as effective. The following dose was signed administered on 4/07/23 at 12:50 AM, documented as ineffective. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 4/05/22 revealed Resident #117 was referred to OT for reasons that included: increased, decrease in strength, functional mobility, reduced ability to safely ambulate, reduced balance, decreased neuromotor control, decreased coordination, decreased judgement, cognitive deficits . The facility provided, Summary of Investigations reflected that when Resident #117 was interviewed, the resident was unable to remember the incident during an interview with a [dialect redacted] speaking staff, due to cognitive impairment. The Summary of Investigations reflected that Resident # 372 was in bed and went to transfer. That was when Resident #117 moved the wheelchair out of Resident #117's path. Resident #372 added that the sudden transfer of the wheelchair caused the alleged fall. Resident #372 called the police and gave a statement. The Emergency Response (Police) report was not provided. The facility provided Summary of Investigations reflected Certified Nursing Aide#1 (CNA#1) was interviewed. CNA #1's statement reflected what she had heard on the night of the Resident # 372's reported un-witnessed fall. A review of the schedule for 4/06/23, reflected there was one RN and two CNAs assigned to Resident #372's unit from 11 PM to 7 AM. CNA #2's statement and other ancillary staff 's statement and interviews were not documented within the summary of investigation. A review of CNA assignment sheet dated 4/06/23 11 PM to 7 AM shift, revealed CNA #2 was assigned to Resident #374's room, beds 1, 2, and 3. There were no documented interviews of other residents within the investigation summary report provided. On 5/30/23 at 12:49 PM, during interview with the survey team, the Director of Nursing (DON) stated we used a form called Unusual Occurrence for statements from the CNA, nurses, and risk management. The DON stated that all notes on investigation were in the resident's PN. The DON also stated that the resident's roommates would also be interviewed. At that time the Licensed Nursing Home Administrator (LNHA), stated the staff and residents were interviewed verbally and documented immediately. The facility places all of the interventions, investigation and conclusion were also documented. The CP was also updated. The LNHA stated that the nurses have to monitor the residents for an undetermined amount of time. At that time, the LNHA was unable to inform the surveyors where the monitoring is documented to prevent an incident from occurring again. On that same date and time, in the presence of the survey team, DON and LNHA, the surveyor requested for all the staff statements relating to the FRE. On 06/02/23 at 10:14 AM, during an interview with the surveyors, the LNHA stated there were no incidents or accidents or reportable for Resident #372 and #117 in the last 6 months. On 6/07/23 at 11:31 AM, during an interview with the survey team, the LNHA stated there should have been more statements collected. The LNHA stated that the other nurses on this shift should have been interviewed. The LNHA acknowledged that the investigation was not thorough, and the investigation process could be improved. The above finding and concerns were discussed with the LNHA. On 6/07/23 at 12:35 PM, the LNHA confirmed the resident-to-resident abuse reported occurred on 4/06/23 as opposed to the reported date of 4/07/23. The LNHA confirmed the investigation could have been better and more interviews should have been conducted. A review of the facility provided policy, Assessing Falls and Their Causes reviewed and revised 01/2023 under Steps in Procedure; After a Fall: section 1. If a resident has just fall or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 38327 3. On 5/26/23 at 7:35 AM, the surveyor asked the Regional Director of Clinical Compliance (RDCC) about Resident#95's incident/accident reports, and the RDCC stated that she will get back to the surveyor. On 5/26/23 at 7:43 AM, the surveyor observed the resident laying on the bed with eyes closed, the cockup splint (used as a post-traumatic rehabilitation aid to get the injured wrist back in shape) on top of the nightstand. On 5/30/23 at 12:03 PM, a review of Resident #95's Risk Assessment investigation report dated 4/07/23 was provided by the LNHA revealed that on 4/07/23 at approximately 6 PM, the resident was found crying at the hallway wherein RN#2 asked the resident why she was crying and the resident showed their right hand, the RN noted hematoma above the right wrist. The resident's description showed that the resident was unable to give a description. The Risk Assessment also showed that the resident was not taken to the hospital. The injuries observed at the time of the incident showed that the injury location was right hand back, the injury type and injury location was blank and there was no documented measurement and description of the hematoma. The investigation also indicated that there were no witnesses found. In addition, the attached care plan in the provided investigation showed that the focus was that the resident was at risk for falls r/t (related to) poor safety awareness, pacing initiated on 6/18/20 with an intervention initiated 4/10/23 moved closer to the nurses station. There was no intervention dated 4/07/23 to reflect the incident about the unknown, unwitnessed hematoma. The LNHA's provided Risk assessment dated [DATE] did not include statements from staff. Further review of the above investigation of Resident #95's unknown hematoma and the unwitnessed incident report revealed there was no documented statement from the other residents on the same unit, direct care staff, and any ancillary staff who may have had contact with the resident. On 5/31/23 at 9:53 AM, the DON provided another Risk Assessment investigation copy of the unknown hematoma to the right hand dated 4/07/23 at 6 PM. The information in the 4/07/23 Risk Assessment that was provided by the DON was the same as what the LNHA provided on 5/30/23 except for the question: Resident Taken to Hospital which had an answer now with Y (Yes). The provided Risk Assessment of the DON included Unusual Occurrence Statements from CNA#4 and Licensed Practical Nurse (LPN). The staff investigative statements were as follows: 1) One statement from CNA #4 that included The nurse notified me that Resident#95 had an injury to his/her right arm. I was feeding residents and collecting trays afterward. 2) A second statement from the LPN included Nurse/CNA reported resident in hallway crying and holding his/her right wrist. Resident unable to say what happened. Telehealth was called. Portable x-ray ordered. Family notified. 3) A third statement from DON typewritten dated 4/10/23 (three days after the incident), indicated that Resident #95 was interviewed by the DON in the presence of the Director of Maintenance (DOM) as a Spanish interpreter. The statement from the DON showed that the resident was asked regarding the bruising to the right wrist area. The resident was questioned about what happened and the resident responded that he/she fell out of their bed onto their arm. Further review of the Staff Investigative statements of Resident #95's incident report revealed there was no documented statement from the other residents on the same unit or any ancillary staff who may have had contact with the resident on 4/07/23. The staff statements did not include information on who, when, where the resident was last seen and what was the resident doing before the incident happened. In addition, there was no further investigation on 4/10/23, after three days, when the DON found out from the interview with a Spanish interpreter to determine the root cause and analysis of the fall incident. The surveyor reviewed Resident #95's medical record. The resident's AR reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential hypertension (high blood pressure), type two diabetes (abnormal blood sugar level), insomnia (common sleep disorder), unspecified dementia with other behavioral disturbance (cognitive impairment), major depressive disorder, anxiety disorder, and age-related nuclear cataract bilateral (the center of the eye's lens becomes thick and discolored). The resident's most recent qMDS with an Assessment Reference Date (ARD) of 3/28/23 reflected that the resident had a BIMS score of 99 which indicated the resident was unable to complete the interview. The qMDS revealed that staff assessment for mental status was conducted due to the resident's unable to complete the interview and showed that the resident's cognitive skills for daily decision-making had a score of 2 (two) which indicated that the resident's cognition was moderately impaired. A review of the resident's individualized CP with an initiated date of 6/18/20 reflected a focus area that the resident had a potential impairment to skin integrity r/t (related to) fragile skin and on 3/16/23 with skin tear to right lower back. There was no evidence that the 4/07/23 right wrist hematoma was identified and included in the care plan. There was no evidence that there were interventions identified and created on 4/07/23 to reflect the unknown hematoma incident. Further review of the resident's personalized CP with an initiated date of 4/21/23 reflected a focus area that the resident had an ADL (activities of daily living) self-care performance deficit r/t dementia with an intervention initiated on 4/21/23 that resident was on NWB (no weight bearing) to the right hand, provided wrist cockup splint, and to be worn after AM (morning) care and removed PM (afternoon) care. In the electronic medical records, PN dated 4/07/23 at 7:29 PM by RN#2 revealed that at approximately 6 PM, the resident was found crying in the hallway and noted a hematoma above the right wrist. In the PN dated 4/07/23 at 7:45 PM by NP#2 showed that the resident was evaluated via telehealth because of the hematoma and swelling to the resident's right lower arm above the wrist and that the resident was not sent to the ED. NP#2 ordered for stat x-ray of the arm and hand. The note of NP#2 also showed that the staff did not know how it happened, no reported fall, and the resident had dementia and can not tell what happened. On 5/31/23 at 10:58 AM, the surveyor notified the above findings to the DON. The surveyor interviewed and asked the DON about the 4/07/23 investigation because the injuries observed at the time of the incident and injury type in the Risk Assessment were not complete which did not include the measurements and description of the hematoma. The surveyor asked the DON if a skin assessment was done on 4/07/23. The surveyor asked also the DON why there was no documentation of what were the interventions after the resident returned from the hospital on 4/08/23. The DON stated that he will get back to the surveyor. On 5/31/23 at 11:13 AM, the surveyor interviewed the DOM who informed the surveyor that his primary language was Spanish. The DOM stated that the resident was Spanish speaking and cognitively impaired. The DOM indicated that the resident does not remember names, times, or dates, and stated that Resident#95 just talked to me because I speak Spanish, other than that I know he/she is confused. He further stated that I know it's in April but I can't remember what exact date when the DON asked him to be the interpreter for the resident. On that same date and time, the DOM informed the surveyor that when he and the DON went to the resident, the resident was asked about what happened, the resident responded that the resident rolled over the bed to the floor and got up. The surveyor then asked the DOM if the resident was asked what was the resident doing before the resident rolled over the bed when the resident fell , if was there someone in the room, and other information that will determine the root cause analysis of the fall incident that resulted in the injury. The DOM stated that after that question about what happened and the resident responded, the DOM and the DON left the resident and there were no further questions asked to the resident. On 6/01/23 at 8:49 AM, The surveyor called and left a message to CNA#4, the CNA who wrote a statement on 4/07/23. On 6/01/23 at 9:46 AM, The surveyor interviewed the LPN who informed the surveyor that she was also the facility educator and does med pass and care of residents. The LPN stated that she remembered the 4/07/23 incident of the resident because it so happened that she was on the 3rd floor at that time when it happened while doing routine rounds as a covering supervisor on that day. The LPN found the resident crying in the hallway with some residents passing by, and the resident was stating in Spanish dolor, dolor, (dolor means pain in Spanish) while the resident touched their right hand. The LPN further stated that at that time the right wrist was slightly swollen, we don't know what happened and where the resident got the hematoma. The surveyor then asked the LPN if the resident had a fall incident on that same date, and the LPN responded that the resident did not fall. On that same date and time, the LPN informed the surveyor that I think the CNA was busy with something but not sure if the CNA was passing trays or helping other residents. The LPN acknowledged it was an injury of unknown origin at that time, and I know from other facilities if that was the case, they go back 72 hours lookback of staff statements. The surveyor asked the LPN if there were staff statements 72 hours from the time of the incident, the LPN stated: I'm not sure if that is what we do here also and don't know if that was done because 4/07/23 was a Friday and I was off during the weekend. Furthermore, the surveyor asked the LPN if there was a skin assessment done on 4/07/23. The LPN stated that there should be a skin assessment for that incident, and the skin assessment should be part of the Risk Assessment. She was unable to remember the name of the nurse at that time who did the Risk Assessment, the LPN stated It was an agency nurse who did the Risk Assessment and the nurse should have included the description of the injury including the measurement, color and what part of the body and if there were other injuries to the other part of the body. At that time, the surveyor notified the LPN that the Risk Assessment did not include the measurement and other descriptions of the injury. The surveyor asked the LPN why the 4/07/23 Risk Assessment did not include the description of injuries and if she as a Supervisor at that time checked if the Risk Assessment was complete. The LPN stated, I don't know. The LPN indicated that after that day she did not know what else happened because she was off the weekend. On 6/01/23 at 11:20 AM, the surveyor called both RN#2 and CNA#4 for the second time. CNA#4's voicemail was full. On 6/01/23 at 11:38 AM, the surveyor received a return call from RN#2. The surveyor interviewed the RN in the presence of another surveyor. The RN informed the surveyor that she was an agency nurse and worked at the facility one time only and was unable to remember when she worked. The RN stated that she remembered it was on the 3rd floor 7 AM-7 PM shift. She acknowledged that the nurses at the facility work 12 hours shift and the CNAs works eight hours shift. RN further stated that she remembered that she was passing medications (meds) I think and the CNAs were passing trays, Spanish speaking Resident # 95 was in the hallway, and had a scratch, I think it was a skin tear but we do not know what happened and why the resident had it but the doctor was called and the supervisor. RN stated that I can't remember who was the supervisor and I did the incident report in the Risk Assessment on the computer on the same date. She further stated the resident was ambulatory, We called the responsible party about the incident, and after that I don't know what else happened. On that same date and time, the surveyor asked RN#2 if she remembered doing a skin assessment since the incident was of unknown origin, the RN stated that whatever in the computer in Risk assessment that's what she documented. RN#2 acknowledged that the skin impairment was an injury of unknown origin. She further stated that since the skin impairment was in the hand she did not think that the other part or whole body should be assessed for possible injury. The RN indicated that she was not sure if it was a bruise or skin tear because she was not sure what was on the right hand. In addition, the RN stated that the right hand should have documentation of the size or measurement of impairment and a description of the injury, and if it was not documented in her Risk Assessment, she claimed that she probably forgot to do so. Furthermore, RN#2 informed the surveyor that the resident did not fall and we don't know what happened and why the resident sustained the injury. She further stated that there should be a staff statement at least 24 hours or 72 hours before the incident since it was unknown but not sure if the supervisor did it and asked for it. On 6/01/23 at 12:53 PM, the survey team met with the LNHA, DON, Regional Administrator (RA), and Assistant Administrator (AA) and was made aware of the above findings. The surveyor asked the facility team why there was a discrepancy with the Risk assessment concerning the question of the resident being taken to the hospital with two different answers different on two submitted copies of LNHA and DON. The surveyor asked the facility team why the Braden Scale for Predicting Pressure Sore Risk (BSPPSR) was initiated on 4/07/23 at 12:50 PM signed and locked on 5/26/23 which the DON claimed was the skin assessment done to the resident for 4/07/23 unknown hematoma incident that happened approximately 6 PM. The surveyor also asked the facility team why the Morse Fall Scale was done on 4/08/23 and was also signed and locked on 5/26/23 after the surveyor's inquiry. On that same date and time, the surveyor asked the facility team why there were no v/s (vital signs; blood pressure, heart rate, respiratory rate, and temperature) taken and recorded at the time of the incident at 6 PM. The LNHA stated that he will get back to the surveyor. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, RDCC, and AA. The LNHA stated that the Risk Assessment on 4/07/23 was not locked. The LNHA further stated that when the DON noticed on 5/26/23 that the investigation was not locked, the DON went in and signed it off that was where the discrepancy for the question of if the resident was taken to the hospital responses were different. On that same date and time, the LNHA acknowledged that there were discrepancies from the provided documents to the surveyor and the LNHA stated that the facility should have done better with documentation and gathering of statements for the investigation. At that same time, the surveyor asked the facility team why there was no investigation for a fall when the team concluded after three (3) days that the incident of unknown origin hematoma was from a fall incident. The LNHA stated that we concluded it was from a fall that the resident sustained hematoma. The LNHA agreed that the interventions should have been done when the team concluded that the hematoma was from the fall and should have further investigated the fall. The LNHA further stated that the investigation was not properly documented we should have done more including the appropriate interventions other than moving the resident closer to the nursing station. Furthermore, the DON stated that I do agree that the investigation should have been thorough. The LNHA further stated that definitely the investigation was lacking information. A review of the facility's Policy for Resident Abuse Investigation with a reviewed/revised date of 10/2022 provided by the LNHA in the Entrance binder of the facility included that in any investigation, in any instance of mistreatment, neglect, or abuse of residents, misappropriation of their property, or injuries of unknown source an incident report is completed. Surveillance procedures for any injuries sustained are followed. Appropriate supervisory personnel is notified, and the investigation begins promptly after the report of a problem. Statements or interviews of the resident, suspect (if identified), any eyewitnesses, and any circumstantial witnesses are taken. Relevant documentation is reviewed. The alleged victim is examined promptly and the finding is documented in the report. Injuries of unknown origin, are investigated by going back 24 hours and speaking to all direct care personnel, to see if when and how the bruise occurred can be ascertained. On 6/08/23 at 01:18 PM, the survey team met with the LNHA, DON, Chief Nursing Officer (CNO), RA, and AA, and there was no additional information provided by the facility. NJAC-8.39-4.1(a)5; 9.4(f)

