Every finding on record at Laurel Brook Rehabilitation and Healthcare Center

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 2 of 4 nursing unit pantries designated for resident food, and was evidenced by the following:On 1/14/26 at 9:56 AM, the surveyor interviewed the Food Service Director (FSD) who explained the procedures for the dietary staff which included:-Staff must wash their hands at the designated handwashing sink.-Dented or compromised canned goods must be stored in a designated dented can area to be disposed of for credit.-Dishware, utensils, and equipment must be air dried and not wet nested.-Food kept in the nursing unit pantry refrigerators must be labeled, dated, and discarded after three days. On 1/14/26 at 10:23 AM, the surveyor, accompanied by the FSD, observed the following in the kitchen: At the designated handwashing sink: 1.When the surveyor turned the hot water handle, the water that came out of the faucet was not hot. At that time, the FSD let the water run for one minute and checked the temperature. The temperature on the FSD's thermometer read 83 F (degrees Fahrenheit). The FSD then stated that the handwashing sink's hot water should be 105 F. The surveyor inspected the ice machine: 2. Inside of the ice machine, there was residue along the white drip ledge. At that time, the FSD donned a glove and was able to wipe the residue off with his gloved finger. The FSD then stated the ice machine was cleaned monthly and that it should be cleaned due to the residue. In the dry storage area: 3. There was a 63.4-ounce can of sliced potatoes that was dented and stored in the area for cans in rotation. The FSD removed the dented can and stated it should have been placed in the dented can area because it could be contaminated. In the dish drying area, there were: 4. Six 2-inch hotel pans that were wet nested.5. Three 4-inch hotel pans that were wet nested.6. Two 6-inch hotel pans that were wet nested. At that time, the FSD removed the wet nested items to be re-washed. On 1/16/26 at 9:52 AM, the surveyor, accompanied by the FSD, observed the following in the refrigerator designated for resident food in the [NAME] Unit pantry: One half pint of reduced fat milk that was dated 12/29 and two that were dated 1/6.One gallon of whole milk that had a best by date of 12/24.Two single-serve containers of pudding prepared by the facility's dietary staff dated 1/3.One previously frozen factory sealed peanut butter and jelly sandwich which was completed thawed without any label to indicate when the sandwich had been placed in the refrigerator. The packaging on the sandwich included Thaw 30-60 minutes. Eat within 8-10 hours.One opened 46-ounce container of thickened cranberry juice that was not labeled with an opened date. The packaging on the juice included use within 10 days of opening. At that time, the FSD removed the expired items from the refrigerator to be discarded and stated the dietary staff was responsible for maintaining the nursing unit pantry refrigerators and that they should check for expired food. On 1/16/26 at 10:07 AM, the surveyor, accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM) #2, observed the following in the refrigerator designated for resident food in the North 1 Unit pantry: One hard-boiled egg in a sandwich bag that was not labeled or dated.One sandwich wrapped in aluminum foil that was not labeled or dated.One opened 46-ounce container of nectar thickened liquids that was not labeled with an opened date. The packaging on the container included, use within 10 days of opening.One Styrofoam food container that was labeled with a resident's name and the date 1/12. At that time, LPN/UM #2 removed the expired items from the refrigerator to be discarded and stated leftover food was only good for 48 hours. On 1/21/26 at 10:21 AM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the above concerns. The LNHA stated the following:-In regard to the handwashing sink, maintenance needed to install a new mixing valve to correct the water temperature.-In regard to the ice machine, it was cleaned monthly, and any visible residue should be rectified immediately.-In regard to dented cans, they should be removed out of rotation and put in a separate area designated for dented cans.-In regard to wet nesting, dishware and equipment should be dried thoroughly before stacked.-In regard to the pantry refrigerators, all items should be labeled and dated, and any leftover food should be thrown away after three days. A review of the facility's Handwashing/Hand Hygiene policy, dated October 2023, did not include the required hot water temperature for the designated handwashing sink in the facility's kitchen. A review of the facility's Cleaning Instructions: Ice Machine and Equipment policy, undated, included, Ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. A review of the facility's Dented Cans Procedure policy, undated, included, During delivery, inspect cans for dents, bulges, and dings by visually inspecting and placing hand around the can while rotating all the way around. Discard into waste area or place into dented can area. A review of the facility's Sanitization policy, dated November 2022, included, Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. The facility's policy did not include how to dry items washed in the dishwashing machine. A review of the facility's Foods Brought by Family/Visitors policy, undated, included, Food brought in by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. The policy further included, The nursing staff will discard perishable foods on or before the 'use by' date. A review of the facility's Floor Stock policy, undated, included, The food and nutrition services staff will:. Rotate stock and remove outdated items. NJAC 8:39-17.2(g)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist were acted upon in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident #17) reviewed for unnecessary medications and was evidenced by the following:On 1/15/26, the surveyor observed Resident #17 sitting in the dining room eating lunch. The surveyor reviewed the medical record for Resident #17. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, vascular dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/10/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the individual comprehensive care plan (ICCP), dated 11/13/23, included the resident was at risk for adverse reaction related to polypharmacy. Interventions included: review Consultant Pharmacist recommendations and follow-up as indicated. A review of the Order Summary Report, as of 1/21/26, included the following physician's orders:-Colace 100 milligrams (mg) Give two capsules by mouth one time a day for constipation with a start date of 2/16/24.-Senna-S 8.6-50 mg Give two tablets by mouth at bedtime for constipation with a start date of 9/9/24. A review of the Consultant Pharmacist (CP) Medication Regimen Review (MRR) Recommendations to Prescriber revealed the following:-On 8/24/25, the CP recommended to evaluate the duplicate therapy of Colace and Senna-S and discontinue one order if appropriate. The provider wrote AGREE and signed the recommendation on 9/10/25.-On 10/26/25, the CP recommended to evaluate a possible duplicate therapy of Colace and Senna-S and consider discontinuing one of them. The provider checked off the box Agree and signed the recommendation on 11/10/25. A review of the Medication Administration Record (MAR) for January 2026 included the active orders for the Colace and Senna-S and revealed that both medications were still being administered daily. On 1/21/26 at 9:48 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated the CP came to the facility monthly and made recommendations. The RN further stated that after recommendations were received, the provider was notified and would address the recommendations and document in their physician visit note. The RN explained that it was important to follow the CP's recommendations to prevent harm to the resident. On 1/21/26 at 9:56 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the CP came to the facility at least once a month and made recommendations. The LPN/UM further stated that after recommendations were received, the provider had 72 hours to address the recommendations and document their response in their note and the physician's orders. The LPN/UM explained that it was important to follow the CP's recommendations to prevent medication mistakes. On 1/21/26 at 10:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated the CP came to the facility monthly and as needed. The DON further stated that the physicians reviewed the CP recommendations and documented their response on the recommendation forms. The DON added that if the physician agreed with the recommendation, they would change the physician's order within 48 hours. The DON explained that it was important to follow the CP's recommendations for resident safety. At that time, the surveyor informed the DON of the above concerns, and the DON stated if the physician agreed with the CP's recommendation, the order should have been corrected. A review of the facility's Medication Regimen Reviews policy, revised July 2025, included the following: Upon receiving the MRR, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. Irregularities that do not represent a risk to a person's life, health, or safety will be addressed within 30 days of receiving the MRR from the consultant pharmacist. NJAC 8:39-29.3

