Every finding on record at Hammonton Center for Rehabilitation and Healthcare

Based on interviews and review of other pertinent facility documentation, it was determined that the facility failed to ensure the implementation of the antibiotic stewardship program, including ongoing monitoring and surveillance for 12 of 12 months and utilization of the infection assessment tool for 3 of 5 residents (Resident #106, #144, #175) reviewed for antibiotics This deficient practice was evidenced by the following:On 1/7/2026 at 1:15 PM, the surveyor interviewed the Infection Preventionist (IP), during the interview, a request was made for evidence of the antibiotic tracking log for January 2025 through January 2026.At that time, the IP provided the surveyor with the Infection Control Binder, which did not include any evidence that the antibiotics were being tracked for all twelve months of 2025 to present. She then confirmed that she did not have the tracking logs for 2025. The IP stated that she assumed the role of IP in October of 2025, and she was not doing the tracking, and had no knowledge of any tracking being completed prior to October 2025. The IP confirmed that the tracking log should have been updated when an antibiotic was initiated and kept in the binder. The IP explained that the infections should be tracked by completing a log that should include if the antibiotic was started in-house, the date of onset, any testing and sensitivity that was done, and date the antibiotic was completed. She further stated that tracking was also important to ensure that the resident was placed on the right precautionary measures, if applicable.The surveyor reviewed the infection control binder, which included the Order Listing Reports (OLR -a list of residents and the antibiotic that was prescribed) for June, July, September, October, November, and December 2025. A random review of the OLR for the month of December 2025 revealed that seven residents received antibiotics. At that time, the surveyor requested that the IP identify the residents who started antibiotics at the facility and provide evidence that the infection assessment tool (used for monitoring and feedback) was completed. The IP stated that Resident #106 was started on antibiotics in-house. The resident was ordered Bactrim 800-160 milligrams (MG) on 12/8/205 at 6:11 PM for five days for a urinary tract infection (UTI). She pulled up their medical record, and there was no documented evidence that the infection assessment tool was completed.The IP also noted that Resident #144 was started on antibiotics in-house. The resident was started on Macrobid 100 MG on 12/1/2025 at 11:46 AM for a UTI for fourteen days. She pulled up their medical record, and there was no documented evidence that the infection assessment tool was completed.The IP stated that Resident #175 was started on antibiotics at the facility. The resident was started on vancomycin 1.5 gram, on 12/5/2025 at 6:04 PM, to be infused for a total of two hours. She pulled up the medical record. There was no documented evidence that the infection assessment tool was completedOn 1/8/2026 at 2:03 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the IP should be tracking all infections and doing surveillance for the antibiotic usage. She further stated that there should be a spreadsheet completed with all pertinent information.01/12/2026 8:06 AM, the surveyor interviewed the Regional Clinical Director (RCD) who stated that the IP should have been able provide evidence of the surveillance and the Antibiotic Stewardship Program should have been implemented. A review of the facility's Antibiotic Stewardship policy, revised 6/25/2025 included: This facility will adhere to the principles of Antibiotic Stewardship as defined and described in the Centers for Disease Control and Prevention.Develops and implements protocols to optimize the treatment of infections by ensuring residents who require an antibiotic are prescribed the appropriate antibiotic.Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics. The Facility Administrator and the Director of Nursing are committed to the implementation of an effective Antibiotic Stewardship Program meeting the needs of the facility.NJAC 8:39-19.4(c) (d)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/5/2026 at 9:30 AM the surveyor, accompanied by the Assistant Director (AD) and the Assistant Licensed Nursing Home Administrator (ALNHA), observed the following in the kitchen:Upon entry to the kitchen the surveyor observed that the baseboard tile molding was missing from the diet office doorway and extending into the kitchen area towards the service line. Observation of the juice box temperature log revealed that temperatures had been recorded daily, up to and including the AM temperature on 1/5/2026. Observation of the interior of the juice box revealed that there was not an internal thermometer to measure temperature. When interviewed, the AD told the surveyor that he was not aware that they needed an internal thermometer and that they used the digital thermometer on the exterior of the juice box.Prior to entry of the walk-in refrigerator, the surveyor reviewed the January 2026 temperature log. The log revealed that the temperatures had been recorded daily in the AM and PM up to and including the AM temperature on 1/5/2026. Observation of the interior of the walk-in refrigerator revealed that there was no interior/internal thermometer to measure the refrigerator temperature. The AD told the surveyor when interviewed that the thermometer had broken, and they he did not have a replacement. The ALNHA provided a new internal thermometer on site.On a rear middle rack of a multi-tiered wire rack in the walk-in refrigerator, a sheet pan contained four white plastic, round bags. The sheet pan was filled to the top edge with what appeared to be a reddish liquid from defrosting meat. The pan and bags were undated. On the shelf/rack directly above, a previously opened deli turkey was wrapped in plastic wrap. The plastic wrap was dated 12-19-26 in black marker. The surveyor questioned the AD how long the deli meat was good for after opening. The AD responded, I am not sure about things like that. It was pulled on the third. It is ground turkey. It is on the menu for tomorrow for turkey meat loaf. The surveyor observed an additional environmental concern under the rear shelf/rack that the defrosting ground turkey meat was observed. The floor beneath the storage rack was covered in a reddish/brown unidentified liquid. When interviewed on how often the walk-in refrigerator was cleaned the AD told the surveyor that they deep cleaned the refrigerator on the weekend and it was to be cleaned daily. The AD agreed that the refrigerator was in need of deep cleaning. In addition to the reddish brown on the rear floor of the walk-in, the surveyor observed individual portion control creamers, plastic wrappers, cardboard and other unidentifiable debris throughout the walk-in refrigerator. The AD was observed to instruct a dietary staff to clean the walk-in refrigerator in the surveyor's presence.The supplement refrigerator had an up-to-date January 2026 temperature log, and the last temperature was recorded on 1/5/2026 in the AM. The surveyor opened the refrigerator and observed frost on the inside. The refrigerator contained portion control butter, Mighty Shakes and creamers. There was no internal thermometer. The AD and ALNHA put a new internal thermometer in the fridge in the presence of the surveyor and agreed that there was no internal thermometer prior to surveyor observation. On 1/7/2026 at 11:17 AM the surveyor, accompanied by the Licensed Practical Nurse (LPN #3), observed the following in the First Floor Pantry, which was used to store foods brought from home for residents in the facility. 1. In the freezer, a frozen 8 oz 2% reduced fat milk on the freezer door shelf had a sell by date of [DATE]. Two (2) clear plastic containers contained unknown frozen contents. The containers had no name, dates or room numbers, as required by facility policy. 2. In the refrigerator on an upper door shelf, a container of Activia yogurt had a manufacturer's date of [DATE]. On the same door and a shelf below a container of Tropicana Pure Premium orange juice had a manufacturer's date of [DATE] for Use By. On a lower shelf in the interior of the refrigerator a clear 4 oz portion control container with a plastic lid contained an unknown orange substance. The container had no name, date or room number. In addition, a plastic storage container with a red plastic lid contained unknown food contents. The container had a name, but no dates and a plastic container covered in aluminum wrap had unknown contents. The container had no name, date or room number. When interviewed, LPN #3 told the surveyor that the facility infection preventionist rounded and checked the refrigerator and freezer for expired foods. In addition, she stated that all staff were responsible for removing undated and expired foods from the refrigerator and freezer. On 1/7/2026 at 11:48 AM the surveyor, accompanied by LPN #4, observed the following on the Second Floor Pantry: 1. On an upper shelf of the refrigerator, a white plastic bag contained two (2) plastic containers with green plastic lids with unknown food contents. The 2 plastic containers had no dates, names, or room numbers. The plastic bag had no date, name or room number. 2. In the freezer a clear, plastic container contained an orange unknown food substance that was frozen. The container had no name, date or room number. When interviewed concerning the unmarked foods the LPN stated, No name, no dates. It goes in the trash. On 1/9/2026 at 10:38 AM the surveyor, accompanied by the AD, observed the following in the kitchen: 1. Upon entry to the kitchen the surveyor observed that the dish machine was in use and actively washing dishware from the breakfast meal at 10:41 AM. The AD told the surveyor that the dish machine was a low temperature machine. Review of the Low Dish Machine Temperature Log, dated January 2026, revealed that on 1/9/2026 in the AM no temperatures had been recorded for the wash cycle and final rinse. In addition, the log also revealed that the sanitizer level in ppm (parts per million) had not been recorded in the AM. The surveyor observed three dietary staff operating the low temperature dish machine. The surveyor asked the dietary aide (DA) if he had tested the sanitizer level prior to initiating dish washing. The DA told the surveyor, No. He further stated that he did not test the sanitizer level prior to washing any dishes and that they had started to wash dishes approximately an hour ago. The surveyor asked the AD if staff should monitor and record dish machine temperatures and sanitizer level prior to initiating the dish washing process. The AD agreed that the temperatures and sanitizer level should be monitored prior to dish washing to ensure that the minimum temperatures and sanitizer level were met. 2. A white plastic bulk storage container with a clear plastic lid contained an opened bag of all-purpose flour used to prepare resident meals. Inside the opened bag the surveyor observed a metal ladle used to scoop flour from the bag. The AD removed the metal ladle from the bag of flour and agreed that it could cause cross contamination. The surveyor reviewed the facility policy titled FOOD STORAGE, last date revised: 5/10/2024. The following was revealed under the POLICY: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination. In addition, the following was revealed under PROCEDURE:6. Scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops are not to be stored in food or ice containers but are kept covered in a protected area near the containers. Scoops are to be washed and sanitized on a regular basis.7. (d) Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food (formerly known as PHF) should be consumed, sold, or discarded will be visible on all high-risk food.13. Refrigerated Food Storage: (a) All refrigerator units will be kept clean and in good working condition at all times.(c) Every refrigerator must be equipped with an internal thermometer.(e) Cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers.(h) Safe thawing: Frozen meat, poultry, and fish should be defrosted in a refrigerator within 3-5 days and should be used after thawing. The surveyor reviewed the facility policy titled DISH WASHING AND STORAGE POLICY, last revised date: 11/08/2024.The following was observed under POLICY:Dishwashing guidelines will be carried out in compliance with the state and local health codes. Dishes, pots, pans utensils and flatware will be washed, sanitized and air-dried following procedures to assure proper function, temperature, and/or chemicals appropriate for cleaning and sanitizing are applied. The following was revealed under PROCEDURE:Personnel1. Prior to use, verify temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning products for the shift. Dish Machine Washing:5. Dish machine temperatures are logged at each meal on the Dish Machine Temperature Log.6. Staff will monitor dish machine temperatures throughout the dishwashing process. 10. Employees are trained in proper dishwashing and drying procedures. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur. The surveyor reviewed the facility policy titled FOOD - FROM OUTSIDE, current revision date: 7/12/2023. The following was revealed under POLICY: Residents have the right to have foods brought in by family and friends. Due to the potential for foodborne illness or interference with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices and the importance of diet order compliance. Food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety.The following was observed under PROCEDURE:12. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. (Label will identify resident name, room number, item, date received and discard date).13. All refrigerated food will be discarded within 48 hours. 14. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal.15. The nursing staff will discard perishable foods on or before the discard date. Review of the Daily Cleaning Schedule revealed that the AM Dietary Aide #2 was responsible for cleaning of the walk-in refrigerator weekly. NJAC 8:39-17.2(g)

Based on interview, 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.) reference checks on employees before their start date for 38 of 77 employee files reviewed; b.) a check of the appropriate licensing boards and registries for 8 of 77 employee files; and c.) a criminal background checks for 6 of 77 employee files.The deficient practice was evidenced by the following: From 1/7/26 through 1/12/26, the survey team reviewed the facilities' new employee files and identified the following: a.) Employee #1 was hired as a Certified Nursing Assistant (CNA) on 2/10/25; there was no evidence of a reference check prior to the start of employment.Employee # 4 was hired as a Certified Nursing Assistant (CNA) on 8/26/24; there was no evidence of a reference check prior to the start of employment.Employee #5 was hired as an Activities Aide on 9/11/25; there was no evidence of a reference check prior to the start of employment.Employee #6 was hired in the Nursing Department on 3/10/25; there was no evidence of a reference check prior to the start of employment.Employee #7 was hired in the Nursing Department on 2/11/25; there was no evidence of a reference check prior to the start of employment.Employee #8 was hired as a Certified Nursing Assistant on 11/12/25; there was no evidence of a reference check prior to the start of employment.Employee #9 was hired in the Nursing Department on 5/1/25; there was no evidence of a reference check prior to the start of employment.Employee #10 was hired as a Registered Nurse on 2/19/25; there was no evidence of a reference check prior to the start of employment.Employee #11 was hired in Administration on 11/24/25; there was no evidence of a reference check prior to the start of employment.Employee #12 was hired as a Licensed Practical Nurse on 11/18/25; there was no evidence of a reference check prior to the start of employment.Employee #13 was hired as a Certified Nursing Assistant on 11/10/25; reference checks were identified as being completed on 9/12/25 Employee #25 was hired as a Registered Nurse on 11/25/24; there was no evidence of a reference check prior to the start of employment.Employee #26 was hired in Dietary on 11/21/24; there was no evidence of a reference check prior to the start of employment.Employee #29 was hired in Social Services on 8/25/25; there was no evidence of a reference check prior to the start of employment.Employee #33 was hired in Staffing on 11/13/25; there was no evidence of a reference check prior to the start of employment.Employee #34 was hired in Maintenance on 10/16/24; there was no evidence of a reference check prior to the start of employment.Employee #37 was hired in Housekeeping on 10/13/25; there was no evidence of a reference check prior to the start of employment.Employee #39 was hired in Dietary on 4/2/25; there was no evidence of a reference check prior to the start of employment.Employee #40 was hired in Dietary on 7/6/25; there was no evidence of a reference check prior to the start of employment.Employee #41 was hired in Dietary on 10/30/25; there was no evidence of a reference check prior to the start of employment.Employee #44 was hired in Dietary on 5/15/25; there was no evidence of a reference check prior to the start of employment.Employee #45 was hired in Dietary on 11/13/24; there was no evidence of a reference check prior to the start of employment.Employee #46 was hired in Activities on 2/17/25; there was no evidence of a reference check prior to the start of employment.Employee #47 was hired as a Licensed Practical Nurse on 10/22/25; there was no evidence of a reference check prior to the start of employment.Employee #48 was hired as a Licensed Practical Nurse on 2/24/25; there was no evidence of a reference check prior to the start of employment.Employee #50 was hired as a Certified Nursing Assistant on 10/1/24; there was no evidence of a reference check prior to the start of employment.Employee #51 was hired as a Licensed Practical Nurse on 5/14/25; there was no evidence of a reference check prior to the start of employment.Employee #52 was hired as a Licensed Practical Nurse on 5/14/25; there was no evidence of a reference check prior to the start of employment.Employee #53 was hired as a Licensed Practical Nurse on 5/14/25; there was no evidence of a reference check prior to the start of employment.Employee #54 was hired as a Certified Nursing Assistant on 3/2/25; there was no evidence of a reference check prior to the start of employment.Employee #55 was hired as a Certified Nursing Assistant on 2/5/25; there was no evidence of a reference check prior to the start of employment.Employee #56 was hired as a Certified Nursing Assistant on 1/29/25; there was no evidence of a reference check prior to the start of employment.; Employee #57 was hired as a Certified Nursing Assistant on 1/1/25; there was no evidence of a reference check prior to the start of employment Employee #58 was hired as a Certified Nursing Assistant on 3/31/25; there was no evidence of a reference check prior to the start of employment.Employee #59 was hired as a Certified Nursing Assistant on 9/4/25; there was no evidence of a reference check prior to the start of employment.Employee #61 was hired as a Certified Nursing Assistant on 3/27/25; there was no evidence of a reference check prior to the start of employment.Employee #62 was hired as a Certified Nursing Assistant on 11/13/24; there was no evidence of a reference check prior to the start of employment.Employee #63 was hired as a Certified Nursing Assistant on 8/23/24; there was no evidence of a reference check prior to the start of employment.b.) Employee #16 was hired as a Licensed Practical Nurse on 12/24/24; there was no evidence of completed licensure verification prior to start of employment. Employee #17 was hired as a Licensed Practical Nurse on 3/28/25; there was no evidence of completed licensure verification prior to start of employment. Employee #18 was hired as a Licensed Practical Nurse on 5/14/25; there was no evidence of completed licensure verification prior to start of employment. Employee #36 was hired as a Certified Nursing Assistant on 3/27/25; there was no evidence of completed registry verification prior to start of employment. Employee #38 was hired as a Certified Nursing Assistant on 8/20/25; there was no evidence of completed registry verification prior to start of employment. Employee #42 was hired as a Certified Nursing Assistant on 2/27/25; there was no evidence of completed registry verification prior to start of employment. Employee #57 was hired as a Certified Nursing Assistant on 1/1/25; there was no evidence of completed registry verification prior to start of employment. Employee #61 was hired as a Certified Nursing Assistant on 3/27/25; there was no evidence of completed registry verification prior to start of employment. c.) Employee #34 was hired in Maintenance on 10/16/24; there was no evidence of completed criminal background check prior to start of employment.Employee #37 was hired in Housekeeping on 10/13/25; the criminal background check was completed on 4/21/25.Employee #56 was hired as a Certified Nursing Assistant on 1/29/25; there was no evidence of completed criminal background check prior to start of employment.Employee #59 was hired as a Certified Nursing Assistant on 9/4/25; criminal background check was completed on 1/13/25.Employee #61 was hired as a Certified Nursing Assistant on 3/27/25; there was no evidence of completed criminal background check prior to the start of employment.Employee #63 was hired as a Certified Nursing Assistant on 8/23/24; there was no evidence of completed criminal background check prior to start of employment.On 1/7/25 at 12:20 PM, the surveyor interviewed the Director of Human Resources ([NAME]) who stated that after an applicant applied, they were interviewed by the department head and then the background checks were run and references were called. If the background check was passed and all the references were called then it would get passed on. When the surveyor asked who was responsible for ensuring that the background checks, references, and licensures/registries were checked, the [NAME] confirmed that she was required to complete them before the applicant was to be hired. When the surveyor asked how the criminal background checks, reference checks, and licensures/registry checks applied to the facilities' abuse policy, the [NAME] further acknowledged that they were to be completed according to the facility's abuse policy. On 1/9/25 at 2:19 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged the employee files were a mess and that they would be better next year. A review of the facility provided Abuse Policy, Revised 12/2022, under the title Screening included: 1. All potential employees, contracts, consultants who will have access to residents are screened for a history of abuse, neglect, or mistreating residents/patients during the hiring process. Screening will consist of, but not limited to: inquiries into State licensing authorities, inquiries into state nurse aid registry, reference checks from previous and/or current employers, criminal background checks [.] 2. Record the results of the screening. Include the data, name and the title of the person contracted for reference and name the person obtaining the title.N.J.A.C. 8:39-13.4(c)2i

Based on observation, interview, and record review, it was determined that the facility failed to provide the correct menu items in accordance with their weekly cycle menu for 5 residents observed during the lunch meal on 1/6/2026 as indicated on a meal ticket. This deficient practice was identified for 5 (five) of 12 residents (Resident #22, #46, #92, #179, #214) reviewed during the dining observation and was evidenced by the following:A review of Resident #22's admission Record (AR-an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but were not limited to, Parkinson's disease and cerebral palsy. A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 11/1/25, indicated that the resident was on a mechanically altered diet. A review of the physician's orders reflected an order dated 9/25/25, indicated the resident was to receive an Advanced Mechanical soft diet, soft texture. A review of Resident #92's AR indicated that the resident was admitted to the facility with the diagnoses that included but was not limited to, arthritis and dementia. The annual MDS dated [DATE], indicated that the resident was on a mechanically altered diet. A review of the physician's orders reflected an order dated 2/5/24, indicated the resident was to receive an Advanced Mechanical soft diet, soft texture, small bites. A review of Resident #179's AR indicated that the resident was admitted to the facility with the diagnoses that included but was not limited to; anemia, dementia and adult failure to thrive. The quarterly MDS dated [DATE], indicated the resident was on a mechanically altered diet. A review of the physician's orders reflected an order dated 7/16/24, indicated the resident was to receive an Advanced Mechanical soft diet, soft texture, small bites with nectar thick liquids. A review of Resident #214's AR indicated that the resident was admitted to the facility with the diagnoses that included but was not limited to; heart failure, mood disorder and dysphagia (difficulty swallowing). The quarterly MDS dated [DATE], indicated the resident was on a mechanically altered diet. A review of the physician's orders reflected an order dated 5/13/25, indicated that the resident was to receive an Advanced Mechanical soft diet with small bites. On 1/6/2026 at 12:52 PM, the surveyor observed dining room service in the A-B dining room on the second floor of the facility. The surveyor observed that three residents, Resident #179, Resident #22, Resident #214 were on advanced mechanical soft diets and received bite size chicken instead of Salisbury steak that was written on their food tickets. On 1/6/2026 at 12:56 PM, the surveyor interviewed a Certified Nursing Assistant (CNA). The CNA explained that if the meal tickets indicated that the residents were supposed to have a specific item and they did not receive the correct item on the food ticket, then the employee who noticed the discrepancy would notify the kitchen to find out why the resident did not receive the correct food item. The CNA then proceeded to the phone the kitchen to find out why the residents were given chicken instead of Salisbury steak. The surveyor was present during the phone call. The CNA explained to the surveyor that the person she spoke from the kitchen did not give her an explanation regarding the menu discrepancy but said that they would send up the right food menu item for the residents. On 1/6/25 at 1:02 PM, the surveyor observed dining in the C-D dining room on the 2nd floor. The surveyor observed that Resident #92 received bite sized chicken instead of bite sized Salisbury steak that was written on the resident's food ticket. On 1/6/2026 at 1:07 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who reviewed Resident #92's meal ticket and confirmed that the resident should have received bite sized Salisbury steak instead of chicken, and she notified the kitchen to find out why. LPN #1 stated that the kitchen did not have a response as to why the meal ticket did not match the meal that was served. He explained to the surveyor that the kitchen staff stated to him that they would send up the correct meal for resident #92. On 1/13/26 at 11:22 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and they did not provide any additional information. According to the admission Record, Resident #46 was admitted to the facility with the following but not limited to diagnoses: malignant neoplasm of prostate, senile degeneration of brain, anxiety disorder, major depressive disorder, and muscle weakness. On 1/6/2026 at 12:46 PM, the surveyor observed the lunch meal on the 2nd floor C/D dining room. The surveyor observed the meal ticket for Resident #46. The observation of the meal ticket dated 1/6/2026 revealed the following diet: Regular, advanced mechanical soft, thin liquids. According to the meal ticket, Resident #46 was to receive the following menu items at the lunch meal: BITE SIZE 3 oz (ounce) Salisbury Steak, 2 fl. oz (fluid ounce) Beef gravy for dipping, 1/2 C (cup) mashed potatoes, 1/2 C yellow squash, 1/2 C cinnamon applesauce, 6 fl. oz beverage, 1 ea. (each) salt, 1 ea. pepper, 2 ea. sugar packet and 1 ea. creamer. Upon observation, Resident #46 received the following items at the lunch meal: 1/2 C mashed potatoes w/gravy, 1/2 C yellow squash, approximately 3oz chopped/diced chicken, 8oz lemonade, 6 oz cranberry juice, 2 sugars and 4oz plain applesauce. No Salisbury steak was provided, and Resident #46 did not receive salt and pepper. On 1/6/2026 at 1:04 PM, the surveyor conducted an interview with the Assistant Director of Dietary (ADOD) who was assigned to the facility for the day from a sister facility. The surveyor questioned why Resident #46 was provided diced chicken at the lunch meal when the 16/2026 Week 2, Tuesday Day 10 [facility name redacted] - Extension sheets indicated that residents receiving an advanced mechanical soft diet were to receive 3 oz of bite sized beef Salisbury steak. The ADOD responded that there was a mix up. The cook gave diced chicken instead of Salisbury steak. I do not know why. I diced up some Salisbury steak and it's fixed now. The surveyor observed Salisbury steak and rice on the tray line in the main kitchen during the lunch meal service to ensure that the Salisbury steak had been prepared and was available. The surveyor then conducted an interview with the Director of Dietary Services (DOD) also in the facility from a sister facility on that day. The surveyor asked the DOD why residents were provided diced chicken instead of Salisbury steak, as per the Week 2 cycle menu for Tuesday Day 10 at lunch. The DOD told the surveyor that the AM cook should not have provided diced chicken. He further stated that when we found out that diced chicken was being served, we chopped Salisbury steak. The surveyor reviewed the facility policy titled MEAL IDENTIFICATION AND DIET ORDER COMMUNICATION, current revision date: 12/15/2025. The following was revealed under POLICY: The facility provides a safe and accurate meal identification and delivery system that supports the resident's individual needs and preferences. The following was observed under Policy Implementation: 5. Meal tickets will be used to identify the resident and validate the diet order, food allergy, food and fluid consistency, and adaptive devices. NJAC 18:39-17.2(b)

