Every finding on record at Hamilton Grove Healthcare and Rehabilitation, LLC

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries and ensure that air mattresses were accurately set according to the resident's weight.This deficient practice was identified for 4 of 4 residents (Residents #6, #7, #106, and #151) reviewed for risk of pressure ulcers and was evidenced by the following:1.On 3/6/26 at 10:50 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 330 pounds.On 3/10/26 at 11:48 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 180-230 pounds.A review of the admission Record (AR) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; hemiplegia (the total or partial paralysis of one entire side of the body) and hemiparesis (a neurological condition characterized by muscular weakness on one side of the body) right dominant side; muscle weakness; and cognitive communication deficit (an impairment in communication such as speaking or listening caused by issues like poor memory or poor attention).A review of the Order Summary Report (OSR) revealed a physician's order (PO) for air mattress on bed for pressure prevention, every shift check setting and function on air mattress, dated 3/7/26.A review of the vital signs in the electronic medical records (EMR) revealed a weight of 210.8 pounds, dated 3/4/26.A review of the annual Minimum Data Set (MDS), an assessment tool dated 1/20/26, revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15, which indicated Resident #6's cognition was severely impaired.A review of the Individual Comprehensive Care Plan (ICCP) completed 1/6/26 revealed focus areas for:Extensive assist x2 with [name redacted] (a mechanical device used to safely transfer individuals with limited mobility) for transfers;Impaired functional status related to decreased mobility and impaired balance due to left Cerebrovascular Accident (CVA) with right sided weakness and dysphagia;Decreased Range of motion (ROM) due to contracture(s); Hemiplegia and hemiparesis; potential for further decline in ROM, potential for pain/discomfort related to contracture(s); andRisk for skin breakdown related to impaired ROM. and incontinence. An intervention for the focus area of risk for skin breakdown included air mattress to bed initiated 3/7/26, and pressure reduction mattress initiated 10/24/25. Wound history .mechanical injury sacrum resolved.On 3/11/26 at 10:32 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) who confirmed Resident #6 had an air mattress because of risk for pressure ulcers.2.On 3/10/26 at 11:45 AM, the surveyor observed Resident #7 in bed with the air mattress setting set at 180-230 pounds.A review of the AR revealed diagnoses that included but were not limited to; bed confinement status; chronic pain syndrome; and dementia.A review of the OSR revealed a PO for weekly skin assessment dated [DATE]; and a PO for air mattress on bed for pressure relieving, every shift for pressure prevention check setting and function on air mattress, dated 3/7/26.A review of the quarterly MDS dated [DATE], revealed a BIMS of 1 out of 15, indicating severe cognitive impairment. Further review revealed the resident had upper and lower extremities impairment on both sides and an indicator for pressure injury.A review of the ICCP dated 2/19/26 revealed a focus areas for:Extensive to dependent assist with Activities of Daily Living (ADLs).Risk for skin breakdown related to incontinence of bowel and bladder and decreased mobility of bilateral lower extremities and preference to stay in bed, frequently squirms around in bed to get into his favorite position requiring staff to reposition him for safety.Right lateral foot arterial wound. Interventions for this focus area included air mattress to bed dated 1/1/24.Potential for pain related to limited range of motion to upper and lower extremity. Interventions for this focus are included to utilize pressure relieving mattress for comfort dated 1/27/26.A review of the vital signs in the EMR revealed a weight of 147.2 pounds, dated 3/10/26.A review of a wound assessment report, dated 2/11/26 revealed a new right lateral foot arterial ulcer. The assessment also revealed current pressure relieving devices as air mattress overlay.A review of a skin and wound note dated 3/4/26 revealed .right lateral foot arterial ulcer .history of chronic wound. Continue with turning and repositioning schedule per protocol for pressure prevention .Wound is stable.On 3/11/26 at 10:27 AM, the surveyor interviewed LPN#1, who confirmed Resident #7 had an air mattress. LPN#1 stated They get out of bed every Tuesday and Thursday due to refusal and as they requested. There are orders for the air mattress to check the setting and function, we make sure it is set to the appropriate weight. That is the setting that determines the amount of air in the mattress to relieve pressure.3.On 3/6/26 at 10:20 AM, the surveyor observed Resident #106 in bed with the air mattress settings set to 325 pounds.On 3/10/26 at 11:34 AM, the surveyor observed Resident #106 in bed with the air mattress settings set to 80 pounds.A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified symptoms involving cognitive function and awareness; and nontraumatic intracerebral hemorrhage (a severe stroke caused by spontaneous bleeding into brain tissue).A review of the OSR revealed a PO for air mattress on the bed for pressure prevention, every shift check setting and function on air mattress, dated 10/20/25. A further review revealed a PO for weekly skin assessment every Tuesday evening shift for monitoring.A review of the quarterly MDS dated [DATE], revealed the BIMS score was unable to be conducted, indicating severe cognition impairment. Further review revealed the resident was at risk for pressure injury.A review of the ICCP dated 1/5/26, revealed a focus area for risk for skin breakdown related to impaired mobility, incontinent. Interventions included air mattress to bed, dated 3/20/23.A review of the vital signs in the EMR revealed a weight of 147.2 pounds dated 3/9/26.A review of the facility provided Unit Wound Rounds form dated 1/12/26 revealed Resident #106 to have a facility acquired upper left buttock wound on 1/5/26, resolved, with a notation for air mattress.4.On 3/6/26 at 10:25 AM, the surveyor observed Resident #151, in bed with the air mattress setting set to 540 pounds.A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; muscle weakness; muscle wasting; and chronic pain syndrome.A review of the OSR revealed a PO for air mattress on bed for pressure prevention, discontinued on 11/4/25. There was no active PO for air mattress was listed on the OSR.A review of the quarterly MDS dated [DATE] revealed a BIMS of 8 out of 15, indicating moderately impaired cognition.A review of the ICCP dated 3/1/26 revealed focus areas for: A preference to stay in bed with a gown on and complete a bed bath on shower days;Risk for skin breakdown related to decreased mobility.Interventions for this focus area included air mattress to bed, dated 6/7/22.A review of the vital signs in the EMR revealed a weight of 201.0 pounds dated 3/6/26.A review of a progress note dated 3/5/26 revealed .skin intact. On 3/11/26 at 10:36 AM, the surveyor interviewed the Unit Manager (UM), who confirmed Resident #151 did not have an order for an air mattress. The UM went to Resident #151's room in the presences of the surveyor to confirm the setting on the air mattress was at 540 pounds and stated it says 540. She further stated I think that has to be adjusted. It should be by his weight. The UM also stated the nurses should be signing out an order for placement and function of the air mattress.On 3/13/26 at 9:53 AM, the surveyor interviewed the Director of Nursing (DON). The surveyor made the DON aware of the above concerns for Residents #6, #7, # 106, and #151. The DON stated I'm not sure what happened. If there is a need for an air mattress, it is ordered. We have a template for an air mattress for skin breakdown and wounds. The DON further stated Paying attention to the correct pressure is what's missed. Looks like we need to provide education, the nurses check off on the Treatment Administration Record (TAR) to check function. The DON described the purpose of an air mattress as preventative care to improve skin integrity, to prevent wounds, and to improve the quality of life for the residents. The mattress uses alternating pressure to improve blood flow. The DON also stated, it should be set to the patient's weight regardless of the pressure.On 3/13/26 at 2:02 PM, the surveyor presented the findings to the facility administration, in the presence of the survey team.On 3/16/26 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA) stated Resident #151 prefers to have a firm mattress. It is not in his care plan, but it will be. No further information was provided.A review of the In-Service Attendance Sheets dated 1/21/26, 1/22/26, and 1/23/26 for Summary: Air Mattress Weight Calibration Why Does It Matter revealed education provided to nursing and certified nursing assistant (CNA) staff. Education focus areas included:The mattress uses air pressure to float the resident and redistribute weight;If the mattress is set too low the resident will bottom out, increasing pressure on the bony area;If set too high, the surface becomes too firm and loses pressure relief benefits;Identify the resident's weight and adjust the setting to line up to resident's weight;On the monitor, there is a yellow dot/indication of resident's weight.A review of the facility Wound Management policy last reviewed by the facility July 2025 revealedPolicy .to prevent pressure ulcer development in our residents and to plan, implement, and evaluate the effectiveness of wound management.Procedure .A pressure reducing mattress will be placed on every bed. Upgraded wound management mattresses will be placed on resident beds as individually assessed. Definitions.Pressure ulcer risk factor-Examples of risk factors include immobility and decreased functional ability.resident refusal of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence.Pressure reducing device-Equipment that aims to relieve pressure away from areas of high risk. May include foam, air, water, or gel, or other cushions placed on a chair, wheelchair, or bed. Includes pressure reducing, and pressure redistributing devices.A review of the C.N.A. Standards of Care policy last reviewed by the facility September 2025 revealed Procedure .All residents are to be properly positioned with appropriate padding protecting bony prominence. NJAC 8:39-27.1 (a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were transported from one area of the unit to another in a dignified manner. This deficient practice was identified for 1 of 1 residents (Resident #45) reviewed for dignity and was evidenced by the following. On 3/10/26 at 11:45 AM, during the initial tour of the [NAME] unit, the surveyor observed the Certified Nursing Assistant (CNA) transport Resident #45 in a recliner chair facing backwards from the hallway near room [ROOM NUMBER] to the lounge area across from the nursing station. The surveyor reviewed the electronic medical record (EMR) for Resident #45. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; bipolar disorder (a mental health condition that causes extreme mood swings), chronic pain syndrome (pain that lasts over 3 months), localized edema (swelling in a specific body area), neuralgia (nerve pain) and neuritis (inflammation of the nerve). A review of the most recent quarterly Minimum Data Set ,assessment tool dated 2/27/26, revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating cognitively intact cognition. Further review revealed the resident required a wheelchair for transfers. A review of the individualized comprehensive care plan (ICCP) revealed a focus area with a revision date of 9/11/24, included risk for falls, knee pain, arthritis, ambulatory dysfunction and antidepressant use. The ICCP interventions included assist with transfers as needed, assist to participate in activities of choice, and escort/transport to activities as needed. On 3/10/26 at 11:50 AM, the surveyor interviewed the CNA, who stated residents should be transported forward facing. She further stated that pulling a resident backwards was not the proper way when transporting a resident. The CNA acknowledged she should have turned the resident around. On 3/10/26 at 12:08 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated the proper way to transfer a resident was to push them forward. She further stated they should not be pulled backwards as this was a dignity issue for the resident. On 3/12/26 at 1:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that staff were expected to transport a resident forward facing due to dignity issues. She further stated that it was for the resident's safety. She acknowledged that the CNA should not have pulled the resident backwards down the hall. On 3/16/26 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Regional Nurse Consultant, and the survey team, were made aware of the above concern for Resident #45. He further acknowledged that the resident should not be pulled down the hallway backwards. A review of the facility policy Resident Rights implemented on April 2025 revealed.physical and personal environment.to be treated with courtesy, consideration, and respect for your dignity and individuality. Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment .Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. NJAC 8:39-4.1(a)12,16

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete a criminal background check prior to the first day of work for 1 out of 96 employees (Employee #4). This deficient practice was identified for newly hired employee files reviewed since last survey from 10/28/24 and was evidenced as follows:During the facility survey dates of 3/10/26-3/16/26, the survey team reviewed the newly hired employee files since the last survey which revealed the following:For Employee #4, a Certified Nursing Assistant (CNA), with a date of hire (DOH) of 2/28/25 and first day of work as 2/28/25, there was no evidence of a background check prior to the start of employment.On 3/13/26 at 2:02 PM, the survey team presented this finding to the administration team including the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional Nurse Consultant, and the [NAME] President of Clinical Services. The LNHA could not provide any additional information regarding this finding.A review of the facility Resident Abuse/Neglect Policy and Procedure reviewed by the facility on February 2, 2026, revealed:Purpose: to ensure prevention (of).abuse, neglect, mistreatment, misappropriation of property, or exploitation of any facility resident.Policy: Screening.All prospective employees, will be carefully screened using the following processes to identify potential risk of abuse/neglect of any resident: 2.background check. Employee criminal and other background checks are run on Applicant Safe.ALL staff (licensed and non-licensed) are screened upon hire and on a monthly basis for exclusions.These records will be maintained in the Human Resources Office.A review of the facility Hiring and Recruitment policy, last reviewed by the facility 8/2025, revealed:Policy .The facility will ensure that all employees meet credentialing, background check, and training requirements before performing resident care duties.Purpose .All staff meet New Jersey .background check requirements.Policy Guidelines .All employees must undergo criminal history background checks as required by New Jersey law. Employees may not begin work until required screening procedures are completed and approved. Prior to employment, the facility may conduct: Criminal background checks .The facility shall maintain a personnel file for each employee containing: Background check documentation. Personnel files will be maintained in accordance with state and federal requirements.Responsibility-The Administrator and Human Resources Department are responsible for ensuring that hiring procedures comply with regulatory requirements and that all documentation is maintained appropriately.NJAC 8:39-9.3(b)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered to a resident according to standards of practice. This deficient practice was identified for 1 of 36 (Resident #9) residents reviewed and was evidenced by the following:On 3/6/26 at 1:30 PM, the surveyor observed Resident #9 lying in their bed, awake, eating their lunch which was on their overbed table. The surveyor observed a medication cup with two (2) unidentified medication tablets in it, on the overbed table. At that time, the surveyor requested the Licensed Practical Nurse/Unit Manager (LPN/UM) come to the room. The LPN/UM acknowledged that in the medication cup there were two tablets: one pink and one white. At this time, the resident stated that they thought they took all their medications. The LPN/UM stated that the nurse should stay with the resident when administering their medications to ensure that they took all of them. She further stated that the nurses should never leave medications at the resident's bedside. On 3/6/26 at 1:45 PM, the surveyor interviewed the Registered Nurse (RN) who stated Resident #9 stated to her that they were going to swallow the medications. She acknowledged that medication should never be left at the resident's bedside unattended. The surveyor reviewed the electronic medical record (EMR) for Resident #9. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; primary open-angle glaucoma (eye disease that causes vision loss), bilateral ocular hypertension (pressure inside the eye is higher than normal), and end stage renal disease (kidney failure). A review of the most recent quarterly Minimum Data Set, an assessment tool dated 1/28/26, revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating cognitively intact cognition. Further review revealed the residents' vision was highly impaired. A review of the March 2026 Order Summary Report, included the following Physician's Order's (PO): Abilify tablet 10mg PO (administered by mouth) one time a day for delusional disorders (mental disorder in which a person has delusions) at 1400, dated 10/16/25 and nephro vitamins tablet 0.8mg PO one time a day for supplement at 1400, dated 5/3/25. A review of the March 2026 Medication Administration Report (MAR) revealed the RN signed the electronic medication administration record (eMAR) for all medications scheduled for 1400 (2:00pm) indicating they were administered as ordered by the physician. On 3/16/26 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), Regional Nurse Consultant, and the survey team, was made aware of the above concern for Resident #9. He acknowledged that the resident's medication should never be left at their bedside and that the nurse should observe the resident taking the medication. He then stated the nurse thought the resident swallowed all the medications. A review of the facility policy Administration Procedures for All Medications reviewed 9-25 revealed.medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. NJAC 8:39-29.2(d)

Based on interview and record review, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 system selected residents with a MDS record over 114 days reviewed (Resident #208), and was evidenced by the following:On 3/11/26 at 11:16 AM, the surveyor reviewed the system selected MDS record over 114 days which revealed Resident #208 was overdue for a MDS assessment. A review of Resident #208's electronic medical record (eMR) revealed that the resident was discharged from the facility on 11/3/25. A review of the residents' MDS assessments revealed the last MDS completed was a quarterly assessment dated [DATE]. There was no assessment completed for the resident's discharge. On 3/11/26 at 1:00 PM, the surveyor interviewed the MDS Coordinator, who confirmed Resident #208 was discharged from the facility on 11/3/25, and there was no completed MDS assessment for the discharge. The MDS Coordinator further stated that a discharge MDS assessment should have been completed. The MDS Coordinator stated that the resident's assessment was missed. On 3/12/26 at 9:31 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility does not have a policy related to MDS assessments, but the facility follows the Resident Assessment Instrument Users' manual. On 3/16/26 at 10:27 AM, the LNHA, in the presence of the Director of Nursing (DON), Regional Nurse Consultant, and the survey team, acknowledged that there was no discharge MDS assessment completed when the resident was discharged . He further stated that it should have been done and was corrected immediately. NJAC 8:39 - 11.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with an order for enteral tube feeding. This deficient practice was identified for 1 of 1 resident reviewed for tube feeding (Resident #1), and was evidenced by the following:On 3/6/26 at 11:26 AM, during the initial tour of the facility, the surveyor observed Resident #1 sleeping in their bed. The surveyor observed the enteral tube feeding running at 70 ml/hr (milliliters per hour). The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dysphagia (difficulty swallowing), gastrostomy (feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition, fluids, and medications), and gastro-esophageal reflux disease without esophagitis (stomach acid flows back up into the esophagus and causes heartburn). A review of the most recent comprehensive Minimum Data Set, an assessment tool dated 12/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severely impaired cognition. A further review of section K swallowing/nutritional status revealed that Resident #1 had a feeding tube on admission. A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 9/19/25, for risk for aspiration related to dysphagia due to a cerebrovascular accident (stroke). The ICCP interventions included; to assist as needed during meals to take small sips of fluids and small mouthfuls of food, assist with feeding only when alert, provide thickened liquids as ordered, and monitor for signs of difficulty tolerating diet consistency. A further review included a focus area with an initiated date of 12/24/25, receiving enteral feedings to meet nutrition and hydration needs. Interventions included administer feeding as ordered, monitoring for intolerance, check residual as ordered, administer flushes as ordered, and maintain NPO (nothing by mouth) status. A review of the Order Summary Report included the following physician orders (PO): A PO, dated 1/9/26, NPO diet, NPO texture, and NPO consistency for diet. A PO, dated 1/26/26, enteral feeding one time a day and take down when the total volume of 1400 ml is completed. On 3/11/26 at 1:21 PM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM), who stated care plans were updated or revised every 3 months, annually and as needed when there was a change in the resident's plan of care. The LPN/UM confirmed that Resident #1 was strictly NPO. She acknowledged that the residents care plan should have been updated when the residents diet changed from PO (by mouth) to NPO to ensure proper patient care. She further stated that she missed it and was going to fix it immediately. On 3/12/26 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON), who stated that care plans were updated when there was any change in the resident's care. The DON confirmed that the resident's care plan should have been updated when their diet order changed and tube feedings were started. The DON further stated that it was the responsibility of the unit manager, DON and nursing team to update the care plans. The DON stated that care plans were important because they reflect how to manage the resident's care. On 3/16/26 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Regional Nurse Consultant, and the survey team, acknowledged that a care plan should be updated when there were any changes in the residents' care. A review of the facility's Care Plans, Comprehensive Person-Centered policy, reviewed March 2025, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.includes the resident's stated goals upon admission and desired outcomes.reflects currently recognized standards of practice for problem areas and conditions.assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure nursing staff appropriately follow a physician orders (PO) and acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes. The deficient practice was identified for 1 of 2 residents (Resident #142) reviewed for smoking. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/06/2026 at 11:32 AM, during the initial tour of the secured Klockner unit, the surveyor observed Resident #142, dressed, sitting in a wheelchair in the common area by the nurse's station. A review of the facility provided smoking list revealed Resident #142 was a smoker. The surveyor reviewed the electronic medical record (EMR) for Resident #142. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms-hallucinations, delusions, disorganized speech-with severe mood swings, specifically mania and sometimes depression). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 2/25/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. A review of the individual comprehensive care plan (ICCP) revealed a focus of requires supervision with smoking- resident chooses to smoke inspite of the possible ill effects of smoking. Date Initiated: 01/07/2025. A review of the smoking evaluation dated 9/23/2025, revealed section AA. Entry Question 1. Does resident smoke? A. yes was selected. A review of the physician orders revealed a PO: CIGARETTES AND LIGHTER KEPT BY STAFFS, 5 CIGARETTED TO BE GIVEN ON 7-3 AND 3-11. every day and evening shift. Start date: 2/28/2023. A review of the February 2026 Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) #1 had signed the above order as completed as ordered on 6 day shifts. A review of the March 2026 MAR revealed LPN #1 had signed the above mentioned PO as completed as ordered on 6 day shifts, including day shift on 3/12/2026. On 3/12/2026 at 11:33 AM, the surveyor interviewed LPN #1, who stated she was Resident #142's assigned nurse. She stated Resident #142 took their medications every day. She added the resident liked to stay in their wheelchair. The surveyor asked LPN #1 if Resident #142 smoked and the LPN #1 stated she never saw [identifier redacted] smoke. The surveyor asked what her signature abbreviations meant, she stated if she signed it (the MAR), it meant she did it. At that time, LPN #1 reviewed the MARs with the surveyor, she acknowledged and verified her signature abbreviations. She was unable to answer why she had signed the order as being completed on multiple days. On 3/12/2026 at 11:36 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1), who stated Resident #142 was periodically a smoker. She stated the resident did not smoke every day. RN/UM #1 stated if the MARs were signed as being done, it meant it should have been done. The surveyor made RN/UM #1 aware LPN #1 was unable to speak to being aware the resident smoked or why she was signing the MARS as administering the cigarettes. On 3/12/2026 at 11:58 AM, the surveyor interviewed the Director of Nursing (DON), who stated if nurses signed the MARs they were giving cigarettes 5 per day and 5 per night, they should be giving them. They should not be signing they were, if they were not giving them. The surveyor made her aware of the above mentioned findings. On 3/13/2026 at 2:02 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Nurse Consultant, and the [NAME] President of Clinical Services were made aware of the above concerns. No additional information was provided. A review of the facility's policy Documentation Policy reviewed 9/2025 revealed Policy: Documentation is a professional tracking to enhance continuity of care. The key goals of sound clinical documentation are to describe information in a way that everyone can understand what is happening to the resident and to enhance continuity of care so that the staff on all shifts and among all disciplines will know what must be carried out to monitor outcomes of care. NJAC 8:39-27.1 (a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 10 residents (Resident #147) observed during incontinence care rounds and b.) provide a resident with nail care during activities of daily living (ADL) care. This deficient practice was identified for 1 of 7 residents reviewed for ADL care (Resident #195),This deficient practice was evidenced by the following:1. On 3/11/26 at 7:54 AM, during incontinence rounds with Registered Nurse/Unit Manager (RN/UM) #1, the surveyor observed Resident #147's incontinence brief completely saturated with urine, and yellow urine-like stains on multiple areas on the top sheet. At that time, the surveyor asked RN/UM #1, if she had any concern with the observation. She stated that it was a concern because the resident was soaking wet. RN/UM #1 stated that the resident's incontinence brief should not have been completely soaked, because the other shift (11:00 PM-7:00 AM) just left and the resident should not have been left in this condition. RN/UM #1 further stated that leaving the resident in a soaked incontinence brief put the resident at risk for skin breakdown. The surveyor asked RN/UM #1 when Resident #147's last incontinence care was completed. RN/UM#1 reviewed the Electronic Medical Record (EMR) system in the presence of the surveyor and confirmed the last documented incontinence care was on 3/10/26 at 10:59 PM during the 3:00 PM-11:00 PM shift. RN/UM #1 confirmed that there was no documentation for the resident on 3/11/26 during the 11:00PM-7:00 AM shift for incontinence care. On 3/11/26 at 8:26 AM, the assigned Licensed Practical Nurse (LPN #1) stated that she received report from the 11:00 PM-7:00 AM nurse that the resident was changed and dry. LPN #1 stated, I did not check the resident. On 3/11/26 at 8:31 AM, the assigned Certified Nursing Assistant (CNA #1) stated that she was assigned to Resident #147 and arrived late on the unit. On 3/11/26 at 8:35 AM, during a follow up observation with CNA #1 and LPN #1 revealed Resident #147's top sheet had yellow colored urine like stains and the surveyor noted a very strong urine odor. Resident #147 was soiled with urine and feces, and urine and feces stains were observed on the bed padding and fitted sheet. On 3/11/26 at 8:45 AM, during a follow up interview with the surveyor, LPN #1 confirmed that the resident was completely soiled with urine and feces, the bed padding was soaked through, and the resident's fitted sheet had urine and feces on it. LPN #1 stated that the resident should not have been soaked through with urine and feces because it could cause skin breakdown. LPN #1 stated that the resident was there for care and needed help from staff. LPN #1 further stated that the previous shift should have taken care of the resident and done the care, including changing the resident's linen. On 3/11/26 at 11:35 AM, the surveyor tried to reach the assigned CNA (CNA #2) on the 11:00 PM-7:00 AM shift via telephone and got no response. On 3/11/26 at 11:37 AM, the surveyor interviewed the assigned nurse on 11:00 PM-7:00 AM shift, LPN #2, via telephone. When the surveyor asked LPN #2 if the resident should have been saturated with urine and feces, she stated, No, the resident should not have been left saturated with urine and feces, that shows that the previous shift did not do their job. LPN #2 further stated that if the resident was not changed in a timely manner, resident could have skin breakdown. LPN #2 stated CNA #2 did not answer the call light multiple times and she had to remind the CNA that the residents needed to be changed. The surveyor reviewed the electronic medical record (EMR) for Resident #147. A review of the Resident's admission Record (AR) (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes, Muscle weakness, difficulty walking, Elevated white blood cell count, Hyperlipidemia (high levels of fat in the blood), Depression, Anxiety Disorder, and Hypertension (high blood pressure). A review of the resident's Annual Minimum Data Set, (MDS), an assessment tool used to facilitate the management of care, dated 2/18/26, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident was severely cognitively impaired. A further review of the resident's MDS, revealed that the resident was Dependent (Helper does ALL of the effort) on assistance for toileting. A review of the Individual Comprehensive Care Plan (ICCP) revealed a Focus: Risk for skin breakdown r/t (related to) . left trochanter (hip) 3 surgical incisions proximal to distal, Initiated on 2/11/26, Revised on 3/8/26, .Interventions: Offer/assist with toileting during care, before/after meals and activities, and at HS (night); Provide prompt incontinence care. Initiated on 2/11/26. On 3/13/26 at 10:38 AM, the surveyor interviewed the Director of Nursing (DON) who stated the expectation was for all 3 shifts was to do rounding on residents, to change the residents if soiled at least two times each shift, and as needed. The DON stated, No resident should be saturated and soiled like that at all. The Nurse should have reported concerns to the supervisor. The CNA should have provided care to the resident to prevent skin breakdown and if the CNA had difficulty, she should have called the nurse for assistance. When the surveyor asked the DON what the expectation for documentation for Resident #147, she stated that the expectation was for incontinence care to be completed it when care was provided. 2.On 3/6/26 at 11:40 AM, during the initial tour of the Klockner unit, the surveyor observed Resident #195 in the main area, across from the nurse's station. The surveyor noted the residents' nails to be long on both hands, with a black substance under the right thumb and index finger. The surveyor reviewed the electronic medical record (EMR) for Resident #195. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), Alzheimer's Disease (unspecified a brain disorder that slowly destroys memory and thinking skills) and hemiplegia (total paralysis)and hemiparesis (weakness) following cerebral infarction (a stroke) affecting left non-dominant side. A review of the annual MDS dated [DATE], revealed the resident had a BIMS of 9 out of 15, indicating the resident was moderately cognitively impaired. Further review revealed the resident was dependent on ADL care. A review of the ICCP revealed a focus of potential for adverse effects r/t (related to) psychotropic med use r/t dx (diagnosis) dementia with psychosis and depression. [identifier redacted] has episodes of combative behaviors during ADL care. Revision on: 2/1/23 with Intervention of allow [identifier redacted] time to calm down. Revisit to provide needed care when combative during ADLS. A review of the order summary report revealed a physician's order (PO) to ensure that nails are clean, trim, and filed as needed. every day shift every Tue for Provision of good nail care, dated 11/29/22. A review of the March 2026 Treatment Administration Record (TAR) revealed the above PO was signed as being completed as ordered by Licensed Practical Nurse (LPN) #3 for the day shift on 3/12/2026. On 3/11/2026 at 7:46 AM, during incontinence rounds with RN/UM #2, the surveyor requested RN/UM #2 to look at the resident's nails, noting both hands had long fingernails, and the right hand thumb and index fingernail had a black substance under them. The surveyor made RN/UM#2 aware of the observation during the initial tour on 3/6/2026. RN/UM #2 acknowledged the nails should not be that long and that nails should be cut and cleaned everyday as needed. At that time, Certified Nursing Assistant (CNA) #3 entered the room with the resident's breakfast tray. CNA#3 confirmed he was the residents assigned CNA and that he was the assigned CNA resident yesterday. CNA#3 stated AM care included bathing, washing hair and doing the residents nails. The surveyor asked if he did the residents nails yesterday, he stated No, the resident was resistant to care. The surveyor asked what he should he have done, he stated, I should have reported it, but it slipped my mind. On 3/12/26 at 11:33 AM, the surveyor interviewed LPN #3, who stated she was Resident #195's assigned nurse. She stated the if she saw the resident needed their nails done, she would let the CNA know immediately. She stated if a resident refused it, it would be documented. In the presence of the surveyor, LPN #3 reviewed the TARS and acknowledged she had signed nail care was done on 3/10/2026 for the day shift. She stated if she signed it (the TAR), she did it. The surveyor made her aware of the observation with RN/UM#2 on 3/11/26 of Resident #195's nails. LPN #3 could not explain why she had signed the nail care was completed. On 3/12/26 at 11:36 AM, RN/UM #1 reviewed the EMR in the presence of the surveyor. She acknowledged if LPN #3 had signed the TARS on 3/10/26, then yes, she should have done nail care. RN/UM #2 reviewed the progress notes and verified that LPN #3 did not document that Resident#195 refused nail care. On 3/12/26 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON), who stated nail care was a standard of care and was part of daily care. The surveyor made the DON aware of the above observations on 3/6/26 and 3/11/26. The Director of Nursing reviewed the TARS in presence of surveyor and stated if it was signed, it meant it was done and if it wasn't there should be a progress note as to why it was not. On 3/13/2026 at 2:02 PM, during a meeting with the survey team, the licensed Nursing Home Administrator, the DON, the regional Nurse Consultant, and the [NAME] President of Clinical Services were made aware of the above concerns. No additional information was provided. A review of the facility's policy Activities of Daily Living (ADLS), Supporting reviewed 3/2025 revealed Policy: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . c. elimination (toileting).4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. A review of the facility's policy Documentation Policy reviewed 9/2025 revealed Policy: Documentation is a professional tracking to enhance continuity of care. The key goals of sound clinical documentation are to describe information in a way that everyone can understand what is happening to the resident and to enhance continuity of care so that the staff on all shifts and among all disciplines will know what must be carried out to monitor outcomes of care .Where It Will Be Documented revealed, All documentation will be documented in the Electronic Health Record (HER) which in this facility is [name redacted]. A review of the facility's C. N. A Standards of Care reviewed 9/2025, revealed Procedure:.21. All resident's' nails to be maintained clean, trimmed and checked weekly with showers .29. As a guide check every incontinent resident every two hours while awake and check/change at night & change as needed; 30). Residents should be rounded on and checked within 1-2 hours of shift for need of incontinence care. NJAC 8:39-27.2 (g)(h)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow up on a physician's recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 5 residents (Resident #5) reviewed for unnecessary medications.This deficient practice was evidenced by the following:On 3/6/2026 at 11:32 AM, the surveyor observed Resident #5 sitting in a reclining area in the hallway near the nursing station. The resident had a splint on their left hand/wrist. The surveyor reviewed the electronic medical record (EMR) for Resident #5.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, single episode, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), Post-Traumatic Stress Disorder (PTSD) (a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events) and Paranoid schizophrenia (a chronic mental disorder defined by intense, irrational delusions and auditory hallucinations, such as believing they are being plotted against or monitored). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/16/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, indicating the resident's cognition was unable to be assessed. Further review revealed the resident was receiving antipsychotic medications.A review of the individualized comprehensive care plan (ICCP) revealed a focus area of Risk for falls r/t hx (related to history). psychotropic drug use and difficulty with environment, revision on 4/19/2022, with an intervention of Monitor [identifier redacted] for adverse effects r/t psychotropic med use. A review of the Psychiatric Progress Note (PPN) dated 1/5/2026, revealed ASSESSMENT/PLAN:.2. GDR: Discontinue current Seroquel order. Start Seroquel 25 mg (quetiapine fumarate-antipsychotic medication primarily used to treat schizophrenia) PO (by mouth) q HS (at bedtime) x 7 days then discontinue. A Dose Reduction (GDR) is: recommended, as per above.Medication Consent: Recommendations discussed with facility staff, who will await approval from PCP (Primary Care Physician) and then obtain consent from appropriate decision-maker.A review of the physician order summary revealed a physician's order (PO) quetiapine fumarate Tablet 50 MG, Give 1 tablet by mouth at bedtime (HS) for SCHIZOPHRENIA B/P PER POLICY. Order date 10/8/2025; discontinue date 02/02/2026.A review of the January and February 2026 Medication Administration Record (MAR) revealed the above order was signed as administered as ordered at 9 PM from 1/6/26 to 2/2/26. A review of the progress notes did not reveal documentation the GDR was addressed by the PCP or the resident representative. Further review of the PPNs dated 2/3/2026 revealed the same recommendation as the 1/5/2026 PPN. A review of the Consultant Pharmacist's Monthly report dated 1/13/2026 revealed a note the psych consult dated 1/5/26 recommended GDR: Discontinue current Seroquel order. Start Seroquel 25 mg PO q (every) HS X 7 days then discontinue. Please follow-up with the recommendation and/or documentation. Action Taken: Seroquel d/c (discontinued) 2/3/2026. On 3/13/2026 at 11:18 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated the psychiatrist usually sent an email by the next day of their recommendations. She stated as soon as she saw the recommendation she would call the attending physician (AP) to let them know what the psychiatrist was recommending. The RN/UM stated if the AP approved it, she would call the resident representative for consent, and documentation would be done with the consent. She stated it would usually be addressed within the day. The RN/UM further stated the pharmacy consultant sends their report with recommendations to the Assistant Director of Nursing (ADON) who then gave it to the unit managers. She stated the recommendations would then be addressed right away or as soon as possible and that she would expect to see a progress note that it was addressed. At that time, the surveyor and the RN/UM reviewed the PPN note for a GDR on 1/5/26, the progress notes from 1/5/2026, and the MARs. The RN/UM acknowledged there was no documentation addressing the requested GDR. On 3/13/2026 at 12:57 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that a psychiatric recommendation for a GDR and the pharmacy consultant recommendation should be addressed as soon as they were made. She stated she would expect to see documentation that the AP and the resident representative were notified whether they agreed or disagreed with the recommendation in progress note. The surveyor reviewed the psych recommendation from 1/5/2026, the DON stated, it should have been addressed. On 3/13/2026 at 2:02 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Nurse Consultant, and the [NAME] President of Clinical Services were made aware of the above concerns. No additional information was provided. A review of the policy Psychotropic Medication Policy updated 5/2025 revealed Policy: It is the policy of this facility to ensure Residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated and with gradual dose reduction and behavioral interventions attempted, unless contraindicated .Gradual Dose Reduction: Residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to find an optimal dose of medications, to determine whether continued use of the medication is benefiting the resident or could have dangerous side effects, or to discontinue these drugs.The GDR will be documented in the electronic health record reflecting the date it was attempted, the outcome of the dose reduction attempt and a plan for future evaluation of GDR attempts. N.J.A.C. 8:39-27.1(a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of Certified Nursing Assistants (CNAs) on an annual basis.This deficient practice was identified for five (5) of five (5) CNAs whose randomly selected employee files were reviewed and was evidenced by the following:On 3/11/26 at 9:34 AM, the surveyor requested the education and performance reviews for five (5) randomly selected CNAs.The surveyor reviewed the education provided by the facility for the five (5) CNAs. No performance evaluations were provided.On 3/11/26 at 11:10 AM, the performance evaluations were requested from the Licensed Nursing Home Administrator (LNHA) who could not provide them.On 3/13/26 at 12:00 PM, the performance evaluations were requested from the Human Resources Director (HRD) who could not provide them.03/13/2026 at 12:16 PM, the HRD stated to the survey team There are no performance evaluations for the last year for CNAs because they are unionized. There are also no facility policies for performance evaluations.A review of the facility Hiring and Recruitment policy, last reviewed by the facility 8/2025, revealed:Policy Guidelines, Personnel Records-The facility shall maintain a personnel file for each employee containing.Performance evaluations.Personnel files will be maintained in accordance with state and federal requirements. NJAC 8:39-43.17 (b)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a medication error rate below 5%. This deficient practice was identified for 2 of 5 residents (Resident #2 and #197) on 2 of 4 units. The surveyor observed 2 nurses administered 28 doses of medication and there were 2 errors resulting in a medication error rate of 7.14%. The deficient practice was evidenced by the following: 1.On 3/11/26 at 8:55 AM, during the morning medication administration pass, the surveyor observed the Licensed Practical Nurse (LPN #1) on the Klockner Unit, preparing the medications (meds) for Resident #2 using the electronic Medication Administration Record (eMAR) while pulling the medications. The surveyor observed an order for one tab of sennosides-docusate sodium 8.6 -50 mg for constipation. At that time, LPN #1 pulled Geri-Kot (Senokot) 8.6 mg one tab and stated, this is the only one we have at the facility and then administered the medication to Resident #2 (ERROR #1). The surveyor reviewed the electronic medical record (EMR) for Resident #2. A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; anemia (a shortage of healthy red blood cells or hemoglobin, which prevents the body from getting enough oxygen), pain in joint and constipation (a condition in which a person has uncomfortable or infrequent bowel movements). A review of the Order Summary Report (OSR) included the following physician's order(PO):sennosides-docusate sodium Tablet 8.6-50 mg- give one tablet by mouth one time a day for constipation. On 3/11/26 at 2:41 PM, during an interview with the surveyor, LPN #1 stated Senokot was a stool softener and sennosides-docusate was a combination of stool softener and a laxative. LPN #1 acknowledged she administered Senokot to Resident #2. On 3/11/26 at 2:47 PM, during an interview with the surveyor, the Registered Nurse/ Unit Manager (RN/UM) stated the nurse brought it (the above-mentioned concern) to her attention. On 3/13/26 at 9:35 AM, during an interview with the surveyor, the RN/UM stated LPN #1 should have performed three checks prior to med administration. The RN/UM stated the three checks were important because the nurses need to know the route, the dose and need to make sure the nurses were giving the right medication to the right patient. The RN/UM acknowledged that LPN #1 did not follow the five rights during med administration. The RN/UM stated if the order said 8.6-50 mg in the order and the bottle had only 8.6 mg, the LPN #1 should not have given the medication. 