C#: NJ 5, NJ 1 Based on observations, interviews, review of medical records (MRs), and other pertinent facility documents on 1/25/2022 and 1/27/2022, it was determined that the facility failed to follow their policies and procedures titled Abuse and Neglect-Clinical Protocol and Resident Abuse Neglect and Mistreatment [The Law] for a resident who encountered verbal abuse from staff. This deficient practice was investigated and identified for 1 of 3 residents (Resident #2), involving three staff members, and placed Resident #2 at risk for psychological harm. This deficient practice was evidenced by the following: Review of a revised facility policy dated 1/2021 titled; Abuse and Neglect-Clinical Protocol included under Definitions 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of good (s) or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology .4. Willful as defined at 483.5 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of a second facility's undated Policy titled Resident Abuse Neglect and Mistreatment The Law included under Policy included, All residents must be treated with dignity and respect. In the event that an allegation of verbal, sexual, physical, or mental abuse is made regarding a resident, a prompt investigation must be conducted by the administrative staff, and their findings must by (be) reported in (a) timely manner, as specified later in this Policy. Under Definitions included Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma cause physical harm, or pain or mental anguish. The Policy also revealed Verbal Abuse refers to any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. A further review of the Policy under Policy and Procedure for Abuse Prevention (continued) included the following: 1. Screening: . Two references (preferably from previous employers) . ASI registry check of current CNA (Certified Nursing Assistant) certification for new hires, with criminal background check completed. . State Board Registry Check, as well as visible check of nursing licenses. . 90-day probationary period with strict monitoring and orientation. . Outside service providers providing services on resident care units will provide the following proof of employment pre-screening requirements prior to providing services at the facility: a. License/certification numbers pertaining to their profession. Expiration dates, and license validation will be checked through New Jersey consumer affairs. b. Criminal background verification or employment application which indicates employee has never been convicted of a crime (such as crimes of abuse/neglect, violence, dishonesty, financial or personal misconduct, etc.) 2. Training: . All orientees regardless of department affiliation attend initial orientation on identifying abuse and reporting abuse, with handouts pertaining to definitions and types of abuse, how to report knowledge of possible abuse to supervisors, including use of toll-free reporting that can be done anonymously. . All employees in all departments attend regular staff in services annually and as needed to maintain knowledge and promote prevention of abuse; including identifying instances of possible abuse, how to report allegations, how to recognize increased stress, signs of burnout and frustration that may lead to abuse situations. What constitutes abuse, neglect, mistreatment and misappropriation of resident property. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Focus with orientation and in-servicing in caring for difficult or aggressive residents and what options are available to caregivers to avoid abusive situations; i.e. changing assignments, buddy-system, etc. including 1:1 counseling if needed. 3. Prevention: On admission and during regularly scheduled interdisciplinary meetings, quarterly, annually and as needed with families, residents and staff, provide information on how and to whom they may report all concerns, complaints and issues of possible abuse, neglect or misappropriation of personal property. Provide reassurance of no fear of retribution and outline plan of immediate investigation and intervention. Prevention Plan includes, but is not limited to the following: A. Environmental rounds by supervisors in each department of secluded areas that may make abuse and/or neglect more likely to occur B. Unit meetings with staff to discuss care issues, complaints and concerns to avoid frustration, lower stress and decrease burnout. C. Meetings of department heads to review all previous 24 hour incident reports and Supervisor's Investigative reports to determine possibility of abuse. D. Staff scheduling daily to balance units according to resident census and acuity level. E. Shift-to-Shift daily report involving direct care staff to ensure continuity of care and empower staff with knowledge beforehand to avoid frustration in meeting residents' needs. F. Supervision of staff daily in performance of job duties to identify potential abuse/neglect; i.e. foul language, rough handling, neglect, with immediate intervention. 4. Identification: Immediate incident reporting (refer to Accident/Incident Policy & Procedure) and investigation of all falls, bruising, skin teras; increase in depressive, isolative fearful behaviors, and occurrences that may constitute abuse. Chain of command monitoring of incidents from charge nurse to Supervisor to Director of Nursing to Administration to determine scope of investigation. 5. Investigation: A. The charge nurse or nursing supervisor will conduct a full body assessment (if the allegation is physical abuse) and document all findings in the medication record. B. Initiate emergency care for resident as warranted. C. complete Unusual Occurrence Report according to Accident and Incident reporting Policy and procedure. D. R.N. (Registered Nurse) Supervisor to complete Supervisory Investigate report with interviews and written statements from all persons involved, including the resident, if possible, investigate three prior shifts. E. If the allegation is against an employee, the employee will be removed from the workplace once the statement has been taken and will be suspended pending completion of the investigation. Union protocol to be followed if applicable. Resident to be protected against possible retribution . H. All written statements and documentation are to be completed and maintained under separate file cover in the Director of Nursing's office . K. Director of Nursing is responsible for the completion of abuse policy and procedure appropriately. 6. Protection: All residents involved in an investigation are monitored closely to avoid further disruption of daily quality of life. Interventions are implemented by Social Services Department and Nursing Administration with (the) resident and family. Immediate removal of threat, where an employee, other resident (s), social circumstance, or physical hazard, to provide security and safety. Counseling (is) available when warranted. 7. Reporting: All violations and alleged or suspected incidents of any form of abuse/neglect will be reported via LTC.reportables@doh.nj.gov system or if computers not available to Department of Health to [PHONE NUMBER] or in off hours to 1-609-392-202. If resident is 60 or over report will also be made to Ombudsman Office at [PHONE NUMBER]. Calls to Ombudsman must be within 2 hours if suspicious event results in injury and within 24 hours if event does not cause injury. This deficient practice was evidenced by the following: During a tour on 1/25/2022 at 12:21 p.m., the Surveyors interviewed Resident #2, who appeared emotional and stated, I've been dealing with ongoing harassment, I feel targeted and bullied with the Administrator. Resident #2 said three separate incidents involving three staff members: the Social Worker (SW), the Director of Nursing (DON), and a nurse occurred. Resident #2 said all of the incidents happened within the past two weeks. Resident #2 stated on 12/27/2021, the former DON called me a prostitute in front of the Administrator, and he did nothing. The resident explained the issue was due to a room change, and she refused. According to Resident #2, the DON said, [why don't you want to switch rooms? You won't be able to prostitute]. Resident #2 stated other residents were present, but he/she didn't want to say who was there. According to Resident #2, another incident occurred on 1/3/2022 with a nurse on the 4th floor who said, me she will f . me up, and the SW yelled at me and called me a prince/princess. During an interview on 1/25/2022 at 2:04 p.m., the SW stated that Resident #2 requested to go out on pass on a Friday, 12/17/2021, but the resident did not give 72 hours' notice per the facility's policy, so the pass was denied. The SW further stated the resident emailed her about the pass at 3:00 a.m. that morning, then he/she came to the lobby and was yelling and using profanity, so the SW felt threatened, so she called the Police, who took a statement from her and the resident. After the Police left, the resident stayed in the lobby yelling at her, so she yelled back at the resident and called the resident a prince/princess. The SW stated she then informed Resident #2 that the Administrator would meet with the resident on Monday. The SW said I should not have raised my voice and the name-calling was unprofessional. She stated she had a meeting with the Administrator and Resident #2 the following week, and she was removed as the resident's SW. During an interview on 1/25/2022 at 2:46 p.m., the Licensed Practice Nurse (LPN) stated Resident #2 came to the fourth floor from the fifth floor on the elevator, and she told Resident #2 he/she was not allowed on her floor due to quarantine and Covid. The resident walked past her and went down the hall; the LPN called the Director of Nursing on the phone with no reply and then the Administrator. There was another staff there (the Receptionist). The LPN stated Resident #2 used aggressive language towards her and behaved in a threatening manner. The LPN explained, I may have said, I'll f . you up! I don't remember; I didn't curse at (him/her). She continued to explain, I used expressive language. Cursing is unprovoked, verbal language. The LPN said, .what I said was inappropriate . She also stated that she did not document the incident and did not receive training on abuse at the facility. The LPN further explained to the Surveyors that she spoke to the Administrator on 1/3/2022 about the incident involving Resident #2, and he said he would handle it. She was not asked to provide a statement about the incident. During an interview on 1/25/2022 at 3:53 p.m., the Administrator stated he was leaving for the day on Friday afternoon (12/17/2021) at 3:00 p.m. when Resident #2 wanted to go out on pass; the resident kept pushing the idea but needed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . So, on that Monday, he met with the SW and Resident #2 and the agreement was to switch the SW. The Administrator further stated this incident went to a place that was not professional. He met with the SW that Monday and counseled her on the verbal unprofessionalism and name-calling that happened with Resident #2. The Administrator explained, I don't feel the resident was threatened by it. The resident knows exactly very well (how) to follow protocol. When asked by the Surveyor what he meant by the SW was counseled? He explained he told the SW not to raise her voice and name-call. I don't feel the resident felt threatened. (The resident) was not getting what( he/she) wanted because the pass was not approved. According to the Administrator, Resident #2 said he/she felt angry & humiliated and being picked on. The Administrator explained when the incident occurred between Resident #2 and the LPN; the resident went to the fourth floor from the fifth floor to shower. The nurse said to the resident, You shouldn't be down here, and the resident used profanity towards the nurse. According to the Administrator, Resident #2 threatened to hurt the LPN physically. When asked by the Surveyors why he did not complete an investigation, the Administrator stated Resident #2 manipulated staff and instigated both incidents. He explained, I did an investigation, I did the camera, spoke to the Receptionist and the resident. The Administrator explained: there's a camera but no audio footage. He received a statement from the Receptionist ( who observed a portion of the incident between the LPN and the resident) and thought he got a statement from the nurse, but he had to check on it. The Surveyors continued to interview the Administrator about the incident with the former DON on 12/27/2021. He explained that Resident #2 was in a private room, the room was needed for isolation, and the resident did not want to move. According to the Administrator, the DON said the resident wanted the room for prostituting; it was unprofessional. He continued to explain Resident #2 verbally puts down staff; there was only so much someone could take, but there is always room for improvement. As a result, he verbally counseled the DON and removed her from the floor, and the ADON (Assistant Director of Nursing) would interact with the resident. The Surveyors asked the Administrator how he counseled the DON? He explained: to remove self from the situation, sustain a professional tone of voice and word choice. There was no copy of the counseling because it was done verbally. When the Surveyor asked the Administrator what was verbal abuse, he replied, I would consider verbal abuse to be the words that would make the resident feel threatened, scared to do something . it hits you, I'm scared to do this, shakes me, shuts me down .goes a step further than talking, afraid to do something. In my eyes, I don't see the resident feeling threatened or scared. When the Surveyor asked the Administrator if he asked the resident how he/she felt after each of the incidents, he replied the following: After the SW incident, I didn't ask his/her feelings until Monday, and the resident said his/her [feelings were angry, upset, and felt like you're picking on me]. The resident did not say, my needs are not met; never said I feel scared or threatened After the incident with the nurse, he further explained that the resident called me on the phone and complained of the nurse using profanity. The Administrator explained with the DON ane Resident #2's incident he was present, and the resident was upset, not scared or threatened. The Administrator stated, I'm good with body language; I could tell the resident was not threatened. He/she was angry and upset. During a phone interview on 1/25/2022 at 4:48 p.m., the former DON stated she asked Resident #2 to change his/her room, which the resident previously agreed to do, but things escalated. Resident #2 said he/she could not change the room because the resident was transgender. This was the first time I heard this about the resident. It was out of the left field. There was no clinical indication for him/her to have a private room. I might have said he/she was making that up. I said, it's difficult to be a prostitute when you have roommates. I was frustrated The DON continued to explain, . I did act out of line. I'm a professional and a DON. I'm upset with myself. It's hard to keep emotions in line The DON stated, . I let emotions get the best of me. It was not a professional thing to do. The Surveyor asked the DON if referring to Resident #2 as a prostitute was appropriate. She replied, Of course not, it was not appropriate, I would not act in that way. She explained after the situation escalated, she walked away. According to the DON, the Administrator spoke with her after the incident. It was unprofessional. I already knew. She stated she did not write a statement. The DON stated, I don't think it was verbal abuse. I don't think (he/she) felt threatened by what I was saying to (him/her). During an interview on 1/25/2022 at 5:13 p.m. with the current DON (the former ADON), he stated he was rounding the floors when Resident #2 and the former DON altercation happened. According to the DON, he vaguely remembered it. He recalled there was a lot of yelling, but he could recall the exact words. When the Surveyor asked him, what verbal abuse was, he replied, definitely the intent to do harm During an interview on 1/27/2022 at 11:33 a.m. with the Receptionist, when the Surveyor asked her about the incident on 1/3/2022 with the LPN, she explained, she got off the elevator on the fourth floor, the resident told the nurse, [You think I threw water on you yesterday? I'm going to put my hands on you today]. During a second interview on 1/27/2022 at 12:00 p.m., Resident #2 stated the issue was not what happened. It's the Administrator not doing anything or protecting me. When the Surveyor asked Resident #2 how he/she felt after each incident, Resident #2 explained the first incident with the SW. Resident #2 felt embarrassed, so he/she reached out to the Administrator, and they had a meeting two days after. Resident #2 stated during the meeting, the SW continued to be demeaning and, rolling her eyes, she got up and walked out of the meeting. The resident said he/she then told the Administrator there needs to be accountability and requested the SW be changed, and she was removed. Resident #2 further explained the second incident involving the DON, the Administrator, and the DON was standing in the resident's doorway. The resident, he/she, didn't want to move; it was his/her home. According to Resident #2, the DON told her in a condescending voice, I won't be able to prostitute. The Administrator didn't do anything. He had no response or no defense. The resident stated he/she felt embarrassed, uncomfortable, horrible, and sad. He/She did not want to leave his/her room. Resident #2 stated he/she did not speak to the Administrator about this incident. Resident #2 stated the LPN; there was a personality clash. Resident #2 knew the nurse from the fifth floor, where they had a previous conflict. According to Resident#2, he/she went to visit a friend on the fourth floor. The nurse said to Resident #2, Take your disrespectful ass off the floor, and then the resident replied, what else are you going to do? Then, the nurse said to the resident, I'll f you up! The resident replied, do it! The resident went to see the Administrator and told him what had happened. The Administrator said to Resident #2, what do you want me to do? The resident said to him, I can't feel safe here. The Administrator asked the resident to explain what he/she meant by that statement. The resident continued to explain what happens if he/she sees the nurse on the elevator and the nurse wants to f k me up? He/she stated at the moment, I felt angry Afterwards, I felt very unsure and unsafe with the nurse. The nurse could do something to me. During a second interview on 1/27/2022 at 12:32 p.m., the Administrator indicated he didn't see the result of the harm to the (resident) as being humiliated. He explained the resident felt comfortable with each incident; the SW was switched, the ADON was the clinical point of contact, and the nurse was switched to another floor. He stated, I was involved with all the resolutions and spoke to the resident. The Surveyor showed the Administrator a copy of the Abuse Policy and asked him if he followed it; he explained that he assessed and de-escalated the situation, he told the former DON to go away, and he would handle it. He spoke to the resident that he/she could stay in the room and figured out a solution with the resident. He stated the resident repeated that he/she was angry and upset, there was no anguish, and the resident was comfortable with the solution. The Administrator further explained he de-escalated and handled the situation concerning the nurse incident and found a resolution. The Administrator stated he spoke to the nurse and the resident, he did not remember what the nurse said, but it was profanity. The Administrator said Resident #2 told him the resident said the profanity first, and the nurse repeated the words back to the resident. He informed the resident that the nurse was moved to another floor, and he told the resident, I'll make it a safe situation. He informed the resident if the nurse was there to call him. The Administrator stated the resident felt angry, but he didn't recall the resident saying he/she felt unsafe. The Administrator explained that if the resident would've said he/ she felt threatened, he would have reported the incidents to the NJDOH. He also said I would have reported it to NJDOH and get a Psychiatrist or Psychologist to see him/her; if I knew she felt like that, I would have acted on it. The Administrator stated he would like everyone to be more professional. Also, after the Surveyor's visit on 1/25, he has now implemented behavioral training on how to handle, de-escalate situations, and not react. He further explained counseling was done in the conference room, talked about the incident, what each person thought happened, how it fits into policy and mission statement, and the staff would sign it; but he did not do it with these three incidents. He only counseled each staff with no documentation. During the exit conference on 1/27/2022 at 1:57 p.m., in the presence of the current DON, ADON, and Regional Nurse Consultant, the Surveyor asked the Administrator what is the meaning of the word derogatory, as stated; in the facility's Abuse Policy under Verbal Abuse? The Administrator replied that Derogatory means it was more than regular name-calling, putting someone down, not on the same level as everyone else, and context, tone. At the time of the survey, the facility could not prove a thorough investigation was completed for each incident for the verbal altercations between Resident #2 and the aforementioned staff members. A review of the Electronic Medical Record (EMR) revealed the following: According to the facility Admission Record, Resident #2 was initially admitted to the facility 2/6/2021 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS), an assessment tool, dated 12/21/2021, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15/15, meaning the resident was cognitively intact and the resident was independent with all Activities of Daily Living (ADLs). A review of Resident #2's Care Plan (CP) included under Focus: Resident has impaired behaviors related to refusals of care/vital signs/weights . dated 2/13/2021. Under Goal: Resident will adjust to facility staff and routines. The resident will be compliant and cooperative with care and treatments through the next review date, revision dated 9/3/2021, under Interventions/Tasks: Avoid power struggles and confrontation . Encourage verbal communication/simple words to communicate wants and needs. Further review of the CP showed under Focus: Resident has evidence of ineffective coping and behavioral symptoms related to: History of Drug abuse dated 2/6/2021. Under Goal: Resident will not consume alcohol or drugs while residing in the facility through next review date, revision dated 9/3/2021, under Interventions/Tasks: Psychology consult as needed, set firm limits to prevent manipulation. N.J.A.C.: 8:39-4.1 (a) 5

