Every finding on record at Homestead Rehabilitation & Health Care Center

Based on interviews, record review, and review of pertinent facility documentation on 7/16/26, it was determined that the facility failed to initiate an investigation into an incident of alleged abuse of a resident (Resident #1). This deficient practice was evidenced in 1 of 3 residents' records reviewed for incident investigation and was evidenced by the following: A review of Resident #1's Face Sheet (FS), an admission record summary revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to chronic multifocal osteomyelitis of the left ankle and foot (bone infection), adult failure to thrive, severe protein-calorie malnutrition, ulcerative colitis with intestinal obstruction, epilepsy, and malignant neoplasm of the bone. According to the Facility's Reportable Event (FRE) which the facility submitted to the New Jersey Department of Health (NJDOH) on 8/4/25, the New Jersey State police (NJSP) went to the facility 8/4/25 at 4:30 PM and informed the administrator that he was at the facility to investigate an alleged abuse that was reported to the police department. The FRE revealed that an employee was placed on suspension by the facility pending the outcome investigation. During entrance conference interview with the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) 7/16/26 at 10:17 AM, the LNHA stated that he started working at the facility in September of 2025 and that the DON started in October 2025. On 7/16/26 at 10:49 AM, the surveyor interviewed the LNHA and the DON. The LNHA stated that the local police investigated the abuse allegation and that the allegation was not substantiated. The surveyor requested for the facility's investigation and summary and conclusion (ISC) for the abuse allegation. At 11:53 AM, the LNHA stated that he became aware of the abuse allegation in October 2025 after he received an email from NJDOH regarding the allegation. LNHA further stated that he was new to the facility and did not know what happened with the investigation. LNHA further stated that the previous Administrator submitted an FRE to NJDOH, and that no investigation was completed. The LNHA stated that there were no grievances filed by Resident #1 nor their family. On 7/16/26 at 2:35 PM, the surveyor interviewed the DON who stated that she became aware of the abuse allegation in October 2025. The DON stated that the NJSP investigated the abuse allegation and exonerated the accused employee. The DON further stated that she was not working at the facility when the incident occurred on 08/04/25. Further review of other facility documents revealed an email communication dated 10/30/25, in which NJDOH requested for the facility to send in their investigation and summary conclusion of the reported abuse allegation event of 8/4/25. There was no documented evidence that the facility initiated a full and thorough investigation into the abuse allegation after they became aware of the incident. A review of the facility's policy titled, Abuse Prohibition and last updated 4/4/25, under .7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following: .7.6 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.6.1 whether abuse or neglect occurred and to what extent . N.J.A.C. 8:39-4.1(a)5

Complaint #:3008822 and 3013216 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure their Licensed Nursing Home Administrator (LNHA) a.) maintained the facility in a safe operable condition including maintaining and testing their fire sprinkler system; b.) ensured the administrator, as well as all staff, implemented facility policies and procedures including conducting a fire watch accurately; c.) and ensured all local and state officials were notified that the facility's fire sprinkler system was in-operable since [DATE]. An interview with the LNHA on [DATE] at 4:38 PM, revealed that the facility's fire sprinkler system was in-operable and he was only made aware of it on [DATE]. When asked, the LNHA stated that he called the New Jersey Department of Health's (NJDOH) hotline on [DATE] and [DATE], to report the in-operable system, but there was no record of the calls. An interview with the facility's Maintenance Director (MD) on [DATE] at 7:53 PM, revealed that the facility had failed the pressure test for their fire sprinkler system for the past two quarterly fire protection equipment inspections. The MD stated the facility's fire sprinkler system had been partially operable and was currently in-operable for the past 3-5 months and he had initiated a fire watch for the building. The MD stated that the facility was also not conducting their weekly fire pump's run tests since the pump was in-operable. An interview with the Fire Marshal (FM) on [DATE] at 8:40 PM, revealed that he was made aware on [DATE], that the facility's fire system was in-operable as of [DATE], and the facility should have immediately notified the local fire department and remedied the situation. The FM confirmed that since [DATE], if there had been a fire at the facility, there would have been no fire protection. The FM stated the facility should have been conducting a fire watch at a minimum of every thirty minutes with a designated staff member going into each room. Observation of the fire watch on [DATE], revealed it took twelve minutes for the Licensed Practical Nurse (LPN #1) assigned to conduct fire watch, to inspect the four floors of the building and she did not go in every room. An interview with the Director of Nursing (DON) on [DATE] at 10:26 PM, revealed that she assigned the two fourth-floor nurses to conduct fire watch every two hours. During separate interviews with both the DON and LNHA, they confirmed that the LNHA was ultimately responsible for the building and ensuring all facility policies and procedures were implemented. The facility's failure to ensure their fire sprinkler protection system was operable in the event of a fire placed all residents, staff, and visitors in the building at risk in the event of fire. This posed the likelihood for serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on [DATE], when the facility's Fire Suppression Vendor identified the facility's automated fire sprinkler protection system was in-operable. The DON was notified of the IJ on [DATE] at 11:59 PM. The facility submitted an acceptable Removal Plan (RP) on [DATE] at 12:22 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on [DATE]. The evidence was as follows:A review of the facility's Job Description for the Classification Title: Nursing Home Administrator dated 02/02, included general summary: administers, directs, and coordinates all activities of a nursing home facility to carry out its objectives as to the care of sick and/or disable citizens; furthers scientific knowledge and participates in the promotion of community health. Job Functions and Responsibilities included but were not limited to:Carries out supervisory/managerial responsibility in accordance with policies, procedures, and applicable laws including: interviewing, hiring and straining [sic] staff; planning, assigning and directing work.Plans and implements short-term or annual goals, objectives, and strategies for projects or programs to ensure efficient operations and completion of work.Interprets, develops, communicates, updates, and monitors ordinances, policies, procedures, and standards; recommends improvement when necessary; and writes/revises same.Responds to audits and survey reports, as needed. Knowledge, Skills, and Abilities Required included but were not limited to:Advanced knowledge of applicable state, federal, and local ordinances, codes, laws, rules, and regulations and legislative issues.Thorough knowledge of standards and regulations of nursing homes.Advanced knowledge of applicable standards or environmental health and safety, local health and safety regulations, general administration, and department organization and management after a period of training.Knowledge of department policies and procedures.Knowledge of County Government organization and operations. A review of the facility's Fire Watch Policy, dated effective [DATE], included that the purpose was to establish procedures for implementing and maintaining a fire watch at [facility name redacted] whenever fire protection systems are impaired, under maintenance, or otherwise unavailable, in order to protect residents, staff, visitors, and property. Policy Statement: [facility name redacted] will provide continuous fire watch coverage whenever any portion of the fire alarm system, sprinkler system, smoke detection system, or other critical fire protection equipment is out of service for more than four (4) hours in a 24-hour period, or as otherwise required by local fire code, state regulations, or the Authority Having Jurisdiction (AHJ). Responsibilities: Administrator/Executive Director: ensure implementation of this policy, notify corporate leadership as required, ensure adequate staffing for fire watch coverage. Maintenance Director: notify the local fire department and monitoring company, initiate fire watch documentation, coordinate system repair and restoration, verify restoration of services.fire watch will be initiated when sprinkler impairment occurs.fire watch personnel shall patrol affected areas at least every 30 minutes, or more frequently if directed by the AHJ.each patrol round shall be documented on the Fire Watch Log including: date and time, name of fire watch personnel, areas inspected, findings/hazards identified, corrective actions take, signature/initials.fire watch may only be discontinued when: the impaired system is fully restored. During a telephone interview with the LNHA on [DATE] at 4:38 PM, he informed the surveyor that the facility's fire protection sprinkler system was not working. The LNHA stated that the facility's fire sprinkler system draws water from the pond outside the facility, and the pump was not working to draw the water from the pond to the facility in the event of a fire. The LNHA stated that the fire department had been at the facility since [DATE], providing fire protection to the building in the event of a fire. The LNHA stated that he had called the NJDOH to report the loss of coverage last evening ([DATE]), and two times today ([DATE]). The LNHA confirmed he did not speak to anyone at the NJDOH. On [DATE] at 7:20 PM, the surveyor interviewed the local Fire Chief, who stated that the FM notified them on Wednesday ([DATE]), that the facility's fire sprinkler system had been in-operable for weeks. The Fire Chief stated that the facility had water stored in the actual pipes of the fire sprinkler system, but the system did not have the pressure needed for operation. The Fire Chief stated that the local fire department was staying on-site until a contracted company arrived on-site with a fire pump and water tanks. At that time, the Deputy Fire Chief stated that the local fire department was just providing coverage for the fire pump in case of an emergency, and the fire department was not conducting any fire watch inside the building. On [DATE] at 7:40 PM, the surveyor interviewed the Facility Concierge, who stated that the facility's jockey pump (primer pump that can assist the fire pump with pressure) for their fire sprinkler system was down and that the main pump was shut off because it had leaks. The Facility Concierge stated the main pump needed to be sealed and could not operate without the jockey pump. The Facility Concierge stated that the facility was renting a fire suppression system from [name redacted], and they were arriving at the facility with the equipment tomorrow. The Facility Concierge stated she was aware the fire sprinkler system needed repairs, but she was unaware it was that bad until the FM informed them it needed to be fixed, or they had to evacuate the building. During a follow-up telephone interview with the LNHA on [DATE] at 7:41 PM, he stated that he had been at the facility for approximately six months and he knew there were issues with the fire pump, but he did not know the severity of the condition of the pump. The LNHA stated from his understanding the fire pump worked, but the FM came recently and said the pump was not really putting out. The LNHA stated he had staff around the clock conducting a fire watch on each floor that was documented on the fire watch log. The LNHA stated staff had been conducting a fire watch for months as a precautionary measure, and he was unsure how long the fire sprinkler system had been down. When asked if he reported the fire sprinkler system being non-operational, the LNHA again stated that he called the NJDOH and left a message. The LNHA stated he had never used the electronic reporting system and that he thought he had 48-72 hours to notify the NJDOH. On [DATE] at 7:53 PM, the surveyor conducted a telephone interview with the Maintenance Director (MD), who stated that the facility failed their past two quarterly fire protection pressure tests to their fire pump. The MD stated that the facility's fire protection sprinkler system had been partially operable and was now in-operable for the past 3-5 months and the LNHA and owners were made aware. The MD stated he had given the owners several times a quote for a new jockey pump and told them they needed to act on it. The MD stated he was later made aware that the facility had purchased a jockey pump in the past five years, and that they wanted to see if there was another route to take instead of replacing the jockey pump. The MD stated the fire sprinkler system was partially operable at first with a leaking pipe from the pump to the building and a cracked header on the pump. The MD stated that they had replaced the pipe and the header, but their [Fire Suppression Vendor] still deemed the system in-operable and tagged it out-of-service about three months ago. The MD stated he had taken it upon himself to start a fire watch with rounding every two hours. The MD stated from 8:00 AM to 4:00 PM, a maintenance worker conducted the watch going on all floors and in every room, and after 4:00 PM, the nursing staff conducted it. The MD stated he was told there was 125 [pounds of] pressure in the system and that someone would have to alert the fire department to come and turn on the pump. The MD stated that both the owners and the LNHA were aware of the severity. The MD stated that he did not notify the local fire department because he was told by the Fire Suppression Vendor that their reports automatically went to the FM, and to his knowledge, the Office of Emergency Management (OEM) was not notified. The MD also stated when asked, that the facility was not conducting their required weekly run test of the fire pump for at least 5-6 months since the pump was in-operable. On [DATE] at 8:40 PM, the surveyor conducted a telephone interview with the FM, who stated that he had learned that the facility's fire pump was in-operable on [DATE]. The FM stated that he was with the State Fire Marshal conducting rounds that day, and since the facility had an outstanding violation on their jockey pump, they were going to follow up. The FM stated he was informed by the MD that the fire sprinkler system was in-operable. The FM stated that the jockey pump maintained the system's pressure and the main pump forced the water through the sprinkler when the system was activated. The FM stated the facility's main pump leaked so it went out of service in March (2026). The FM stated that the facility received and signed the document in March that the system was in-operable, and the facility by code was supposed to notify him. The FM stated that he was not notified, and he had met earlier that day with the LNHA, DON, Facility Concierge, and the MD, and asked if they had notified the NJDOH, and the LNHA confirmed no. The FM stated that they issued the facility an Imminent Hazard, which was a fire code operation for inadequate fire protection that the facility had the option to vacate, close, or remove the hazard. The FM stated with the facility's life hazard of being a twenty-four seven institution, doing a fire watch alone was not adequate. The FM stated the fire watch should be conducted at least every thirty minutes with a designated person going room to room. The FM stated that the facility told him they had 90 minutes of water in the pipes. The FM stated that the facility had water stored in the pumps and the pressure gauge was registering pressure, but as soon as the system was activated, the pressure would drop to zero and the water in the sprinkler system would either trickle or dump out depending upon location in the building. The FM stated in the event of a fire, the system would not have put out the fire, and lives could have been lost. The FM stated that the facility has been in Imminent Hazard since [DATE], and they should have immediately acted on it. A review of the facility's quarterly fire protection equipment inspections reports from the facility's [Fire Suppression Vendor] revealed the following: An inspection dated [DATE], with a report dated [DATE], indicated that the wet sprinkler/standpipe combo (combination of water filled sprinkler piping serving both the sprinkler heads and the hose connections on each floor) in Stairwells A and B were partially operational. (The system has impairments that could affect its ability to detect and/or suppress a fire condition. The system is non-compliant.)An inspection dated [DATE], with a report dated [DATE], indicated that the wet sprinkler/standpipe combo in Stairwell A and B were non-operational. (The system will not detect and/or suppress a fire condition.) There was no record of the facility reporting the fire sprinklers system's operational status. A review of the fire watch log from [DATE], revealed only one entry for a fire watch conducted on [DATE] at 12:00 AM. The watch was being conducted after from [DATE] at 2:00 AM, every two hours for the entire building with no consistent signature that it was completed. There were also multiple pages of pre-filled Fire Watch Logs that the date was blank, times were completed in increments of two hours, and the area patrolled was written as the entire building. On [DATE] at 9:45 PM, the surveyor interviewed LPN #2, who stated that the fourth-floor nurse (LPN #3) was designated to conduct a fire watch. LPN #2 stated that she knew the facility was having issues with their fire sprinkler system since the fire truck was there, and that she thought fire watch was conducted every two hours. On [DATE] at 9:57 PM, the surveyor interviewed LPN #1 and LPN #3, who both stated one of them made rounds every two hours. LPN #3 stated when conducting fire watch, the person walked from the stairs by the elevator down the hallway to the stairs at the opposite end of the hallway, then down those stairs to the next floor. LPN #3 stated that you went floor to floor walking down the hallway down the opposite stairwell. LPN #3 stated that LPN #1 was assigned to do the 10:00 PM fire watch, and she covered her residents during that time. The surveyor asked how long it took to conduct the fire watch, and LPN #3 stated, how fast can you walk? On [DATE] from 10:03 PM to 10:15 PM, the surveyor observed LPN #1 conduct the fire watch and observed the following: At 10:03 PM, LPN #1 started in the hallway outside room G-1 and went down the hallway to the end by the opposite stairway. LPN #1 did not go inside any rooms and went down the stairs to the third floor.At 10:06 PM, LPN #1 entered the third floor and started by the dining room, room [ROOM NUMBER]. LPN #1 looked inside the dayroom and the second common area next to it by the doorway in the hallway. Then LPN #1 walked down the hallway to room [ROOM NUMBER], and then exited the stairwell closest to that room, and went down the stairs to the second floor.At 10:09 PM, they entered the second floor and LPN #1 went into rooms [ROOM NUMBERS] looking for an intravenous (IV) pole that she obtained from room [ROOM NUMBER] and dragged it down the hallway during the watch. LPN #1 stopped outside the dayroom and exited down the stairwell closest to the dayroom. LPN #1 carried the IV pole down the stairs for the remainder of the watch to the first floor.At 10:12 PM, LPN #1 entered the first floor by the back exit, and they walked to the front exit. LPN #1 went into no rooms and continued to drag the IV pole with her.At 10:15 PM, LPN #1 stated she had completed her fire watch as she had been directed to perform. LPN #1 stated she was in-serviced by the DON today to walk down the hallways only for the fire watch. On [DATE] at 10:26 PM, the surveyor interviewed the DON, who stated her role was to ensure resident safety and care. The DON stated she was only aware that the fire sprinkler system was in-operable as of yesterday or the day before by the LNHA and MD, and that she had not been made aware in March. The DON stated that the facility had forty-eight hours to turn the situation around by developing and implementing a viable plan. The DON stated she was not part of the planning, but she was being kept abreast as changes occurred. The DON stated that there was concern that there was no fire system and the response if a fire occurred. When asked what would happen if a fire occurred, the DON stated she was told that there was ninety-minutes with what we have in the building which would give ample time to evacuate. The DON stated the MD was told that by one of the contractors. The DON stated that the facility had a fire watch policy that was activated in which staff were in high alert and monitored the building. The DON stated the process was for the staff to walk through the hallway looking into rooms observing for signs and smells of smoke. The staff went to the opposite stairwells on each floor and down the hallways. The DON stated it was done every two hours, and she had assigned the two nurses on the fourth floor since their census was more manageable with one nurse. When asked who was responsible for the overall building, the DON stated that the LNHA had the ultimate responsibility for the building, then her. On [DATE] at 9:07 AM, the FM emailed the surveyor a copy of the correspondence between him and the facility. The email chain began on [DATE] at 10:37 AM, from the FM to the MD and the Facility Concierge, regarding their report from the Fire Suppression Vendor at that time. The email indicated that due to the sensitive nature of the suppression equipment and the type of occupancy you are, I have issued a [violation] which you should have received in a separate email. Please let me know your plans to rectify.The next email was dated [DATE] at 9:54 AM, from the FM to the MD and Facility Concierge which indicated I wanted to follow up on the status of this repair. The Facility Concierge responded on [DATE] at 12:25 PM, and included along with the MD, the LNHA, the owner/ Chief Operating Officer (COO), and accounts payable. The email indicated, We are still trying to figure things out. With each year, all the water supplies are getting lower, lakes, reservoirs, ect. The concern is, the same issue may occur with a new jockey pump and were [sic] out $12,000 again. Here's my question to you, what do other facilities do that have Lakes in their backyards? Our sprinkler system draws from our wells and there are two large containment tanks. Please give us advice on what else we might be able to do if anything.The next email is dated [DATE] at 3:22 PM, written by the Facility Concierge to the FM that included, the LNHA and COO. The email included I am still trying to figure out if we need a secondary water source. We have two large containment tanks and wells for the sprinkler system. Is it mandatory to have a second source.On [DATE] at 6:31 AM, the FM responded to the Facility Concierge and included the LNHA and COO, and stated that, You would need to understand if it was a requirement of the original site plan and construction approvals for the building to be occupied. That would be more of a question for township zoning/construction department. I will follow up with them as well. Do you have any information on the wells/containment tanks as it relates to the availability of water readily available that we could use to evaluate?On [DATE] at 5:17 PM, the facility's Consulting Company that handles their water system reached out the FM and included the LNHA, COO, Facility Concierge, and MD. The Consulting Company stated, Could you please share the notice of violation you issued to them as well as any additional information in regards to what you are looking for them to do to the sprinkler system to return them to compliance.On [DATE] at 8:59 AM, the FM responded to the Consulting Company and included the LNHA, COO, Facility Concierge, and MD that, The notice of violation is off of the deficiency report that I was sent through the NJDFS portal which was uploaded by their fire suppression vendor. Both are attached here.There were no additional emails and attached was a copy of the [DATE], inspection from the facility's Fire Suppression Vendor's indicating the fire pump was partially operation, a copy of the violation issued on [DATE], that the facility's pump was partially operational and in a non-compliant state, and a copy of the Notice of Imminent Hazard and Orders to Take Corrective Action, issued [DATE], to vacate the building by [DATE] at 8:00 PM. On [DATE] at 11:55 AM, the surveyor conducted a telephone interview with the LNHA and asked what the facility used as guidance for what they needed to report to the NJDOH. The LNHA provided no resources used for guidance and stated that he reports everything to the NJDOH with no specifics given. The LNHA stated he used the hotline to report, and he was unaware of the electronic reporting system. The LNHA that he was only made aware of the condition of the facility's fire sprinkler system on [DATE], and that the MD had only made the owner (COO) aware. At that time, the surveyor informed the LNHA that they had email correspondence with the FM regarding the facility's fire sprinkler system from the past year that he was included on. The LNHA acknowledged that he was responsible for knowing everything that was occurring in the building as the administrator. On [DATE] at 9:53 AM, the surveyor interviewed the FM and the local Mayor. The FM stated that the facility's fire system was hooked up to the pond outside and drew water through a pump to their fire sprinkler system. The FM stated that the facility did not maintain the pond and the pipe from the pond to the fire pump was plugged up. The FM stated he was at the facility back in February when the system was partially operable, and the following month it became in-operable. The FM stated that there was no city water that the facility could hook up to and he did not believe it was possible that the facility could connect to their well. An acceptable Removal Plan (RP) was received on [DATE] at 12:22 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including; on [DATE], the local fire department was deployed to the facility to provide continuous fire coverage and on [DATE], the facility contracted with [name redacted] fire protection to construct an emergency fire protection infrastructure. The NJDOH was notified. On [DATE], the fire watch policy was updated, and education was provided to staff. On [DATE] the Chief Operating Officer (COO) in-serviced the LNHA on maintaining, testing and monitoring the facility's fire suppression system by regulation standards, the facility's Fire Watch Policy, including full understanding of the policy, ensuring all staff in all departments on all shifts understand the requirements of a proper fire watch; the process of reporting significant events which include all local and state officials in a timely manner; and working directly with all authorities until the issues are fully resolved. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on [DATE] at 2:28 PM. NJAC 8:39-9.2(a)NJAC 8:39-9.3(a)NJAC 8:39-27.1(a)NJAC 8:39 31.1(c)NJAC 8:39-31.2(e)NJAC 8:39 31.6(a)