2.On 3/11/26 at 9:29 AM, the surveyor observed LPN #2 on the [NAME] Unit, preparing the meds for Resident #197 using the eMAR while pulling the medications. The surveyor observed an order for two tabs of sennosides-docusate sodium 8.6 -50 mg for constipation. At that time, LPN #2 pulled Geri-kot (Senokot) 8.6 mg two tablets and then administered them to Resident #197 (ERROR #2). The surveyor reviewed the EMR for Resident #197. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but were not limited to; muscle weakness and essential hypertension (high blood pressure). A review of the OSR included the following PO:senna plus 8.6-50 mg (Sennosides-Docusate Sodium) - give two tabs by mouth two times a day. On 3/11/26 at 2:22 PM, during an interview with the surveyor, LPN #2 confirmed that she had administered geri-kot (Senokot) to Resident #197 in the morning. LPN #2 further stated, senna plus and Senokot were both the same thing and both meds had 8.6 mg. On 3/11/26 at 2:31 PM, during an interview with the surveyor, LPN/UM stated the process during med administration was to perform three checks to make sure the meds are correct for the patient. The LPN/UM stated it was important to review POs prior to med administration to make sure that we were not giving wrong meds or wrong doses to the residents. The LPN/UM stated the difference between the senna plus and Senokot was that the Senokot did not have docusate in it. The surveyor made the LPN/UM aware of the above-mentioned concerns for Resident #197. The LPN/UM acknowledged that it was a med error. On 3/13/26 at 11:25 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the expectation from the nurses during med pass was to identify the residents, review and ensure what was ordered and what was available to administer. The DON stated the nurses should verify the meds prior to administration. The DON stated Senna and Senokot were two different meds and further stated the nurses should have held the medication if it was not available. The surveyor made the DON aware of the above-mentioned concerns for Resident #2 and #197 from the med pass error observation. On 3/13/2026 at 2:02 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the DON, the Regional Nurse Consultant, and the [NAME] President of Clinical Services were made aware of the above concerns. No additional information was provided. A review of the policy Administration Procedures for All Medications reviewed 9/2025 revealed Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. Under section Procedures: III. 5 rights (at a minimum) At a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. Check the MAR/TAR for the order. 2. Prior to removing the medication from the container: a. Check the label against the order on the MAR. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interviews, record review, and review of facility documents, it was determined that the facility failed to ensure tracheostomy (a surgical opening directly into the trachea (windpipe) used to assist breathing) care was completed using sterile technique per facility policy and clinical guidelines. This deficient practice was identified for 1 of 4 residents (Resident #46) reviewed for respiratory care and was evidenced by the following:On 3/11/26 between 10:20 AM and 10:37 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform tracheostomy care for Resident #46. During that time, the LPN was first observed performing hand hygiene, then placing a nonsterile drape over a bedside table. She was then observed opening and placing a tracheostomy care kit on the drape. She then opened a packet of 4x4 sterile gauze and a disposable inner cannula and placed them onto the drape. The LPN then used two single use sterile saline containers and emptied their contents into the open packet of sterile gauze. The LPN then reached into the packet (with bare hands) and pulled out the sterile gauze, then placed the saline soaked gauze into the tracheostomy care kit's basin. A packaged pair of sterile gloves were noted inside the tracheostomy care kit, the LPN's hands remained ungloved throughout the preceding preparations. The LPN then went to the treatment cart and retrieved a box of nonsterile exam gloves and a packet of sterile gauze and placed them onto the draped bedside table. The LPN performed hand hygiene, donned a pair of gloves from the nonsterile box, then wiped the resident's tracheostomy site with the gauze from the tracheostomy kit's basin. The LPN removed the resident's tracheostomy inner cannula and disposed of the cannula. She removed her gloves and threw them away. She then performed hand hygiene. The LPN donned a pair of nonsterile gloves from the box, opened a new sterile gauze packet and removed the gauze to dry the resident's tracheostomy site, then she removed the gloves and performed hand hygiene. The LPN put on a set of clean gloves from the box, placed the new inner cannula and placed a sterile slit-gauze at the resident's tracheostomy site. The packaged sterile gloves were noted to be inside of the tracheostomy care kit and remained unused.The surveyor reviewed the medical record for Resident #46. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; autistic disorder, aphagia (inability to swallow), unspecified asthma, and chronic obstructive pulmonary disease (lung condition characterized by airflow obstruction) with acute exacerbation.A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 1/9/26, revealed the resident had a Brief Interview for Mental Status score of 99, which indicated that the resident's cognition was severely impaired and was rarely/never understood. A further review revealed the resident was dependent on staff for activities of daily living and required tracheostomy care.A review of the individual comprehensive care plan (ICCP) included a focus area, dated 1/27/22, that the resident was at risk for complications related to having a tracheostomy. Interventions included monitoring skin integrity and performing tracheostomy care every shift.A review of the Order Summary Report (OSR), included the following physician orders (PO):A PO, dated 2/12/26, for tracheostomy, every shift.A PO, dated 2/13/26, for oxygen, 2 liters per minute via Trach collar, every shift.A PO, dated 2/12/26, for tracheostomy care, every shift.A PO, dated 2/12/26, for suctioning, as needed for increased secretions.On 3/13/26 at 11:17 AM, the surveyor interviewed the LPN who stated that nursing carried out respiratory care every shift as ordered by the physician and that staff were in-serviced on the procedure. When asked if tracheostomy care required aseptic (sterile) technique the LPN replied yes, it did. She further stated that the sterile gloves in the kit should be used when performing tracheostomy care. The LPN stated they did not remember if they had used the sterile gloves from the kit during care. The surveyor then asked the LPN why maintaining sterility and using aseptic technique was important for a ventilated patient during tracheostomy care. The LPN replied that they were important measures used to prevent the spread of infections.On 3/13/26 at 10:57 AM, the surveyor interviewed the Unit Manager (UM), who stated that nursing was responsible for carrying out respiratory orders and were recently in-serviced by the facility. When asked what gloves should be used during tracheostomy care, the UM stated staff should use the ones provided in the tracheostomy care kit, the sterile gloves. When asked if any nonsterile items should be placed onto the sterile field during care the UM stated no, that aseptic technique should be used to minimize the risk of infection for a ventilated resident.On 3/13/26 at 1:15 PM, the surveyor interviewed the Director of Nursing (DON). When asked how the facility makes sure nurses were competent in tracheostomy care, the DON replied that the facility recently had tracheostomy care education taught by a respiratory therapist, competencies were done yearly and the procedure was taught during orientation. When asked if tracheostomy care would be considered a clean or sterile procedure and if any aseptic technique should be used, the DON replied that the procedure was sterile because of the airway and it had to be very particular for infection control, she stated that the sterile gloves inside of the tracheostomy care kit should be used and that nonsterile items should not be placed onto the sterile field.On 3/13/26 at 2:02 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns that were identified with the resident's tracheostomy care.A review of the facility's undated Tracheostomy Care policy .Procedure for Changing Disposable Inner Cannula: 1. Wash hands and explain procedure to the patient. 2. Confirm the patient's identification using two identifiers. 3. Gather equipment: sterile disposable inner cannula, sterile suction catheter, sterile container, sterile gloves, sterile water, trach ties, drain sponge, sterile cotton applicators. 4. Put sterile gloves on.12. Using aseptic technique, cleanse the stoma site with the hydrogen peroxide, rinse with sterile water and dry it with a sterile 4x4 dressing.It is recommended infection control practice that trach care be performed on each shift.NJAC 8:39-27.1(a)

Complaint #: 2788031Based on interviews, record reviews, and review of other pertinent documentation, it was determined that the facility failed to ensure that a cognitively impaired resident received nectar thick liquids (slightly thicker consistency than water, coats a spoon) as ordered and failed to develop interventions to ensure that the resident did not receive liquids that were inconsistent with their ordered diet. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for diet accuracy and was evidenced by the following:Resident #2 was no longer in the facility; a closed record review was conducted. A review of the admission Record (AR) for Resident #2, revealed that the resident was admitted with diagnoses including but not limited to: metabolic encephalopathy (brain dysfunction caused by non-traumatic issues like organ failure (liver, kidney), chemical imbalances, or toxins); need for assistance with personal care; dysphagia (difficulty swallowing), oral phase; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool dated 12/19/2025, revealed that Resident #2 had a Brief Interview for Mental Status score of 99, which indicated that the resident was unable to complete the assessment interview. The MDS revealed that Resident #2 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. A review of the physician orders (POs) for Resident #2 revealed an order for regular diet, pureed texture with nectar (mildly thick) consistency liquids. The order start date was 10/18/2025. A review of the care plan (CP) for Resident #2 was conducted. The CP revealed a focus, initiated on 04/21/2025, that the resident was at risk for aspiration related to their dementia and did not want to be assisted by staff during meals. Interventions included but were not limited to: monitor for signs and symptoms of aspiration including coughing, gurgling sounds, and difficulty breathing; and provide thickened liquids as ordered. The progress notes (PNs) for Resident #2 were reviewed. A PN dated 02/21/2026 at 11:40 AM, revealed that Resident #2's family member (FM) brought a smoothie into the facility from outside and asked Registered Nurse (RN) #1 if it was alright to give it to the resident. RN #1 informed the FM that Resident #2 was supposed to receive nectar thick liquids and the FM stated that the smoothie looked alright and that the resident was only going to have a taste. The PN further revealed that the cup of smoothie contained approximately 45 cubic centimeters (1.5oz) of smoothie and that RN #1 did not witness the smoothie being given to Resident #2. The PN did not reveal that RN #1 followed up with Resident #2's FM to determine of the smoothie was given to the resident, or with the resident's physician to inform them of the potential concern. On 02/27/2026 at 11:03 AM, the Licensed Nursing Home Administrator informed the surveyor that there were no incident/accident reports for Resident #2 regarding FMs bringing in inappropriate food items for the resident on 02/21/2026. An interview was conducted with RN #1 on 02/27/2026 at 12:13PM. RN #1 stated that on 02/21/2026 Resident #2's FM showed her a smoothie from McDonald's and asked about giving it to Resident #2. RN #1 stated that she informed the FM that the smoothie was not consistent with the PO for Resident #2. RN #1 further stated that she did not know if the smoothie was given to Resident #2 or how much was given. During a follow up interview on 02/27/2026 at 3:15 PM, RN #1 stated that she did not follow up with Resident #2's FM to find out if Resident #2 was given any of the smoothie. RN #1 further stated that she did not notify the resident's physician, RN #1 could not identify a reason why she did not notify the resident's physician. An interview was conducted with Unit Manager (UM) #1 on 02/27/2026 at 3:41 PM. The 02/21/2026 11:40 PN by RN #1 was reviewed. UM #1 stated that the FM should have been educated and the resident's physician should have been notified. UM #1 stated that there was no documentation that a physician was notified that the resident was given the wrong thickness of fluids. UM #1 further stated that the UM or Director of Nursing (DON) were responsible for updating the resident's CP with any new interventions. An interview was conducted with the DON on 02/27/2026 at 3:57 PM. The DON stated Resident #2 was ordered nectar thick fluids because the resident had dysphasia, and to prevent aspiration. The DON stated that the usual process when outside food was brought in, was for FMs to have the food checked by a nurse. The DON stated that the food was checked by a nurse for safety reasons, to ensure that it met with the resident's ordered diet, and to make sure that nothing happened. The DON stated that if a resident's family brought in outside food, it should be added to the resident's CP because the resident had dysphasia, and outside food may not have been appropriate. The DON stated that the CP was to guide care and to make sure care was appropriate and timely. During the same interview the DON stated that if the nurse knew for sure that Resident #2 received the wrong fluid thickness, the resident's physician should have been notified. The DON stated that in general, a family meeting to educate FMs could be held. The DON stated that this was not done after the 02/21/2026 incident. When asked what was done to prevent a similar incident from happening again, the DON responded that there was no measure put into place to prevent this from happening again. The facility policy, Risk Management Incident/Accident with an effective date of February 2015 and a review date of September 2025 was reviewed. Under, Policy the policy revealed that facility staff would document all accidents, incidents and unusual occurrences experienced by residents in the facility's electronic medical record. Under, Purpose, the policy revealed that the purpose of the procedure was to provide guidelines for assessing a resident after an accident or incident and to assist in identifying its cause. Under, Procedure, the facility policy revealed that all incidents and accidents must be reported to the Nursing Supervisor immediately to ensure timely assessment of the resident. This section of the facility policy revealed that the attending physician should be notified of all incidents and accidents. This section of the facility policy further revealed that the DON will investigate incidents or accidents and ensure completeness of the reports. NJAC 8:39-27.1(a)

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 2) sampled for medication errors, was free from significant medication errors of 11 sample residents. Specifically, R2 was administered another resident's medications. This continued practice fails to protect residents from receiving the wrong medications that could result in significant harm.Findings include:Review of the facility's policy titled, Medication Administration, dated 09/25, revealed It is the policy of the facility to administer medications according to accepted standards of practice.Medication and treatment errors and/or undesirable effects are to be immediately reported to the attending physician, and the resident will be monitored. A medication/treatment error report will be turned in to the nursing office as part of the quality assurance program.Prepare all meds for the resident as ordered for the time it is due. Take meds to the resident after identifying the resident correctly. This can be accomplished by asking the resident his/her name or checking their Identification (ID) band.Review of R2's undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed R2 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage, dysphagia, and pleural effusion and was transferred to the hospital on [DATE] for coffee ground vomiting.Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R2 was severely cognitively impaired. R2 exhibited behaviors including behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and disruptive sounds).Review of R2's Facility Reportable Event, dated 07/07/25, provided by the facility, revealed on 07/04/25 at approximately 4:40 PM, Agency Nurse [Licensed Practical Nurse (LPN) 1], administered Rivaroxaban 15mg [milligram] (Xarelto, is an anticoagulant medication used to prevent and treat blood clots), Nifedipine 30mg (calcium channel blocker used to treat high blood pressure and angina) (chest pain), Flomax 0.4mg (benign prostatic hyperplasia (BPH), also known as an enlarged prostate), and Insulin Lispro 2 units subcutaneously to [R2]. [LPN1] administered the medication intended for another resident to [R2] erroneously. [R2] developed nausea and vomiting on 07/05/25 requiring hospitalization for upper gastrointestinal (GI) bleed. [LPN1] provided the facility with a statement acknowledging that she did not inform the supervisor on duty or inform the primary care physician (PCP) that she administered the wrong medication to the wrong resident.Review of the Progress Notes located under the Progress Notes tab of the EMR and Medication Administration Records (MAR) located under the Orders tab of the EMR revealed the medication error was not documented. LPN1 was not available for an interview.During an interview on 09/30/25 at 7:45 AM, Certified Nurse Aide (CNA) 1 stated she had just come into work when R2's family asked if they could take him outside, the nurse spoke to the family and CNA1 went back to work. CNA1 stated that LPN1 did not ask her to identify the R2 and CNA1 did not witness the administration of the medication.During an interview on 09/30/25 at 9:30 AM, Medical Director (MD) was questioned if he was familiar with R2 and his past history. MD responded that he had taken care of R2 in the hospital. MD stated that R2 was a [AGE] year-old male, with a history of a recent subdural hemorrhage, metabolic encephalopathy, and anemia. MD was questioned if he was notified of the medication error on 07/04/25. MD responded that his team was made aware on 07/05/25 of R2 having nausea and vomiting coffee ground emesis, and he was sent to the hospital. He stated the hospital notified him of a possible medication error. MD was questioned in his opinion, did the medication error have caused the upper GI bleed and decline in the R2's condition. MD stated that it was merely speculation and that he did not believe the medication errors had caused GI bleed. The MD stated because R2 was not eating, there was a possibility of ulcers, and was on aspirin for coronary artery disease (CAD) and had a diagnosis of adult failure to thrive and poor appetite several months prior to incident. MD added that R2 was discharged to another facility on 07/10/25 from the hospital. He stated R2 was stable, he had an esophagogastroduodenoscopy (EGD), evaluated by GI [gastrointestinal], and was cleared as stable for discharge.During an interview on 09/30/25 at 2:35 PM, Registered Nurse (RN) 1 (also the Unit Manager for the Smart Unit) was questioned when she was made aware of the medication error. RN1 stated that the Director of Nursing (DON) made her aware on 07/07/25, not sure when DON was made aware. RN1 stated the initial actions were to contact the Agency where LPN1 was employed and started providing education to nurses concerning the rights of medications, to report medication errors immediately, and monitor the residents. She stated the agency requested facility to develop an orientation packet specific to the facility for their agency nurses.During an interview on 09/30/25 at 5:11 PM, the Assistant Director of Nursing (ADON) was questioned when she had been notified of R2's medication error. ADON responded that the DON notified her when she arrived at the facility on 07/07/25. The facility was unaware of the incident until the morning of 07/07/25, and the DON was notified by the hospital. ADON was asked what the facility did immediately after being informed of incident. ADON responded we started an investigation immediately; there was no documentation from LPN1 for administering the wrong medications. I interviewed the nurse involved who would not state what caused her to administer the wrong medication. We (facility) would've had no idea if facility had not interviewed the nurse.