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to a.) provide services consistent with professional standards of practice by failing to document weekly skin assessments for a resident with a history of pressure ulcers; b.) consistently implement pressure relieving interventions in accordance with the facility policy and professional standards of nursing practice.This deficient practice was identified for 2 (two) of three (3) residents reviewed for pressure ulcers (Resident #8 and #199) and was evidenced by the following:a.) A review of the admission Record (admission summary) reflected that Resident #199 was admitted to the facility with diagnoses which included, but were not limited to: unspecified dementia, anxiety and major depressive disorder. A review of the annual Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 9/30/25, included the resident was dependent with all aspect of activities of daily living (ADL's). Further review of the MDS indicated that the resident had long and short-term memory deficits and was severely impaired with decision making. Further review of the MDS reflected that the resident was at risk of developing pressure ulcers but did not have an unhealed pressure ulcer during this assessment. The MDS assessment also indicated that the resident had a pressure reducing device to the chair and to the bed. On 01/08/2026 at 10:08 AM, the surveyor observed Resident #199 lying in bed on an air mattress. The resident was non-verbal at the time of observation, and the surveyor was unable to conduct an interview. The surveyor reviewed the resident's electronic medical records (EMR) which revealed the following: A review of a Physician's Order (PO) dated 12/25/23, indicated that weekly skin assessments were to be conducted on Monday during the 7:00 AM-3:00 PM shift for skin monitoring. The order specified that skin monitoring must be completed in the UDA (utilization data assessment) within the EMR. A review of the PO dated 3/5/25, indicated that the resident was admitted to hospice services for a diagnosis of senile degeneration of brain. A review of the Progress Note (PN) dated 8/18/25 at 16:14 (4:14 PM), indicated a nursing clinical evaluation was performed and the resident had a new skin alteration to the sacrum (a small triangular bone at the base of the spine) measuring 0.5 cm (centimeters) x 2.0 cm. The medical doctor was made aware, and a new treatment was ordered. The wound care interventions were reviewed, and the implementation of the interventions were verified. A review of Resident #199's EMR revealed the resident had a sacral wound on and off since August of 2025. Preventive /Protective skin care measures were in place prior to wound development. The documentation revealed that the resident's skin breakdown was unavoidable secondary to: Comorbidities', malnutrition, immobility and incontinence. A review of the Treatment Administration Record (TAR) for September 2025 contained a treatment order dated 9/93/25, to cleanse the sacrum with NNS (normal saline solution), pat dry, and apply Duoderm (dressings create a moist healing environment that aids in the healing process) during the day shift on Tuesdays for wound treatment. A review of the weekly skin assessment dated [DATE] and 9/27/25 indicated that the resident's skin was intact. There was no documented evidence that the resident had any changes in the skin on the sacral area. A review of the IDT (interdisciplinary team) note dated 9/24/25 at 19:22 (7:22 PM), indicated that the resident remained on hospice services with notable emaciation, advanced illness despite no loss of appetite. The note indicated that the resident's sacral wound had resolved however, continued to apply Duoderm to the sacral area for skin protection. A review of the physician PN dated 10/3/28, indicated that the resident did not have any rashes or evidence of skin breakdown. A review of the TAR indicated there was an order dated 12/25/23, for a weekly skin evaluation to be completed on 10/6/25, 10/13/25 or 10/20/25. Nursing signatures were present on these dates, which indicated skin assessments were performed; however, the surveyor was unable to locate documentation detailing the condition or appearance of the resident's skin during those assessments. A review of the PN dated 10/27/25 at 16:39 (4:39 PM), indicated that skin monitoring was completed and the residents previously noted reddened area being treated with Duoderm was now opened and measured 2.0cm x 2.3 cm. Evaluation of Wound Pain: Resident showed no signs or symptoms of pain, the hospice Registered Nurse (RN) assessed the wound and new recommendations were made to cleanse the area with NSS, pat dry, apply Medihoney (sterilized medical grade honey used for promoting wound healing) to the site and cover clean dry dressing, until healed. A review of the facility form titled, Facility Acquired Pressure Ulcer Investigation Tool dated 10/27/25, which indicated that the ulcer was a previously healed ulcer and upon discovery it was a stage two wound. The form indicated that the pressure ulcer was unavoidable related to chronic incontinence and that the resident was actively declining. A review of TAR contained a physician order dated 10/27/25, for wound care as follows: to cleanse area w/ NSS, pat dry, apply Medihoney at site and cover with clean dry dressing (CCD) every shift for wound care until healed. A review of Resident #199's Care Plan dated 10/28/25, contained a focus area: Alteration in skin integrity - resident had an actual pressure injury r/t: generalized decline/end of life. Sacral Pressure Injury stage II (involves partial thickness skin loss). On 01/08/2026 at 10:11 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the resident had severe cognitive impairment and was nonverbal. He further reported that the resident was incontinent of bladder and bowel and required total care with all aspects of activities of daily living (ADLs). He confirmed that the resident had a wound on the sacral area, identified as a stage 4 and that treatments were being completed once a day as ordered. He stated that all residents in the facility had weekly skin assessments completed. LPN #1 explained that the documentation included initials on the TAR to indicated completion of skin assessments and further documentation was entered on the skin assessment form describing whether the skin was intact or if impairment was identified. Upon review of the resident's electronic medical record (EMR), the surveyor was unable to locate the documented skin assessments for the month in question. LPN #1 confirmed that he was also unable to locate the skin assessment documentation on 10/6/25, 10/13/25 and 10/20/25. LPN #1 acknowledged that skin assessments should have been completed and documented but he was unable to explain why the assessments were not documented in the EMR. He then confirmed that he signed the TAR on 10/13/25 that he completed the skin assessment, however, he could not explain why he had not actually completed the skin assessment in the EMR. He further added that he should have completed the skin assessment or should have documented the condition of the resident's skin in the progress notes. He stated that it would have been important to document the condition of the resident's skin because the resident had a history of skin breakdown. On 01/08/2026 at 10:25 AM, the surveyor interviewed the LPN #2 who documented on the TAR 10/6/25 and 10/20/25 that she completed the resident's skin assessments. She stated that although she completed the assessments, documentation describing the resident's skin condition was not entered into the electronic medical record. She further stated that she performed a PRN (as needed) skin assessment on 10/27/25 after being notified by the hospice nurse of a repeated opening on the resident's sacral area. On 01/08/2026 at 10:41 AM, the surveyor interviewed the Assistant Director of Nursing # 2 (ADON) #2 who stated that all residents in the facility were seen weekly by a nurse for skin assessments. She explained that documentation included initialing the TAR to confirm the completion of the assessment, with findings documented in the weekly UDA (utilization data assessment) within the EMR. She emphasized the importance of documenting a detailed skin description in the assessment so that the facility could track the condition of a resident's skin over time. ADON #2 stated that if the UDA was not completed in the EMR and the nurse signed the TAR to indicate the skin assessment was completed, it would be difficult to verify completion of the assessment. She further added that a secondary confirmation of skin monitoring was documented by the Certified Nursing Assistants (CNAs) in the resident's Point of Care (POC) records located within the EMR. In the presence of the surveyor, ADON #2 reviewed Resident #199's POC for October 2025 and confirmed that the CNAs documented that there was no skin impairment from 10/1/25 until 10/26/25. She added that according to the documentation in the progress notes on 10/27/25, the hospice nurse notified the nurse on duty that the resident had a skin alteration requiring a PRN skin assessment. Further review of the PN indicated that the hospice nurse recommended discontinuation of the protective Duoderm treatment to the resident's sacral area and a change in treatment to Medihoney. On 01/09/2026 at 10:52 AM, the Regional Clinical Director (RCD) provided the surveyor with completed skin assessments for the month of October 2025. The RCD confirmed that she could not provide any documentation that skin assessments were performed on 10/6/25, 10/13/25 and 10/20/25. She stated that the only skin assessment she could provide was dated 10/27/25. A review of the facility policy dated 3/13/23 and titled, Skin and Pressure Injury Prevention indicated that the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. The policy indicated that a risk assessment would be performed on admission/re-admission for existing pressure/injury risk factors utilizing the Braden Risk Assessment. The facility would also conduct a comprehensive skin assessment on admission/re-admission and would perform weekly skin assessment by a Licensed Nurse. Once the assessment is conducted and risk factors were identified and characterized, a resident centered care plan would be developed to address the risks for pressure injuries and skin protection interventions. NJAC 8:39-27.1(a) b.) On 1/5/26 at 12:40 PM, the surveyor observed Resident #8 who was fully dressed and was seated in a wheelchair at the bedside. The resident stated that they had a wound on their left foot that may have resulted from their boot. On 1/7/26 at 12:50 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to Resident #8. When the surveyor asked if the resident had any wounds she stated that the resident had no wounds. On 1/7/26 the surveyor reviewed the medical record for Resident #8. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: nontraumatic intracerebral hemorrhage, unspecified (bleeding from a blood vessel in the brain), monoplegia (paralysis of one side of the body) of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side, muscle weakness (generalized), and dysphasia (impaired speech resulting from brain injury) following nontraumatic intracerebral hemorrhage. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 12/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident had one unstageable deep tissue injury that was not present upon admission/entry or reentry to the facility. Further review of the MDS Section M1040 Other Ulcers, Wounds and Skin Problems designated for Foot Problems, and Other Problems revealed that none of the above (infection of the foot (e.g., cellulitis, purulent drainage), Diabetic foot ulcer (s), other open lesion (s) on the foot, open lesion (s), other than ulcers, rashes, cuts (e.g., cancer lesion), surgical wound (s), burn (s) (second degree or third degree), skin tear (s), or Moisture Associated Skin Damage (MASD).were present. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/26/25, which revealed a focus area dated 7/24/25, which indicated the resident had an alteration in skin integrity, resident has an actual pressure injury r/t (related to): Right heel DTI (deep tissue injury, pressure-induced damage to underlying tissue). The interventions included: .Apply treatment per order, Weekly assessment of wound, by LN (licensed nurse) or Provider, including length: width, depth, tissue type, drainage, odor, pain, s/sx (signs and symptoms) of infection, monitor daily for signs and symptoms of infection Further review of the ICCP revealed a focus area dated 6/26/25, which indicated the resident was at risk for pressure injury development r/t (related to) impaired mobility. Interventions included an entry dated 10/13/25, for Heel (s) protection: Offload with pillows or (Specify Heel Boots or Heel Suspension Boot) as tolerated. A review of the Order Summary Report (OSR), dated as of 1/8/26, included the following physician orders (PO): A PO, dated 10/10/25, for Weekly skin evaluation done on Wednesday during the 7-3 shift. Every day shift every Wednesday for Weekly Skin Monitoring Must Complete LN: Weekly Skin Monitoring UDA (Utilization Data Assessment). A review of a Wound Assessment Detail dated 12/18/25, that was documented by the Wound Consultant Advanced Practice Nurse (APN) revealed the resident had one wound described as a right heel pressure ulcer, deep tissue injury that was persistent non-blanchable, with deep red, maroon or purple discoloration, that measured 1.0 cm (centimeter) x 1.0 cm x 0.1 cm. Wound status: not healed. A review of the Wound orders included: Cleanse wound with betadine OTA (open to air), change daily, change prn (as needed), Pressure Relief/Offloading: Facility Pressure Ulcer Prevention Protocol and Offload heels per facility policy. A review of a Podiatry Consult dated 9/29/25 at 10:13 AM, revealed: Resident was seen at beside on consult for podiatric evaluation and at-risk foot care. Physical Exam (PE): on b/l (bilateral, both sides) offloading boots. A review of the January 2026 Treatment Administration Record (TAR) revealed an entry dated 10/22/25, for Weekly skin evaluation done on Wednesday during the 7-3 shift.Further review of the TAR revealed that on Wednesday 1/7/26, the entry was charted and was signed out as administered to indicate that the skin evaluation was completed. Further review of the medical record failed to include a corresponding Weekly Skin Monitoring UDA assessment that described the resident's skin condition. On 1/8/26 at 10:05 AM, the surveyor observed Resident #8 lying in bed asleep with their left heel on the bed and their right foot crossed over the left lower leg with the right heel elevated off the bed. On 1/8/26 at 10:30 AM, the surveyor noted that there were two pair of padded heel boots on top of the resident's wardrobe closet. When the surveyor asked the resident if they used the heel boots the resident stated, They used to put them on me, but it has been a while. On 1/8/26 at 11:01 AM, the surveyor interviewed CNA #2 who stated that she was not the resident's regular assigned aide, but she knew the resident. The surveyor asked CNA #2 if the resident used the heel boots that were on top of the wardrobe closet and the CNA #2 stated, I did not see them on the resident today. CNA #2 further stated, They will be on today. On 1/8/26 at 11:01 AM, the surveyor interviewed LPN/UM #1 who stated that the resident had a DTI (deep tissue injury) , and weekly assessments should be documented in detail in the assessments. The LPN/UM #1 stated the assigned nurse should have documented a full assessment yesterday, but after reviewing the documentation, she did not. The surveyor questioned LPN/UM #1 regarding Resident #8's heel booties in which LPN/UM #1 stated that she did not see them on the resident when she initially came in today. On 1/9/26 at 11:55 AM, the surveyor interviewed the Regional Clinical Director (RCD) who stated that the resident's right heel DTI was facility acquired, and it was identified on the skin assessment by a facility LPN on 7/23/25. The RCD further stated that an incident report was not completed upon the identification of the DTI, but it should have been done. On 1/12/26 at 9:12 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) #2. The surveyor asked ADON #2 if a head-to-toe assessment were completed on 1/7/25, should the wound on the resident's left great toe and the resident's elongated toenails have been documented on a weekly skin assessment, rather than just documenting completion of a skin assessment on the TAR? ADON #2 stated, some nurses do the assessment, but they do not document it, or some agency people do not care. ADON #2 further stated, I saw the resident's feet on Friday, and it was an ingrown toenail. The resident definitely could have used some foot care. ADON #2 stated that the aides are obviously not looking at the resident's feet if they have not identified that there was an alteration in the lower extremities. ADON #2 further stated, sometimes you do not see an ingrown toenail until it breaks through the skin. ADON #2 further stated that staff should assist the resident to turn as tolerated every one to two hours and off load the heels and any pressure prone areas. ADON #2 stated that staff could use heel boots or pillows to elevate the heels off the bed. ADON #2 stated that the Unit Manager was responsible to ensure that the Care Plan interventions were implemented. A review of the facility's Skin and Pressure Injury Prevention policy, revision date 6/27/24, included: The facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice.Weekly Skin Monitoring by Licensed Nurse; Staff inspect the skin when performing or assisting with personal care or ADLS (activities of daily living).Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan shall be developed to address the modifiable risks for pressure injuries and skin protection interventions. A review of the facility's Health Care Provider (HCP) Consultations policy, revision date 7/30/25, included:.Consultants.may provide recommendations that must be reviewed and approved by the attending HCP. A review of the facility's Care Plans Comprehensive policy, revision date 10/19, 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. NJAC 8:39-27.1 (e), 27.2 (g)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 5 forms reviewed. This deficient practice was evidenced by the following: On 1/9/25 at 2:09 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on five of the five provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form #240870463 dated 3/11/25 #240870454 dated 5/27/25 #250798148 dated 7/31/25 #250798149 dated 9/5/25 #250798150 dated 10/15/25 - Part 5 was not completed with the number of items received and the date they were received On 1/12/2026 10:00 AM, the surveyor interviewed the Director of Nursing (DON) who stated the process for completing the DEA 222 form entailed that the DON filled in Part 1 and Part 2 of the form, then the Medical Director would review the form and sign it. The DON would then make a copy to keep in the file for reconciliation, and the original form was then sent to the provider pharmacy. She continued to explain the following steps:-Once the pharmacy delivered the medication, two nurses must sign and verify the contents of the package were correct based on the packing sheet and the DEA 222 form. -Task 5 should then be completed with the number of packages received and the date the medications were received. -The nurses would then load the medications into the automated medication dispensing machine. -The DON or the assistant DON (ADON) would ensure the form had been correctly filled out. The surveyor and the DON reviewed the DEA 222 form and confirmed task 5 had not been completed as instructed. The DON acknowledged according to the instructions on the reverse of the DEA 222 form Task 5 should be completed upon receipt of the medications. A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item . A review of the Medication Storage policy, dated revised 12/17/25, did not address the process for completing the DEA 222 form. NJAC 8:39-29.7(c)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to: follow appropriate infection control practices by having necessary personal protection equipment (PPE) readily available for a resident who required enhanced barrier precautions (EBP). This deficient practice was identified for 1 of 10 residents (Resident #55) reviewed for infection control and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 1/9/26 at 11:18 AM, the surveyor knocked on Resident #55's closed door, at that time the surveyor observed a sign posted outside of Resident #55's door that revealed Enhanced Barrier Precautions, once inside the room, the surveyor observed the resident seated in a wheelchair, hair disheveled and the resident smelled of smoke. When the surveyor asked the resident if the staff wore a gown and gloves while caring for them, Resident #55 stated, I don't know. The surveyor did not observe any PPE (personal protective equipment-Clothing or equipment worn to protect one from injury or infection) readily available for staff use. On 1/9/26 at 11:20 AM, the surveyor interviewed Certified Nurse Aide (CNA) #6 who stated she cared for Resident #55 who mostly stayed to themselves and was noncompliant with care, often refusing a shower and could be verbally abusive to staff. When asked if she needed to wear PPE when caring for Resident #55, she stated, no. When asked about the red sign beside the door, CNA #6 stated the sign was for the resident in the room next door. On 1/9/26 at 11:33 AM, the surveyor interviewed Resident #55's Licensed Practical Nurse #7 (LPN) #7 who stated the resident did not really socialize but they did go out to smoke. LPN #7 stated the resident had behaviors, but usually because of people bothering them about not smelling great from refusing to shower. LPN #7 stated the resident was on EBP related to their communicable disease and if staff were assisting them with care, staff must wear a gown and gloves. LPN #7 stated when the resident went out to smoke the staff would change Resident #55's sheets and both a gown and gloves were worn. When asked how staff knew the resident was on EBP, LPN #7 stated because there should be red signage and PPE on the door. LPN #7 checked Resident #55's room and door and confirmed there was no PPE readily available for use on Resident #55's door. On 1/9/26 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager #4 (LPN/UM) #4 who stated the red sign outside Resident #55's room was posted because the resident was on EBP. She explained that enhanced barrier precautions meant that staff must wear a gown, gloves, mask and a face shield when performing direct resident care. She confirmed that there should be a kit outside the door or a yellow caddy on the door that would have all the essentials like gloves, masks and gowns. LPN/UM #4 checked the resident's door and confirmed there was no PPE readily available for use. On 1/9/26 at 1:39 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated Resident #55 did not require EBP based on their communicable disease. The physician had ordered the resident be placed on EBP based on a prior Infection Preventionist's preference. When asked if there should be PPE readily available if the resident had current orders to be on EBP, and the DON stated yes. On 1/12/26 at 11:22 AM, the surveyor interviewed the Regional Clinical Director (RCD) who confirmed that if Resident #55 had active physician orders for EBP, then there should there have been PPE readily available for staff use when caring for the resident. A review of the facility provided Enhanced Barrier Precautions policy revised 3/12/25, included .EBP is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities are commonly bundled together.EBP requires wearing disposable gloves and an isolation gown prior to high contact activity. Face protection may also be needed/worn if performing activities with a risk of splash or spray. Hand hygiene should be performed before and after each resident contact and after removing PPE. High contact resident care activities include: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care/use and wound care. NJAC 8:39 - 19.4(a); 27.1 (a)

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain weekly weights according to a physician's order, and b.) obtain re-weights according to the facility's policy for 1 of 3 residents (Resident #7) reviewed for nutrition. This deficient practice was evidenced by the following: On 1/5/2026 at 11:26 AM, the surveyor observed Resident #7 in their room seated in a wheelchair beside their bed, dressed and groomed. Resident #7 stated they were vegetarian and wanted better food, like fresh fruits and vegetables. Resident #7 also stated they had lost a lot of weight since admission to the facility.A review of the admission Record, an admission summary, revealed that Resident #7 had diagnoses which included, but were not limited to, Parkinson's disease, anxiety, type 2 diabetes (a chronic condition in which the body does not make enough insulin or does not use insulin properly leading to high blood sugar (glucose) and hypertension (elevated blood pressure). A Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. Further review of the MDS included the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. A Review of the Individualized Comprehensive Care Plan (ICCP) included a focus area, initiated on 5/12/25, that the resident had a nutritional problem or potential nutritional problem and was at risk for malnutrition related to a history of weight fluctuations related to edema (swelling), Parkinson's disease, cellulitis, hypertension, Type 2 diabetes, dysphagia (difficulty swallowing). Requesting sugar in place of sugar substitute. Had significant weight loss. Further review of the ICCP included an intervention to Follow weights as ordered, revised 5/12/25. A Review of the Order Listing Report, with an order date range from 10/7/25 until 12/31/25, included a physician's order for weekly weights for four weeks every dayshift every Monday and Wednesday for monitoring for four weeks. ordered 11/24/25. A Review of the Dietary progress notes, Comprehensive Nutritional Assessment, dated 11/6/25 revealed the resident's weight had ranged from 211 pounds to187 pounds over the past six months, and no significant weight loss was noted. A further review of the progress notes revealed an Interdisciplinary team meeting High Risk Meeting note dated 11/20/25, for significant weight loss which revealed the resident's hospital readmission weight was 164 pounds, down 18.5% from last month. The team initiated twice daily nutritional supplement, referral to speech therapy and orders to monitor weights weekly. A review of the November 2025 and December 2025 Treatment Administration Record (TAR) revealed an order for weekly weights for four weeks, every day shift on Monday and Wednesday for monitoring for four weeks with a start date of 11/24/25 at 7:00 AM. According to the TAR, the nurse indicated the resident's weight had been taken on 11/24/25 and 11/26/25. A review of the December 2025 Treatment record revealed the nurse had indicated the resident's weight had been taken on 12/1/25, 12/3/25, 12/8/25, 12/10/25, 12/15/25, and 12/17/25. A review of Resident's Electronic Health Record (EHR), under the weights and vitals tab in the EHR, revealed the following weight documentation: On 10/7/25 the resident weighed 200 pounds (mechanical lift)On 11/11/25 the resident weighed 164.2 pounds (chair)On 11/20/25 the resident weighed 163 pounds (wheelchair)On 11/24/25 the resident weighed 157.6 pounds (wheelchair)On 11/26/25 the resident weighed 157.2 pounds (mechanical lift)On 12/5/25 the resident weighed 159 pounds (mechanical lift)On 12/22/25 the resident weighed 156.2 pounds (mechanical lift)On 1/8/26 the resident weighed 155.6 pounds (mechanical lift) There were no corresponding weights for the dates of the physician's order for 12/1/25, 12/3/25, 12/8/25, 12/10/25, 12/15/25 or 12/17/25. A further review revealed that on 10/7/25, the resident weighed 200 pounds. On the subsequent date of 11/11/25, the resident weighed only 164.2 pounds. That was a 17.9% difference in one month. There was no documented evidence that a re-weight was done to verify the significant weight loss that the resident may have experienced. On 1/8/26 at 11:05 AM, the surveyor interviewed the resident's Licensed Practical Nurse #6 (LPN #6) who stated the resident was on weekly weights. At that time, the surveyor reviewed the resident's November and December TARs with LPN #6. She verified that nurses initialed the TAR, which indicated that the resident's weights were taken weekly per the physician's order. The surveyor then reviewed the weights and vitals tab located in the EHR with LPN #6. She explained that the dates that the weights were supposed to be completed on the TAR, did not correspond with dates the weights that were completed on the weights and vs tab located in the EHR. The only weights that matched the weights documented on the TAR and the weights and vs tab were dated 11/24/25 and 11/26/25.On 1/8/26 at 11:17 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager #4 (LPN/UM #4) for the second floor A/B wing who stated that resident's weights were taken by the certified nurse aides (CNA) who would then report the weights to the LPN/UM or the dietician. She stated that she or the dietician would enter them into the EHR. LPN/UM #4 added that the resident should be weighed using the same method each time and if there was more than a two percent difference from the last time, the resident should be re-weighed. At that time the surveyor reviewed the resident's EHR weights and the TARs. LPN/UM #4 confirmed the dates on the TAR should correspond to the dates of the weights documented in the EHR. She also confirmed there should have been a re-weight done in November after the significant weight difference was recorded.On 1/9/26 at 12:59 PM, the surveyor interviewed the Registered Dietician (RD) via telephone who stated the CNAs were responsible for weighing the residents and the nurses were responsible for recording the weights in the EHR. The surveyor reviewed Resident #7's weights with the RD who confirmed that after the recorded weight loss from October to December these weights were considered a significant weight loss, and the resident should have been re-weighed. The surveyor then reviewed the dates in the TAR that indicated that the resident should be weighted and the dates in the weight section of the EHR that indicated the resident was actually weighted. The RD confirmed that there were missing dates and that the dates did not correspond with each other.On 1/9/26 at 2:07 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who confirmed there was a discrepancy in recording and monitoring the resident's weights according to the physician's orders for weekly weights. The DON also acknowledged there should have been a re-weight in November after the significant weight loss recorded from October to November. On 1/12/26 at 11:22 AM the surveyor interviewed the Regional Clinical Director (RCD) who acknowledged the EHR weight days did not correspond to the dates the nurse indicated the resident's weights had been recorded in the TAR, and after a significant weight loss was recorded the resident should be re-weighed within 48 hours to ensure the weight was accurate.A review of the facility's Weight Management policy, dated revised 3/1/2024, included, The facility shall manage resident's weights in accordance with current evidence-based standards of practice, state/federal regulations and resident desires and preferences. The resident's weights shall be obtained. as clinically indicated for the residents and documented in the clinical record. Resident's may require a re-weight for a weight change of five pounds in a month or three pounds in a week, the re-weigh should be completed within forty-eight hours after the identified discrepancy and documented in the clinical record.NJAC 8:39-27.2 (a)(e)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure necessary services and assistance, specifically incontinent care, was provided to a dependent resident (Resident #199) for 1 of 5 residents reviewed for bladder incontinence and b.) ensure that a resident's urinary catheter bag was covered with a privacy bag to maintain the resident's dignity. This deficient practice was identified for 1 of 1 resident, (Resident # 14) reviewed for urinary catheter.This deficient practice was evidenced by the following:a.) On 1/9/2026 at 9:44 AM, the surveyor completed a facility wide incontinence rounds. The surveyor requested Certified Nursing Assistant (CNA) #4 and another staff member to announce and request permission to see Resident #199's brief. CNA #4 indicated that the resident was on hospice and was cognitively impaired. CNA #4 proceeded to knock on the door and guided Resident #199 as they revealed what appeared to be a urine saturated brief, that had seeped up the back of their incontinence brief. The surveyor asked what the dressings were on the resident's buttocks. CNA #4 stated that Resident #199 had a wound. The surveyor reiterated that Resident #199 had a wound and was sitting in a saturated incontinence brief. The surveyor observed that the urine was brown in color. When asked to described the incontinence brief, CNA #4 confirmed that the brief was saturated in urine. The surveyor inquired when was the last time CNA #4 had checked Resident #199' brief to which she responded that the resident was on hospice and that the hospice aide had been providing care to the resident that morning. The surveyor then asked CNA #4 when the hospice aide had left for the day, but CNA #4 was unable to provide a time. The surveyor then proceeded to ask if hospice patient's were included in incontinence rounds. CNA #4 confirmed and further elaborated that incontinence rounds should be conducted every 2 (two) hours. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Unspecified Dementia. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/30/2025, included the resident was moderately impaired with daily decision making. Further review of the MDS under Section H- Bladder and Bowel revealed the resident was always incontinent of bowel and bladder. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 11/12/2018, that the resident had bowel and bladder incontinence [related to] cognitive impairment. Interventions included: check resident every 2-4 hours and assist with toileting as needed. A review of the CNA Task for Bowel Toileting Care every 2-4 hours and as tolerated during waking hours and PRN revealed that the resident only received care at 6:22 AM, on 1/9/25. On 1/9/25 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #5 who stated, the hospice aide had left the floor around 9:30 AM. It was unknown if she gave report to Resident #199's assigned nurse. When asked if it was important that residents with wounds receive regular incontinent care LPN #5 responded, absolutely. LPN #5 further stated that incontinence rounds are to be completed every 2 (two) hours. On 1/9/2025 at 9:58 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated, that hospice residents were not to be excluded from the incontinence rounds and they should also be checked every two hours. LPN/UM #3 attempted to locate the hospice aide in the building, but they were unable to be found. On 1/9/2025 at 12:46 PM, the surveyor interviewed the Hospice Home Health Aide (HHA), who provided care to Resident #199. The HHA stated that she ended her care with the resident at approximately 7:30 AM and gave report to the nurse. The HHA stated that when she left the resident, they were not soiled and were freshly changed. The HHA further stated that when she had come in to care for the resident the past two days, the resident was found to be saturated to the point that the urine had went through the incontinence brief, through the sheets, the clothing, and onto the bed with bright yellow urine noted. On 1/9/2025 at 2:19 PM, the in the Regional Clinical Director (RCD), in the presence of the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the survey team, acknowledged that hospice residents were still a part of the CNA assignment and they should be rounded on every two hours. A review of the facility's Activities of Daily Living (ADL) Care and Support policy, revised 11/6/2025, included: 1. ADL care and support will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that includes, but not limited to supervision and assistance with: [.] elimination (toileting): transfers and incontinent care; [.] 8. Toileting/perineal care/incontinence care will be provided with care and as needed. A review of the facility's Certified Nurses Aide documents included under Specific Responsibilities Continued: Takes care of incontinent residents, (clean and dry) and provides skin care; Ensures that residents who are unable to call for help are checked frequently. NJAC 8:39-19.4 (a) b.) On 1/5/2026 at 11:34 AM, the surveyor observed Resident #14 lying in bed with their catheter bag hanging from the bed frame. The catheter bag was not in a privacy bag and was visible from the hallway. On 1/6/2026 at 9:46 AM, the surveyor observed Resident #14 lying in bed with the catheter bag hanging from the bed frame. The catheter bag was still not in a privacy bag and was visible from the hallway. On 1/6/2026 at 12:29 PM, the surveyor reviewed the medical record for Resident #14. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to: neuromuscular dysfunction of the bladder (occurs when nerves from the brain, spinal cord, or peripheral nerves were damaged, disrupting signals to the bladder, causing issues like incontinence), muscle weakness, and difficulty walking. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/30/2025, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the resident had an indwelling urinary catheter (a thin flexible tube that drains urine from the bladder). A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 8/27/2025, that the resident had an indwelling catheter. Interventions included: maintain privacy bag and catheter care. A review of the Order Summary Report (OSR), dated as of 1/5/2026, included a physician's order dated 12/29/2025, for an indwelling catheter. On 1/8/2026 at 1036 AM, the surveyor made a follow-up visit with the resident. The resident was in bed watching television. When interviewed the resident stated that they would like a privacy bag. They further stated that when they left their room to go to therapy, the staff placed the catheter bag next to them, and the urine was visible to others. At that time, the catheter bag was still uncovered and could be seen from the hallway. On 1/8/2026 at 10:49 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) #1, went to the resident's room. LPN/UM #1 confirmed the finding. At that time, LPN/UM #1 stated that there should be a privacy bag covering the urine catheter bag to maintain the resident's dignity. She further stated that the Certified Nurse Assistant (CNA) should have obtained a privacy bag from the nurse. On 1/8/2026 at 11:09 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #2 who stated that privacy bags were available at the facility, and the catheter bags should always be covered. On 1/8/2026 at 1:46 PM, the surveyor interviewed the Director of Nursing (DON) who also stated that Resident #14 should have had a privacy bag in place for dignity. A review of the facility's Quality of Life/Dignity policy revised 5/28/2024 included, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Staff shall promote, maintain and protect resident privacy, . NJAC 8:39- 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident received proper foot care that included treatment to prevent complications, including but not limited to, following up with podiatry (foot doctor) recommendations. This deficient practice was identified for 2 of 2 residents (Resident #8 and Resident #164) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following:1.On 1/5/26 at 12:40 PM, the surveyor observed Resident #8 who was fully dressed and was seated in a wheelchair at the bedside. The resident stated that they had a wound on their left foot that may have resulted from their boot.On 1/7/26 at 12:50 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to Resident #8. When the surveyor asked if the resident had any wounds she stated that the resident had no wounds. CNA #1 further stated that the resident needed help to dress and when transferred required total assistance from staff.On 1/7/26 the surveyor reviewed the medical record for Resident #8.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: nontraumatic intracerebral hemorrhage, unspecified (bleeding from a blood vessel in the brain), monoplegia (paralysis of one side of the body) of upper limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side, muscle weakness (generalized), and dysphasia (impaired speech resulting from brain injury) following nontraumatic intracerebral hemorrhage.A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 12/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident had one unstageable deep tissue injury that was not present upon admission/entry or reentry to the facility. Further review of the MDS Section M1040 Other Ulcers, Wounds and Skin Problems designated for Foot Problems, and Other Problems revealed that none of the above (infection of the foot (e.g., cellulitis, purulent drainage), Diabetic foot ulcer (s), other open lesion (s) on the foot, open lesion (s), other than ulcers, rashes, cuts (e.g., cancer lesion), surgical wound (s), burn (s) (second degree or third degree), skin tear (s), or Moisture Associated Skin Damage (MASD).were present.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/26/25, which indicated resident had an alteration in skin integrity, resident has an actual pressure injury r/t (related to): Right heel DTI (deep tissue injury, pressure-induced damage to underlying tissue). The interventions included: .Apply treatment per order, Weekly assessment of wound, by LN (licensed nurse) or Provider, including length: width, depth, tissue type, drainage, odor, pain, s/sx (signs and symptoms) of infection, monitor daily for signs and symptoms of infection.A review of the Order Summary Report (OSR), dated as of 1/8/26, included the following physician orders (PO):A PO, dated 10/10/25, for Podiatry Consult as needed.A review of a Podiatry Consult dated 9/29/25 at 10:13 AM, revealed: Proper feet and shoe hygienic strongly recommended. Walk with socks and proper shoe gear at all times. Monitor pressure areas. Recommend larger and bigger shoes to accommodate painful digital deformities. Poor vascular supply to both feet-Podiatry will continue to monitor.Further review of a Podiatry Consult dated 10/23/25, revealed the following: Recommend larger and bigger shoes to accommodate painful digital deformities.Poor vascular supply to both feet-Podiatry will continue to monitor; Poor vascular supply to both feet-Podiatry will continue to monitor.On 1/12/26 at 9:12 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) #2. The surveyor asked ADON #2 if the facility was responsible to ensure that the Podiatry Consultant recommendations for larger and bigger shoes to accommodate painful digital deformities? ADON #2 stated we should contact the family to bring the shoes in. Then if the family did not bring larger shoes in, the facility would provide new shoes on behalf of the resident and get reimbursed for them.On 1/12/2026 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) who provided the surveyor with a copy of a Charting By Exception Note dated 10/24/25, which specified that the facility notified the resident's brother, and daughter, regarding the resident who required bigger shoes. The DON further stated that the resident had a tendency to refuse, but that was not care planned. The DON further stated that the facility failed to close the loop, and did not ensure that they followed up with the resident's responsible party to ensure that larger shoes were provided. The DON further stated that we absolutely should have followed up, and that did not happen. The DON further stated that the care plan also should have been updated in October, not after surveyor inquiry. 2. On 1/5/26 at 12:35 PM, the surveyor observed Resident #164 lying in bed. When interviewed, Resident #164 expressed concerns with their lack of toenail care. The surveyor observed that the resident's toenails were long.On 1/6/26 at 11:55 AM, the surveyor interviewed Certified Nursing Assistant (CNA) # 5 who stated that Resident #164 required total care from staff and the resident was only able to wash their face. CNA #5 stated that either the aides or the residents cut the resident's fingernails, but Podiatry cut the resident's toenails. CNA #5 further stated that Podiatry had visited the facility last Tuesday. When the surveyor asked CNA #5 if the resident were referred to Podiatry for toenail care at that time? CNA #5 stated, You would have to ask a manager about that.On 1/6/26 at 12:05 PM, the surveyor reviewed Resident #164's hybrid paper medical record and there was no documented evidence of a Podiatry Consult within the paper chart.On 1/6/26 at 12:13 PM, the surveyor reviewed the electronic medical record (EMR) of Resident #164 which revealed the following:A review of the admission record, an admission summary, revealed the resident was admitted to the facility with diagnosis which included but were not limited to: Type 2 diabetes mellitus without complications (persistently high levels of sugar (glucose) in the blood), muscle weakness (generalized), difficulty in walking, not elsewhere classified, morbid (severe) obesity due to excess calories, and Unspecified B-Cell Lymphoma (blood cancer in the lymph nodes).A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/16/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was fully intact.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/10/24, that the resident required assistance with self-care and mobility r/t (related to) deconditioning. Interventions included: Putting on/taking off footwear: Substantial assist x 2 (two) staff (both provide hands-on CNA care) Two helpers complete more than half of the activity. Both helpers use their own strength during the activity to lift or hold the resident's body, arms, or legs. While the resident requires 2 (two) helpers, the resident participated and completed less than half of the activity using own physical strength.Further review of the ICCP revealed an intervention dated 9/29/25, for Chair/Bed-to-chair transfer: Two-person mechanical lift. Inspect mechanical lift sling prior to use.A review of the Order Summary Report (OSR), dated as of 1/9/26, included the following physician orders (PO):A PO, dated 9/13/25, for Podiatry Consult as needed.A review of a facility provided Consultant Note: Podiatry, dated 9/29/25 at 10:18 AM, revealed the resident was seen at beside on consult for podiatric evaluation and at risk foot care.Further review of the Consult revealed nails and digital ends painful upon palpation (touch), 1, 2, 4 b/l (bilateral, both sides) with nails digging into skin and discolored, thick, dystrophic (thickened and discolored) and very long x 10.Aseptic debridement (removal of damaged tissue) of nails x 10 .F/U (follow-up) in 2-3 months.On 1/7/26 at 12:39 PM, the surveyor observed the resident lying in bed awake. The resident stated that their toenails were very sharp and needed to be cut. The resident stated that the Podiatrist used to come and see me.On 1/8/26 at 9:57 AM, the surveyor observed the resident lying in bed awake. The resident reported still not having had their toenails cut.On 1/8/26 at 9:58 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that for a podiatry consult to be initiated nursing had to give the request to the scheduler who then set up the appointment on behalf of the resident.On 1/8/26 at 11:21 AM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 to look at the resident's toenails with resident permission in the presence of the surveyor. When LPN/UM #1 looked at the resident's toenails she stated that their toenails needed to be cut to prevent a wound. LPN/UM #1 further stated that the resident's toenails should not have been that long.On 1/8/26 at 12:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that it was her expectation for the aides to tell the unit manager when the resident needed to have their toenails cut. The DON further stated that the resident could get an infection or an ingrown toenail if their toenails were not maintained.A review of the facility's Activities of Daily Living (ADL) Care and Support policy, revised 11/6/2025, included: .Nail care should be provided as needed for the resident.A review of the facility's Skin and Pressure Injury Prevention policy, revision date 6/27/24, included: The facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice; Staff inspect the skin when performing or assisting with personal care or ADLS (activities of daily living).Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan shall be developed to address the modifiable risks for pressure injuries and skin protection interventions.A review of the facility's Care Plans Comprehensive policy, revision date 10/19, 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.A review of the facility's Health Care Provider (HCP) Consultations policy, revision date 7/30/25, included:.Consultants.may provide recommendations that must be reviewed and approved by the attending HCP.A review of the facility's Foot Care-Nail Clipping policy, revision date 3/23, included: The facility shall provide necessary treatment and foot care to residents in accordance with state standards of practice to maintain mobility and good foot health and to minimize the complications from conditions such as diabetes, peripheral vascular disease, or immobility.NJAC 8:39-27.1 (e), 27.2 (g)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to accurately complete a Minimum Data Set (MDS), an assessment tool, for 1 of 56 residents (Resident #184) reviewed.This deficient practice was evidenced by the following:On 1/5/2026 at 10:26 AM, the surveyor observed Resident #184 in the bed with a C-PAP (Continuous Positive Airway Pressure machine that helps treat sleep apnea (a sleeping disorder in which temporary cessation of breathing occurs) on their nightstand next to them. The C-PAP mask was uncovered and touched the surface of the nightstand.At that time, Resident #184 stated that they last used their C-PAP machine one day last week, and they also used it a couple of times per week.A review of the admission Record, an admission summary, revealed the resident had a diagnosis which included, but was not limited to, anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood).The admission summary did not include a diagnosis of obstructive sleep apnea (when you stop breathing during sleep).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/28/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A further review of the MDS did not reflect that the resident used a C-PAP.A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 10/22/205, that the resident was at risk for alteration in respiratory system related to shortness of breath. Interventions included but were not limited to: elevate the resident's head of bed to help alleviate shortness of breath.A further review of the ICCP did not include the use of the C-PAP.A review of the Order Summary Report (OSR), dated as of 1/6/2026, did not include a physician's order for a C-PAP. A review of the Consultant Pulmonologist Progress Note dated 12/31/2025 at 2:58 PM, revealed that the resident had obstructive sleep apnea and was on a C-PAP and should continue using the C-PAP at night. A further review of the Consultant Pulmonologist progress note (CPPN) dated 10/28/225 at 8:50 AM, also revealed that the resident should continue using the C-PAP at night.A review of the Physician's Progress Note dated 10/23/2025 at 8:50 AM, reflected that the resident had obstructive sleep apnea (OSA) and should continue using the C-PAP.On 1/8/2026 at 12:33 PM, the surveyor interviewed the MDS coordinator who stated that when she completed the resident assessments, she looked at the admitting doctor's orders and would speak with the resident if she had to. She further stated that the end goal was to create a person-centered care plan on how to care for the resident. She also stated that the MDS should be an accurate reflection of the resident.On 1/12/2026 at 10:57 AM, in the presence of the survey team, the Regional Clinical Director (RCD) stated that the MDS coordinator should also interview the resident to gather information when assessing the resident. NJAC 8:39-11.1