Based on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents completed monthly progress notes. This deficient practice continued over several months for 9 of 11 residents reviewed, Resident #2, #4, #7, #8, #10, #11, #39, #59, and #67 reviewed for physician progress notes.This deficient practice was evidenced by the following:1. On 7/16/24 at 10:57 AM, the surveyor reviewed Resident #8's hybrid medical records (combination of electronic and paper chart).Review of Resident #8's admission Record (AR) reflected that Resident #8 was admitted to the facility with medical diagnoses that included but were not limited severe protein-calorie malnutrition, chronic obstructive pulmonary disease, hypothyroidism and hypertension. Review of the Medical Progress Notes (PN) written by Physician #1(MD#1), from 4/23/25 to 6/20/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 2. On 7/16/24 at 11:00 AM, the surveyor reviewed Resident #2's hybrid medical records. Review of Resident #2's AR reflected that Resident #2 was admitted to the facility with medical diagnoses that included but were not limited Parkinson's disease, asthma, type 2 diabetes mellitus, and wedge compression fracture of T11-T12 vertebra. Review of the Medical PN written by MD#1, from 3/18/25 to 7/11/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 3. On 7/16/24 at 11:04 AM, the surveyor reviewed Resident #4's hybrid medical records. Review of Resident #4's AR reflected that Resident #4 was admitted to the facility with medical diagnoses that included but were not limited sepsis, pneumonia, chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia. Review of the Medical PN written by MD#4, from 1/21/25 to 6/20/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 4. On 7/16/24 at 11:06 AM, the surveyor reviewed Resident #11's hybrid medical records. Review of Resident #11's AR reflected that Resident #11 was admitted to the facility with medical diagnoses that included but were not limited metabolic encephalopathy, sepsis, cystitis and hydronephrosis. Review of the Medical PN written by MD#1, from 1/31/25 to 7/11/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 5. On 7/16/24 at 11:10 AM, the surveyor reviewed Resident #59's hybrid medical records. Review of Resident #59's AR reflected that Resident #59 was admitted to the facility with medical diagnoses that included but were not limited end stage renal disease, chronic congestive heart failure, myocardial infarction, and type 2 diabetes mellitus. Review of the Medical PN written by MD#1, from 1/21/25 to 7/11/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. On 7/21/2025 12:40 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns found during the survey. The DON stated MD#1 who also serves as the Medical Director, should be writing complete and signing the progress notes at the time of visit, leaving the notes in draft for months is unacceptable. On 7/21/25 at 12:56 PM, the DON provided the surveyor with a facility policy titled, By-laws, rules and regulations for medical staff of the Homestead Rehabilitation and Healthcare Center, LLC with a revised date of 5/6/2016. Under the procedures section of the chart it states, 9. The Medical Director shall be responsible for all medical policies of the Facility. He/she shall see that proper medical records are maintained.G. A Progress Note is written and signed by the Attending Physician at the time of each visit, and he/she signs all orders. On 7/22/25 at 11:19 AM, the surveyor conducted a phone interview with MD#1. MD#1 stated they are the current Medical Director for the building and have been so for the past 8 to 9 years. MD#1 further stated he is in the building at least two times per week to see the residents. MD#1 agreed that progress notes should be completed and signed at the time of service but acknowledged he does not complete and sign his progress notes at the time of service. MD#1 agreed this was not in the best interest of the residents and is not best practice. 7/24/25 at 1:15 PM, the surveyor met with the LNHA and DON for the exit conference. The DON stated that MD#1 subacute residents have been switch to another physician and MD#1 would not be getting any new residents until he was in compliance with his progress notes. No further pertinent information provided.6. On 7/16/24 at 10:20AM, the surveyor reviewed Resident #7's hybrid medical records (combination of electronic and paper chart). Review of Resident #7's admission Record (AR) reflected that Resident #8 was admitted to the facility with medical diagnoses that included but were not limited schizophrenia, major depressive disorder, hyperlipidemia, and chronic kidney disease. Review of the Medical Progress Notes (PN) written by Physician #1(MD#1), from 3/04/25 to 7/21/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 7. On 7/16/24 at 10;47 AM, the surveyor reviewed Resident #39's hybrid medical records. Review of Resident #39's AR reflected that Resident #39 was admitted to the facility with medical diagnoses that included but were not limited to schizophrenia, hypertension, schizoaffective disorder, bipolar type, and generalized anxiety disorder. Review of the Medical PN written by MD#1, from 4/23/25 to 7/21/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 8. On 7/16/24 at 11:11 AM, the surveyor reviewed Resident #4's hybrid medical records. Review of Resident #10's AR reflected that Resident #10 was admitted to the facility with medical diagnoses that included but were not limited to chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and acute and vitamin deficiency. Review of the Medical PN written by MD#1, from 3/04/25 to 07/21/25 were held in DRAFT by MD#1 documenting a letter (Z) to keep the place. No other information was evidenced in the Medical PN. 9. The surveyor reviewed the closed medical record for Resident #67. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs). A review of the Progress Noes revealed the following Medical Notes entered by the Medical Director (MD) in draft status that only included a z as the note for 2/18/25 at 7:00 PM, 2/28/25 at 10:42 PM, 3/4/25 at 8:37 PM, and 3/7/25 at 8:47 PM. On 7/22/25 at 10:06 AM, the surveyor reviewed with the DON Resident #67's Progress Notes, and she acknowledged the physician Progress Notes were in draft status with z as the note. The DON acknowledged that physician's notes were to be documented at the time of the visit. On 7/22/25 at 11:20 AM, the surveyor conducted a telephone interview with the MD, who stated that he was at the facility twice a week. When asked how often a resident needed to be seen, the MD stated once a month. When asked when he documented the notes of the visits, the MD stated that he took his personal notes home and put them in the resident's electronic medical record later on and whenever have a chance. The surveyor asked when the MD was required to document the visit into the resident's medical record, the MD stated at the time of visit or in a reasonable amount of days. At this time, the surveyor stated that they observed notes that were still not written from February of 2025, and the MD confirmed and stated that he was catching up and should be finished documenting by the end of the month. NJAC 8:39-23.2(b)(d)