Complaint NJ #:178839 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an abuse policy that addressed sexual abuse to ensure a resident was protected from staff-to-resident sexual abuse. This deficient practice was identified for one (1) of one (1) residents (Resident #59) reviewed for abuse, and was evidenced by the following: On 10/22/24 at 1:00 PM, two surveyors interviewed the Director of Nursing (DON) who stated that a Certified Nursing Assistant (CNA#1) reported that on 10/15/24, the CNA#1 observed a Licensed Practical Nurse (LPN #1) standing over Resident #59 in a compromising position. A review of the investigation revealed the Social Worker (SW) interviewed Resident#59, who stated, I gave him oral sex. Resident #59 stated that the sexual contact occurred in [Resident #59's] room and that Resident #59 told LPN #1, I'm scared because there are people around, and [LPN #1] shut the door. The resident began performing oral sex on LPN #1 until the resident heard the door open, and the resident said that they stopped and asked, what was that? The SW asked the resident if they continued after the door was closed and the resident responded that they continued for about two minutes until he ejaculated in my mouth. The facility failed to ensure all residents were protected from sexual abuse by not fully investigating, assessing, and reporting the witnessed actions of LPN #1. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/15/24, after LPN #1 had a sexual encounter with Resident #59. The facility DON, Assistant Director of Nursing (ADON), and [NAME] President of Clinical Services (VPCS) were notified of the IJ on 10/22/24 at 6:20 PM. The facility submitted an acceptable Removal Plan (RP) on 10/23/24 at 1:10 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 10/23/24. The evidence was as follows: A review of the facility policy Abuse and Neglect Policy and Procedure dated November 2022, revealed Purpose: To ensure prevention, protection, prompt reporting and interventions in response to alleged, suspected or witnessed abuse .of any facility resident .Policy: The Facility will not condone the abuse/neglect of any resident by anyone, including, but not limited to, staff members, other residents .Crime: .examples of crimes that would be reported include but are not limited to .sexual abuse .Abuse is the willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting a physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Investigative and Reporting Procedure: 2. If abuse/neglect is suspected or confirmed, the resident shall be assessed to determine the need for counseling. The Administrator or his/her designee will form an investigatory team that will thoroughly investigate the allegation and document the investigation .(a) Incident report will be completed. (b) Interviews will be conducted .All such statements will be in writing and placed in the investigatory file related to the alleged incident. (d) Medical records of the resident including, but not limited, to documentation related to the physical assessment of the resident, as well as any assessment relating to the resident's psychological condition, will be reviewed .will be documented and placed into investigatory file. Federal Requirement: Reporting Reasonable Suspicion of a Crime in Long-term Facility: (i) report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of crime against any individual who is a resident of, or receiving care from the facility and (ii) report immediately but not later than 2 hours after forming the suspicion. A review of the facility policy Risk Management Incident/Accident review date March 2024, revealed: Policy: The facility staff will document all accidents and incidents in Risk Management. Purpose: The purpose of these procedure as to provide guidelines for assessing a resident after an incident/accident and to assist staff in identifying causes of the incident. Procedure: .The attending physician will be notified by the charge nurse of all occurrences of Incidents and Accidents when applicable. Chart the incident in the progress notes sections. Include, as applicable: Factors that may have attributed to the incident/accident .A detailed prescription of findings, observations, and interventions. The time of physician notification .Any resident observations or comments. On 10/22/24 at 12:08 PM, during an interview with the surveyor, CNA #1 stated, I saw something inappropriate that happened last Tuesday (10/15/24) at the beginning of my shift between a resident (later identified as Resident #59) and a staff member (later identified as LPN #1). I told the DON. She added, the staff member is no longer here. The surveyor reviewed the electronic medical record (EMR) for Resident #59. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a chemical imbalance in the blood which can cause difficulty thinking clearly), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and major depressive disorder, single episode, unspecified (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities.) A review of the quarterly Minimum Data Set, an assessment tool dated 8/21/2024, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #59's individual comprehensive care plan revealed: Goal .has difficulty processing complex thinking skills and is occasional forgetful of [Resident #59] prior request and actions. Revision on: 9/12/2022. Further review revealed: Goal . is receiving Psychotropic (high-risk) medication(s) by pharmacological classification r/t (related to) MDD [major depressive disorder]. Revision on 3/13/2024. Interventions: Document changes in mood/behavior noting precipitating factors .Keep MD (medical doctor) informed of concerns, date initiated 3/13/2024 .Observe/Monitor responses to tx/care (treatment), progress toward goal, for improvements, complications, or adverse consequences. Report concerns to MD [medical doctor] for prompt intervention, date initiated 3/13/2024. A review of the Psychiatric Evaluation dated 9/16/2024, revealed: denies any symptoms of depression or anxiety .Assessment/Plan: A Dose Reduction (GDR) is: contraindicated .due to noted efficacy and improvement in quality of life with current treatment, contraindicated, patient has major psychiatric illness, current regimen is required to maintain functional status at this time. A review of the Individual Psychotherapy progress noted dated 10/15/24 from 1:50 PM to 2:11 PM revealed: Observable Evidence Of Patient's Response To Treatment Intervention: .Follow Up will include addressing the following issues in treatment: Continue to monitor depressive symptoms and assist resident in increasing social interactions. A review of the facility provided Nursing, Daily Attendance Report revealed LPN #1 worked the day shift (7 AM to 3 PM) on 10/15/24. A review of the facility provided Assignment for [Name Redacted] Unit sheets revealed that LPN #1 was the assigned nurse for Resident # 59 for the day shift on 10/15/24. A review of the staff list provided by the facility revealed: LPN#1, DOH (date of hire)12/9/21, terminated 10/15/24, resigned effective immediately. A review of the facility provided employee file for LPN #1 revealed: -LPN #1 had an active Nursing, Lic. (licensed) Prac. (Practical) Nurse, expiration date: 5/31/2025. - Employee Performance Evaluation for LPN#1 for the evaluation period 12/9/22-12/9/23 dated and signed by LPN# 1 on 12/11/23 revealed 3. Satisfactory .Improvement plan: a check next to teamwork. -Background Screening Report dated 12/2/2021, Results: No reportable Records Found. - Background Screening Report dated 10/15/24, Results: No reportable Records Found. -Abuse Policy-Freedom from Abuse signed by LPN #1 on 6/18/24. -Essentials of Resident Rights completed 4/10/2024. -Ethics and Corporate Compliance completed on 9/1/2024. A review of Resident #59's EMR for 10/15/24, did not reveal documentation of the above mentioned incident, a nursing or physician assessment, or physician orders. On 10/22/24 at 12:14 PM, the surveyors interviewed the Unit Manager (UM), who stated that if any abuse was seen or heard, she would tell the DON, then the DON would call the police, the state or depending on what it was. The surveyor asked if there was any abuse recently. The UM stated, Yes, a male nurse (LPN#1) was accused of having oral sex with a patient (Resident #59), his penis was in the resident's mouth. She stated the DON came to the unit to collect the nurse's belongings, he was not allowed back on the unit. The UM stated LPN#1 was no longer here. The UM stated CNA#1 observed it (the incident) and reported it to the DON. On 10/22/24 at 1:00 PM, during an interview with two surveyors, the DON stated the full investigation was still open, she printed a copy of the investigation for the surveyors. The DON stated, needs work on it. According to the investigation, the DON stated she was in her office when CNA #1 told her what happened on 10/15/24. The DON went to the unit, but LPN#1 was not on the unit. The DON stated he (LPN#1) left the unit, he was not in the building, he left the facility. The DON called the Social Worker (SW) and the Assistant Director of Nursing (ADON) to the unit. The SW went to speak with the resident. After approximately 20 minutes, LPN#1 came back to the unit and the DON met him at the nurse's station. The DON asked LPN #1 for his keys and took him to the conference room to wait. The SW and the DON spoke to other residents. The Licensed Nursing Home Administrator (LNHA) and the DON went to the conference room to speak to LPN#1. The LNHA led the interview. The DON explained LPN #1 did not say much, he denied that it happened. The DON stated LPN#1 resigned immediately. The DON stated we did not report it to the state (New Jersey Department of Health (NJDOH)) or the police because it (the sexual encounter) was consensual, and the resident wanted everything to remain confidential. The DON stated the LNHA had left messages twice to the Board of Nursing to report the incident. A review of the undated investigation revealed the Statement Summary: Documented as written Writer (the DON identified as the SW) asked the resident about the relationship with LPN #1, inquiring if there has been any sexual contact. Resident #59 responded just today, adding that they otherwise have just joked. The writer asked what sexual contact happened today and the resident responded, I gave him oral sex. Writer asked about how this interaction occurred, and the resident responded, We're always joking about it .he came in my room when I was in the bathroom. He said, here you go, making a gesture with their hand, cupping their hand in an upward motion. The writer asked if that was a sexual gesture, and Resident #59 confirmed it was. The resident stated that the sexual contact occurred in (their) room and that the resident told LPN#1, I'm scared because there are people around, and he shut the door. The resident began performing oral sex on him until the resident heard the door open, and the resident said that they stopped and asked, what was that? The resident said the person closed the door. The writer asked if the resident continued after the door was closed and the resident responded that they continued for about two minutes until he ejaculated in my mouth. The resident stated that sexual contact had never occurred before, adding that they were a consenting adult and I don't want to get him in trouble. The resident added LPN#1 said, it wouldn't take long adding and it wasn't. The resident stated, I've never seen anything that fast. Resident #59 said, I figured it wasn't kosher for him to do that or for me to do that. Further review of the investigation revealed: Writer asked more about their relationship, and Resident #59 stated, We joke about oral sex a lot. Writer asked how long these kinds of jokes have been going on and the resident stated, Almost as long as he's been here. Resident #59 gave an example of a joke, stating they usually take their own medications, but that LPN#1 would give them the inhaler and say suck. Resident #59 said, I flirt with everyone and I am a jokester. On 10/22/24 at 2:21 PM, the surveyor interviewed the Director of Social Services (DSS), who stated if there was an allegation of abuse, the staff would be suspended and the allegation of abuse would be reported (to the NJDOH) within two hours, a full investigation would be completed, and the police would be called. She then stated, the DON and LNHA are responsible to report the event. She confirmed she was aware of the sexual incident that occurred on 10/15/24, between LPN#1 and Resident #59. She also confirmed that the sexual incident was not reported to the NJDOH or to law enforcement. The DSS stated she met with Resident#59 who acknowledged what had happened and that it happened only one time and it was consensual. She stated Resident #59 was flirty but had no knowledge of the resident having a history of inappropriateness. She stated statements were taken. She added, the LNHA and DON met with LPN#1 to obtain a statement but, I don't think he gave one; he resigned. The DSS further stated that she met with the LNHA, the DON, and the ADON to see if any follow up was required. She stated, we were all unsure because the resident was adamant about it being consensual. She added the resident was worried about being in trouble. The DSS stated the LNHA reviewed the regulations, and it was concluded that the incident did not meet the standards for reporting. She added, it was a collective discussion. On 10/22/24 at 3:21 PM, the surveyors met with Resident #59 and asked if they could interview the resident in private. The resident agreed. The SW offered her office for the private interview. The surveyor informed the resident that at any time during the interview the resident does not have to answer the questions and could stop the interview. The resident acknowledged understanding. The surveyor asked what had happened on 10/15/24, between the nurse and the resident. Resident #59 stated, I am a jokester. He told me to hold it, he then unzipped his pants, I regret it happened. The resident stated, it happened about 9:30 in the morning. He was passing medications. I have COPD (chronic obstructive pulmonary disorder-lung disease that block airflow and make it difficult to breath) and use an inhaler. He stated ready to suck for me. The resident told the nurse, There are too many people, he said nobody is here and he shut the door. The resident stated. He pulled his fly down. He came in my mouth, and I swallowed it. The resident added, I am afraid the facility will kick me out. On 10/22/24 at 5:15 PM, the LNHA approached the survey team in the conference room and apologized, but stated he had to go it's my holiday. The Team Coordinator stated that you may want to stay. He stated, I know the [NAME] but I have to go. He stated the DON would still be available. On 10/22/24 at 5:56 PM, during an interview with the survey team, the ADON, the VPCS, and the DON stated sexual abuse was inappropriate touching from one person to the other, undesired touching. When asked if sexual abuse was a crime, the DON stated, yes. When asked if a crime occurs would you call police, the DON stated, yes. When asked what should be done for any incident, the DON stated an investigation was started, obtain statements from employees, an incident report was started, the MD and family were notified. When asked why were you reporting the incident to the Board of Nursing, she stated, I think it is unethical based on professional standards. When asked what did he do that was unprofessional, she stated, he had interactions with a resident under his care. At that time the VPCS, stated, The LNHA makes the decision to report or not. The DON stated it was not reported because it was consensual. An acceptable removal plan was received on 10/23/24 at 1:16 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: 1) LPN#1 was immediately removed from the facility; 2) Resident #59 was assessed; 3) the resident's physician was notified; 4) the incident was reported to the New Jersey Department of Health (NJDOH); 5) the abuse and neglect policy was updated; 6) the police were called; and 7) all staff were educated on the facility abuse policies and procedures. The survey team verified the implementation of the removal plan during the continuation of the on-site survey on 10/23/24. On 10/25/24 at 1:42 PM, in the presence of the survey team, the Medical Director was interviewed via the phone. He agreed to being placed on speaker phone. The surveyor asked if he was the primary care physician for Resident #59, he stated yes. When asked if he was aware of the incident that occurred on 10/15/24, regarding Resident #59. He stated, he was made aware this past week, sometime this past weekend. He was unable to recall exactly what day he was notified. When asked when you were made aware of the incident what recommendations did you make, he stated, a psychology consult, therapy sessions and testing. On 10/28/24 at 11:48 AM, the survey team met with DON, the ADON, the LNHA and the Regional LNHA. The LNHA stated he was the abuse officer. He stated an allegation of abuse example was someone who said they were punched in the face. He stated it would be investigated and if it was something that needs to be reported, then it would be reported within two hours. He stated the above incident was not reported because we did not feel abuse took place. He stated, I read through the regulations and felt that there was no abuse that had occurred since it was consensual. He confirmed he had been inserviced on reporting and investigating for F 600. He then stated after rereading F 600 it (the above mentioned incident) should have been reported. NJAC 8:39-4.1 (a) NJAC 8:39-33.2 (c) (12)

Complaint # NJ 178839 Refer to F 600 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse by a staff member to a resident to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 1 resident (Resident #59) and was evidenced by the following: On 10/22/24, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. On 10/22/24, a review of an investigation provided by the facility revealed that on 10/15/24, a staff member observed the resident in a compromising position with another staff member (Licensed Practical Nurse (LPN) #1). A review of the investigation revealed the Social Worker (SW) interviewed Resident #59 who when asked what sexual contact happened today stated, I gave him (LPN#1) oral sex. Further review revealed that Resident #59 stated that the sexual contact occurred in the room and that the resident told LPN #1, I'm scared because there are people around, and he (LPN#1) shut the door. Resident #59 began performing oral sex on him until the door was heard to open, when Resident #59 said the activity was stopped and asked, what was that? The person closed the door. The SW asked if the oral sex continued after the door was closed and Resident #59 responded that it continued for about two minutes until he (LPN#1) ejaculated in the mouth. Resident #59 stated that sexual contact had never occurred before, and further stated, I don't want to get him in trouble, and I figured it wasn't kosher for him to do that or for me to do that. On 10/22/24 at 1:00PM, the surveyors interviewed the Director of Nursing (DON) who stated the investigation was still open and was not completed yet. She further stated that according to the resident, the incident was consensual but that it was not appropriate. She also stated that neither the police, nor the NJDOH were notified because the encounter was consensual, and the resident requested privacy regarding the incident. On 10/22/24 at 3:21 PM, the surveyors met with Resident #59 and asked if they could interview the resident in private. The resident agreed. The SW offered her office for the private interview. The surveyor informed the resident that at any time during the interview the resident does not have to answer the questions and could stop the interview. The resident acknowledged understanding. The surveyor asked what had happened on 10/15/24 between the nurse and the resident. Resident #59 stated, I am jokester. He told me to hold it, he then unzipped his pants, I regret it happen. The resident stated, it happened about 9:30 in the morning. He was passing meds. I have COPD (chronic obstructive pulmonary disorder-lung disease that block airflow and make it difficult to breath) and use an inhaler. He stated ready to suck for me. The resident told the nurse, There are too many people, he said nobody is here and he shut the door. The resident stated. He pulled his fly down. He came in my mouth, and I swallowed it. The resident added, I am afraid the facility will kick me out. When asked if the facility offered to call the police, Resident #59 stated they did not and that the resident did not want the police called as it was partly his/her fault. On 10/22/24 at 5:56PM, the surveyor interviewed the DON and the [NAME] President of Clinical Services in the presence of the surey team, who stated that crimes were reported to the police and that what happened to Resident #59 was consensual, therefore it was not a crime. On 10/28/24 at 11:48AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the surey team, who stated that abuse should be reported (to the NJDOH) within 2 hours of the allegation. He further stated he reread Federal Tag (the system through which federal nursing home regulations are identified in the survey process) #600 and the incident should have been reported. A review of the facility policy Abuse and Neglect Policy and Procedure dated November 2022, revealed Policy: The Facility will not condone the abuse/neglect of any resident by anyone, including, but not limited to, staff members, other residents .Crime: .examples of crimes that would be reported include but are not limited to .sexual abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting a physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Federal Requirement: Reporting Reasonable Suspicion of a Crime in Long-term Facility: d. (i) report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of crime against any individual who is a resident of, or receiving care from the facility and (ii) report immediately but not later than 2 hours after forming the suspicion. NJAC 8:39-9.4(f)