Complaint # NJ 8, NJ 7 Based on observations, interviews, review of Medical Records (MR), and review of other pertinent facility documents on 12/15/20 and 12/18/2020, it was determined that the facility failed to ensure that a resident with a recent resident to resident sexual encounter with a cognitively impaired resident, was consistently monitored to protect, and prevent against further abuse of other cognitively impaired residents from sexual abuse for 1 of 3 residents (Resident #1) sampled for abuse. When on 12/15/20, Resident #1 was able to enter Resident #3's room, who is severely cognitively impaired, and nonverbal, and was able to lift the covers, and her nightgown, before a staff member could intervene. Resident #1 was placed on 1:1 monitoring on 12/15/20 at 8:40 a.m., for the inappropriate behavior. On 12/15/20 at 10:15 a.m., during a tour observation of the unit it was observed by the surveyor and the Unit Manager (UM) that the assigned Certified Nursing Assistant (CNA #1) left Resident #1 unattended and the surveyor observed no other staff in the area. The facility also failed to follow their policies titled Safety and Supervision of Residents and Abuse Prevention Program to protect residents from abuse for 1 of 3 residents (Resident #1) sampled for abuse. This placed all residents with cognitive impairment living on the unit in an Immediate Jeopardy (IJ) situation. The IJ was identified on 12/18/20 at 2:21 p.m., when the Administrator (ADMIN) and the Director of Nursing (DON) were notified of the IJ situation and were provided the IJ template. The Immediate Jeopardy was Past Non-Compliance and ran from 12/15/20 at 10:15 a.m., to 12/15/20 at 12:00 p.m., when CNA #1 was in-serviced on 1:1 monitoring and the facility provided an acceptable Removal Plan to remove the immediacy which included staff in-servicing. This deficient practice was further evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 10/19/20, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated that the resident had moderate cognitive impairment. The MDS also revealed that Resident #1 required supervision with Activities of Daily Living (ADLs) and self-propels in the wheelchair on the unit. 2. According to the AR, Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 11/24/20, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3/15, which indicated that the resident had severe cognitive impairment. The MDS also revealed that Resident #2 required supervision with ADLs and was able to ambulate ad lib on the unit with supervision. 3. According to the AR, Resident #3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 10/21/20, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 00/15, which indicated that the resident had severe cognitive impairment. The MDS also revealed that the resident required total staff assistance with ADLs and is unable to transfer or ambulate independently. Review of Resident #3's Progress Notes dated 11/17/20 at 10:03 a.m., the Nurse Practitioner documented that the resident is only able to communicate non-verbally with head nods and mouthing words. According to the documentation on the Facility's Reportable Event Record/Report (FRE), reported to the New Jersey Department of Health (NJDOH) by the DON on 12/8/20, with an event date of 12/7/20 at 3:40 p.m., the DON reported the type of incident as Resident to Resident sexual interaction. According to the Summary of Investigation (SOI) the DON documented that Resident #1 and Resident #2 were observed by the staff having sexual intercourse together in bed in Resident #1's room. When the staff entered the room Resident #2 stated: we are two consenting adults, and everyone should mind their own business. The DON also documented on the SOI that the incident appeared to be an isolated incident. According to the statements on the FRE which were obtained by the facility staff regarding the incident, the Certified Nursing Assistant (CNA #2) reported, she was making rounds and observed 2 residents in a resident's room having sexual intercourse. She notified the nurse and upon returning to the room she recognized the 2 residents as Resident #1 and Resident #2. The Licensed Practical Nurse (LPN#1) reported, that she was called to the room by the CNA and upon arrival she observed Resident #1 on top of Resident #2. Both residents had their pants down and the curtain was closed. The LPN also reported that Resident #2 stated, we are two consenting adults, and this is what we want, and everyone should mind their own business. LPN #2 reported that she was also called to the room by the CNA and upon arrival she observed Resident #1 on top of Resident #2 on the bed and in-between Resident #2's legs. Both residents without their pants on. Resident #2 verbalized mind your business, we are two consenting adults. According to the FRE, statements were taken from Resident #1 and Resident #2 after the 12/7/20 incident. Resident #1 acknowledged what happened and expressed feeling badly because he did not want anyone to get in trouble. Resident #2 stated that she is a consenting adult, and this is what she wants, and she had not experienced anything like that in years and it is no one else's business. The FRE also indicated that the facility staff reported the incident to the Primary Nurse Practitioner (NP), the Psychiatric NP, the Emergency contact of both parties and Local Law Enforcement on 12/7/20. In addition, the FRE verified that the residents were immediately separated and seen by the psychiatric nurse practitioner. Changes were made to Resident #1's [CONDITION(S)] medications. Resident #1 was moved to another unit/floor to deter any further incidents between the two residents. Resident #2 was sent out to the hospital for an evaluation and gynecological exam and sexually-transmitted disease (STD) panel. Both residents were placed on 30-minute documented checks for one week. Review of Resident #1's Care Plan (CP) dated 12/7/2020, revealed a Focus of: Impaired behaviors related to 12/7/2020: alleged sexual contact with another resident. Interventions in place included but were not limited to: Transferred to another floor, 30 minute checks in place for one week, consultation with psychotherapy regarding thoughts and feelings, and further management of sexual desires and expression. Seen by psych and medication [MEDICATION(S)] discontinued and [MEDICATION(S)] started. According to the documentation on the FRE dated 12/8/20, the DON reported the following summary of the investigation: In my best professional opinion, I do not believe that any abuse occurred. Both residents appear to have consented to engaging with one another. Despite a BIMS score of 3, Resident #2 articulated that she is a consenting adult and showed no signs of emotional, psychological, physical harm following the incident. Medical and psychiatric evaluations immediately following the incident confirmed that no harm occurred. However, given Resident #2's dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Both residents will be seen by the psychologist to discuss appropriate sexual expression in a facility. At this time the residents have been separated. According to the Psychiatry Progress Note dated 12/7/20, Resident #1 was seen by the Psychiatric NP and the following recommendations were made: unit change, decrease the [MEDICATION(S)] dose for 5 days then discontinue the medication, start/continue psychotherapy to address the behavior, and start [MEDICATION(S)] for [CONDITION(S)]. According to the Psychiatry Progress Note dated 12/7/20, Resident #2 was seen by the Psychiatric NP and the following recommendations were made: continue medications, send the resident to the hospital for an evaluation, monitor and document every 30 minutes for 7 days, start/continue psychotherapy to address inappropriate behavior. During an interview on 12/15/20 at 9:30 a.m., the DON reported that Resident #1 was placed on 30 minute monitoring on 12/7/20, for one week then it was discontinued. The DON also stated that Resident #1 had no other contact or sexual events with any residents prior to this incident on 12/7/20 with Resident #2. During an interview on 12/15/20 at 9:55 a.m., the DON reported that in addition to the incident on 12/7/20, between Resident #1 and Resident #2, there was another incident involving Resident #1 that morning on 12/15/20 at 8:30 a.m. Resident #1 was observed by staff members in another resident's room, he was observed lifting the covers and the nightgown of Resident #3 who is nonverbal and unable to express her needs. According to the DON Resident #1 was immediately removed from the room and placed on 1:1 monitoring for inappropriate behavior. The psychiatric NP was notified of the second incident involving Resident #1 and the NP reported to the facility staff that the behavior could be a side effect of the medication [MEDICATION(S)], and that was why the medication was decreased, but it could take a while for the [MEDICATION(S)] to get out of the residents system. The DON also reported that the Social Worker (SW) will investigate placing Resident #1 in a facility that has an all-male unit. Resident #1 will remain on 1:1 monitoring for safety until he is transferred out of the facility. During a tour observation on 12/15/20 at 10:15 a.m., accompanied by the unit manager (UM), upon entering the room, Resident #1 was observed by the surveyor to be in his room sitting in his wheelchair without a 1:1 monitor/staff member in sight. No staff member was observed in the room, in the hallway, or outside of the doorway to Resident #1's room. During an interview on 12/15/20 at 10:16 a.m., the UM was asked where the monitor should be? The UM responded that the 1:1 monitor should be with the resident. The UM further stated that a 1:1 monitor is someone who is with the resident at all times. During this interview the surveyor and the UM observed the CNA #1 assigned to the 1:1 monitoring of Resident #1 come out of the physical therapy department/break room. During an interview on 12/15/20 at 10:16 a.m. with the CNA#1/1:1 monitor assigned to Resident #1 on 12/15/20, reported she started monitoring the resident around 8:45 that morning and she was told to watch the resident from a distance. When asked why she left the resident the CNA stated: I went to take my 15-minute break. My breakfast came. I was hungry. It was 5 minutes that I was gone from him, 5 minutes. I was told to be there but not on top on him. The CNA further stated she did not get anyone to cover for her while she took her break. On 12/15/20 at 10:20 a.m., the surveyor observed the physical therapy department/staff break room, which was located at the end of the hallway, appropriately 30 feet from Resident #1's room. Observed was a kitchenette on the right side with a table and chairs. Resident #1's room was not visible from the kitchenette. During an interview on 12/15/20 at 10:25 a.m., the UM reported that he had given CNA #1 instructions on 1:1 monitoring that morning, by instructing her to remain with the resident at all times and she should not have left the resident without someone covering for her. The UM manager also reported that a 1:1 observation is someone who is with the resident at all times. In addition, the UM reported that staff sometimes take their breaks in the PT room. During an interview on 12/15/20 at 10:55 a.m., the UM reported that at 8:40 a.m., he was making rounds on the unit and saw Resident #1 in Resident #3's room in his wheelchair he self-propels . I saw him near the bed . he was lifting her gown up. The housekeeper was passing and came in. The covers were down, and he was lifting her gown. He pulled the gown up and I could see her brief. He did not pull the brief down. He further stated that he immediately put Resident #1 on a 1:1 monitoring and notified the DON. Review of the facility document provided to the surveyor by the DON on 12/18/20, revealed that Resident #1 was monitored by the staff every 30 minutes from 4:00 p.m., on 12/7/20, to 9:00 a.m. on 12/15/20, when placed on 1:1 monitoring. On 12/18/20 at 12:44 p.m., the facility's security video camera recording was reviewed for the 12/15/20 8:30 a.m., incident involving Resident #1 entering Resident #3's room and allegedly lifting the covers. The video was reviewed in the presence of the Admin, DON and the Executive Director. The video verified that Resident #1 did enter Resident #3's room at 8:27 a.m., by self-propelling his wheelchair. The video also verified that the UM and the Housekeeper (HK) never entered the room while Resident #1 was inside Resident #3's room. The video recording revealed that the HK saw Resident #1 in the room from the hallway and went immediately to the nursing station to notify the UM. When the UM got to the room Resident #1 had already back out of the room in his wheelchair and was in the hallway. Review of the facility document titled One to One Inservice/Education dated 12/15/20, indicated that CNA #1 was educated on the role and duties of her job as a 1:1 monitor to Resident #1. She signed to acknowledge that she will not leave the resident unattended without another staff member in place to consistently monitor the resident until she returns. The document was signed by the UM and CNA #1 on 12/15/20 at 12:00 p.m. Review of the facility policy titled Abuse Prevention Program with a revised date of 12/2019, revealed the following under Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident symptoms. Review of the facility policy titled Safety and Supervision of Residents with a revised date of 12/2018, revealed the following under Policy Statement: Our facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Under Individualized, Resident-Centered Approach Safety: section #5: Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions. The IJ was identified on 12/18/20 at 2:21 p.m., when the Admin, the Executive Director and the DON, were notified of the IJ situation. The IJ was Past Non-Compliance and ran from 12/15/20 at 10:15 a.m., to 12/15/20 at 12:00 p.m., when the facility provided an acceptable Removal Plan to remove the Immediacy. The Removal Plan included in-servicing the CNA who left Resident #1 unmonitored on 12/15/20. The Removal Plan was verified the second day 12/18/20, of the survey. The surveyor observed Resident #1 with a 1:1 monitor in place on 12/18/20 at 3:35 p.m. A planned discharge to another facility was scheduled for 12/18/20 at 4:00 p.m. N.J.A.C. 8:39-4.1(a)5

C #: NJ 3 Based on interviews, record review, as well as review of other facility documents on 9/14/20 and 9/15/20, it was determined that facility failed to ensure a safe environment by not implementing their written policies and procedure to prohibit and prevent Resident abuse for 1 of 4 residents (Resident #1). On 5/25/20 approximately 6:00 am to 6:30 am, Certified Nursing Aide (CNA #1) stated that when she walked into the dining room, she saw Resident #2 (cognitively intact) touching Resident #1 (cognitively impaired) pants. Resident #2 told CNA #1 that Resident 1 wanted it. The facility failure to investigate, report and taking corrective actions when an incident was identified on 5/25/20 involving Residents #1 and #2, resulted in Resident #2 being sexually assaulted by Resident #1 the following day on 5/26/20, which led to Resident #1's hospitalization requiring emergency treatment and received prophylaxis medication for Sexually Transmitted Disease and [CONDITION(S)]. This deficient practice is evidenced by the following: 1. According to the Admission Record (AR) Resident #1 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 3/12/20 showed that the Resident was cognitively impaired and required extensive assistance from staff with Activities of Daily Living (ADLs). The MDS showed that the Resident would require supervision in ambulation. The Focus care plan for Resident #1, was initiated on 5/26/20, showed that the Resident was care planned for Sexual abuse as evidenced by an unusual occurrence on 5/26/20 involving a Resident (Resident #2). According to the AR Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS for Resident #2 dated 5/14/20 showed the Resident was cognitively intact and required supervision from staff with ADLs. The MDS showed that the Resident would require supervision in ambulation. The undated Focus care plan for Resident #2, showed that the Resident was on [CONDITION(S)] medication related to [CONDITION(S)], Anxiety and [CONDITION(S)]. Intervention included but was not limited to: on 5/26/20, the Resident was sent to the emergency room (ER) for evaluation and the Police Department was notified. The Resident did not return to the facility. The Facility Reportable Event (FRE) dated 5/26/20 at 4:00 am involving Residents #1 and #2 was called in to the New Jersey Department of Health (NJDOH) on 5/26/20 at 2:00 pm. Attached with the FRE the form INVESTIGATION INTO INCIDENT OF SEXUAL ABUSE involving Residents #1 and #2. This form showed that on 5/26/20 at approximately 4:00 am during rounds, CNA #1 saw Resident #2 getting off of Resident #1 who was lying in bed. Resident #2 verbalized that Resident #1 wanted it. Resident #2 verbalized that Resident #1 was his/her girlfriend and Resident #2 had sex with Resident #1. Resident #2 revealed that he/she had prior sexual encounter with Resident #1 which was last night (5/25/20) at 3:00 am. However, the NJDOH did not receive the FRE nor the facility conduct an investigation regarding an incident on 5/25/20 involving Residents #1 and #2, which was witnessed by CNA #1 and reported to Licensed Practical Nurse (LPN #3). The same form under Summary of the Investigation showed that on 5/26/20 at 4:00 am, CNA #1 saw Resident #2 in Resident #1's room. Resident #2 was getting up off of Resident #1 who was lying in bed, both clothing below the waist were not present. Resident #2 verbalized having sex with Resident #1. Resident #1 did not respond to the questions and refused to be examined. The Police Department was notified and interviewed both residents. Resident #1 was sent to an Acute Care Hospital (ACH) for Forensic Sexual Assault evaluation and Resident #2 was transferred to another ACH for Crisis evaluation. The facility NEW JERSEY UNIVERSAL TRANSFER FORM [NJUTF] for Resident #1 dated 5/26/20 under the reason for transfer showed Sexual Abuse Sexual Molested by another Patient. The surveyor conducted a tour with the Licensed Practical Nurse (LPN #1), on the 5th floor on 9/14/20 at 9:30 am. LPN #1 stated that Resident #1 was confused and Resident #2, who no longer at the facility was very alert, oriented and ambulatory. The surveyor conducted an interview Resident #1 on 9/14/20 at 9:55 am, the Resident just stared at the surveyor and could not answer the questions. The surveyor conducted an interview with Resident #3 (the roommate of Resident #1), who had intact cognition, on 9/14/20 at 9:58 am. Resident #3, unable to recall the exact date and time of the incident, stated that a Resident came into their room twice and told Resident #1 that he/she was his/her woman. The privacy wall between the Resident #3 and Resident #1 prohibited Resident #3 to see who was the other Resident talking to Resident #1. Resident #3 recalled not able to use the call bell because it was not working at that time. However, a staff member came in and told the other Resident to leave the room. Follow up interview with Resident #3 on 9/15/20 at 10:15 am, the Resident stated that he/she would feel terrible if someone would touch them without their consent. Resident #3 would not let anyone touch him/her because Resident #3 would beat that person up. Resident #3 stated that the facility staff should protect them. Furthermore, the Resident stated that this was like a bad dream, painful and being sent to the Hospital would not help. On 9/14/20 at 12:12 pm, the surveyor conducted a telephone interview with the LPN #2 (the primary nurse for Residents #1 and #2, who worked on the night shift at 11:00 pm-7:00 am. She stated that when residents were on monitoring or frequent supervision they would tell the CNAs at the beginning of their shift. She stated she could not recall if there was monitoring in place for Residents #1 and #2 when she worked on the aforementioned shift. She recalled that in May 2020, was the peak of Covid 19 and residents were not allowed to be together neither were they allowed to come out of their rooms. CNA #1 did not tell her and it was on the report that