Based on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. This deficient practice was evidenced by the following:On 7/16/25 at 10:29 AM, during the entrance conference, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 6/29/25 through 7/5/25; 7/6/25 through 7/12/25 and 3/2/25 through 3/8/25.The surveyor reviewed the Nursing Staffing Reports, which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 7/4/25; the last RN was scheduled on 7/3/25 2. No RN on 7/5/25; the last RN was scheduled on 7/3/25 3. No RN on 7/6/25; the last RN was scheduled on 7/3/25 4. No RN on 7/9/25; the last RN was scheduled on 7/8/25 5. No RN on 7/10/25; the last RN was scheduled on 7/8/25 A review of the corresponding nursing staff sheets verified the following: During the 7-3 shift on 7/3/25, there was an RN scheduled, and the next RN scheduled to work on 7/4/25. During the 7-3 shift on 7/3/25, there was an RN scheduled, and the next RN scheduled to work on 7/5/25. During the 7-3 shift on 7/3/25, there was an RN scheduled, and the next RN scheduled to work on 7/6/25. During the 3-11 shift on 7/8/25, there was an RN scheduled, and the next RN scheduled to work on 7/9/25. During the 3-11 shift on 7/8/25, there was an RN scheduled, and the next RN scheduled to work on 7/10/25. On 7/21/25 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she was aware that the facility required an RN to be present in the facility daily. She further stated the facility would need an RN for critical care and assessments. On 7/21/25 at 12:30 PM, the surveyor interviewed the scheduling coordinator (SC), who stated that she was aware of the need for an RN in the facility for 8 hours in a 24-hour period and further stated that the facility had more Licensed Practical Nurses (LPN) in the facility than RN's and does the best she could to staff the facility. On 7/24/25 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, acknowledged the facility had days where there were no RNs scheduled for eight consecutive hours. No further pertinent information or policies were provided by the facility for review. NJAC 8:39-25.2(h)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice was identified for 5 of 5 CNA's whose personnel records were reviewed and was evidenced by the following: On 7/24/25 at 10:17 AM, the surveyor reviewed the personnel files for 5 CNAs:1. CNA#1, with a date of hire of 8/17/22, no recent employee evaluation was completed.2. CNA#2, with a hire date of 8/23/23, no recent employee evaluation was completed.3. CNA#3, with a hire date of 7/2/24, no recent employee evaluation was completed.4. CNA#4, with a hire date of 10/1/24, no recent employee evaluation was completed.5. CNA#5, with a hire date of 7/22/23, no recent employee evaluation completedOn 7/24/25 at 10:17 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility does not have competencies for the CNAs. The DON stated that she had a stack of folders on her desk but was unable to provide the five employee evaluations or competencies. On 7/24/25 at 11:30 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the DON, who stated that no policy could be provided, and no further pertinent information was provided. NJAC 8:39-43.17 (b)

Based on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening (HS) when there was more than 14 hours between dinner and breakfast mealtimes. This deficient practice was identified for 3 of 3 residents (Resident #15, #38, and #42) during the 7/21/25 resident council group meeting and evidenced by the following:On 07/21/2025 at 10:33 AM, the surveyor conducted the resident council meeting with three residents (Residents #15, #38 and #42) who were alert and oriented and selected by the facility to attend the group meeting. The residents stated that they received dinner between 5:00 PM-5:30 PM, and breakfast was delivered between 8:00 AM-8:30 AM. All three residents stated that they were not offered nor received snacks in the evening. On 7/21/25 at 12:40 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The LNHA stated that evening snacks were delivered to the units and that he would investigate what the process was.On 7/22/25 at 9:51 AM, in the presence of the survey team, the LNHA stated that he was unable to find the accountability book for the 8 PM snacks. The DON confirmed that the recreation staff passed out the 8 PM snacks but that she was also unable to locate the book which would confirm that the residents either received or refused the evening snacks.On 07/22/2025 at 10:27 AM, during an interview with the surveyor, the Food Service Director (FSD) stated that the dietary staff sends up extra snacks to the units which include sandwiches, cookies, beverages and yogurt. Once on the units, the activities staff and the CNAs were responsible for delivering the snacks to the residents. The FSD further stated, if there were more than a 14-hour gap between meals, snacks needed to be offered to all residents. On 7/24/25 at 8:30 AM, during an interview with the surveyor, the Director of Recreation confirmed that the activity staff only distributed the morning 10:00 AM, and afternoon 2-3:00 PM snacks. She further stated her staff was not responsible for passing out the evening snacks.On 7/24/25 at 8:45 AM, during an interview with the surveyor, the DON stated that she had not been aware that the activity staff were not passing out the 8:00 PM snacks, until it was discussed at the resident council meeting. The DON met with the Director of Recreation who confirmed that activity staff were not responsible for passing out evening snacks. A review of the evening (HS) snack policy and procedure dated 12/14/23 reflected: It is the policy of this facility to ensure that residents are offered snacks three times day. The facility will ensure that snacks are offered to all residents as a strategic intervention for meeting nutrition care goals. The food service director will ensure a supply of snacks are available on each unit.On 7/24/ 2025 at 10:00 AM, during an interview with the surveyor, the LNHA stated that he had not been aware, before the surveyor's inquiry, that there was no documentation or accountability regarding whether snacks were offered, accepted, or refused, and that such accountability was necessary. On 7/24/25 at 1:15 PM, no further information was provided by the facility.NJAC 8:39-17.2 (f))(1) (i) (ii)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 7/16/2025 at 10:01 AM, the surveyor in the presence of the chef toured the kitchen and observed the following:1. In the 3-door standing refrigerator, the surveyor observed 10, 2oz cups of sliced pickles dated 7/7/25 -7/12/25 and 12, 2oz cups of grated cheese with a use by date of 7/15/25. The chef was unable to state why those items had not been disposed of by the use-by date. 2. In the 6-door standing refrigerator, the surveyor observed a round container of grape jelly covered with plastic wrap, labeled opened on 7/11/25. The chef was unable to explain why the label did not have a use-by date but stated that the jelly should have been discarded three days after opening. The surveyor also observed an open package of sliced American cheese without a label. The chef was unable to state when the American cheese was opened and why the use-by label had not been placed.3. In the dry storage area, the surveyor observed a 5lb bag of B'gan brand biscuit mix, the bag was observed distended, all other bags of biscuit mix observed not distended. Multiple ceiling tiles were observed to be discolored. At that time, the chef discarded the biscuit mix and further stated that maintenance would be informed of the discolored ceiling tiles.4. In the Walk-in freezer, the surveyor observed that the circulating fans had a dust-like debris, and a rapid cooling ice container was observed with dust-like debris on the handle. The chef stated that maintenance was responsible for cleaning the fans, and the cooling container would be cleaned immediately.On 7/17/2025 at 9:35 AM, the surveyor interviewed the Food Service Director (FSD), who stated that all items in the kitchen needed to be labeled with a received, opened, and use-by date, and all items should be disposed of by the use-by date. The FSD further stated that the fans and the rapid cooling container in the freezer should always be clean and in good repair.On 7/17/25 at 1:45 PM, the FSD provided the surveyor with multiple facility policies, all of which were last reviewed on 12/14/23. The Labeling and Dating policy states under the procedure section, # 2. Do not write over the expiration date. Receive date and expiration date must be visible.5. All prepared foods are dated the date they were made and counting as day one. Must have a use by date. All foods prepared in the kitchen must be dated with a use by date and discarded in three days. The Freezer policy states under the procedure section, 4. For walk-in freezers, mop floors, wash walls, and ceiling as needed.On 7/21/2025 at 12:40 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns identified during the survey. The DON stated that their kitchen concerns are ongoing, and the FSD conducts multiple in-services for the staff.On 7/24/25 at 1:15 PM, the surveyor met with the LNHA and DON for an exit conference; no further pertinent information was provided.NJAC 8:39-17.2(g)

Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was evidenced by the following:On 7/16/2025 at 10:01 AM, the surveyor, in the presence of the chef, toured the kitchen and garbage area and observed the following:There was garbage debris that included food wrappers, food containers, cups, gloves, paper products, and medication cups around the dumpster and surrounding areas. The chef said that the maintenance and dietary departments should have cleaned the area.On 7/17/2025 at 9:35 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the garbage areas are a shared area; the kitchen, maintenance, and housekeeping departments are all in charge of cleaning that area. On 7/21/25 at 12:36 PM, the FSD provided the surveyor with a facility policy titled Dumpster Sanitation Policy with a revised date of 4/1/25. Under the procedure section of the policy, it states, 2. Dietary, Housekeeping, and Maintenance Departments will monitor when taking out garbage, that the areas are clean of debris and other items.On 7/21/2025 at 12:40 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns found during the survey. The DON stated that the garbage area concerns will immediately be addressed.On 7/24/25 at 1:15 PM, the surveyor met with the LNHA and DON for the exit conference; no further pertinent information was provided.NJAC 8:39-19.7