Based on interview, record review, and review of facility documents, it was determined that the facility failed to consistently follow medication hold parameters according to the physician's order and Consultant Pharmacist's recommendations. This deficient practice was identified for 1 of 5 residents (Resident #17) reviewed for unnecessary medications and was evidenced by the following:On 1/15/26, the surveyor observed Resident #17 sitting in the dining room eating lunch. The surveyor reviewed the medical record for Resident #17. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, vascular dementia and hypertension (high blood pressure). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/10/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the individual comprehensive care plan (ICCP), dated 11/1/24, included the resident had hypertension related to lifestyle. Interventions included: Give anti-hypertensive medications as ordered and obtain blood pressure readings as ordered. A review of the Order Summary Report, as of 1/21/26, included the following physician's order:Hydralazine 50 milligrams (mg) Give one tablet by mouth three times a day related to essential hypertension, hold for SBP (systolic blood pressure) less than 130, with a start date of 7/3/25. A review of the Consultant Pharmacist (CP)'s Nursing Recommendations revealed the following:-On 9/17/25, the CP documented that hydralazine was administered outside of the hold parameters on 9/5/25 and 9/13/25 and to follow up with nursing if appropriate. Under the comments, the facility responded that nurses were provided one on one education, and the physician was made aware.-On 12/18/25, the CP documented that hydralazine was administered outside of the hold parameters on multiple days and to follow up with nursing if appropriate. Under the comments, the facility responded that an in-service was completed, and the physician was made aware. A review of the Staff In-Service & Education, dated 12/23/25, revealed the nursing staff was in-serviced on Medications with parameters should be given as ordered. Vitals outside of parameters should be documented. Notify MD [medical doctor] of medications given outside. A review of the Medication Administration Record (MAR) for December 2025 and January 2026 included the above hydralazine order was documented as administered outside of the hold parameters on the following dates after the nurses received in-servicing:On 12/26/25 at 5:00 PM with a SBP of 127On 12/27/25 at 9:00 AM with a SBP of 123On 12/29/25 at 5:00 PM with a SBP of 105On 1/15/26 at 9:00 AM with a SBP of 126On 1/16/26 at 9:00 AM with a SBP of 118On 1/16/26 at 1:00 PM with a SBP of 118On 1/18/26 at 9:00 AM with a SBP of 124 On 1/21/26 at 9:48 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated if an anti-hypertensive medication had a hold parameter, the nurse should check the resident's blood pressure and if it was outside of the parameter, the nurse should hold the medication. The RN further stated it was important to follow blood pressure parameters to prevent the resident from bottoming out. On 1/21/26 at 9:56 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated if an anti-hypertensive medication had a hold parameter, the nurse should check the resident's blood pressure before giving the medication and hold the medication if the blood pressure was outside of the parameters. The LPN/UM further stated certain nurses received on the spot in-servicing on following parameters in September 2025 and then all nurses were in-serviced on following parameters in December 2025 due to the CP's recommendations after medications were still being administered outside of the hold parameters. On 1/21/26 at 10:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated if an anti-hypertensive medication had a hold parameter, the nurse should assess the resident's blood pressure prior to administration. The DON added that if the medication was held due to parameters, the nurse would code it as held on the MAR. The DON explained it was important to follow blood pressure parameters to prevent a crisis and prevent the resident from bottoming out. At that time, the surveyor informed the DON of the above concerns and the DON stated that the nurses should have followed the hold parameters for the hydralazine. A review of the facility's Administering Medications policy, revised April 2019, included, When indicated, validate physician ordered parameter prior to medication administration. NJAC 8:39-27.1(a)

Complaint # 2671178Based on observation, interview, and review of facility documentation it was determined that the facility failed to follow the wound care consultant's treatment recommendations for a resident with pressure ulcers (skin damage caused by pressure). This deficient practice was identified for 1 of 2 residents (Resident # 6) reviewed for pressure ulcers. On 1/14/26 at 10:40 AM, during the initial tour of the facility, Resident #6 was observed in a reclining chair in the dayroom with eyes closed. On 1/15/26 at 11:15 AM, the surveyor entered Resident #6's room and noted a malodorous odor. The surveyor asked the nurse caring for the resident if the resident had any wounds. The nurse stated the resident had multiple wounds and that wound care was completed on the 3:00 PM-11:00 PM shift. A review of the admission Record, an admission summary, revealed Resident #6 had diagnoses which included, but were not limited to, quadriplegia (cannot move arms or legs), kidney failure, depression, and schizophrenia (a condition that can make it hard to tell what is real). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/16/25, included that Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Further review revealed that the resident had one stage 3 pressure ulcer (a deep sore where the skin is broken and the tissue underneath is damaged), and two stage 4 pressure ulcers (severe sores that extend down to the muscle or bone). A review of Resident #6's wound care consultant visit note dated 1/6/26 showed that Resident #6 had multiple wounds. The sacral wound was a stage 4 pressure ulcer that measured 10 centimeters (cm) x 11 cm x 2 cm. The right posterior thigh wound was also a stage 4 pressure ulcer that measured 9 cm x 6 cm x 2 cm. The wound consultant recommended packing both wounds with Dakins solution (a liquid used to clean wounds and kill germs) and covering them with a superabsorbent dressing (a bandage that soaks up a lot of fluid). On 1/15/26 at 12:10 PM, the surveyor reviewed the physician orders for Resident #6. The wound care orders for both the sacral wound and the right posterior thigh wound were to cleanse with Vashe solution (a liquid solution, oxygen-based cleaner used to kill germs and helps remove dead tissue), apply Vashe-moistened gauze, and cover with a superabsorbent dressing. These orders were dated 12/4/25 and remained active. Further review revealed the wound care consultant's recommendations dated 1/6/26 and 1/13/26 were not implemented and physician orders were not updated to reflect those recommendations. On 1/16/26 at 9:20 AM, the surveyor reviewed the Treatment Administration Record (TAR) for January 2026. The TAR showed the resident continued to receive Vashe wound treatments to the sacral wound and right posterior thigh every shift from 1/1/26 through 1/14/26. On 1/20/26 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the Central Unit regarding wound care consultants and their recommendations. The LPN stated that the Unit Manager rounds with the wound care consultant and that pictures were taken during wound rounds. The Unit Manager then received the recommendations, and either the Unit Manager or the resident's nurse would contact the physician. According to the LPN, the physician always agreed with the recommendations, and the orders were then updated in the computer. The surveyor and the LPN then reviewed the resident's wound care consultant recommendations from 1/6/26 and 1/13/26, which showed a recommendation to use Dakins solution on both wounds. In the LPN's presence, the surveyor reviewed the physician's orders on the Treatment Administration Record (TAR) and found that the treatments had not been updated to reflect the wound care consultant's recommendations. When asked if the recommendations were missed, the LPN replied, Yes. On 1/20/26 at 10:52 AM, the surveyor reviewed the resident's individualized comprehensive care plan (ICCP), initiated 7/28/25, which identified the resident as having pressure ulcers related to immobility. Interventions included administering treatments as ordered and monitoring for effectiveness.On 1/21/26 at 10:33 AM, the surveyor interviewed the Director of Nursing (DON) regarding the wound care consultant process. The DON stated there was a lack of consistency when she arrived at the facility. When asked what should occur following wound care consultant recommendations, the DON stated, They need to be followed. Review of the active physician orders with the DON confirmed the orders were not updated following the wound consultant's recommendations. On 1/21/26 at 10:00 AM, the surveyor reviewed the facility's policy titled, Wound Meeting and Wound Rounds dated February 2022. The policy did not address the process for implementing wound consultant recommendations. NJAC-8:39 27.1 (a)