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, sanitary, and home-like environment for 1 of 4 nursing units (1C), reviewed for environment. This deficient practice was evidenced by the following:On 1/12/2026 at 9:02 AM, the surveyor went to Resident #180's room to conduct an interview with them. When the resident sat upright, a large brown embedded stain was noted on the resident's fitted sheet.At that time, the resident stated that the stain was there when they received the fitted sheet. They further stated that on occasions, they received linens with holes.On 1/12/2026 at 9:19 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 observed the first floor, C-hall clean linen cart. The surveyor observed there a washcloth with multiple large red stains and two reddish-brown particles on it stored on the clean linen cart. There was also a fitted sheet with a golf ball-sized hole in it. LPN/UM #1 immediately removed the items from the cart.It was further observed that all three shelves on the clean linen cart had a build-up of a brown residue on multiple areas of the cart.At that time, the surveyor interviewed LPN/UM #1 who stated that about once or twice per week, bed linen would come up torn and/or a washcloth would have brown stains on it. She further stated that once identified, the stained and damaged linens should be removed promptly, placed in a bag and sent back to the laundry room. LPN/UM #1 also stated that the cart should be kept clean. On 1/12/2026 at 9:26 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that the linen cart should be kept clean, neat, and orderly, and the linen should be without stains, rips, or holes. She further stated that if the linen was found to be stained or torn, it should be taken off the cart and sent back to laundry for infection control purposes and to maintain the resident's dignity. On 1/12/2026 at 9:35 AM, the surveyor interviewed the Laundry Technician (LT) who stated that the linen should be white, intact, and in good condition when it goes up to the units. She further stated that any damaged linen should be removed from the inventory.On 1/12/2026 at 9:38 AM, the surveyor interviewed the Environmental Service Director (EVSD) who stated that the linen should be intact and clean when it leaves the laundry area, for both infection control purposes and the dignity of the residents. He also stated that the linen carts should be wiped down daily.On 1/12/2026 at 9:43 AM, the surveyor interviewed the Licensed Nursing Home Administrator ( LNHA) who stated that the linen carts she be kept clean. He stated that they did not have a cleaning schedule for the linen carts, but they were cleaned as needed, and they should be checked quite often. He further stated that once the linen got too stained, it should be pulled from production. The surveyor showed the LNHA a picture of Resident #180's stained fitted sheet. The LNHA confirmed the findings.A review of the facility's Environmental Services policy, revised 5/18, included, Bring emptied linen cart to the linen room. If cart cover and cart are soiled, place cover in area to be washed and sanitize the cart.Linen cart and covers are scheduled for cleaning on a weekly basis.N.J.A.C. 8:39-31.4 (c )(F)

Based on record review, interview, and review of facility documents, it was determined that the facility failed to a.) document the administration of the influenza vaccine after signed consent was obtained for one (Resident #41) of five sampled residents; b) ensure the provision of the influenza and pneumococcal vaccines were properly offered to a resident with impaired cognition for one (Resident #6) of five residents reviewed for influenza and pneumococcal immunizations. This deficient practice was evidenced by the following:On 1/6/2025 at 12:42 PM, the surveyor observed Resident #6 walking in the hallway and yelling. A review of the admission Record, an admission summary, revealed Resident #6 had diagnoses which included, but were not limited to: Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. A review of Resident #6's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/8/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/27/2023, that the resident [had] impaired cognition related to disease process (schizophrenia). Interventions included: ask yes/no questions in order to determine the resident needs; provide simple directions to resident. A review of the Psychiatric progress notes dated 5/2/2025 included documentation on 3/17/2025 and 1/29/2025 of Resident #6 as being confused and only oriented to name. A review of the facilities' Influenza Immunization Consent Form for Resident #6 identified that the Influenza Vaccine was declined and above the signature of recipient unable to sign was identified. The facility was not able to produce any documentation that Resident #6 received or declined the Pneumococcal Vaccine. On 1/9/2026 at 12:39 PM, the surveyor interviewed the facility Infection Preventionist (IP) who stated that providing residents with immunizations was the responsibility of the IP. She stated that she offered flu/pneumonia vaccines and obtained consents and declinations. When asked what would happen if a resident had a low BIMS score, the IP told the surveyor they should not sign the form and reached out to the guardians for consent. On 1/9/2025 at 2:19 PM, the surveyor, in the presence of the Regional Clinical Director (RCD), the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the survey team, acknowledged that they were not able to produce any evidence that Resident #6 received or declined the Pneumococcal Vaccine. In addition, when asked if a resident with a BIMS of 0, an implemented care plan of impaired cognition, and psychiatrist documentation of being confused and only oriented to name had the ability to refuse vaccines, the facility responded that Resident #6 was their own guardian. The surveyor again questioned if that was possible given the facility documentation. The RCD stated that this consent should have proceeded to the IDT (interdisciplinary team) and the Physician as to whether or not it should have been administered. b.)A review of the admission Record (admission summary) reflected that Resident #41 was admitted to the facility with diagnoses that included but were not limited to: unspecified dementia, bipolar disorder, and osteoarthritis. A review of the comprehensive Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 11/23/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS also indicated that the resident was independent with all aspects of activities of daily living (ADL's). On 1/9/2026 at 11:32 AM, the surveyor reviewed the Electronic Medical Record (EMR) to verify the vaccination status for Resident #41. The EMR revealed that Resident #41 did not have the flu vaccination for flu season 2025. The facility provided the surveyor with an influenza consent form dated 12/1/25, which indicated Resident #41 had signed consent to receive the influenza vaccine. The consent also reflected documentation of the site and location the flu vaccination was administered, the manufacture date, lot number and expiration date of the flu vaccine vial that was administered to the resident. The consent was not completed and there was no documented evidence that the facility asked the resident pertinent health questions prior to administration of the vaccination. The surveyor reviewed the resident's EMR and there was no documented evidence that a physician's order was obtained prior to the administration of the vaccination, nor was there documentation in the progress notes or Medication Administration Record (MAR) that verified that the resident received the vaccination. In addition, there was no documentation in the EMR that the resident was monitored for side effects post administration of the vaccination. On 1/9/2026 at 11:51 AM, the surveyor interviewed Resident #41 who verified that the flu vaccination was administered to him/her during the 2025 flu season. The surveyor reviewed the comprehensive MDS dated [DATE], which indicated that Resident #41 had the flu vaccination for the 2024 flu season, not the 2025 flu season. On 1/9/2026 at 12:39 PM, the surveyor interviewed the facility Infection Preventionist (IP) who stated that providing residents with immunizations was the responsibility of the IP. She stated that she offered flu vaccines and obtained consents and declinations. She stated that it was the responsibility of the IP to obtain a physician's order, check the residents' vital signs (VS) prior to and for 72 hours after the administration to monitor for side effects. She stated that it should be documented in the MAR. On 1/12/2026 at 11:00 AM, the surveyor interviewed the facility Director of Nursing (DON) who stated that the resident first declined the flu vaccination but then agreed to have the vaccination. According to the DON, the former IP administered the flu vaccination to Resident #41, however, failed to document in the medical record that the vaccination was given. She also confirmed the former LPN/IP did not get a physician's order for the vaccination and did not document the vaccination administration in the MAR. A review of the facility's Pneumococcal Vaccination policy, dated/revised: 10/22/2025, included: 1. Prior to or within (5) working days after admission, residents will be assessed for eligibility to receive pneumococcal vaccine and when indicated will be offered and provided the vaccine within thirty (30) days of admission to the facility unless medically contraindicated, the resident refuses, or the resident is not eligible to receive [.]. A review of the facility's Influenza Vaccine policy, dated/revised: 8/22/2024, included under the title Residents: 2a. Resident without decision making capacity and who have no resident representative will be immunized with the influenza vaccine annually as ordered by their healthcare provider unless medically contraindicated [ .]. A review of the facility's, Influenza Vaccine policy, dated 9/26/2024 (C-IC-5), indicated that the facility shall provide the resident vaccine Information Sheet (VIS) and documentation of the education would be maintained in the resident's clinical record. The policy also indicated that the facility licensed nurses would contact the healthcare providers for influenza vaccination orders for their residents. The policy indicated that the influenza immunizations would be administered by licensed nurses in accordance with standards of states Nurse Practice Act. For residents who receive the vaccination the following information would be included in the resident's medical record: education was provided regarding the benefits and potential side effects of the vaccine. NJAC 8:39-19.4(h), (i), (j)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a.) respiratory equipment was stored in an appropriate way to prevent the spread of infection, and b) a physician's order (PO) was obtained for necessary treatment for 2 of 3 residents (Resident #110 and #184) reviewed for respiratory care.This deficient practice was evidenced by the following:On 1/5/2026 at 10:26 AM, the surveyor observed Resident #184 in the bed with a C-PAP (Continuous Positive Airway Pressure) machine (a common treatment for sleep apnea that uses pressurized air delivered through a mask to keep your airway open during sleep, improving breathing, and overall health by preventing pauses in breathing which consisted of a motor, a hose, and a mask (nasal or full-face) that delivers a steady stream of air) on the nightstand next to them. The C-PAP mask was uncovered and touched the surface of the nightstand.At that time, Resident #184 stated that they last used their C-PAP one day last week, and they typically used it a couple of times per week.On 1/6/2026 at 9:53 AM, the surveyor made a follow-up visit to the resident's room. The C-PAP was still uncovered. The resident stated that they did not use it on the night of 1/5/2026.A review of the admission Record, an admission summary, revealed the resident had a diagnosis which included, but was not limited to, anemia (a condition marked by deficiency of red blood cells or of hemoglobin in the blood). The admission summary did not include obstructive sleep apnea.A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/28/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 10/22/205, that the resident was at risk for alteration in respiratory status related to shortness of breath. Interventions included but were not limited to: elevate the resident's head of bed to help alleviate shortness of breath. The interventions did not identify C-PAP use. A review of the Order Summary Report (OSR), dated as of 1/6/2026, did not include a physician's order for a C-PAP. A review of the Consultant Pulmonologist Progress Note (CPPN) dated 12/31/2025 at 2:58 PM, revealed that the resident had obstructive sleep apnea and was on a C-PAP and should continue using the C-PAP at night. On 1/8/2026 at 12:22 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 who stated that the C-PAP mask should be cleaned daily once the resident was finished using it. She further stated that after the mask was cleaned and dried, it should be placed in a plastic bag with the resident's name written on the bag. On 1/8/2026 at 12:41 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who stated that the C-PAP mask should be placed in a plastic bag when it was not in use. She further stated that there should have been a physician's orders for the C-PAP use, setting, and maintenance.On 1/8/2026 at 1:46 PM, the surveyor interviewed the Director of Nursing (DON) who stated that physician orders for the C-PAP should have been obtained upon admission to the facility. She further stated that the C-PAP mask should have been bagged when not in use.2. On 1/5/2026 at 11:11 AM, the surveyor observed resident #110 in their room, sitting on the bed. A nebulizer machine (a machine that turns liquid medicine into a fine, inhalable mist, allowing it to be breathed directly into the lungs through a mouthpiece or mask to treat respiratory conditions like asthma, wheezing, and shortness of breath) on the nightstand with the face mask on the machine and opened to the air. The resident stated that they last received medication via the nebulizer a couple of days ago.On 1/6/2026 at 9:38 AM, the surveyor conducted a follow-up visit to the resident's room. Resident #110 was observed in their room, sitting on the bed. The nebulizer mask was still uncovered and opened to air.On 1/6/2026 at 11:10 AM, the surveyor reviewed Resident #110's medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to: chronic obstructive pulmonary disease (COPD) a progressive lung condition causing airflow blockage leading to shortness of breath, cough with mucus, wheezing, and chest tightness, anemia (a condition marked by deficiency of red blood cells or of hemoglobin in the blood).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/26/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 2/5/2024 that the resident had an alteration in respiratory system related to COPD. Interventions included but were not limited to; administer treatments (nebulizer) and medication per doctor's orders, incentive spirometry (use to help take slow, deep breaths to expand your lungs, prevent lung infections, clear mucous, and improve breathing) as ordered.A review of the Order Summary Report (OSR), dated as of 1/5/2026, revealed the following POs:A PO, dated 8/25/2024, to change and date the nebulizer kit and storage bag once per week.A PO, dated 8/19/2024, to rinse and disinfect the nebulizer equipment after each use and to wash the pieces with warm soapy water.Further review of the OSR did not reveal orders for the DuoNeb or a PO for the incentive spirometer.A review of the CPPN (Consultant Pulmonologist Progress Note), dated 12/10/25, revealed that the resident should continue with DuoNebs (a medication administered via a nebulizer for controlling symptoms such as wheezing, shortness of breath, and asthma).A further review of the CPPN, dated 12/10/25, revealed that the resident should continue with incentive spirometry.On 1/6/2026 at 11:53 AM, the surveyor interviewed LPN #4 who stated that Resident #110 was getting breathing treatments via the nebulizer. She then went to the medication cart and pulled out a three-milliliter vial of ipratropium bromide albuterol sulfate and stated that the resident was getting that medication via the nebulizer. LPN #4 then pulled up the resident's medical record and stated that the resident did not have a current order for the DuoNeb or any medications that needed to be administered via the nebulizer, and she did not know what happened to the physician's order. She then stated that she did not recall the last time that she personally administered that medication to the resident.At that time, LPN #4 further stated that the care plan guides the care needed for the resident and it should have been implemented. She added that the nebulizer mask should have been covered for infection control purposes.On 1/6/2026 at 12:18 PM, the surveyor, accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM) #2, went to the resident's room. She confirmed that the nebulizer mask was on the nightstand, uncovered and open to air.At that time, LPN/UM #2 stated that all medications administered required a physician's order. She also stated that the care plan should be current and followed.On 1/6/2026 at 1:23 PM, the surveyor interviewed the Attending Physician (AP) who stated that typically he followed the consultant recommendations unless the resident does not want the medication. He further stated that he spoke with the resident after surveyor inquiry, and they would like to continue with the nebulizer treatments. He added that any medications administered should have a doctor's order. He also noted that sometimes the orders just drop off. He added that if the resident needed an order for medication, he should have been notified.On 1/7/2026 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nebulizer masks should be in a bag and it should not have been lying on the counter for infection control reasons. She further stated that the nurse should have reviewed the consultant pulmonologist recommendations and notified the physician to obtain orders if the physician was in agreement. She also added that the communication should be documented in the medical record. She further noted that if the consultant made a recommendation for something and it was not addressed, that would be considered a missed order. The DON also stated that all medications required a physician's order.A review of the facility's Health Care Provider (HCP) Consultations, policy, reviewed 7/2025, included, The attending HCP will review the appropriateness of the consultant's recommendations relative to the resident current condition, risk factors, existing medication regimen, etc.The attending HCP is responsible for all orders and should remain involved with any aspect of care for which a consultant is involved; .As appropriate, the attending HCP will approve orders based on consultant recommendations.A review of the facility's Medication Orders policy, last revised 9/2020, included, Medications shall be administered only upon the written/or entered order of a person duly licensed and authorized to prescribe such medications in this state .A review of the facility's Nebulizer (small volume) Medication policy, last revised 8/27/2025, included, .store dried equipment in a labeled plastic bag.Once treatment series for resident is completed, remove the nebulizer equipment from the resident's room, clean and disinfect following manufacturer's instructions for useNJAC 8:39-27.1(a), 19.4(a)

Based on interviews and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to ensure that the Administrator ensured that two staff that were currently working as Assistant Administrators were licensed as Nursing Home Administrators (NHA) per the facility's Job Description for Assistant Nursing Home Administrator. On 11/01/24, at 10:20 AM, the surveyor completed the entrance conference with Assistant Administrator (AA) #1, who stated that he had worked at the facility for 2.5 months. On 11/01/24, at 2:20 PM, Surveyor #1 requested a copy of Nursing Home license from AA #1 and AA #2. AA #1 stated that he was licensed in New York and not in New Jersey. AA #2 stated that he did not have a Nursing Home Administrator License. Both AA #1 and AA #2 stated that their job titles at the facility were Assistant Nursing Home Administrator. On 11/01/24, at 2:43 PM, AA #1 verified that he is a licensed Administrator in New York, and not in New Jersey. A copy of the license was provided for review. 48618 Surveyor #2 reviewed the undated, Hammonton Center Job Description for an Assistant Nursing Home Administrator which revealed the following under the Minimum Requirements section, This position requires the incumbent to be licensed as a Nursing Home Administrator . The license must be in good standing . On 11/04/24 at 1:35 P.M., Surveyor #2 interviewed the Administrator who stated that he was aware that AA #1 and AA #2 were not licensed in the State of New Jersey as NHAs. In the presence of the surveyor, the Administrator reviewed the Hammonton Center Job Description for Assistant Nursing Home Administrator and stated, Oh I see it. The Administrator did not add any additional information. N.J.A.C.: 8:39-9.3(a), (4)

COMPLAINT #: NJ00179283 Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident that included action taken by staff to educate the resident regarding alternatives and consequences. The facility also failed to follow its Care Plans - Comprehensive policy. The deficient practice was identified for 1 of 9 residents (Resident #9) reviewed for CP and was evidenced by the following: On 11/06/24 Surveyor #2 observed Resident #9 seated in a wheelchair dressed in a sweatshirt and pants. The resident was self-propelling the wheelchair out of the elevator onto the first floor. The resident stated recalling a recent incident that involved him/her and another resident. Surveyor #2 reviewed Resident #9's Admission Record which revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain), cognitive communication deficit, and adjustment disorder. Surveyor #2 reviewed Resident #9's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/07/24, which revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Surveyor #2 reviewed Resident #9's progress notes which contained a social service note that revealed: 10/31/24 at 3:24 PM: IDT met on this date . Smoking was suspended for 2 days. [Resident #9] was found out back again by staff smoking a cigarette. [He/She] is now suspended for 7 days. Surveyor #2 reviewed a Smoking Violation Notice which was provided by the facility for Resident #9, dated 10/30/24. Under the Intervention(s) section, two items were checked: Room search as needed, and Other 2 days. Surveyor #2 reviewed Resident #9's CP which revealed that the resident had a focus that indicated that the resident was a smoker that was initiated on 02/13/24. Under the Interventions section, revealed that staff were to, Reeducate as needed to facility smoking rules/policy, which was initiated on 02/13/24. Further review of the CP showed no additional revision or updates. On 11/06/24, at 1:45 P.M., Surveyor #2 interviewed the Director of Social Services (DSS) who stated that she recalled catching Resident #9 smoking in a non-designated smoking area. She stated that Resident #9 handed the item to her, which she destroyed. The DSS further added that the resident agreed to a room search and was suspended from smoking for two days, and that this was obtained in writing. The surveyor asked the DSS if she was responsible for updating care plans, to which she stated, I do not update care plans and I have never been instructed to do so. On 11/06/24, at 2:47 PM, Surveyor #2 interviewed the Director of Nursing (DON) who stated that Resident #9's care plan should have been updated to reflect the incident that occurred on 10/30/24. Review of the facility's Care Plans - Comprehensive policy, reviewed 08/02/24, revealed a Procedure section that included, 8. The comprehensive, person-centered care plan will: .f. Incorporate identified problem areas; g. Incorporate risk factors associated with identified problems . NJAC: 8:39-11.2(i); 27.1(a)

Based on observation, interview, and review of other faciloirty documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: A review of the facility policy titled Food Storage, Last Date Revised [DATE], revealed the following under the heading POLICY: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The following was revealed under the PROCEDURE section: 10. Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 12. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within ,d+[DATE] hrs (hours). Check state regulations as state regulations may allow shorter time frames for use of leftovers. 13. Refrigerated food storage: a. All refrigerator units will be clean and in good working condition at all times. b. TCS (temperature control for safety) foods must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 F. Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day. c. Every refrigerator must be equipped with an internal thermometer. f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 14. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All frozen leftovers must be used within 30 days. The surveyor reviewed the facility provided copy of the Daily Cleaning Schedule for the facility kitchen, undated. Review of the schedule did not include cleaning of the reach-in refrigerator daily. The surveyor reviewed the facility policy titled Dish Washing and Storage Policy, Last Date Revised: [DATE]. The following was revealed under POLICY: Dishes, pot and pans will be washed and dried using procedures, chemicals and equipment that result in clean, sanitized dishes, pans, flatware, and utensils. The policy revealed the following under the heading PROCEDURE: Dish Machine Washing: 3. Dish machine temperatures are logged at each meal on the Dish Machine Temperature log. 4. Staff will monitor dish machine temperatures throughout the dishwashing process b. Low Temperature Dishwasher: Spray Type Dish Machine Using Chemicals to Sanitize Minimum Wash Temperature: 120 F Final Rinse Temperature 120 F and sanitization 50 ppm Hypochlorite (chlorine). Dishes, pots, pans, utensils and flatware must be air dried before being stored, Do not dry with towels. 7/ Employees are trained in proper dishwashing and drying procedures. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur. The surveyor reviewed the facility policy titled FOOD FROM OUTSIDE-SAFETY, Last Date Revised: ,d+[DATE]. The following was revealed under the Monitor section: Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy. On [DATE] from 9:17 to 9:50 AM, the surveyor in the presence of the facility Registered Dietitian/Nutritionist (RDN), observed the following in the kitchen: 1. On an upper shelf/rack in the walk-in freezer a package of frozen sausage was removed from its original container and had no dates. In addition, a clear garbage size bag contained what appeared to be frozen zucchini slices. The bag had no dates. 2. In the walk-in refrigerator a previously opened clear plastic bag on a middle shelf contained chopped lettuce. The bag had a manufacturer's best if used by date of [DATE]. On the same shelf, a clear plastic bag contained chopped lettuce and carrots. The lettuce appeared slimy, and the bag had a manufacturer's best if used by date of [DATE]. On an upper shelf a 10 pound container of [NAME] slaw had been previously opened. The [NAME] slaw had a manufacturer's Best If Used By date of [DATE]. 3. The surveyor approached the designated hand washing sink to get a paper towel to perform hand hygiene. There were no paper towels in the wall mounted paper towel dispenser. 4. A white refrigerator/freezer in front of the dietary office had no internal thermometer in the freezer to monitor freezer temperatures. In addition, styrofoam take-out style container in the refrigerator that contained unknown food contents had no dates. A dietary aide (DA) threw the container in the trash. On [DATE] at 08:46 AM, on the 2nd Floor Pantry (2A hallway) the surveyor, accompanied by the facility Infection Preventionist (IP) observed the following: 1. In the bottom left drawer of the pantry refrigerator, used to store resident food and beverage, (19) 4oz containers of Thick & Easy moderately thick/honey consistency thickened waters used for residents had a Use by Jun 22, 24 manufacturer's label. In addition, four (4) more containers of the same product were observed on the lower shelf of the refrigerator door and had Use By Jun 22, 24 manufacturer's date. According to the IP on interview it (thickened beverages) was normally kept in the nutrition closet on the unit and then the nurses would stock the fridge as needed. The surveyor asked the IP who was responsible for ensuring the use by dates of products in the pantry refrigerator. The IP replied, The nurse is absolutely responsible for checking the use by date when stocking the fridge. The IP removed the expired thickened waters to the trash. On [DATE] from 09:53 to 10:23 AM the surveyor, accompanied by the Food Service Director (FSD), observed by the following in the kitchen: 1. In the three compartment sink/manual dish washing area a DA was actively washing pots and pans. Observation of the pot/pan drying rack revealed (4) quarter pans stacked on top of each other. The surveyor lifted the top pan and observed a wet/watery, clear substance on the bottom of the pan below (wet nesting, occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The FSD agreed the pans were not air dried prior to stacking and instructed the DA to rewash and air dry the quarter pans before stacking. 2. At approximately 10:00 AM, kitchen staff were actively using the low temperature dish machine after the breakfast meal. When asked to see the dish machine temperature log the FSD stated, It's hanging on the wall. (opposite wall of dish machine). Observation of the temperature log revealed that no wash/rinse or sanitizer ppm levels (parts per million) had been recorded for the breakfast on [DATE]. The kitchen had a low temperature dish machine, according to the FSD and it had a minimum wash and final rinse temperature of 120 Fahrenheit (F). The FSD told the surveyor that they used chlorine as the sanitizing agent. At that time the facility had cleaned several racks of pellet bottoms and lids and several racks of hard plastic trays used to serve resident food. Upon observation of the sanitizer container mounted on the wall (a sanitizing agent that utilizes sodium hypochlorite to sanitize dishware) the FSD stated that it was empty. The FSD then went to the DA at the three compartment sink and asked for another bottle of sanitizer. The DA handed the FSD an approximate half bottle of sanitizer from the designated chemical closet and stated that he had more down stairs. After replacing the empty bottle of sanitizer, the FSD restarted the dish machine, and a DA assisted the surveyor in putting an empty plastic pellet lid in the plastic dish rack and the FSD then proceeded to run the rack through the wash and rinse cycle which was observed at 120 F. The rack that contained the pellet lid exited the dish machine after going through a full wash and rinse cycle. The FSD obtained a white chlorine test strip and dipped the test strip into the dishwater that had collected in the pellet lid from the wash and rinse cycle. The test strip remained white after dipping it into the collected dish machine water, indicating that no chlorine was present or 0 ppm. The surveyor then requested the FSD to attempt a second test of the sanitizer by passing the pellet lid in the dish rack through the machine a second time. The FSD dumped the previous dish water from the pellet lid. Upon placing the rack in the machine, the surveyor and FSD observed that the pump for the chlorine sanitizer was not pulling the sanitizer completely through the wall mounted pump and the chlorine sanitizer remained in the pump tubing, which was visible through the clear tubing and was unable to enter the dishwater to sanitize dishes. The FSD shut down the dishwasher at this point and told the surveyor they would contact the foodservice contract company to do necessary repairs. The surveyor told the FSD that all trays and pellet lids that had been washed would have to be rewashed and sanitized. The FSD agreed. The surveyor re-visited the kitchen at approximately 11:30 AM and the repair service had not arrived at that time. The surveyor observed the kitchen dish room, and all dish washing could be confirmed as stopped when the FSD shut down the dish machine. The FSD stated that paper products will be used for the lunch meal and until the machine is repaired. A review of the service invoice dated [DATE]T16:03:00, revealed the following: Final rinse sanitizer not working. Replaced a bad injector fitting and chemical line. Issue resolved. The sanitizer was test (sic) and adjusted to ,d+[DATE] ppm. 2. Observation of the floor of the reach-in refrigerator revealed an approximate ,d+[DATE] to ,d+[DATE] inch level of clear liquid fluid on the floor of the refrigerator. When asked what the fluid was the FSD stated, The line is leaking. We need to get a new refrigerator, but we have been using a shop type vacuum to remove the water. It just really started to leak. Beverages (iced tea containers) were observed to be above the level of the water on the bottom of the fridge. No active leakage was observed by the surveyor. NJAC 18:,d+[DATE].2(g)

NJ COMPLAINT #: 169607 Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete a significant change in status assessment using the Resident Assessment Instrument (RAI) process for a resident who elected hospice services. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #565), and was evidenced by the following: A review of facility's Electronic Submission of MDS policy dated revised August 2023, included that all MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data .a Significant Change in Status (SCSA) Comprehensive has a MDS Completion Date is the 14th calendar day after determination of significant change in status . A review of the facility's Centers Health Care MDS Coordinator Job Description document dated 12/6/22, included . Complies with federal and state regulations regarding completion and coordination of the RAI process. Maintains the frequent and accurate data entry of resident information into appropriate computerized MDS programs. The surveyor reviewed the medical record for Resident #565. A review of the Admission Record Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses including but not limited to; Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), metabolic encephalopathy (problems with your metabolism cause brain dysfunction) and dysphagia (difficulty swallowing). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 12/7/23, revealed the resident had a brief interview for mental status (BIMS) score of 8 out of 15, which indicated moderately impaired cognition. Section I - Active Diagnoses of the MDS revealed Resident #565 had an active diagnosis of Alzheimer's disease. According to section O - Special Treatments, Procedures, and Programs revealed Resident #565 received hospice care (provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) while a resident. A review of the current physician's order sheet (POS) included a physician's order (PO) dated 11/17/23, for hospice evaluation and treat. The POS reflected a physician's order dated 11/18/23, for Hospice Services related to Alzheimer's disease. A review of the Progress Notes dated 11/20/23, included documentation that the resident was admitted to hospice care on 11/18/23, with a diagnosis of Alzheimer's disease. A further review of the MDS assessments revealed Resident #565 had a quarterly MDS completed on 12/7/23. There was no documentation that the facility completed a significant change in status assessment (SCSA) within 14 days after the resident was admitted to hospice care on 11/18/23. During an interview with the surveyor on 7/29/24 at 1:40 PM, the MDS Coordinator stated that she was made aware of significant changes with a resident during morning meetings or the unit manager informed her verbally. The MDS Coordinator stated that a significant change in status was completed when there was a decline in the resident's status that was permanent or if a resident was placed on hospice. She also stated it should be completed within 14 days from discovery of the significant change in status. The MDS Coordinator confirmed that Resident #565 was admitted to hospice care on 11/18/23, and that a SCSA MDS was not completed. During an interview on 7/30/34 at 1:38 PM, the Director of Nursing in the presence of the Licensed Nursing Home (LNHA) and the survey team, stated when the resident was placed on hospice care, a SCSA MDS should have been completed within 14 days of the change. The surveyor reviewed the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, updated October 2023, which revealed a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). NJAC 8:39-11.2(i)

Complaint #: NJ00173786 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify in writing, the representative of the New Jersey Long-Term Care Ombudsman's office (LTCO) of resident emergency transfers to the hospital/discharges, when practicable, as mandated by Federal law. This deficient practice was identified for 2 of 37 sampled residents (Resident #54 and Resident # ADD NUMBER) and was evidenced by the following: On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO. 1. On 07/22/2024 at 01:29 PM, the surveyor reviewed the Electronic Medical Record (EMR) for Resident # 54 which revealed the following: Resident # 54 was admitted to the facility with diagnoses including but not limited to: Urinary Tract Infection, Urinary Calculus (kidney stones), and Hydronephrosis (excess fluid in the kidney due to a backup of urine). A review of the Discharge Return Anticipated Minimum Data Set (DRAMDS) revealed under the Entry/Discharge reporting section that Resident #54 was discharged with return anticipated on 2/28/2024, 3/27/2024, 4/19/2024 and on 6/20/2024. 2. On 07/24/2024 at 10:20 AM, the surveyor reviewed the EMR for Resident #516 which revealed that the resident was admitted to the facility with diagnosis that included, but not limited to: Osteoarthritis of left shoulder (degenerative joint disease), Diabetes Mellitus, Chronic Obstructive Pulmonary Disorder (long-term lung disease that makes it hard to breathe). A review of the DRAMDS revealed under the Entry/Discharge reporting section that Resident #516 was discharged with return anticipated on 2/1/24. During an interview with the surveyor on 07/24/2024 at 09:26 AM, the Director of Social Work (DSW) said he has been here a few months. When asked if he was responsible to send resident discharges to the hospital to the LTCO the DSW replied since he has been here, he has not sent any notifications to the LTCO of resident discharges to the hospital. He said I wasn't told I had to do that here. I am familiar with the process. During a follow-up interview with the surveyor on 07/24/2024 at 09:28 AM, the DSW said I don't send OMB (ombudsman) notifications. During an interview with the surveyor on 07/24/2024 at 09:31 AM the Assistant Administrator (AA) said the Social Worker (SW) is responsible to send notification to the LTCO office when residents are discharged to the hospital as well as send a monthly list. On 07/24/2024 at 10:25 AM, the AA told the surveyor he found the binder in the SW office, and it has not been done since the new SW started. On 07/24/2024 at 10:33 AM, a review of the binder provided by the facility contained a form titled Discharge Log by each Month. The form indicated resident name, discharge date , columns for Home, SNF (Skilled Nursing Facility), ALP (Assisted Living), AMA (Against Medical Advice), other as well as Home Care and DME company used. There was no column that indicated a discharge to the hospital. There was no documentation regarding the LTCO being notified of hospitalization s. During a follow-up interview with the surveyor on 07/24/2024 at 11:56 AM, the AA said It doesn't look like they were sending notifications of the discharged residents to the hospital, just AMA and discharged to home. We will now be notifying the LTCO of residents discharged to the hospital. On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO. NJAC 8:39-4.1(a) 32 45209

Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident # 140 and Resident # 162. This deficient practice was evidenced by the following: A review of a facility policy on 07/29/2024 at 8:32 AM, titled Notice-Advanced Beneficiary Notice (ABN) with a creation date of 7/2019, revealed under the Policy section; The Advanced Beneficiary Notice of non-coverage (ABN) is issued by the facility to original Medicare (fee for service-FFS) beneficiaries in situations where Medicare payment is expected to be denied. Medicare requires SNF's (Skilled Nursing Facilities) to issue SNFABN to Original Medicare, also called FFS beneficiaries prior to providing care that Medicare usually covers but may not pay for in this instance because the care is: not medically reasonable and necessary or considered custodial. On 07/23/2024 at 01:45 PM, the surveyor requested 3 random residents, 1 resident who went home and 2 residents who remained in the facility beneficiary notification forms from the Assistant Administrator (AA). On 07/24/2024 at 12:29 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility as follows: 1. A review of the SNFBPNR for Resident #140 indicated that the last covered Medicare Part A Day was 04/12/2024 and the resident remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #140. There was no documentation to indicate why the form was not given to Resident #140. 2. A review of the SNFBPNR form for Resident #162 completed by the facility indicated that the last covered Medicare Part A Day was 06/24/2024. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #162. There was no documentation to indicate why the form was not given to Resident #162. During an interview with the surveyor on 07/24/2024 at 12:42 PM, the Assistant Administrator said that Director of Rehab and MDS (Minimum Data Set) helped out giving notifications to residents cut from Medicare Part A. During an interview with the surveyor on 07/24/2024 at 01:07 PM, the Director of Rehabilitation (DOR) said I give part B cut letter and Social Service is responsible for Part A notifications. In recent months the MDS coordinator has helped out. During an interview with the surveyor on 07/24/2024 at 01:11 PM, the MDS coordinator said I have not been giving them. They took them away from me few years ago. During a follow-up interview with the surveyor on 07/24/2024 at 01:15 PM, the surveyor reviewed that residents who remained in the facility should have received a SNFABN. The AA said I know the form and will follow up. On 07/25/2024 at 09:21 AM, the surveyor confirmed with the AA that 100% the SNFABN was not given to the residents. NJAC 8:39-4.1(a)(7)

Complaint # NJ164849 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to A.) administer physician ordered insulin timely for 18 of 45 residents who receive diabetic medication. This occurred on 2 floors on 4 of 8 units. Failure to administer the prescribed Insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglemic reaction, hospitalization and possible death. On 6/11/2023 at 10:38 AM, Licensed Practical Nurse (LPN) #1 who was assigned to first floor C hall, had not completed her medication pass within the acceptable timeframe parameters. LPN #1 had not administered Insulin and/sliding scale insulin to include blood sugars for 2 residents (Resident #9 and Resident #10) that were due at 7:30 AM. On 06/11/2023 Unit Manager LPN #1 arrived to 1st floor D unit to complete the medication pass. This included 4 residents (Resident #4, Resident #6, Resident #7 and Resident #8) on insulin/sliding scale Insulin and blood sugars due at 07:30 AM. On 06/11/2023 at 10:33 am and 11:04 am, LPN #3 was administering medications on the 2nd floor C wing. LPN #3 confirmed that medications were being given late including Resident #1 who received insulin. In addition, Resident #49, #50, #51, #66 and #70 all received their am accuchecks and/or insulin past physican ordered parameters on 6/11/23. On 6/11/2023 at 11:01, LPN #5 (2nd fl) confirmed that she had not yet administered physician ordered insulin which was due at 07:30 AM for Resident #2. LPN #5 confirmed she had not yet completed her morning medication pass. Interviews with Residents on 1st floor B unit revealed there was no nurse on the unit on 06/10/2023 and they had not received their scheduled Insulin dose or blood sugars due at 07:30 AM and 11:30 AM on 06/10/2023. LPN #3 who refused to take the assignment of 1st floor B unit on 6/10/2023, which included residents on prescribed Insulin, continued to work on 06/11/2023. This resulted in an Immediate Jeopardy (IJ) situation which was identified on 06/11/2023 when the facility licensed staff failed to administer prescribed Insulin. The facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified of the IJ on 06/11/2023 at 05:37 PM. A removal plan was received on 06/12/2023 and was verified by the surveyor on 06/13/2023 at 2:16 PM. The facility also B.) failed to administer all medications prescribed for the residents by the physician in accordance with acceptable standards of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; the practice of nursing as a Registered Professional Nurse is defined as diagnosing, and treating human response to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/11/23 at 11:08 am, Surveyor #2 asked both LPN #1 and Unit Manager LPN on the 1st floor which residents had not yet received their morning medications. The nurses provided Surveyor #2 with the names of those residents who had not yet received their morning medications to include Insulin and blood sugars that were due at 07:30 AM and 08:00 AM. On 6/11/23 at 11:04 am and 11:01 am, both LPN #3 and LPN #5 confirmed that medication passes for 2 units on the 2nd floor had not yet been completed. LPN #3 and #5 confirmed that medication was to be given at the physican ordered time and nurses had 1 hour (hr.) prior to and 1 hr. after that time to administer medications. 1. Resident #1 (2nd floor) was admitted to the facility with diagnoses including but not limited to: Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD). a. A review of the current Order Summary Report (OSR) revealed the following physician orders; HumaLOG Subcutaneous Solution 100 UNIT/ML (milliliters) (Insulin Lispro) Inject as per sliding scale: if 150 - 200= 2 unit; 201 - 250 = 4 unit; 251 - 300 = 6 unit; 301 -350 = 8 unit; 351 - 4001 = 10 unit, subcutaneously before meals for Diabetes Mellitus (DM) NOTIFY MD if BS is above 400 and below 70, check before meals. A review of the 6/2023 Medication Administration Record (MAR) confirmed the order for the aforementioned medication and noted it was scheduled to be administered on 6/11/23 at 7:30 am. Review of the MAR revealed the Humalog Subcutaneous Solution (insulin)10 units was documented as administered at 7:30 am with a BS of 365. Review of the facility electronic Medication Admin Audit Report (MAAR) revealed the insulin was administered at 10:16 am (1 hr. 46 min late). During an interview with the surveyor on 6/11/23 at 4:50 pm, Resident #1 confirmed that he/she received his/her Blood Sugar (BS) check and insulin late, at around 10:30 am. Resident #1 stated that ususally his/her medications are administered late. 2. Resident #2 (2nd floor) was admitted to the facility with diagnoses including but not limited to: Type 2 DM with Foot Ulcer and COPD. a. A review of the current OSR revealed the following order; Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 9 unit subcutaneously before meals for DM. A review of the 6/2023 MAR confirmed the aforementioned order and noted it was scheduled to be administered on 6/11/23 at 7:30 am. Review of the MAAR revealed the insulin was administered at 11:21 am (2 hr. 51 min late). During an interview with the surveyor on 6/11/23 at 4:55 pm, Resident #2 did not remember getting insulin that morning. Resident #2 stated most days medications are given late. b. A further review of the OSR/MAR and MAAR for Resident #2 revealed: Turmeric Oral Capsule 500 MG Give 1 capsule by mouth one time a day for supplement scheduled 7:00 am-10:00 am was given at 11:19 (19 min. late) Farxiga Oral Tablet 10 MG scheduled 7:00 am-10:00 am was administered at 11:19 am (19 min late) CetirizinenHCL Tablet 10 MG Give 1 tablet by mouth one time a day for Allergy symptoms, scheduled 7:00 am-10:00 am was administered at 11:18 am (18 min. late) Cholecalciferol Tablet 1000UNIT Give 2 tablet by mouth one time a day for supplement 2 tablets=2000mg, scheduled 7:00 am-10:00 am was administered at 11:19 (19 min late) Aspirin EC Tablet Delayed Release 81 MG Give 1 tablet by mouth one time a day, scheduled 7:00 am-10:00 am was administered at 11:17 (17 min late) Furosemide Oral Tablet 40 MG Give 1 tablet by mouth one time a day for Hypertension (HTN) scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late) Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day for supplement, scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late) Folic Acid Oral Tablet 1 MG Give 1 tablet by mouth one time a day for supplement, scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late) Metformin HCL Tablet 850 MG Give 1 tablet by mouth two times a day for DM. Take with breakfast and dinner, scheduled 7:30 am was administered at 11:14 (2 hr. 44 min late) Entresto Oral Tablet 97-103 MG Give one tablet by mouth two time a day for heart failure, scheduled 9:00 am was administered at 11:17 (1 hr. 17 min. late) Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for HTN hold SBP (systolic blood pressure)< 110, scheduled 9:00 am was administered at 11:21 (1 hr. 21 min late) TIZANidine HCL Tablet 2 MG Give 1 tablet by mouth three times a day for muscle relaxant/back pain, scheduled 10:00 am was administered at 11:14 (14 min late) 3. Resident #3 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease (ASHD), Peripheral Vascular Disease, Old Myocardial Infarction (Heart Attack), Local Infection of the Skin and Subcutaneous Tissue, Essential Hypertension (HTN), and Major Depressive Disorder. A review of the current Order Summary Report (OSR) revealed the following physician orders: Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: is 0-150=0 unit; 151-200 =2 unit; 201-250=4 unit, 251-300=6 unit; 301-350 =8 unit; 351-400=10 unit. If BS (blood sugar) is less than 70 or greater than 401 notify MD (medical doctor) subcutaneously before meals and at bedtime A review of the MAR for 6/1/2023-6/30/2023 revealed the Insulin Lispro Injection Solution for sliding scale. For the date of 6/10/23 timed at 0730am and 1130am, there was no documentation that the medication had been administered as timed and prescribed. The documented blood sugar at 1730 (5:30 PM) was 400 (normal 70-100). A review of the Medication Admin Audit Report (MAAR) revealed no documentation of the time of the 0730am and 1130am Lispro as having been administered as prescribed on 6/10/23. b. A further review of the OSR revealed: Aspirin Oral Capsule 81mg give 2 capsules by mouth one time a day for supplement Bacillus Coagulans-Inulin Oral Capsule Give 2 capsule by mouth one time a day for irritable bowel syndrome Carvedilol Tablet 3.125mg give 1 tablet by mouth two times a day for HTN Ceftriaxone Sodium Injection Solution Reconstituted 2 GM (grams) Use 2 grams intravenously one time a day for infection for 42 days Sodium Chloride 0.9% intravenous solution 100 ml (milliliter) Cholecalciferol Tablet 1000 units give one tablet by mouth one time a day for supplement Docusate Sodium Capsule 100mg give 1 capsule by mouth two times day for constipation Gabapentin Capsule 100mg give 1 capsule by mouth three times a day for nerve pain Glycolax Powder give 17 grams by mouth one time a day for constipation 4-6 ounces of water 70 or greater than 401 notify MD (medical doctor) subcutaneously before meals and at bedtime Lisinopril Tablet 2.5mg give one tablet by mouth one time a day for hypertension Lovenox Solution 30mg/0.3ml Inject 30mg subcutaneously every 12 hours for blood thinner Metformin HCL Oral Tablet Give 850mg by mouth two times a day for DM (Diabetes Mellitus) Plavix Oral Tablet 75mg give one tablet by mouth one time a day for Coronary Artery Disease Venlafaxine HCL ER Extended Release 24 hour 150mg Give 2 tablet by mouth one time a day for depression A further review of the MAR revealed Metformin timed at 1000, Aspirin timed at 7-10a, Bacillus Coagulans timed 7-10a, Ceftriaxone timed 0900, Plavix timed at 0900, Carvedilol timed at 1000, Cholecalciferol timed at 1000, Docusate Sodium timed at 1400 (2:00PM), Gabapentin timed at 1000 and 1400 (2:00 PM), Glycolax Powder timed at 0900am, Lisinopril timed at 0900, Lovenox timed at 0900, Venlafaxine timed at 0900. A further review of the MAAR revealed that Glycolax Powder, Lovenox, Venlafaxine, Cholecalciferol, Carvedilol, Gabapentin at 1000 and 1400, Metformin, and Docusate Sodium indicated no documentation that the medication had been administered as prescribed on 6/10/23. The MAAR reflected that on 6/10/23 the Bacillus Coagulans, Aspirin was documented as administered at 18:10 (6:10 PM), the CefTRIAXone was documented as administered at 16:20 (4:20 PM), Plavix and Lisinopril were documented as administered at 18:11 (6:11pm). During an interview with the surveyor on 6/11/2023 at 4:45 PM, Resident #3 said when asked if he/she received their blood sugars and/or insulin on 6/10/2023, Resident #3 responded I did not get my blood sugars or Insulin until the second shift came on duty yesterday. We got no meds yesterday. 4. Resident #4 was admitted with diagnoses including but not limited to: Type 2 DM. A review of the current OSR revealed the following physician orders: Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit Call if less than 70 or greater than 400 subcutaneously before meals for DM A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Humalog Solution inject per sliding scale order. On 6/11/23 at 0730 and 1130am was documentation of 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the PN did not include documentation to indicate why the medication was not administered. A review of the MAAR revealed the 0730am ordered Humalog was administered at 12:14pm and the 1130am Humalog was administered at 12:14pm (2 doses at the same time). The MAAR also showed that on 6/10/23 the 0730am and the 1130am doses were documented as having been administered at 1750 (5:50 PM) (2 doses at the same time). 5. Resident #6 was admitted with diagnoses including but not limited to: Type 2 DM. A review of the current OSR revealed the following physician orders: Admelog Injection Solution 100unit/ml (Insulin Lispro) Inject 10 units subcutaneously before meals and at bedtime for DM. Admelog Injection Solution 100units/ml (Insulin Lispro) Inject as per sliding scale: if 201-250 =2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 =8 units call MD if less than 70 or greater than 401, subcutaneously before meals for DM A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Admelog Insulin Inject 10 units subcutaneously before meals and bedtime for DM. On 6/10/23 at 0730am it was documented as a 2, which according to the Chart Codes indicates refused. On 6/11/23 at 0730am and 1130am, was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the PN did not include documentation to indicate why the medication was not administered nor of the resident refusal. A review of the [NAME] revealed the 0730am and 1130am Admelog was administered on 6/10/23 at 13:27 (1:27pm) (2 doses) along with the sliding scale and the 1130am insulin and sliding scale was administered at 1340 (1:40 PM). On 6/11/23 the 0730am insulin and sliding scale was documented as administered at 14:18 (2:18 PM) and the 1130am insulin was documented at 13:28 (1:28 PM). 6. Resident #7 was admitted to the facility with diagnoses including but not limited to: Type 1 DM. A review of the current OSR revealed the following physician orders: Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale: if 0-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units <70 or > 400 call MD subcutaneously before meals and at bedtime. Insulin Glargine Subcutaneous Solution Inject 42 units subcutaneously every 12 hours for DMII. Insulin Lispro Injection Solution 100 unit/ml Inject 10 units subcutaneously with meals for DMII Hole if NPO (nothing by mouth) A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Humalog Solution inject per sliding scale order. On 6/11/23 at 0730 was documentation of 5. According to the Chart Codes 5=Hold/See Nurses Notes. The MAR also indicated that the Insulin Glargine was signed as administered at 9 am by the Unit Manger/Licensed Practical Nurse (UM/LPN#1). The Insulin Lispro on 6/11/2023 was documented as a 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the Medication Admin Audit Report revealed the Humalog and Lispro Insulins were not administered at the prescribed times on 6/10/2023 and 6/11/2023. The audits also reflected that the 9:00 AM dose, that was signed as administered, was documented as having been given at 11:34 AM. 7. Resident #8 was admitted to the facility with diagnoses including but not limited to: Type 2 DM. A review of the current OSR revealed the following physician order: Novolog Injection Solution 100 unit/ml Inject as per sliding scale: 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit subcutaneously before meals for DM Call MD if glucose level < 70 or >400. A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for NovoLog sliding scale. There was no documentation on 6/11/23 at 0730am or 1130am to indicate the blood sugar was taken and the medication administered as prescribed. A review of the PN did not indicate why the insulin had not been administered as prescribed. A review of the Medication Admin Audit Report revealed there was no documentation that the medication had been administered as timed and prescribed. 8. Resident #9 was admitted to the facility with diagnoses including but not limited to: Type 2 DM. A review of the current OSR revealed the following orders: a.Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 units, 251-300= 4 units, 301-350 =6 units, 351-400 = 8 units subcutaneously before meals for DMII Notify MD for BS<70 or>400 A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog sliding scale Insulin. There was no documentation on 6/4/2023 to indicate the medication was administered at 0730am or 1130am as prescribed. On 6/11/23 at 0730am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the Medication Admin Audit Report revealed that the 0730am blood sugar and insulin was administered at 11:01am and the 1130am blood sugar and insulin was administered at 11:02am (2 doses administered). b. A further review of the OSR revealed: Amlodipine 10mg tab (tablet) give 1 tablet orally one time a day for HTN hold SBP<110 Aspirin EC Relayed Release 81mg give 1 tablet by mouth one time a day for CVA (cerebral vascular accident). Calcium Carbonate Oral Tablet 600mg give 1 tablet by mouth one time a day for supplement Carvedilol Oral Tablet 3.125 mg give 1 tablet by mouth two times a day for HTN Colace Oral Capsule 100mg give 1 capsule by mouth one time a day for constipation Duloxetine HCL Oral Capsule Delayed Release Sprinkle 40mg give 1 capsule by mouth one time a day for depression Iron Oral Tablet 325 (65Fe) mg give 1 tablet by mouth every morning and at bedtime for supplement Magnesium Oxide 400mg tab give 1 tablet orally one time a day for supplement Protonix Oral Tablet Delayed Release 40 mg give 1 tablet by mouth one time a day for GERD Psyllium Oral Packet give 1 packet by mouth one time a day for constipation. b. A further review of the MAR revealed that on 6/11/2023 the Duloxetine, Amlodipine, Magnesium, Calcium Carbonate, Iron Tablet, Protonix and Psyllium were timed at 7-10a. The Carvedilol, Colace were timed for 0900am. A review of the PN did not indicate why the insulin had not been administered as prescribed. The MAAR further showed the Duloxetine, Protonix, Iron Oral, Amlodipine, Magnesium, were documented as administered at 11:02am. The Carvedilol and Aspirin were documented as administered at 10:59am. The Colace was documented as administered at 11:00am. 9. Resident #10 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus. A review of the current OSR revealed the following physician orders: a. Insulin Lispro Injection Solution 100unit/ml inject 10 unit subcutaneously with meals for IDDM (Insulin Dependent Diabetes Mellitus) give prior to snack Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: is 0-150=0 unit; 151-200 =2unit; 201-250=4 unit, 251-300=6 unit; 301-350 =8 unit; 351-400=10 unit. subcutaneously before meals and at bedtime for diabetes call MD if below 70 or above 400 give prior to snack. Lantus Subcutaneous Solution 100unit/ml Inject 22 unit subcutaneously two times a day for DM. a. A review of the MAR dated 6/1/2023-6/30/2023 revealed that there was no documentation on 6/3/23 at 0730am, 0800am and 1200pm the Lantus and Lispro insulin nor the blood sugar sliding scale were administered as ordered. On 6/11/23 at 0730am and 0800am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the MAAR revealed that on 6/10/23 the 0730am the Lispro sliding scale was administered at 10:38 AM, the 0730am Lantus was administered at 10:38 AM and the Lispro 10 units was administered at 10:40 AM. On 6/11/23 the 07:30am Lispro sliding scale was documented as administered at 12:55pm, Lantus administered at 12:55pm and the Lispro 10 unit administered at 12:55pm (2doses/ same time). During an interview with the surveyor on 06/11/2023 at 04:50 PM, Resident #10 said he/she did not receive their morning insulin before breakfast. Resident #10 said he/she left their room at 10:30am and the nurse wasn't here and I am supposed to get them before meals. A review of the PN did not include documentation of why the insulin had not been administered. b. A further review of the OSR revealed: Amlodipine Besylate Oral Tablet 5 mg give one tablet by mouth one time a day for HTN hold sbp <110 or hr<60 Notify MD Aspirin 81 Oral Tablet Chewable give 1 tablet by mouth one time a day for analgesic Bactrim Oral Tablet 400-80mg give 1 tablet by mouth two times a day for left hip until 7/15/2023 Bumex Tablet 1 mg give 1 tablet by mouth one time a day for edema Clonidine HCL Oral Table 0.1mg give 1 tablet by mouth every 12 hours for htn hold SBP <110 and HR<60 Coreg 25 mg give 25 mg by mouth every 12 hours for HTN Hold for SBP less than 110 Cyanocobalamin Tablet 1000mcg give 1 tablet by mouth one time a day for supplement Duloxetine HCL Oral Capsule Delayed Release Particles 20mg give 1 capsule by mouth one time a day on odd days for neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). Ferrous Sulfate Tablet 325 (65Fe) mg give 1 tablet one time a day for supplementation/anemia Flomax Oral Capsule 0.4mg give 1 capsule by mouth one time a day for urinary retention Fluticasone Propionate Suspension 50Mcg/ACT 1 spray each nostril one time a day for nasal congestion. Gabapentin Capsule 400mg give 1 capsule by mouth every 8 hours for nerve pain Glycol Lax Powder give 17 gram by mouth one tie a day for constipation in 4-6 ounces of water Levaquin Oral Tablet 500 mg give 1 tablet by mouth one time a day for left hip infection until 7/15/2023 Mesalamine Oral Tablet Delayed Release 1.2GM give 2 tablet by mouth one time a day for ulcerative colitis (a chronic inflammatory bowel disease) 2 tabs=2.4gm Multivitamin Oral Tablet give 1 tablet by mouth one time a day for supplement Pantoprazole Sodium Tablet Delayed Release 40mg give 1 tablet by mouth one time a day for GERD Prednisolone Acetate Ophthalmic suspension 1% (percent) instill 1 drop in the left eye two times a day for inflammation administered drops until resolved Probiotic Oral Capsule give 1 capsule by mouth three times a day for sever urinary yeast infection-pt on long term antibiotics Sucralfate Oral Tablet 1GM (gram) give 1 tablet by mouth before meals for gastric protection 1 hour before meals Turmeric Oral Tablet 500mg give 1 tablet two times a day for joint pains b. A further review of the MAR showed that the Bactrim, Levaquin, Prednisolone, Probiotic were timed for 1000am. The Amlodipine, Clonidine, Coreg, Bumex, Flomax Mesalamine and Turmeric, Cyanocobalamin, Duloxetine and Fluticasone were timed at 0900am. The Multivitamin and Pantoprazole, Ferrous sulfate and Glycolax were timed at 7-10a. A further review of the MAAR showed the Multivitamin, Pantoprazole, Ferrous Sulfate, Glycolax, Flomax, Bactrim, were documented as administered on 6/11/23 at 12:47pm. The Sucralfate timed at 0730am was documented as administered at 12:44pm and the 11:00am dose was documented as administered at 12:47pm on 6/11/23. The Bumex, Aspirin, Amlodipine, Coreg were documented as administered at 12:45pm. The Clonidine, Duloxetine, Cyanocobalamin, Mesalamine, Turmeric, Levaquin, Prednisolone, Probiotic were documented as administered at 12:46pm on 6/11/23. 10. Resident #13 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus. a. A review of the current OSR revealed the following physician orders: Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale: if 70-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400 = 10 unit subcutaneously in the morning for IDDM before breakfast call MD if below 70 or above 400. A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog sliding scale Insulin timed at 0800am. On 6/10/23 at 0800am was signed as having been completed. On 6/11/23 at 0800am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes. A review of the MAAR revealed the 6/10/23 the 0800am Humalog blood sugar/dose was administered at 21:05 (9:05 PM). On 6/11/23 the 0800am blood sugar and insulin was administered at 14:15 (2:15 PM). b. A further review of the OSR revealed: Amlodipine Besylate Oral Tablet 10 mg give one tablet by mouth one time a day for HTN hold sbp <110 or hr<60 Notify MD Aspirin EC Tablet Delayed Release 81mg give 1 tablet by mouth one time a day for supplement Carvedilol Oral Tablet 25 mg give 1 tablet by mouth two times a day for hold heart rate <60 or BP <120 Clopidogrel Bisulfate Oral Tablet 75mg give 1 tablet by mouth one time a day for PPX dvt (deep vein thrombosis) monitor for s/s of bleeding Glimepiride Tablet 2 mg give one tablet by mouth one time a day for diabetes Isosorbide Mononitrate Oral Tablet give 30 mg by mouth in the morning for angina (chest pain) Metformin HCI Oral Tablet 850 mg give 1 tablet by mouth two times a day for DM take with breakfast and dinner b. A further review of the MAR revealed the that the Carvedilol, Amlodipine, and Isosorbide were timed at 0900am. The Metformin was timed for 0730am. The Clopidogrel, Aspirin, Glimepiride were timed 7-10am. The MAR documentation indicated a 2 which according to the chart codes indicated the Resident refused the medication. A further review of the MAAR reflected that the Aspirin, Glimepiride, Clopidogrel, Metformin, Isosorbide, Amlodipine and Carvedilol were documented as having been refused on 6/11/2023 at 14:16 (2:16 PM) 11. Resident #14 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Urinary Tract Infection, Unspecified Psychosis, Peripheral Vascular Disease, Hyperlipidemia and Constipation. a. A review of the current OSR revealed the following physician orders: Insulin Lispro Injection Solution Inject as per sliding scale: if 70-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400 = 10 unit subcutaneously before meals and at bedtime for IDDM call MD if below 70 or above 400. A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for the blood sugar sliding scale Lispro insulin timed at 0730am, 1130am, 1730 (5:30 PM) and 2100 (9PM). On 6/10/23 there was no documentation to indicate the medication was administered at 0730am or 1130am as ordered. A review of the MAAR did not include documentation that the blood sugar sliding scale was administered as prescribed on 6/10/23 at 0730am or 1130am. b. A further review of the OSR revealed: Abilify Tablet 10 mg give one tablet by mouth one time a day for depression. Alogliptin Benzoate Oral Tablet 25 mg give 1 tablet by mouth one time a day for diabetes. Aspirin EC Tablet Delayed Release 81mg give 1 tablet by mouth one time a day for ppx (prophylaxis). Atorvastatin Calcium Tablet 40 mg give 1 tablet by mouth one time a day for hyperlipidemia Cipro Oral Tablet 500mg give 1 tablet by mouth two times a day for UTI for 10 days Colace Capsule 100mg give 1 capsule by mouth two times a day for constipation Flomax Capsule 0.4mg give 2 capsule by mouth one time a day for BPH 2 caps =0.8mg A further review of the MAR revealed the Aspirin EC, Abilify, Atorvastatin, and Alogliptin, timed at 7-10am Cipro oral tab and Colace all timed at 0900am did not include documentation that the medication had been administered as ordered. A review of the MAAR did not include documentation that the blood sugar sliding scale was administered as prescribed on 6/10/23 at 0730am or 1130am. A further review of the MAAR revealed the Aspirin EC and Atorvastatin were administered at 19:45 (7:45 PM). The Abilify, Alogliptin, Cipro, and Colace did not include documentation of having been administered on 6/10/23. 12. Resident #15 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Cerebral Infarction (stroke) Atherosclerotic Heart Disease (ASHD) Chronic Atrial Fibrillation (abnormal heartbeat), Gastrointestinal (GI) Bleed and Cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A review of the current physician orders revealed the following physician orders: Insulin Lispro Subcutaneous Solution Cartridge 100unit/ml Inject 3 unit subcutaneously with meals for IDDM (insulin dependent diabetes mellitus) Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8unit Call if less than 70 or greater than 400 subcutaneously before meals for DM A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog blood sugar sliding scale insulin timed at 0730am and 1130am and 1730 (5:30 PM). An order for Lispro timed at 0800am, 1200pm and 1800 (6PM.) There was no documentation to indicate the medication had been administered as prescribed on 6/10/23. A review of the PN did not include documentation as to why the medications were not administered. A review of the MAAR did not include documentation that the HumaLog blood sugar and sliding scale insulin and the Lispro Insulin were administered as prescribed at the indicated times. 13. Resident #16 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes, Bipolar Disorder, Schizophrenia, Toxic Encephalopathy, Essential Hypertension (HTN). a. A review of the current OSR revealed the following physician orders: Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit Call if less than 70 or greater than 400 subcutaneously in the morning for DM before breakfast. A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog blood sugar sliding scale insulin timed at 0800am. There was no documentation that the medication had been administered as prescribed on 6/10/23. A review of the MAAR revealed there was no documentation that the Humalog sliding scale insulin and blood sugar had been administered as prescribed. b. A further review of the OSR revealed: Benztropine Mesylate Oral Tablet 1 mg give 1 tablet by mouth two times a day for involuntary movement Cholecalciferol Tablet 1000 unit give 1 tablet by mouth one time a day for supplement Clozapine oral tablet 25mg give 2 tablet by mouth one time a day for schizophrenia Glycolax Powder give 17 gram by mouth one time a da [TRUNCATED]