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the medical director: a.) implemented the facility's policies and procedures for resident care including physician visits documented at the time of visit and b.) ensure facility policies and procedures were reviewed and updated as needed. This deficient practice has the potential to affect all residents, and was evidenced by the following:Refer F 711A review of the undated facility provided Director Roles and Responsibilities for the Medical Director's job description included:Physician Leadership: Help the facility ensure that patients have appropriate physician coverage and ensure the provision of physician and health care practitioner services.Provide guidance for physician performance expectations; Help the facility ensure that a system is in place for monitoring the performance of health care practitioners.Patient care-Clinical Leadership: Participate in administrative decision-making and the development of policies and procedures; Help develop, approve, and implement specific clinical practices for the facility to incorporate into its care-related policies and procedures, including areas required by laws and regulations.Help review policies and procedures regarding the adequate protection of patient's rights, advance care planning, and other ethical issues.On 7/22/25 at 11:20 AM, the surveyor conducted a telephone interview with the Medical Director (MD), who stated that he has been the medical director at the facility for 8-9 years. The MD stated his job responsibilities included: to take care of resident care, oversee all resident, and fill in for another physician as needed. The MD stated that he was at the facility twice a week and participated in the facility's Quality Assurance and Improvement Program (QAPI). When asked how often a resident needed to be seen, the MD stated once a month. When asked when he documented the notes of the visits, the MD stated that he took his personal notes home and put them in the resident's electronic medical record later on and whenever have a chance. The surveyor asked when the MD was required to document the visit into the resident's medical record, the MD stated at the time of visit or in a reasonable number of days. At this time, the surveyor stated that they observed notes that were still not written from February of 2025, and the MD confirmed and stated that he was catching up and should be finished documenting by the end of the month. The surveyor asked how many residents the MD saw, and he stated about 40 residents. (Facility census upon entrance was 58.) The surveyor asked if documenting months later was allowed, and the MD stated that he did not know.The surveyor then asked if he reviewed Statements of Deficiencies for the facility's surveys to see what they were cited for, and the MD confirmed no. The surveyor asked if he recalled having a conversation during the previous standard survey about not documenting at the time of the physician's visit, and the MD confirmed he did. The surveyor asked if he reviewed the facility's policies and procedures, and the MD stated if there were changes. The MD confirmed he had not reviewed all the facility's policies.On 7/22/25 at 12:00 PM, the surveyor reviewed the facility's Census Detail Report, which revealed that the Medical Director saw 38 residents, and the other two physicians saw 20 residents combined.On 7/24/25 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), who stated that the facility had a binder of nursing policies and procedures that had not been updated since 2020. The LNHA stated certain policies like infection control and antibiotic stewardship were updated annually. The DON stated that the facility had a care plan policy, but it was not updated since 2014. The MD stated that policies should be reviewed at least annually and updated as needed.NJAC 8:39-23.1(a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies. The facility was cited during last standard survey on 3/12/24, and was evidenced by the following:Refer to F686, F711, F755, F880 During the entrance conference on 7/16/24 at 10:29 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) a copy of the facility's QAPI program plan and the 2024 and 2025 quarterly sign-in sheets and QAPI notebook.On 07/21/2025 at 12:40 PM, the survey team met with the LNHA and DON to discuss their concerns, which included treatment and services to prevent pressure ulcers, physician visits, pharmacy services, and infection control.A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies from the facility's last standard survey included the facility was cited for the following concerns: treatment and services to prevent pressure ulcers, physician visits, pharmacy services, food storage and sanitation, and infection control.On July 24, 2025, at 10:46 AM, the surveyor interviewed the LNHA and DON to discuss the facility's QAPI program, which both staff members were involved in. When asked where the facility obtained their concerns for their QAPI program, the LNHA stated the facility utilized information from the residents, minutes from the resident council meeting, employees, and visitors' comments. The survey team informed the facility that there were repeated concerns from the last standard survey, which included treatment and services to prevent pressure ulcers, physician visits, pharmacy services, and concerns regarding infection control. The LNHA acknowledged that even though he and the DON started at the facility in January 2025, they both were present for the April 2025 quarterly QAPI meeting. At that time, the LHNA stated he was aware of the facility's previous deficiencies and that the facility had educated its staff and completed reports.A review of the facility provided Director of Nursing job descriptions included . The Director of Nursing is responsible for being an active member of the QAPI committee, coordinating and/or developing ongoing QAPI activities for nursing service to monitor nursing compliance with standards and regulatory requirements through rounds, interviews, and record reviews. Compiles a summary of findings for the Quality Assurance committee. Participates in the preparation of the Plan of Correction response to an inspection survey and implements any follow-up QAPI required for any nursing allegations.NJAC 8:39-33.1(a)(e); 33.2 (a)(b)(c)(d)

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that Certified Nurse Assistant (CNA) received at least 12 hours of mandatory in-service training for 5 of 5 CNA's education reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5).This deficient practice was evidenced by the following: On 7/24/25 at 10:17 AM, the surveyor requested the personnel education files for 5 CNA's1. CNA#1, with a date of hire of 8/17/22 no record of education was provided.2. CNA#2, with a hire date of 8/23/23 no record of education was provided.3. CNA#3, with a hire date of 7/2/24 no record of education was provided.4. CNA#4, with a hire date of 10/1/24 no record of education was provided.5. CNA#5, with a hire date of 7/22/23 no record of education was provided.On 7/21/25 at 12:20 PM, the survey requested CNA education from the Director of Nursing (DON).On 7/24/25 at 10:17 AM, the surveyor interviewed the DON, who stated that she could not provide any staff education including the CNA's 12-hour mandatory education. She stated that the program used for staff education was changed to a different system and was not able to retrieve the education of the staff, and copies were not saved in the employee files. At this time, the surveyor requested the policy for mandatory staff education.On 7/24/25 at 11:30 AM during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and DON stated the facility could not provide policies and provided no further pertinent information.N.J.A.C. 8:39-43.17(b)

Based on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner on 1 of 3 Nursing Units (Unit 3). The deficient practice was evidenced by the following:On 7/21/25 at 11:25 AM, during a tour of the 3rd floor nursing unit, the surveyor observed cracked floor tiles and chipped paint throughout the unit on the low and high sides. The surveyor also observed soiled and cracked ceiling tiles on the low side near the elevator.On 7/22/25 at 10:40 AM, during an interview with the surveyor, the Director of Maintenance acknowledged that the floor, paint, and ceiling tiles were all in disrepair.On 7/22/25 at 1:15 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that he was aware of the cracked flooring, chipped paint, and soiled ceiling tiles on the 3rd floor Nursing Unit. The LNHA stated that the last contractor was in the middle of repairs and then left abruptly. The LNHA stated that the facility needed a new roof, and as a result, the tiles needed to be replaced every time it rained. The LNHA acknowledged that the residents should be provided a clean homelike environment.NJAC 8:39-4.1(a)11. 31.4 (a)

NJ Complaint#: NJ0018771Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident abuse between Certified Nursing Assistant (CNA #1) and Resident #29 that occurred on 2/2/25 and a Licensed Practical Nurse (LPN#1) that appeared intoxicated when reporting to work on 7/2/25. This deficient practice was identified for 1 of 2 reported complaints reviewed.On 6/26/25 the NJDOH received an anonymous complaint from an employee of Homestead Rehabilitation and Health care Center. The employee claimed there was an issue with quality of care specifically citing, an allegation of staff to resident abuse from a CNA (name detached) which had resulted in injury as well as a nurse being intoxicated when reporting to work.On 7/17/25 at 10:04 AM, the surveyor reviewed the employee files for CNA#1 and LPN#1. A review of CNA#1's employee file revealed a Facility Reported Incident dated 5/23/25 at 3:00 PM revealed a staff member reported to the Licensed Nursing Home Administrator (LNHA) that they felt CNA#1 was inappropriately touching a resident, the staff member further stated that they did not witness anything but wanted to report it. CNA#1 was suspended pending the investigation. The investigation included statements from staff and residents who all worked with or received care from CNA#1. None of the statements accused CNA#1 of abuse. CNA#1 returned to work on 5/27/25. Further review of CNA#1's employee file revealed an employee disciplinary action sheet, marked as Final Warning dated 2/4/25. An employee statement provided by CNA#2 dated 2/2/25 at 1:00 PM, revealed CNA#1 was upset about not being able to take their break because they had to provide feeding assistance to Resident #29. Upon entering Resident #29's room, CNA#1 slammed their door. CNA#2 further stated upon seeing the resident's door slam, they entered the room and saw CNA#1 was visibly upset. CNA#1 was observed cutting the residents food and pushed the food towards Resident #29 in an aggressive manner. CNA#2 told CNA#1 to go on break, and they would provide feeding assistance to the resident. CNA#1 left the room without incident. A review of CNA#1 statement on 2/2/25 at 1:07 PM, revealed they were feeding Resident #29, when CNA#2 barged into the room and stated they would take over assisting Resident #29 and accused CNA#1 of abuse. No further information paperwork regarding the issue was provided.A review of LPN#1 employee file revealed an employee disciplinary action form marked as; Final Warning dated 7/3/25. The specifics of the incident portion of the form revealed, Name redacted (LPN#1) showed up to scheduled 11-7 shift on 7/2 smelling of alcohol as well as appearing intoxicated. The employee statement portion of the form revealed, employee admitted to taking some shots prior to coming to work and admitted to knowing it was wrong. The corrective action to be taken portion of the form indicated: 1. Name redacted (LPN#1) is on family medical leave act (FMLA). 2. With clearance will return in a supervised setting on 7am-3pm shift. 3. Reported to Board of Nursing (BON) and Department of Health (DOH). On 7/17/25 at 10:43 AM, the surveyor interviewed the DON, who stated a Facility Reported Incident (FRI) for CNA#1 was completed on 5/23/25. The DON further stated that CNA #1 was suspended pending the investigation, was cleared of any allegation, and returned to work. The DON stated there had not been an FRI reported for the 2/2/25 allegation of abuse and was unable to provide reasoning why an FRI was not reported. The DON stated with regarding to LPN#1, on 7/2/25 the DON observed LPN#1 clock into work, appeared intoxicated and was sent home immediately. DON also stated they had reported LPN#1 to nursing boards and DOH.A review of a facility policy title, Abuse Prohibition, with an updated date of 4/4/25. Under the process section of the policy revealed, 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.1 Report allegation involving abuse (physical, verbal, sexual, mental) not later than 2 hours after allegation is made. 7.2 Report allegation to appropriate state and local authority(s) involving neglect, exploitation or mistreatment, suspected criminal activity, and misappropriation of patient property not later than two hours after allegation is made.7.4 Notify local law enforcement, licensing boards and registries and other agencies as required.On 7/17/25 at 1:00 PM, the DON provided the surveyor with an FRI dated 7/17/15 at 12:45 PM. DON stated that they called in the FRI to the NJDOH after surveyor inquiry. The DON was unable to provide evidence of LPN#1 actions being called into the DOH. The DON further stated that LPN#1 alleged violations should be reported to the DOH in a timely manner and abuse allegations should have been reported within 2 hours, On 7/21/2025 at 12:40 PM, the surveyor met with the LHNA and DON and the LNHA stated they believed the allegation of abuse by CNA#1 was more of a personal issue between CNA#1 and CNA#2 and felt an FRI was not needed at that time. The LNHA stated any abuse allegation should always be reported. The further information was provided for LPN#2. On 07/24/2025 at 1:15 PM, the surveyor met with the LNHA and DON and no further pertinent information provided. NJAC 8:39-9.4(f)

Complaint #: NJ184361 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure care plan interventions were implemented for a resident's skin integrity. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #67), and was evidenced by the following:The surveyor reviewed the closed medical record for Resident #67. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs).A review of the individualized comprehensive care plan (ICCP) included a focus area dated effective 2/7/25, for at risk for skin breakdown related to impaired circulation, decreased mobility, and poor intake. Interventions included: to keep skin clean and dry; inspect skin daily and monitor for any reddened areas or skin breakdown; notify physician as needed for skin breakdown; turn and reposition every two hours while in bed or chair; and monitor for changes in circulation. A review of the Facility Reportable Event (FRE) dated 3/10/25, included that Resident #67's Representative (RR) informed the Social Worker (SW) that they had numerous complaints about the resident's skin when they left the facility including skin irritations. On 7/22/25 at 1:00 PM, the surveyor reviewed the resident's ICCP with the Director of Nursing (DON), and asked how the facility ensured the resident's intervention for inspection of skin daily was completed. The DON stated that she would have to get back to the surveyor. On 7/24/25 at 10:12 AM, the surveyor interviewed the DON, who stated that the resident's inspect skin daily was an automated intervention in the facility's electronic medical record system, and the resident should not have had that intervention. The surveyor asked then if everyone should have that intervention then, the DON stated that the nurse misread it when she implemented the intervention in the ICCP. The DON stated it should have just been a visual look when the aide was providing care. and The DON stated that care plans were done by the MDS Coordinator and updated by her as needed. The DON confirmed that staff were expected to implement all interventions in the resident's ICCP. On 7/24/25 at 10:49 AM, the surveyor interviewed the MDS Coordinator, who confirmed that she took part in the ICCP process. The MDS Coordinator stated that care plans were done annually and updated as needed. The MDS Coordinator stated that interventions were selected from a library in the facility's electronic medical record system, and that she could add additional interventions as needed. When asked about Resident #67's ICCP intervention for inspecting skin daily, the MDS Coordinator stated that she thought it meant for the Certified Nursing Aide (CNA) to inspect during care. The MDS Coordinator stated that she found out that she could link the intervention to the CNA instructions to do. The MDS Coordinator acknowledged that staff are expected to implement all ICCP interventions and if they were unaware of what an intervention meant, staff should have asked for clarification. A review of the facility provided Interdisciplinary Care Plans policy dated revised 3/17/14, included 2. Interventions: a. all interventions must be clear, concise and measurable. b. Interventions must address how each problem will be resolved . NJAC 27.1(a)