Based on interviews, medical record reviews, and review of other pertinent facility documents, it was determined that the facility failed to conduct a thorough investigation for an allegation of verbal abuse. This deficient practice was identified for 1 of 9 residents reviewed for abuse (Resident #2), and was evidenced by the following:A review of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) dated 8/01/24, included an allegation of rough handling of Resident #2.According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; unspecified sequelae of cerebral infarction (long-term, residual problems after a past stroke), acute embolism and thrombosis (occurs when a clot (or other foreign material) breaks free and travels through the bloodstream, blocking a vessel elsewhere), gangrene (the death of body tissue that occurs when blood supply is interrupted) and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing).A review of the Minimum Data Set (MDS), an assessment tool dated 7/21/24, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated Resident #2's cognition was moderately impaired.A review of the Progress Notes (PNs) written by the Director of Social Worker, revealed that a care conference via telephone was set up for 8/02/24 with Resident #2's Representative (RR). A second PNs written by the Director of Nursing (DON #1), revealed that a care conference was conducted on 8/02/24, related to concerns the RR had regarding Resident #2's care.A review of the FRE packet that the facility provided to the surveyor included a piece of paper, signed by the Unit Manager of Resident #2's unit regarding the incident on 7/31/24. It indicated that a care conference had occurred on 8/02/24. This paper did not include a date that it had been created, and it also was not included in the original FRE paperwork submitted to the NJDOH.A review of the grievances for Resident #2 revealed that a grievance had been filed 8/02/24, and under the grievance details, it indicated, during care conference [RR] expressed concerns of nursing care and how staff was rude during room transfer.On 9/18/25 at 10:57 A.M., the surveyor reviewed with DON #2 and the Licensed Nursing Home Administrator (LNHA) that the FRE indicated that the RR notified the facility of alleged verbal abuse on 8/02/25, and informed them that no evidence was provided that the allegation was investigated.On 9/18/25 at 12:22 P.M., the surveyor conducted an interview with DON #2 and the LNHA together. The surveyor requested DON #2 to define abuse, and she stated that abuse could by physical, mental, or anything related to misappropriation.On 9/23/25 at 10:36 A.M., the surveyor conducted a telephone interview DON #1, the previous DON. When asked if he recollected the FRE and Resident #2, he stated that he did but was unable to recall the exact time frame. DON #1 further stated that standard procedure for the facility was to file a report to the NJDOH and then to conduct a facility investigation that would either substantiate or unsubstantiate an allegation that was brought forward.On 9/23/25 at 11:57 A.M., the surveyor interviewed DON #2 and the LNHA together. DON #2 was questioned regarding the grievance from 8/02/24, that stated that the Certified Nursing Assistant (CNA) was rude to Resident #2. DON #2 stated that any time a resident reported that they were uncomfortable regarding a verbal communication, we (the facility) would investigate that. At that time, the surveyor requested an investigation regarding the grievance from 8/02/24. The facility stated they did not have an investigation for this grievance.When DON #2, was questioned why an investigation was not done regarding the CNA's alleged rudeness by RR, she stated she could not attest to that as both she and the LNHA were not working at the facility at the time.A review of the facility's policy titled Grievance and Complaint Procedure dated January 2022, included the following information under Policy Interpretation and Implementation:6. Upon receipt of a grievance or complaint, the facility administrator or designee will review and investigate the allegation and compile documentation of such findings within a reasonable timeframe of receiving the grievance/complaint.7.The administrator or designee will coordinate actions with the appropriate agencies, depending on the nature of the grievance. All alleged cases of resident abuse, neglect, and financial exploitation will be reported and investigated in accordance with facility policy and state law.A review of the facility's policy titled Accidents and Incidents-Investigating and Reporting last revised January 2017, included the following information under Policy Interpretation and Implementation:1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on the form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g./ bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts of the accident or incident.NJAC 8:39-4.1(a)5

Complaint #: 2614619 Based on interviews, record review and review of pertinent facility documents 09/18/2025 and 09/23/2025, it was determined that the facility failed to ensure a resident was protected from verbal and physical abuse on 12/18/24 when a house keeping staff was observed yelling and kicking a resident (Resident #4). The facility also failed to follow its policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Resident. This deficient practice was identified for 1 of 9 residents and was evidenced as follows:According to the admission Record (AR), Resident #4 was admitted to the facility with diagnoses that include but not limited to: Unspecified Dementia (loss of cognitive function, thinking), Depression (feeling of severe despondency and dejection), and History of Falling. According to the Resident #4's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 07/04/2025, under Section C-Cognitive Patterns showed that the Resident had a Brief Interview for Mental Status (BIMS) Score of 7 out of 15 indicating Resident's cognition was severely impaired and totally dependent on staff for activities of daily living. A review of the residents Progress Notes (PNs) dated 12/18/2025 revealed: 'I spoke with [resident's name] and asked the resident if I could look at their skin and the resident agreed stating Sure. I assisted the resident to their bathroom and inspected their skin. The resident skin was clean, dry and intact except for the existing self-inflicted discoloration to right eye. The resident was cooperative and pleasant during and after. No s/s (sign and symptom) of anguish observed. The resident denied having pain when asked. A review of the facility submitted document to the New Jersey Department of Health (NJDOH), a facility reportable event (FRE), with attached facility's Summary and Conclusion, dated: December 18, 2024, Event: Allegation of Abuse. Under Narrative: It was witnessed by an employee of the activity department that a housekeeping aid was kicking [resident's name] in the side to get them to get up and go back to their room. Under Facility Investigation and Conclusion, With the allegation brought to our attention, staff witness statements/interview, and [housekeeping aid's name] phone interview the facility is not able to corroborate the allegation of abuse due to [housekeeping aid name] denying any interaction with the resident, the resident not having any recall of the event, no additional witnesses to the event and absence of resident injury as a result of the witnessed allegation. It was however concluded based on facility investigation, that the facility is not comfortable with [housekeeping aid name] guarded interaction and failure to engage in the facility investigation. As a result, the facility is not comfortable with furthering the employment relationship with [housekeeping aid name] and have ended his employment relationship with [facility's name] effective 12/30/2024. On 09/18/2025 at 12:02 P.M., the surveyor interviewed the Activity staff who stated on 12/18/2024, she observed