there was an incident between Residents #1 and #2 in the DR on 5/25/20 between 6:00 am and 6:30 am. She explained if she knew about it, these Residents would not be on the same floor if possible or would be on constant monitoring such as one to one monitoring Continued interview with LPN #2 on 9/14/20, she stated she was not aware of the incident involving Residents #1 and #2 when they were found in the DR together. However, she knew about the incident on 5/26/20 at approximately 4:00 am. LPN #2, stated what was on the aforementioned FRE. She stated that Resident #1 was confused and unable to explain what had happened on 5/26/20. The LPN stated on 5/26/20, Resident #1 was naked, incontinent brief was on the floor, which made her believe something had happened. Resident #2 told LPN #2 that Resident #1 was his/her woman and they had sex. LPN #2 stated that after she was alerted by the CNA #1, she immediately reported to the nurse supervisor and the former Director of Nursing (DON). Residents #1 and #2 were assessed and transferred to an ACH separately. The surveyor conducted a telephone interview with CNA #1 on 9/14/20 at 1:17 pm. CNA #1 stated she was doing her rounds on 5/26/20 at approximately 4:00 am and noticed that Resident #2 was not in his/her room. CNA #1 immediately went to check Resident #1's room and she went on to state what she witnessed on the aforementioned FRE dated 5/26/20 at 4:00 am. CNA #1 stated the reason she went directly to Resident #1's room to look for Resident #2 was because she saw both Residents in the Dining Room (DR) on 5/25/20 at approximately 6:00 am to 6:30 am the previous morning. Continued telephone interview with the CNA #1 on 9/14/20 and 9/17/20. She stated that she was the CNA for both Residents #1 and #2 at 11:00 pm to 7:00 am from 5/24/20 into 5/25/20. She revealed at approximately 6:00 am to 6:30 am, when she walked into the 5th floor DR, she saw Resident #2 touching the pants of Resident #1. She revealed that Resident #1's pants was slightly pulled down from his/her waist. CNA #1 asked Resident #2 what was he/she doing and the Resident stated that Resident #1 wanted him/her to touch Resident #1. CNA #1 explained that Resident #1 could not consent to the touching because Resident #1 was confused. CNA #1 stated that what she saw was inappropriate touching and with or without consent from Resident #1 she had to report what she saw. CNA #1 explained that after she separated both Residents and she immediately reported what she saw to LPN #3 (nurse assigned to Residents #1 and #2). She stated that she reported to LPN #3 what she saw in the DR. She heard LPN #3 ask Resident #2 why Resident #2 did that to Resident #1. However, LPN #3 did not check Resident #1. CNA #1 felt that LPN #3 did not listen to what she said and so she wrote her statement and went to see the Nursing Supervisor (NS #1) on 5/25/20 approximately closer to 7:00 am. She reported to NS #1 what she saw in the DR involving Residents #1 and #2 and the NS said she did not hear from LPN #3. CNA #1 gave the copy of her statement to the NS, in which she realized later she did not keep a copy to herself. The CNA stated that the original copy of her statement was given to LPN #3. Continued telephone interview with CNA #1. The CNA stated when she returned to work on the night shift 11:00 pm to 7:00 am (5/25/20 into 5/26/20), she was surprised that Resident #2 was still on the 5th floor on the same floor with Resident #1. She was expecting that Resident #2 would have been moved to another floor away from Resident #1 because of what she saw in the DR. CNA #1 was not assigned for both Residents that night (5/25/20 into 5/26/20). However, she mentioned exactly what she saw to the CNA (CNA #2), the assigned CNA for both the Residents #1 and #2 that night shift from 5/25/20 into 5/26/20. CNA #1 knew that LPN #2 did not know about the incident in the DR because LPN #2 did not give them report about it at the start of their shift. CNA #1 stated that she had tried to check on Resident #2 frequently if she could but it was impossible because she had to look after those residents assigned on her section. The surveyor conducted a telephone interview with LPN #3 on 9/14/20 at 11:50 am, she stated that she was not the nurse for both Residents #1 and #2 and she did not work on the 5th floor where Residents #1 and #2 resided. Follow-up telephone interview with LPN #3 on 9/14/20 at 2:24 pm. She confirmed she was the assigned nurse for both Residents #1 and #2 when both Residents were found in the DR on 5/25/20 approximately 6:00 am and 6:30 am. LPN #3 recalled CNA #1 told her that Resident #2 was following Resident #1, in which she told the Unit Manager (UM #1) on 5/25/20 at 7:00 am. She stated that she gave CNA #1's statement to the UM that same day (5/25/20). On 9/15/20 at 9:00 am, the surveyor conducted an interview with the former Administrator (A #1, who was employed at the facility on 5/25/20 and 5/26/20). He stated that he was not aware of the incident on 5/25/20 approximately 6:00 am to 6:30 am. He explained that Resident #2 admitted having sex with Resident #1 the night before which was on 5/25/20. He stated that there was no investigation done on 5/25/20 because the former DON did not indicate to him that something happened that day (5/25/20). The surveyor conducted a follow-up telephone interview with the former DON on 9/16/20 at 12:56 pm. The DON stated that he found out about the incident in the DR involving Residents #1 and #2 the day after the incident on 5/26/20. He recalled during the interview with CNA #1, the CNA told him that Resident #1 and Resident #2 were in a close proximity to each other in the DR. The DON did not remember if the CNA mentioned inappropriate touching between the Residents. CNA #1 stated she mentioned this incident and gave her statement to LPN #3. When the DON interviewed LPN #3, on 5/26/20, LPN #3 also brought with her the Statement from CNA #1 and gave it to the DON. The DON stated that staff statements (including CNA #1 and LPN #3) were given to the Administrator and the DON had no idea what the Administrator did with those staff statements. The DON stated that he did not read the statements written by the CNA #1 and LPN #3. The DON explained that what CNA #1 witnessed between Residents #1 and #2 in the DR would need an investigation because in May residents were not allowed to leave their rooms and being in close proximity to each other was not a normal situation due to Covid-19 situation and especially that CNA #1 had concerns. The DON stated if he knew about the DR situation on 5/25/20, it would be investigated immediately, reported to the Administrator and appropriate agencies and Residents would be transferred to an ACH. The Progress Notes (PN) for May 2020 for Residents #1 and #2, showed no documentation from LPN #3 regarding Residents #2 following Resident #1 in the DR. The surveyor conducted a telephone interview with the Unit Manager (UM #1) on 9/14/20, 9/15/20 and post survey on 9/16/20. However, the UM was not available. The surveyor viewed the video of the incident in the DR on 9/15/20 at 12:47 pm. The current Administrator (A #2) stated that what will be seen on the video would have a date a day ahead in which at 5/25/20 (DR incident) incident would have a date of 5/26/20. The 5/26/20 (bedroom incident) would have a date appearing 5/27/20. Video viewing. The video dated 5/26/20 at 6:18 am ( original date was 5/25/20 at 6:18 am) showed that Resident #2 was walking into the DR with Resident #1 behind Resident #2. Resident #2 pulled down his/her pants in front of Resident #1 while talking to Resident #1. Then Resident #2 appeared to touch Resident #1's clothes, then CNA #1 walked in and Resident #2 pulled up his/her pants. CNA #1 appeared to be talking to both Residents. Then both Residents followed the CNA exiting the DR. Continued viewing the Video camera. The video dated 5/27/20 at 3:48 am (original date was 5/26/20 at 3:48 am). The video showed Resident #2 walked into Resident #1's room. Then at 4:14 am, CNA #1 went into the Room of Resident #1. Then CNA #1 stepped out of the room with Resident #2. CNA #1 came back to Resident #1's room with CNA #2 and LPN #2. The rest of the video was mentioned on the aforementioned FRE. The NJUTF from an AH for Resident #1 dated 5/26/20 showed a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1's Representative agreed for the Resident to receive the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Attached with the NJUTF form was the Emergency Department Clinical Summary dated 5/26/20, under Instructions given to the Patient at Discharge showed education on Sexually Transmitted Disease, Sexual Assault. Under the Medications instructed to take home, showed [MEDICATION(S)] ([CONDITION(S)] medication) to take daily. The facility's policy titled, POLICY FOR RESIDENT ABUSE INVESTIGATION was reviewed/revised on 7/2020 showed: .Residents have the right to be free from abuse, may it be verbal, sexual, physical or mental abuse .Policy Interpretation and Implementation: .Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion or sexual assault .PREVENTION: Situations in which abuse .are more likely to occur are identified and correction or intervention is made .INVESTIGATION: .In any instance of .abuse of residents .an incident report is completed .1. Appropriate supervisory personnel is notified, and investigation begins promptly after report of problem. Statements or interviews of resident, suspect (if one is identified), any eyewitnesses and any circumstantial witnesses are taken. 2. Relevant documentation is reviewed and preserved. 3 Alleged victim is examined promptly .and finding documented in the report .In the case of either resident to resident abuse .where warranted, the police will be notified. If resident or family requests that police be involved, .with or without an injury, police will be notified .Residents involved in the investigation are monitored closely to avoid further disruption of daily quality of life. Interventions are implemented .Immediate removal of threat. whether employee, other resident .to provide security and safety. Counseling available when warranted. REPORTING/RESPONSE: [Name of the facility] will notify New Jersey State Department of Health, .no later than two hours .Any information which person making report considers necessary to further the investigation . The facility's policy titled, RESIDENT RIGHTS POLICY was reviewed/revised 12/2019, showed; .1 .c. Be free from abuse . NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a system was in place to address aspiration risk by failing to: a.) provide the appropriate pureed diet consistency and fluid consistency for an unsupervised resident with a known history of aspiration, b.) appropriately position a resident during feeding to prevent aspiration, and c.) ensure direct care staff on 4 of 4 nursing units (Second, Third, Fourth, and Fifth Floors) who were responsible for thickening of liquids, were knowledgable as to how to appropriately thicken liquids to the necessary consistency in accordance with physician orders. This deficient practice was identified for 3 of 5 residents reviewed with a history of difficulty swallowing (Resident #37, #70, and #111). The facility's failure to ensure safe feeding strategies and the appropriate dietary and fluid consistencies, and the likelihood that a resident with a known history of choking and difficulty swallowing could aspirate, based upon interviews with direct care staff identifying a lack of knowledge of how to appropriately thicken liquids to prevent aspiration on all 4 of 4 nursing units, posed a serious and immediate threat to the residents who had a history of [REDACTED].#111 and #70. The second IJ was identified on 9/12/18 at 12:56 PM and corrected on 9/12/18 at 4:41 PM for Resident #37. Both corrections were based upon an acceptable Plan of Correction that was implemented by the facility. The survey team verified the elements of the P[NAME] and continued to do so for the remainder of the survey. The evidenced was as follows: 1. On 09/11/18 at 9:32 AM, the surveyor observed Resident #111 in bed with his/her eyes closed. The head of the bed was elevated, and there were no staff present in the room. Positioned in front of the resident and within an easily accessible reach was an over-bed table with a breakfast tray. The surveyor observed that the breakfast tray contained a ready-to-use eight (8) ounce (oz) carton of labeled nectar thickened (a consistency of apricot nectar or thicker cream soups) milk, a ready-to-use four (4) oz cup of nectar thickened apple juice, and an eight (8) oz mug of coffee. The coffee cup had the appearance of consumption and there was approximately one-third of the coffee left in the mug. The coffee in the mug appeared to be of a thin liquid consistency (consistency of water). The food on the breakfast tray consisted of two small bowls of cream of wheat and a bowl of fluffy, regular-prepared scrambled eggs. At that time, the surveyor observed the resident produce a moist cough. The surveyor then observed Resident #111's breakfast meal ticket which was placed on the breakfast tray. A review of the meal ticket indicated that the resident was on a pureed-consistency diet with nectar thickened liquids. The surveyor attempted to interview the resident, but the resident was unable to be interviewed due to his/her impaired cognitive status. On 09/11/18 at approximately 09:34 AM, the surveyor interviewed the fourth floor Charge Nurse (CN). The CN stated that Resident #111 was on a pureed consistency diet with nectar thickened liquids. The surveyor brought the CN into the resident's room to look at the resident's breakfast tray. The surveyor asked the fourth floor CN regarding the thin appearance in the consistency of the coffee, and if the regular-prepared scrambled eggs were an appropriate consistency for a resident on a pureed diet. The CN stated that the coffee was delivered not thickened and that staff need to thicken it on the floors. The CN looked at the coffee and eggs and stated that she was unsure if the coffee had been thickened, and she acknowledged it appeared thin. In addition, she stated that she did not know if the scrambled eggs were appropriate to serve to a resident on a pureed diet. On 09/11/18 at 9:35 AM, the surveyor interviewed the fourth floor Licensed Practical Nurse (LPN). The LPN stated that the resident was on a pureed consistency diet with nectar thickened liquids. The surveyor showed the LPN the resident's breakfast tray and asked the LPN about the consistency of the mug of coffee on the resident's tray. The LPN stated that she was unsure if the coffee was thickened and acknowledged the coffee appeared thin to be considered nectar thickened. The fourth floor LPN then picked up the ready-to-use 8-oz carton of milk on the resident's tray and stated that maybe whoever served the tray poured some milk in the coffee to make the coffee a thicker consistency. The fourth floor LPN then stated that she was unsure if the regular-prepared scrambled eggs were an appropriate consistency for a resident on a pureed diet. The breakfast tray was then removed from the resident's over bed table. On the same day on 09/11/18 at 9:45 AM, the surveyor interviewed the Registered Nurse/Supervisor (RN/S) at the fourth floor nurses station. The surveyor showed the RN/S the breakfast tray belonging to Resident #111 served that morning. The RN/S stated that the coffee appeared to be a thin liquid and was not appropriately thickened. The RN/S stated that she was unsure if scrambled eggs were appropriate to be served to a resident on a pureed consistency diet and would have to ask the Registered Dietician (RD) or a member of the dietary staff. The surveyor asked to speak to the RD and was told by the RN/S that the RD was not in the facility as she had off that day and was unable to be reached. On 09/11/18 at 9:47 AM, the surveyor interviewed the fourth floor Certified Nursing Aide 1 (CNA1) who brought Resident #111 his/her breakfast tray that morning. The CNA1 stated that the resident was on nectar thickened liquids, and a pureed-consistency diet. The CNA1 stated that she brought the resident his/her breakfast tray around 8:00 AM that morning. The CNA1 added that she had thickened the resident's coffee that morning when she dropped the tray off in the resident's room. At that time, the surveyor showed the CNA1 the resident's breakfast tray, and the CNA1 picked up the resident's coffee mug and pointed to a small brown powdery substance that was on the lip of the coffee mug and stated that the powdery substance was proof of adding a thickener packet to the mug of coffee. The surveyor asked the fourth floor CNA1 to explain how she thickened the resident's coffee. The CNA1 stated that she opened a single thickener powder packet, poured it into the resident's mug of coffee, and stirred in the thickener powder until the powder was dissolved. She could not recall how long she stirred the thickening powder into the resident's coffee or how long she waited before serving it to the resident but recalled that the coffee was thick. The CNA1 further stated that she was unsure if a resident on a pureed consistency diet could be served scrambled eggs and would have to find out. The CNA1 stated that the resident ate a little bit of the scrambled eggs that morning. On 09/11/18 at 9:58 AM, the surveyor interviewed the Dietary Supervisor 1 (DS1) in the presence of a second surveyor. The surveyors showed the DS1 the breakfast tray served to Resident #111 that morning. The DS1 stated that the coffee was not nectar thick. The DS1 further stated that the scrambled eggs were not appropriate to be served to a resident on a pureed consistency diet. She then stated that she educated the staff on serving the appropriate consistency foods and drinks, but the staff do not listen. The surveyors asked the DS1 to further explain what she meant by the staff not listening. The DS1 stated that sometimes a resident would complain about the diet and then the staff would bring them whatever they wanted even if it was not the correct diet or diet consistency for the resident. The DS1 was unsure if Resident #111 requested a different consistency diet that morning. The DS1 further stated that the dietary aides served breakfast on the units from the steam table, and it was the CNA's responsibility to help serve the food to the residents on the unit. The DS1 explained that a dietary card was placed next to the resident's tray which indicated the type of diet ordered by the physician in which the resident was to receive. The DS1 further stated that the thickening powder packet was placed on the trays, so the staff could thicken the liquids at the bedside. The DS1 was unsure of how many thickening packets Resident #111 received on his/her breakfast tray that morning. The DS1 provided to the surveyors two packets of Hormel plain thickening product one for nectar consistency and the other for honey-consistency (a thickener that resembles the consistency of honey). The packets reflected the following on the label: The single Hormel Thick & Easy Instant Food and Beverage Thickener packet for Nectar Consistency liquids had a green label. Directions for use on the back of the packet included to Add 1 packet (4.5g) Thick & Easy Instant Food & Beverage to 4 fl oz of liquid and stir for 15 seconds. Allow 1-4 minutes for liquid to reach optimal thickness. The amount of thickener may need to be adjusted to meet your individual needs. Instructions further specified for Nectar-like Consistency to add one packet to 4 oz of liquid. The single Hormel Thick & Easy Instant Food and Beverage Thickener packet for Honey Consistency liquids had a yellow/gold label. Directions for use on the back of the packet included to Add 1 packet (6.5g) Thick & Easy Instant Food & Beverage to 4 fl oz of liquid and stir for 15 seconds. Allow 1-4 minutes for liquid to reach optimal thickness. The amount of thickener may need to be adjusted to meet your individual needs. Instructions further specified for Honey-like Consistency to add one packet to 4 oz of liquid. At that time, the DS1 further stated that based on the instructions on the packet, two packets of nectar thickening powder were required to ensure the 8-oz of coffee was appropriately thickened, and that one packet would be used for a 4-oz liquid. The DS1 confirmed that the coffee on the resident's tray was served in an 8 oz coffee mug, and that therefore two packets would be required. She could not verify if residents were given two packets on their trays or one with the coffee. On 09/11/18 at 10:39 AM, the surveyor interviewed the full time AM Cook regarding the preparation of the breakfast meal. He stated that he pureed the scrambled eggs that morning and pureeing scrambled eggs was appropriate for the puree diet. He further stated regular-prepared scrambled eggs were not appropriate for a resident on a puree consistency diet. On 09/11/18 at 10:55 AM, the surveyor requested to view a sample of pureed scrambled eggs from the DS1. The DS1 indicated that the kitchen did not have any evidence or remnants of the pureed scrambled eggs prepared that morning but that they could make a sample for the survey team. The surveyor reviewed the medical records for Resident #111. A review of the resident's hospital records prior to admission to the facility revealed a Speech Pathology Consult (SPC) dated 07/23/18. The SPC indicated that the resident was admitted to the hospital with [REDACTED]. The consultation note further indicated that a security guard had called 911 because of an episode of choking and that he/she has had multiple recent admissions with similar complaints in recent months. The SPC further indicated that a chart review had been performed from the previous admissions which revealed that the resident had a modified [MEDICATION NAME] swallow (a diagnostic test designed to determine if food or liquid was entering the airway) on 1/21/18, which revealed, aspiration with thin liquids with spontaneous cough and prolonged mastication with solids. A repeat modified [MEDICATION NAME] swallow study was conducted on 5/7/2018 which revealed, oral and pharyngeal phases were essentially within normal limits with thin liquid and puree. The SPC included that from that study that the resident appears safe for a modified diet with the use of compensatory strategies including recommendations of supervision with the head of the bed in the full upright position for 60 minutes after meals. Further review of the same SPC dated 07/23/18 included that the most recent chest x-ray was conducted on 07/21/18 with an Impression: Early infiltrate in the right lower lobe. Follow up study recommended. It further indicated that when questioned if (he/she) was having any difficulty swallowing, (Resident #111) reported 'Yeah, I did, that's why I came to the hospital.' The note further included that the resident was edentulous (no natural teeth) and had a vertical chewing motion on a pureed diet. A review of the resident's Admission Record indicated that the resident was admitted to the facility on [DATE] following the hospitalization , and had [DIAGNOSES REDACTED]. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/09/18, reflected that the resident had short and long-term memory problems and a severely impaired decision-making capacity. A further review of the MDS reflected that the resident required extensive assist by another person for eating and was on a mechanically-altered diet. A review of the (MONTH) (YEAR) Physician order [REDACTED]. In addition, the admission POS dated 08/02/18 reflected a Speech and Swallow evaluation and to position the resident at the table for meals sitting upright in a chair. A review of the resident's individualized, 48 Hour Baseline Care Plan dated 08/02/18 reflected that the resident was on a pureed diet with thickened liquids and had dysphagia. The baseline care plan did not specify what consistency of thickened liquids the resident was on upon admission. A review of the Speech Therapy Evaluation and Plan of treatment for [REDACTED]. The resident was, choking after being fed by a Home Health Aide. The bedside assessment of swallowing indicated that the resident had excessive mastication (chewing) time and oral residue in mouth after eating. The bedside assessment further reflected that the resident had coughing after swallowing thin liquids. A further review of the same Speech Therapy Evaluation and Plan of Treatment indicated that skilled speech therapy treatment was indicated to treat the resident's dysphagia and reduce the risk of aspiration while swallowing. A review of the Speech Therapy Discharge Summary electronically signed on 09/07/18, reflected that the resident was to be discharge from Speech Therapy services on a puree consistency with soft sandwiches and on a nectar thick liquid diet. A review of the (MONTH) (YEAR) POS revealed a PO dated 09/05/18, for a pureed consistency diet with soft sandwiches, and nectar-thick liquids. A review of the resident's individualized Nutrition Assessment/Care Plan (NA/CP) dated 08/06/18 included that the resident had a high nutritional risk secondary to the pureed diet and thickened liquids. The goals of the NA/CP indicated that the resident was to achieve a weight gain, improved oral intake, and maintain adequate hydration status. Interventions of the NA/CP indicated to continue the current diet, provide daily food preferences within dietary restrictions, monitor food intake, and monitor for signs and symptoms of dehydration. On 09/11/18 from 10:30 AM until approximately 11:30 AM, the survey team dispersed to each of the 4 of 4 nursing units to interview direct care staff regarding procedures for thickening liquids and their knowledge of the consistency of scrambled eggs. The interviews on the Second Floor revealed the following: On 09/11/18 at 10:50 AM, the surveyor interviewed a second floor CNA. The CNA stated the breakfast and lunch trays usually come up with a thickening packet on them. The CNA further stated that a cup of coffee would come with a single packet of thickener and that the juice and milk already came pre-thickened. The CNA stated that she would put the single packet of thickener in the mug of coffee or tea, whatever was served for the resident that day. The CNA stated that no one had officially trained her on the thickening of a liquid and/or how many packets to use. She confirmed she just used what was on the tray. On 09/11/18 at 10:57 AM, the surveyor interviewed the second floor Licensed Practical Nurse/Charge Nurse (LPN/CN). The LPN/CN stated that the CNA's only use one packet of thickener for the 8 oz of liquid in the mug. The LPN/CN on the second floor stated that the facility trained the staff on how to appropriately thicken liquids but was unsure how often the staff received training. The LPN/CN further stated that a resident on a pureed diet could eat scrambled eggs in its regularly prepared form. On 09/11/18 at 11:02 AM, the surveyor 4 interviewed another CNA (CNA2) on the second floor. The CNA2 stated that one packet of the nectar thickener would be used for a cup of coffee and that was what came up on the trays. The CNA2 further stated that scrambled eggs in the regularly prepared form were safe to be served to all residents on a pureed diet. On 09/11/18 at 11:05 AM, the surveyor interviewed a third CNA (CNA3) on the second floor. The CNA3 stated that sometimes the trays would have one packet of thickener on them and sometimes they would have two packets. The second floor CNA3 stated that for the coffee she would usually just use one packet of thickener in the 8 ounce mug unless for some reason the coffee didn't seem to be thick and then she might add 2 packets of thickener, but that it was based on what was served on the tray. The second floor CNA3 further stated that a resident on a pureed diet could not receive scrambled eggs in their regularly prepared form. On 09/11/18 at 11:10 AM, the surveyor interviewed a fourth CNA (CNA4) on the second floor. The second floor CNA4 stated that she would add one packet of nectar thickener to 8 oz of a liquid to make it thickened. The interviews on the Third Floor revealed the following: On 09/11/18 at 11:07 AM, the surveyor interviewed the third floor CNA about her knowledge of the thickened liquids process. She stated that she fed a resident this morning that required a thickened liquid consistency. The CNA stated that there were two packets of thickener on the tray. She stated she used one packet for the coffee mug, which she estimated to be a four-ounce mug but stated that she wasn't sure. She stated that she added the other packet in the resident's hot cereal that she stated was Wheatena. The third floor CNA could not speak to why she added a thickener packet to the hot cereal. At that time, she stated she had not been in-serviced regarding how to thicken liquids. On 09/11/18 at 11:10 AM, the surveyor interviewed another CNA (CNA2) on the third floor. The CNA2 told the surveyor about her knowledge of the thickening liquids process. She stated that a nursing supervisor came in that morning at approximately 09:45 AM and had her sign an in-service paper that she was supposed to put two packets of thickener in the mug. She further stated, she had not received an in-service prior to today. She would not speak to how she would thicken liquids prior to being in-serviced that morning when the survey team had started inquiring from staff. She could not speak to the scrambled eggs in the regularly prepared form. On 09/11/18 at approximately 11:30 AM, the surveyor interviewed the third floor LPN regarding her process for thickened liquids. She stated most products arrived at the unit pre-thickened. The third floor LPN stated that if a resident consumed tea, portioned thickening packets are served on the tray from the kitchen. The LPN stated that usually the CNAs thickened liquids on the trays, but occasionally she would do it. She further stated, the CNAs just know how to thicken liquids based on what was provided on the tray. She further stated the CNAs had not received training to her knowledge. Further interviews on the Fourth Floor revealed the following: On 09/11/18 at 11:00 A.M., the surveyor interviewed the fourth floor CNA. The CNA stated that she had worked for the facility for at least a year and she would thicken water, juice, coffee or tea with one packet of thickener which comes on the resident's tray from the dietary department. The CNA added that the dietary department puts the right amount of packets on the tray. The CNA also stated that if a resident was on a pureed diet then the resident should not be served scrambled eggs in their regular-prepared form. The CNA was not sure if the dietary department had pureed eggs. The CNA added that the speech therapist taught her that if a resident coughed while feeding to let the resident finish before the next drink or spoonful of food and if the cough continues to notify the nurse. On 09/11/18 at 11:06 A.M., the surveyor interviewed a second CNA (CNA2) from the fourth floor. The CNA2 stated that he had worked in the facility since (MONTH) (YEAR) and was trained how to thicken liquids by another CNA. The CNA2 also stated that he would use one packet of thickener provided by the dietary department on the tray to thicken any liquid in the mug that was on the resident's tray. The CNA2 added that the mug on the tray usually contained coffee or tea. The CNA2 could not speak to the number of ounces that the mug contained. The CNA2 stated that he was aware that the dietary department had pureed scrambled eggs but was not sure if residents were served it. On 09/11/18 at 11:25 AM, the surveyor interviewed two Recreation Aides on the fourth floor. The aides both stated that they recently started working at the facility on 07/16/18 and they were responsible for activities for their floor. They stated to the surveyor that they both thicken liquids for residents during the lunch meals. The surveyor asked how they know how much to thicken the liquids, and the recreation aides both stated to the surveyor that the CNA tells us what to do and we do it. They stated that they will add a single packet of thickener to a mug of whatever liquid was served that day. The surveyor asked how many ounces the mug was, and the recreation aides stated that they did not know how many ounces the mug was, but that they would add a single packet and stir it and then show a CNA what was inside. The recreation aides stated they had never been formally trained on how to thicken liquids except from the CNA who directed them how to do it. The aides both stated that they don't recall a resident coughing on liquids, but that they haven't been working at the facility all that long. They could not speak to if regularly prepared scrambled eggs were considered a pureed consistency. The interviews on the Fifth Floor revealed the following: On 09/11/18 at 11:06 AM, the surveyor interviewed the fifth floor CNA. The CNA stated that thickened liquids either come prepared in a container or they send a little package up on the trays. Sometimes they will send up two packages on the trays but one packet will be for the milk and the other one would be for the coffee. The CNA added that sometimes the milk did come up on the tray pre-thickened, and when that happens only one packet would be on the tray, so that would be for the coffee or tea. The surveyor asked how many ounces of liquid was the mug for the coffee and/or tea, and the CNA stated that she thought it was about eight (8) fluid (fl) ounces (oz). She confirmed that she would add one packet of thickener to an 8 fl oz mug of coffee. She then stated that she would stir it until it was thickened. The surveyor asked how she would know if the liquid was thick enough, and the CNA stated that if the resident drinks it and starts to cough then it might need more thickener. The surveyor asked if there was anyway she could know if it was thick enough prior to giving it to the resident, and she stated that she could ask the nurse if it looked too thin but that usually one packet was enough for the mug of coffee. The surveyor asked if she had been in-serviced on thickening liquids at any point that she can recall during her employment at the facility, and she added that she had not recalled being trained at the facility regarding thickening of liquids. The CNA stated that the facility has pureed scrambled eggs and that they are soupy in texture, but could not confirm if the residents on a pureed diet got them that morning because she did not check the meal tickets for accuracy that morning when she served her resident's breakfast. She confirmed she had residents on a pureed diet texture but could not speak to if the eggs were pureed. On 09/11/18 at 11:13 AM, the surveyor interviewed the fifth floor Registered Nurse (RN). The RN stated that the nurses use a can of thickener on the medication carts. The RN stated that whatever the label says on the can is what we do. The surveyor asked regarding the thickener packets sent up on the meal trays. The RN stated that the CNA's thicken the liquids with the packet sent up on the tray. The RN could not speak to the individual thickening packet stating that the CNA's do it and they were supposed to read the package label. The RN confirmed the mugs are approximately 8 oz. At that time the LPN approached the RN in the presence of the surveyor and stated that CNA's know to put a packet of thickener in the resident's liquids at meal time if they are on thickened liquids, and that they know how thick to make it based on their individual meal cards that had diet orders. The LPN could not speak to if CNA's know how much liquid was in the mug being served to the residents, and/or if one packet of thickener was sufficient for an 8 oz mug. The LPN stated that if a resident started coughing on a liquid such as nectar thick consistency liquid she would need to inquire about getting a speech therapy screening to see if the resident needed a downgrade. The LPN added that regularly prepared scrambled eggs were soft enough for residents on a pureed diet to have. On 09/11/18 at 11:11 AM, the surveyor conducted a follow-up interview with the fourth floor CNA1 who was assigned to care for Resident #111. The CNA1 stated that one packet of nectar thick powder came on the resident's breakfast tray that morning and that she used one packet of the nectar powder to mix in with the coffee to make it nectar thickened. She stated that the mug was an 8-oz mug. The fourth floor CNA1 further stated that the resident always eats very slowly and that she had never heard the resident cough or show signs of choking while he/she was eating. The CNA1 added that she did not recall the last time she received education on how to properly thicken a liquid, but that the nurses check for proper thickening of a liquid on a regular basis. At approximately 11:30 AM, the survey team received the sample of the pureed scrambled eggs from the Dietary Supervisor (DS1) and prepared by the AM Cook. The scrambled eggs were of the appropriate pureed consistency, and they were not formed. On the same day on 09/11/18 at 11:47 AM, the surveyor interviewed the Speech Language Pathologist (SLP) in the presence of the survey team. The SLP stated that he worked at the facility about 3 to 4 hours a week and he had recently evaluated and treated Resident #111 for speech therapy services because he/she was admitted to the facility on a mechanically-altered diet. The SLP stated that the resident was trialed to be upgraded from a pureed diet to a mechanical soft diet with thin liquids but that the trial had failed because he noticed that the resident was pocketing food (food being held in the mouth and not swallowed) and aspirated (food or drink being breathed into the airways). The SLP further stated that after his assessment, he determined that the resident was to stay on the nectar thickened liquids and pureed consistency foods, but that staff were to allow soft sandwiches. The SLP confirmed that the resident was at risk for aspiration, especially if staff did not follow the diet recommendations and physician orders. The surveyor continued to interview the SLP who stated that the facility had pre-packaged thickened liquids such as in the form of milk and juice. The surveyors showed the SLP the same style 8-oz coffee mug which was observed on Resident #111's tray and asked how many fluid oz he knew the coffee mug to hold. The SLP stated that the coffee mug was 4 oz and would require one packet of the nectar consistency thickener. The surveyor asked the SLP if regular-prepared scrambled eggs were appropriate to serve to a resident on a pureed diet. The SLP stated that it depended on the resident. The SLP could not recall if Resident #111 was able to swallow scrambled eggs and stated that if the resident was able to swallow specific foods, he would write a recommendation for a physician's orders [REDACTED]. He confirmed that if a resident had an order for [REDACTED]. The surveyor continued to interview the ADON who stated that the coffee mug was an 8-oz mug and according to the directions on the nectar thickening packet, 8 oz of a thin liquid required two nectar consistency packets to properly thicken. The ADON stated that she trained the staff on how to appropriately thicken liquids based off the instructions on the thickening packet after the surveyor had inquired about it on the floor. The ADON stated that anything served in a mug did not come pre-thickened. The ADON stated that the facility previously used cans of thickener and then switched over to the thickening powder. The ADON was unsure of when the facility switched over to using the thickening powder packets but estimated that it was approximately one year ago. Both the DON and ADON could not recall any in-service training that was done for staff when the facility switched over to a new system for the thickening of liquids. On 09/11/18 at 02:37 PM, the surveyor interviewed DS1 again regarding the process of thickening liquids in the facility. She stated that she had worked here a little over two years, and the facility had used pre-thickened liquids and the packets of thickener prior to her hire. (This did not correspond with what the ADON told the survey team in the presence of the DON). The DS1 stated that she purchased these items, and that although she had not demonstrated to her staff regarding the thickening procedures, she stated that the dietary staff know to serve two packets of thickener for an eight-ounce coffee and one packet for a four-ounce liquid. 2. On 09/11/18 at 09:35 AM, the surveyor observed Resident #70 in bed with padded half side rails secured to the bed frame and in the up position. There was a breakfast tray on the bedside table in front of the resident which included a bowl of regular prepared scrambled eggs and two cups of hot cereal. There was also four ounces of cranberry juice cocktail. The breakfast did not appear to be touched by the resident, and the resident was alone in the room. At that time, the surveyor observed that the resident was awake and smiling. The surveyor attempted to interview the resident, but the resident just smiled and nodded his/her head. The resident was unable to state his/her name. At 09:38 AM, the surveyor interviewed t (TRUNCATED)