COMPLAINT#: NJ158446, NJ158513 Based on observations, interviews, review of medical records, and other pertinent facility documents on 10/13/2022 and 10/14/2022, it was determined that the facility failed to follow and implement their Abuse Policy and Procedure for 1 of 9 residents (Resident #2), who has a known history of self-injurious and violent behaviors, delusions, paranoia, resistance to care, noncompliance/refusals with medication and a diagnosis of Schizoaffective Disorder Bipolar Type after a staff and a Resident had a physical altercation that occurred on 10/1/2022. On 10/13/2002 at 12:15 p.m., during a tour of the first floor, Resident #2 was observed with a cast in place on the left forearm. The Resident reported to the surveyor that a staff member broke his/her arm. The staff member was a nurse still working in the facility and was moved upstairs to another floor. According to the Certified Nursing Assistant (CNA) on 10/1/2022, Resident #2 had been having a rough day, vocal most of the day. LPN #1 came to the nursing station to her medication cart and asked Resident #2 to go to his/her room. Resident #2 became angry with LPN #1 and thought LPN #1 had a needle in her hand, but it was her pen. When LPN #1 turned around, Resident #2 knocked the pen out of LPN #1's hand. When the LPN bent down to pick up her pen, Resident #2 was physically and verbally aggressive. Resident #2 was in LPN #1's face, but the CNA could not clearly see the nurse holding onto Resident #2's arm. The Registered Nurse (RN) came to the nursing station to try and diffuse the situation. The CNA then called 911, and the Police arrived. According to the CNA, Resident #2 said to the Police, my arm hurts .she broke my arm, referring to LPN #1. According to the Nursing Supervisor/Licensed Practical Nurse (NS), she was upstairs on the second floor and received a call from the RN to come to the first floor. When the NS arrived on the first floor, she observed Resident #2 on a stretcher; two Emergency Medical Technicians (EMTs) and the Police were present. LPN #1 informed the NS that Resident #2 was acting aggressively, and they were sending him/her out. The NS stated she heard Resident #2 say, she broke my arm, she broke my arm, and pointed to LPN #1. Resident #2 was holding his/her arm out and said see, LPN #1 has broken my arm. The NS assessed Resident #2's arm but did not see any redness, swelling, or bruising to the left arm. According to the NS, Resident #2 makes many allegations, so she was more concerned with getting the Resident out to the Hospital. The NS did not suspend LPN #1 or send her home she started the investigation and did interviews on 10/1/2022. The NS then called the DON and informed her there was an incident between Resident #2 and LPN #1. According to the Assistant Director of Nursing (ADON), Resident #2 has behaviors and gets aggressive at times. The ADON stated that approximately one week ago, on 10/1/2022, Resident #2 was having a bad day, was physically aggressive with staff, and threatened to hit residents. Resident #2 also became aggressive toward the Licensed Practical Nurse (LPN #1) and was hitting her. As the LPN moved and held her hands up, the Resident continued to hit and punch her, and the LPN held the Resident's arms until 911 was called. The EMTs and the Police Officers arrived, and Resident #2 continued being combative with the EMTs. The Resident was then taken to the Hospital for combative and aggressive behaviors. On 10/3/2022, the facility called the Hospital to get a report about Resident #2 and was notified the Resident had a fracture. A reportable was at this time sent to the New Jersey Department of Health (NJDOH) for the staff-to-resident incident, howevever the reportable did not specify that Resident #2 accused LPN #1 of breaking his/her arm. LPN #1 was at this time was taken off the schedule. The facility's failure to implement its Abuse and Behavior Management policies when the physical altercation occurred between Resident #2 and LPN #1 put all other residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/13/2022 at 5:25 p.m. The Administrator was presented with the IJ template that included information about the issue on 10/14/2022. The IJ began on 10/1/2022 and continued through 10/2/2022 when the facility started in-services of their staff. The facility implemented the Removal Plan, which included a). Education on abuse, neglect, mistreatment, and misappropriation. b). Education on informing the administration immediately of an allegation of abuse, fracture, or injury of unknown origin. c). Education on the immediate removal of the accused staff member. d). Education on dealing with difficult behaviors, and e). Education on de-escalation techniques. So, the noncompliance remained on 10/14/2022 as a level G for actual harm that is not an IJ based on the following: Resident #2 was physically abusive to LPN #1. The LPN held Resident 2's arm to prevent the Resident from punching her. The Resident complained of pain before being sent to the Hospital, where an x-ray was completed, which showed a left arm fracture. Acccording to the ADON, the Police Department was notified on 10/3/2022 of the broken arm. This deficient practice was identified for 1 of 9 residents (Resident #2) and was evidenced by the following: The Facility Reportable Event (FRE), a NJDOH document used by healthcare facilities to report incidents, dated 10/3/2022, with an event date of 10/1/2022 at 5:45 p.m., revealed the following: On 10/1/2022 at approximately 5:25 p.m., Resident #2 was observed with verbal outbursts toward staff and other residents. LPN #1 attempted to redirect Resident #2 to his/her room. However, Resident #2 did not respond to redirecting and became physically aggressive towards LPN #1 and hit LPN #1 multiple times. Several staff members were present and attempted to verbally redirect Resident #2 from hitting LPN #1 without effectiveness. 911 was called, and Resident #2 was transferred to the Hospital. A verbal report from the Hospital indicated that Resident #2 had a left ulnar fracture and was admitted . Further review of the FRE included a written statement by LPN #1 dated 10/1/2022. According to the statement, on 10/1/2022 at approximately 5:45 p.m., Resident #2 began verbally assaulting other residents in the Activity Room. Resident #2 was redirected by LPN #1 to stop calling other residents names. Resident #2 started pacing but was still verbally assaulting other residents. When LPN #1 asked Resident #2 to go to his/her room, Resident #2 started verbally attacking LPN #1; he/she then started swinging at the LPN. According to the FRE, LPN #1 blocked Resident #2 by holding hands in front of her face and backing up, but Resident #2 kept swinging forcefully, making contact with LPN #1's face, neck, and forearm. LPN #1 reported that she was able to hold Resident #2 until another staff member was able to help get her off LPN #1. Resident #2 then sat down in a chair, still verbally aggressive, until the Police came to the facility. A review of the Electronic Medical Record (EMR) for Resident #2 revealed the following: According to the Admission Record (AR), Resident #2 was initially admitted to the facility on [DATE] with diagnoses which included but were not limited to: Schizoaffective Disorder Bipolar Type, Diabetes, Hypertension, Heart Failure, and Anemia and was readmitted on [DATE] with a diagnosis of displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed fracture with routine healing, dated 10/4/2022. Review of the Minimum Data Set (MDS), an assessment tool dated 8/14/2022, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #2 was cognitively intact. The MDS also showed Resident #2 required extensive assistance with Activities of Daily Living (ADLs). According to the MDS dated [DATE], Resident #2 had Physical behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) 1 to 3 days and Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days and had Other behavioral symptoms not directed toward others (e.g , physical symptoms include 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), 4 to 6 days but less than daily over the look-back period. A review of the Resident's Care Plan (CP) initiated on 5/25/2021 revealed under Focus that Resident #2 exhibits behaviors and symptoms such as self-injurious behavior, history of violent behaviors, delusions, paranoia, resistance to care, noncompliance/refusals with medication plan; resident places self on the floor and pretends to have a loss of conciseness (LOC), calls the Police, refuses to maintain a clean environment, and is physically aggressive towards other residents. Accusatory towards staff and other residents. Interventions/Tasks included but were not limited to: Redirecting negative behavior as needed, ensuring the Resident is safe, and giving the Resident some time and reapproach. The CP also included under Goals Resident safety will be maintained through the review date. Further review of Resident #2's CP included under Focus: Fracture/Joint replacement: Alteration in physical function related to the left fracture wrist dated 10/5/2022. Under Goal: Resident will improve mobility, strength, and functioning through the next review date, dated 10/5/2022. Interventions included: Cast care as ordered, follow-up with Orthopedic Surgeon as ordered, medications as ordered, and monitoring for decreased sensation and pulse in affected extremities, dated 10/5/2022. A review of the Behavior Monitoring sheet for Resident #2 revealed the following: On 9/29/2022 at 10:22 p.m., When Transport arrived at 10:10 p.m., the Resident refused to go to crisis. The Resident stated he/she wanted to go to bed and went to his/her room. On 9/30/2022 at 5:00 a.m., it revealed, Resident had to be continuously redirected to room during 3-11 shift for verbal outbursts toward staff and other residents. He/ She responded well to redirecting to room and calm approach. On 9/30/2022 at 9:00 p.m., revealed documentation by the nurse showed: No behaviors requiring staff interventions. On 10/1/2022 at 1:00 p.m., 10/1/2022 at 3:00 p.m., and 10/1/2022 at 5:00 p.m., revealed the following documentation by the nurse: Resident calm, no outburst noted will continue to monitor. On 10/1/2022 at 5:25 p.m., revealed the following documentation by the nurse: Resident had to be continuously redirected to room during the 3-11 shift for verbal outbursts toward staff and other residents. The Resident did not respond well to redirecting to the room. Resident continues to be verbally aggressive toward staff. Yelling, cursing, and name-calling. Resident then physically and verbally assaulted the writer in front of the nursing station. The Resident was transferred to Hospital. The MD (Medical Doctor) and the guardian were called with a message left. Review of Resident #2's Progress Notes (PNs) revealed the following: On 9/29/2022 at 9:00 p.m., the Registered Nurse (RN) documented: Resident #2 was verbally aggressive, not making sense, very delusional, and threatened residents and staff. Resident #2 called 911 several times. Call place to NP (Nurse Practitioner), who heard Resident #2 aggressively threatening staff. NP gave the order to send the Resident to crisis. On 9/30/2022 at 5:00 a.m., the LPN documented: The Resident displayed behaviors. The behaviors displayed are the Resident's target behaviors. An increase in verbal outbursts noted. Increase in refusal of care or treatment noted. No change in neurological status or residents' pain from baseline. The behaviors required staff intervention. On 10/5/2022 at 12:00 p.m., revealed the following: .was sent to the ER (emergency room ) with c/o (complaint of) left forearm pain on 10/2/22 (sic) (10/1/2022) after an altercation with staff. X-ray of left forearm showed a minimally displaced spiral oblique fracture of the distal ulnar shaft Patient was placed in a cast in the ER. The Universal Transfer Form (UTF) dated 10/1/2022 indicated that Resident #2 was transferred to the Hospital due to combative and aggressive behaviors. A review of the Hospital records sent to the facility on discharge on 10/4/2022 verified Resident #2 was treated in the Emergency Department (ED) on 10/1/2022 and had an x-ray of the left forearm on 10/1/2022 at 10:53 p.m., after complaining of left wrist pain. The x-ray was of the left wrist 2 views. Under History was left wrist pain. Under Findings: Bones and Joints: There is a nondisplaced oblique fracture involving the distal ulnar shaft. During an interview on 10/13/2022 at 12:19 p.m. with the DON and the ADON, the ADON stated, Resident #2 has behaviors and gets aggressive at times. One week ago, Resident #2 was having a bad day and was physically aggressive with staff and threatening to hit residents. Resident #2 became aggressive towards LPN #1, hit the nurse, and continued to hit the nurse. As the LPN ambulated and held her hands up, the Resident continued to hit and punch her. LPN #1 held the Residents arms until the Registered Nurse (RN #1) called 911. Resident #2 continued being combative even with the EMTs. During an interview on 10/13/2022 at 12:21 p.m., the DON stated they were told by the Hospital staff that Resident #2 had a fracture. The ADON added, at first, we thought it was just a behavior, but when they called us on 10/3/2022 to say it was a fracture, we sent in the Reportable for the staff-to-resident incident, and LPN #1 was taken off the schedule on 10/3/2022. During an interview on 10/13/2022 at 1:35 p.m., LPN #1 stated, on 10/1/2022, around 5:30 p.m., Resident #2 was observed cursing at other residents, not making any sense, she was maniac. LPN #1 said to Resident #2, you can go to your room, relax and take a break. Resident #2 hit LPN #1 on the hand, causing LPN #1 to drop her pen. LPN #1 bent down to get the pen, and Resident #2 started swinging and punching me. Resident #2 then grabbed LPN #1 by her shirt, and LPN #1 was able to hold both of Resident #2's hands. LPN #1 demonstrated this to the surveyor by applying her hand to her wrist. LPN #1 said she did this in an attempt to defend herself. LPN #1 continued to say she was able to hold Resident #2 by both hands and (demonstrated to the surveyor by holding her hand to her wrist) until staff stepped in. I didn't want to be hit no more. LPN #1 stated Resident #2 did not twist or turn when she held the Resident's wrist. The LPN said her right arm was swollen and pointed to her wrist area after the incident, but LPN #1 did not go to the ED or have an x-ray done and returned to work. LPN #1 further stated she did not return to work until 10/7/2022, they didn't tell me I was suspended; I just didn't return until they told me to come back, which was 10/7/2022. During an interview on 10/13/2022 at 2:57 p.m., the CNA assigned to Resident #2 at the time of the 10/1/2022 incident stated, Resident #2 had been having a rough day, vocal most of the day. LPN #1 came to the nursing station to her medication cart and asked Resident #2 to go to her room. Resident #2 became angry with LPN #1. When LPN #1 turned around, Resident #2 knocked the pen out of LPN #1's hand. LPN #1 bent down to pick up her pen, and Resident #2 was physically and verbally aggressive. Resident #2 went right into LPN #1's face. LPN #1 was holding onto Resident #2, but the CNA said she did not have a clear view. The Registered Nurse (RN) came to the nursing station to try and diffuse the situation. The CNA called 911, and the Police arrived. The CNA stated, Resident #2 said to the Police, my arm hurts .she broke my arm, referring to LPN #1. During an interview on 10/13/2022 at 3:32 p.m., the DON stated she received a call from the Nursing Supervisor on 10/1/2022. The NS reported that Resident #2 was aggressive toward staff, so she would send her to the crisis center. The DON stated she was unaware of a staff to Resident incident at that time. The DON said, Resident #2 has a history of Schizoaffective disorder and bipolar disorder and is sent out frequently to crisis for behaviors. During an interview on 10/13/2022 at 4:21 p.m., the NS stated she was upstairs on the second floor and received a call from the RN to come to the first floor. When the NS arrived on the first floor, she observed Resident #2 on a stretcher; two EMTs and the Police were present. LPN #1 informed the NS that Resident #2 was acting aggressively, and they were sending him/her out. The NS stated she heard Resident #2 say, she broke my arm, she broke my arm, and pointed to LPN #1. He/she was holding his/her arm out and said see (name), she (has broken) my arm. The NS stated she did not see any redness, swelling, or bruising to the left arm. The NS further said LPN #1 told me she held him/her (Resident #2) by his/her arms. but she did not suspend LPN #1 or send her home on 10/1/2022. The NS started the investigation and did interviews on 10/1/2022 with residents and staff. NS then called the DON and informed her there was an incident between Resident #2 and LPN #1. The NS said she also told the DON that Resident #2 accused LPN #1 of breaking his/her arm. On 10/2/2022, the NS received a call from the hospital physician informing her that Resident #2's arm was broken. The NS stated she was aware of the facility's policy for Reportable events for injuries, and staff should be suspended while an abuse investigation is conducted. During an interview on 10/13/2022 at 5:20 p.m., the DON and the ADON verified that the facility Abuse policy states that if an abuse allegation is made against a staff member, the accused staff member should be sent home immediately. The investigation started, and the NS should know the rules and regulations related to abuse and could have implemented them. During an interview with the Regional Director of Clinical (RDC) and the DON on 10/14/2022 at 9:40 a.m., the DON stated she was not aware on 10/1/022 that the Resident made an allegation of abuse. Resident #2 called her from the Hospital on 10/3/2022 and said he/she thought someone was going to give him/her an injection. The RDC further stated, when we found out on Monday morning (10/3/2022), we then suspended the staff member (LPN #1). A review of the facility's policy titled Abuse, dated 2/2019 under Policy: The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled Resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Under Protocol The Shift Supervisor is identified as responsible for immediate initiation of the reporting process. The policy also showed under Protection: Immediate suspension of the suspected employee (S), pending outcome of the investigation. Under Employee Suspension from Duty: Anytime an allegation is made involving abuse, neglect, or mistreatment of a resident/patient, which names a specific employee, the employee is suspended until the completion of the investigation. The employee is not to remain on duty and is not to be assigned to any other area of the facility. A review of the facility's policy titled Behavior Management, dated 5/2020 under Policy: It is the policy of this facility to provide an interdisciplinary approach for the care of residents who exhibit problem behavioral symptoms which could lead to negative consequences for themselves or others. Residents demonstrating change/s in behavior shall be evaluated to ensure that appropriate interventions, as needed, are instituted in a timely manner. Under Procedure: 2. Behavior symptoms that are dangerous or threatening must be controlled before further assessment and planning are done. Techniques for immediate management of a behavioral symptom include but are not limited to: Stay calm and use a firm, confident (but not bossy) tone of voice. Stay at a safe distance from the Resident and respect his/her need for personal space. Do not confront or accuse the Resident of wrongdoing. Do not argue or try to reason with the Resident. N.J.A.C. 8:39-13.4 c (2. iii)

C#: NJ158446, NJ158513 Based on interviews, medical record (MR) review, and review of other pertinent facility documents on 10/13/2022 and 10/14/2022, it was determined that the facility failed to protect and ensure that the residents were free from actual physical harm during an altercation between a resident (Resident #2) and a staff Licensed Practical Nurse (LPN), on 10/10/2022 when Resident #2 and the LPN were in a physical altercation which resulted in Resident #2 sustaining serious bodily injury, a fractured left arm, which required hospitalization . The facility also failed to follow its policy titled Abuse. This deficient practice was identified for 1 of 9 residents and was evidenced by the following: During a tour on 10/13/2022 at 12:15 p.m., Resident #2 was observed with a cast in place on the left forearm and reported to the surveyor that a staff member broke his/her arm, and the staff member was a nurse, and the nurse was still working in the facility. During an interview on 10/13/2022 at 12:21 p.m., the DON said they called the Hospital the next day and were told Resident #2 had a fracture. The fractured happened while still in their care. The ADON added, at first, we thought it was just a behavior, but when they called us on 10/3/2022 to say it was a fracture, that's when we sent in the Reportable for the staff-to-resident incident, and LPN #1 was taken off the schedule on 10/3/2022. This deficient practice was identified for 1 of 9 residents (Resident #2) and was evidenced by the following: According to the Admission Record (AR), Resident #2 was initially admitted to the facility on [DATE] with diagnoses which included but were not limited to: Schizoaffective Disorder Bipolar Type, Diabetes, Hypertension, Heart Failure, and Anemia and was readmitted on [DATE] with a diagnosis of displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed fracture with routine healing, dated 10/4/2022. Review of the Minimum Data Set (MDS), an assessment tool dated 8/14/2022, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #2 was cognitively intact. The MDS also showed Resident #2 required extensive assistance with Activities of Daily Living (ADLs). According to the MDS dated [DATE], Resident #2 had Physical behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) 1 to 3 days and Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4 to 6 days, but less than daily, and had Other behavioral symptoms not directed toward 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). 4 to 6 days but less than daily over the look-back period. A review of the Resident's Care Plan (CP) initiated on 5/25/2021 revealed under Focus that Resident #2 exhibits behaviors and symptoms such as: self-injurious behavior, history of violent behaviors, delusions, paranoia, resistance to care, noncompliance/refusals with medication plan; resident places self on the floor and pretends to have a loss of consciousness (LOC), calls the Police, refuses to maintain a clean environment, and is physically aggressive towards other residents. Accusatory towards staff and other residents. Interventions/ Tasks included but were not limited to: Redirect negative behavior as needed, ensure the Resident is safe, and give the Resident some time and reapproach. The CP also included under Goals Resident safety will be maintained through the review date. The CP also showed a Focus of Fracture/Joint replacement: Alteration in physical function related to the fracture left wrist dated 10/5/2022. Under Goal: Resident will improve mobility, strength, and functioning through the next review date, dated 10/5/2022. Interventions included: Cast care as ordered, follow-up with Orthopedic Surgeon as ordered, medications as ordered, and monitor for decreased sensation and pulse in affected extremities, dated 10/5/2022. A review of the Behavior Monitoring sheet for Resident #2 dated 10/1/2022 at 5:25 p.m. revealed the following documentation by the nurse: Resident had to be continuously redirected to room during the 3-11 shift for verbal outbursts toward staff and other residents. The Resident did not respond well to redirecting to the room. Resident continues to be verbally aggressive toward staff. Yelling, cursing, and name-calling. Resident then physically and verbally assaulted the writer in front of the nursing station. The Resident was transferred to Hospital. The MD (Medical Doctor) and the guardian were called with a message left. According to the Accident/Incident Statement by Nursing Supervisor/LPN #2 (NS) on 10/1/2022, LPN #1 reported to the NS that Resident #2 physically and verbally assaulted her. The NS did a visual assessment of Resident #2's arm and wrote, there was no swelling, bruises or abrasion on bilateral arms. Resident #2 stated the nurse broke his/her arm. The Universal Transfer Form (UTF) dated 10/1/2022 indicated that Resident #2 was transferred to the Hospital due to combative and aggressive behaviors. A review of the hospital records sent to the facility on discharge on 10/4/2022 verified Resident #2 was treated in the Emergency Department (ED) on 10/1/2022 and had an x-ray of the left forearm on 10/1/2022 at 10:53 p.m., after complaining of left wrist pain. The x-ray was of the left wrist 2 views. Under History was left wrist pain. Under Findings: Bones and Joints: There is a nondisplaced oblique fracture involving the distal ulnar shaft . During an interview on 10/13/2022 at 12:19 p.m., in the presence of the DON, the ADON stated, Resident #2 has behaviors and gets aggressive at times. One week ago, Resident #2 was having a bad day and was physically aggressive with staff and threatening to hit residents. Resident #2 became aggressive towards LPN #1, hit the nurse, and continued to hit the nurse. As the LPN moved and held her hands up, the Resident continued to hit and punch her. LPN #1 held the Residents arms until the Registered Nurse (RN #1) called 911. Resident #2 continued being combative even with the EMTs. During an interview on 10/13/2022 at 12:21 p.m., the DON stated they were told by the Hospital staff that Resident #2 had a fracture.The fractured happened while still in their [the Hospital's] care. The ADON added, at first, we thought it was just a behavior, but when they called us on 10/3/2022 to say it was a fracture, we sent in the Reportable for the staff-to-resident incident, and LPN #1 was taken off the schedule on 10/3/2022. During an interview on 10/13/2022 at 1:35 p.m., LPN #1 stated, on 10/1/2022, around 5:30 p.m., Resident #2 was observed cursing at other residents, not making any sense, she was maniac. LPN #1 said to Resident #2, you can go to your room, relax and take a break. Resident #2 hit LPN #1 on the hand, causing LPN #1 to drop her pen. LPN #1 bent down to get the pen, and Resident #2 started swinging and punching me. Resident #2 then grabbed LPN #1 by her shirt, and LPN #1 was able to hold both of Resident #2's hands. LPN #1 demonstrated this to the surveyor by applying her hand to her wrist. LPN #1 said she did this in an attempt to defend herself. LPN #1 continued to say she was able to hold Resident #2 by both hands and (demonstrated to the surveyor by holding her hand to her wrist) until staff stepped in. I didn't want to be hit no more. LPN #1 stated Resident #2 did not twist or turn when she held the Resident's wrist. The LPN said her right arm was swollen and pointed to her wrist area after the incident, but LPN #1 did not go to the ED or have an x-ray done and returned to work. LPN #1 further stated she did not return to work until 10/7/2022, they didn't tell me I was suspended; I just didn't return until they told me to come back, which was 10/7/2022. During an interview on 10/13/2022 at 2:57 p.m., the CNA assigned to Resident #2 at the time of the 10/1/2022 incident stated, Resident #2 had been having a rough day, vocal most of the day. LPN #1 came to the nursing station to her medication cart and asked Resident #2 to go to her room. Resident #2 became angry with LPN #1. When LPN #1 turned around, Resident #2 knocked the pen out of LPN #1's hand. LPN #1 bent down to pick up her pen, and Resident #2 was physically and verbally aggressive. Resident #2 went right into LPN #1's face. LPN #1 was holding onto Resident #2, but the CNA said she did not have a clear view. The Registered Nurse (RN) came to the nursing station to try and diffuse the situation. The CNA called 911, and the Police arrived. The CNA stated, Resident #2 said to the Police, my arm hurts .she broke my arm, referring to LPN #1. During an interview on 10/13/2022 at 3:32 p.m., the DON stated she received a call from the Nursing Supervisor on 10/1/2022. The NS reported that Resident #2 was aggressive toward staff, so she would send her to the crisis center. The DON stated she was unaware of a staff to Resident incident at that time. The DON said, Resident #2 has a history of Schizoaffective disorder and bipolar disorder and is sent out frequently to crisis for behaviors. During an interview on 10/13/2022 at 4:21 p.m., the NS stated she was upstairs on the second floor and received a call from the RN to come to the first floor. When the NS arrived on the first floor, she observed Resident #2 on a stretcher; two EMTs and the Police were present. LPN #1 informed the NS that Resident #2 was acting aggressively, and they were sending him/her out. The NS stated she heard Resident #2 say, she broke my arm, she broke my arm, and pointed to LPN #1. He/she was holding his/her arm out and said see (name), she (has broken) my arm. The NS stated she did not see any redness, swelling, or bruising to the left arm. The NS further said LPN #1 told me she held him/her (Resident #2) by his/her arms. but she did not suspend LPN #1 or send her home on 10/1/2022. The NS started the investigation and did interviews on 10/1/2022 with residents and staff. NS then called the DON and informed her there was an incident between Resident #2 and LPN #1. The NS said she also told the DON that Resident #2 accused LPN #1 of breaking his/her arm. On 10/2/2022, the NS received a call from the hospital physician informing her that Resident #2's arm was broken. The NS stated she was aware of the facility's policy for Reportable events for injuries, and staff should be suspended while an abuse investigation is conducted. During an interview on 10/13/2022 at 5:20 p.m., the DON and the ADON verified that the facility Abuse policy states that if an abuse allegation is made against a staff member, the accused staff member should be sent home immediately. The investigation started, and the NS should know the rules and regulations related to abuse and could have implemented them. According to the facility's policy titled Abuse, under Policy: The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Under Protocol The Shift Supervisor is identified as responsible for immediate initiation of the reporting process. The policy also showed under Protection: Immediate suspension of the suspected employee (S), pending outcome of the investigation. Under Employee Suspension from Duty: Anytime an allegation is made involving abuse, neglect, or mistreatment of a resident/patient, which names a specific employee, the employee is suspended until the completion of the investigation. The employee is not to remain on duty and is not to be assigned to any other area of the facility. N.J.A.C: 8:39-4.1(a)5

Complaint Intakes NJ 4 and NJ 2 Based on record review, document review, facility policy review, and interviews, it was determined that the facility failed to ensure residents were free from abuse for 3 (Resident #25, Resident #4, and Resident #3) of 5 residents investigated for abuse. Specifically, the facility failed to ensure Resident #25 was free from physical abuse when the resident was grabbed around the neck by another resident (Resident #29), resulting in Resident #25 feeling fearful. The facility failed to ensure Resident #4 and Resident #3 were free from sexual abuse, when the two residents were touched inappropriately by another resident (Resident #2), resulting in Resident #4 feeling fearful. Findings include: 1. Resident #29's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. Behaviors included hallucinations. The resident was independent with ambulation. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's quarterly MDS, dated [DATE], revealed the resident had moderately impaired cognition with a BIMS score of 10 out of 15. No behaviors exhibited. Resident #25 was independent with ambulation. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the investigation form, dated as occurring 05/02/2021, revealed in part, Licensed Practical Nurse (LPN) reported she was standing in the hallway with her medication cart in the hallway of unit 2B. (Resident #29) came out of their room asking for help to turn off the air conditioner. As the nurse locked her medication cart to assist, she witnessed Resident #29 lunge toward Resident #25 who was sitting in the hallway and put his/her hands around the resident's neck area. An LPN immediately intervened and separated both residents. Resident #29 was redirected to their room and was unable to give an explanation. Resident #25 was unable to give an account of events. No visible injuries were noted. No pain or discomfort. The physician was called and labs, urine, psych, psychology, and social services follow up were ordered. Findings: There was an identified trigger to Resident #29's aggression toward Resident #25. The LPN intervened with no physical contact occurring; both residents immediately separated. Conclusion: Resident #29 lunged at Resident #25 attempting to put their hands around the resident's neck. The LPN intervened and avoided any physical contact. This incident was unpredictable and unavoidable due to the resident's psychological condition and congregate living. Interventions were put into place to avoid any future. A reasonable person would include that there was no abuse, neglect, mistreatment, and/or misappropriation. An interview with the LPN completed by the facility revealed, On May 2nd, 2021, at 1530 [3:30 PM]; I was at the nurse station by 2A wing, when (Resident #25) came to me saying that a [gender] choked [gender]. I moved (Resident #25) to the dining room and asked [gender] to remain there until I came back. I went to inform nurse in charge, nurse was already aware. She said (Resident #29) was trying to choke (Resident #25) and she separated them. A review of the behavioral physician notes, dated 05/20/2021, revealed in part, Patient last seen 05/11/2021. No medication adjustments made at that time. Follow-up requested today due to another incident of physical assault towards another resident. [Gender] was witnessed ambulating down the hallway when an elderly [gender] resident approached [gender]. There were words exchanged and then [gender] attempted to strangle [gender]. Staff immediately separated them. No injury to either resident. Staff report increased episodes of delusions and [CONDITION(S)] have been verbalized by [gender]. Patient seen. In bed. Mute and disengaged .Plan: Increase [MEDICATION(S)]/[MEDICATION(S)] to 750 milligrams (mg) orally (po) every 8 hours (q8h) for impulsivity and mood swings. Dx: [CONDITION(S)] .Unfortunately [gender] behavior is very hard to predict. It is generally triggered and unprovoked. Two episodes in a very short period where [gender] attempted to strangle another resident. Suggest transfer to a more appropriate behavioral setting. Resident #25 was interviewed on 06/01/2021 at 9:08 AM and 06/02/2021 at 11:55 AM. The resident said there was a concern about another resident abusing him/her. The resident said the incident happened when he/she was living on the first floor. Resident #25 said a resident grabbed the resident by the neck and the resident was still afraid. Resident #25 stated he/she was placing a table in front of the door; but stopped because it was scaring the resident's roommate. The resident said [gender] felt okay on the current floor they resided, away from the person who choked the resident. The resident remained shocked the other resident was still in the building. Resident #25 said he/she was still afraid it might happen again. Certified Nurse Aide (CNA) #1 was interviewed on 06/02/2021 at 11:37 AM. She said Resident #29 had behaviors and thought the resident was spaced out. CNA #1 said Resident #29 had been like this over the past month. The Unit Manager (UM) was interviewed on 06/02/2021 at 11:41 AM. The UM said Resident #29 had not had any recent behaviors. The UM said this resident tended to self-injure and was partially blind. The UM said there was a previous incident where Resident #29 punched their roommate in the stomach because of the TV volume. The UM said this occurred because they had completed a gradual dose reduction on one of their medications but there were not any changes before the incident with Resident #25. The UM said this resident may not be appropriate for this facility due to a long psych history. The UM said she was not aware of Resident #25 being fearful. The UM said the resident was frightened when it happened, but then was fine. She said Resident #29 mostly stayed in their room unless they needed to go to the shower room or ask for more food. The Director of Nursing (DON) was interviewed on 06/02/2021 at 1:26 PM. She said she was told Resident #25 was standing in the hallway and talking to the nurse. The DON said the nurse was getting medication pass ready and Resident #29 came out of his/her room for assistance. She said the nurse locked her cart and turned around and Resident #29 just went across to Resident #25 and headed for the resident's neck. She said they moved Resident #25 to another hall and had the resident on supervised monitoring. The DON said she was not aware this resident was still fearful. The social worker (SW) was interviewed on 06/02/2021 at 2:38 PM. She said she remembered this incident and completed some of the interviews with the resident. The SW said it was difficult trying to interview Resident #29. She said she did not remember if she interviewed any other residents on the hall. The SW said she was unaware Resident #25 was still fearful. 2. Resident #2 was admitted on [DATE] and discharged on [DATE]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had intact cognition with a Brief Interview for Mental Status score of 15 out of 15. Behaviors were not exhibited. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was independent with ambulation. Resident #4 was admitted on [DATE]. The quarterly MDS, dated [DATE], revealed the resident had intact cognition with a BIMS score of 14 out of 15. Behaviors were not exhibited. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not ambulatory but able to use wheelchair with supervision. A review of the investigation form, dated as occurring 03/02/2021, revealed in part, On 03/02/2021 at 12:00 PM (Resident #4) reported to the activity director that around 11:00 AM [gender] was in the 1st floor blueberry dining room when another resident (Resident #2) walked up to [gender] and grabbed [gender] jacket near [gender] breast area and immediately walked away. (Resident #4) reported that (Resident #2) did not say anything to [gender]. (Resident #4) reported to the activity director that [gender] does have any issues with (Resident #2) and [gender] is not afraid of [gender] . (Resident #4) reported that the incident occurred in the blueberry dining room while the residents were waiting to go outside to smoke. The resident reported that the smoke monitor was present in the room . (Resident #2) denied any interaction with (Resident #4). [Gender] stated [gender] did not grab or touch [gender] jacket. The smoke monitor reported that he was in the dining room with the resident at 11:00 AM and he did not witness (Resident #2) approach (Resident #4), touch [gender] or speak to [gender] . (Resident #4) requested to have a room change and the resident was moved from (room #) to (room #) .Conclusion: The .team met to discuss and review the incident. A reasonable person would conclude that this allegation could not be substantiated as the smoke monitor was present and with the residents. At no time did he witness (Resident #2) speak to or touch (Resident #4). Resident #4 was interviewed on 06/02/2021 at 5:18 PM. He/she said Resident #2 had pulled Resident #4's sweater and coat out to look at his/her breasts. The resident said he/she was still fearful something would happen again. The resident said this incident occurred in the smoking lounge area. Resident #4 said Resident #2 walked up to him/her and pulled his/her top back to look at their chest. The resident said the smoke monitor was there, but Resident #2 did it when the smoke monitor was not looking. The SW was interviewed on 06/02/2021 at 3:48 PM. She said Resident #4 accused Resident #2 of touching [gender] breasts, but Resident #2 denied it. She said the smoke monitor denied seeing anything. The DON was interviewed on 06/02/2021 at 1:26 PM. She said they were unable to find the psych reports completed for Resident #2. She said the reports were not in the resident's record. She said she was not in the building at the time of these incidents. She said the care plan revealed the residents were to remain separated but was not sure what that entailed. She acknowledged there were multiple occurrences regarding Resident #2 and women. 3. Resident #2 was admitted on [DATE] and discharged on [DATE]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had intact cognition with a Brief Interview for Mental Status of 15 out of 15. Behaviors were not exhibited. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was independent with ambulation. Resident #3 was admitted on [DATE]. The quarterly MDS, dated [DATE], revealed the resident had intact cognition with a BIMS of 15 out of 15. Behavior included hallucinations and delusions. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was independent with ambulation. A review of the investigation form, dated as occurring 03/09/2021, in part, On 03/10/2021 at approximately 10:00 PM, (Resident #3) came out of [gender] room to the nurses' station and was visibly upset. The resident reported to staff that (Resident #2) came into [gender] room uninvited, sat on [gender] bed and touched [gender] inappropriately and kissed [gender]. (Resident #2) room was located on the same hallway. (Resident #2) was immediately moved to another hallway and kept on close observation .As per (Resident #3), (Resident #2) entered [gender] room uninvited following a smoke break they were both on. (Resident #2) sat on [gender] bed, placed [gender] hand in [gender] underwear and then between [gender] legs. The resident resisted and kicked [gender] out of [gender] room. [Gender] roommate returned to the room following [gender] smoke break. (Resident #3) was visibly upset and told [gender] roommate what occurred. (Resident #2) was interviewed by the nurse that evening and the next day through an interpreter. (Resident #2) stated that following the smoke break, [gender] was passing (Resident #3's) room and [gender] invited [gender] in. [Gender] requested that [gender] sit on [gender] bed. (Resident #2) denied anything else occurred. (Resident #2) was put through the national sex offender database with (Resident #2) not identified in the national registry .A review of (Resident #2's) medical record and past incidents brought forth two other incidents for review. The first incident was when (Resident #2) put [gender] finger through the hole of a [gender] resident's nightgown and poked [gender] breast in the process .The second incident occurred following a smoke break and was not witnessed .Conclusion: as per both resident's statements (Resident #2) went into (Resident #3's) room on the night of 03/10/2021. As per (Resident #3), (Resident #2) was not invited and [gender] proceeded to touch [gender] breast and [body part] in addition to trying to kiss [gender]. (Resident #2) denied the incident and staff did not witness, nor did they witness (Resident #2) in (Resident #3's) room. (Resident #2) had two other allegations of touching [gender] breasts however, those two allegations were concluded as psychological abuse in contrast to this allegation of sexual abuse. The outcome of this investigation is inconclusive. A review of the physician's progress note, dated 03/15/2021, revealed Resident seen and examined for discharge to another facility .Resident is medically stable at this time. This resident discharge is necessary and appropriate for being an endangerment to other residents. Resident #3 was interviewed on 06/01/2021 at 3:07 PM. The resident said there was an incident that occurred with another resident. Resident #3 said Resident #2 got touchy feely and put [gender] hands down [gender] pants. Resident #3 said [gender] pushed Resident #2 off. Resident #3 said Resident #2 left the facility shortly after the incident. The social worker was interviewed on 06/02/2021 at 3:48 PM. She said she completed some of the interviews, but the Director of Nursing and the Nursing Home Administrator completed the actual reports of the investigation. She said Resident #3 accused Resident #2 of trying to kiss [gender] and Resident #2 denied it happened. She said the roommate did see Resident #2 in the resident's room, but [gender] was leaving the room. A review of the abuse policy, revised 02/2019, provided by the DON on 06/02/2021 at 4:28 PM revealed in part, The facility prohibits the mistreatment, neglect, and abuse of resident's/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc.New Jersey Administrative Code S 4.1 (a)(5)