Resident #4 laying on the floor by their doorway. She stated the housekeeping staff was on the unit at the time and she observed him yelling and telling the resident to get back in their room and kicking Resident #4. When asked by the surveyor which part of the resident's body did the housekeeping staff kicked, she said, I don't recall specifically where, but I remembered that he was kicking the resident and yelling. I told him he cannot do that, I told him We are not allowed to yell or kick the residents. I told the housekeeping staff to stop, and he did. I immediately informed my supervisor and the Administrator. She further stated, the housekeeping staff was not seen in the building after the incident occurred that day. On 09/18/2025 at 12:24 P.M., during and interview with the Licensed Nursing Home Administrator (LNHA) in the presence of the Acting Director of Nursing (ADON), the LNHA said the activity aid observed the housekeeping staff kicking and using his foot to slide Resident #4 into their room as the resident was sitting in the hallway. The LNHA stated the activity aid immediately stopped the housekeeping staff and reported the incident to her supervisor and they informed me of the incident. She said, the housekeeping staff had left for the day, he was immediately notified via a phone call about the abuse allegation. The LNHA further stated, yes it was substantiated that abuse occurred after our investigation. When asked if the facility's policy was followed, the LHNA said; no, the housekeeping staff did not follow the facility's policy on abuse. The expectation is for all staff to follow the facility's Abuse Policy. On 09/18/2025 at 1:00 P.M., the surveyor attempted to interview Resident #4 but was unable to conduct an in-person interview due to the resident's severe cognitive impairment. A review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with Revision date of April 2021, under Policy Statement reveals: Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Under Policy Interpretation and Implementation reveals: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff; . NJAC 8:39-4.1 a(5)

Complaint #: NJ179543 Based on observation, interview, and review of pertinent facility documents on 1/16/2025, it was determined that the facility failed to follow appropriate hand hygiene during an observation of a resident's wound treatment for 1 of 3 residents ( Resident #1). This deficient practice has the potential spread of infection in accordance wiht the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice and facility policy as evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. On 1/16/2025 at 9:43 A.M., during a unit tour with the Unit Manager/Licensed Practical Nurse (UM/LPN), the surveyor observed Resident #1 in their wheelchair with a pressure-relieving device who stated he/she had a wound on their sacrum. The surveyor reviewed the medical record for Resident #1. A review of the Resident's Face Sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but not limited to: Diabetes Mellitus (condition in which the body has trouble controlling sugar), Anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), Hypertension (a condition in which the force of the blood against the artery walls is too high), and Wound to the Sacrum (lower portion of the spine near the pelvis). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/6/24, revealed a score of 15 out of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident was admitted with a sacral wound. A review of the Physician's Orders dated 12/24/24, indicated to cleanse the sacral wound with a wound cleansing solution; apply calcium alginate (used to aid in wound absorption and healing); and cover with border foam dressing daily. On 1/16/2025 at 11:12 A.M., the surveyor observed the Licensed Practical Nurse (LPN) in the presence of the UM/LPN perform a wound care treatment on Resident #1 and observed the following: The UM/LPN entered the resident's room used an alcohol-based hand rub (ABHR), placed gloves on and sanitized the resident's bedside table with Super Sani-cloth wipes. After allowing the bedside table to air dry for approximately 60 seconds, he placed the wound treatment supplies on the resident's bedside table. The LPN than placed clean gloves on without washing her hands with soap and water, she dated, and initial the foam dressing. Resident #1 was able to stand up from their wheelchair independently for wound care. The LPN remove the resident's soiled dressing, without removing her contaminated gloves and washing her hands with soap and water, she cleaned the wound with her contaminated gloves. The LPN attempted to apply the dressing when the UM/LPN said, change your gloves. The LPN than removed the contaminated gloves, without washing her hand with soap and water, she applied a clean pair of gloves, and applied the dressing to the resident's sacral wound. At 11:26 A.M., the surveyor attempted to interview the LPN who at this time refused to be interviewed. In the presence of the LPN, the UM/LPN confirmed the surveyor's observation that the LPN did not perform hand hygiene prior to and during Resident #1's wound care. At 11:35 A.M., during an interview with the UM/LPN in the presence of the Director of Nursing (DON), he confirmed the LPN did not perform hand hygiene prior to and during Resident #1's wound care treatment. The UM/LPN further stated, the LPN did not follow the facility's policy for wound care and infection control. During the same interview, the DON stated the importance of performing hand hygiene during wound care is to prevent cross contamination which has a potential for infection. At 12:16 P.M., during an interview with the Infection Preventionist (IP) she stated, her expectation would be for the LPN to perform hand hygiene before and during a wound care treatment, remove soiled gloves after removing a soiled dressing and apply clean gloves to provide wound care and to follow the facility's wound care policy. The IP stated, if these steps are not followed, the wound could become infected, and the patient could become septic. A review of the facility's Wound Care policy dated revised October 2010, included the purpose of this procedure is to provide guidelines for the care of wounds to promote healing .steps in the procedure .2. wash and dry your hands thoroughly. 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. A review of the facility's Handwashing/Hand Hygiene policy dated August 2021, under Policy Statement reveals: this facility considers hand hygiene the primary means to prevent the spread of infections. Under Policy Interpretation and Implementation revealed: 6. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressing, gauze pads, etc.; k. After handling used dressing, contaminated equipment, etc NJAC 8:39-19.4(a)

Complaint#: NJ00176792 Based on interviews, medical record review, and review of other pertinent facility documents on 11/19/2024, it was determined that the facility failed to notify a resident's physician of unavailable medication, follow facility policies regarding unavailable medication, and charting and documentation. This deficient practice was identified for 1 of 1 resident (Resident # 3) reviewed for physician notification. This deficient practice was evidence by the following: According to the Admission Record (AR), Resident #3 was admitted to facility with diagnoses which included but were not limited to aftercare following joint replacement, unspecified atrial fibrillation (an irregular, rapid heart rhythm that can lead to blood clots in the heart and increase the risk of stroke), and anxiety. A review of the Resident #3's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/15/2024, reflected the resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #3's Order Summary Report revealed medication orders, with an order date of 05/12/2024, that included but were not limited to the following: Cartia XT Oral Capsule Extended Release 24 Hour (Diltiazem HCl Coated Beads) Give 90 mg by mouth two times a day for Hypertension with a start date of 05/12/2024. Azathioprine Oral Tablet 75 MG (Azathioprine) Give 1 tablet by mouth in the morning for Ulcerative colitis with a start date of 05/13/2024. Azelastine HCl Nasal Solution 137 MCG/SPRAY (Azelastine HCl) 1 spray in each nostril two times a day for nasal dryness with a start date of 05/13/2024. Sotalol HCl AF Oral Tablet 80 MG (Sotalol HCl (AFIB/AFL)) Give 1 tablet by mouth two times a day for arrythmia with a start date of 05/13/2024. A review of Resident #3's Medication Administration Record (MAR) revealed that the Chart Code 22 was entered on Resident #3's MAR for the following medication dose on 05/12/2024: Cartia XT Oral Capsule Extended Release 24 Hour, 90 milligrams (mg) at 9:00 PM. The Chart Code 22 was also entered on Resident #3's MAR for the following medications at 9:00 AM on 05/13/2024: Cartia XT Oral Capsule Extended