Part A Based on observation, interview and review of facility documents, it was determined that the facility failed to a.) ensure an electric burner stove was turned to the off-position inside an unattended kitchen area with a closed door, b.) ensure the sprinkler head in the same kitchen was not blocked by a suspended light fixture, and c.) ensure a flammable cleaning solution was not stored in proximity of the area. This deficient practice was identified in 1 of 2 kitchen areas on the ground floor (the Indian kitchen) when the cook of the designated kitchen left early for the day and did not report to another staff member and/or supervisor that the burner was left on. The facility's failure to ensure a safe kitchen environment for the unattended Indian kitchen, and the likelihood the kitchen would not have been entered and/or occupied until the next day in accordance with staff interviews, posed a serious and immediate threat to the residents related to a fire safety hazard. This resulted in an Immediate Jeopardy (IJ) situation that was identified on 9/8/17 at 1:29 p.m., and corrected on 9/8/17 at 2:22 p.m., based on an acceptable Plan of Correction that was implemented by the facility and verified by the survey team. The evidence was as follows: On 9/8/17 at 10:15 a.m. during the initial tour of the kitchen area, the surveyor and the Dietary Supervisor (DS) observed a closed door adjacent to the Kosher kitchen. At that time, the DS stated that the closed door led to the Indian kitchen. The DS indicated that the door was closed because the cook for that designated kitchen had left early for the day and would not return until the next day at approximately 6 a.m. The surveyor and DS entered the vacant Indian kitchen together. On the same day on 9/8/17 at 10:22 a.m., the surveyor observed a red light illuminating from the unattended electrical stove. The stove top was empty and void of cooking materials. The surveyor asked the DS if the oven was on. The DS stated that the oven was not on, and that all cooking had been completed in this kitchen for that day. At that time, the surveyor observed the dial to the back, left electrical burner was positioned to reflect it was on. Upon closer examination, the DS confirmed that the back burner to the stove top was left on, and she immediately turned it off in the presence of the surveyor. At that time, the illuminating red light turned off. The DS stated that she was not aware the stove had been left on or why it was still on. The surveyor and DS placed their hands above the electrical burner and palpated heat radiating from the coils. On the open shelves in the kitchen in close proximity to the stovetop were large transparent containers of spices, multiple stored food containers/items, and clear plastic bins. In addition, the surveyor observed on an electrical panel in proximity to the unattended heated stove, a stainless steal cleaner in aerosol form by the company SprayPAK which reflected on its label Flammable aerosol. Pressurized container. May burst if heated. The surveyor observed a sprinkler head above the area of the stove top. Directly adjacent to the sprinkler head was a four inch suspended fluorescent light fixture. The sprinkler head was oriented parallel with the light fixture and if activation was to occur, the sprinkler head would not provide coverage to the area where the stove was located within the kitchen space. The DS confirmed that no one would have returned to the Indian kitchen until the following morning at approximately 6 a.m. that cook returned the next day for her shift. The DS acknowledged that the stove top burner should have been turned off after the cook finished her shift in accordance with kitchen/fire safety standards. At 10:30 a.m., the Assistant Administrator entered the Indian kitchen with the surveyor and the DS. The Assistant Administrator confirmed that the stovetop should not have been left on and unattended. The Assistant Administrator stated that the DS was not the immediate supervisor for the cook of the Indian kitchen, but the third-floor unit manager was the cook's supervisor. The Assistant Administrator requested the presence of the third-floor unit manager in the kitchen. At 10:38 a.m., the third-floor unit manager (UM) entered the Indian kitchen in the presence of the Assistant Administrator, DS, and the surveyor. The UM stated that he was not responsible to ensure kitchen safety or proper sanitation practices; his job expectation was to communicate any residents medical and/or cultural needs to the kitchen cook. The UM also stated that he would assist the cook as needed to purchase spices specific to menu items. He further confirmed that the designated cook had left for the day and could not speak to the unattended electrical stove burner that was left on. At 11:15 a.m., the surveyor interviewed the DS a second time. She stated that she would conduct her daily rounds in the Indian kitchen while the cook was in the kitchen cooking, but otherwise would not have a reason to return to the kitchen after the cook had left for the day. The DS confirmed staff would not be in that kitchen until the following morning when the cook returned to report for her shift. The DS informed the surveyor that the cook for the Indian kitchen would usually arrive around 6 a.m. and and would leave around 1 p.m. daily after she finished cooking that day's food. The DS further stated that the UM was responsible for overseeing the cook's regular schedule for the Indian kitchen. At 11:20 a.m., the surveyor interviewed the cook for the Kosher kitchen who stated that he was not familiar with the foods or ingredients stored in the Indian kitchen, so he would not have a reason to go into that kitchen after the cook had left for the day. He further stated that routinely after the cook in the Indian kitchen finished cooking the meals for the day, she would transfer the meals into the main kitchen for storage until they were ready to be served that day. The cook for the Kosher kitchen could not speak to what time she transferred the meals to the main area in preparation for service to residents that day or what time she left for the day. The surveyor interviewed two dietary workers in the Kosher kitchen who confirmed they would have no need to enter the Indian Kitchen since the food was already delivered to the main kitchen to be served to the residents. At 11:27 a.m., the surveyor interviewed the UM a second time who confirmed he was not responsible to go into the kitchen to do any sanitation inspections or rounds. The UM confirmed that the cook worked from 6 a.m. to 9:20 a.m., as it would take at least three hours to have cooked the meals for the day. At 12:10 p.m., the surveyor conducted a phone interview with the cook from the Indian kitchen. The cook informed the surveyor she started her shift at approximately 6 a.m. that day and left sometime after 9 a.m. The cook indicated that she prepared the food for the day and had used the stovetop that morning to make hot tea. The cook was unsure what time she made the tea, and confirmed she did not recall turning off the stove or telling a staff member that the stove had been left on. She confirmed it was standard kitchen safety practice to turn a stove top off immediately after using. At 12:20 p.m., the Assistant Administrator informed the surveyor that the cook was a contracted employee through an agency company, (name redacted, LLC). At 12:45 p.m., the DS provided a copy of kitchen inservice training for the dietary staff and kitchen cooks. A review of the Attendance In-Service sheet dated 5/22/17 reflected that the cook from the Indian kitchen worked the 7 a.m. to 1 p.m. shift and received an education training on kitchen safety on that day which included topics such as safe work practices, equipment safety, reckless use of kitchen equipment, and disconnecting equipment when not in use. The DS could not speak to why the cook left the burner on if she had just been inserviced on kitchen safety. A review of the Material Safety Data Sheet (MSDS) for a 3M Stainless Steel Cleaner provided by the Assistant Administrator included information that the cleaner is an extremely flammable aerosol. Contains gas under pressure; may explode if heated. It further indicated to keep away from heat/sparks/open flames/hot surfaces . and under directions for storage to do not expose to a temperature exceeding 122 degrees Fahrenheit (F), Store in a well-ventilated place and locked up. The MSDS for the 3M brand stainless steel cleaner provided by the facility did not match the brand SprayPAK that was observed in the unattended kitchen. On 9/8/17 at 1:29 p.m. the Assistant Administrator was notified in the presence of the survey team that the failure to ensure a safe kitchen environment when an unattended electrical stove burner had been left on with the door to the kitchen closed and staff interviews indicated the kitchen would likely not be entered/occupied until the next day when the cook returned resulted in an Immediate Jeopardy (IJ) situation. At approximately 2:00 p.m., two surveyors returned to the Indian kitchen. The bottle of stainless steal cleaner was still resting on the electrical panel. At that time, the surveyor interviewed the cook for the Kosher kitchen who indicated he did not know why the cleaner was there and not stored appropriately. He could not speak to who placed it there as he stated he did not work in that kitchen. The IJ was corrected on 9/8/17 at 2:22 p.m. based on an acceptable Plan of Correction (P(NAME)) which included the following: 1. The burner was immediately shut off. The cook that left the burner on was immediately educated/inserviced via phone as to the dangers and importance of checking that the burners are shut off when leaving the kitchen. The stainless steel aerosol can was immediately removed. 2. All residents have the potential to be affected by this deficient practice. 3. All staff in the kitchen were re-inserviced regarding safety issue in leaving burners open, with no visual observations or use. Chart will be devised each time the stove is used cook will be accountable to check and ensure that burners are totally off. Inservice will be given for the cooks repeatedly on safety and the importance of closing burners, once a month for three months. 4. Dietary Supervisor or designated staff, will check each time cook leaves and ensure that burners are off and that cook was compliant for three months. Results of both the on-going chart check-off of the cultural cooks and the Dietary Supervisor checks will be presented to the QAPI (Quality Assurance Performance Improvement) Committee for review and evaluation. F323 remains a deficiency, at a scope and severity level of D based upon the following: Part B Based on observation, interview and record review it was determined that the facility failed to a.) implement new safety interventions for a resident with recurring falls from the bed, b.) ensure there was a physician order and consent for the use of side rails for the same resident, and c.) supervise a resident while a physical restraint was not in use. This deficient practice was identified for 2 of 16 residents reviewed for falls/supervision (Resident #7 and #11). The evidence was as follows: 1. On 9/8/17 at 10:35 a.m. during the initial tour, the surveyor observed Resident #11 in bed with his/her eyes closed. There were three half-side rails secured to the bedframe and in the up position. There were safety mats positioned on the floor next to the bed. At that time, the Director of Nursing (DON) stated to the surveyor that the resident was alert to self only and had a history of [REDACTED]. On 9/11/17 at 8:42 a.m., the surveyor observed that the resident's door was closed to the room. At that time, the surveyor knocked and requested to enter without a response. Upon opening the resident's door, the surveyor observed Resident #11 in bed with the eyes closed. Three half side rails were in the up position and fall mats were positioned on the floor. There were no staff present in the room. On 9/11/17 at 10:30 a.m., the surveyor reviewed the medical record for Resident #11 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a fall assessment evaluation dated 5/10/17 indicated that the resident had a total fall score of 12 which reflected that the resident was at high risk for falls. A review of the resident's individualized comprehensive care plan initiated on 5/10/17 indicated the resident was at risk for falls due to an unsteady gait, cognitive deficits, impaired safety awareness, and due to the use of psychotropic medications. The care plan specified that the resident had a history of [REDACTED]. Interventions which were undated, included keeping the bed low and locked. The care plan indicated that the resident experienced a fall from bed on 6/1/17 and was found on a safety floor mat without injury. A review of the investigative Incident/Accident Report dated 6/1/17, reflected that at 10 a.m., the Certified Nursing Aide (CNA) heard the bed alarm sounding and found the resident on a safety floor mat next to the bed. The report indicated that side rails were not ordered, but were present at the time of the fall and in the up position. In the section titled, comments and/or steps taken to prevent recurrence, interventions indicated to Continue low bed and bed alarm. Staff to monitor (resident). (Bilateral) floor mattress. Further review of the resident's individualized care plan for falls reflected that the resident had a second fall on 6/11/17 in which the resident was found in the room sitting on the floor mattress next to bed, with bed alarm in place and floor mattress in place. The care plan specified, Care plan continue. There was no evidence that the care plan was updated to reflect new interventions to ensure the resident's safety after the second fall. Further review of the resident's care plan reflected that the resident had a third fall on 6/21/17 in which the resident was found by staff on the floor next to the bed. The care plan included, Staff will continue to anticipate needs. Bed remain in lowest position with bilateral floor mats - plan of care to continue. A review of the investigative Incident/Accident Report for the fall that occurred on 6/21/17 reflected that the resident was found on the floor at the bedside next to the floor mat by the incoming CNA at 7:10 a.m. The report reflected that side rails were in the down position, and the bed alarm was in place, but alarm was not heard. The report reflected will continue to monitor resident for safety and ensure all safety precautions in place at all times. A review of the Alarm Accountability and Function forms dated 6/20/17 and 6/21/17, the CNA signed for the 7 a.m. - 3 p.m. shift but did not specify whether the alarm was on and/or off or functioning properly. The 3 p.m. - 11 p.m. shift and 11 p.m. - 7 a.m. shift was not signed by the CNA to indicate the use of a bed/chair alarm. A comparative review of the investigative Incident/Accident Report dated 6/21/17 and the comprehensive care plan did not indicate evidence that a review of the effectiveness of the fall interventions was conducted and/or the implementation of new interventions to ensure the resident's safety while in bed. The care plan did not include dated interventions for the use of the side rails and/or bed alarm. Further review of the resident's care plan for falls indicated a fourth fall on 8/21/17. The care plan indicated that the resident was last seen in bed and was found on the floor in the room. There was no evidence of new safety interventions and the care plan reflected to continue care plan. A review of the investigative Incident/Accident Report for the same fall that occurred on 8/21/17 indicated that the resident was found on the safety floor mat by the bedside, responding to cries of hello, hello at 11:50 p.m. The report indicated that the side rails were in the up position, and that the bed alarm not heard. The report further reflected that staff will ensure all safety precautions are in place at all times and monitor resident closely to prevent falls. A review of the Alarm Accountability and Function forms dated 8/21/17, indicated that the CNA signed for the 7 a.m. - 3 p.m. shift that the alarm was in place from 7:10 a.m. to 2:40 p.m. during the shift and was functioning. The 3 p.m. - 11 p.m. shift and 11 p.m. - 7 a.m. shift was not signed by the corresponding assigned CNA. A comparative review of the care plan for falls and the investigative Incident/Accident report dated 8/21/17 indicated there was no evidence of an evaluation review for the effectiveness of interventions for the repeated falls from bed and/or evidence of implementation of new interventions to ensure the resident's safety while in bed, including the use and audible functioning of a bed alarm and the use of side rails. On 9/12/17 at approximately 8:50 a.m., the surveyor observed the CNA provide morning care to Resident #11. At that time, the CNA removed two rolled up pillows from under the resident's mattress and placed them on a chair in the resident's room. The CNA stated that the resident utilized a low bed, side rails, a bed alarm, two rolled up pillows under the mattress, and safety floor mats to prevent falls. A review of the resident's comprehensive care plan for falls did not include interventions for the use of side rails, a bed alarm or the need to place pillows under the resident's mattress. A review of the September 2017 Physician Order Sheet (POS) did not include a physician order for [REDACTED]. Further review of the medical record did not include evidence of a consent for the use of the three half-side rails that were secured to the bedframe and observed to be in the up position during the survey. On 9/15/17 at approximately 9:15 a.m. the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to Resident #11. The LPN was unaware that the resident was utilizing three half-side rails. She stated that the resident utilized two half-side rails as an enabler for repositioning. The surveyor brought the LPN into the resident's vacant room and observed three half-side rails secured to the resident's bedframe in the down position. At that time, the LPN reviewed the resident's chart and confirmed there was no physician order for [REDACTED]. On 9/15/17 at 11:27 a.m., the surveyor interviewed the DON and Assistant-DON (ADON) in the presence of the survey team. The DON confirmed the interventions in the care plan for falls were not dated to reflect when they had been implemented. He acknowledged that the bed alarm and floor mats had been initiated at some point prior to 6/1/17 as those interventions were in place for the first fall that occurred on 6/1/17. The DON confirmed the side rails, bed alarm and floor mats did not reflect as an updated intervention on the resident's plan of care for fall prevention. The DON confirmed that the subsequent falls that occurred on 6/11/17, 6/21/17, and 8/21/17 there was no documented evidence that the interventions were evaluated for effectiveness and/or new interventions put in place to ensure the resident's safety while in bed. The DON confirmed that two rolled up pillows placed under the resident's mattress were not an appropriate intervention for the prevention of falls and could not speak to who initiated that and when, or why the CNA was doing that, as it was not an approved intervention in the resident's plan of care. The DON confirmed the pillows placed under the mattress were not considered a physical restraint as the resident would have still had the functional ability to get out of bed with them there, although he acknowledged he had no prior knowledge of the pillows being there. He did confirm however, it would pose the potential that the resident could fall from a higher platform in the event the resident tried to get out of bed. The DON further stated that he tracks the trends of falls on residents, but not the interventions/effectiveness of interventions, and confirmed that is evaluated during the investigative process. The ADON confirmed there was no order for the use of side rails in the resident's POS and acknowledged there should have been and could not confirm when the side rails had been initiated. The DON/ADON also confirmed that there was no consent for the use of side rails for this resident, as they were not aware a consent was needed for the use of side rails if it was not considered a physical restraint. A review of the undated Patient Care Policy Manual for accident control includes that the safety committee will create a process for teams of facility staff to conduct on-going analysis and application of patient safety practices. Care plans are initiated or updated as required. The policy further included that if a fall score is greater than ten, the resident is considered at high risk for falls. Items to be used will be decided on a case by case basis and documented on the care plan. According to the Post Unusual Occurrence Investigation policy, the charge nurse tries to ascertain why fall occurred and how further falls can be prevented. The procedures included to update care plan to reflect any changes necessary. 2. On 9/8/17 at 11:18 a.m., during the initial tour with the Assistant Director of Nursing (ADON), the surveyor observed the door to the resident's room closed. ADON stated that the resident had a Physician's Order (PO) for the use of hand mittens to be worn on both hands as a physical restraint. The ADON further explained that the use of hand mittens was necessary for safety because the resident had a behavior of pulling out his/her [DEVICE] (surgically inserted tube for nutritional feedings) and indwelling urinary catheter (flexible tube inserted through the urethra to collect and drain urine). Upon entering the room the surveyor observed Resident #7 lying in bed. The resident had both hands resting across his/her chest without evidence of the hand mittens. There were no staff were present in the room while the door was closed. On 9/11/17 at 10:30 a.m., the surveyor reviewed the resident's medical records. The resident was admitted to the facility on [DATE] and then re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the September 2017 Physician Order Sheet (POS) revealed a PO dated 7/27/17 for the use of bilateral hand mittens as a physical restraint. The order specified to check skin integrity and range of motion (ROM) every shift and to remove the bilateral hand mittens every two hours. A review of the resident's Comprehensive Care Plan (CCP) dated 4/25/17 for restraint use revealed that the resident had hand mittens and was at risk for injury as evidenced by removal of lines or tubes. An intervention indicated staff awareness of resident's restraints and the release of the restraints every two hours for a period of 15 minutes. A review of the September 2017 Treatment Administration Record (TAR) revealed that the nurses were signing to remove the bilateral hand mittens every 2 hours and check skin integrity followed by ROM every eight hours. The nurses were signing the TAR on the 11:00 p.m., - 7:00 a.m. shift, the 7:00 a.m., - 3:00 p.m. shift, and the 3:00 p.m., - 11:00 p.m. shift accordingly. On 9/11/17 at 10:58 a.m., the surveyor observed the resident in his/her room lying in bed. The resident was awake and alert. The surveyor observed that the resident did not have bilateral hand mittens on. At that time, no staff were present in the resident's room or general area. On 9/14/17 at 9:50 a.m., the surveyor interviewed the Certified Nursing Assistant (CNA) who was responsible to care for Resident #7. The CNA stated that the resident's bilateral hand mittens were needed for safety and were removed every two hours for 15 minutes. The surveyor inquired if staff were present when the resident did not have on the hand mittens. The CNA stated, I don't sit with (Resident #7) in the room. The CNA further explained to the surveyor that she checks on the resident between care of other residents when the hand mittens are removed, and confirmed that the resident did not always have staff present when the hand mittens were off. On 9/14/17 at 10:47 a.m., the surveyor observed the resident in bed with his/her eyes closed. The surveyor observed the resident's hand resting on his/her chest. No hand mittens were observed on the resident and no staff were present in the resident's room. On 9/14/17 at 10:49 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN) responsible for the oversight of care for Resident #7. The LPN explained to the surveyor that the resident had his/her hand mittens removed every two hours for 15 minutes. The LPN further explained that a staff member does not sit in the room with the resident when the hand mittens were removed and would not typically be present during 15 minutes in which the hand mittens were off. On 9/15/17 at 12:11 p.m., the ADON acknowledged that nursing staff are responsible to supervise the resident during the 15 minutes in which the hand mittens are removed to ensure the resident was not pulling out his/her gastrostomy feeding tube and indwelling urinary catheter. According to the undated Patient Care Policy Manual on use of restraints, Restraints are removed for fifteen minutes every two hours. Removal may occur at mealtimes and during supervised activities. NJAC 8:39-27.1 (a)