Complaint #: NJ 9 Based on observation, interview, review of medical records and other facility documentation, it was determined that facility failed to ensure a safe environment by not implementing their abuse policy and procedure when an allegation of physical abuse was reported. The resident reported to the Nursing staff that a staff member pushed a bedside table that hit his/her right shin. The facility's failure to initiate the process of investigation of alleged abuse placed Resident #2 at risk for harm as well as other residents with a similar incident. This deficient practice was revealed for 1 of 3 sampled residents (Resident #2) as evidenced by the following: On 10/22/2019, the Department of Health, Long-Term Care Complaints Program received a Facility Reporting Event of an alleged staff to resident abuse. The facility indicated in the Investigative Summary that the conclusion to their investigation indicated upon review of employee and resident statement, a reasonable person would conclude that abuse occurred. There were 5 witnesses stating that the Licensed Practical Nurse LPN #1 was either verbally and/or physically aggressive during the incident on 10/19/19 at 5 p.m. An on-site investigation revealed the following: On 10/28/19, the Assistant Director of Nursing (ADON) provided to the surveyor the facility Abuse Policy No. CA-1 Last Date Revised: 2/2019, which indicated the following: Policy: The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriate of resident/patient property by anyone involving staff, family, friends, etc The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Investigation Allegations/report of suspected abuse, neglect, mistreatment, shall be promptly and thoroughly investigated by facility management. The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process upon receipt of the allegation. Collect factual data on the Incident Entry Report Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interview and have information regarding the allegation. Conclusion must include whether the allegation was substantiated or not and what information supported the decision. Employee Suspension from Duty Any time an allegation is made involving abuse, neglect or mistreatment of [REDACTED]. The employee is not to remain on duty and is not to be assigned to any other area of the facility. Reporting Report the incident to the Administrator and Director of Nursing. The Administrator and Director of Nursing or designees will report to the Regional Clinical manager and RDO. Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. Initiate process according to the elder Justice Act and State-specific regulations. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information. An investigation MUST be directed by the Administrator or designee immediately. Upon receiving reports of physical or sexual the DON/designee shall immediately examine the resident. Findings of the examination must be recorded in the resident's record. For any allegations of physical assault with evidence of injury or witnessed physical assault the police should be contacted immediately. On 10/28/19, the surveyor received from the ADON the Resident Abuse Response Checklist worn by facility staff on their badges, indicated the following: Separate residents and/or send staff home. Provide for the residents' safety. Report to the incident to the supervisor. Prepare a physical assessment. Call doctor and family. Call police in the event of physical or sexual abuse by staff. Begin investigation. Obtain statements from residents and staff on unit. Notify the administrator and DON. Begin 72 hours of Nurse Notes for any resident involved in an altercation either verbal, physical or sexual. Notify social worker (5 days of notes). Update care plan. On 10/28/19, the surveyor reviewed the medical record of Resident #2 who was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 9/12/19, indicated that Resident #2 had a brief Interview for Mental Status (BIMS) score of 7 indicating Resident #2's cognition was severely impaired; however, Resident #2 was able to understand what is being said to him/her. During a tour of the unit on 10/28/19 at approximately 1:00 p.m., the surveyor observed Resident #2 in his/her room sitting in a wheelchair on D Wing. The surveyor interviewed Resident #2 about the incident that occurred on 10/19/19. The resident stated that at approximately 5 p.m., LPN #1( Licensed Practical Nurse ) pushed the wheelchair into his/her room on D Wing from the B Wing. As LPN #1 was leaving the room, I shoved the overbed table at the nurse and the nurse shoved it back hitting my right leg. At this time, in the presence with another surveyor, Resident #2 picked up his/her right pant leg and the right lower leg had a yellowish bruise and a small scabbed area. Resident #2 recalled that none of the staff looked at the leg. On 10/28/19, the surveyor requested Resident #2's Interdisciplinary Care Plan (IDCP). The facility provided an undated IDCP. The surveyor reviewed that the IDCP did not include the bruise to the right shin or injury secondary to staff to resident abuse. On 10/29/19, the surveyor was provided with an IDCP initiated 10/29/19, which included but was not limited to: In the Focus section: Resident is at risk for impaired skin integrity r/t (related to) history of impaired skin to amputation site, bruise to right shin. In the Goal section: Resident skin will remain intact throughout the review period, initiated 10/29/19. In the Interventions/Tasks section: Avoid mechanical trauma, initiated 10/29/19. Report to MD (Medical Doctor) any signs of deterioration or significant change to area of improvement, initiated 10/29/19. The facility failed to update the IDCP when the incident occurred on 10/19/19 and upon discovery of the incident on 10/21/19. On 10/30/19, the surveyor conducted a post-survey interview via telephone with LPN #1 who had allegedly hit the resident on 10/19/19. LPN #1 was suspended by the facility on 10/21/19 pending the investigation and terminated on 10/25/19. LPN #1 stated that on 10/19/19 at 5 p.m., he observed Resident #2 in a wheelchair on the B-wing nursing unit talking very loudly and being uncooperative with staff during dinner time. LPN #1 stated he went over to Resident #2 and bent down to the resident at eye level and was struck on the cheek. After being struck by the resident, LPN #1 stated he went to the sink to wash his face. When he returned to the floor, Resident #2 was still yelling loudly at the staff. He took Resident #2 back to his/her room. During the return to D Wing, the resident was still yelling and making attempts with his arms to reach behind the wheelchair to hit LPN #1. LPN #1 stated he had to use his thigh 2 times to hit the back of the wheelchair to prevent the wheel chair from tipping backwards. When he wheeled Resident #2 into his/her room, the resident was still yelling extremely loud to him. He assumed the resident was getting ready to throw something at him, so LPN #1 walked backwards out of the room still facing the resident. At this time, Resident #2 grabbed the overbed table and pushed it at him. The overbed table hit the foot of the bed and fell on Resident #2's right shin. LPN #1 then exited the room and told LPN #2 that the resident had tried to attack him. Also, LPN #1 went on to state that he failed to inform LPN #2, that the resident's overbed table fell on his/her right shin. LPN #1 stated that he proceeded to the nurses' station to contact a supervisor (Registered Nurse) RN#1. The surveyor attempted to interview by phone RN #1 on 10/30/19 at 3:09 p.m., but she did not return the phone call. This employee was terminated by the facility on 10/21/19. During an interview with the surveyor on 10/28/19 with LPN #2, she stated that she was assigned to Resident #2 on this 3PM- 11PM shift. She observed LPN #1 exit Resident #2's room and she confirmed that he didn't inform her of the overbed table hitting the resident's right shin. When LPN #2 entered Resident #2's room, he/she informed her that LPN #1 kicked him/her. Resident #2 then lifted his/her right pant leg to show an abrasion and some bluish discoloration to the right shin. LPN #2 stated she left the resident's room to call supervisor RN #1. LPN #2 stated she observed RN #1 enter Resident #2's room for approximately 2 minutes, then left the room and the unit. She stated RN #1 did not request an incident report or a statement from her on 10/19/19. LPN #2 further stated she didn't document in the Interdisciplinary Progress Note (IPN) about the resident's injury to the right shin. She further stated she did not initiate an incident report, notify the physician of the injury, follow-up about the incident with RN#1 and update the care plan. LPN #2 stated that she should have followed the Abuse policy and procedure. During an interview with the surveyor on 10/28/19, CNA #1 stated that on 10/19/19, around dinner time, she observed LPN #1 pushing Resident #2's wheel chair really fast towards the resident's room on D wing. CNA #1 stated she observed that LPN #1's eyes were bulging. She heard Resident #2 say to LPN #2 that he/she was kicked by LPN #1 on the leg. Later that evening, she observed RN #1 come to the unit and speak to LPN #1. RN #1 did not speak to her about what she observed during the incident or request a written statement. CNA #1 stated she spoke to LPN #3 on 10/20/19, on the 3 p.m.-11 p.m. shift regarding the incident on 10/19/19. She was concerned that LPN #1 was back at work on 2B wing. CNA #1 also stated that she observed LPN #1 had no contact with the resident on the 3 p.m.-11 p.m. shift. During an interview with the surveyor on 10/29/19, LPN/Unit Manager/Supervisor of the Nursing Unit (UMS #3) on 10/19/19 stated that on 10/20/19 between 4:15 p.m. and 4:30 p.m., CNA #1 informed her she was not comfortable with LPN #1 being assigned back on the floor because of the incident that happened yesterday with him and Resident #2. UMS #3 did not check if the incident report was done. However, she obtained written statements from CNA #1, LPN #2 and LPN #4. LPN #4 informed her that she overheard Resident #2 say Hey, Hey Stop That and that LPN #1 hit the resident like he would be hitting a child. UMS #3 stated, I was supposed to call Assistant Director of Nursing (ADON), but I didn't. Normally staff to resident abuse is investigated and LPN #1 should have been suspended pending the investigation. UMS #3 stated she should have followed the Abuse policy and notified the Assistant Director of Nursing immediately but failed to do so. During an interview with the surveyor on 10/29/19 at 3:06 PM., LPN #4 stated she observed LPN #1 turn Resident #2's wheelchair around quickly and proceeded to run with the wheel chair to the resident's hallway and took the resident into his/her room. LPN #1 went into the room and slammed the door. LPN #4 stated I heard noises, like bumping into things, like muffled bumping. She said she heard Resident #2 say stop that. However, she didn't observe the incident. During an interview with the surveyor on 10/30/19 at 11:34 AM. via telephone, RN #2 who worked the 7PM-7AM shifts on 10/19/19 and 10/20/19 stated she was aware that Resident #2 hit LPN #1 but was not aware of the alleged allegation that LPN #1 hitting Resident #2. RN #2 further stated she did not investigate to see what precipitated the incident between Resident #2 and LPN #1. The surveyor requested the Time Cards provided by the facility to confirm that LPN #1 was not suspended even though RN #1 was aware of the incident on 10/19/19. LPN #1 continued to work in the facility until 10/21/2019 as indicated by the following: 10/19/19 4:11 PM 10/20/19 7:30 AM 14.25 10/20/19 2:53 PM 10/21/19 7:46 AM 15.75 The facility was not able to provide the actual Assignment Sheet for 10/20/19, 3 PM-11PM. and 11PM.-7 PM. shifts. During an interview with the surveyor on 10/30/19 at 3:36 PM, via telephone, the Medical Director (MD) stated that on 10/19/19 at approximately 5 p.m., he received a call from the answering service to call the facility. The MD stated he spoke to a nurse who informed him of a change in Resident #2's behavior. The MD stated he was not informed of the allegation of physical abuse involving LPN #1 injuring Resident #2 until 10/21/19 by the ADON. It was at this time he gave orders to assess the injury and mental status of the resident. During the interview with the surveyor on 10/29/19 at 12:20 PM., the ADON stated after she finished reading the staff statements provided to her by UMS #3 on 10/21/19 at 8:30 a.m., regarding the staff to resident abuse on 10/19/19, she immediately notified the Administrator and the Regional Director Clinical Services (RDCS). The ADON stated the incident report completed by the RN #1 was found hidden in the back of the narcotic book. The report indicated that RN #1 was aware that Resident #2 reported LPN #1 hit him. RN #1 did not report the allegation of abuse. The ADON stated RN #1 should have notified Administration immediately and LPN #1 should have been suspended pending the investigation. During an interview with the surveyor on 10/29/19 at 1:35 PM., the Regional Director Clinical Services (RDCS) stated she was notified by the ADON on 10/21/19 at approximately 9 a.m. of the allegation of abuse by LPN #1 hitting Resident #2. The RDCS stated that on 10/19/19, the staff should have acted upon the information they received according to the facility policy, to report the allegation of abuse, but failed to do so. On 10/21/19 the RDCS instructed the ADON to notify the Department of Health and the Police. According to RDCS, LPN #2, LPN #4 and CNA #1 were educated and received disciplinary actions. UMS #3 was suspended. LPN #1 and RN #1 were terminated. On 10/28/19, the ADON provided the surveyor the Investigational Summary dated 10/21/19. The facility conclusion to their investigation of the alleged staff to resident abuse indicated: Upon review of employee and resident statement, a reasonable person would conclude that abuse occurred. There were 5 witnesses stating that the LPN (#1) was either verbally and/or physically aggressive during the incident on 10/19/19 at 5 p.m. NJAC 8:39-4.1 (a) 5

COMPLAINT # NJ 2 Based on interviews, review of the medical record as well as other pertinent facility documentation on 8/8/17 and 8/10/17, it was determined that on 6/22/17 on the 3 PM to 11 PM shift, while Certified Nursing Assistant (CNA #1) was assisting a Resident (Resident #3), Resident #3 fell and CNA #1 placed Resident #3 in bed and did not report the fall to the charge nurse and/or Registered Nurse (RN) Supervisor (RN #1), which resulted in a failure to assess Resident #3 for injuries and causing a delay in treatment. The facility staff also failed to follow their own policy titled Accidents and Incidents to include the reporting and investigating of incidents as well as the Change is (sic) a Resident Condition Center: or Status policy by failing to document the assessment. Resident #3 had sustained a fractured left distal femur and required transfer to the hospital on [DATE]. This deficient practice was evidenced by the following: 1. According to the Admission Record, Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 5/3/17, revealed a Brief Interview for Mental Status (BIMS) score of 10/15, indicating Resident #3 had moderately impaired cognition. The MDS included documentation that Resident #3 required staff assistance for Activities of Daily Living (ADLs). A review of Resident #3's care plan with an initiated date of 11/02/2016 and revision date of 6/23/2017, revealed Resident #3 was at risk for falls. A review of a Therapy Inservice Form with signature dates of 6/20/17 and 6/21/17, indicated that Resident #3 was contact guard assist for transfers with R (right) brace. A review of a Individual Statement Form dated 6/24/17, signed by RN #1 who was on duty on 6/22/17, revealed the RN #1 received a call from the local Police Department (PD) that Resident #3 had called 911. The statement further reflected that the RN #1 asked the Charge Nurse, Licensed Practical Nurse (LPN #1), what had happened and LPN #1 replied they did not know. RN #1 documented that they noticed Resident #3's left knee was swollen and 'CNA (#1) told me that patient did not fall.' The documentation further indicated that RN #1 asked coworkers who said the Residents left knee had been swollen and it was not new. RN #3 came into the room to assist and said the Resident was awake, alert and oriented x 3 (oriented to person, place and time), but he/she had slurred speech. RN #3 asked the Resident a few questions, Resident denied falling. The RN #1 went on to document that We told the Resident we would order an X-ray of the left knee, unfortunately the x-ray was not followed-up. I know that failing to follow-up on the x-ray was an oversight on my part. There was no documentation in RN #1's Individual Statement Form to indicate an assessment was done or that any treatment was ordered for Resident #3. A review of a Progress Note (PN) documented as a late entry with an effective date of 6/22/17 timed at 8:50 PM, signed by LPN #1 revealed Notified by RN #1 that patient had pain and swelling in left knee. Patient had been assessed by RN #1. Medicated with PRN (as needed) Motrin as ordered. There was no documented assessment in the PN for 6/22/17 written by RN #1. A review of a PN dated 6/23/2017, signed by the RN #2 Unit Manager, indicated that This writer was notified by the 7 AM-3 PM shift CNA at 8:30 AM that the Resident was crying and c/o (complained of) pain to their left leg and the left leg looked swollen. This writer went in Residents room and assessed them immediately. Upon my assessment, observed left leg to be swollen and external rotation and shortening noted. limited range of motion, pain noted during examination. The PN further reflected that The Physician was notified and ordered an X-ray of the left hip and left knee to rule out a fracture. A review of a Radiology Report of the left knee, with a service date of 6/23/17, reflected severe osteoporosis. Under the Impression section reflected Fracture of the distal femur with marked angulation and separation. A review of a Universal Transfer Form dated 6/23/17, reflected that Resident #3 was sent to the hospital for evaluation and treatment of [REDACTED]. A review of a facility Accident/Incident Report dated 6/23/17 and timed at 8:30 AM, revealed under the First Aid administered section administered Tylenol with a date of 6/23/17 time of 8:35 AM. A review of a Accident/Incident Statement Form dated 6/23/17, signed by the RN #2, revealed under section #4 Resident reported they had fallen during the evening shift (6/22/17) when the CNA was getting them ready for bed. A review of the facility Post Accident/Incident Investigation dated 6/23/17, included the following: Accident/Incident Statement Form signed by CNA #1, and dated 6/23/17 timed at 3:19 PM, revealed that I removed his/her shoes and foot brace. stood him/her up to remove their pants and he/she fell to their knees. Further review of the statement did not include documentation of a fall. Individual Statement Form dated 6/26/17 and signed by RN #3, indicated that he/she asked the Resident if he/she fell and the Resident said no. The Statement further revealed that Resident #3 was asked how the knee came to be swollen and Resident #3 said it had been that way for a few days. RN #3 went back to his/her unit. Individual Statement Form dated 6/26/17 and signed by LPN #1 reflected that I did not get anything in report about his/her knee and if he/she fell (Resident #3). The statement further revealed One of them (RN #1 or RN #3) asked do you want to get an x-ray and that Resident was an alert patient. There was no documentation that the Physician was notified or that an x-ray was ordered. A review of an Individual Statement Form signed by LPN #2 dated 6/26/17, reflected they were unaware of any incident and the Resident did not complain of any pain within the course of their shift. A review of an Educational Review form dated 6/27/17, for RN #1 revealed that RN #1 was educated on 1) Assessment of Resident to be documented, 2) call to Physician to be completed or clearly delegated, 3) Follow-up to resolution at end of shift to ensure Physician notified, tests were ordered and family notified as appropriate. A review of an Employee Warning Record dated 6/27/17, signed by CNA #1, revealed under the Employee Statement section; In the future I will notify the nurse if there is a fall. Under the Action to be taken section reflected that CNA #1 was educated on not moving a Resident post fall and reporting immediately to the nurse. During a telephone interview on 8/8/17 at 12:18 PM, CNA #1 stated I was getting the Resident ready for bed and stood them up and did not have their brace (foot) and the Resident fell down on both knees. CNA #1 went on to say I think I put the Resident in bed instead of getting the Nurse which I should not have done. Within 20 minutes the Resident c/o of pain and I think the Supervisor (RN #1) was in the hall and noticed the leg. I think I told him/her that the Resident went down on their knees but not 100% sure, but probably did. CNA #1 went on to say Not that I can remember did the RN Supervisor do anything but elevate the Residents leg. I did tell LPN #1 that the Resident went down on their knees but not right away. I definitely told CNA #2 that the Resident fell . CNA #1 stated The facility policy is to leave Resident where they are and go get a nurse. I knew this before Resident #3 fell but wasn't thinking about it. During a telephone interview on 8/8/17 at 12:42 PM, CNA #2 stated I was not told by CNA #1 that the Resident had fallen. During an interview with the Director of Nursing (DON) on 8/8/17 at 2:27 PM, the DON stated We determined this was a fall after the investigation. The CNA did not report the fall. The DON went on to say that LPN #1 no longer works at the facility and had quit without notice. The surveyor attempted to interview LPN #1, but LPN #1 was unavailable. On 8/8/17, the surveyor requested from the DON, documentation of an assessment done for Resident #3 on 6/22/17 by RN #1, to include the medical record, incident report, and 24 hour nursing report for supervisors, and the facility was unable to provide the documentation. During an interview with the Assistant Director of Nursing (ADON) on 8/8/17 at 2:30 PM, the ADON stated that The RN Supervisor and CNA #1 were suspended pending investigation. LPN #1 immediately came to the facility on [DATE] and provided their statement and felt no suspension was warranted. During a telephone interview on 8/10/17 at 9:28 AM, RN #1 stated I specifically asked the assigned aide (CNA #1) who said Resident did not fall. I went in and asked the Resident if they fell and numerous times the Resident said I did not fall. The RN #1 further stated Not really, I did not ask and I do not know why the Resident called 911. We did an assessment but I don't know where I wrote it, probably on the notes on computer. But if not there probably on incident report. The surveyor questioned the RN #1 if there was not an incident that they were aware of, then why would there have been an incident report and the RN #1 did not answer. I think monitor was the follow-up. I think we instructed the assigned nurse to call for x-ray, but I don't think they did. The RN #1 stated Yes, part of my responsibility as a supervisor is to make sure nurses follow-up. I don't remember if I followed-up. During an interview on 8/10/17 at 10:05 AM with the Assistant Director of Nursing (ADON), the ADON stated that LPN (#1) was not present in the room nor was he/she told to get an X-ray. The ADON went on to state that I interviewed all staff involved on 6/23/17. A review of the hand written staff interview notes, provided to the surveyor by the ADON, revealed that CNA #1 'can not remember' if they told anyone. The RN #1 interview reflected that they were told Resident #3 did not fall and told staff to order an x-ray and was on a cart (medication) so no follow-up and No note in computer re: events. LPN #1's interview revealed RN (RN #1) assessed and told them to give pain medication. LPN #1 stated they were not directed to call for an x-ray by the RN #1. During an interview with the DON on 8/10/17 at 12:22 PM, the DON stated Yes it is a standard of practice to do an assessment if there was a change in condition or new finding for a Resident and it would be documented as per #6 in the Change in Condition policy. The DON went on to say that My expectation is for the staff to ask the Resident who called 911, why they called 911 and to resolve the issue. The DON went on to say that by giving pain medication the would deal with or resolve the issue. The DON further stated that My expectation is that an assessment by a Supervisor should be documented in the medical record. There was no documentation to indicate that RN #1 asked Resident #3 why they called 911 and that the Residents issue was dealt with or resolved. A review of a care plan Intervention/Task with an initiated date of 6/26/17 revealed that staff was to ensure Resident #3 has their right leg brace in place during ambulation/transfers. Brace is only removed after lying down in bed. A review of a facility policy titled Accidents and Incidents with a revision Date of March 2015, under the Policy Statement section revealed All occurrences of accidents or incidents occurring on the center's premises must be investigated and reported. The policy also reflected under the Process section 1. The Nursing Supervisor/Charge Nurse, Unit Manager . shall promptly be notified and then responsible for assessing, reviewing, documenting and reporting of the incident and or accident. 2.2 Employees witnessing an accident or incident involving a resident must report the occurrence to the Nurse Manager or Nursing Supervisor as soon as practical. 3.1.1 Should an employee witness an accident . Do not move the victim until he/she has been examined by a Nurse for possible injuries. A review of a facility policy with a revision date of December 2011, titled Change is (sic) a Resident Condition Center: or Status under the Policy Interpretation and Implementation section #6. The Unit Manager/Nurse Supervisor/Charge Nurse will record in the residents record information relative to changes in the residents medical/mental condition or status. NJAC 8:39-27.1 (a)