Release 24 Hour, 90mg. Azathioprine Oral Tablet 75 mg. Azelastine HCl Nasal Solution 137 MCG/SPRAY. Sotalol HCl AF Oral Tablet 80 mg. Further review of the MAR revealed that the Chart Code 22 was used to indicate Drug/ Treatment Not Administered. An interview was conducted with the Director of Nursing (DON) on 11/18/2024 at 2:13 PM. The DON confirmed that the code 22 on the MAR indicated that a drug or treatment was not administered. An interview was conducted with a Registered Nurse (RN) on 11/18/2024 at 1:05 PM. The RN stated that if a resident's ordered medications did not arrive from the pharmacy timely, the nurse should have checked the facility's Pyxis (automated medication dispensing system) and then followed up with the pharmacy. The RN stated that if a nurse was not able to obtain a medication there should have been a note in the MAR. The note in the MAR should have indicated why a medication was not given and that a provider was notified. A review of Resident #3's Progress Notes (PN) on 11/18/2024 revealed Medication Administration Notes that read awaiting delivery or awaiting phx (pharmacy) for the unadministered doses of Cartia XT Oral Capsule Extended Release 24 Hour, 90 mg; Azathioprine Oral Tablet 75 mg; Azelastine HCl Nasal Solution 137 MCG/SPRAY; and Sotalol HCl AF Oral Tablet 80 mg. Further review of Resident #3's PN for 05/12/2024 and 05/13/2024 revealed no documentation of provider notification of unavailable or unadministered medications. During the interview conducted on 11/18/2024 at 2:13 PM, the DON stated that if a resident's medications were not available in the facility's Pyxis, the physician should have been notified. During a follow-up interview at 4:14 PM, the DON further stated that the resident's physician should have been notified of unavailable medications because an alternative medication may have been ordered. The DON stated that it was their expectation that physician notifications should have been documented. The DON stated that they were unable to find documentation that a physician was notified of Resident #3's unavailable medications. A review of the facility policy titled Unavailable Medication, adopted June, 2021, showed In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall . Contact the pharmacy regarding the unavailable medication. Attempt to obtain the medication from the facility's automated medication dispensing system .Notify the physician of the unavailable medication, explain the circumstances, report the date of expected availability, and provide the alternative medication(s) recommended by pharmacy . or . Obtain a hold order for the unavailable medication. A review of the facility policy titled Charting and Documentation, revised July 2017, showed The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy further showed Documentation of procedures and treatments will include care-specific details, including . notification of family, physician or other staff, if indicated. NJAC 8:39-29.2 (d)

Part A: Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure their smoking policy interventions were implemented to reduce hazard(s) and risk(s) for residents who smoked tobacco and to ensure resident safety. This deficient practice was identified for 1 of 7 residents reviewed for smoking (Resident #144). On 10/9/24 at 12:27 PM, the surveyor entered Resident #144's room and smelled a cigarette-like smoke scent. The resident was observed lying in bed with the fan on and the window open. At that time, the surveyor interviewed the resident who stated they were not allowed to smoke in their room, but they had to wait for hours for the staff to come into the room to assist them. The resident stated that the staff did not take them out to smoke, so they smoked tobacco in their room. During a follow-up interview with the surveyor on 10/9/24 at 2:19 PM, the resident pulled a lighter out of a red bag to show the surveyor and the resident ignited the flame. Resident #144 stated the facility did not review the smoking policy with them, and acknowledged the last time they smoked in their room was today (10/9/24) at 5:00 AM. During an interview on 10/9/23 at 2:16 PM, the Certified Nursing Assistant (CNA #1), stated that a few months ago she reported to the nurse that she observed the resident holding a lighter and smoking in their room. A review of Resident #144's incident reports revealed that the resident was observed smoking cigarettes in their room on 11/16/23, 1/26/24, and 2/9/24. Interventions included that the individualized comprehensive care plan (ICCP) was updated. The facility's failure to implement the smoking policy for safety to reduce hazard(s) and risk(s) for residents who smoked tobacco posed a likelihood of serious injury, harm, impairment, or death could occur to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 11/16/23, when Resident #144 was reported to have smoked tobacco in their room. The facility Administration was notified of the IJ on 10/9/24 at 5:13 PM. The facility submitted an acceptable Removal Plan (RP) on 10/10/24 at 9:51 AM. The survey team verified the implementation of the RP during the continuation of the on-site on 10/10/24. The evidence was as follows: A review of the facility's Smoking policy dated revised March 2024, included, 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances .11. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely and with available levels of support and supervision .13. Residents who have independent smoking privileges are permitted to keep cigarette, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. On 10/9/24 at 12:27 PM, the surveyor entered Resident #144's room and smelled a cigarette-like smoke scent. The resident was observed lying in bed with the fan on and the window open. At that time, the surveyor interviewed the resident who stated that they were not allowed to smoke in their room, but they had to wait for hours for the staff to come into the room to assist them. The resident stated that the staff did not take them out to smoke, so they smoked tobacco in their room. On 10/9/24 at 1:15 PM, the surveyor reviewed the medical record of Resident #144. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; paraplegia, muscle wasting, lack of coordination, major depressive disorder, and tobacco use. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/18/24, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated a fully intact cognition. A review of the ICCP included a focus area, dated 5/3/23, for smoking interventions that included: I understand that for my safety, the facility will store my nicotine products and my lighter. The ICCP was updated on 6/12/24, to include the intervention. I am able to smoke independently, follow facility policy, and store all smoking materials in my room. These interventions were added to the ICCP after the resident was discovered smoking in the facility three times. A review of the Full Quality Assurance (QA) Reports (incident report) for Resident #144 revealed the following: On 11/16/23 at 3:00 PM, the Licensed Practical Nurse (LPN) observed the resident smoking in their room. Actions taken included that the resident was re-educated on the smoking policy. On 1/26/24 at 11:00 AM, the resident was noted smoking and the resident admitted to smoking in their room. Actions taken included that the ICCP was updated, and a psychiatric consultation ordered. On 2/9/24 at 9:30 AM, the resident was noted smoking tobacco in their room. Actions taken included local police department was notified, and the resident was educated on safety concerns related to smoking in the room. On 3/12/24 at 12:00 PM, another resident suspected Resident #144 of smoking and called the local police. Actions taken included local police department came to the facility and the resident was re-educated on safety concerns and the smoking policy. On 4/18/24 at 11:00 AM, during rounds, a staff member smelled cigarette smoke coming from resident's room, and towels were observed covering the bottom of the floor. Actions taken included clinical staff were assigned to the unit; monitor for further behaviors; ICCP updated; routine safety checks; and the resident was educated. During an interview with the surveyor on 10/9/24 at 1:30 PM, the Director of Nursing (DON) stated that the resident was assessed as an independent smoker and was allowed to hold their cigarettes and lighter. When asked did the resident smoke in their room, the DON stated that the resident informed them that they had smoked in their room. The DON stated the facility had completed several incident reports, called the resident's representative, and they have called the local police because staff reported smelling smoke in the resident's room. During an interview with the surveyor on 10/9/24 at 2:08 PM, CNA #5 stated that she never observed the resident smoking in the facility, but the CNA had smelled tobacco smoke in the resident's