Based on interview and review of pertinent facility documents, the facility failed to ensure a resident who required assistance for bathing received a shower upon admission to the facility and on their scheduled shower day. This deficient practice was identified for 1 of 3 residents reviewed for activities of daily living (Resident #67), and was evidenced by the following:The surveyor reviewed the closed medical record for Resident #67. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/11/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs). A review of the individualized comprehensive care plan (ICCP) included a focus area dated effective 2/7/25, for requiring increased assistance with ADL function due to debility due to recent hospitalization, impaired mobility, cognitive deficit with poor safety awareness, and medication changes. Interventions included to assistance provided with care as needed, administer medication as ordered, and encourage participation in self-care as able. A review of the Facility Reportable Event (FRE) dated 3/10/25, included that Resident #67's Representative (RR) informed the Social Worker (SW) that they had numerous complaints about the resident smelled and was not showered. A review of the Certified Nursing Aide (CNA) Documentation Detail for bathing, provided by the Director of Nursing (DON), revealed that while the resident was in the facility, they refused a shower on 2/13/25 at 7:26 PM, received a shower on 2/17/25 at 10:38 AM, did not received a shower on 2/20/25, and received a shower on 2/27/25 and 3/6/25. On 7/22/25 at 12:35 AM, the surveyor interviewed CNA #1 and CNA #2, who both stated that they knew what care a resident received on their assignment from the ADL tracker that the resident's shower day was highlighted and the schedule was also on the wall. They both stated on shower days, a box for bathing would appear that you put a code in that it was completed or not completed. The CNAs stated that if the resident was not showered, the CNA coded that an 8 and they were required to document why the resident was not showered. The CNAs stated the nurse was informed, and the nurse might document as well. On 7/22/25 at 12:51 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the CNAs documented the resident's showers in the ADL Tracker system, and the nurses documented the resident's refusal of a shower in the progress notes. The surveyor reviewed the resident's medical record with the DON, who confirmed that there was no documentation on 2/20/25, as to why the resident was not showered, and there should have been. The surveyor requested the physician's order (PO) for when the resident's shower days were scheduled, and any additional information regarding when the resident was showered. On 7/24/25 at 10:12 AM, the DON informed the surveyor that there was no PO for bathing, that it was documented on the resident's ADL schedule. The DON provided a bathing schedule that indicated Resident #67 was to be bathed every Thursday during the 3:00 PM to 11:00 PM shift. When asked when a resident should be showered upon admission, the DON stated with 72 hours of their admission. The DON stated that the resident should be showered at least twice a week and confirmed the resident was only scheduled for once a week on Thursdays. The DON stated that the resident did receive a shower the night before their discharge from the facility. The DON also confirmed there was no documentation as to why the resident did not receive a shower on 2/20/25. On 7/24/25 at 11:40 AM, the surveyor interviewed the DON and Licensed Nursing Home Administrator (LNHA), who both confirmed the facility had a nursing binder of policies that had not been updated since 2020. The DON stated that the facility did not have an ADL or showering policy, but a resident should receive a shower within 72 hours of admission and at least once a week. The DON stated that in the sub-acute unit, residents are offered a shower daily, and the CNA documented in the ADL tracker if they received one. The DON confirmed there was no documentation that the resident received a shower within 72 hours of admission. NJAC 8:39-27.1(a); 27.2(h-i)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #2) reviewed for care and services for pressure ulcers.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 responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 7/21/25 at 11:30 AM, the surveyor observed Resident #2 in bed. The surveyor obtained the resident's permission to observe the treatment to his/her sacral wound. The surveyor observed signage on the door, which indicated the resident was on Enhanced Barrier Precautions (an infection control strategy implemented in long term care facilities that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug- resistant organisms.) The surveyor reviewed the medical record for Resident #2.A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to: Parkinson's Disease, Diabetes Mellitus, and a Stage 3 Pressure Ulcer of the sacral region (full thickness skin loss into subcutaneous tissue and fat).A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 6/22/25, reflected that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2 of 15, indicating a severe cognitive impairment. Section M documented that the resident had one stage 3 pressure ulcer.A review of the 7/21/25 Weekly Wound Assessment Report included documentation regarding the stage 3 sacral pressure ulcer, which was currently improving.A review of the Physician's Order (PO) dated 6/25/25 included: clean sacrum with saline, pack with Iodoform, also pack tunnel, protective dressing daily and prn (as needed.) On 7/21/25 at 11:35 AM, the surveyor observed the Licensed Practical Nurse/Wound Nurse (LPN/WN) perform the treatment to Resident #2's stage 3 pressure ulcer and observed the following: The Certified Nursing Assistant (CNA), who assisted the LPN with positioning of Resident #2, donned (put on) a disposable gown, mask, and gloves, entered Resident #2's room, and disinfected the over-bed table. The LPN/WN gathered the supplies, which included three (10 cc) Normal Saline syringes (NSS), a container of packing strips, a foam dressing, 4x4 gauze pads, a bag of cotton tip wooden applicators, scissors, and a marker. The LPN/WN donned a mask, disposable gown, and gloves and entered Resident #2's room. The LPN/WN placed a clean barrier on the overbed table and then placed all of the supplies on it. The LPN/WN reviewed the supplies at the resident's bedside and realized he had brought in packing strips that did not contain the Iodoform as per the physician's order. The LPN/WN doffed (took off) his disposable gown, mask, and gloves, sanitized his hands with Alcohol Based Hand Rub (ABHR), and left the room.The LPN/WN returned to Resident #2's room with the Iodoform packing strips (used to prevent bacterial infection and promote healing). The LPN/WN donned a gown and gloves and placed a plastic bag on Resident #2's bed, which he stated would be used to collect the soiled dressing and used supplies. The LPN/WN removed the soiled dressing, which he described as having a moderate amount of serosanguinous drainage (a mix of serous fluid and blood), and discarded it into the bag on the resident's bed. The LPN/WN removed his gloves and discarded them into the bag on the bed. The LPN/WN applied ABHS, donned a new pair of gloves, cleaned the wound with the NSS syringe, measured the sacral wound, and, with the same gloves (now contaminated) opened the Iodoform packing strips. The LPN/WN used the wooden end of the Q-Tip to pack the wound. The LPN measured the packing strip as he removed it from the container, touching it with his gloved hand (now contaminated). After packing the wound, the LPN/WN cut the strip from the container. The LPN then taped the end of the packing strip to the resident's already compromised skin. The LPN used the same contaminated gloves to put the lid back on the Iodoform packing strips. The LPN applied the foam dressing, put the date, time, and initials on a piece of tape, and applied the tape to the dressing. The LPN cleansed the scissors and pen with alcohol pads. The LPN discarded the used supplies in the bag on the resident's bed. The CNA who assisted with the resident's positioning removed her mask, gown, and gloves and performed hand hygiene. The LPN/WN and surveyor observed that the CNA washed her hands under the stream of water for 8 seconds without first lathering and applying friction to her hands outside of the running water.The LPN removed the trash bag from the resident's bed, doffed his gown, mask, and gloves, and washed his hands. The LPN/WN brought the containers of Plain and Iodoform packing strips out of the resident's room (now contaminated) and put them back into the treatment cart. The LPN did not disinfect the overbed table after the treatment was completed. The surveyor observed that throughout the treatment, the LPN did not assess the resident for pain.On 7/21/25 at 12:25 PM, the surveyor discussed the breaks in technique with the LPN/WN. The LPN/WN confirmed that he had not assessed the resident for pain or checked with the medication nurse to see if the resident received pain medication prior to the wound treatment. The LPN acknowledged that he should not have placed the trash bag on the resident's bed, should not have touched the packing strip with his soiled gloves, and should not have placed the containers of packing strips back into the treatment cart for infection control prevention. The LPN/WN further confirmed that he should have disinfected the overbed table after the treatment was completed. The LPNWN stated that he observed the unacceptable hand washing performed by the CNA. On 7/21/25 at 12:30 PM, during an interview with the surveyor, the CNA acknowledged she should have washed her hands for 20 seconds outside the stream of water. The CNA stated that she usually lathered outside of the water but didn't this time because she was nervous. On 7/21/25 at 12:40 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns.A review of the facility's policy Wounds: Pressure Ulcers & Ulcers of different types of Protocol for: Prevention, Assessment & Monitoring, Intervention, Documentation, and Evaluation updated 2/23/2016 reflected.In the event that a resident is admitted with a pressure sore or a resident develops a pressure sore, the resident will receive the necessary care and services to promote healing and prevent additional ulcers. A review of the facility's Hand Washing policy revised 3/9/2021 reflected.Hand hygiene techniques.Wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 30 seconds, covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use a towel to turn off the faucet. On 7/24/25 at 1:15 PM, no further information was provided by the facility.NJAC 8:39-19.4(a); 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to (a) ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing and (b) ensure a system was in place for the accurate acquiring, receiving, and dispensing of medications in accordance to professional standards of practice. This deficient practice was identified for 2 (two) of 4 (four) residents (Resident #33 and Resident #42) observed during the medication observation pass and had the potential to affect all residents. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1). On 07/21/25 at 8:37 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #42. The surveyor observed LPN#1 checking the resident's identification bracelet and informed Resident #42 that she would be administering the resident's medications. On 07/21/25 at 8:40 AM, the surveyor observed LPN #1 preparing to administer nine (9) medications to Resident #42 which included the following: Calcium Carbonate 600 mg tablets (supplement), Eliquis 5 mg (blood thinner), Lexapro 5mg (anti-depressant) tablet, Gabapentin 100 mg tablet (nerve pain), multivitamin tablet (supplement), Vitamin D3 1000-unit tablet (supplement), Vitamin B-12 500 mg (supplement), Torsemide 20 mg (water pill) and Potassium Cl 10 MEQ. The surveyor observed LPN#1 prepared Resident #42's Potassium. The electronic medication administration record (EMAR) revealed that the resident had an order for one Potassium 10 MEQ tablet to be administered. The surveyor observed the Potassium 10 MEQ medication packaging a pharmacy label to administered two tablets which was equivalent to 20 MEQ. At that time, LPN#1 stated that the resident had an order for one tablet and that she was going to call the pharmacy and have them change the label. LPN#1 acknowledge that the pharmacy medication packaging was confusing and had the potential to cause a medication error. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; hypokalemia (low potassium), vitamin deficiency, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment of daily functions). A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 4/25/25, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident's cognition was intact. A review of the July 2025 Physician's Orders (PO) revealed a Physician's Order dated 6/26/25, for Potassium chloride ER 10 mEq tablet, extended-release tablet, give 1 tablet by mouth one time a daily with food for hypokalemia. A review of the April 2025 electronic medication administration record (EMAR) revealed an order dated 06/26/25, for Potassium Chloride ER 10 mEq tablet, extended release, give 1 tablet by mouth once daily with food for hypokalemia (plotted time at 8:30 AM). On 07/22/25 at 10:20 AM, the surveyor in the presence of LPN#3 inspected the third-floor high side medication card. In the presence of the surveyor, LPN#3 pulled out Resident #42's Potassium medication card (medication packaging) which still included the instructions to administer 2 tablets of Potassium for a dose of 20 MEQ. LPN#3 reviewed the EMAR and stated that the resident had an order for one tablet of 10 mEq of Potassium. LPN#3 stated that the instructions on the medication card was confusing and had the potential to cause a medication error. She stated that she will remove this medication card from active medication and will call the pharmacy for a new medication card with proper instructions. 2). On 07/21/25 at 9:19 AM, during the medication administration observation, the surveyor observed the LPN #2 in the room of Resident #33. The surveyor observed LPN#3 checking the resident's identification bracelet and informed Resident #33 that she would be administering the resident's medications. On 07/21/25 at 9:20 AM, the surveyor observed LPN #3 preparing to administer nine (9) medications to Resident #33 which included the following: Abilify 5 mg tablets (anti-depressant), Zyrtec 10 mg tablet (allergies), Dilantin 30 mg extended-release capsules (seizures), two Dilantin 50 mg chewable tablets (seizures), Ferrous sulfate 325 mg (supplement), Primidone 250 mg tablets (seizures), Folic Acid 1 mg (supplement), Namenda 10 mg (dementia), and B-complex tablet (supplement). The surveyor observed LPN#3 administer Resident #33's medications. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to epilepsy (a neurological condition characterized by recurrent, unprovoked seizures), Alzheimer's disease (a progressive disease that destroys memory and other important functions) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment of daily functions). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 5/08/25, reflected that the resident's cognitive skills for daily decision-making score was 10 out of 15, which indicated that the resident had moderate cognitive impairment. A review of the July 2025 Physician's Orders (PO) revealed two Physician's Orders dated 02/19/25, for Dilantin 30 mg capsule, give 1 capsule by mouth every 12 hours for seizure disorder every 8 AM and every 8 PM and for Phenytoin (Dilantin) 50 mg chewable tablet, chew 2 tablets (100mg) by oral route 3 times per day for seizure disorder every 8:00 AM, 4:00 PM, and 8:00 PM. A review of the July 2025 EMAR revealed two physician's orders dated 02/19/25, for Dilantin 30 mg capsules, give 1 capsule every 12 hours for seizure disorder (plotted time 8:00AM and 8:00 PM) and an order for Phenytoin 50 mg chewable tablets, chew two tablets (100 mg) by oral route three times daily for seizure disorder (plotted time 8:00 AM, 4:00 PM, and 8:00 PM). On 7/21/25 at 11:14 AM, the surveyor interviewed LPN#2 regarding two orders (Dilantin 30 mg and Dilantin 50 mg) administered late (outside from the allotted time frame). LPN#2 reviewed the orders and acknowledge that both Dilantin orders should have been administered no later than 9 AM. LPN#2 also stated that it was important that a medication being taken more than once a day should be administered at the appropriate time. LPN#2 further acknowledge that Dilantin 30 mg was ordered to be administered every 12 hours and Dilantin 50 mg had an order to administered three times daily. On 07/21/25 at 12:30 PM, the surveyor discussed the above concerns with the facility administration team that consisted of both the Director of Nursing (DON) and the Licensed Nursing Home Administrator. There was no additional information provided. A review of the facility's policy for Medication Administration that was undated and was provided by the DON revealed no information that address the concerns presented by the surveyor. 3. On 7/22/25 at 9:51 AM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), and the DON stated that the facility had a policy that allowed staff to borrow medication from a resident to administer to another resident. The DON continued that the facility would borrow the medication from a resident, and they completed a form that the medication was borrowed from the resident, and the form was sent to the Provider Pharmacy, and the medication was replaced. The surveyor asked if the facility was allowed to borrow medication from another resident, and the DON stated it was the facility's policy that we can borrow and the fill out the form. The surveyor then requested a copy of all borrowed medication since last standard survey, and the DON denied borrowing any medication from residents. A review of the facility's Medication Administration: Borrowing Policy updated 2/23/16, indicated that nursing staff may, on a temporary basis, borrow prescribed medication until the next delivery. Medication may be borrowed from the supply of another resident only for the following reasons: resident ran out of medication; new order received after daily pharmacy delivery, needed medication before the pharmacy delivery; or the emergency pharmacy was closed . On 7/22/25 at 11:07 AM, the surveyor attempted to conduct a telephone interview with the Consultant Pharmacist (CP) who did not answer, and the surveyor was unable to leave a message. On 7/22/25 at 11:20 AM, the surveyor conducted a telephone interview with the Medical Director (MD), who stated that you were not allowed to borrow medication from one resident for another resident because it was that resident's property. The surveyor asked if the facility had a policy to borrow medication from another resident was it okay, and the MD stated no, that the facility had an emergency back-up box of medication to use. The surveyor informed the MD that the facility did not have narcotics in their emergency back-up supply and asked if it was okay to borrow a narcotic. The MD stated no. The MD also acknowledged that he was unaware the facility had a borrowing policy for medications and acknowledged that he had not reviewed all the facility's policies. On 7/22/25 at 11:56 AM, the surveyor conducted a telephone interview with the Provider Pharmacist (PP), who stated that the facility received deliveries twice a day, and if there was a medication needed stat (immediately), the pharmacy would call in the prescription to a local pharmacy for the facility to pick up. The surveyor asked f it was acceptable for the facility to borrow medication from one resident to give to another resident, and the PP stated no, that as far as the pharmacy was concerned, a pharmacist was not dispensing the medication. The PP stated that it was the pharmacist's scope of practice to dispense medications to ensure the correct dosage, drug interactions, and allergies, and the facility would be acted out of their scope of practice since the pharmacy would no longer be dispensing the medication. NJAC 8:39-11.2 (b), 29.2 (d)