Based on observation, interview, and record review, it was determined that the facility failed to provide services in a manner consistent with standards of practice to maintain a urinary catheter from 8/28/24 until surveyor inquiry. The deficient practice was identified for one (1) of three (3) residents, (Resident #55), reviewed for urinary catheter care. The deficient practice was evidenced by the following: On 10/22/24 at 10:42 AM, the surveyor observed Resident #55 in a wheelchair in their room. The resident stated that they had just returned from physical therapy and was exhausted. The surveyor had not observed a urinary catheter drainage bag (a device inserted to collect urine from the bladder into a drainage bag). On 10/22/24 at 10:49 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she was familiar with Resident #55 and had the resident on her assignment. CNA #1 added that the resident had a urinary drainage bag when they were in bed and when the resident was out of bed, the urinary drainage bag was changed to a leg bag. The surveyor reviewed the electronic medical record for Resident #55. A review of the comprehensive admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 9/4/24, reflected that the resident had a Brief Interview for Mental Status score of 11 out of 15, which indicated the resident had an intact cognition. In addition, the MDS reflected that the resident had an indwelling catheter. A review of the individualized comprenhesive care plan (ICCP) created on 8/28/24 with a revision date of 9/14/24, reflected a focus area Risk for UTI (urinary tract infection) r/t (related to) cath (catheter) use. A review of the Order Summary Report reflected diagnoses which included but were not limited to, hydronephrosis with renal and urethral calculous obstruction (a blockage in one or both of the tubes (ureters) that carry urine from the kidneys to the bladder causing a swelling of the kidneys) and chronic kidney disease. Further review of the Order Summary Report reflected the following physician's orders (PO) dated 8/28/24: -[name redacted] Catheter care every shift. -Follow up with [name redacted] for urinary retention in 1-2 weeks. Call [phone number redacted] to schedule. -Follow up with [name redacted] nephrology in 1 week. [address and phone number redacted]. The surveyor was unable to identify any documented consult reports or scheduled appointments for a consult for the resident. On 10/24/24 at 9:31 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who verified that Resident #55 had a urinary catheter upon admission. The UM/LPN stated that she was unaware that the resident required any consults to be scheduled. At that time, the UM/LPN reviewed the POs for the resident. The UM/LPN verified that there were PO's for a urology consult and a nephrology consult that had been ordered on 8/28/24. The UM/LPN added that she was responsible for checking the POs and setting up the consults. The UM/LPN also stated that she had not been working for a while during September due to personal reasons and the appointments were not done. The UM/LPN added that she was unaware of the PO for appointments to be scheduled for the urologist and nephrologist and would have to schedule them now. On 10/24/24 at 2:25 PM, the survey team met with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional [NAME] President of Clinical Services. The surveyor reviewed the above concern that the PO for the nephrology and urology consults were not completed for Resident #55. On 10/28/24 at 12:50 PM, the survey team met with the Licensed Nursing Home Administrator, DON and ADON. The ADON stated that Resident #55 was originally admitted to the sub-acute unit and the PO were obtained for the consults but was unsure if the nurse had scheduled the appointments. The ADON added that shortly after admission the resident was transferred to the [NAME] Unit on 9/4/24, and the nurse who accepted the in-house transfer had missed the PO and had not scheduled the appointments. The ADON stated Somehow the orders fell through the cracks. In addition, the ADON stated that there was no facility policy for the nurses when admitting a resident but that the process was that nurses were to follow an in-house check-off list as a guide to make sure every order was followed through. Also, the ADON stated that there was no facility policy for the transcription of a PO but that the nurses were to follow the standard of practice that a PO was to be completed. NJAC-8:39-11.2(b), 27.1(a)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a.) all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 5 of 5 CNAs and b.) abuse prevention training was completed for 2 of the 5 CNA files reviewed for in-service training. This deficient practice was evidenced by the following: On 10/24/24, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #1 was hired on 8/17/18, with a total of 6 hours (hrs.) of in-service training for the current 12-month period. CNA #2 was hired on 8/25/15, with a total of 5.5 hrs. of in-service training for the current 12-month period. CNA #3 was hired on 8/10/23, with a total of 6 hrs. of in-service training for the current 12-month period, which did not include abuse prevention training. CNA #4 was hired on 9/27/18, with a total of 6.5 hrs. of in-service training for the current 12-month period, which did not include abuse prevention training. CNA #5 was hired on 8/10/23, with a total of 8.25 hrs. of in-service training for the current 12-month period. The above in-service content was provided to the surveyor as a Transcript print out for each of the five CNAs reviewed. The transcript reflected online education module titles with respective quantified hours of training, and date completed. The surveyor reviewed additional information submitted by the DON, which did not reflect quantifiable time related to topics of education and therefore could not be included in total hours of education. On 10/24/24 at 1:03 PM, the surveyor interviewed the Director of Human Resources who stated that she provided the CNA files, and the in-services included all the orientation and education provided by the facility. On 10/24/24 at 2:25 PM, the surveyor interviewed the DON, in the presence of the survey team, as well as the Assistant DON (ADON) and the [NAME] President of Operations. The DON acknowledged that the additional information provided [Inservice Attendance Records, Educational Enhancement Seminar and User Learning tracking sheets] had no quantification of time to include in the calculation of the 12 hours of mandatory in-service training. On 10/25/24 at 1:47 PM, the surveyor interviewed the DON, in the presence of the survey team and the ADON, who stated the previous educator who was responsible to ensure CNAs received their 12 hours of mandatory training had been out on a leave, then returned in July of this year and then left the role. She further stated, so we had sort of a gap. The DON stated that corporate scheduled monthly online education and that the Licensed Nursing Home Administrator (LNHA) and herself were responsible to ensure staff completed the education. At that same time, the DON stated that the facility did not have a policy related to CNA education. NJAC 8:39-43.17 (b)

Complaint # NJ 178839 Refer to F 600 Based on interviews, review of the medical record and other facility documentation, it was determined that the facility failed to thoroughly investigate an alleged incident of sexual abuse between a staff member and a resident. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for abuse and was evidenced by the following: On 10/22/23, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 08/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. On 10/22/24, a review of an investigation provided by the facility revealed that on 10/15/24, a staff member observed the resident in a compromising position with another staff member (Licensed Practical Nurse (LPN) #1). A review of the investigation revealed the Social Worker (SW) interviewed Resident #59 who when asked what sexual contact happened today stated, I gave him (LPN#1) oral sex. Further review revealed that Resident #59 stated that the sexual contact occurred in the room and that the resident told LPN #1 I'm scared because there are people around, and he (LPN#1) shut the door. Resident #59 began performing oral sex on him until the door was heard to open, Resident #59 said the activity was stopped and they asked, what was that? The person closed the door. The SW asked if the oral sex continued after the door was closed and Resident #59 responded that it continued for about two minutes until he (LPN#1) ejaculated in their mouth. Resident #59 stated that sexual contact had never occurred before, and further stated, I don't want to get him in trouble, and I figured it wasn't kosher for him to do that or for me to do that. On 10/22/24 at 1:00PM, the surveyors interviewed the Director of Nursing (DON), who stated the investigation was still open and was not completed yet. She further stated that according to the resident, the incident was consensual but that it was not appropriate. The surveyors were provided a printed summary of the incident. No incident report was provided as the DON stated that she ensured the resident was safe and did not think of an incident report. The summary provided included interviews with six alert and oriented residents that were on LPN #1's assignment. Interviews did not include Resident #59's alert and oriented roommate. No documentation was noted regarding an assessment of Resident #59 after the incident - summary indicated the DON noted no injury during interview. No documentation provided indicated that non alert and oriented residents were assessed for any inappropriate sexual contact. There was no documentation to indicate that Resident #59's primary physician was notified. No written statements were included in the summary from the witness or anyone else. On 10/22/24 at 3:21PM, the surveyor interviewed Resident #59, who was agreeable to speak to two surveyors. The resident stated that she and LPN #1 both joked around with sexual undertones. On the morning of 10/15/24, LPN #1 during morning medication pass, brought the resident his/her inhaler and asked if he/she was ready to suck for him. The resident was sitting in the room when LPN #1 came closer and pulled down his zipper and told Resident #59 to put his/her hand in his pants. Resident #59 told him there were too many people around, including an alert, oriented roommate. LPN #1 stated that nobody was around, and he shut the door. Resident #59 stated that he/she put their hand in his pants and that LPN #1 ejaculated into their mouth, which the resident swallowed. Resident #59 stated that he/she was not forced or coerced. Resident #59 further stated that it was an indiscretion and a mistake and that it was quick, very short. On 10/22/24 at 3:21 PM, the surveyors met with Resident #59 and asked if they could interview the resident in private. The resident agreed. The SW offered her office for the private interview. The surveyor informed the resident that at any time during the interview the resident does not have to answer the questions and could stop the interview. The resident acknowledged understanding. The surveyor asked what had happened on 10/15/24 between the nurse and the resident. Resident #59 stated, I am jokester. He told me to hold it, he then unzipped his pants, I regret it happen. The resident stated, it happened about 9:30 in the morning. He was passing meds. I have COPD (chronic obstructive pulmonary disorder-lung disease that block airflow and make it difficult to breath) and use an inhaler. He stated ready to suck for me. The resident told the nurse, There are too many people, he said nobody is here and he shut the door. The resident stated. He pulled his fly down. He came in my mouth, and I swallowed it. The resident added, I am afraid the facility will kick me out. On 10/25/24 at 11:31 AM, the surveyor interviewed the Medical Director who stated he was the attending physician for Resident #59, and he was made aware of the incident this past weekend. Upon notification, he stated that he recommended a psychiatric consultation, sexually transmitted infections testing, and psychotherapy. On 10/25/24 at 01:48 PM, the surveyors met with the DON and the Assistant DON (ADON). The DON stated that the attending physician should have been notified about the time when the incident happened. She also stated that the notification of the attending physician should be documented and that if something was not documented, it was not done. A review of the facility policy Abuse and Neglect Policy and Procedure dated November 2022, revealed Policy: The Facility will not condone the abuse/neglect of any resident by anyone, including, but not limited to, staff members, other residents .Crime: .examples of crimes that would be reported include but are not limited to .sexual abuse .Investigative and Reporting Procedure: 2. If abuse/neglect is suspected or confirmed, the resident shall be assessed to determine the need for counseling. 3. The Administrator or his/her designee will form an investigatory team that will thoroughly investigate the allegation and document the investigation .(a) Incident report will be completed. (b) Interviews will be conducted .All such statements will be in writing and placed in the investigatory file related to the alleged incident A review of the facility policy Risk Management Incident/Accident review date March 2024 revealed: Policy: The facility staff will document all accidents and incidents in Risk Management. Purpose: The purpose of these procedure as to provide guidelines for assessing a resident after an incident/accident and to assist staff in identifying causes of the incident. Procedure: .The attending physician will be notified by the charge nurse of all occurrences of Incidents and Accidents when applicable. Chart the incident in the progress notes sections. Include, as applicable: Factors that may have attributed to the incident/accident .A detailed prescription of findings, observations, and interventions. The time of physician notification .Any resident observations or comments. NJAC 8:39-9.4(f)

Based on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties were consistently applied to prevent skin breakdown. This deficient practice was identified for Resident #72, 1 of 2 residents reviewed for position and mobility. This deficient practice was evidenced by the following: On 10/18/24 at12:18 PM, during initial tour, the surveyor observed Resident #72 sitting in a reclining chair in the main activity area. The resident was wearing white socks with their heels resting on the footrest. A review of the electronic medical record (EMR) for Resident #72 revealed the following: A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities) and Alzheimer's Disease, unspecified a brain disorder that slowly destroys memory and thinking skills.) A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/7/24, revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was severely cognitively impaired. Further review revealed the resident did not have a pressure ulcer. A review of the individual comprehensive care plan (ICCP) revealed: Intervention/Tasks: Booties to feet bilateral while in and oob (out of bed) for skin protection, Date Initiated: 08/06/2024. A Review of the physician orders (PO) revealed: HEEL BOOTIES TO BILATERAL HEELS AT ALL TIMES. CHECK PLACEMENT Q SHIFT every shift for skin integrity Active 8/6/2024 15:00. A review of Treatment Administration Record (TAR) revealed: HEEL BOOTIES TO BILATERAL HEELS AT ALL TIMES. CHECK PLACEMENT Q SHIFT had a check, check=administered, for the day shift by the Licensed Practical Nurse/Unit Manager (LPN/UM) for 10/24/24. On 10/24/24 at 1:34 PM, the surveyor interviewed the LPN/UM, who was Resident #72's assigned nurse. She stated the resident wears booties at night in bed. The LPN/UM reviewed the PO in the presence of the surveyor and confirmed that the heel booties should be worn at all times. She stated the purpose of booties was for skin integrity. She stated the resident did not have any skin breakdown. The LPN/UM observed the resident, in the presence of the surveyor, in a recliner chair and confirmed that the resident was currently wearing black socks and that the booties were not on the residents. She confirmed she had signed the order on the TARs as being completed. She acknowledged it's my fault. On 10/24/24 at 2:36 PM, in the presence of the survey team, Assistant Director of Nursing and the [NAME] President of Clinical Services, the surveyor interviewed the Director of Nursing (DON), who stated the nurses and certified nursing assistants make sure heel booties are applied. She stated, if a resident is in a recliner the booties should be on. The surveyor made the DON aware of the above observation. The Licensed Nursing Home Administrator was not available for interview. A review of the facility's policy Policy for Splint Application reviewed 08/2024, revealed: Policy: It is a policy of this facility to apply splints, braces, hand rolls and etc. as per physician's orders. NJAC 8:39-27.1 (a)

Based on observation, interview, review of medical records and other pertinent facility documentation, during a survey conducted on 1/11/21, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that the facility was in compliance with all recommended infection control measures in accordance with the Centers for Disease Control (CDC) and the New Jersey Department of Health (NJDOH) guidelines and b.) the implementation of mitigation strategies to prevent the transmission of COVID-19 were appropriately followed to prevent the spread of the infection which affected residents' safety. Additionally, during a removal plan verification survey on 1/14/21, it was determined the facility failed to ensure that a.) staff donned (wore) appropriate personal protective equipment (PPE) for residents who were considered persons under investigation (PUI) for a known COVID-19 exposure and b.) staff changed PPE between residents on transmission-based precautions (TBP) which resulted in a second Immediate Jeopardy (IJ). Refer to F880K as it pertains to the facility's failure to ensure the implementation of Infection Control Practices and Precautions during an identified COVID-19 outbreak. During the survey conducted on 1/11/21, the surveyors identified and observed deficient practices for infection control regarding the isolation of two residents who were placed on TBP for community based exposure to COVID-19 from their well and non-exposed roommates. This deficient practice was identified on 1 of 4 nursing units. The facility submitted a Removal Plan by email on 1/12/21, and after several revisions and review at the Department of Health (DOH), the RP was accepted on 1/13/21. On 1/14/21, the surveyors conducted an onsite visit to verify the Removal Plan. During the verification of the Removal Plan, the surveyors observed staff members wearing the same isolation gowns from resident to resident who were considered PUI and on TBP for a known exposure to COVID-19. Staff members were also observed not wearing the recommended N95 (respirator) mask while caring for PUI residents on TBP. The surveyor also observed a Maintenance Assistant go from one isolation room to the next wearing only a KN95 mask and goggles. The Maintenance Assistant did not wear the required isolation gown or gloves in any of the rooms. The Maintenance Assistant was observed opening doors and touching light switches with no hand hygiene in between resident rooms. This resulted in a second IJ situation. These deficient practices were identified in 2 of 2 nursing units with residents who were on TBP for a known COVID-19 exposure from a staff member. The facility submitted a Removal Plan by email which after one revision was reviewed and accepted on 1/15/21 at the DOH. This deficient practice was evidenced as follows: A review of the Administrator's job description provided by the facility revealed the following: Purpose of Your Job Position: The primary purpose of your job position is to direct day-to-day functions of the facility in accordance with current federal, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Duties and Responsibilities: Administrative Functions - Essential Duties Plan, develop, organize, implement, evaluate, and direct facility's programs and activities. Develop and maintain written policies and procedures that govern the operation of the facility. Assist department directors in the development and use of departmental policies and procedures, and establish a rapport in and among departments so that each can realize the importance of teamwork. Review the facility's policies and procedures periodically, at least semi-annually, and make changes as necessary to assure continued compliance with current regulations. Ensure all employees, residents, visitors, and the general public follow established policies and procedures. Assume the administrative authority, responsibility, and accountability of directing activities and programs of the facility. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Participate in facility surveys (inspections) made by authorized government agencies. Safety and Sanitation - Essential Duties Ensure that all facility personnel, residents, visitors, ect., follow established safety regulations, to include fire protection/prevention, smoking regulations, infection control, ect. Ensure that personnel follow established policies governing the use/disposal of personnel protective equipment and disposal of infectious wastes. Other(s) that may become necessary/appropriate to assure that the facility is maintained in a clean, safe and sanitary manner. Specific Requirements: Must be thoroughly familiar with laws, regulations, and guidelines governing personnel administration. On 1/11/21 at 4:30 PM, the facility's Licensed Nursing Home Administrator (LNHA) was notified that an IJ situation was identified related to the facility cohorting residents identified as PUIs on TBP for a possible community based exposure to COVID-19, with their well and non-exposed roommates. On 1/13/21, the facility's Removal Plan was accepted. According to the Removal Plan, Resident #1 and #2 were moved to private rooms to continue on TBP until the end of their fourteen-day quarantine and their roommates remained on TBP until the end of a fourteen-day quarantine. Licensed staff were in-serviced on the policy created on 1/11/21 for the use of the COVID-19 Exposure Risk Assessment Template for Patients in Post-Acute Care settings which included COVID-19 exposure risk for assessing and planning placement considerations for residents upon their return to the facility. During verification of the Removal Plan on 1/14/21, the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) informed the survey team that the facility had three additional COVID-19 positive staff members since 1/11/21. The ADON/IP stated that a Licensed Practical Nurse (LPN) tested COVID-19 positive on 1/12/21. She added that this LPN had worked on 1/11/21 on both the Mercer and Klockner nursing units so all the residents on both units were considered PUIs and were placed on TBP for fourteen days. Observations and interviews of both the Mercer and Klockner nursing units revealed that staff wore the same gown for all residents unless the gown became visibly soiled or staff left the nursing unit. Observations of multiple staff members revealed staff not wearing N95 (respirator) masks for residents on TBP in accordance to CDC and NJDOH guidance. Observation and interview revealed a Maintenance Assistant traveled from isolation room to isolation wearing no gown or gloves, and performing no hand hygiene in between resident rooms. This lead to a second IJ situation, which the facility Administration was notified of on 1/14/21 at 4:20 PM. On 1/11/21 at 9:15 AM, the survey team conducted an entrance conference with the DON and ADON/IP. The LNHA was unavailable/had not joined the meeting. At 4:28 PM, upon request by the survey team for the LNHA to join a meeting with the DON, ADON/IP, and Assistant Administrator, the survey team called the first IJ situation at the facility at 4:30 PM. The LNHA had no response or comment during this time. On 1/12/21 and 1/13/21, the surveyor had multiple communications with the DON regarding the Removal Plan and revisions required. The LNHA was not in contact with the DOH during this time. On 1/14/21 at 9:18 AM during a RP verification survey, the surveyor conducted an entrance conference with the DON and ADON/IP for the Removal Plan from the IJ called on 1/11/21. The LNHA was not present for this meeting. At 3:37 PM, the surveyor interviewed the LNHA who stated that he had been the Administrator at this facility for ten years. At this time, the surveyor requested a copy of his Administrator's license and a copy of his job description. The surveyor also informed the LNHA that the survey team requested to meet with him, the Assistant Administrator (Assist Admin), DON, and ADON/IP at 4:00 PM. At 4:01 PM, the ADON/IP provided the surveyor team with the LNHA's license and job description. At this time, the ADON/IP stated that for TBP, staff should be donning a N95 mask, gown, gloves, and goggles, The ADON/IP stated that staff were all wearing the same gown because all the residents were on TBP so all were at the same risk level. The ADON/IP stated that the facility was in contact today with their Local Health Department (LHD) regarding the usage of the same gowns. The ADON/IP stated that contact person from the LHD informed the facility that the preferred process was to change gowns in each PUI room unless the facility did not have an adequate supply of gowns. At 4:09 PM, the DON stated that the facility determined that they would need approximately 2,500 gowns a day to do this. The DON confirmed that the facility was utilizing washable gowns and had both an active supply of PPE and a thirty day emergency supply of PPE with more than eight sister facilities. At this time, the survey team requested for the LNHA and the Assist