C# NJ Based on interviews and record reviews the facility failed to develop and implement policies to prevent neglect and ensure the safety for 1 of 4 residents (Resident #4). Resident #4 had a [DIAGNOSES REDACTED]. This deficient practice created a potential immediate threat to the Resident's health and safety which began on 7/20/16, and was identified as Immediate Jeopardy (IJ) situation on 12:15 p.m. on 7/26/16 p.m. The facility Director of Nursing, Assistant Director of Nursing (ADON), Facility Owner and the Assistant Administrator in Training were notified on 7/26/16 at 12:15 p.m. The IJ was lifted on 7/26/16 at 3:04 p.m. with the implementation of an acceptable Plan of Correction (POC). This deficient practice was evidenced by the following: Reference: A review of the Facility's undated Policy for Patient Abuse Investigation showed under prevention: Situations in which abuse, neglect and/or misappropriation of resident property are more likely to occur are identified and correction or intervention is made. Reference: A review of the Admission Policy did not include residents refusing admission. According to the facility Admission Record, Resident #4 was to be transferred for admission from the hospital to the facility on [DATE]. According to the hospital medical record form titled Progress Note Trauma Surgery (PNTS), dated 7/13/16, Resident #4, is a [AGE] year old, admitted to Acute Care hospital on [DATE] with [DIAGNOSES REDACTED]. This record also revealed that the Resident had S/P (status [REDACTED]. The PNTS showed: TBI w/ SDH ( [MEDICAL CONDITION] with subdural hematoma), Left Proximal Humeral Neck, Alcohol Withdrawal/Dependence, [MEDICAL CONDITION] Disorder and Dementia. Further review of the PNTS for Resident #4 revealed the following hospital notes from 7/8/16 to 7/10/16: 7/8/16 at 6:58 p.m., written by Registered Nurse (RN)-1700 noted Patient was hoarding food within room. Chicken, mac and cheese, milk cartoons noted to be in closet. Informed patient food was not good to eat, patient immediately became agitated and began to eat food stored in closet and ate food dropped on ground. Patient could not be redirected. Eventually food was removed from the room, however, patient became extremely agitated and posed a risk to staff for physical harm. Patient was holding fists up screaming for me to leave the room. 7/9/16 at 7:08 a.m., written by RN -0600 Patient became agitated stated he was going to Puerto Rico needed me to get out of my room. 7/10/16 at 12:59 p.m., written by MD (Medical Doctor), under Assessment/Plan Altered Mental Status- pt (patient) lacks capacity, d/c (discharge) planning for safe discharge. Additional review of the PTNS on 7/26/16, showed that the Resident was on the following medications: [REDACTED]. During an interview with the facility's Admission Director (AD) on 7/26/16 at 10:55 a.m., the AD indicated that Resident #4 was accepted for long term care admission after approval from both the Director of Nursing (DON) and the Financial Officer and was assigned to a bed. On 7/20/16 after 5 p.m., the AD indicated that Resident #4 was transported by ambulance personnel from the hospital and stayed in the facility's lobby, because the Resident refused to go up to the unit. The AD further stated I was convincing the Resident to go up to the unit, but the Resident was yelling, talking in English and Spanish. The AD stated that the Resident kept on showing a piece of paper with a name and telephone number on it but refused to give it to the AD and the DON. The AD indicated that he/she called Resident #4's niece and left her a message. The AD further indicated that he/she called the Hospital's SW (HSW) and asked what should they do, since the Resident refused to stay. Furthermore, the AD stated While I was persuading the Resident to stay, I received a call from the HSW and said to let the Resident go. During an interview with the Director of Nursing (DON) on 7/26/16 at 11:13 a.m., the DON indicated that on 7/20/16, the Nursing Supervisor was convincing the Resident to go to the room but the Resident refused. The DON went on to say The Resident kept showing me a name and a telephone on a card but the Resident refused to give the number so we can call that person. Afterwards, the HSW said to our AD to let him go. We offered the Resident a taxi but the Resident said no, subsequently, the Resident left the facility. The surveyor asked the DON if he/she called the Police Department to report about Resident #4. The DON stated No, we didn't call the Police Department. The DON further added The Resident said that he/she knows where to go. During a follow up interview with the AD on 7/26/16 at 11:20 a.m., the surveyor asked if he/she heard from a family member of Resident #4 on 7/20/16. The AD indicated that on 7/21/16, he/she had a telephone conference with the HSW and Resident #4's family member (FM) about the Resident's refusal to stay and leaving the facility on 7/20/16. The AD further stated The FM was asking why I didn't call the police and I said I didn't think of that. The surveyor asked the AD if the FM heard from the Resident, since the Resident left the faciity on [DATE]. The AD stated that during the telephone conference with the family on 7/21/16, the Resident's brother mentioned that he thinks he knew where the Resident might have gone. Additionally, the AD stated that the Resident left the facility at about quarter to 6 (p.m.) dressed in a shirt and pants, and wearing shoes. A review of the Accu Weather Forecast for East Orange, New Jersey revealed that on 7/20/16, the actual temperature that day was 86 degrees Fahrenheit. During a post survey interview with the HSW on 7/28/16 at 10:49 a.m., the HSW stated that on 7/20/16 at around 5 p.m., he/she received a call from the facility AD about Resident #4 who was agitated and refusing admission. The HSW also stated I suggested to the AD to call the niece because I couldn't do anything about it. Later on, I received a phone message from the AD that the Resident refused to stay and left the building. The Immediate Jeopardy (IJ) was identified on 7/26/16, at 12:15 p.m. and was lifted on 7/26/16 at 3:04 p.m. with the acceptable POC as follows: A. The admission policy of the facility was re-evaluated today 7/26/16, to include potential admissions to the facility that refuse to be admitted , this policy will indicate actions on behalf of the facility to ensure safety and security of the individuals refusing to be admitted . B. All residents who refuse to be admitted to the facility will have the potential to be affected. Therefore: 1. The facility assures that they will institute the admission policy update immediately that residents accepted from any medical institution will be the responsibility of the facility, once present within the facility. The safety and security of the resident/potential admission will be the focus of care. 2. Admission potentials that refuse to be admitted to the facility will be followed up by an unusual occurrence report, reporting to the New Jersey Department of Health (NJDOH) and Senior Services, The Law Enforcement, 911 emergency services, Physician, family and facility of origin. All efforts identified will be focused on the safety of the residents/admission potentials. 3. Nursing supervisors will be responsible for reports and follow up related to admission potential refusals to be admitted . C.1. The facility revised it's admission policy on 7/26/16, and incorporate measures that focus on the safety and security of admissions potentials refusing to be admitted to the facility. 2. Nursing supervisors will be responsible for the unusual reports and the follow up regarding admissions with the refusals to stay in the facility. 3. Heads of departments will receive inservices on 7/26/16 related to admission policy changes. Inservice will be effective as of today 7/26/16. 4. Nursing Supervisors on a daily basis will report to the ADON on all occurrences of refusals to be admitted to the facility and the actions related to these occurrences. The DON will inform the Administrator. 5. Admission potentials that refuse to be admitted to the facility will be followed up by the unusual occurrence report, reporting to the NJDOH and Senior Services, the Law Enforcement, 911 emergency services, Physician, family and facility origin. All efforts identified will be focused on the safety of the resident/admission potentials. D.1.The DON, Administrator and Nursing Supervisors will review documentation on a daily basis regarding occurrences of this nature at the heads of the department meetings to ensure resident safety was not jeopardized, and the required follow up was reflective of concern for the resident safety ongoing. 2. The Quality Assurance committee will review on a quarterly basis occurrences of this nature and address concerns related to safety as required ongoing. On 7/26/16, the facility revised it's Policy On Admission/Transfer/Discharges. This policy included under 5.5 Residents within the facility refusing to be admitted : A. All efforts will be made to encourage the resident to be admitted to the facility. B. If resident refuses to be admitted (taken into consideration the resident's cognitive status) the following actions will be instituted for resident safety. Inform the hospital of origin, physician will be notified, family resident will be notified, unusual occurrence report will be initiated, 911 emergency will be notified. C. Resident safety will be the primary consideration of the policy. Effective date: 7/26/16 NJAC 8:39-4.1 (a)5, 27.1

C # NJ Based on interviews and record reviews, the facility staff failed to ensure the safety for 1 of 4 residents (Resident #4). Resident #4, who had a [DIAGNOSES REDACTED]. This deficient practice created a potential immediate threat to the Resident's health and safety which began on 7/20/16, and was identified as an Immediate Jeopardy (IJ) situation on 12:15 p.m. on 7/26/16 p.m. The facility Director of Nursing, Assistant Director of Nursing (ADON), Facility Owner and the Assistant Administrator in Training were notified on 7/26/16 at 12:15 p.m. The IJ was lifted on 7/26/16 at 3:04 p.m. with an implementation of an acceptable Plan of Correction (POC). This deficient practice was evidenced by the following: Cross Reference F 224 NJAC 8:39-4.1 (a)5, 27.1

A) Based on observation, interview and record review, it was determined that the facility failed to prevent a serious safety hazard from occurring and failed to ensure that all residents were safe from a resident's careless smoking in unauthorized areas. Resident #26 was found, unsupervised by staff, with a lit cigarette in the resident's room. Staff observed smoke emanating from the resident's room and found three cigarettes, one still burning. Resident #26 had a history of [REDACTED]. Staff continued to observe the resident possess cigarettes and matches and failed to provide remedial measures to prevent future safety hazards. There was no evidence that the facility followed clinical recommendations from the crisis team or develop an immediate care plan to address the resident's non-compliance and provide a safe environment for all residents. The deficient practice was identified for 1 of 9 residents reviewed for behavioral symptoms affecting others, Resident #26, who was identified as being non-compliant with the smoking policy. The immediate jeopardy was identified on 2/14/14 at 12:25 p.m., and the immediacy was abated at 1:20 p.m., when the resident was discharged to the crisis center for another behavior that affected resident safety. A formal plan of correction for the deficient practice was submitted to the team and accepted on 2/14/14 at 3 p.m. The team validated that the elements were completed and compliance was achieved on 2/20/14. The deficient practice for the Immediate Jeopardy situation was evidenced by the following: On 2/11/14 at 9 a.m., during the initial tour of the unit the charge nurse stated that Resident #26 had a psychiatric illness with behaviors of taking items that did not belong to him/her and of resisting care. On 2/12/14 at 10:30 a.m., the surveyor met with a group of residents who stated that Resident # 26, "almost burned the building down"; "stuffs paper in radiators" and that he / she takes items out of residents ' rooms. On 2/14/14 at approximately 9 a.m., the surveyor observed Resident #26 in the lobby area pacing the hall in a wheelchair in front of the Social Service Office. The surveyor greeted the resident and observed that the resident was upset that the Social Worker's (SW) door was closed and she was not yet in to work. On 2/14/14 at 9:05 a.m., the surveyor reviewed the record of Resident #26. The resident had [DIAGNOSES REDACTED]. On 11/6/13, the interdisciplinary team completed the current smoking assessment for Resident#26, which indicated that the resident required supervision with smoking. The Minimum (MDS) data set [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS), a cognition assessment tool, score of 15 out of 15. This indicated that the resident had good cognition skills. The Behavioral assessment indicated the resident exhibited verbal behavioral symptoms directed towards others 1 to 3 days a week. The assessment indicated that these behaviors had worsened. On 12/30/13 the nurse documented in the Nurse's Notes (Monthly Psychotropic Note) that the resident frequently refused medications, was re-directed by staff and counseled, but there had been no positive effects. On 12/30/13 the resident was sent out to the hospital crisis unit with police escort for combative behavior and being verbally abusive to staff. On 1/18/13 at 4:30 p.m., the nurse documented that the resident was found in the room with fumes of smoke coming out of the room. The nurse observed the radiator cover with several butts of cigarettes on it and one butt still burning. When approached, the resident became agitated and combative. A call was made to the physician who gave the order that the resident be sent to the crisis unit. The crisis team came to the facility to interview the resident, but did not suggest transfer to the crisis unit at the hospital at that time. On 1/30/14 at 2:30 p.m., the nurse documented that the resident was again found with a cigarette. The resident handed over the cigarette to the recreation department after much encouragement. The resident continued to exhibit additional behaviors. A call was made to the physician who ordered the resident to again be sent to the crisis unit at the hospital. These behaviors were not documented on the January 2014 Behavior Monitoring Form. (Refer to F329) On 2/4/14 at 12:30 p.m., the Advanced Practice Nurse (APN) from the crisis team performed a consult for Resident #26. Recommendations included "Develop a behavioral contract with consequences for smoking policy compliance." On 2/12/14 between 6 and 8 p.m., according to the Nurses Notes, the nurse documented "Resident on ground floor, back to unit another resident stated, resident has matches in (his/her) pocket, when asked (he/she) denied." On 2/12/14 at 9:30 p.m., approximately 1 and 1/2 to 3 and 1/2 hours later, the nurse documented, "Resident refused meds, asked security guard making rounds on unit to ask resident about matches. Started to deny having matches, but matches were found in the resident pocket." The surveyor reviewed the current care plan for the resident's non-compliance to smoking dated 11/7/12. There was a goal that indicated: "Resident will be a safe smoker within 90 days." Interventions included: to offer the resident a smoker's bib and if declined to encourage to extinguish the ashes into the ashtray. The care plan was last updated on 12/5/13 and an evaluation indicated," Resident remains compliant with facility smoking policy, continue with care plan." There was no evidence that the facility made revisions to the care plan to address the resident's non compliance with the smoking policy after several instances of being found with either cigarettes or matches in his/her possession. (Refer to F279) The surveyor obtained the facility's smoking policy on 2/14/14 at 10:30 a.m. from the Recreation Director (RecD). The smoking policy established set smoking times which were monitored by Recreation staff. The policy also included that all smoking materials were to be held by Recreation. The RecD told the surveyor that they had no knowledge of how the resident obtained cigarettes or matches. She added that there was no monitoring tool or intervention in place to make sure Resident #26 did not have any smoking material. The policy also listed that "Room checks are made of smoker's rooms to ensure that smoking paraphernalia has not been placed or secreted in resident's room." There was no evidence that this was done for Resident #26's room. On 2/14/14 at 10:40 a.m., the surveyor interviewed the social worker (SW). She stated that she was unaware of how the resident obtained the cigarettes or matches and that they only search the resident when they see the cigarettes or matches. She said that the resident would come downstairs to her office to ask her about his/her smoking privileges. The surveyor then asked the SW for documentation that a behavioral contract was made for Resident #26 according to recommendations made by the APN on 2/4/14. She stated that she was unaware of the recommendations that the APN made. The SW also stated the facility just limited his/her smoking privileges when Resident #26 was found with smoking materials. She added that the APN from the crisis team came to the facility and spoke to her first and then she visited the resident and wrote her recommendations. On 2/14/14 at 11:15 a.m., the surveyor interviewed the charge nurse on the unit. She stated that she did not know where the resident got the cigarettes or matches. She stated, "He/she is all over the building." She confirmed that they did not perform room checks for this resident. The immediacy of the Jeopardy situation was corrected on 2/14/14 at 1:20 p.m., when the resident was discharged to the crisis unit at the hospital for another behavior that affected resident safety. The resident was readmitted on [DATE] and team verified that the plan of correction was implemented throughout the course of the survey and corrected as of 2/20/14 at 10 a.m. The plan of correction included the following: 1. Care Plan adjusted immediately to include non-compliance with smoking regulation.2. Smoking contract specific to this resident was instituted.3. One on One supervision was instituted for this resident.4. Smoking Violation investigation will be used for any further non-compliance.5. Resident's room and person will be checked before and after smoking time.6. Potential for room change closer to nursing station for observation (with resident's consent.)7. Call made to consult with attending physician and psychiatrist regarding resident smoking status due to non-compliance with facility smoking policy. 8. Explore with IDC team and attending physician smoking cessation via nicotine patch, e-cigarettes, gum, etc in association with non-compliance and danger to himself and others.9. Reassessment in regard to level of care necessary will be explored.10. Transfer to Crisis for re-evaluation of smoking behaviors that are a danger, as well as, if contraband or paraphernalia is found.11. In services on new smoking policy were initiated. Facility presented team with documentation and monitoring tools. 