Number of residents sampled: Number of residents cited: The surveyor reviewed the closed medical record for Resident #67.A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, heart failure, need for assistance with personal care, and major depressive disorder.A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated a severely impaired cognition. A further review revealed that the resident needed partial assistance from another person to complete activities of daily living (ADLs).A review of the individualized comprehensive care plan (ICCP) included a focus area dated effective [DATE], for requiring increased assistance with ADL function due to debility due to recent hospitalization, impaired mobility, cognitive deficit with poor safety awareness, and medication changes. Interventions included to assistance provided with care as needed, administer medication as ordered, and encourage participation in self-care as able.On [DATE] at 10:15 AM, the surveyor requested from the Licensed Nursing Home Administrator a copy of the complete Facility Reportable Event (FRE) including all witness statements dated [DATE], for Resident #67.On [DATE] at 10:23 AM, the LNHA provided the surveyor with Resident #67's FRE.A review of the FRE dated [DATE], included that Resident #67's Representative (RR) informed the Social Worker (SW) that they had numerous complaints about the resident smelled and was not showered. I review of the Grievance/Concern Form included in the FRE indicated that the Recommended Corrective Action(s): were reviewed documentation [.] showers were given twice a week and confirmed compliance with Certified Nursing Aide (CNA). The FRE did not include any witness statements from staff including CNAs.A review of the Certified Nursing Aide (CNA) Documentation Detail for bathing, provided by the Director of Nursing (DON), revealed that while the resident was in the facility, they refused a shower on [DATE] at 7:26 PM, received a shower on [DATE] at 10:38 AM, did not received a shower on [DATE], and received a shower on [DATE] and [DATE]. This documentation did not corroborate the Grievance/Concern Form that indicated the resident received showers twice a week.On [DATE] at 12:40 PM, the survey team met with the LNHA and DON, and the surveyor requested any statements obtained for Resident #67's FRE dated [DATE].On [DATE] at 9:51 AM, the surveyor team met with the LNHA and DON to discuss concerns addressed the day before. The surveyor asked for the statements requested for the FRE from [DATE], and none were provided.On [DATE] at 12:51 PM, the surveyor interviewed the DON, who stated that during an investigation for an injury of unknown origin or abuse, statements were gathered by staff who were assigned to the resident for the past 72 hours. The DON stated for grievances; statements were also obtained. The DON stated that she completed the grievance for Resident #67, which included collecting statements from the CNAs who took care of the resident. The DON stated that she had those statements, and the surveyor requested a copy of the statements.On [DATE] at 10:12 AM, the surveyor interviewed the DON, who stated that a resident received a shower within 72 hours of admission, and then at least twice a week. The DON stated that the resident was only scheduled to receive showers on Thursdays, which was not twice a week. The DON stated that the resident received a shower the night before they were discharged from the facility. The surveyor inquired about the statements from the investigation, and the DON stated she would provide them.On [DATE] at 10:23 AM, the LNHA provided the survey team with Resident #67's FRE from [DATE]. It included a typed page with Interviews conducted by the DON which included one nurse and two CNAs' statements. There were also two additional handwritten statements from staff.On [DATE] at 11:34 AM, the surveyor asked the LNHA if the facility had a medical records policy, and he stated he was unaware if the facility did because the policies were not updated annually or kept in one place. The surveyor asked where the statements for the resident's FRE was located, and the LNHA stated there were 17 binders to look through. The LNHA acknowledged that all medical records should be maintained accurately and accessible.On [DATE] at 11:51 AM, the surveyor interviewed the DON, who stated that the resident should have received a shower within 72 hours of admission to the facility, and then at least once a week after. The DON stated that residents on the sub-acute unit were also offered showers daily, and showers were documented in the ADL Tracker. The DON stated there were no policies for showering or ADLs for residents. A review of the facility provided Medical Records Policy and Procedure dated revised [DATE], included that medical records are to be maintained on all residents admitted to [facility name redacted] in accordance with professional standards of practice. Medical records of discharged or deceased persons are maintained in the medical records area as designated in locked file cabinets to prevent loss, destruction or unauthorized use.Health Records are maintained on each individual admitted to the nursing facility, initiated on the day of admission. The health record contains sufficient information to identify the resident clearly, to justify diagnoses and treatment and to document the results accurately. These records are filed in the nursing unit.NJAC 8:39-35.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and maintain an infection prevention and control program (IPCP) that included all of the required elements, the facility failed to review the IPCP policy on an annual basis b.) failed to follow infection control procedures with 2 of 3 residents on Oxygen (O2) Therapy. This deficient practice was identified for 2 of 3 residents (Resident #4 and #8) reviewed for O2 therapy.This deficient practice was evidenced by the following: 1.The Surveyor reviewed the facility's IPCP policy which reflected that the policy did not include A system of surveillance which is designed to identify possible infections before they spread to other residents in the facility; who possible infections should be reported to; and failed to document the requirements for the isolation of a resident. A review of the facility's IPCP policy reflected that it was last reviewed January 2024. On 7/24/25 at 10:15 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the IPCP policy was required to include a system of surveillance, elements for when and to whom an infection was to be reported to and should include that a resident received the least restrictive isolation procedure possible. The DON confirmed that the IPIC Policy did not include these required elements. The DON further acknowledged the IPCP policy's last review date was January 2024 and should have been reviewed annually, no later than January 2025. 2. On 7/16/25 at 10:57 AM, the surveyor observed and interviewed Resident #8 awake in bed, with oxygen (O2) via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 2.0 liters/minute (LPM), O2 running. The surveyor further observed the O2 tubing laying directly on the floor of the resident's room. The surveyor reviewed the admission Record (AR; or face sheet; an admission summary) which revealed that the resident had been admitted to the facility with diagnosis that included severe protein-calorie malnutrition, chronic obstructive pulmonary disease, hypothyroidism and hypertension. A review of the Quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/29/25, revealed that the resident had a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident has severe cognitive impairment. The MDS also reflected that the resident received continuous O2 therapy. On 7/17/25 11:09 AM, in the presence of the Licensed Practical Nurse (LPN#1), the surveyor observed Resident #8's O2 tubing on the floor of the resident's room. LPN#1 stated they Resident #8's O2 tubing should be secured in a bag and/or off the floor. LPN#1 immediately changed and disposed of the soiled O2 tubing and secured the new tubing in a bag off the floor. 3. On 7/16/25 at 11:04 AM, the surveyor observed Resident #4 in bed, lethargic during interview, observed O2 set 1.5 L/min. resident currently on hospice O2 tubing noted on the floor. The surveyor further observed the O2 tubing laying directly on the floor of the resident's room. Review of Resident #4's AR reflected that Resident #4 was admitted to the facility with medical diagnoses that included but were not limited sepsis, pneumonia, chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia. A review of the Significant Change MDS with an ARD of 5/4/25, revealed that the resident had a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident has moderate cognitive impairment. The MDS also reflected that the resident received continuous O2 therapy. On 7/17/25 11:13 AM, in the presence of the Licensed Practical Nurse (LPN#1) the surveyor observed Resident #4 O2 tubing on the floor of the resident's room. LPN#1 stated Resident #4's O2 tubing should be secured in a bag and/or off the floor. LPN#1 immediately changed and disposed of the soiled O2 tubing and secured the new tubing in a bag off the floor. On 7/21/25 12:40 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns found during the survey. The DON stated all O2 resident will be checked to assure the O2 tubing is secured to prevent infection control concerns. On 7/21/25 at 12:56 PM, the DON provided the surveyor with a facility policy titled, Infection Control Policy with a revised date of 5/20/21. The surveyor reviewed the policy which revealed, the purpose is to, To control spread of infection. Under the procedure portion of the policy revealed, Resident care equipment, handle soiled patient care equipment in a manner to prevent, skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other resident and environments. On 7/22/25 at 9:00 AM, the surveyor interviewed the Infection Preventionist (IP), who stated O2 tubing should be secured in a bag, dated, changed weekly, and stored off the floor to prevent contamination. On 7/24/25 at 1:15 PM, the surveyor met with the LNHA and DON for the exit conference. No further pertinent information provided. NJAC 8:39- 27.1 (a)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 1 of 2 resident units (observed on 3rd floor nursing unit). This deficient practice was evidenced by the following:On 07/21/25 at 9:12 AM, the surveyor was observing medication administration pass on the 3rd floor low-side and observed two handrails that were missing the return part (end part of the handrail) which was located next to room [ROOM NUMBER] and room [ROOM NUMBER]. The missing return part of the handrail exposed a screw and metal components that attached the handrail to the wall.On 07/22/25 at 10:30 AM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) on the 3rd floor low side, who in the presence of the surveyor observed the handrail missing the return part. At that time, LPN#1 stated that the handrail that was missing the return part was a potential hazard to the resident's because it exposed the residents to a sharp object (screw and metal component that was affixing the handrail to the wall).On 07/22/25 at 10:35 AM, the surveyor interviewed a Certified Nursing Assistant (CNA) who was providing care to residents on the 3rd floor low side. In the presence of the surveyor the CNA observed the handrails that were missing the return part and stated that not having a fully attached handrail was a potential hazard to residents.On 07/22/25 at 12:30 PM, the surveyor interviewed the Maintenance Director (MD), who acknowledge that two handrails (one next to room [ROOM NUMBER] and another next to room [ROOM NUMBER]) were missing the return portion of the handrail. The MD told the surveyor that a contractor was working on the handrails and quit working and never put the return portion back on the handrail. The MD acknowledge that the handrails that were missing the return part was a potential hazard to the residents who are using these handrails.On 07/22/25 at 1:15 PM, the above concern was presented to the facility administration team that consisted of the License Nursing Home Administrator (LNHA) and the Director of Nursing. The facility had no additional documentation to provide the surveyors. The surveyor was provided the facility's Maintenance Service policy from the LNHA which revealed the following: 10. The facility will equip corridors with firmly secured handrails on each side. NJAC 8:39-31.2(e)