Admin to join the discussion. At 4:11 PM, the LNHA and Assist Admin joined the survey team, DON, and ADON in the conference room. The Assist Admin stated that the facility had both an active supply of PPE as well as a thirty day emergency supply. At this time, the LNHA stated that the emergency supply needs were determined possibly back in May using a burn rate calculator accessed online that determined the amount of each PPE needed per day based on the highest amount used per day during a surge. The LNHA stated that the facility had no difficulty ordering or receiving PPE. The facility also had no restrictions on ordering PPE and they ordered PPE as often as needed. The LNHA stated that the facility at times received PPE the same day ordered. The LNHA confirmed that the facility also had access to a corporate supply of PPE if needed. At 4:16 PM, the survey team asked the facility Administration why staff were wearing the same PPE from resident to resident in light of sufficient PPE supply and no difficulty obtaining additional supplies. The DON stated because all the residents were at the same risk level. At 4:17 PM, the survey team asked the LNHA what his role was with infection control for the facility and what he has done since the first IJ on 1/11/21. The LNHA stated that his role in infection control was to oversee that the facility has the proper people in place which would be the ADON/IP. The LNHA stated that he meets with the ADON/IP to discuss different infection control issues that come up. The LNHA stated that he was at the facility late on 1/11/21 because he was very involved with the creating of the Removal Plan (which after multiple attempts to contact the facility, multiple conversations with the DON and Regional staff, and multiple revisions, the Removal Plan was accepted on 1/14/21). The LNHA stated that he was aware that staff were wearing the same gowns for all residents on TBP. The LNHA stated that he was aware that the ADON/IP and DON spoke with (name redacted) from the LHD today, but he was unaware that the LHD advised against this practice unless there was a PPE shortage until now. The LNHA stated that is why I have staff. The LNHA stated that he oversees and discusses with the staff. At 4:20 PM, an IJ was called and the facility Administration was notified. An acceptable Removal Plan was submitted by email to the DOH by the DON on 1/15/21. The Removal Plan included the LNHA was educated on guidelines for maintaining PPE for residents on TBP in accordance with CDC and NJDOH guidelines and mitigation strategies to prevent the transmission of COVID-19. On 1/19/21 at 9:27 AM, the survey team conducted an onsite verification of the Removal Plan from 1/15/21. At 11:12 AM, the survey team met with the facility Administration which included the DON, ADON/IP, and the Assist Admin. The survey team was informed that LNHA was sent home from the facility today upon arrival for experiencing COVID-19 like symptoms. A review of the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 which was provided by the DON as the facility's cohorting policy included cohorting using traditional symptom-based screening alone should be avoided if possible but when necessary, done with caution given the risk of asymptomatic or pre-symptomatic infection. The facility should review or develop a cohorting plan before the identification of the first case. When testing capacity is available and facility spacing permits, residents should be organized into the following cohorts. The guidance included Cohort 3 as residents who are COVID-19 negative and non-exposed who have tested COVID-19 negative with no COVID-19 like symptoms and no known exposures. The guidance also included Cohort 4 new or re-admissions which includes all persons from the community or other healthcare facilities who are newly or readmitted . These residents should remain on TBP for fourteen days being monitored for COVID-19. If after fourteen days, these residents have not met the criteria to discontinue TBP, then the resident should be placed as a Cohort 1 (COVID-19 positive). A review of the facility's undated Outbreak Investigation/Management policy included that cohort residents and staff as available. A review of the facility's undated Outbreak Response Plan accessed from the facility's website on 1/11/21 included that the Facility will cohort residents to the extent possible according to most current applicable Government Guidelines and Directives. Review of the facility's undated Infection Prevention and Control Program included isolate or cohort residents with known or suspected infectious diseases in effort to reduce the risk of disease transmission. A review of the undated CDC Transmission-Based Precautions provided to the surveyor by the ADON/IP as the facility's TBP policy included under droplet precautions that ensure appropriate patient placement in a single room if possible. In long-term care, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. A review of the CDC Responding to Coronavirus (COVID-19) in Nursing Homes dated updated 4/30/2020 included that exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. A review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated updated 12/14/2020 included that the infection prevention and control recommendation for patients on a fourteen day quarantine for a close contact to COVID-19 or suspected COVID-19 should be isolated in a single-person room and care for by healthcare personnel using all PPE recommended. These patients should not be cohorted with COVID-19. The recommendation also included under patient placement that if admitted , place a patient with suspected or confirmed COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. A review of the Center for Disease Control's (CDC) Strategies for Optimizing the Supply of Isolation Gowns dated updated 10/9/2020, included under Crisis Capacity Strategies that extended use of isolation gown consideration can be made to extend the use of isolation gowns (disposable or washable) such that the gown is worn by the same healthcare personnel when interacting with more than one patient housed in the same room location known to be infected with the same infectious disease (such as COVID-19 residents residing in an isolation cohort). The guidance also included that the risks to healthcare personnel and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be reused, and washable gowns should NOT be reused before laundering because reuse poses risks for possible transmission among healthcare personnel and patients that likely outweigh any benefits. If reuse is considered, gowns should be dedicated to care of individual patients. A review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated updated 12/14/2020 included the PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: N95 respirator or equivalent or higher-level respirator (facemask if respirator is not available), eye protection, gloves, and gown. The guidance also included that when the supply chain is restored, facilities should return to use respirators for patients with suspected or confirmed COVID-19 infection. The guidance also included that clean isolation gowns should be put on upon entry to patient room or area, and removed and discarded in a dedicated container for waste or linen before leaving the patient room or care area. A review of the facility's Infection Prevention and Control Program Guidelines dated updated 2/2020 included in the topic Hand Hygiene, that hand hygiene is the single most important measure to prevent infection. The guidelines also included that hand hygiene should be performed after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. The guidance also included, under Universal (Standard) Precautions, that hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or enviroments. N.J.A.C 8:39-27.1(a)

PART A Based on observation, interview, medical record review, and other facility documentation, during a survey conducted on 1/11/21, it was determined that the facility failed to isolate residents on transmission-based precautions (TBP) for unknown COVID-19 community exposure in a high risk COVID-19 positive county from their well and non-exposed roommates to prevent the transmission of COVID-19. This deficient practice was identified for 2 of 3 residents (Resident #1 and #2) reviewed for community based medical appointments. On 12/22/2020 and 1/4/2021, Resident #2 left the facility for a same day medical appointment in a high risk COVID-19 positive county (8.2%, and 10.64% respectively). On both dates Resident #2 returned to their same room in the facility with their same three well non-exposed roomates and all were placed on TBP for a possible unknown COVID-19 community exposure in effort to mitigate the spread of [MEDICAL CONDITION] to their three well and non-exposed roommates. On 12/30/2020, Resident #1 left the facility for a same day medical appointment in a high risk COVID-19 positive county (10.64%). On the same date the resident returned to their same room in the facility with their two well and non-exposed roommates and all were placed on TBP for a possible unknown COVID-19 community exposure in effort to mitigate the spread of [MEDICAL CONDITION] to their two well non-exposed roomates. The facility's failure to isolate Resident #1 and #2 from their well, non-exposed roommates posed a serious and immediate threat to the safety and wellbeing of well non-exposed residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/22/2020 when Resident #2 returned to their same room in the facility on TBP for an unknown COVID-19 community exposure with their three well and non-exposed roommates. The facility Administration was notified of the IJ on 1/11/21 at 4:30 PM. The immediacy was removed on 1/13/21 at 3:16 PM based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 1/14/21. The evidence was as follows: On 1/11/21 at 9:15 AM, the surveyors met with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP stated that each nursing unit had residents who were considered persons under investigation (PUI) as a new admission or readmission to the facility from a same day medical appointment or [MEDICAL TREATMENT]. These residents were placed on TBP for fourteen days. Staff upon entering these rooms donned (wore) personnel protective equipment (PPE) including a N95 (respirator) mask, eye protection, gown, and gloves. The ADON/IP stated that residents who were newly admitted or went to [MEDICAL TREATMENT] resided in a private room, while residents who were readmitted from a medical appointment returned to their room with their roommates. This was determined by the amount of time (same day) the resident was out of the facility. The ADON/IP stated that the facility followed the infection control guidance from both the Centers for Disease Control (CDC) and the New Jersey Department of Health (NJDOH). The ADON/IP also stated that the facility was in contact with the Local Health Department (LHD) daily for their guidance. The surveyor reviewed the facility's floorplan provided by the ADON/IP. A review of the Hamilton Wing revealed that resident room [ROOM NUMBER] and #127 were on TBP from a readmission to the facility from a medical appointment. The floor plan reflected that both rooms could accommodate four residents in total. At 11:22 AM, the surveyor observed that resident room [ROOM NUMBER] had a sign outside the door which indicated TBP from 12/22/2020 to 1/19/2021. The surveyor observed the Registered Nurse (RN) enter this room carrying a supplemental dietary shake. The RN wore only a surgical mask and eye protection. At 11:23 AM, the surveyor interviewed the RN who stated that all the residents on this wing were considered well and non-exposed. The RN stated that to enter all of these residents' rooms, there was no requirement for additional PPE. The RN stated that if a resident was on TBP, then she would have to don the N95 mask, gown, and gloves. At 11:30 AM, the surveyor observed resident room [ROOM NUMBER] had a sign outside the door which indicated TBP from 12/22/2020 to 1/17/2021 . The surveyor observed a PPE bin outside the door which contained washable gowns, gloves, and N95 masks. At 11:35 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated that she was a fulltime CNA with no permanent assignment. The CNA stated that resident room [ROOM NUMBER] was on her assignment for the day. The CNA stated that outside that room today was both a sign indicating TBP and a PPE bin so she had to don in addition to her eye protection a N95 mask, gown, and gloves prior to entering the room. The CNA stated she was unaware if there was a particular resident on TBP in that room so she donned full PPE prior to entering the room for all residents. The CNA stated that out of the three residents who resided in that room, two residents were mobile and used the bathroom. The CNA stated that in room [ROOM NUMBER], Resident #2 was recently out for an appointment. The CNA stated that the resident was only on precautions and not isolation so you do not have to don a N95 mask. The CNA stated that if the resident was on full TBP, then there would be a PPE bin outside the door. The CNA also stated that Resident #2 was mostly independent and used the bathroom. At 11:48 AM, the surveyor interviewed the RN/Unit Manager (RN/UM) who stated that all the residents in rooms #123 and #127 were on TBP since one resident in each room went out of the facility. The RN/UM stated that both Resident #1 and #2 went out separately for appointments and were considered exposed from the community and were on TBP for fourteen days. The RN/UM stated that all staff prior to entering these rooms donned a N95 mask, eye protection, gown, and gloves, which was to be changed in between residents. The RN/UM stated that the facility posted TBP signs outside these doors with the dates that the TBP started and ended. The RN/UM stated there was no PPE bin outside of resident room [ROOM NUMBER] since the facility was low on bins, but the PPE bin next to room [ROOM NUMBER] was accessible to room [ROOM NUMBER]. At 12:34 PM, the surveyor observed the RN deliver Resident #2 their lunch meal tray. The RN wore only a surgical mask and eye protection. The RN then proceeded to bring Resident #2's roommate (Resident #3) their lunch tray. The RN still wore only a surgical mask and eye protection. The RN proceeded to feed Resident #3. At 12:41 PM, the surveyor and the RN/UM observed the RN feeding Resident #3 wearing only a surgical mask and eye protection. The RN/UM stated that despite there being no PPE bin outside the resident's room, the RN should be aware that she needed to don a N95 mask, gown, and gloves to enter the room because of the TBP sign. The RN/UM at this time instructed the RN to leave the room. The RN/UM informed the RN that she needed to don full PPE to enter that room. At 12:44 PM, the RN/UM provided the surveyor with Resident #1 and #2's medical appointment consultation sheets. The consultation sheets revealed that Resident #1 left the faciity on [DATE] for a medical appointment, and Resident #2 left the faciity on [DATE] and 1/4/21 for medical appointments. At 1:30 PM, the surveyor interviewed the DON, ADON/IP, and the ADON/Licensed Practical Nurse (ADON/LPN). The ADON/IP stated that all residents were last tested for COVID-19 on 12/18/2020. The ADON/IP stated that residents were no longer required weekly testing because their outbreak concluded. The ADON/IP stated that if a resident was admitted to the facility, the facility would perform a baseline COVID-19 test for them, then the facility would retest that resident seven days later. The facility only tested residents going to a medical appointment if the incoming facility requested a negative COVID-19 test. At this time the ADON/LPN stated that she performed rapid [MEDICATION NAME] COVID-19 tests (a nasal swab test that detected a body's immune response to COVID-19 which results were known in fifteen minutes) last week on newly admitted residents. At 1:37 PM, the surveyor reviewed the facility's Resident COVID Testing Week of 1/4/21 provided by the ADON/LPN. This documentation reflected that Resident #1 and #2 had not received a COVID-19 test last week as stated by the ADON/LPN. At 2:08 PM, the ADON/IP confirmed that a resident who left the facility for a medical appointment did not receive COVID-19 testing prior to leaving the facility or upon their return. The ADON/IP stated that upon their return, residents were automatically placed on TBP for fourteen days and monitored for signs and symptoms of COVID-19 because of their possible exposure to COVID-19 in the community. The ADON/IP acknowledged that a person could be COVID-19 positive, but be asymptomatic. The ADON/IP confirmed that both Resident #1 and #2's roommates had all remained in the facility, and had no possible community exposure. The ADON/IP stated that only residents who were newly admitted or readmitted to the facility from the hospital or [MEDICAL TREATMENT] went into a private room. The ADON/IP could not speak to why Resident #1 and #2 would not be isolated from their well, non-exposed roommates. The ADON/IP stated that the facility used the guidance from the NJDOH Communicable Disease Services (CDS) for their cohorting policy and procedures. A review of the NJDOH/CDS COVID-19 Activity Level Report provided to the surveyor by the facility, reflected that the facility was in a region of High COVID-19 Activity level for both the weeks ending on 12/26/2020 and 1/2/21 (8.2% and 10.64% respectively). At 2:40 PM, the DON stated that the facility had only received the COVID-19 Activity Level Report for the week ending on 1/2/21 which indicated the county positivity rate increased from 8.2% from the week ending on 12/26/2020 to a 10.64% in the week ending on 1/2/21. The DON stated that because of the increase in that rate, staff would now be tested twice a week. The DON also confirmed that the facility had unoccupied rooms that could have been utilized. A review of the Daily Census dated 12/22/2020 reflected that the facility had 23 unoccupied rooms on that day. A review of the Daily Census dated 12/30/2020 reflected that the facility had 27 unoccupied rooms on that day. A review of the Daily Census dated 1/4/21 reflected that the facility had 29 unoccupied rooms on that day. At 3:48 PM, the DON provided the survey team with an email from the LDH. The DON stated that the information provided to them from the LHD was from the State Epidemiologist regarding cohorting of residents. A review of the email provided by the LHD dated 1/11/21 at 3:39 PM reflected a forwarded email from (name redacted) from the NJDOH. The email included from the NJDOH/CDS cohorting documentation that for residents who routinely left the facility, the exposure risk may vary based on local community transmission. The email also included that if available, these residents may be prioritized for a private room or cohorted with others who frequently leave the facility. The writer stated, if this is someone who left once and it was deemed from the above to have been a risky enough exposure outside the facility to warrant being admitted to the new admit/readmit unit then they would not be placed back with their previous roommate if say they were both in Cohort 3. At 3:49 PM, the surveyor spoke with (name redacted) from the LHD via telephone who stated to refer to the email sent to the facility today regarding cohorting guidance. A review of the NJDOH/CDS Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities revised 10/22/2020 provided by the DON as the facility's cohorting policy, included cohorting using traditional symptom-based screening alone should be avoided if possible but when necessary, done with caution given the risk of asymptomatic or pre-symptomatic infection. The facility should review or develop a cohorting plan before the identification of the first case. When testing capacity is available and facility spacing permits, residents should be organized into the following cohorts which included: Cohort 3 as residents who are COVID-19 negative and non-exposed who have tested COVID-19 negative with no COVID-19 like symptoms and no known exposures. The guidance also included Cohort 4 as new or re-admissions which includes all persons from the community or other healthcare facilities who are newly or readmitted . These residents should remain on TBP for fourteen days being monitored for COVID-19. If after fourteen days, these residents have not met the criteria to discontinue TBP, then the resident should be placed as a Cohort 1 (COVID-19 positive). A review of the facility's undated Outbreak Investigation/Management policy included to cohort residents and staff as available. A review of the facility's undated Outbreak Response Plan accessed from the facility's website on 1/11/21 included that the facility will cohort residents to the extent possible according to most current applicable Government Guidelines and Directives. Review of the facility's undated Infection Prevention and Control Program included to isolate or cohort residents with known or suspected infectious diseases in effort to reduce the risk of disease transmission. A review of the undated CDC Transmission-Based Precautions provided to the surveyor by the ADON/IP as the facility's TBP policy included under droplet precautions to ensure appropriate patient placement in a single room if possible. In long-term care, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. A review of the CDC Responding to Coronavirus (COVID-19) in Nursing Homes updated 4/30/2020 included that exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. The IJ was identified on 1/11/21 at 4:30 PM and the Licensed Nursing Home Administrator (LNHA), Assistant Administrator, DON, ADON/IP, and ADON/LPN were notified of the IJ at 4:30 PM. A Removal Plan was accepted on 1/13/21 which included that Resident #1 and #2 were COVID-19 tested immediately and placed in private rooms on TBP until the end of their fourteen day quarantine, Resident #1 and #2's roommates remained on TBP until the end of the fourteen day quarantine. Licensed staff were inserviced on the policy created on 1/11/21 for the use of the COVID-19 Exposure Risk Assessment Template for Patients in Post-Acute Care settings which included COVID-19 exposure risk for assessing and planning placement considerations for residents upon their return to the facility. The implementation of the removal plan was verified on-site on 1/14/21. On 1/14/21 at 10:30 AM, the surveyors toured the Hamilton Wing and verified through observations, interviews with facility staff, and review of in-service education and facility documents that the Removal Plan had been implemented. A review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated updated 12/14/2020 included that the infection prevention and control recommendation for patients on a fourteen day quarantine for a close contact to COVID-19 or suspected COVID-19 should be isolated in a single-person room and care for by healthcare personnel using all PPE recommended. These patients should not be cohorted with COVID-19. The recommendation also included under patient placement that if admitted , place a patient with suspected or confirmed COVID-19 in a single-person room with the door closed. The patient should also have a dedicated bathroom. PART B Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to maintain transmission-based precautions (TBP) for residents identified as a person under investigation (PUI) for a known COVID-19 exposure by a.) not changing gowns between residents, b.) not donning (wear) a N95 (respirator) mask, c.) not donning a gown and gloves in resident rooms on TBP, and d.) not performing hand hygiene prior to exiting resident rooms in an effort to mitigate the spread of COVID-19. This deficient practice was identified on 2 of 2 nursing units (Mercer and Klockner) reviewed for TBP for a known COVID-19 exposure on 1/14/2021 during a verification of a removal plan survey previously conducted on 1/11/2021. 