12. All residents who smoke will have smoking assessments reviewed and care plans adjusted. 13. All staff and smokers were in serviced on the smoking policy. 14. Non compliant smoking issues will be discussed at the quarterly QA/QI meetings for evaluation. B) This deficient practice continued at a lower scope and severity of an E level. The facility failed to maintain a safe enviornment for residents on 3 of 4 floors in resident units, and for 1 of 9 residents reviewed for behavioral symptoms affecting others. This deficient practice was evidenced by the following: 1. On 2/14/14 at 9:30 a.m., in the presence of the nurse, the surveyor took temperatures of the hot water in resident rooms 117, 212, 215 and 216 and found the temperature to be 120-122 degrees Fahrenheit (F). Temperatures of the hot water taken in rooms 304 and 405 were 112, and 118 degrees F, respectively. At 10:30 a.m., the surveyor tested the hot water in the 5th floor main shower room with a calibrated analogue thermometer which revealed a temperature of 120-degrees. This was also noted in the sinks of resident rooms #501 and #506. The surveyor requested access to the building's hot water source (boiler room) at 10:35 a.m. and was told by the facility's Administrator that the room was only accessible from the outside of the building and the area was currently inaccessible due to the accumulation of snow. After staff cleared the snow, the surveyor accessed the boiler room at 11:30 a.m. and was met by a contracted vendor who indicated in an interview at 11:32 a.m. that he was there to repair a mixing valve on the hot water system after receiving prior notification. The system's thermometer for the outgoing domestic hot water was 125-degrees Fahrenheit, thus ensuring that hot water provided to resident rooms and bathing areas exceeded 110-degrees F. On 2/14/14 at 1 p.m., the surveyor re-checked the hot water in resident's rooms and found it to be adjusted to 110 degrees F. 2. On 2/14/14 at 12:25 p.m., the 3rd floor main shower room had water pooling on the floor by the sink. The area was not provided with a wet floor sign or restricted from resident use. It was noted that the sink area was approximately 6-feet away from an unenclosed shower stall with a floor drain. The facility's Administration indicated in an interview at 12:27 p.m. that residents used the sink instead of the shower for bathing due to custom. He constantly warned the staff to not allow residents to bathe in this manner. The surveyor observed a sign attached to a section of the wall above the sink which read, " Please do not use water from sink for bathing. " The surveyor observed that the floor area by the sink was not pitched to the drain located in the shower stall. When residents bathed in the sink, the water was not mopped up or pushed to the shower floor drain, thus pooling and creating an accident/ slip hazard. 3. On 2/14/14 at 10:30 a.m., the surveyor interviewed the Nursing Supervisor of the 2nd floor. This interview revealed that Resident #26 routinely poured water into electrical sockets. She indicated that the resident tried to remove the protective electrical outlet plates and proceeded to douse the socket with water. The Nursing Supervisor identified 2 areas where this occurred: the corridor by the nurse's station and the Day Room. The surveyor noted that the electrical outlet plate in the Day Room was bent. The facility had not de-energized these electrical outlets to prevent an electrical hazard. The surveyor reviewed the record on 2/14/14 at 9:05 a.m. On 2/7/14 at 11:30 a.m. the nurse documented in the Nurses Notes that Resident #26 was hitting the electrical socket with a cup and at 2:55 p.m. that the resident was observed pouring water in the electrical outlet in the dining room. The nurse redirected and counseled the resident on safety. The physician was called and ordered the resident to be sent to the crisis unit at the hospital. On 2/8/14 the resident returned and again at 6 p.m., the nurse observed the resident pour water into the electrical outlet near the nurses' station. Resident #26 was again redirected and counseled. On 2/12/14 at 10:45 a.m., the nurse observed the resident bending the plate of the electrical socket in the dining room. The resident was redirected and educated about safety. The resident stated, "ok,ok, leave me alone." On 2/14/14 at 12:02 p.m., the nurse again observed the resident pour water into the electrical outlet and was redirected. The physician was called and the resident was again sent to the crisis unit at the hospital. On 2/20/14 at 12:45 p.m., the Maintenance Director stated that the electrical outlet was not repaired, but if the water was poured and reached the socket it would trip the circuit breaker and shut off the electric on everything connected to that line as a safety feature. On 2/20/14 at 1 p.m., the surveyor questioned the Administrator why the electric outlet was not repaired or measures put into place to address the resident's behavior. He stated, "We would have to change every outlet." NJAC 8:39-31.4(a), 4.1(a)11

A) Based on observation, interview and record review, it was determined that the facility failed to develop comprehensive care plans to prevent a serious safety hazard from occurring and to ensure that all residents were safe from a resident's careless smoking in unauthorized areas. Resident #26 was found, unsupervised by staff, with a lit cigarette in the resident's room. Resident #26 had a history of [REDACTED]. Staff observed smoke emanating from the resident's room and found three cigarettes, one still burning. Staff continued to observe the resident to possess cigarettes and matches and failed to provide care plan interventions to prevent future safety hazards. There was no evidence that the facility followed clinical recommendations from the crisis team to develop an immediate care plan to address the resident's non- compliance and provide a safe environment. The deficient practice was identified for Resident #26, 1 of 9 residents reviewed for behavioral symptoms. The immediate jeopardy was identified on 2/14/14 at 12:25 p.m., and corrected at 1:20 p.m., when the resident was discharged to the crisis center for another behavior that affected resident safety. A formal plan of correction for the immediacy was submitted to the team and accepted on 2/14/14 at 3 p.m. The team validated that the elements were completed and compliance was achieved on 2/20/14. The deficient practice for the Immediate Jeopardy situation was identified by the following: On 2/11/14 at 9 a.m., during the initial tour of the unit the charge nurse stated that the resident had a psychiatric illness with behaviors of taking items that did not belong to them and of resisting care. On 2/12/14 at 10:30 a.m., the surveyor met with a group of residents who stated that Resident # 26, "almost burned the building down", "stuffs paper in radiators" and takes items out of residents rooms. On 2/14/14 at approximately 9 a.m., the surveyor observed Resident #26 in the lobby area pacing the hall in a wheelchair in front of the Social Service Office. The surveyor greeted the resident, and the resident was agitated that the Social Worker's (SW) door was closed and she was not in to work yet. On 2/14/14 at 9:05 a.m., the surveyor reviewed the record of Resident #26. The resident had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS), a cognition assessment tool, score of 15 out of 15. This indicated that the resident had good cognition skills. The MDS also stated that the resident exhibited verbal behavioral symptoms directed towards others on 1 to 3 days a week, and that that these behaviors had worsened. On 1/18/13 at 4:30 p.m., the nurse documented that the resident was found in the room with fumes of smoke coming out. The nurse observed the radiator cover with several butts of cigarettes on it and one was still burning. The resident became agitated and combative when approached. The physician was called and ordered that the resident be sent to the crisis unit. The surveyor reviewed the current care plans related to smoking for Resident #26. Goals were as follows: 1) "Resident will be a safe smoker within 90 days" dated 11/7/12. Interventions dated 11/7/12 included: Offer the resident a smoker's bib and if declined to encourage to extinguish the ashes into the ashtray; and 2) "Resident will comply with smoking regulations of the facility," with a start date of 7/4/08. The last update and evaluation on 12/5/13 indicated, "Resident remains compliant with facility smoking policy, continue with care plan. " On 1/30/14 at 2:30 p.m., the nurse documented that the resident was found with a cigarette. The resident handed over the cigarette to the recreation department after much encouragement. The care plan was not revised to reflect the resident's non compliance to the smoking policy. On 2/4/14 at 12:30 p.m., the Advanced Practice Nurse (APN) performed a consult for Resident #26. Recommendations included: "Develop a behavioral contract with consequences for smoking policy compliance." The surveyor reviewed the behavioral care plan for Resident #26, dated 10/7/08, for resisting care, refusing medications and combative behavior. The last revision was dated 12/2/13. There was no evidence that the care plans were updated to include a behavioral contract or interventions to address compliance to the smoking policy. On 2/12/14 between 6 and 8 p.m, according to the Nurses Notes, "Resident on ground floor, back to unit another resident stated, resident has matches in his pocket, when asked he/she denied." On 2/12/14 at 9:30 p.m., the nurse documented, "Resident refused meds, asked security guard making rounds on unit to ask resident about matches. Started to deny having matches, but matches were found in the resident pocket." A review of the smoking policy indicated that "Room checks are made of smoker's rooms to ensure that smoking paraphernalia has not been placed or secreted in resident's room." There was no log to document if this was done for Resident #26's room or that this was an intervention added to the resident's care plan. On 2/14/14 at 10:40 a.m., the surveyor interviewed the social worker (SW) and asked the SW for documentation that a behavioral contract was made for Resident #26 according to recommendations made by the APN on 2/4/14. She stated that she was unaware of the recommendations and stated the facility just limited Resident #26's smoking privileges when Resident #26 was found with smoking materials. The surveyor questioned the SW as to why the care plan was not revised and updated. She stated that the team reviewed the care plans on a quarterly basis. There were no revisions made to the resident's care plan when behaviors occurred from 1/18/13 to 2/14/14. There was no evidence that the Interdisciplinary Team (IDT) conducted a root cause analysis to establish causal factors for the resident's continued behaviors and non-compliance to the smoking policy. There was no evidence that the IDT reviewed and revised Resident #26's care plans when needed. The immediacy of the Jeopardy situation was corrected on 2/14/14 at 1:20 p.m., when the resident was discharged to the crisis center for another behavior that affected resident safety. The resident was readmitted on 2/14/14 and the team verified that the plan of correction was implemented and corrected as of 2/20/14 at 10 a.m. Refer to F323 for the plan of corrections. B) This deficient practice continued at a lower scope and severity at an E level for accident/ hazards. The facility failed to establish a comprehensive care plan for Resident #26, 1 of 9 residents reviewed for care planning interventions related to behavioral symptoms. This was evidenced by the following: On 2/14/14 at 10:30 a.m. the surveyor interviewed the Nursing Supervisor of the 2nd floor who stated that Resident #26 routinely poured water into electrical sockets. She indicated that the resident tried to remove the protective electrical outlet plates and proceeded to douse the socket with water. The Nursing Supervisor identified 2 areas where this occurred: the corridor by the nurse's station and the Day Room. The surveyor observed that the electrical outlet plate in the Day Room was bent. The facility had not de-energized these electrical outlets to prevent electrical hazard. The surveyor reviewed the record on 2/14/14 at 9:05 a.m. and observed the following: On 2/7/14 at 11:30 a.m. the nurse documented in the Nurses Notes that the resident was hitting the electrical socket with a cup, and at 2:55 p.m. that the resident was observed to pour water in the electrical outlet in the dining room. The nurse redirected and counseled the resident on safety. The physician was called and ordered the resident to be sent to the crisis unit at the hospital. On 2/8/14 the resident returned and again at 6 p.m., the nurse observed the resident pour water into the electrical outlet near the nurse's station. Resident #26 again was redirected and counseled. On 2/12/14 at 10:45 a.m., the nurse observed the resident bending the plate of the electrical socket in the dining room. The resident was redirected and educated about safety. The resident stated, "ok,ok, leave me alone." On 2/14/14 at 12:02 p.m., the nurse again observed the resident pour water into the electrical outlet and was redirected. The physician was called and ordered the resident be sent to the crisis unit at the hospital. The surveyor reviewed the behavior care plan for Resident #26 and observed the plan failed to include a problem area or revision(s) to address the resident tampering with electric outlets. NJAC 8:39-11.2(e) 1,2

Based on observation, interview, and record review it was determined that the facility failed to prevent the development of avoidable pressure sores and provide effective interventions for 3 of 6 residents , Resident #4, #18 and # 21 reviewed for pressure sores. This resulted in harm for Resident #4, who developed 2 unstageable pressure sores. The findings are as follows: 1. During the initial unit tour the surveyor observed Resident #4 on 11/14/11 at 9:30 a.m. The resident self propelled down the hallway in a motorized wheelchair and had socks on his feet. The resident was alert and oriented. The unit nurse stated the resident currently had 2 sores on the left foot which were unstageable. The surveyor spoke to the resident on 11/17/11 at 9 a.m. Resident # 4 was in bed wearing heel booties on the left and right feet. The resident stated he did not know how he developed the pressure sores. He said he did not wear heel booties prior to the development of the sores on his foot. The surveyor observed the pressure sores on 11/17/11 at 9:25 a.m. The surveyor asked the treatment nurse to measure the sores. The left heel pressure sore measured 10 cm. in length and 9 cm. in width. The plantar surface of the left foot measured 8 cm. in length and 7 cm. in width. The skin was intact and blackened in color on both sites. On 11/17/11 at 10 a.m., the surveyor reviewed Resident #4's medical record. The resident was readmitted to the facility from the hospital on [DATE]. The Nursing Admission Assessment of 8/16/11 indicated that the resident was readmitted with a "black spot under the (right) foot." No measurements were documented. No further reference to the black spot on the right foot was found on the record. There was no documentation of any abnormality on the left foot at the time of the [DATE] readmission. The Admission Care Plan of 8/16/11 did not list any interventions under "Pressure Sores/Skin Care." An 8/16/11 Braden Scale (a tool for predicting pressure sore risk) indicated a calculation showing that the resident was at mild risk of developing a pressure sore. The 8/16/11 readmission physician's orders [REDACTED]. The 8/26/11 quarterly Minimum Data Set (MDS) indicated that the resident's bed mobility (the ability to move and change position while in bed) required the extensive assistance of 2 or more caregivers. The resident's range of motion was assessed as limited on one side for both upper and lower extremities. The resident was assessed to be always incontinent of bowel and bladder. The resident was assessed to have no pressure sores, but to be at risk of developing pressure sores. The nurse documented in the nurse's progress note on 9/12/11 at 9:45 a.m., that the resident was noted with an unstageable pressure sore on the left medial foot measuring 0.1 cm by 0.4 cm. On 9/12/11 at 10:45 a.m. a physician's telephone order prescribed Skin Prep to the unstageable pressure sore on the left lateral foot twice daily at 6 a.m. and 6 p.m. until healed. Heel protectors to both feet while in bed were also ordered at that time. A 9/12/11 care plan was initiated which included the use of bilateral heel protection when in bed. The Certified Wound Nurse initially examined the resident on 9/15/11 (11:46 a.m.) The nurse described the left medial heel as a 9 cm by 7.5 cm full thickness ulceration. Additionally, the plantar surface of the left foot was assessed with [REDACTED]. "Contributing [DIAGNOSES REDACTED]. . . offload pressure on wound . . . heel lift boot." There was no evidence that the recommendation for the heel lift boot was ever implemented. A 9/15/11, 11-7 shift, physician's telephone order prescribed "unstageable ulceration of the left heel - medial surface cleanse area with NSS or wound cleanser. Apply skin prep to wound base bid & prn. Cover with abd pad and loose kling wrap dressing." A second order prescribed "unstageable ulceration of the left foot, plantar surface. Cleanse area with NSS or wound cleanser. Apply skin prep to wound base bid and prn. Cover with abd pad and loose kling wrap dressing." The surveyor spoke with the Director of Nursing (DON), the Administrator, and the Assistant Administrator on 11/17/11 at 1:30 p.m. The surveyor requested additional information regarding the accuracy of the assessment of the resident's Braden Scale and asked what interventions were initiated following his readmission from the hospital on [DATE]. The DON responded on 11/21/11 at 10:20 a.m. stating the 8/16/11 Braden Scale was corrected. He also stated that nursing staff was re-inserviced on skin assessment. 2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS of 7/15/11 indicated that the resident did not have any pressure sores. According to the resident's care plan for "At risk for skin breakdown," an open blister was found along the residents incontinence brief line on her right anterior thigh on 11/1/11. On 11/3/11 a nurse practitioner wound care specialist (NP) saw the resident. The NP recommended a loose fitting brief for the resident. The resident's skin care plan indicated that on 11/4/11 there was an intact fluid filled blister on the resident's right anterior upper thigh. On 11/10/11, the NP saw the resident and again recommended a loose-fitting brief. On 11/17/11 at 11:38 a.m. the surveyor observed the resident in bed wearing a plastic diaper. The NP was present and said that she had recommended a loose fitting brief for the resident but the resident was not wearing them. The NP said that she had evaluated the resident for an opened blister that was resolving and that now there was another blister. The NP said she would recommend toileting the resident every 2 hours and again recommend using pull-ups instead of plastic incontinence briefs. On 11/21/11 at 9:45 a.m. the surveyor observed the resident with a Certified Nursing Assistant (CNA) present. The surveyor observed the residents wearing a plastic incontinence brief. On 11/21/11 at 9:50 a.m. the nurse said that she told the CNAs to use pull-ups and did not know why the resident still had on plastic briefs. At 11:05 a.m. the resident was in her room sitting in her wheelchair. The nurse was present and said the resident was now wearing pull-ups. 3. On 11/16/11 at 11:23 a.m. the surveyor observed a pressure sore treatment to Resident #21's right upper anterior thigh. The resident was wearing plastic incontinence briefs. The surveyor observed 3 pink open areas. The resident said that she got the pressure sore from wearing the plastic briefs. On 11/10/11 the NP evaluated the resident. The report from the NP included that a possible contributing [DIAGNOSES REDACTED]." This report also indicated that the NP recommended a loose-fitting incontinence brief. On 11/16/11 at 11:45 a.m. the surveyor asked the nurse about the plastic incontinence briefs on the resident. The nurse spoke with her supervisor in reference to the NP's recommendation for loose-fitting briefs. The nurse told the supervisor that the resident was wearing the same briefs that she had been wearing. The nurse requested pull-ups for the resident. On 11/16/11 at 12:35 p.m. the nurse obtained large pull ups for the resident and said she was going to start using them on the resident after lunch. On 11/17/11 at 12:15 p.m. the surveyor interviewed the NP about the resident's sores. The NP said that she had recommended loose fitting diapers for the resident the previous week. On 11/21/11 at 11 a.m. the surveyor observed the resident sitting in her wheelchair in her room. The resident said that she was wearing pull-ups now and they feel so much better. The resident also said that the blisters were almost gone. NJAC 8:39-27.1(e)