Complaint # NJ Based on interviews and review of medical records (MR) and other facility documentation, it was determined that the facility failed to ensure that 1 of 5 sampled residents (Resident #1), assessed for smoking, was consistently supervised and/or monitored to prevent injuries according to the care plan. Resident #1 was identified on his care plan (CP) and/or smoking assessment with a history of unsafe smoking and needed assistance and/or monitoring while smoking. On 7/10/2014 at 2:30 p.m., Resident #1 was outside in the smoking area, unsupervised and lit a cigarette while on continuous oxygen via a portable oxygen tank and nasal cannula (NC). Resident #2, who was in the smoking area with Resident #1, stated he observed Resident #1 light a cigarette butt and saw "flames" come out of Resident #1's nostrils and he immediately went inside the facility to notify a nurse. Resident #1, according to the nurse's assessment, was observed with localized redness to the left cheek area and the left portion of his moustache was singed. Resident #1 was transported to the emergency room (ER) and was diagnosed with [REDACTED]. The Immediate Jeopardy (IJ) was past non-compliance, which began on 5/11/2014, when a care plan (CP) for Resident #1 was revised from "unsafe smoker" to "smokes occasionally", without a smoking assessment. The IJ was relayed to the Administrator and Director of Nursing (DON) on the second day of survey, 7/24/2014 at 1:30 p.m. The IJ was corrected based on an acceptable plan of correction, which was implemented on 7/10/2014. 1. According to the "Resident Information" Sheet, Resident #1 was initially admitted to the facility in 11/2013 and readmitted in 3/2014 with [DIAGNOSES REDACTED].A Minimum Data Set (MDS), an assessment tool, dated 4/22/2014, revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of "15" which indicated intact cognition, needed assistance with activities of daily living (ADLs) and ambulated with assistance.A readmission facility smoking assessment, dated 3/12/2014, indicated Resident #1 did not smoke. However, review of previous smoking assessments, indicated that on 2/28/2014, Resident #1 was assessed as a smoker, was able to light his own cigarettes and needed supervision and a 1/31/2014 smoking assessment indicated Resident #1 was not a smoker.On 7/24/2014, the surveyor requested Resident #1's facility Admission Agreement. Review of the Admission Agreement, Smoking Policy Agreement/Contract, dated 2/4/2014, initialed by Resident #1 revealed; "I (Resident #1) do hereby state that I am a smoker", however, further down on the contract was hand written; "not a smoker".A Physician order [REDACTED]. On 6/17/2014, the order for continuous oxygen was decreased to 2 L via NC.Review of Treatment Administration Records (TAR) from 3/2014 through 7/2014 verified Resident #1 was receiving continuous oxygen therapy via NC. A facility care plan (CP) revealed a [DIAGNOSES REDACTED].The CP which addressed oxygen therapy r/t COPD, initiated 2/12/2014 and was "resolved" 5/5/2014. Interventions included but were not limited to; oxygen via NC/mask at 2 L continuously, if the resident is allowed to eat, oxygen still must be given to the resident but in a different manner. Additionally, there was no documention noted in the CP that addressed smoking and removal of the continuous oxygen prior to smoking. Additionally, a CP, initiated 4/21/2014 revealed that Resident #1 "is an unsafe smoker". The "unsafe smoker" CP was "resolved/canceled" on 5/11/2014. Interventions in the "unsafe smoker" CP included but were not limited to; instruct on admission regarding facility's smoking policy and consequences of failure to adhere to same, monitor rooms for signs of smoking, reinforce smoking policy as needed, assess residents physical and mental ability as needed for ability to understand and follow policy and remove oxygen prior to smoking. The surveyor interviewed the Registered Nurse (RN) Unit Manager (UM) r/t the facility protocol for a resident who had a history of [REDACTED]. The RN UM confirmed that education to a resident should be documented in the MR by the staff if it is done, however, she stated that since she was not aware Resident #1 smoked she did not review tobacco and oxygen risks with Resident #1.Review of the MR did not reveal any documentation r/t education by staff to Resident #1 on the risks of smoking and/or oxygen use.There was no smoking assessment/re-assessment noted in the MR after the CP, on 4/21/2014, was initiated which indicated Resident #1 was an unsafe smoker. During a telephone interview with the surveyor on 7/23/2014 at 3:40 p.m., the RN UM stated that when Resident #1 was admitted to the facility in 3/2014, he/she was a non-smoker and remained a non-smoker to her knowledge. The surveyor interviewed the RN UM as to why she initiated a CP on 4/21/2014 which indicated Resident #1 was an "unsafe smoker". The RN UM stated Resident #1 was not smoking when she wrote the CP and she could not recall what triggered her to initiate the "unsafe smoker" CP but she thought maybe she was reviewing the MR and noted that Resident #1 had a history of [REDACTED]. The RN UM stated that on 4/24/2014, Resident #1 was transferred to another unit so she was unaware why the CP was resolved/canceled on 5/11/2014, but stated that on review of the CP in the computer system, she noted it was updated on 5/11/2014 by the Director of Nursing (DON). Further review of the CP indicated it was updated/revised again on 5/11/2014, with a focus on "(Resident #1) smokes occasionally". The goal was to have Resident #1 demonstrate compliance with the smoking policy through the review date of 10/2014 and the resident would smoke safely. Interventions included but were not limited to; "make sure (Resident #1) smokes only in designated area, All which is fully aware, ensure that cig (cigarette) is lit and dispose of properly, offer support when (Resident #1) opts to cease from smoking, continue to enforce smoking policy and as needed". There was no indication that another smoking assessment was done prior to initiation of the 5/11/2014 CP. The CP for "smokes occasionally" was resolved/canceled on 7/11/2014, the day after the smoking incident for Resident #1 occurred. A new CP, dated 7/11/2014, revealed a focus on Resident #1's option for a smoking cessation program with interventions which included; administer nicotine patch as ordered, encourage, praise successful attempts, notify the physician when the resident becomes non-compliant with cessation plan and monitor for potential risk of unsuccessful cessation, discourage behaviors that may cause resident to be unsuccessful at his efforts to stop smoking, like going to smoking area. During an interview with the surveyor on 7/24/204 at approximately 12:45 p.m., the DON stated he was unaware who "resolved" the 4/21/2014 CP and updated/revised the CP on 5/11/2014 to "smokes occasionally" and stated that as far as he was aware, Resident # 1 was a nonsmoker since his admission in 3/2014.Review of General Clinical Documentation, dated 4/23/2014 at 9:06 a.m., revealed a nursing note (NN) by Licensed Practical Nurse (LPN) #1 which indicated Resident #1 was non-compliant with his oxygen use and nebulizer treatments and "Resident (#1) still continues to go outside an (and) smoke, even though is (in) respiratory discomfort."During a telephone interview with the surveyor on 7/23/2014 at approximately 4 p.m., the Administrator stated he had clarified the meaning of the NN with LPN #1, who wrote the 4/23/2014 at 9:06 a.m. note. He stated that "she (LPN #1) did not mean (to indicate that Resident #1) was smoking outside"; but that Resident # 1 "goes outside to the smoking area and inhales the smoke of other smokers". A statement, dated 7/23/2014, signed and faxed to the NJ Department of Health (DOH) by the Administrator, revealed a "clarification" of the 4/23/2014 note by LPN #1 which indicated that despite interventions and treatments Resident #1 would continue to go outside to the smoking area, "not to smoke" and would likely inhale the second-hand smoke even though he would sometimes be in respiratory discomfort. During a post survey telephone interview with the surveyor on 7/29/2014 at approximately 10 a.m. LPN #1 stated she was unable to discuss the incident at that time. On 8/1/2014 at 11:00 a.m. LPN #1 called the surveyor and stated that she "should have made the note more clear; that (Resident #1) would tell me he was going out to smoke, not that I (LPN #1) saw him smoking". LPN #1 stated that although she never saw Resident #1 smoke, he was able to ambulate and he would tell her that he was going out to smoke. LPN #1 stated that Resident #1 would not have his continuous oxygen on when she saw him ambulating out in the hall going to the smoking area. Review of the MR revealed no further documentation related to smoking until an incident the 7/10/2014 at 3:36PM, when a note by the Director of Nursing (DON) revealed; "was called to assess resident who felt he had inhaled smoke during smoking. observed in a wheelchair, calm, not in any distress. on visual observation, a localized redness to left cheek area, and left portion of moustache was singed. respiration was normal...bilateral nostrils were pinkish and appearances were normal. continued on oxygen at 2 L (liters)/ min (minute) via nasal cannula, stated no difficulty breathing. silvadine applied to redden (sic) area on check (sic) speech normal. resident sent to ER (emergency room ) for evaluation..."A facility Accident/Incident Report (IR), dated 7/10/2014, completed by the Unit Manager (UM), LPN #2, revealed that at 2:30 p.m. on the "patio" (smoking area), Resident #1 was observed with redness to his face and he stated he had put out a cigarette after smoking. He then connected his oxygen and he attempted to put cigarette back into his pocket and it got "inflamed" and felt that he had inhaled some smoke. "At time of my (LPN #2) arrival did not observe any flames". The IR indicated the incident was "unobserved". Silvadine was applied to the reddened area and Resident #1 was transported to the ER. A facility universal transfer form, dated 7/10/2014 at 2:20 p.m., revealed the reason for transfer; "Respiratory evaluations (secondary to) smoke inhalation from smoking". Review of the hospital ER documentation, dated 7/10/2014 at 7:11 p.m. indicated Resident #1 was a "current every day smoker" and Resident #1 was smoking while wearing oxygen and his mustache ignited on the left side of his upper lip burning left upper lip and nasal vestibule and distal nose on the left. Resident #1 was discharged back to the facility on the same day with [DIAGNOSES REDACTED]. An "Individual Statement Form", dated 7/10/2014, by LPN #2 revealed that Resident #1 stated he had put out his cigarette after smoking, connected his oxygen and as he attempted to put the cigarette back in his pocket, it reinflamed and he felt that he may have inhaled some smoke.A facility Investigational Summary for the incident on 7/10/2014 revealed; Resident #1 reported that he felt he had inhaled some smoke and was noted with redness on the left cheek area and upper lip on assessment. The Summary noted that Resident #1 "had gone out to smoke, first time since his re-admission of 3/28/2014...(Resident #1) had gone outside and felt the urge to smoke so he picked up a used cigarette and borrowed a lighter from another smoker. (Resident #1) states that he connected his oxygen after he had finished smoking and put out the cigarette. as he make an attempt to put cigarette but (butt) back to pocket, it got inflamed and felt he had inhaled some smoke. A staff nurse was (called)...Staff nurse did not observe an active flames upon arrival...Localized redness to left cheek area and upper lip, and left side of moustache singed...."The Summary Conclusion revealed that Resident #1 had not smoked since his last admission on 3/28/2014 and did not present a smoking problem. "He was obviously tempted to smoke on 7/10/2014 when he was in the smoking area. He was convinced that he had put the cigarette out and therefore was safe to connect his oxygen tube on. (Resident #1) has had multiple admissions to...(facility) this year 2014. His smoking evaluation on 1/31/2014 indicated not a current smoker, readmit on 2/28/14 indicated a smoker; 3/12/2014 evaluation indicated not a smoker and last evaluation on 4/21/14 confirmed that he had quit smoking recently...(Resident #1) had opted to smoking cessation and orders for nicotine patches approved by MD (physician)(on 7/11/2014). A facility-wide scheduled smoking meeting on (7/14/2014) to involve all smokers to review new smoking schedules, non-sharing of smoking paraphernalia and smoking cessation options. Current smokers have been observed, re-evaluated and are considered predictable safe based on current assessments." Resident #1 was observed by the surveyor on 7/21/2014 at 10:40 a.m. dressed and lying in bed, awake and alert. His facial skin appeared intact with no redness. During an interview with the surveyors on 7/21 and 7/24/2014 at 11:30 a.m. Resident #1 stated that he had smoked occasionally prior to the incident on 7/10/2014 and was able to turn his continuous oxygen on and off. He further confirmed the incident on 7/10/2014; that he had purchased a cigarette from Resident #7 and smoked it outside in the smoking area that afternoon and that he put the cigarette out and picked it up off the ground to smoke again and that is when he saw and smelled smoke. Resident #1 stated that he thought the oxygen tank was turned off prior to smoking.On 7/21/2014 at approximately 12:45 p.m., in the DON's office, the surveyor requested the facility smoking policy from the DON, and in the presence of the Administrator, the DON removed a smoking policy titled; "Smoking policy-Residents" from a policy binder and gave it to the surveyor. After review of the policy, which was dated/updated 8/2013 and 10/2013, the surveyor noted the following; "All residents who smoke require monitoring when smoking and shall have the direct supervision of a staff member at all times while smoking". When the surveyor asked the DON about the policy and the facility implementation of the policy related to (r/t) the incident on 7/10/2014 with Resident #1, the DON stated that the surveyor was given the wrong policy and that was "not" the policy that the facility was following. The DON left the office and at 1:00 p.m., the DON gave the surveyor an undated policy titled "Smoking", which did not include staff monitoring of residents while smoking. The facility DON provided a third "revised" smoking policy, dated 7/2014, which was titled; "Smoking policy-Residents"; identical to the smoking policy dated 10/2013. During an interview with the surveyor on 7/24/2014 at 2:30 p.m., second floor LPN #3, stated Resident #1 was on continuous oxygen and could turn it off and on by himself. She stated she was aware of his history of smoking but he did not smoke while on her unit. The surveyor asked LPN #3 about Resident #1's CP for "unsafe smoker" and "occasional smoker" which was in effect while he was on her unit and LPN #3 stated she thought it was r/t Resident #1's history of smoking. LPN #3 also stated that although she did not witness it, she thought Resident #1 would go out to the smoking area and informed the resident that he should not sit with the smokers and needed to inform a nurse or have a staff member call a nurse prior to going out to the smoking area so the oxygen tank could be removed. Review of the MR showed no documention that Resident #1 was instructed on the continuous oxygen use and smoking. During an interview with the surveyor on 7/24/2014 at 11:30 a.m., Resident #1 stated education regarding oxygen use and smoking had never been done. Review of a statement dated; 7/10/2014 by LPN #2, r/t the smoking incident on 7/10/2014, revealed that Resident #1 had stated that he had put out his cigarette after smoking then connected his oxygen and as he attempted to put the cigarette back in his pocket, it reinflamed and he felt he may have inhaled some smoke. During an interview with the surveyor on 7/21/2014 at 10 a.m. and 7/24/2014 at approximately 12 p.m., LPN #2 stated that Resident #1 was transferred to her unit on the first floor mid-June, 2014 from the second floor. She stated she was not aware that Resident #1 smoked or had a CP in place for "smoking occasionally". She stated she responded to the incident on 7/10/2014 for Resident #1 after she was notified by Resident # 2 and confirmed her statement. During an interview with the surveyor on 7/24/2014 at approximately 10:30 a.m., CNA #1, who had worked with Resident #1 in the past confirmed she was aware Resident # 1 smoked, at least since 6/2014 when he was transferred to her unit and instructed him to inform a nurse prior to going out to smoke so the oxygen tank could be removed. CNA #1 stated "if we actually see him, we take off the oxygen", "he knows it, that he had to remove it". During an interview with the surveyor on 7/24/2014 at approximately 12 p.m., CNAs #2 and #3 stated they were aware Resident #1 smoked and also instructed him to inform staff prior to smoking so that they could remove the oxygen tank. CNA #2 stated; "He put us all in danger when he smoked in his room" but she was unable to be specific with the date of that incident. Both CNAs confirmed that they recommended to the Nurse UM that Resident #1 be transferred back to the second floor as they thought he was smoking more while on the first floor with easy access to the smoking area.The surveyor requested the facility's 24 hour nursing reports from 3/2014 through 7/2014 however, the facility did not provide them. The RN In-service co-coordinator did provide the surveyor with Resident #1's 24 hour reports which consisted of the General Clinical Documentation from the MR. During an interview with the surveyor on 7/24/2014 at 2:55 p.m., the Administrator stated that no prior smoking incidents had been reported.During an interview with the surveyor on 7/21/2014 at 10:40 a.m. and on 7/24/2014 at 9:45 a.m., Resident #2 whose MDS revealed an intact cognition, stated that he was a smoker and had been at the facility for a couple of months. He stated that the smoking area was not consistently monitored by staff and on 7/10/2014, sometime in the afternoon, he was outside in the smoking area with approximately 5 other smokers when he observed Resident #1 pick up a cigarette butt and light it with a lighter. Resident #2 stated he saw "flames" come out of Resident # 1's nose. Resident #2 added that Resident #1 started to remove the oxygen tubing (nasal cannula) and it was still lit. "(Resident #1) thought the (oxygen) tank was off but it was behind him". Resident #2 confirmed that there was no staff outside on the smoking area so he went in and notified LPN #2.Additionally, Resident #2 stated he observed Resident #1 in the past outside in the smoking area but did not remember if he had been smoking.During an interview with the surveyor on 7/21/2014 at 10:35 a.m., Resident #7 stated that he had observed Resident #1 smoking outside in the smoking area in the past and facility staff had given Resident #1 several warnings about smoking, although he was unable to identify any specific staff and "he (Resident #1) knew better". On the day of the incident Resident #7 stated he observed Resident #1 light his cigarette with a lighter with the oxygen tank on the back of his chair, he stated; "It scared me, I left". Resident # 7 confirmed that there was no staff member in the smoking area at the time of the incident.During an interview with the surveyor on 7/24/2014 at 10 a.m., Resident #9, whose MDS revealed an intact cognition, stated that he had observed Resident #1 smoking cigarettes in the past in the smoking area. Additionally, Resident #9 stated that he had sold Resident # 1 cigarettes in the past, "I would only sell them to him without the (oxygen) tank". He further stated that he was aware that selling cigarettes was against facility policy but it paid for his own cigarettes. During an interview with the surveyor on 7/21/2014 at 2:55 p.m., the DON stated that he was aware Resident #1 had a history of [REDACTED].#1 had smoked since his admission in 3/2014. During an interview with the surveyor on 7/24/2014 at 2:55 p.m., and in a post survey telephone interview on 7/29/2014 at approximately 10 a.m., the Administrator stated that he was unaware that Resident #1 had smoked since his admission in 3/2014. He stated that he had observed Resident #1 numerous times sitting outside in the smoking area but without a cigarette. The Administrator stated he was unable to remember if Resident #1 had removed his oxygen during those times. Additionally, the surveyor asked the Administrator regarding the documention in the "summary conclusion" for the incident on 7/10/2014 where it indicated that the last smoking assessment, on 4/21/14, confirmed that Resident #1 had quit smoking. However, MR review did not show documention of a smoking assessment, dated 4/21/2014. The Administrator stated that he was referring to the "unsafe smoker" CP that was put in place on 4/21/2014. Review of the CP, dated 5/11/2014, which indicated Resident #1"smokes occasionally" was reviewed by the surveyor, Administrator and the DON. There was no evidence that the licensed staff nurses were aware of the CP and the interventions documented to ensure safety such as; ensure that cigarette is lit and disposed of properly or that staff had instructed Resident #1 r/t to the use of continuous oxygen use and smoking. Both the DON and Administrator stated that the CP was in place due to a "history of smoking" and they had not been aware Resident #1 smoked at the facility. The Administrator confirmed that prior to the incident on 7/10/2014, the smoking area was not consistently supervised but staff would "spot" check the area when they walked by. He stated that supervised smoking times were put into effect after the incident with Resident #1 on 7/10/2014 and all staff and residents were educated on the new procedure. On 7/24/2014 the facility initiated staff monitoring of all residents during smoking and non-smoking times beginning 7/24/2014 from 7 a.m. through 10 p.m. At 10 p.m. the doors to the smoking patio area are to be locked. He further stated that there were no previous incidents for Resident #1 or any other resident r/t smoking. Review of an undated facility policy titled; "Smoking", revealed; "It is the policy of (this facility) to provide a safe smoking environment to staff and residents while protecting other residents ad staff from harm...a plan of care shall be developed for each resident who is a smoker." The Immediate Jeopardy, past non compliance, to resident's health and safety was identified and corrected on 7/10/2014 as evidenced by the following; 1. Supervised smoking times were initiated immediately following the incident on 7/10/2014. 2. A meeting was held on 7/10/2014 with staff and residents to review the implementation of supervised smoking times and is ongoing. 3. Resident #1 was re-educated on 7/10/2014 of the benefits of not smoking and agreed to comply with current policy and procedures. 4. Smoking assessments were completed on 7/14 and 7/15/2014 and CPs updated for all smokers along with signed smoking contracts. Additionally, other residents who express the desire to smoke will be assessed and care planned. 5. The DON or designee will audit the MR of all new admissions to ensure the smoking assessment and CPs are in place. All audits are reviewed by the Administrator during the Quality Assurance Committee meetings for recommendations. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to protect residents, visitors and staff from verbal and physical abuse as well as intimidation by a resident with a history of [MEDICAL CONDITION] (Resident #15). This lack of protection resulted in the potential for serious harm through physical and verbal confrontations and intimidation and psycho-social anguish occurring to 8 of 8 alert and oriented residents who attended the Group Interview, including Residents #9 and #16 as well as unsampled residents and visitors that the facility's Administrator (LNHA) or Director of Nurses (DON) could not identify from facility documentation. The Immediate Jeopardy began on 5/11/12. The surveyor interviewed the facility's LNHA and DON and reviewed records which confirmed the complaints of physical and verbal abuse obtained from the 8 alert and oriented residents at the Group Interview. The LNHA, the DON and the Registered Nurse (RN) Corporation Representative were notified of the Immediate Jeopardy on 5/11/12 at 2:42 p.m. The Immediate Jeopardy was removed on 5/11/12 at 5 p.m. when Resident #15 was transferred out of the facility. The Immediate Jeopardy that began on 5/11/12 was removed at 5 p.m. and a plan of correction was accepted on 5/11/12 at 7:30 p.m. when the facility took the following steps: 1. Placed Resident #15 on 1 to 1 supervision until transport to a psychiatric hospital emergency room could be arranged; 2. Transferred Resident #15 from the facility to the psychiatric hospital emergency room for an acute psychiatric evaluation and treatment; 3. Provided inservice training to Administrative staff on Abuse investigations, Resident to Resident abuse, Resident to Visitor abuse and the Management of Difficult Behaviors; 4. Scheduled staff inservice training regarding how to handle difficult resident behavior and managing aggressive patients, Resident to Resident abuse, Resident to Staff abuse and all other training on abuse prevention; and 5. Performed an administrative review of the facility's Abuse policy and Procedure regarding Resident to Resident altercations, verbal and physical abuse. This deficient practice was evidenced by the following: On 5/7/12 at approximately 12:15 p.m., the surveyor observed Resident #15 seated in a chair across from the first floor nurses' station. The resident was yelling loudly but incoherently. When interviewed at this time, a RN working on the unit stated that Resident #15 was probably upset because her lunch tray was late. This RN added that Resident #15 was used to being served at a specific time but the facility was making changes to the meal delivery times. On the same day at 12:22 p.m., Resident #15 was served her lunch meal in the hallway where she was seated. On 5/8/12 at 10:30 a.m., 8 of 8 alert and oriented residents at the Group Interview told the surveyor that Resident #15, who they identified by name, was "very demanding" and would "scream and yell all of the time." The residents also stated that Resident #15 was a "very scary person" and that they were "scared to death of her." The residents stated that they felt "better" when Resident #15 left the areas where they would gather, such as the smoking patio or the "Blueberry" dining room. The residents stated that when they are out on the patio and Resident #15 came there to smoke, they "fly in the door" because they are scared. The residents stated that Resident #15 stared at them and made threatening remarks to them. The residents also stated that the staff, both on the unit and the administrative staff, were aware of Resident #15's behavior but they "don't listen" when complaints were made to them about it or they told the residents that they cannot do anything about Resident #15's behavior and threats. On 5/10/12 at 10:40 a.m., the surveyor observed Resident #15 seated on a bench on the outside patio smoking area. There were 3 other residents as well as 3 visitors observed on the patio at this time. There were no staff present during this observation. At 10:50 a.m. on the same day, the surveyor observed Resident #15 ambulate back into the facility from the patio. On 5/10/12 at approximately 2 p.m., the surveyor requested from the DON all the investigations involving Resident #15. On 5/11/12 at 9:07 a.m., the surveyor observed Resident #15 ambulate out of her room and over to a housekeeping cart that she shoved at a Certified Nursing Assistant (CNA). At 9:55 a.m., the surveyor observed Resident #15 ambulate in from the outside smoking patio. The resident sat down in a chair across from the nurses' station and began talking and laughing loudly and uncontrollably. At 11:50 a.m. on 5/11/12, the surveyor observed Resident #15 lying in bed, on her right side. The resident was rocking back and forth. According to the medical record, Resident #15 was originally admitted to the facility 6/11/10 from a state psychiatric hospital and had a readmission to the facility on [DATE]. The resident was approximately 5 feet 11 inches tall and weighed 310 pounds as of March of 2012. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Resident Assessment Instrument (RAI), dated 3/22/12, indicated that Resident #15, who scored a 14 out of 15 on her Brief Interview for Mental Status (BIMS), was usually understood and usually understands. This RAI also revealed that the resident had hallucinations and [MEDICAL CONDITION] and had physical and verbal behavior directed towards others. The RAI indicated that Resident #15's ambulation was not steady but she was able to stabilize her gait without assistance. This RAI also indicated that discharge of this resident was "determined not to be feasible." On the evening of 11/9/11 (untimed), a facility Licensed Practical Nurse (LPN #1) documented that Resident #15 was "agitated all shift" and "almost got into an altercation with residents in the TV room." LPN #1 documented that Resident #15 was "shouting and cursing. Making statements about other persons." LPN #1 wrote that Resident #15 was "very loud" and would not go to bed. On 11/10/11 at 8 a.m., a housekeeper went into Resident #15's room to empty the trash and the resident told the housekeeper to get out of her room. Resident #15 also told the housekeeper, "I'm going to kill you." At 9 a.m., Resident #15 got upset because she only had 1 cigarette left. The resident grabbed the cigarette from the medication cart and ran outside. At 10 a.m., the supervisor and social worker spoke to the resident and to the resident's mother about the resident's behavior and agitation. The Crisis Center Nurse Practitioner (NP) was also called and "new recommendations were given." These recommendations, however, were not documented. At 3 p.m. on 11/10/11, Resident #15 "took somebody's cigarettes" and "smoked the entire pack." On 11/16/11 at 10 p.m., LPN #2 documented that a visitor told her that Resident #15 was out on the smoking patio. Resident #15 had seen another unidentified resident throw a cigarette butt onto the ground. Resident #15 picked up the cigarette butt and "began to approach" the unidentified resident who threw the butt. This unidentified resident's visitor pushed the resident inside of the building and back to his room. Resident #15 followed them inside of the building but did not make contact with the unidentified resident and his visitor. LPN #2 documented that this visitor told her that the unidentified resident was "afraid" of Resident #15. On 12/24/12 at 10:45 a.m., LPN #3 documented that Resident #15 and a "visitor" got into a "verbal altercation" in the patio area. According to LPN #3's documentation, Resident #15 struck the visitor in the arm. "No injuries were noted and visitor able to move arm freely." At 11 a.m. that same day, Resident #15's attending physician and family were notified of the incident. On 12/25/11, Resident #15 was out of the facility on a pass with her family. On 12/27/11 at 1 p.m., Resident #15 returned to the facility from her pass. According to the Registered Nurse's (RN #1) documentation on the Interdisciplinary Progress Notes, Resident #15 was supposed to return to the facility on [DATE] but, according to the resident's mother, the resident had "physically attacked" her female sibling while on the home visit. According to Resident #15's mother, the resident's father had to call the crisis center and have the resident removed from the home via ambulance. At the time of this readmission, Resident #15 was "sedated from the sedation given at crisis center early 12/27." On the day shift of 2/9/12 (untimed), LPN #2 documented that Resident #15 refused to take a bath and that her room was "extremely foul with the smell of urine." On 2/10/12 at 7 a.m., the resident had a "foul smell of urine" and was refusing to "get changed." On 2/17/12 at 10 a.m., there was documentation in the Interdisciplinary Progress Notes that Resident #15 was "found outside having a bowel movement on outside smoking bench" of the smoking patio. On 3/19/12 at 6 p.m., LPN #1 documented that the kitchen staff called the first floor nursing unit and requested that someone come to the dining room and sit with Resident #15 "due to the problems earlier in the day." When dinner was done, Resident #15 refused to leave the dining room. LPN #1 wrote that Resident #15 "threatened to punch me out and carve me up." Resident #15 then attempted to go into the main kitchen. The kitchen staff closed and locked the kitchen door as well as held it closed from the inside. Resident #15 was "screaming" while "banging and punching" the kitchen door. The resident then picked up a chair and threw it at the sliding glass doors in the dining room before going back to her table and sitting down. There was no documentation in the medical record preceeding this entry regarding the "problems" that Resident #15 had "earlier in the day." On 3/31/12 at 10 p.m., LPN #4 documented that Resident #15 was "yelling and bothering the other smokers." Resident #15 was redirected back to her room. On 4/6/12 at 7:30 (no a.m. or p.m. documented), LPN #1 wrote that Resident #15 was yelling, "You b****" in the hallway. On the evening shift of 4/7/12, LPN #1 documented that Resident #15's mother was in to visit and that Resident #15 was "yelling, screaming at her mother because she didn't get a hot dog." On 4/10/12 at 7:45 p.m., LPN #1 documented that Resident #15 was "yelling, screaming" with "frequent outburst of erratic behavior." LPN #1 documented that the supervisor was able to "divert" Resident #15's attention with food. On 4/12/12 at 9 p.m., LPN #1 documented that Resident #15 had soiled herself and "had quite an odor." LPN #1 wrote that the other residents that were out in the smoking area were complaining. Resident #15 refused to change her pants until after dinner. Resident #15 went back out to the smoking area. After dinner, Resident #15 asked LPN #1 for a cigarette. LPN #1 documented that she told the resident that she could have the cigarette after she changed her pants. Resident #15 began talking to herself and yelling. When LPN #1 began her medication pass, Resident #15 "started yelling and screaming" at her for a cigarette. LPN #1 told the resident to wait by her room. LPN #1 then wrote that Resident #15 used both of her hands to push LPN #1 away from the medication cart "with enough force" that LPN #1 "went backwards away from the cart into the wall." Resident #15 then knocked the medication book off of the top of the medication cart. LPN #1 documented that Resident #15 then came up to LPN #1 "with her fists raised" in the LPN's face and "yelled you will give them to me now." Resident #15 then went into her room and slammed the door. LPN #1 wrote that she told the nursing supervisor what happened and attempted, unsuccessfully, to call and talk to Resident #15's mother. LPN #1 also called the resident's attending physician, who ordered an antianxiety medication to be administered intramuscularly (IM) to Resident #15 and to transport the resident out to the crisis center. There was no documentation as to whether the resident was admitted or returned to the facility after her evaluation at the crisis center. The psychiatric NP documented on the "Report of Evaluation" dated 4/19/12 at 11 a.m., indicated that Resident #15 was sent to the crisis center on 4/5/12 for "assault" and on 4/12/12 for "aggression." On 4/19/12 at 12 p.m., the psychiatric NP ordered medications changes for Resident #15. These included increasing the doses of Visteral for the resident's anxiety and increasing the doses of [MEDICATION NAME] for the resident's behavior. The psychiatric NP also documented that Resident #15 should be sent out to the crisis unit "for any threat of harm to self or others." On 4/22/12 at 2 p.m., there was documentation in the Interdisciplinary Progress Notes that Resident #15 was yelling "That's my coffee" at another resident. Resident #15 took the resident's coffee and drank it. Resident #15 also spilled coffee onto the lap of a visitor. Resident #15 was removed from the "Blueberry room and continued to yell at residents and visitors." On 4/24/12 at 3 p.m., LPN #2 documented that Resident #15 was yelling loudly while seated in her room at lunch time. Resident #15 was "very belligerent and threatening stating, 'I'm going to kill you and I'm going to chop you into pieces' to no visible person in particular." In addition, LPN #2 documented that it was reported to her that Resident #15 was "verbally screaming 'I don't care what they say, I hate you, I'm going to kill you' very loudly to the point when other residents were backing away from her out @ the smoking patio." LPN #2 wrote that an antianxiety was administered orally to Resident #15 at lunch time for "her aggressive behavior". On the evening shift of 4/24/12, LPN #1 documented that Resident #15 was "yelling, demanding, threatening." An antianxiety was administered orally to the resident. On 4/30/12 at 2 a.m., there was documentation in the Interdisciplinary Progress Notes that Resident #15 woke up extremely agitated, yelling and screaming. On the evening shift of 5/7/12, there was documentation in the Interdisciplinary Progress Notes that Resident #15 was yelling and walking up and down the hallway. When interviewed by the surveyor on 5/11/12 at 10:27 a.m., the Social Worker (SW) stated that Resident #15 had originally been admitted to this facility from a state psychiatric hospital and that the resident did well for quite awhile but had recently been sent out to "crisis." The SW stated that she would have to look at the universal transfer sheet to see when and why Resident #15 was sent out to "crisis." The SW added that she knew that Resident #15 "got sent out and sent back." The SW stated that she was not told any details about the crisis issues or why the resident was sent. During this same interview with the surveyor, the SW also stated that she had not received any complaints from other residents about Resident #15. The SW also stated that Resident #15 did stare and that this was "a comment" made by other residents. The SW stated that there was no formal or structured behavior program or care plan developed for Resident #15. The SW added that the staff needed to maintain a routine with Resident #15 and redirect her. The SW stated that she knew that psychiatric consults had been done with Resident #15 and that the facility had attempted to transfer the resident to a facility with a specialized behavior unit but did not know why the transfer was unsuccessful. The SW stated that the nurse that approved the resident's Long Term Care placement was in the other day but the SW did not know if the nurse saw Resident #15. (Refer to F250) At approximately 12 p.m. on 5/11/12, the surveyor requested from the DON all the investigations in the last 6 months involving Resident #15. At 12:15 p.m., the DON presented 1 investigation to the surveyor. At this time, the DON stated that this was the only investigation done involving Resident #15. This investigation, dated 4/6/12 at 7:30 p.m., revealed that Resident #15 had fallen while running back to her room after "grabbing handfuls of snacks" from the snack cooler. The DON again stated that this was the only investigation done involving Resident #15. When interviewed by the surveyor, on 5/11/12 at 2:30 p.m., the LNHA stated that Resident #15 had "violent behaviors." The LNHA also stated that "we wanted to remove her (Resident #15) from the facility in December" and that he had sent a "30 day discharge letter" to Resident #15's mother and father. The LNHA stated that the "30 day discharge letter" did not work because no other facility would take her. The LNHA also stated that the facility had also attempted to transfer her to other facilities but they denied the resident's admission because they "could not meet her (Resident #15's) needs." According to the "30 day discharge letter," dated 12/29/11, the LNHA documented that the discharge action was being taken "as a result of the behaviors displayed by the resident at this current placement. The behaviors that have been demonstrated cause concern for her safety as well as the safety of other residents." This letter also indicated that the "Social Work Department will assist in any discharge planning needs." During the interview with the surveyor on 5/11/12 at 2:30 p.m., the LNHA stated that he witnessed an altercation on the smoking patio last month when Resident #15 told the other residents and visitors, who were also on the patio, that she (Resident #15) would cut out their eyes and chop them into pieces. The LNHA stated that he did not initiate an investigation into this incident, appoint any other administrative staff to initiate an investigation into this incident or write a statement regarding what he witnessed and heard. The LNHA stated that the other residents and visitors were protected from Resident #15 when she was removed from the patio following this incident. The LNHA stated that Resident #15 was never restricted from using the patio after this or any other incidents and did not require the supervision of staff while out on the patio with other resident and visitors. According to the LNHA, the only restriction for Resident #15 was that she was not permitted to carry her own matches and lighter and that her cigarettes were stored in the medication cart to be doled out to the resident at the resident's request. When interviewed by the surveyor, via phone, on 5/11/12 at 3:30 p.m., Resident #15's psychiatrist stated that there was documentation in the resident's medical record that attempts were made to discharge the resident but no one would take her. The psychiatrist also stated that Resident #15 was not appropriate for this facility. On 5/11/12 at 3:50 p.m., the surveyor observed ambulance personnel with a stretcher, and police officers standing outside of Resident #15's door. When interviewed by the surveyor on the same day at 4:15 p.m., the SW stated that the ambulance personnel and the police were there for Resident #15 and added that she doesn't know what was happening. When interviewed by the surveyor on 5/11/12 at 4:20 p.m., the DON stated that the ambulance was there to transport Resident #15 to the crisis center. The DON added that the police were here because the facility called "911" for the ambulance and the police always responded to a "911" call. Also during this interview, the DON stated that Resident #15's attending physician was "out of the country" and that the facility's Medical Director was covering for the attending physician. The surveyor requested that the Medical Director be contacted. When interviewed by the surveyor via phone on 5/11/12 at 4:45 p.m., the facility's Medical Director stated that he knew that there were "problems" with Resident #15 "in the past 24 hours" but he was not made aware of the situation until today. The Medical Director stated that Resident #15 was not placed appropriately at this facility and that Resident #15 being at this facility was "not the optimal situation." The Medical Director also stated that "Our institution was not the best option for this resident." According to a follow-up medical record review, Interdisciplinary Progress Notes, dated 5/11/12 at 3:45 p.m., revealed that Resident #15 had "threatening behavior." Resident #15 stated that she was going to "poke them (other residents) in the eye" and "chop them up in pieces." The psychiatrist was notified of the resident's behavior and ordered that Resident #15 be sent to "crisis" for "inpatient evaluation." At 3:50 p.m., Resident #15 was threatening staff members, residents and visitors. The resident was stating that "I will chop you up into pieces. I will cut your eyes out with a knife." Resident #15 was "charging at other residents" and was a "high risk for harm to herself and others." The documentation indicated that the staff were "unable to redirect" Resident #15. This note also indicated that "residents, staff and visitors were fearful" of Resident #15. On 5/11/12 at 5 p.m., Resident #15 was transferred out of the facility to a hospital for evaluation. According to the facility's policy titled, "Accident and Incidents-Investigating and Reporting," incidents should be reported "regardless of how minor" and a "Report of Incident/Accident" form must be completed for all incidents. The 14 items listed on this policy that must be in the "Report of Incident/Accident" included, but was limited to: the date and time of the incident, the nature of the injuries, the names of the witnesses and their accounts of the incidents, any corrective action and any follow up information. According to the facility's policy titled, "Abuse and Neglect-Clinical Protocol," abuse was defined as "the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish". The policy titled, "Abuse Prevention Program" indicated that the facility was to protect residents from abuse "by anyone including but not necessarily limited to: facility staff, other residents...or any other individual." The policy governs that, at a minimum, there will be timely and thorough investigations of all reports and allegations of abuse; reporting and filing of accurate documents relative to incidents of abuse; an on-going analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse. The policy titled, "Abuse Investigations" indicated that "should an incident or suspected incident of resident abuse...the Administrator or his/her designee, will appoint a member of management to investigate the alleged incident." This policy also contained the "investigative process" that the individual conducting the investigation must follow, at a minimum. The Administrator would provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification agency and the local police department within 5 working days of the reported incident. According to the facility's policy titled, "Resident to Resident Altercations," "all altercations, including those that may represent resident to resident abuse shall be investigated by the unit manager and/or nursing supervisor and reported to the Director of Nursing Services and the LNHA through accident/incident reporting procedure." NJAC 8:39-4.1(a)(5)