room. CNA #5 stated that she often smelled smoke and reported it to the Nursing Supervisor. CNA #5 stated that certain residents were able to keep their smoking materials, but if a resident was a supervised smoker or an independent smoker who was caught smoking in the facility, then the smoking material was kept at the front desk, or the nurse kept it in the narcotic box. CNA #5 stated that the resident probably had smoking material in their possession, but she never saw the resident smoking, she just smelled smoke. CNA #5 stated that the resident was able to transfer themselves out of the bed onto the motorized wheelchair with a one person assist and took themselves outside. She stated that the resident sometimes refused to get out of bed. During an interview with the surveyor on 10/9/24 at 2:16 PM, CNA #1 stated that she was familiar with the resident's smoking habits and stated that she guessed the resident smoked cigarettes because she smelled it in the hallway. CNA #1 stated that visitors had also raised concerns regarding the smell of cigarette smoke in the hallway. When asked if she had ever witnessed the resident smoking in their room, CNA #1 nodded her head, yes. CNA #1 stated that a couple of months ago when she went into the resident's room, she saw the resident holding a lit cigarette in their hand. CNA #1 stated that she reported it to the nurse but could not recall which nurse she reported it to. CNA #1 stated that the staff reported that the resident smoked in their room, but nothing happened after the smoking was reported. She explained that the smoking material was supposed to be kept at the front desk, and when the resident was ready to go outside, staff provided the resident with the smoking materials. CNA #1 stated that the resident used to go outside, but now the resident just laid in the bed and smoked, even though the resident could go outside at any time. During a follow-up interview with the surveyor on 10/9/24 at 2:19 PM, Resident #144 stated that it took one and a half hours to get help just to see what I want. When asked if they smoked, the resident stated, yes, because my nerves get really bad and most of the time I wait until late night to smoke. At that time, the resident pulled a lighter out of a red bag to show the surveyor and ignited the flame. The resident stated that the facility called the local police department on them because they smelled smoke. The resident further stated that the facility did not go over a smoking policy with me and that they do not do anything. The resident stated in the past, the front desk kept their smoking materials, but staff was not getting them out of bed regularly, so they purchased another lighter. Resident #144 stated that the last time they smoked tobacco in the room was on 10/9/24 at 5:00 AM (that morning). The surveyor conducted a telephone interview on 10/16/24 at 8:48 AM, with the Medical Doctor (MD), who stated that he had a problem with Resident #144 smoking since they had been caring for the resident. The MD stated that the resident had been resistant to care and that the staff bend over backward. The MD stated that the facility had done everything to keep the lighter and cigarettes from the resident, and the facility was going to do better with the smoking residents and the other residents. An acceptable RP on 10/10/24, indicated the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including the resident was placed on one-to-one (1:1) supervision on 10/9/24 at 3:10 PM; the resident was re-educated on the facility's smoking policy and relinquished their smoking materials; a smoking evaluation was completed; the facility will conduct routine safety rounds in Resident #144's room; and the ICCP was updated. The survey team verified the implementation of the removal plan during the continuation of the on-site survey on 10/10/24. 37547 Part B. The facility further failed to: complete a safe smoking evaluation immediately upon the identification of a change in resident's smoking status. This deficient practice was identified for 1 of 7 residents (Resident #191) reviewed for smoking. This deficient practice was evidenced by the following: 2. ) On 10/9/24 at 1:44 PM, the surveyor attempted to meet with Resident #191 who was not in their room. Licensed Practical Nurse (LPN) #10 was present outside of the resident's room and stated that the resident was outside smoking. The surveyor went to the courtyard and observed Resident #191 seated at a table with another resident in the designated smoking area. When interviewed, the resident stated that they only smoked now and then. Resident #191 stated that they had matches and a pack of cigarettes and proceeded to show the surveyor the matches that were stored in a pencil case and a pack of cigarettes that were on the table in front of the resident. The resident stated that there was no smoking allowed inside of the facility. The resident stated that he/she was allowed to keep their smoking materials in their room. There was no smoking attendant in the courtyard at the time of the observation. A review of Resident #191's Admission Record (an admission summary), revealed that the resident was admitted to the facility with diagnosis which included but were not limited to; Fracture of one rib, left side, Fracture of unspecified part of neck of right femur (the bone of the thigh, articulating at the hip and the knee), and emphysema (a lung condition that causes shortness of breath). A review of Resident # 191's Comprehensive Minimum Data Set (MDS), an assessment tool, dated 08/27/24 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 13 out of 15, which indicated that the resident was fully cognitively intact. A review of Section J-Health Conditions indicated that the entry was coded as a 0 or No for Current Tobacco Use. A review of Resident #191's Care Plan failed to identify Resident #191 as a smoker. A review of Resident #191's Admission/Readmission Evaluation Packet dated 8/23/24 at 3:45 PM revealed that the resident Smoking Safety Evaluation and History of Smoking detailed that the resident did not currently smoke or vape. During an interview with the surveyor on 10/9/24 at 1:55 PM, LPN #10 stated that smoking assessments were completed upon admission. LPN #10 reviewed Resident #191's electronic health record (EHR) in the presence of the surveyor and stated that she did not see that a smoking evaluation was completed for the resident. LPN #10 stated that Resident #191 needed a smoking evaluation to see if he/she were safe to smoke. During a review of Resident #191's EHR the surveyor observed a Smoking Safety Evaluation that was completed on 10/9/24 at 2:19 PM after surveyor inquiry, which detailed, Does the resident currently smoke or Vape? Yes. Further review of the assessment revealed that the resident was safe to light their own cigarette, hold their own cigarette, and self extinguish or ash cigarette in an ashtray without adaptive equipment such as a smoking apron, cigarette holder,or flameless lighter. Further review of the assessment revealed that the resident was able to smoke independently, follow the facility policy, and safely secure all smoking materials in their room. On 10/10/24 at 10:29 AM, the surveyor observed Resident #191 seated in a chair at the bedside. When interviewed, the resident stated, A man told me yesterday that I am not allowed to have matches, so I threw the matches down the toilet. The resident stated that his/her friend had given the resident a lighter. The resident stated, I was told to follow the rules, with no matches. The resident further stated, I did not know that I could not use matches. LPN #10 was present at that time, and stated that residents were not permitted to borrow lighters. LPN #10 stated that if a resident was admitted as a non-smoker then the resident needed to be reassessed. During an interview with the surveyor on 10/10/24 at 10:45 AM, the Registered Nurse/Unit Manager (RN/UM) stated that upon admission to the facility nursing did a smoking assessment as part of the screening process. The RN/UM stated that upon admission to the facility Resident #191 was deemed to be a non-smoker and within the past day or two, was identified as a smoker. The RN/UM stated that she did not know who identified when the resident started smoking or when he/she was identified as a smoker. The RN/UM stated that it was brought to our attention that the resident was going outside and smoking. The RN/UM stated that the resident may only use a safety lighter (equipped with a child resistant mechanism) and matches were not permitted. The RN/UM stated that a smoking assessment was necessary to determine if a resident were safe to smoke. During an interview with the surveyor on 10/15/24 at 11:13 AM, the Director of Nursing (DON) stated that the smoking evaluation was part of the admission assessment. The DON stated that the purpose of a smoking assessment was to identify if the resident was a smoker, and to make sure that the resident had the dexterity to safely manage smoking materials. The DON stated, As part of the admission agreement, resident's are not supposed to have matches in their rooms, and are supposed to have lighters. The DON stated that when he spoke to Resident #191 the resident only had one match left that was already struck. The DON stated that the resident obtained lights from other residents in the courtyard. The DON stated that a smoking evaluation should have been completed when the nurse realized that the resident was smoking. The DON further stated, If it were not done, there was a potential safety hazard. A review of the facility policy, Smoking Policy-Residents dated revised October 2023 revealed the following: This facility has established and maintains safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking is only permitted in designated smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. .Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: Current level of tobacco consumption; method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); desire to quit smoking; and ability to smoke safety with or without supervision (per a completed Safe Smoking Evaluation). The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. .Resident's who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. Residents are not permitted to give smoking items to other residents . N.J.A.C 8:39-31.6(e)

Complaint #: NJ177765; NJ177069 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified on 5 of 5 resident units (East, West, Central, North 1, and North 2) and was evidenced by the following: 1.) During the initial tour of the facility on 10/8/24 at 11:31 AM of the East Unit, the surveyor observed the following: -room [ROOM NUMBER]-A: the air conditioner (AC) unit had unidentified black discolorations on the vent grill and the front of the AC unit had an accumulation of dust. During an interview with the surveyor on 10/15/24 at 4:14 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that housekeeping and maintenance should ensure the AC units were cleaned and remained dust free weekly. 41072 2.) During a tour on 10/9/24 at 8:34 AM of the North 2 Unit, the surveyor observed the following: -room [ROOM NUMBER]: dust on the front cover of the window AC unit -room [ROOM NUMBER]: the inside of the bathroom door had brown paint peeling off. -room [ROOM NUMBER]: dust on the front cover of the window AC unit -room [ROOM NUMBER]: the inside of the bathroom door had brown paint peeling off. -room [ROOM NUMBER]: dust on the front cover of the window air conditioner (AC) unit. -room [ROOM NUMBER]: dust on the front cover of the window AC unit -room [ROOM NUMBER]: dust on the front cover of the window AC unit, napkins stuffed into open area on the side of the Window AC unit to prevent outside air from coming into the room. -room [ROOM NUMBER]: observed an uncovered mattress propped against the wall and a cabinet with visible red colored spots on the mattress -room [ROOM NUMBER]: the inside of the bathroom door had brown paint peeling off. -room [ROOM NUMBER]: dust on the front cover of the window AC unit During an interviw with the surveyor on 10/15/24 at 2:36 PM, the Maintenance Director (MDR), in the presence of the survey team stated that he will check if any maintenance orders were placed for the peeling paint. The MDR did not bring any additional information regarding the paint. On 10/15/24 at 3:06 PM, the surveyor interviewed the Director of Housekeeping (DHK) and the Regional DHK (RDHK) in the presence of the survey team. The DHK stated that floor mats and mattresses should be cleaned. 40041 3). During the initial tour on 10/8/24 at 10:35 AM of the North 1 Unit, the surveyor observed the following: -Yellow tape on the hallway floor in multiple areas. -A strip of the flooring was partially raised off of the floor. On 10/9/24 at 2:19 PM, during a surveyor visit to room [ROOM NUMBER], a resident occupied room, the following was observed: -a hardened brown substance on the resident's floor. During an interview with the surveyor, the resident in room [ROOM NUMBER] stated, my room has not been cleaned in a couple weeks. On 10/10/24 at 12:33 PM, the surveyor returned to room [ROOM NUMBER] and the hardened brown substance was still on the resident's floor. An empty clear manufacture packaging, an empty carboard juice wrapping, and small debris were noted on the floor near the resident's bed. On 10/15/24 at 3:06 PM during an interview with the surveyor in the presence of the Director of Houskeeping (DHK) and the survey team, the Regional Director of Housekeeping (RDHK) stated that the resident rooms were cleaned daily which included, the tray tables, high touch areas, door knobs, furniture, and floors. When asked about the hardened substance stuck on the floor, the DHK replied, we usually spray, then we have scrappers for anything that is stuck to the floor. 37547 4.) During the initial tour on 10/8/24 from 10:55 AM to 1:11 PM of Central Unit, the surveyor observed the following: -room [ROOM NUMBER]-A: There was a hole in the ceiling that was covered with clear plastic surrounded by black electrical tape. There was a dried substance noted in the center of the plastic that covered the hole in the ceiling. A PTAC (packaged terminal air conditioner unit) had a visibly dented and damaged front cover, and a portable air conditioner unit that was vented out of the resident's window were both in the room. Resident #81 and his/her spouse were present and stated, the ceiling should not be that way, and it has been that way since around Christmas. They put the plastic up in the early part of the year. I would think it would have been fixed by now. The resident's spouse stated that he/she mentioned it to maintenance previously, who stated that they would come back and fix it. -Room: 15-B: A wall unit air conditioner had a thick coating of dust on the outside of the vent cover. During an interview with the surveyor on 10/9/24 at 12:20 PM, Certified Nursing Assistant (CNA) #8 stated that if she noted anything in need of repair she told the nurse and put a maintenance request into the system. CNA #8 further stated that she noticed the hole in the ceiling and saw the tape in room [ROOM NUMBER]-A and figured that it was being taken care of. During an interview with the surveyor on 10/9/24 at 12:25 PM, Licensed Practical Nurse (LPN) #9 stated that when she noted something in need of repair, she placed a maintenance call and they responded within thirty minutes. LPN #9 further stated, I think that they may have taken a vent out of room [ROOM NUMBER]-A. LPN #9 stated that she would follow-up with maintenance. During an interview with the surveyor on 10/9/24 at 12:32 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) #4 stated, I honestly did not notice the air conditioner units. It has to be cleaned. LPN/UM #4 stated that he would notify maintenance or housekeeping. During an interview with the surveyor on 10/9/24 at 12:35 PM, Resident #123 stated that he/she had not seen the air conditioner unit filter changed or cleaned since he/she was admitted to the facility. During a later interview with the surveyor on 10/9/24 at 1:07 PM, LPN/UM #4 stated that he did not see a hole in the ceiling in room [ROOM NUMBER]-A. He stated, It was not acceptable. They probably attempted to fix it, but had to see how to resolve it. LPN/UM #4 further stated, It was not acceptable for it to be like that since January. LPN/UM #4 stated that he would inform maintenance. During an interview with the surveyor on 10/10/24 at 11:24 AM, the Maintenance Director (MDR) stated that he had worked at the facility since 1997. He stated that he was not sure how long room [ROOM NUMBER]-A had been like that, but it was brought to his attention yesterday by the LPN/UM, and was being patched now. The MDR stated that we do weekly walk throughs. The MDR stated that he did not think that the plastic should have been there and the repairs should have been made immediately or ASAP. At 11:33 AM, the surveyor asked the MDR about the condition of the air conditioning unit in room [ROOM NUMBER]-B on Central Unit. The MDR stated that housekeeping was responsible to clean the outside of the air conditioning units and maintenance cleaned the filters. During an interview with the surveyor on 10/10/24 at 12:00 PM, Housekeeper (HK) #3 stated that she was responsible to dust the air conditioning units. HK #3 stated that her boss brought it to her attention today and the vent was wiped with an all purpose cleaner. HK #3 stated that it was important to clean the outside of the air conditioner vents because the resident's had to breathe air from it. The surveyor noted that there was still dust that remained on the air conditioner vent after it was reportedly cleaned. During an interview with the surveyor on 10/15/24 at 2:37 PM, the MDR stated when an