1. On 1/12/21, the facility became aware that a Licensed Practical Nurse #1 (LPN) tested positive for COVID-19 using a rapid [MEDICATION NAME] test (a nasal swab test that detected the body's immune response to COVID-19 which results are known in fifteen minutes). The facility immediately sent the LPN home and conducted contact tracing for possible exposure. The facility determined that the LPN had worked two shifts on 1/11/21; the first shift was on the Mercer Unit and the second shift was on the Klockner Unit. All residents on both the Mercer Unit and Klockner Unit were identified as exposed to COVID-19 as persons under investigation (PUI) and placed on TBP for fourteen days in an effort to mitigate the spread of [MEDICAL CONDITION]. Staff were to don PPE which included a N95 mask, eye protection, gown, and gloves prior to entering these residents' rooms. During the survey conducted on 1/14/21, staff were observed wearing the same gown between residents. Interview with staff confirmed that they wore the same gown between residents, changing the gown only if visibly soiled or exiting the unit. Certified Nursing Aide #1 (CNA), in addition to not changing her gown between residents, was observed donning only a surgical mask in residents' rooms and not a N95 mask. The Maintenance Assistant was observed entering/exiting resident rooms entering the residents' bathrooms and testing their light switches. The Maintenance Assistant did not don gloves or gown and did not perform hand hygiene prior to entering or exiting resident rooms. Staff were unaware of the appropriate TBP protocol that should have been implemented for exposure to [MEDICAL CONDITION]. The facility's failure to ensure that appropriate TBP were followed for residents with a known exposure to COVID-19 posed a serious and immediate threat to the safety and wellbeing of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/12/21 when the facility identified that LPN #1 was COVID-19 positive. The facility Administration was notified of the IJ on 1/14/21 at 4:20 PM. The immediacy was removed on 1/15/21 at 10:13 AM based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site survey conducted on 1/19/21. The evidence was as follows: 1. On 1/14/21 at 9:18 AM, the surveyors met with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP stated that the facility had two additional staff members (LPN #1 and Staff Coordinator) test positive for COVID-19 on 1/12/21. The two staff members were immediately sent home and contact tracing was conducted. It was determined that LPN #1 worked two shifts on 1/11/21; the first shift on the Mercer Unit and the second shift on the Klockner Unit. The facility determined that all residents on both units were exposed to COVID-19 by LPN #1 so they were considered PUIs and placed on TBP for fourteen days. The ADON/IP stated that no risk assessment was conducted on these residents since the LPN was the only nurse on the Mercer Unit so she came in contact with every resident on that unit. The ADON/IP also stated that no risk assessment was conducted on the Klockner Unit since the unit was a locked dementia unit and residents tended to wander. All residents were placed on TBP. At this time, the DON stated that staff donned full PPE of a N95 mask, gown, gloves, and eye protection on that unit. The DON stated that staff were wearing the same gown room to room for all residents and in the hallways unless visibly soiled or exiting the unit. The DON stated that since the residents all had the same exposure to COVID-19, staff were permitted to do this. The DON confirmed that the facility used washable gowns and had no gown shortage. At 12:10 PM, the surveyor observed at the entrance to Mercer Unit a Stop sign which indicated before entering Mercer Unit Droplet Precautions (TBP). At the entrance was a PPE bin which contained gowns, gloves, and N95 masks. At 12:16 PM, the surveyor observed LPN #2 in the hallway wearing a gown, N95 mask, and eye protection. The LPN informed the surveyor that on this unit, all the residents were on TBP so staff donned a N95 mask, gown, gloves, and eye protection. The LPN stated that staff changed gloves in between residents, but they wore the same gown throughout the unit. The LPN stated that staff do not have to change their gown from resident to resident because no resident on that unit was COVID-19 positive. At 12:18 PM, the surveyor observed CNA #2 exit resident room [ROOM NUMBER] without doffing (removing) or changing her gown. At 12:25 PM, the surveyor observed the Maintenance Assistant enter resident room [ROOM NUMBER] wearing only goggles and a KN95 mask. The Maintenance Assistant proceeded to open the closed bathroom door, enter into the bathroom and immediately exit the bathroom and close the bathroom door. The Maintenance Assistant then proceeded towards the bed in the room and turned on and off the light. The Maintenance Assistant then exited the room with no observed hand hygiene and proceeded directly into resident room [ROOM NUMBER] and performed the same tasks as in resident room [ROOM NUMBER]. The Maintenance Assistant then exited resident room [ROOM NUMBER] with no observed hand hygiene and walk directly into resident room [ROOM NUMBER]. The Maintenance Assistant performed the same tasks as the other two resident rooms and then exited the resident room with no observed hand hygiene. At this time, the surveyor interviewed the Maintenance Assistant who stated that he was going resident room to room ensuring that all the light switches worked. When asked if he had to do anything different when entering these rooms, the Maintenance Assistant looked at the TBP sign outside the door and stated No. The Maintenance Assistant stated that he already wore a mask and eye protection, which was all that he needed. The surveyor questioned if he had to do anything prior to entering or exiting a resident's room. He stated that he should sanitize his hands, but he forgot to, and forgets a lot to sanitize his hands. The Maintenance Assistant then proceeded down the hall continuing to enter each resident room donning only his KN95 mask and goggles with no observed hand hygiene. At 12:30 PM, the surveyor questioned LPN #2 if the Maintenance Assistant needed to don a gown or gloves prior to entering these residents' rooms. The LPN#2 confirmed yes and went to instruct the Maintenance Assistant to don additional PPE while entering every resident room on that wing. At 12:33 PM, the surveyor observed the Maintenance Assistant don a gown only at the entrance to the Mercer Unit. No hand hygiene was observed at this time. The Maintenance Assistant then proceed to the other wing into resident room [ROOM NUMBER] wearing a KN95 mask, gown, and goggles. The Maintenance Assistant opened the bathroom door went into the bathroom and proceeded immediately out of the bathroom and closed the bathroom door. The Maintenance Assistant went towards the bed and turned on and off the light. He proceeded out of the room without doffing his gown or performing hand hygiene and went directly to resident room [ROOM NUMBER]. The resident was sitting in the entrance of room [ROOM NUMBER] so the Maintenance Assistant had to go around the resident brushing his gown against the resident's wheelchair. The Maintenance Assistant then proceeded to the bathroom and performed the same tasks prior to exiting the room brushing by the resident again. The Maintenance Assistant performed no hand hygiene or doffed his gown. The Maintenance Assistant then went directly to resident room [ROOM NUMBER] and performed the same tasks as he had in previous resident rooms with no hand hygiene or doffing of PPE prior to exiting the room. At this time the surveyor re-interviewed the Maintenance Assistant who stated that he could wear the same gown from room to room without having to change it. The Maintenance Assistant stated that he did not have to wear gloves and he acknowledged that he keeps forgetting to perform hand hygiene. The Maintenance Assistant confirmed that the Maintenance Director was currently on a leave of absence, but he was recently in-serviced on the appropriate mask to wear in resident care areas. The Maintenance Assistant then proceeded directly into resident room [ROOM NUMBER] without changing his gown, donning gloves, or performing hand hygiene. At 12:45 PM, the surveyor observed CNA #2 in resident room [ROOM NUMBER]. The CNA wore a gown, gloves, eye protection, and surgical mask. The CNA was observed removing linen from the resident's bed while the resident was in bed. The CNA then placed clean linen on top of the resident. The CNA then proceeded to the doorway where she removed only her gloves and performed hand hygiene. The CNA then proceeded to resident room [ROOM NUMBER] to remove a finished lunch tray. At this time, the surveyor interviewed CNA #2 who stated that these residents were on TBP because they could possibly have COVID-19. The CNA stated that you have to don in these rooms a mask, gown, gloves, and eye protection. When asked what type of mask she should be wearing, the CNA stated that she should be wearing a N95 mask and not the surgical mask. The CNA stated that she did not need to change her gown unless it was visibly soiled or she was leaving the unit because all the residents were on the same TBP. At 12:55 PM, the surveyor observed CNA #3 enter resident room [ROOM NUMBER] with a hoyer lift (an assistive device used to transfer residents from a bed to chair or vise versa) wearing a gown, gloves, N95 mask, and eye protection. CNA #1 followed into the room wearing a gown, gloves, eye protection, and surgical mask. CNA #1 closed the door behind her. At 1:06 PM, CNA #1 exited resident room [ROOM NUMBER] with the hoyer lift wearing the same gown. At this time, the surveyor interviewed the CNA regarding why the residents on this unit were on TBP and what PPE was required to enter these rooms. The CNA stated that these residents on this unit were on TBP because they returned to the facility from either the hospital or a doctor's appointment so they were being monitored for fourteen days for possible COVID-19. The CNA stated that staff were required to wear a N95 mask, gown, gloves, and eye protection upon entering these residents rooms. The CNA acknowledged that she was wearing a surgical mask and not a N95 mask because she preferred the surgical mask; it was easier to breathe with. The CNA stated that she wore the same gown for all the residents unless it was visibly soiled or she was leaving the unit because the residents were all on the same precautions so this practice was acceptable. At 1:52 PM, the surveyor reviewed the Maintenance Assistant's education transcripts which reflected that he received education on 2/17/2020 for Infection Control Essentials, 12/7/2020 for Infection Control: Droplet Precautions, and 12/7/2020 for Personal Protective Equipment. At 4:01 PM, the survey team interviewed the DON and ADON/IP again. The ADON/IP stated that for Droplet Precautions (TBP), staff should be donning a N95 mask (preferably), gown, gloves, and goggles. The ADON/IP stated that staff were all wearing the same gown because all the residents were on TBP so they all had the same risk level. The ADON/IP stated that the facility was in contact today with their Local Health Department (LHD) regarding the usage of the same gowns. The ADON/IP stated that (name redacted) from the LHD informed the facility that the preferred process was to change gowns in each PUI room unless the facility did not have an adequate supply of gowns. At this time, the DON stated that the facility determined that they would need approximately 2,500 gowns a day to do this. The DON confirmed that the facility was utilizing washable gowns and had both an active supply of PPE and a thirty day emergency supply of PPE with more than eight sister facilities. At 4:11 PM, the Licensed Nursing Home Administrator (LNHA) and the Assistant Administrator (Assist Admin) joined the DON and ADON/IP in the conference room. The Assist Admin informed the survey team that he was in charge of ordering PPE. The Assist Admin stated that the facility had both an active supply of PPE as well as a thirty day emergency supply. At this time, the LNHA stated that the emergency supply needs were determined possibly back in May using a burn rate calculator accessed online that determined the amount of each PPE needed per day based on the highest amount used per day during a surge. The LNHA stated that the facility had no difficulty ordering/receiving PPE. The facility also had no restrictions on ordering PPE, and they ordered PPE as often as needed. The LNHA stated that the facility at times received PPE the same day ordered. The LNHA confirmed that the facility also had access to a Corporate supply of PPE. At 4:16 PM, the surveyor asked the facility Administration if the facility had no shortage of PPE and had no difficulty obtaining PPE, to clarify the re-use of staff wearing the same PPE from resident to resident. At this time, the DON stated because all the residents were at the same risk level. At 4:17 PM, the LNHA stated that he was aware that staff were wearing the same gowns for all residents on TBP. The LNHA stated that he was aware that the ADON/IP and DON spoke with (name redacted) from the LHD today, but he was unaware that the LHD advised against this practice unless there was a PPE shortage. The IJ was identified on 1/14/21 and the LNHA, Assist Admin, DON, ADON/IP were notified of the IJ at 4:20 PM. A Removal Plan was accepted on 1/15/21 which included that nursing and ancillary staff were educated on the use and disposal of PPE for residents on TBP including removing gowns after each resident, performing hand hygiene, and the use of a N95 mask. The implementation of the Removal Plan was verified on-site on 1/19/21. On 1/19/21 at 10:18 AM, the surveyors toured the Mercer and Klockner nursing units and verified through observations, interviews with facility staff, and review of in-service education and facility documents that the Removal Plan had been implemented. A review of the Center for Disease Control's (CDC) Strategies for Optimizing the Supply of Isolation Gowns dated updated 10/9/2020, included under Crisis Capacity Strategies that extended use of isolation gown consideration can be made to extend the use of isolation gowns (disposable or washable) such that the gown is worn by the same healthcare personnel when interacting with more than one patient housed in the same room location known to be infected with the same infectious disease (such as COVID-19 residents residing in an isolation cohort). The guidance also included that the risks to healthcare personnel and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be reused, and washable gowns should NOT be reused before laundering because reuse poses risks for possible transmission among healthcare personnel and patients that likely outweigh any benefits. If reuse is considered, gowns should be dedicated to care of individual patients. A review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel D (

# 3 Based on interviews, record review as well as review of pertinent facility documents on 4/18/19, it was determined that the facility failed to provide adequate supervision to prevent an Elopement for 1 of 5 sampled residents ( Resident #2). An Immediate Jeopardy Past Non-Compliance was identified on 4/18/19. On 3/23/19, at 10:30 a.m., Resident #2, who was cognitively impaired and assessed for wandering behaviors and elopement risk, ambulated with a walker out of the front lobby doors. The Receptionist failed to prevent Resident #2 from exiting the facility by not following written protocols. The Receptionist didn't review the Happy Feet binder with a resident list and updated photos and failed to have resident sign out at the Reception Desk upon leaving. However, at the time of the elopement, Resident #2's walker nor the resident didn't have placement of any Wanderguard devices. This device would have sounded, alerted the Receptionist that this was a resident and the lobby doors would have remained closed. The facility staff noticed that Resident #2 was not back in to the room at 11:30 a.m. for a medication due at 12:00 p.m. and a lunch tray that was served around 12:30 p.m. On the same day at approximately 1:00 p.m., a family member called the facility that Resident #2 was not in the building, but was at a coffee shop. The resident was found and returned to the facility at 2:45 p.m. by local police. The resident was examined by staff and found no injuries and was placed on a 1:1 staff to resident supervision. In addition, Resident #2's care plan was updated to include a Wanderguard device on his/her walker. The Immediate Jeopardy Past Non-Compliance started on 3/23/19 and corrected on 3/30/19, when the facility in-serviced all staff on Resident Elopement and Wander Guard. During the complaint visit on 4/18/19, there was sufficient evidence that the facility's non-compliance on 3/23/19 to 3/30/19, when the facility was back in substantial compliance. The deficient practice was evidenced by the following: During a tour of the facility's 2nd floor on 4/10/19 at 10:35 a.m., in the presence of the Unit Manager (UM), the surveyor observed Resident #2 sitting on his/her bed watching TV inside his/her room. The surveyor observed there was a wander guard on the resident's wheel chair and walker. The surveyor reviewed the electronic medical records (EMR) on 4/10/19 that revealed the following: Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/8/19, Section C- revealed that the resident had a Brief Interview for Mental Status score of 3 out of 15 which indicated cognition difficulty. According to the MDS, Resident #2 required the use of picture boards, gestures and grunts in order to communicate with staff. In section G - Functional Status revealed that Resident #2 required assistance from one staff member with activities of daily living. The resident was able to self propel in a wheelchair or utilized a rolling walker to ambulate in the facility. A review of Resident #2's care plan for elopement and wandering revealed, an initiated date on 11/8/17. The care plan was revised on 8/15/18. The care plan indicated under Goal: The resident will remain safe and secure in present environment which would be evidenced by no injury and no incident of elopement. Interventions/Tasks listed on the CP were for staff to do the following: Encourage the resident to remain in supervised areas when out of bed. Encourage the resident to participate in activities of choice throughout the day and the resident picture to be maintained at reception desk for easy identification. A review of the Social Worker (SW) Progress Notes (PN) dated 12/31/2018, revealed that Resident #2 had removed his/her Wanderguard while outside smoking on this day. The SW was going to have a family member speak to the resident about the importance of keeping the Wanderguard in place and stop removing it. A review of the PN dated 3/23/19 at 3:56 p.m. revealed that at approximately 11:30 a.m., Resident #2 was seen ambulating in hallway with a rolling walker and wearing a coat and hat. At approximately 12:00 p.m., the resident was not in his/her room to receive medications and at approximately 12:15 p.m. the resident's lunch tray was delivered to the room and resident was not in the room. Further review of this same note revealed that Resident #2 was outside smoking and would usually come back to the room around meal time to eat. Then at approximately 12:40 p.m., the Supervisor notified the writer that the resident was not in the facility. At approximately 2:50 p.m., Resident #2 returned to the floor using his/her rolling walker smiling and was in no distress. The resident went to his/her room and sat in his/her wheel chair. The resident transferred him/herself to the bed and a full body assessment was done and it was noted that his/her skin was clear and the resident had no signs of pain.Staff 1:1 initiated with resident. During an observation conducted by the surveyor on 4/10/19 at 11:25 a.m., in the presence of the UM, Resident #2 was observed self-propelling in a wheel chair wearing a coat and sunglasses. The resident wheeled him/herself towards the elevator doors. The surveyor observed as the resident entered the elevator and exited on the first floor and propel down the hallway towards the lobby and courtyard entrance. Receptionist #1 showed the surveyor the Happy Feet book which contained Resident #2's picture. The surveyor observed Receptionist #1 demonstrate the functioning of the lobby entrance door by buzzing the UM and Resident #2 out to the lobby. The UM then demonstrated the functioning of the wander guard system on the wheel chair by accompanying Resident #2 toward the lobby exit door, causing the alarm to sound and door remain locked. The surveyor then observed the resident re-enter the facility entrance door with access by Receptionist #1 and proceed to the courtyard to smoke a cigarette. During an interview conducted by the surveyor on 4/10/19 at 11:35 a.m., Certified Nursing Assistant (CNA #3) stated the doors do not open by themselves and employees have to swipe their badges in order for the doors to open and others must be buzzed in and out by the receptionist. The CNA also stated that residents were only allowed in the lobby when they are escorted by their representative or staff. On 4/10/19 at 12:15 p.m. the surveyor conducted an interview with the UM. The UM stated that residents were allowed to go downstairs alone but they can not leave the building alone. The UM stated that residents must be accompanied by an escort and the escort must sign the resident out of the building. The UM stated Resident #2 used to remove the Wanderguard. During an interview conducted by the surveyor on 4/10/19 at 1:35 p.m., the Director of Nursing (DON) stated Receptionist #2, could identify Resident #2 from seeing him/her come past the doors using a wheelchair. However, on the morning of 3/23/19, the resident was wearing a coat and using a walker. Receptionist #2 buzzed the resident into the lobby and he/she left the building. The DON also,stated that Receptionist #2 did not instruct Resident #2 to sign out of the facility on 3/23/19. The day of the elopement, was Receptionist #2's first day working alone at the receptionist desk after being trained for four days. The DON stated that there was a binder called Happy Feet at the receptionist desk with resident's pictures and an updated list who were at risk for elopement. The DON stated Receptionist #2 knew the process of visitors having to sign in and out of facility and she was aware of the facility's policy of residents only being allowed into lobby with their representative or an escort. A follow-up interview on 4/10/19 at 3:55 p.m., the DON stated when Receptionist #2 let Resident #2 out of the building, there was a potential for the resident to sustain an injury or become lost. During a telephone interview conducted by the surveyor on 4/11/19 at 1:11 p.m., Licensed Practical Nurse (LPN #1) stated on 3/23/19 she was the nurse assigned to Resident #2. LPN #1 stated that she saw the resident in the hallway using a walker between 11:30 a.m. and 12:00 p.m. The LPN #1 stated she went to Resident #2's room to see if the resident had come back from smoking and the resident was not in the room. LPN #1 stated between 12:30 and 1:00 p.m., she observed the lunch trays being distributed and went to Resident #2's room to give him/her a routine noon time medication and noticed the resident was not in the room. LPN #1 stated she went to the nurse's desk to speak to the Supervisor and was told by the Supervisor the resident was not in the building but at a coffee shop. On 4/18/19, at 10:15 a.m., the surveyor observed Resident #2 on the second floor. The resident came over to the surveyor in a wheelchair with a Wanderguard device in place. At this time, the resident showed the surveyor that a Wanderguard device was also located on the left ankle. The surveyor reviewed the facility's policy for Elopement Risk/Wanderguard Devices dated 1/10/19. According to the Policy: it is the policy of the facility to ensure that each resident receives adequate supervision and protects residents at all times by identifying and preventing the possibility of elopement. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision during care in a manner that maximized resident safety and minimized the risk of accidents and injury. Resident #14, who was identified as being at high risk for falls, experienced a fall from the bed requiring 10 sutures to the left forehead and requiring pain medication. The facility also failed to consistently utilize a new intervention intended as a fall prevention measure for Resident #8. This deficient practice was identified for Resident #14 and Resident #8, 2 of 15 residents reviewed for falls, fractures/abrasions/bruises as evidenced by the following: 1. During the initial tour on 4/27/15 at 10:25 a.m., the surveyor observed Resident #14 in a lounge chair in a reclining position. The Unit Manager (UM), who accompanied the surveyor during the tour, stated that Resident #14 had advanced dementia and was blind. On 4/28/15 at 8:17 a.m., the surveyor observed the resident asleep in a low bed with a fall mat adjacent to the low bed. According to documentation in the medical record, Resident #14 had [DIAGNOSES REDACTED]. The resident's 1/12/15 Minimum Data (MDS), an assessment tool, indicated the resident was dependent on staff for activities of daily living including dressing, transfers and bed mobility. The resident was non-ambulatory, unable to make his/her needs known and non-verbal. Fall risk assessments dated 10/26/14 and 1/17/15, indicated that the resident was assessed to be at high risk for falls. The resident's ongoing plan of care, initiated 2/23/11, identified the resident at risk for falls related to changes in cognition due to dementia. The resident's plan of care indicated he/she was dependent on staff for activities of daily living and that staff would anticipate the resident's needs. The resident's plan of care also identified that the resident had impaired communication and had a sensory loss related to blindness. The 4/15 physician's order sheet (POS) indicated the resident had an ongoing order, initiated 10/09/06, for a low bed. A 1/17/15 untimed Interdisciplinary Progress Note (IPN) indicated at 8:40 a.m., that the nurse was called to Resident #14's room. The nurse documented that the resident was found lying on his/her left side and presented with frank blood coming from the head. The nurse applied pressure, "911" was called, and the resident was sent to the hospital to be evaluated. A 1/17/15 untimed IPN indicated the resident returned to the facility at 4:30 p.m., with a dressing to the left upper forehead and sutures. Further medical record review revealed that Resident #14 had sustained a laceration to the left forehead which required 10 sutures. In addition, the nurse documented that the resident was medicated with Tylenol 650 mg at 6 p.m. and at 10 p.m. for comfort. The facility's Incident/Accident Report revealed that on 1/17/15 at 8:40 a.m., the resident fell out of the bed and was found lying on his/her left side with frank red blood was coming from the left side of the resident's head. The resident was sent out to the hospital "911." Facility documentation also indicated a possible cause of the fall for this cognitively impaired resident was loss of his/her balance from the bed. An addendum to the possible causes indicated the resident rolled from the bed when his/her care giver turned to retrieve a hair brush from the night stand. According to the CNA's statement dated 1/17/15 at 8:45 a.m., she was washing and dressing the resident that morning. The CNA indicated that she turned away from the resident to grab a hair brush that fell on the floor. The CNA documented she heard a "lil thump" and when she turned back towards the resident, she was shocked to see the resident on the floor. The CNA immediately called for help. There was no information in the investigation to indicate how the resident was positioned in bed just prior to the fall. The 1/19/15 Interdisciplinary Team Care Conference Summary indicated the resident had severe contracture of the lower extremity, was blind, had advance dementia, and was non-verbal. The CNA reported that after providing a.m. care, she turned to retrieve a brush from the night stand when it fell to the floor. The CNA bent to pick up the hair brush from the floor and heard a noise. The CNA immediately turned around and noticed the resident on the floor. The CNA immediately called for help. The CNA was reeducated on positioning techniques. During an interview on 5/4/15 at 11 a.m., the Director of Nursing (DON) stated the 1/17/15 fall was unwitnessed. In addition, the DON told the surveyor that the height of the bed was waist high and the side rails were not up when the CNA had turned away from the resident to pick up the hair brush. The CNA received in-service education on 1/20/15 for proper bed position and safe care while giving care to residents in bed. Inservice education included the following: Keep resident in the center of the bed; roll the resident toward you for hygienic care; ask for assistance when needed; never leave the resident or turn back on a resident to get something; and, to keep the resident close when rolled onto one side in order to keep the resident safe. 2. During the initial tour on 4/27/15 at 11:50 a.m., the UM, who provided the tour information, stated that Resident #8 had been lowered to the bathroom floor by a CNA on 4/16/15. The UM stated the resident's knees had given out during the transfer. On 4/28/15 at 8:25 a.m., the surveyor observed the resident sitting up in bed during the breakfast meal which was served on the overbed table. According to documentation in the medical record, Resident #8 had [DIAGNOSES REDACTED]. A 4/16/15 at 9 p.m., IPN indicated that the resident was unable to sit in the wheelchair during a transfer so the resident was lowered to the floor in the bathroom. The facility Incident/Accident Report dated 4/16/15 indicated the resident was observed sitting up in front of the wheelchair and was unable to state what had happened secondary to cognitive impairment. The resident, at that time, required a one person assistance for transferring. No injury occurred. According to the CNA's statement, the resident was about to slide during the transfer and she helped the resident by lowering the resident to the floor. The 4/17/15 Interdisciplinary Team Care Conference Summary indicated that staff were to use two persons assist for transfers until seen by therapy. The resident's plan of care for fall risk was updated on 4/16/15 with a new intervention. The 4/16/15 intervention indicated the resident was to have a two person assist for transfers until seen by therapy. When reviewed by the surveyor on 4/29/15, the CNA Care Plan (CNA CP) for Resident had not been updated to indicate a two person assist for transfers. Documentation on the CNA CP indicated the resident would transfer by standing and pivoting with a one person assist. On 4/30/15 at 10:35 a.m., the surveyor reviewed the resident's medical record with the UM. The PT had screened the resident on 4/17/15 and his recommendation was that the resident would benefit from short term physical therapy to restorative ambulation with a rolling walker. No physician order for [REDACTED]. The UM called the PT on the telephone and spoke with him about physical therapy for this resident. According to the UM, the PT stated he had not yet evaluated the resident for PT. During an interview on 4/30/15 at 11:37 a.m., the CNA stated that she had provided morning care to the resident. The CNA stated that she had transferred the resident from the bed to the wheelchair by herself. No documented evidence of a PT evaluation and treatment was found in the resident's medical record. On 4/30/15 at 3:15 p.m., the DON stated she did not know if a physician's order for PT evaluation and treatment was required. On 5/4/15 at 11:25 a.m., the Director of Nursing stated that PT had evaluated the resident on 5/2/15 and, the resident had been cleared on that day for a one person assist with transfers. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to: provide supervision and assistive devices to prevent accidents, revise fall interventions; and implement identified assistance for safe transfers. Resident #25 fell and sustained a hematoma and laceration which required 4 staples to the left forehead area. This deficient practice was identified for 2 of 9 residents reviewed for falls and accidents, Residents #14 and #25, as evidenced by the following: 1. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor toured with the Unit Manager (UM) on 2/21/14 at 10:00 a.m., who identified Resident #25 as requiring "total care" and the assistance of 2 persons for transferring. The UM stated that the resident had sustained a fall about three weeks prior which resulted in a hematoma on his/her head and which required the resident to be transferred to the emergency room for evaluation. On 2/25/14 at 10:30 a.m., the surveyor reviewed the medical record of Resident #25 which revealed the resident had three falls with injuries between April 2013 and January 2014. The resident also had one fall without injury during that time. Review of the nurses notes dated 4/21/13 at 11:00 p.m., indicated that at 8:15 p.m., Resident #25 climbed out of his/her chair and fell on the floor on his/her left side. A review of the Occurrence Incident Report for the fall revealed that the resident sustained [REDACTED]. The report further indicated that the resident's chair alarm was sounding at the time of the fall. The resident was found to be wet with urine when assessed by the nurse after the fall. The surveyor reviewed the care plan for Resident #25 at the above mentioned time, which revealed that the resident was identified as a high risk for falls and injury related to his/her dementia, gait problems, and history of falls at home. Interventions included, but were not limited to, having bed and chair alarms in place, toileting him/her, and when "fidgety," talk to him/her on 1:1 basis. On 4/22/13, interventions were added to the care plan to call the resident's family for extreme agitation to help calm the resident. Review of nurses' notes dated 8/30/13 at 11:15 a.m., revealed that Resident #25 was found lying on the floor on his/her left side in the TV room. At that time, bright red blood was observed on the floor, resident's hands, and on the left side of the resident's head. According to the notes, the chair alarm was functioning. A 2 cm. linear laceration was noted on the left side of the resident's head, and no injury was found to the resident's hands. The resident was sent to the emergency room and received 4 staples to the head laceration site and returned to the facility. The surveyor reviewed the Incident/Accident Report for the fall of 8/30/13 which indicated that the resident had been in activities and became restless, at which time an activities aide returned the resident to the nursing unit. A statement form completed by the activities aide revealed that when the resident was returned to the nursing unit he/she was placed in front of the nurses station. The activities aide indicated in her statement that she did not verbally inform the nurse that the resident had returned to the unit, however she saw the nurse look in the direction of where the resident was placed and believed the nurse had seen the resident. The surveyor interviewed the UM who stated that she assigns a CNA (Certified Nurse Aide) every 30 minutes to sit at the nurses station to monitor residents, and that a CNA should have been stationed there during that time period. The Incident/Accident Report concluded that the resident had wheeled his/herself into the TV room and had attempted to stand up, and fell . A review of Interdisciplinary Team Notes Care Conference Summary signed by the Director of Nursing indicated that the activities staff should verbalize to a nurse that a resident has returned to the nursing unit and that Resident #25's care plan would be updated on his/her return to the facility. The surveyor reviewed the resident's care plan for falls which did not reflect changes to the care plan subsequent to the fall. On 8/31/13 at 10:00 a.m., review of nurses notes revealed that the resident was found sitting on the floor mat leaning against the bed. According to the note, the bed alarm was activated. The surveyor reviewed the Incident/Accident Report which indicated that the resident had returned from the hospital the previous day with a [DIAGNOSES REDACTED]. A review of the resident's care plan indicated there were no new interventions to the resident's care plan after this occurrence. Review of a nurse's note dated 1/31/14 at 10:20 a.m., indicated that Resident #25 was found on the floor on his/her right side, lying on top of the floor mat. According to the report, the alarm was not sounding because it had fallen off the bed with the resident. The resident was found to have a "large lump the size of a golf ball" on top of his/her right eye on the forehead, and a laceration on his/her left lower leg which was actively bleeding. The resident was transferred to the emergency room for evaluation and treatment which included sutures to repair the leg laceration. The resident returned to the facility the same day with a [DIAGNOSES REDACTED]. The surveyor reviewed the Incident/Accident Report which revealed that an employee left Resident #25 in bed, in order obtain supplies for his/her care, without the bed being placed in its lowest position. Upon returning to the room the resident was found on the floor. The surveyor reviewed the physician's orders [REDACTED]. The order was continued on the Physicians Orders for February 2014. The care plan for falls revealed an intervention dated 7/6/12 to keep the bed in low position. The surveyor interviewed the UM who stated she was aware the resident was left unattended without the bed in its lowest position. The UM stated that there were 1/4 siderails in place and stated that the siderails would not have kept the resident from falling out of the bed, because they were not high enough. The UM also stated that at the time of the incident, the curtain around the resident's bed was partially pulled and the resident could not be observed from the hallway. A review of the care plan revealed that on 1/13/14 new interventions were added to the care plan to address falls for Resident #25, which included keeping the curtain around the bed open when not needed, keeping the resident out of bed within a line of vision when restless, and toileting the resident after breakfast. 2. The surveyor reviewed the medical record of Resident #14 on 2/25/14 at 9:30 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), which are assessment tools, revealed that on 8/31/13 and 1/13/14, the resident was assessed to require the assistance of two people for transfer. Review of nurses' notes on the above mentioned date and time revealed that on 2/10/14 at 11:00 a.m., the resident was eased to the floor during a transfer from the bed to the wheelchair. Review of the MDS ADL Tracking Tool By Shift, revealed that on 2/10/14, the resident was identified to require two person physical assist with transfers. Review of the Incident /Accident report provided by the facility, for the date of 2/10/14, revealed that the Resident was being transferred from the bed to the chair by one CNA, when the Resident lifted both her legs off the ground and the CNA lowered him/her to the floor. Review of the Care Conference Summary that was attached to the Incident Report, revealed the the "CNA will be educated resident is 2 person assist." NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to develop care plans based on individual assessment, with progressive interventions to protect residents from falls with injuries and to provide pressure relief for residents with pressure ulcers. Resident #25, identified as a high risk for falls, fell and sustained a hematoma with laceration requiring hospital treatment with 4 staples to the left forehead area. This deficient practice was identified for 4 of 31 residents reviewed for care plans, Resident #2, #12, #13, and #25, as evidenced by the following: 1. During the initial tour of the facility on 2/21/14 at 10:00 a.m. with the Unit Manager (UM), the surveyor observed Resident #25 out of bed in a lock and go wheelchair in front of the nurse's desk. A small discolored area was noted under the resident's right eye. An alarm was attached to the back of the resident's wheelchair which the UM identified as a motion alarm. The UM stated that the resident had a fall about 3 weeks prior, which resulted in a hematoma to the resident's head. The surveyor reviewed the medical records for Resident #25 on 2/25/12 at 11:00 a.m., which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record at that time revealed that the resident had sustained falls on 4 occasions between April 2013 and January 2014. A care plan was in place for the resident identifying him/her as a high risk for fall and injury. Interventions for fall risk included, but were not limited to, bed and chair alarms, keeping the bed in low position, and toileting the resident. There was no evidence of revisions to the care plan after the falls, to prevent further occurrence until January 2014, as evidenced by the following: On 4/21/13 at 8:15p.m., Resident #25 was found on the floor with a left scalp hematoma and a skin tear to the left lower leg. No revisions to fall interventions were made to the care plan after the fall. On 8/30/13 at 11:15 a.m., Resident #25 was found on the floor with a laceration to the left side of his/her head which required 4 staples to repair when sent to the emergency room . A review of the Accident /Incident Report on 2/25/14 at 11:30 a.m., concluded that the fall was a result of the activity aide returning the resident to the unit and not verbally informing the nursing staff that he/she had returned. The Accident /Incident Report included an In-service Attendance Record titled "Safe escort to and from Activities" indicating staff was inserviced to verbally notify nursing staff when taking and returning fall risk residents to and from activities. The surveyor reviewed the Care Conference Summary signed by the Director of Nursing which indicated "care plan will be updated on return to the facility." The surveyor then reviewed the resident's care plan for fall risk which was not updated following this occurrence. On 8/31/13 at 10:20 a.m., Resident #25 was found on the floor in his/her room on top of a floor mat. The surveyor interviewed the UM on 2/25/14 at 11:30 p.m., who stated that the resident had returned from the hospital after the previous fall with a [DIAGNOSES REDACTED]. There were no revisions to the care plan interventions to reflect this in order to prevent further falls. On 1/31/14 at 10:20 a.m., Resident #25 was found on the floor next to the bed on his/her right side and was found to have sustained a lump on the right forehead over the eye and a laceration to his/her left lower leg. The resident was sent to the emergency room for evaluation and treatment. The resident returned the same day with a [DIAGNOSES REDACTED]. The Accident/Incident Report indicated that the resident fell as a result of being left unattended with the bed not in its lowest position, and that the curtain around the resident's bed was partially pulled around the resident, blocking him/her from being observed from the hallway. The surveyor reviewed the care plan for fall risk on 2/25/14 at 11:30 a.m., which revealed that revisions had been made following this occurrence which included keeping the curtain around the resident's bed open when not needed, and getting the resident out of bed and placed within a line of vision. 2. On 2/20/14 at 11:30 a.m., during the initial tour of the facility and at 1:45 p.m., the surveyor observed Resident #12 in bed. The surveyor also observed the resident in bed on 2/21/14 at 10:11 a.m. and on 2/24/14 at 9:50 a.m. and 12:20 p.m. On 2/24/14 at 12:00 p.m., the surveyor reviewed the medical record of Resident #12. The physician's orders [REDACTED].#12 on five occasions during the first three survey dates, there was no bed alarm observed attached to the resident's bed and no mat on the floor next to the resident's bed. On 2/25/14 at 9:00 a.m., the surveyor reviewed the nurse's notes which revealed that the resident was found on the floor on 8/7/13 at 7:30 a.m. after the bed alarm sounded. The surveyor reviewed the Incident/Accident Report for this fall on 2/26/14 at 1:30 p.m. The report included a statement that the resident was found sitting on the right side of the bed on a floor mat, at the time. The report also indicated that Resident #12 had a prior fall from bed on 6/4/13. On 2/25/14 at 9:15 a.m., the surveyor reviewed the care plan for Resident #12 which did not include a plan to prevent falls or injuries. The interventions of a floor mat and bed alarm were not included in the resident's current care plan. 3. During the initial tour on 2/20/14 at 11 a.m. the Assistant Director of Nurses (ADON) told the surveyor that Resident #2 had recently been hospitalized with a [MEDICAL CONDITION] of the right leg. The nurse further stated that the resident was readmitted to the facility with a wound on the right leg. The nurse did not refer to any other wounds on the resident's body. The surveyor observed the resident seated in a geri chair. There was no pressure relief in the chair. On 2/21/14 at 9 a.m., the surveyor reviewed Resident #2's medical record. The resident was readmitted to the facility on [DATE]. According to the Nursing Admission Assessment the resident was readmitted with multiple Stage II pressure sores on the buttock and sacrum. The corresponding "Wound Assessment Flow Sheet", dated 2/17/14, included three Stage II pressure sores on the right buttock, measuring 1 cm. by 0.2 cm., 1 cm. by 0.5 cm. and 0.2 cm. by 0.2 cm. The sacrum had a Stage II pressure sore measuring 1 cm. by 0.2 cm. A physician order [REDACTED]. Further review of the medical record failed to reveal a Care Plan for the actual wounds on Resident #2's buttock and sacrum. The resident had a Care Plan for the potential for skin breakdown which included to "Encourage/assist to shift weight when in bed or chair, offloading pressure." The Care Plan did not include pressure relief to the wheel chair. The surveyor observed Resident #2 on 2/21/14 at 11:55 a.m., in a wheel chair at the bedside. There was no pressure relief in the wheel chair. The surveyor again observed the resident seated in the wheel chair on 2/25/14 from 11 a.m. thru 1:25 p.m. The resident was seated on a folded sheet. There was no pressure relief cushion on the chair. On 2/25/14 at 1:25 p.m., the surveyor interviewed the unit nurse who stated that the resident should have a pressure relief cushion when seated in the wheel chair. 4. During the initial tour on 2/20/14 at 10:15 a.m., the ADON told the surveyor that Resident #13 had a history of [REDACTED]. The ADON stated that the wound vac had been discontinued and the wound was "50 % healed." The surveyor observed the resident seated in a wheel chair at the bedside. Although the resident was seated on a pressure relief cushion, there was no pressure relief to the back of the chair. On 2/25/14 at 11 a.m., the surveyor reviewed Resident #13's medical record. According to the wound management note, written on 2/19/14, the resident had a wound on the mid back measuring 6.0 cm. by 4.0 cm. by 0.1 cm. with "100% pink, red granular tissue." In addition to the treatment applied to the wound, the note recommended to "off-load pressure on wound." At that time the surveyor reviewed the Care Plan for Resident #13. Although the resident had a Care Plan for "Actual skin breakdown" the Care Plan did not include the use of pressure relief to the wound when out of bed. The Care Plan included off loading pressure to the lower extremities but did not address off loading pressure to the area of the wound on the mid back. On 2/25/14 at 11:30 a.m., the surveyor observed the resident in the presence of the unit nurse. The resident was seated in a wheel chair without pressure relief to the mid back. At that time the unit nurse told the surveyor that the resident should have pressure relief to the area of the wound and further stated "I will call therapy to get a back cushion." Refer to F 314 Refer to F 323 NJAC 8:39-11.2(e)