Based on observation, interview and record review, it was determined that the facility failed to manage the unpredictable, threatening and violent behavior of 1 of 15 residents (Resident #15) sampled for behaviors and who had a recent documented history of threats and violence while at the facility. The behavior of this resident resulted in the potential for serious psycho-social, verbal and physical harm to herself and other residents at the facility, including the 8 of 8 alert and oriented residents who attended the Group Interview. In addition, the facility failed to assist in providing residents, visitors and staff, who expressed fear and intimidation, with counseling services and assistance in managing their physical and psychosocial needs regarding the unpredictable, threatening and violent behavior of Resident #15. The Immediate Jeopardy began on 5/11/12. The surveyor interviewed the facility's LNHA and DON and reviewed records which confirmed the complaints of physical and verbal abuse from the 8 alert and oriented residents at the Group Interview. The LNHA, the DON and the Registered Nurse (RN) Corporate Representative were notified of the Immediate Jeopardy on 5/11/12 at 2:42 p.m. The Immediate Jeopardy was removed on 5/11/12 at 5:00 p.m. when Resident #15 was transferred out of the facility. The Immediate Jeopardy that began on 5/11/12 was removed on 5/11/12 when the facility took the following steps:1. Placed Resident #15 on 1 to 1 supervision until transport to a psychiatric hospital emergency room could be arranged;2. Transferred Resident #15 from the facility to the psychiatric hospital emergency room for an acute psychiatric evaluation and treatment;and 3. Provided inservice training to Administrative staff, including the Social Worker, on the Management of Difficult Behaviors.This deficient practice was evidenced by the following:On 5/7/12 at approximately 12:15 p.m., the surveyor observed Resident #15 seated in a chair across from the first floor nurses' station. The resident was yelling loudly but incoherently. When interviewed at this time, a RN working on the unit stated that Resident #15 was probably upset because her lunch tray was late. This RN added that Resident #15 was used to being served at a specific time but the facility was making changes to the meal delivery times. On the same day at 12:22 p.m., Resident #15 was served her lunch meal in the hallway where she was seated.On 5/8/12 at 10:30 a.m., 8 of 8 alert and oriented residents at the Group Interview told the surveyor that Resident #15, who they identified by name, was "very demanding" and would "scream and yell all of the time." The residents also stated that Resident #15 was a "very scary person" and that they were "scared to death of her." The residents stated that they felt "better" when resident #15 left the areas where they would gather, such as the smoking patio or the "Blueberry" dining room. The residents stated that when they were out on the patio and Resident #15 came there to smoke, they "fly in the door" because they were scared. The residents stated that Resident #15 stared at them and made threatening remarks to them. The residents also stated that the staff, both on the unit and the administrative staff, were aware of Resident #15's behavior but they "don't listen" when complaints were made to them about it. The residents also stated that the administrative staff, including the SW, told the residents that they could not do anything about Resident #15's behavior and threats.On 5/10/12 at 10:40 a.m., the surveyor observed Resident #15 seated on a bench on the outside patio smoking area. There were 3 other residents as well as 3 visitors observed on the patio at this time. There was no staff present during this observation. According to the medical record, Resident #15 was originally admitted to the facility 6/11/10 from a state psychiatric hospital and had a readmission to the facility on [DATE]. The resident was approximately 5 feet 9 inches tall and weighed 310 pounds as of March of 2012. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Resident Assessment Instrument (RAI), dated 3/22/12, indicated that Resident #15, who scored a 14 out of 15 on her Brief Interview for Mental Status (BIMS), was usually understood and usually understood others. This RAI also revealed that the resident had hallucinations and delusions and had physical and verbal behavior directed towards others. The RAI indicated that Resident #15's ambulation was not steady but she was able to stabilize her gait without assistance. This RAI also indicated that discharge of this resident was "determined not to be feasible."A review of the "Admission/Readmission Quarterly Resident Assessment Summary" dated 11/29/11 (untimed), revealed that the SW documented that a meeting was held with Resident #15's parents, unit manager, Administrator and the SW regarding the resident's "recent verbal outbursts" and the possibility of alternate placement into a facility that had a behavioral unit. The SW documented that this would be "more beneficial for resident." Resident #15's medical record also contained documentation that the resident was agitated, threatening, intimidating, physically and verbally abusive to staff, residents and visitors and had displayed socially inappropriate behaviors as well as unpredictable violence (refer to F223). There was no documentation, aside from the entry in the "Admission/Readmission Quarterly Resident Assessment Summary" dated 11/29/11 (untimed), that the SW acknowledged Resident #15's "verbal outbursts" only. There was no documented evidence that the SW counseled, supported or advocated for the residents who expressed their fear of Resident #15. In addition, there was no other documentation in the medical record that the SW worked with Resident #15 on developing her social interaction skills or counseling the resident regarding her intimidating and threatening behaviors toward residents, visitors and staff. When interviewed by the surveyor on 5/11/12 at 10:27 a.m., the Social Worker (SW) stated that Resident #15 had originally been admitted to this facility from a state psychiatric hospital and that the resident did well for quite a while but had recently been sent out to "crisis." The SW stated that she would have to look at the universal transfer sheet to see when and why Resident #15 was sent out to "crisis." The SW added that she knew that Resident #15 "got sent out and sent back." The SW stated that she was not told any details about the crisis issues or why the resident was sent.During the interview with the surveyor, on 5/11/12 at 10:27 a.m., the SW also stated that she had not received any complaints from other resident about Resident #15. The SW stated that Resident #15 did stare and that this was "a comment" made by other residents. The SW stated that there was no formal or structured behavior program or care plan developed for Resident #15. The SW added that the staff needed to maintain a routine with Resident #15 and redirect her. The SW stated that she knew that psychiatric consults had been done with Resident #15 and that the facility had attempted to transfer the resident to a facility with a specialized behavior unit but did not know why the transfer was unsuccessful. The SW stated that the nurse that approved the residents' Long Term Care placement was in the other day but the SW did not know if the nurse saw Resident #15. On 5/11/12 at 3:50 p.m., the surveyor observed ambulance personnel, with a stretcher, and police officers standing outside of Resident #15's door. When interviewed by the surveyor on the same day at 4:15 p.m., the SW stated that the ambulance personnel and the police were there for Resident #15 and added that she did not know what was happening.According to the job description of the facility's Social Service Director, the Social Service Director "is responsible for the development, implementation and the coordination of the facility's social service policies, procedures and service programs to meet the residents' needs. The Social Worker (SW) should have knowledge of social work practice, effective counseling techniques, working with residents, working effectively with families, documentation standards and effective discharge planning. " The SW's "skills/competencies" included the following:1. The formulation of realistic intervention goals, recommendations and plans based on needs/problems identified during assessment; 2. The involvement of residents and their families in planning objectives and goals for residents as indicated in the residents' medical records;3. The assessment of each residents' needs and develop an effective counseling/supportive relationship with residents and their families;4. The overall management and implementation of resident care plans and psychosocial needs. Act as an advocate for residents;5. Work with the resident and their family on social interaction;6. Council residents and families;7. Update residents' care plans as a residents' condition changes;8. Advocates on behalf of residents and families to enable them to obtain necessary services;9. Informs and educates residents and families about available alternatives for obtaining care;10. Establishes effective working relationships with the medical community, referral sources and community agencies;11. Coordinate and implement the discharge planning process for residents and ensure it is documented according to standards and;12. Responds to issues to resident care and follow up, as appropriate, with the residents, family, staff and visitor requests. NJAC 8:39-39.3(b) NJAC 8:39-39.4(c, e, f, h & i)

Based on observation, interview and record review, it was determined that the facility failed to develop, implement and/or revise interventions for unpredictable, threatening, and violent behavior directed toward residents, visitors, and staff for 1 of 15 residents (Resident #15) reviewed for behaviors. This failure to develop, implement, and /or revise interventions to control the resident's unpredictable, threatening, and violent behavior resulted in the potential for serious harm to the resident, and other residents, visitors and staff at the facility, including the 8 of 8 alert and oriented residents who attended the Group Interview. The Immediate Jeopardy began on 5/11/12 and through interviews with the facility's LNHA and DON, as well as a record review, the surveyor confirmed the complaints of physical, verbal, and mental abuse from the 8 alert and oriented residents at the Group Interview. The LNHA, the DON, and the Registered Nurse (RN) Corporation Representative were notified of the Immediate Jeopardy on 5/11/12 at 2:42 p.m. The Immediate Jeopardy was removed on 5/11/12 at 5:00 p.m. when Resident #15 was transferred out of the facility. The Immediate Jeopardy that began on 5/11/12 was removed on 5/11/12 when the facility took the following steps:1. Resident #15's plan of care was up-dated to include 1 to 1 observation to keep this and other residents safe until transport to a psychiatric hospital emergency room could be arranged for this resident;2. Resident #15 was transferred from the facility to the psychiatric hospital emergency room for an acute psychiatric evaluation and treatment; and 3. Resident #15 s plan of care was reviewed to ensure that the plans reflected interventions that were individualized to the resident' s needs;This deficient practice was evidenced by the following:According to the medical record, Resident #15 was originally admitted to the facility 6/11/10 from a state psychiatric hospital and had a readmission to the facility on [DATE]. The resident was approximately 5 feet 9 inches tall and weighed 310 pounds as of March of 2012. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Resident Assessment Instrument (RAI) dated 3/22/12, indicated that Resident #15, who scored a 14 out of 15 on her Brief Interview for Mental Status (BIMS), was usually understood and usually understood others. This RAI also revealed that the resident had hallucinations and [MEDICAL CONDITION] and had physical and verbal behavior directed towards others. The RAI indicated that Resident #15's ambulation was not steady but she was able to stabilize her gait without assistance. This RAI also indicated that discharge of this resident was "determined not to be feasible." The surveyor reviewed a "Monthly Summary Sheet," dated December 2011, which indicated that Resident #15's targeted behaviors were listed as "depression, anxiety, [MEDICAL CONDITION]." In the section titled, "Behavior & Mood Quantify episodes with narrative," there was documentation that Resident #15 had "4 episodes of target behaviors" but did not identify which behavior. In addition, there was documentation that Resident #15 was "sent out to crisis for eval x 1" and that the resident "responds well to 1:1 and talking." According to the Interdisciplinary Plan of Care (POC), Resident #15 was alert and agitated at times. This Interdisciplinary POC also contained hand written [DIAGNOSES REDACTED]."On the care plan for [MEDICAL CONDITION] medication, originally dated 8/23/10 and last reviewed 5/2012, the interventions included the monitoring of Resident #15's behavior "every shift and document," "set goals with resident for appropriate behavior," "make clear to resident what the limitations are," "all staff to deal with resident consistently," and "give positive feedback for socially appropriate behaviors." The goal for this plan of care was that the resident would be free of any discomfort or adverse side effects x 90 days. There was no specific documentation in the plan of care or medical record that indicated that Resident #15's behavior was monitored every shift, that goals or limitations were provided to Resident #15, or that training to "deal with resident consistently" was provided to the staff. On the care plan for the "potential for confrontational behavior secondary to [MEDICAL CONDITION]", that was originally dated 6/13/10 and last dated as reviewed 2/15/12, the interventions included the monitoring of behaviors and a list of diversion techniques, such as "television show," "walk outside with staff," "offer phone call to family" and " offer 1:1 interaction" to be used before Resident #15's behavior "escalates." The goal for this plan of care was that Resident #15 would have minimal episodes of confrontational behavior and would be redirected x 90 days." There was documented evidence in the medical record that Resident #15 exhibited confrontational behaviors, however, the episodes had not been quantified. There was no documented evidence that the resident's behavior was monitored on a monthly summary sheet after December 2011 and there was no documented evidence that all of the diversion techniques, listed on the care plan, were implemented.On the care plan for "Socially Inappropriate Behavior related to [MEDICAL CONDITION], personality disorder, poor impulse control", originally dated 8/23/10 and last reviewed on 3/2012, the interventions included the assessment of Resident #15's "coping skills and support system," "set goals with resident for appropriate behavior," "make clear to resident what limitations are," "all staff to deal with resident consistently" and to "give positive feedback for socially inappropriate behaviors." The goals for this plan of care included the following:1. less than one episode/fewer than 3 episodes per shift/per day;2. Resident will verbalize understanding of need to control socially inappropriate behavior;3. Resident will demonstrate effective coping skills; and4. Resident will demonstrate compliance with social norms x 90 days.There were episodes of Resident #15 exhibiting socially inappropriate behaviors documented in the medical record of Resident #15, however, these episodes had not been quantified by the staff. In addition, there was no documented evidence that Resident #15 verbalized that she understood the need to control socially inappropriate behavior or the ability to demonstrate effective coping skills. There was no evidence that interventions were changed when the listed interventions for the resident's behaviors were not effective. There were no interventions to address the resident's threatening behaviors or to ensure the safety of other residents, visitors or staff from Resident #15 s verbal, physical and threatening behaviors.When interviewed on 5/11/12 at approximately 3 p.m., the Director of Nurses stated that she was not aware of the exact and specific interventions or goals that had been documented on Resident #15's care plans.NJAC 8:39-11.1

Based on observation, interview and record review, it was determined that the facility's Administrator (LNHA) failed to protect residents, visitors and staff by being proactive in ensuring that interventions were in place and implemented or that appropriate placement was secured for a resident, Resident #15, with a history of verbal, physical, and mental abuse and intimidation. The LNHA's lack of action resulted in the potential for serious harm through physical and verbal confrontations and intimidation occurring to 8 of 8 alert and oriented residents who attended the Group Interview, as well as other residents, visitors and staff that came in contact with this independently ambulatory resident.The Immediate Jeopardy began on 5/11/12 and through interviews with the facility's LNHA and DON, as well as a record review, confirmed the complaints of physical and verbal abuse from the 8 alert and oriented residents at the Group Interview. The LNHA, the DON and the Registered Nurse (RN) Corporation Representative were notified of the Immediate Jeopardy on 5/11/12 at 2:42 p.m. The Immediate Jeopardy was removed and the deficient practice was corrected on 5/11/12 at 5 p.m., when Resident #15 was transferred out of the facility. The Immediate Jeopardy that began on 5/11/12 was removed on 5/11/12 when the facility took the following steps:1. Resident #15 was placed on 1 to 1 supervision until transport to a psychiatric hospital emergency room could be arranged;2.Resident #15 was transferred from the facility to the psychiatric hospital emergency room for an acute psychiatric evaluation and treatment; 3. Inservice training was provided to Administrative staff on Abuse investigations, Resident to Resident abuse, Resident to Visitor abuse and the Management of Difficult Behaviors; and4. An administrative review of the facility's Abuse policy and Procedure regarding Resident to Resident altercations, verbal and physical abuse was completed. This deficient practice was evidenced by the following:On 5/7/12 at approximately 12:15 p.m., the surveyor observed Resident #15 seated in a chair across from the first floor nurses' station. The resident was yelling loudly but incoherently. When interviewed at this time, a RN working on the unit stated that Resident #15 was probably upset because her lunch tray was late. This RN added that Resident #15 was used to being served at a specific time but the facility was making changes to the meal delivery times. On the same day at 12:22 p.m., Resident #15 was served her lunch meal in the hallway where she was seated.On 5/8/12 at 10:30 a.m., 8 of 8 alert and oriented residents at the Group Interview told the surveyor that Resident #15, who they identified by name, was "very demanding" and would "scream and yell all of the time." The residents also stated that Resident #15 was a "very scary person" and that they were "scared to death of her." The residents stated that they felt "better" when Resident #15 left the areas where they would gather, such as the smoking patio or the "Blueberry" dining room. The residents stated that when they were out on the patio and Resident #15 came there to smoke, they "fly in the door" because they were scared. The residents stated that Resident #15 stared at them and made threatening remarks to them. The residents also stated that the staff, both on the unit and the administrative staff, were aware of Resident #15's behavior but they "don't listen" when complaints were made to them about it or they told the residents that they could not do anything about Resident #15's behavior and threats.According to the medical record, Resident #15 was originally admitted to the facility 6/11/10 from a state psychiatric hospital and had a readmission to the facility on [DATE]. The resident was approximately 5 feet 9 inches tall and weighed 310 pounds as of March of 2012. Resident #15 had [DIAGNOSES REDACTED]. The Quarterly Resident Assessment Instrument (RAI), dated 3/22/12, indicated that Resident #15, who scored a 14 out of 15 on her Brief Interview for Mental Status (BIMS), was usually understood and usually understood others. This RAI revealed that the resident had hallucinations and [MEDICAL CONDITION] and had physical and verbal behavior directed towards others. The RAI also indicated that Resident #15's ambulation was not steady but she was able to stabilize her gait without assistance. This RAI indicated that discharge of this resident was "determined not to be feasible." The surveyor reviewed the "30 day discharge letter" dated 12/29/11 addressed to Resident #15's parents. The LNHA documented that the discharge action was being taken "as a result of the behaviors displayed by the resident at this current placement. The behaviors that have been demonstrated cause concern for her safety as well as the safety of other residents." This letter also indicated that the "Social Work Department will assist in any discharge planning needs." When interviewed by the surveyor on 5/11/12 at 2:30 p.m., the LNHA stated that Resident #15 had "violent behaviors." The LNHA also stated that "we wanted to remove her (Resident #15) from the facility in December" and that he had sent a "30 day discharge letter" to Resident #15's mother and father. The LNHA stated that the "30 day discharge letter" did not work because no other facility would take her. The LNHA also stated that the facility had also attempted to transfer her to other facilities but they denied the resident's admission because they "could not meet her (Resident #15's) needs." During the interview with the surveyor on 5/11/12 at 2:30 p.m., the LNHA stated that he witnessed an altercation on the smoking patio last month when Resident #15 told the other residents and visitors, who were also on the patio, that she (Resident #15) would cut out their eyes and chop them into pieces. The LNHA stated that he did not initiate an investigation into this incident, appoint any other administrative staff to initiate an investigation into this incident, or write a statement regarding what he witnessed and heard. The LNHA stated that the other residents and visitors were protected from Resident #15 when she was removed from the patio following this incident. The LNHA stated that Resident #15 was never restricted from using the patio after this or any other incident and did not require the supervision of staff while out on the patio with other resident and visitors. According to the LNHA, the only restriction for Resident #15 was that she was not permitted to carry her own matches and lighter and that her cigarettes were stored in the medication cart to be doled out to the resident at the resident's request. The surveyor reviewed the job description for the facility's LNHA which indicated that the Administrator was responsible for the overall operations of the facility in accordance with policies and procedures; as well as the federal, state and local standards, guidelines and regulations. The LNHA would ensure quality of care and resident rights to ensure that the health, safety, welfare and satisfaction of the residents was the primary concern of all employees at the facility. The skills/competencies of the LNHA included: 1. Made routine inspections of the facility to assure that established policies and procedures were being implemented and followed;2. Consulted with department directors concerning the operation of their department to assist in eliminating/correcting problem areas and/or improvement of services required by current regulations;3. Reviewed accident/incident reports and established accident prevention programs;4. Responded to issues relating to resident care and followed-up, as appropriate, to resident, family, staff and visitor requests;5. Understood the process for referring customer complaints; and6. Had direct contact with residents, staff and visitors on a frequent basis. NJAC 8:39-5.1(a & d)NJAC 8:39-9.2(a)(e)(1)

C# Based on observation, interview and record review, it was determined that the facility failed to provide care in a safe manner. One resident sustained [REDACTED]. This deficient practice was identified in 2 of 11 residents (Residents #8 and #17) reviewed for falls and fractures and was evidenced by the following: 1.) On 5/8/12 at 12:15 p.m., the surveyor observed Resident #17 in the Steel Pier Room during lunch service. The resident was seated at a table in a wheelchair, complaining of pain in the left arm. The resident's family member, who was present during this observation, stated that Resident #17 had recently hurt the arm, but was not specific about the nature of the injury. According to the medical record, Resident #17 had multiple diagnoses, which included Dementia and a Seizure Disorder. A Resident Assessment Instrument (RAI), dated 11/9/11, indicated that the resident had impaired cognition, did not walk, required extensive assistance with transfers and was dependent on staff for other aspects of care. This RAI also identified that Resident #17 displayed mood problems and received multiple psychoactive medications. The Interdisciplinary Plan of Care identified that the resident displayed behaviors of yelling and hitting during care and that the staff were to provide safety measures as needed. A review of an Interdisciplinary Progress Note, dated 4/7/12, revealed that Resident #17 had been combative during care. During this provision of care, a Certified Nursing Assistant (CNA #1) had heard a "pop" in the resident's left arm, with the immediate onset of severe pain, while attempting to reposition the resident. The resident was transferred to the hospital and was admitted with a fracture and dislocation of the left shoulder. According to the investigative documentation which was provided by the facility, this incident occurred in Resident #17's bedroom. In a written statement, dated 4/7/12 (untimed), CNA #1 documented that they had observed Resident #17 attempting to get out of the wheelchair, while in attendance at a group activity. According to the statement, CNA#1 responded by removing the resident from the activity to reposition the resident for safety. CNA #1documented that the resident was "kicking and punching" at that time and continued to attempt to exit the wheelchair, despite CNA #1's efforts to reposition the resident. The statement also revealed that Resident #17 became physically aggressive and "punched" CNA #1 in the chest during an attempt to pull the resident up in the wheelchair, knocking CNA #1 off balance. At that time, CNA #1 felt the Resident#17's left arm "pop". In another written statement, dated 4/7/12, a second CNA (CNA #2), described that, while in another resident bedroom across the hall, a "noise" was heard coming from the Resident #17's bedroom. CNA #2 documented that upon entering Resident #17's room, she observed Resident #17 punching and trying to kick CNA #1. The statement indicated that CNA #2 offered to help however, CNA #1 had refused the offer of assistance. CNA #2 left the room and resumed her duties in the bedroom across the hall, leaving the CNA #1 alone with Resident #17. There was no documented evidence that the resident's physically aggressive behavior towards CNA #1 had subsided when CNA #2 left the room. In addition, there was no documented evidence that either CNA #1 or CNA #2 attempted to notify any licensed nursing personnel of the CNA #1's inability to alleviate Resident #17's potentially harmful behavior. On 5/11/12 at 11a.m., the Assistant Director of Nurses (ADON) stated that the facility routinely provided inservice training related to the provision of care to residents with problematic behaviors. A review of the Employee Education Competencies dated 9/2011, revealed that both CNAs involved in the incident on 4/7/12, had received training in the management of residents with Dementia. Upon review, the curriculum had included the management of aggressive behavior and catastrophic reactions (an extreme emotional response out of proportion to the actual event). Training interventions included assessing the level of danger and maintaining staff and resident safety. 2.) A review of the medical record indicated that Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Resident Assessment Instrument (RAI)), dated 1/29/12, Resident #8, who was cognitively impaired, required total assistance with activities of daily living (ADL). An Interdisciplinary Progress Note dated 1/29/12 at 10:30 a.m., indicated that a Certified Nursing Assistant (CNA) reported to the nurse that Resident #8 was on the floor in her room. When the nurse entered the room, Resident #8 was found on the floor, by her bed, lying on her stomach with a moderate amount of bright red blood on the left side of her head and on the floor. A laceration of 3 x 3 centimeters (cm) was noted on Resident #8's right forehead. Pressure was applied to Resident #8's forehead, 911 was called and Resident #8 was sent to the emergency room (ER) for evaluation. Resident #8 returned to the facility that same day at 6:00 p.m., with 4 sutures and a dressing on her right forehead. A review of the facility's Accident/Incident Report dated 1/29/12, reported that, during morning care on 1/29/12 at 10:15 a.m., a CNA was turning Resident #8 on to her left side to pull up her pants and Resident #8 rolled out of the bed on to the floor sustaining a laceration to her right forehead. . A review of the "Employee Warning Record" dated 1/30/12, revealed that the CNA who was providing morning care to Resident #8 failed to have the most distant side rail up. When the CNA turned the resident, she (Resident #8) fell on the floor. Resident #8 sustained a laceration that required treatment at the local ER. NJAC 8:39-27.1(a) B.) Based on observations, in the presence of facility management, it was determined that the facility failed to provide a safe, hazard-free environment for all residents. This deficient practice was evidenced by the following: 1.) On 5/11/12 at 9:57 a.m., the surveyor observed a cart of medical equipment next to the second bed in resident room B-214. The equipment consisted of a easy-air and suction pump with an oxygen concentrator on the floor next to the cart. The surveyor observed that this equipment was plugged into a power strip and was being used the resident sitting in a geri-chair, in this room. 2.) On 5/11/12 at 10:34 a.m., the surveyor observed that a tube feeding pump, which was being used for a resident in room C-101, was plugged into a power strip. NJAC 8:39-31.2(e)

Based on observation, interview and record review, it was determined that the facility failed to protect residents from theft of money and personal property. This deficient practice occurred to 1 of 4 residents (Resident #16) sampled for abuse/misappropriation of resident property. As a result, the resident suffered mental anquish over the loss of her possessions, including the theft of her coins, clothing, and other belongings. This deficient practice was evidenced by the following: Resident #16, who was alert and oriented, attended the Group Interview that was conducted, by the surveyor, on 5/9/12 at 10:30 a.m. During the Group Interview, Resident #16 told the surveyor that, "I had underwear, wigs, a pocketbook, jackets, $40 in dimes and silver coins missing from my room." When interviewed by the surveyor, on 5/10/12 at 9:35 a.m., Resident #16 said, "Let me tell you the story of how I got here to this place." The resident related part of her family history and concluded with, "I have real bad diabetes and lost my right leg because of it. My niece wanted me to live with her, but I didn't want to be a burden to her. I was saving those silver coins to give to her. I thought they would be worth something someday and she would be able to use them." Resident then said, "I'll talk to you again later." The surveyor had occasion to speak with the resident again on 5/10/12 at 10:15 a.m. At this time, Resident #16 said, "I remember a girl who helped me move, big girl, after dinner. I took all my stuff and put it in plastic bags myself. She picked them up and carried them out for me. I didn't unwrap everything or take everything out of the bags right then. I did later that day and the next day after I moved to another room. I looked for some things but couldn't find them. I talked to someone in laundry about my underwear and jackets, but she didn't know anything about them and I know I didn't put them in because they were clean. She looked but couldn't find anything in laundry. Then I saw that some other things were missing, some wigs, silver coins, $40 in dimes and a brand new pocketbook. I had all that stuff locked up upstairs, but I couldn't find it again when I looked in the plastic bags to put it away. If they told me they needed some money, I wouldn't have said no. I'd a given them half of what I had. Oh well." When asked by the survyeor as to whether she had reported the missing items to anyone, the resident said, "Yes, someone who works here, but I can't remember who." The resident then said, "I'm just so upset someone would do such a thing. I don't have much either. "I've collected some of those coins for such a long time. I never hurt anyone, but someone here hurt me. I saved those silver coins for a long time." My grandmother once told me, (If you come across something interesting or what may be valuable to you later, save it, you may need it or like to have it). I was going to give them to my niece. I guess someone needed those things more than I did." When interviewed by the surveyor on 5/10/12 at 2:10 p.m., the facility Administrator (LNHA), the Director of Nurses (DON) and the Social Worker (SW), stated that "We were unaware of any missing items lately. We haven't heard anything about this resident missing anything. Whoever she (Resident #16) said she reported it to didn't say anything to us." The LNHA stated that, if he had known that Resident #16 had personal items and money stolen, he would have given the resident money to replace her missing items. The LNHA also stated that he carries $100.00 in his pocket to replace missing money or reimbuse for missing items. During a review of the resident's Social Progress Notes that was conducted by the surveyor, on 5/11/12 at 11:30 a.m., Resident #16 had been transferred from the 2nd floor to the 1st floor on 4/4/12. The resident then requested another room change and was subsequently transferred to another room on the 1st floor on 4/5/12, where she currently resides. On 5/14/12 at 8:35 a.m., the DON stated that clothing/property form are filled out "for most residents", however, the forms are not consistently done for all residents. This resident did not have a clothing/property form filled out upon admission. On 5/14/12 at 8:55 a.m., Resident #16 requested to speak with the surveyor. When asked by the surveyor as to whether any facility staff member had spoken to her regarding the missing items, the resident said, "I'm not sure who she was, but I did tell her about the missing underwear, the new jackets, pocketbook and wigs. I didn't say anything about the money. I figured it was gone and I can't prove it and that's that. I told whoever it was when it first went missing and I told you two state people. No one did anything at first until now. It's gone. Oh well." Resident #16 had her head in her hands as she was speaking with the surveyor. N.J.A.C. 8:39-4.1(a)(5)(15)

C# Based on interview and record review, it was determined that the facility failed to notify the appropriate authorities following injuries that resulted in more than minimal physical harm and a reported allegation of theft. As a result the facility failed to demonstrate its intention to prevent the recurrence of care related injuries, and the misappropriation of residents personal property. This deficient practice was identified in 3 of 4 residents reviewed for abuse, neglect and misappropriation of property (Residents# 8, #16 and #17) and was evidenced by the following: 1.) According to the medical record and documentation provided by the facility, Resident #17 sustained a fracture and dislocation of the left shoulder during the provision of care on 4/7/12. The facility documented that the occurrence was not reported to the Department of Health and Senior Services (DHSS) or Office of the Ombudsman for the Institutionalized Elderly (OOIE). When interviewed, by the surveyor on 5/11/12 at 7:25 p.m., the Director of Nurses stated that this incident of harm to Resident #17 had not been reported to the appropriate state agencies, as required. The facility's policies related to Abuse and Neglect identified risk factors for abuse within the facility. These factors included significant numbers of residents with unmanaged, problematic behavior, significant injuries in physically dependent residents, and problems related to the staff's knowledge, skill or performance that might affect how residents were cared for. The policies also specified that all allegations of abuse or neglect would be reported to the appropriate State Agencies within 5 working days of the occurrence. (Refer to F323, example 1) 2.) An Interdisciplinary Progress Note, dated 1/29/12 at 10:30 a.m., indicated that a Certified Nursing Assistant (CNA) reported to the nurse that Resident #8 was on the floor in her room. When the nurse entered the room, she observed Resident #8 on the floor, by her bed, lying on her stomach, with a moderate amount of bright red blood on the left side of her head and on the floor. A laceration of 3 x 3 centimeters (cm) was noted on Resident #8's right forehead. Pressure was applied to Resident #8's forehead, 911 was called and Resident #8 was sent to the emergency room (ER) for evaluation. Resident #8 returned to the facility later that same day at 6:00 p.m., with 4 sutures and a dressing on her right forehead. A review of the facility's Accident/Incident Report for Resident #8, dated 1/29/12, reported that during morning care on 1/29/12 at 10:15 a.m., a CNA was turning Resident #8 on to her left side to pull up her pants without the side rail in the proper position. Resident #8 rolled out of the bed, on to the floor sustaining a laceration to her right forehead. When interviewed, by the surveyor on 5/14/12 at 8:20 a.m., the Administrator (LNHA) and Director of Nursing (DON) stated that it was the facility's policy to notify the state survey and certification agency of this incident but this notification had not been done. (Refer to F323, example 2) 3.) During the Group Interview that was conducted on 5/9/12 at 10:30 a.m., Resident #16, who was alert and oriented, told the surveyor that personal items including underwear, wigs, a pocketbook, jackets, $40 in dimes and silver coins were missing. When interviewed on 5/10/12 at 10:15 a.m., Resident #16 stated that she told "someone who works here" that the items were missing but could not remember the identity of that person. A review of the medical record revealed that there was no documentation anywhere in the medical record or the Social Progress Notes regarding the resident's allegations of theft. According to the facility's Abuse Prevention Program, the facility residents have the right to be free from abuse and misappropriation of resident property..." and that the facility's "abuse prevention program provides...the development of investigative protocols governing resident theft/misappropriation of resident property; timely and thorough investigations of all reports and allegations of abuse and that the Administrator will provide a written report of the results of all investigations...to the state survey and certification agency and the local police..." When interviewed by the surveyor on 5/10/12 at 2:10 p.m., the facility Administrator (LNHA), the Director of Nurses (DON) and the Social Worker (SW), stated that "We were unaware of any missing items lately. We haven't heard anything about this resident missing anything. Whoever she (Resident #16) said she reported it to didn't say anything to us." The LNHA stated that, if he had known that Resident #16 had personal items and money stolen, he would have given the resident money to replace her missing items. The LNHA also stated that he carries $100.00 in his pocket to replace missing money or reimburse for missing items. N.J.A.C. 8:39-4.1(a)(5)(15)

C# NJ Based on interview and review of medical records and facility documentation, it was determined that the facility failed to implement an identified intervention, including staff observation until bedtime, to prevent falls for 1 of 3 sampled residents, Resident #1. Resident #1 had an unwitnessed fall in her room and sustained several lacerations on the head resulting in overnight hospitalization for observation. This deficient practice is evidenced by the following: Medical records were reviewed and interviews conducted on 3/16/11, unless otherwise indicated. 1. According to the Minimum Data Set, an assessment tool, dated 8/13/10, Resident #1 had multiple [DIAGNOSES REDACTED]. In addition, the resident had both short and long term memory deficits, moderately impaired decision making skills, was non-ambulatory and had a recent history of falls. A review of the resident's Interdisciplinary Care Plan (IDCP) dated 8/9/10 indicated the resident was at risk for falls secondary to a falls history and actual falls. Appropriate interventions were identified and implemented. An Interdisciplinary Progress Note (IPN) dated 9/01/10 7:30 p.m. indicated the resident had been sitting in her wheelchair, unbuckled her seat belt and slid to the floor. An assessment indicated there were no injuries sustained. An Interdisciplinary Fall Meeting form dated 9/02/10, indicated the resident's fall on 9/1/10 was discussed and a determination to keep the resident at the nurse's station or in view of staff until bedtime, was implemented. The resident's IDCP was updated on 9/2/10 to reflect the new intervention. Subsequent review of an IPN dated 9/19/10 5:30 p.m. indicated the resident had another fall. The resident was found on the floor in her room, lying on her stomach, with a "pool of blood" on the right side of her head. 911 was called and the resident sent to the hospital. The facility Quality Improvement Fall Investigation Tool dated 9/19/10 indicated the resident had been sitting in her room in the wheelchair waiting to be served dinner when the incident occurred. The resident had unbuckled her seatbelt and fell face down on the floor. The facility transport form dated 9/19/10 indicated the resident had an unwitnessed fall in her room and sustained head trauma. A hospital Operative Note dated 9/19/10 indicated the resident sustained [REDACTED]. The 12 cm. scalp laceration was stapled. The other two lacerations were sutured. A hospital Discharge Summary dated 9/20/10 indicated the resident had sustained lacerations on the right forehead and concussion, status [REDACTED]. In a post survey telephone interview on 3/23/11 at 11:45 a.m., the Certified Nursing Aide assigned to Resident #1 on 9/19/11 stated that she usually works on a different wing but was working a double shift that evening. She had observed the resident in the hallway sometime prior to the incident but could not state the exact time. She heard the resident yell, went to the room and found her on the floor and called for assistance. The surveyor then asked the CNA if she was aware that the resident's care plan had indicated that the resident was to be kept at the nurse's station or in sight of staff until bedtime. The CNA replied, "No, I wasn't." In an interview at 11:00 a.m., the Director of Nursing stated that any change in the resident's care plan interventions such as a need for increased supervision is discussed during shift report. A review of the facility's policy entitled, "Fall Prevention-Falling Star Program" indicated that each resident shall be assessed upon admission and quarterly (at a minimum) for fall risk and appropriate interventions shall be instituted to prevent fall/injury. After each fall, the Fall Committee shall meet to discuss the fall and the cause(s) of it. New intervention(s) shall be put in place if necessary/appropriate. NJAC 8:39-27.1(a)