Complaint #s: NJ00182470, NJ00182480 Based on interview, record review, and review of pertinent facility documents on 03/26/2025 and 04/01/2025, it was determined that the facility failed to (a) provide a safe environment for a wandering, ambulatory, and cognitively impaired resident (Resident #1) and (b) follow facility policy on thorough investigation of accident/incident. On 10/15/2024 Resident #1 was found stuck to the floor in an opened room where the floor was being redone. Resident #1 was found by a Certified Nursing Assistant (CNA) when she/he fell backwards and hit her/his head hard and started vomiting which resulted in Resident #1 being sent out to an acute care hospital #1[name] ER [emergency room ] and later was transferred to acute hospital #2 [name] where she/he was found to have three (3) brain bleeds. Resident #1 was not in the facility during the survey. The Surveyor reviewed the closed medical records of Resident #1. This deficient practice was identified in 1 of 6 residents reviewed for incidents/accidents and was evidenced as follows: According to Resident #1's recent Resident Face Sheet (RFS), the Resident was readmitted to the facility with diagnoses that included but was not limited to Nontraumatic subarachnoid hemorrhage, nontraumatic subdural hemorrhage, Vascular dementia, Alzheimer's Disease, Essential Hypertension, Malignant Neoplasm of central portion of left breast, Acute ischemia heart disease, Osteoarthritis of knee, and Hyperlipidemia. Review of the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated 08/24/2024, Resident #1's Brief Interview for Mental Status (BIMS) score was 99 indicating that the Resident was unable to complete the interview. Under C1000 of Section C, Resident #1's Cognitive Skills for Daily Decision Making was coded as 3-severely impaired. The Resident's MDS further revealed in Section GG-Functional Abilities and Goals that the Resident was dependent on staff for the completion of her/his Activities of Daily Living (ADL). Review of Resident #1's Care Plan Activity Report (CPAR) reflected a list of Focus [health problem] that included but not limited to and as follows: -Focus: Elopement: Wanders the unit at times; Wanders in and out of other residents' room; At risk of elopement. -Focus: Behavior: I [Resident] have behaviors such as constant pacing up and down the halls, wandering in other resident's rooms, declines to care and rummaging through drawers due to Alzheimer's dx [diagnosis]. -Focus: Falls: I [Resident] am at risk for falls. Review of Resident #1's Progress Notes (PN) dated 10/15/2024 at 7:05 pm [evening] and documented by [name redacted] (Nurse #1), that the resident was found in room [number] stuck to the floor. The room was accessible to the resident the floor is being redone. The CNA [certified nursing assistant] found Resident #1 had fallen backwards and hit his/her head. Vital signs and neurological checks were done by the nurse. The resident began to vomit when the staff sat him/her up. The resident's physician was notified and ordered the resident be evaluated in the Emergency Department (ED). The resident's daughter was notified, and the Nursing Supervisor was made aware. The resident left facility at 5:35pm on a stretcher. The PN further revealed Nurse #1 documented on 10/15/2024 at 10:38 pm, Call placed to [NMC] acute hospital, the Resident was transferred to [another hospital name] .She [Resident #1] has 3 brain bleeds. Review of Resident #1's Hospital Records [hospital name] ED [emergency department] to Hospital -admitted d 10/15/2024, Reason for Visit: Fall. Head Injury. A Neurosurgical Consultation documented by Neurosurgeon attending Dr. [doctor] [name redacted] revealed Reason for Consult: 1. S/p [status post, after] fall; 2. CT [computed tomography, a procedure that combined x-ray and computer technology image to view the inside of body] of head demonstrated a 1.1 cm [centimeter] focus of parenchyma hemorrhage [bleeding]/contusion in the right frontal lobe [right area of brain] with subarachnoid extension and .subdural [areas in inner brain] hematomas [bruising]. Review of the document titled, Incident Summary (IS), provided by the facility with Resident #1's [name, room number] with Date of Incident: 10/15/2024. According to the IS, under Incident, on 10/15/2024 at 5:50 pm [afternoon], resident [Resident #1's name] wandered into room [number] which was being remodeled, CNA#1 saw the resident and went to get the resident from the room. Resident #1 was trying to get their foot stuck from the glue on the floor. Resident #1 was trying to raise her/his foot and lost balance. CNA #1 tried to catch the resident from falling but was not able to catch him/her to prevent the fall. Resident #1 had fallen and landed on his/her buttocks first then hit his/her head on the floor. CNA#1 called for help and Licensed Practical Nurse (LPN) [name] came and assessed Resident #1. Resident #1 was alert lying on the floor, skin was intact, no bruises or bumps noted to his/her head. Resident #1 was assisted by 3 staff in the wheelchair when the Resident started vomiting twice. MD [doctor] was notified and ordered to transfer Resident to [acute hospital name] ED for evaluation and treatment. Resident #1 was admitted to [acute hospital name #1] and was found to have a small intracranial [within the skull] hemorrhage [bleeding]. Resident #1 was then transferred to [acute hospital name #2] for further evaluation. POA [Power of Attorney] [name redacted] was aware of the incident. [Resident #1] returned to facility on 10/16/2024. The Surveyor requested for the full Incident/Accident (I/A) Report of Resident #1 on 10/15/2024 from the facility. On 04/01/2025 at 10:21 AM, in an interview with the Surveyor, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were not able to provide the IA of the Resident. The LNHA and DON stated they were new management and administration and had started on January of this year 2025. LNHA and DON were not able to provide the I/A and statements collected. The LNHA and DON further stated they could not locate the document but found the IS of the above-mentioned incident. Review of the facility policy titled, Accidents/Incidents, effective 04/01/2025, under Policy: Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property involving, or allegedly involving, a patient who is receiving services .; under Process: 3. Reporting: 3.1 All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. 3.1.1 Employees witnessing an accident/incident involving a patient will communicate a factual description of his /her findings to the supervisor or the nurse responsible on the unit .4. Follow-up/Investigation: .4.3 When conducting an investigation, the Administrator, DON, or designee will: .4.3.4 Conduct witness interviews from all staff and visitors who may have knowledge of the accidents/incident .4.3.6 Monitor that all aspects of the accident/incident and investigation involving patients are documented. N.J.A.C. 8:39-27.1(a)

NJ00169688 NJ00169710 Based on interview, and record review, it was determined that the facility failed to ensure that Resident #10 who was at risk for falls, accurately investigated the cause of each fall, the prevention of future falls, including a fall that resulted in serious injury. This deficient practice was identified for 1 of 3 residents reviewed for falls. Review of history of falls for Resident #10 revealed that they had 2 falls, on 11/11/23 and 11/13/23 with injuries. A review of the Investigation reports for the falls that occurred on 11/11/23 and 11/13/23, revealed that they did not include possible causes/root cause of the falls. Review of the investigations report supported that there was no appropriate Intervention evaluation or interventions put in place after the resident's falls relating to the resident's involuntary movements. Resident #10's care plan (CP) was not appropriate or specific to the resident's individualized needs including the resident's jerking movements which abetted in causing falls. The surveyor reviewed Resident #10's medical records. On 3/4/24 at 10:59 AM, the surveyor observed Resident #10 in the day room seated in a Broda chair (chair that provides safe, comfortable long-term seating that can reduce the number of falls for residents). A review of the Admission Record for Resident #10 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Unspecified Convulsions, Hemiplegia and Hemiparesis following Cerebral infarction and Restlessness and Agitation. A review of Resident #10's Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/20/23, reflected that Resident #10 had a BIMS score of 99 out of 15, indicating a severe impaired cognition. The following were the reported and documented fall incidents: 1. On 11/11/23 at 7:50 PM fall incident report revealed a witnessed fall resulting in minor injuries which included 3 skin tears to the left arm, 2 skin tears to the right arm and bruising noted to right groin and scrape on the knee. A review of the form titled, Employee/Witness Statement Form documented by Certified Nursing Assistant #4 (CNA #4) stated, was cleaning the resident the resident moved and fell off the side of the bed. On 3/7/24 at 10:45 AM, the surveyor interviewed CNA #1 who was the regular CNA for Resident #10. CNA #1 stated that occasionally when the resident was turned to their side, the resident would develop involuntary spasms/jerky movements. The surveyor asked CNA #1 if there were any documented medical alerts related to Resident #10's occasional spasms/jerky movements in the medical records or CNA tasks to aid the facility staff in taking care of the resident. CNA #1 could not locate any type of medical alert indicating the spasms/jerky movements. A review of the resident's CP activity report titled; Falls revealed that there were no interventions added to address the resident's occasional spasms/jerky movements. On 3/11/24 at 3:30 PM, the survey team discussed the above concerns to the facility's Licensed Nursing Home Administrator, Director of Nursing (DON) and Licensed Practical Nurse #2. The facility could not provide further information. The DON also agreed that the investigation was not thoroughly assessed and evaluated to determine the cause of the fall. 2. On 11/13/23 at 12:45 PM fall incident report revealed an unwitnessed fall resulting in major injury which included laceration to forehead which required hospitalization . A review of the form titled, Incident/Accident Report documented by Licensed Practical Nurse #3 (LPN #3) stated, After resident eat lunch with CNA staff (feeder) and after nurse left the dining room after all residents finished eating, CNA staff starting to pull up all resident from dining room, resident found on the floor and was bleeding from forehead . A review of the staffing for the week of Complaint staffing from 11/12/2023 to 11/18/2023, the facility was deficient in CNA staffing for residents on 2 of 7 day shifts as follows: -11/12/23 had 5 CNAs for 66 residents on the day shift, required at least 8 CNAs. -11/13/23 had 6 CNAs for 66 residents on the day shift, required at least 8 CNAs. The staffing report revealed that on 11/13/23, the facility was short of CNAs in the day shift. A review of the progress notes dated 11/16/23 and documented by the Certified Occupational Therapy Assistant (COTA) reflected that Resident #10 was screened due to recent falls. The COTA documented, Resident had 2 falls recently. One from bed and another from broda chair. Upon investigation, the resident was left unattended in the dining room with broda chair completely upright instead of reclined. A review of the resident's CP activity report titled; Falls revealed that there were no interventions found indicating that the resident required the use of broda chair when out of bed. On 3/11/24 at 3:30 PM, the surveyor discussed the above concerns to the facility's Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Licensed Practical Nurse #2. The DON agreed that the investigation was not conducted and assessed thoroughly for the fall incident on 11/11/23. The LNHA stated that the staffing was short on the day of the second fall incident which was 11/13/23. No further information was provided. NJAC 8:39-27.1(a); 31.4(a); 33.1(d)

Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision for residents with a history of falls and failed to provide effective safety measures to prevent falls. Resident #12 had falls which resulted in 2 fractures and a decline in activities of daily living. This deficient practice was identified for 2 of 6 residents reviewed for falls, Resident #12 and Resident #13, as evidenced by the following: 1. On 7/8/13 at 10:10 a.m. during the initial tour of the facility, the surveyor observed Resident #12 in the hall in his/her wheelchair with a fastened Velcro seat across the lap. On 7/11/13 at 9:56 a.m. the surveyor observed the resident in bed asleep with a sensor alarm on his/her bed. On 7/11/13 at 12:38 p.m. the surveyor interviewed Resident #12. The resident said that s/he did not remember everything about his/her falls, but knew that s/he broke his/her hip and ribs. The resident also said that s/he got up by his/herself to use the bathroom even though the staff said not to, because s/he would ring the call bell, no one would come, and s/he could not wait any longer. On 7/11/13 at 1 p.m. the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/20/12 the Interdisciplinary (IDC) team assessed Resident #12 as being cognitively intact utilizing a Quarterly Minimum Data Set (MDS), an assessment tool, . The IDC team further assessed the resident as requiring set- up assistance of 1 person for transfers, ambulation, and toilet use. The surveyor reviewed the Progress Notes in the resident's medical record which revealed that the resident had 7 falls between 1/23/13 and 6/14/13: i.) The first fall occurred on 1/23/13 at 10:55 p.m. According to the facility investigation report, the resident was found on the floor next to his/her bed. The resident said that s/he felt him/herself slipping so s/he sat down on the floor. The resident did not sustain an injury. The surveyor reviewed the post fall checklist of 1/23/13 that documented that the resident was alert and oriented and had poor safety awareness. The IDC team documented an intervention in the fall care plan of 9/13/12 that the resident was to have a bed alarm and a chair alarm in use to prevent falls. The fall investigation report did not indicate that an alarm was sounding. A new intervention was added to the resident's care plan on 1/23/13 to monitor the resident's level of safety awareness. On 7/12/13 at 11:10 a.m. the survey team interviewed the Director of Nursing (DON). The DON did not respond when asked how the resident was being monitored and where could the documentation be found. ii.) The nurse documented in the investigative report of 2/3/13 that Resident #12 was found on the floor of his/her room, wearing a tee-shirt and underwear at 3:30 p.m. His/her non-skid socks were on the bed. The nurse documented on the report that the resident said that s/he took off the non-skid socks and tried to stand up. S/he started to slip and then fell hitting his/her nose on the garbage can. The resident sustained [REDACTED]. The post fall checklist included that the resident had previous falls in the last 6 months and had poor safety awareness. There was no documentation on the investigation report that the bed alarm was sounding. Although the care plan already contained an intervention for bed and chair alarms since 9/13/12, the intervention added to the care plan on 2/4/13 was to add a tab alarm while in bed, . The facility failed to address why the care plan wasn't being followed if the devices (alarms) were not in place. The facility failed to address the problem of the resident not being able to stand up or address what impact the non-skid socks being removed by the resident had on the resident falling. On 2/4/13 the resident was seen by Occupational Therapy. The Occupational Therapist (OT) wrote a note on 2/4/13 that stated the resident "now requires supervision to be safe in his/her environment." The post fall checklist of 2/4/13 included the following from OT, "Pt continues to use poor judgment and requires supervision with transfers and functional mobility in room." This was not added to the resident's care plan. On 7/12/13 at 11:20 a.m. the surveyor interviewed the OT. The OT confirmed that nursing staff was aware the resident now required supervision. The OT stated that she advised nursing of this requirement both verbally and in her note on the Post Fall Checklist. iii.) According to the Investigation Report of 3/15/13, Resident #12 fell at 4:20 p.m. and was found sitting on the floor next to his/her wheelchair in the dining room. According to the Post Fall Checklist, the resident stated she slipped out of the wheelchair because the cushion was slippery. There was no validation documented on the investigation report that the chair alarm was sounding. The checklist indicated that the resident had a cognitive deficit and poor safety awareness. The facility investigation report included that the resident was confused and disoriented. The resident did not sustain an injury. On 3/15/13 the resident's fall care plan was updated by the IDC team to include the provision of a non-slip cushion pad on the wheelchair. The surveyor noted that the IDC team continued to neglect to document as an intervention in the care plan Resident #12's increased need for supervision as recommended by the OT. iv.) According to a facility investigation report of 3/21/13 at 11 a.m., the resident stated that s/he was getting into bed and his/her slipper fell off and s/he slipped off of the bed. The staff reported in the investigation report that the resident was seen walking in the hallway with a cane and slip-on slippers prior to the fall. The facility failed to indicate what caused the resident to slip off the bed. The IDC team added a new intervention to the resident's care plan to place nonskid strips to floor in resident's room. There was no indication that increased supervision was provided as recommended by OT. v.) According to the investigation report, on 3/30/13 at 6:55 a.m. the resident was found on the floor in his/her room. The resident stated that s/he was trying to reach the bed and fell . The resident complained that his/her left hip hurt. The physician was notified and the resident was sent to the emergency room for evaluation. The resident was admitted to the hospital with [REDACTED]. The nurse documented in the fall investigation report that the resident needed monitoring every 2 hours and 1 to 1 supervision. The nurse noted the care plan would be updated when the resident returned from the hospital. The resident returned to the facility on [DATE]. Wheelchair and bed alarms were added to the resident's care plan, although they were already in the care plan from 9/13/12 and had proved to be an ineffective device for preventing the resident from falling. The facility failed to evaluate the care plan interventions and instead continued to provide the same interventions that had not been effective in preventing the resident from falling in the past. The surveyor reviewed a Significant Change MDS of 4/12/13 completed by the IDC team upon the resident's return to the facility. The IDC team assessed the resident as requiring extensive assistance of 2 persons for transfers, bed mobility, and toilet use. The resident was assessed as requiring extensive assistance of 1 person for dressing, hygiene, and bathing. The team further assessed that the resident was not able to walk. vi.) The nurse documented in the investigation report on 4/8/13 at 3:35 p.m. that the resident was found on the floor between his/her bed and the wheelchair. According to the report the resident stated that s/he was sitting in the wheelchair and had his/her feet up on the bed when the chair moved and s/he slipped out of it onto the floor. The nurse noted in the investigation report that the resident was alert and confused. The nurse failed to investigate if the alarm was sounding or if there was adequate supervision to prevent the resident from falling as noted in the interventions to prevent falls documented in the care plan. The Post Fall Checklist included that the resident had poor safety awareness. vii.) According to a nurse's note of 6/15/13 at 6:10 a.m., the resident was found in his/her room beside his/her bed sitting on the floor. The bed alarm was noted to be disassembled and therefore did not sound an alarm. The nurse further noted that the resident had a history of [REDACTED]. The nurse documented in the report that the resident said "went to the toilet and socks went off and fell backward sitting on the floor." The resident did not complain of any pain at that time. At 2:30 p.m. the resident complained that his/her rib cage hurt on the left side. An x-ray done on 6/15/13 reported that the resident had a subacute fracture of the left 10th rib. The fall investigation report failed to evaluate the effectiveness of a bed alarm in preventing falls in light of the fact that the resident could disassemble the alarm and did so repeatedly. The investigation report failed to evaluate the facts documented in the report that the resident needed to use the bathroom at this time, and failed to determine if adequate supervision had been provided to escort the resident to the bathroom. On 7/12/13 at 9:55 a.m., the surveyor asked the Unit Manager/Registered Nurse (UMRN) if it was safe for the resident to be left alone. The UMRN told the surveyor that the resident had a mind of his/her own and did whatever s/he wanted to. The UMRN did not indicate that the resident required supervision. On 7/12/13 at 11:10 a.m. the surveyor interviewed the resident's Certified Nursing Assistant (CNA). The CNA said that the resident cannot walk, but can stand and pivot but only with assistance in order to transfer. The CNA also said that the resident cannot propel him/herself in the wheelchair. The resident was total care and did not do anything for him/herself . The CNA also said that she had only worked with the resident for a couple of months and did not know what his/her behavior was before s/he sustained the hip fracture. On 7/12/13 at 12:10 p.m. the surveyor interviewed the DON. The DON said that she was aware that the OT recommended that the resident needed supervision and that the resident was on Restorative Nursing. The DON and OT provided the surveyor with a Rehabilitation and Restorative Nursing Program Training Participant Verification. The form dated 2/15/13 indicated that the resident would transfer and stand with assistance and needed occasional contact guard assistance due to poor balance and forgetfulness of safety precautions. The DON was unable to provide the surveyor with any documentation that the resident received Restorative Nursing. The facility failed to provide proper supervision for Resident #12 even after it was recommended by therapy. Care plan interventions were not followed and/or were not evaluated to determine if the interventions the IDC team had in place were effective in preventing the resident from falling or if further interventions in the plan of care were necessary to protect the resident from injury. The resident continued to have falls which resulted in a fracture and a decline in activities of daily living (extensive assistance of one staff.) 2. The surveyor toured the facility with the unit nurse on 7/8/13 at approximately 10:45 a.m. The nurse told the surveyor that Resident #13 had Parkinson's disease, Dementia, and a history of falls. The nurse also stated that the resident was confused and recently fell , bumped his/her forehead, went to the Emergency Department (ED) and returned to the facility. On 7/11/2013, at 10 a.m. the surveyor observed Resident #13 asleep in bed. The resident slept on a low bed, with a floor mat to the right side of the bed. The left side of the bed was against the wall. On 7/12/2013 at 3:10 p.m. the surveyor observed the resident sitting in his/her wheelchair with a seat belt on. The surveyor asked the nurse if the resident could release his/her seat belt on command. Although the nurse asked the resident several times to release the seat belt, the resident could not open the seat belt. The resident asked the nurse "where ' s the screwdriver?" Resident #13 continued to play with the seatbelt until the seat belt accidentally opened. On 7/11/2013, at 10:30 a.m., the surveyor reviewed Resident #13's medical record. The resident was admitted on [DATE]. The resident sustained [REDACTED]. The IDC team assessed Resident #13's cognitive level utilizing the MDS quarterly assessment dated [DATE] and the Brief Interview for Mental Status (BIMS). The resident scored 5 out of 15 which indicated that the resident was cognitively impaired. The resident required extensive assistance of two people for assistance with activities of daily living (ADL) including assistance with toileting. On 7/11/13 at 2:00 p.m. the surveyor reviewed the resident's 5 fall investigation reports: i.) On 10/5/2012 at 10:20 a.m. the resident attempted to walk from the toilet and fell on the bathroom floor. The nurse documented that Resident #13 hit his/her head. The resident went to the hospital. No injury was identified and the resident returned to the facility. The intervention to prevent recurrence of falls was to have staff present at all times when the resident used the toilet. The facility failed to determine how the resident got into the bathroom, since the IDC team documented in the Admission MDS dated [DATE] that the resident required extensive assistance of one staff member to ambulate. The IDC team documented in the care plan on 9/27/12 an intervention to prevent falls was to use a bed alarm and attach a tab alarm to the resident's wheelchair. The nurse did not report in the fall investigation report whether or not the alarm sounded in order to determine if this was an effective intervention to prevent further falls for Resident #13 who had a history of [REDACTED]. ii.) On 10/6/2012 at 8:15 p.m., staff responded when the resident's chair alarm went off and found the resident sitting on the floor in the hallway in front of the wheelchair. The nurse documented in the investigation report that the resident did not recall what happened. On 10/7/12 the IDC team added an intervention to the care plan to prevent recurrence of falls that the resident was to use a self release seat belt when the resident sat in the wheelchair. iii.) On 1/12/13 at 11:15 p.m. a certified nursing assistant found the resident sitting on the bedside matt. The resident's bed alarm box was not attached to the bed alarm pad and therefore no sound went off to alert nursing staff members. The intervention was to educate the CNA to report missing alarm boxes to nurses. No apparent injuries were reported. iv.) On 1/19/13 at 9:15 p.m. the nurse documented in the investigation report that the resident was confused and disoriented and sat in a wheelchair in the hallway. The nurse documented in the Progress Note that the resident kept standing up and releasing his/her belt alarm. The staff responded to an alarm and found that the resident slid from the wheelchair and sat on the floor. The intervention was to place the resident by the nurse's station for close observation when the resident was not in bed. The facility failed to evaluate the effectiveness or ineffectiveness of the seat belt and alarm if the belt alarm failed to prevent the resident from falling. The facility failed to determine why the staff did not provide increased supervision when the resident was repeatedly observed releasing the seat belt and trying to stand up from the wheelchair prior to the resident falling. v.) On 6/30/13, the nurse documented in the investigation report that the staff found the resident in the hallway on the floor with a right forehead abrasion. The nurse documented that the resident was confused, that the fall occurred at 6:30 p.m. and reported that the resident's seatbelt was broken. The facility failed to identify that for 4 of the 5 falls the resident fell on the 3-11 shift in order to determine if sufficient supervision was provided to prevent falls. NJAC:8: 39-27.1 (a)