AC unit went bad, they placed a portable window unit. When asked if the maintenance department did walking rounds for preventative maintenance he stated, We do more of a visual rounding, they take notes, and make repairs. The MDR described the maintenance notes as personal notes and stated that there was no official form that staff were required to turn in. During an interview with the surveyor on 10/15/24 at 3:07 PM in the presence of the survey team, the Director of Housekeeping (DHK) stated that air conditioner vents were supposed to be wiped daily and deep cleaned weekly. The DHK stated that she did not expect to see a thick coating of dust on the outside of the air-conditioning units. The DHK further stated that it could cause health issues in residents with respiratory problems. At that time, the surveyor showed the DHK photos of the air conditioner unit in room [ROOM NUMBER]-B, both before and after it was reportedly cleaned. The DHK stated, They can do better than that. 5.) During a tour of East Unit on 10/10/24 at 10:29 AM, the surveyor observed the following: -room [ROOM NUMBER]-A: The surveyor observed Resident #191 who was seated in a wheel chair directly beneath a patched area on the ceiling that had a white coating over it with a visible crack through the patched area that ran along the ceiling. Licensed Practical Nurse (LPN) #10 was present at the bedside and stated that she had not noticed the condition of the ceiling before. During an interview with the surveyor on 10/10/24 at 10:59 AM, the Registered Nurse/Unit Manager (RN/UM) and the surveyor went into room [ROOM NUMBER]-A together to see the condition of the ceiling. At that time, the RN/UM stated, Oh my God. When the surveyor asked her to clarify what she meant, she stated, I want to see if it were previously addressed. During an interview with the surveyor on 10/10/24 at 11:30 AM, the surveyor and the MDR went to room [ROOM NUMBER]-A to view the ceiling together. The MDR stated, I see buckling here and we have to immediately address it and get the resident out of the room. The Regional Director of Maintenance (RDM) was present and stated that the area looked like it was previously patched. The RDM stated, It was very concerning to me. We cannot let it go on. During an interview with the surveyor on 10/15/24 at 2:37 PM, the MDR stated that he was unsure of the cause of the ceiling damage in room [ROOM NUMBER]. 43308 6.) During the initial tour on 10/8/24 at 10:34 AM of the [NAME] Unit, the surveyor observed the following: In room [ROOM NUMBER]-B, the resident's intravenous (IV) pole (a stand that holds enteral feeding pumps - a device that delivers hydration and nutrition) had hardened, dried, spillage on it. The wheels of the IV pole had dust and debris on it. At 1:07 PM the surveyor observed the following in the [NAME] Unit: -In the hallway, there were three (3) geriatric chairs (geri-chair - used for those with mobility issues and have difficulty sitting upright) that had debris on the back of the chairs. One (1) of the geri-chairs had a tear on the right arm rest. -In the same hallway there was a linen cart with a black net covering that had white spatter on it and was torn. -In the activities/dining room, there was an air conditioning (AC) unit in the back of the room that had a brown color noted on the vents with visible debris. There was no cover over on AC unit vents. The middle window was partially opened and had dust, debris, and cobwebs noted on the windowsill. The AC unit in the window in the front of the room had dust and cobwebs on it. During an interview with the surveyor on 10/9/24 at 11:54 AM, LPN #9 stated the overnight nursing staff was responsible for cleaning the IV poles and pump machines. She further stated it was documented on the Treatment Administration Record (TAR) that the machine was cleaned. During an interview with the surveyor on 10/9/24 at 11:58 AM, LPN #8 stated that both nursing and housekeeping were responsible for cleaning the enteral feeding pumps and the IV poles. She stated they were cleaned weekly and as needed. She further stated that the housekeeper wiped it daily, but was not sure if there was a cleaning schedule or where it would be documented. During an interview with the surveyor on 10/9/24 at 12:05 PM, CNA #9 stated the nurses were responsible for cleaning the enteral feeding pumps and IV poles. She stated that maintenance was responsible for checking the air conditioners. During an interview with the surveyor on 10/9/24 at 12:07 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 stated that if there was spillage in the resident's room then the nurses would clean it, but then they would call housekeeping to follow up and disinfect it. LPN/UM #2 stated that she did not know if there was a cleaning schedule. She then stated if she had seen it, then she would notify housekeeping. At 12:10 PM, the surveyor continued to interview LPN/UM #2, who stated she was not sure if there was a cleaning schedule for the cleaning of the wheelchairs and geri-chairs. She stated that she knew they were cleaned but was unsure of how often they were cleaned. On 10/9/24 at 12:13 PM, LPN/UM #2 and the surveyor went to room [ROOM NUMBER]-B and at that time LPN/UM #2 confirmed there was spillage and drippings of the enteral feeding on the machine, the IV pole, and on the wheels of the pole. She stated that she would get housekeeping to clean it. On 10/9/24 at 12:15 PM, LPN/UM #2 and the surveyor toured the hallway were the geri-chairs where located. LPN/UM #2 stated that the geri-chairs and high back wheelchair in the hallway were from the hospice company. She stated that the hospice company was supposed to come pick them up but did not come yet. During an interview with the surveyor on 10/9/24 at 12:26 PM, the Housekeeper (HK #1) stated that housekeeping would wipe the poles if we have time after doing everything we are supposed to do. HK #1 stated that he mainly cleaned the main areas and not the resident's rooms. HK #1 explained if he cleaned the resident's room he would clean the bathroom, sweep, and mop the floor. During an interview with the surveyor on 10/9/24 at 12:29 PM, the Director of Nursing (DON) stated housekeeping and nursing were responsible for cleaning the enteral feeding pump and the IV poles. He stated that he would have to research to see if there was a cleaning schedule since he had only been the DON at the facility for three (3) months. The DON stated that even if the geri-chairs are from hospice the facility was still responsible for cleaning them. He stated that housekeeping was responsible to clean out any visible cobwebs and debris on the windowsill. He further stated housekeeping was also responsible for cleaning the air conditioners to ensure there was no dust and to ensure everything was clean. The DON stated it was important to keep the equipment and areas clean to prevent infection and to create a homelike environment. On 10/9/24 at 12:36 PM, the DON and the surveyor conducted an environmental tour on the [NAME] Unit. At that time, the DON stated the geri-chairs in the hallway were not being used, but he could see the areas that needed to be cleaned. At 12:37 PM, the DON and the surveyor entered room [ROOM NUMBER]-B. The DON confirmed there were drippings and spillage from the enteral feeding on both the pump and IV pole. He stated he would have to check the frequency that equipment was cleaned but would expect it to be clean. At 12:39 PM, the surveyor showed the DON the linen cart in the hallway. He stated he was aware of the linen cart and had ordered replacement covers but was waiting on a shipment. At 12:41 PM, the surveyor and the DON entered the activities/dining room. At that time, the DON confirmed the AC unit in the back of the room needed to be fixed, and the cobwebs and the dust on and by the air conditioner and in the windowsill needed to be cleaned. He stated it was the expectation for it to be cleaned to prevent allergens. During an interview with the surveyor on 10/10/24 at 10:41 AM, HK #2 stated that he was mainly on the [NAME] Unit. He stated that he was responsible for cleaning the resident's rooms, dining room, medication room, oxygen room, the unit manager's room, the spa/shower room, the pantry, and the supply room. He further stated in the resident's room, he cleaned the toilets, windowsills, handrails, soap dispenser, paper towel dispenser, swept and mopped the floors, the nightstands, IV poles and mirrors. HK #2 stated that he tried to clean the IV poles daily because they got dirty quick. He further stated, it looks like I did not even clean it. He explained there was no documentation, but that it was done daily. HK #2 stated housekeeping was responsible for cleaning the wheelchair and geri-chairs and that he did them today, 10/10/24. When asked how often they are cleaned, HK #2 stated I am not going to lie, I am not sure how often they were supposed to get cleaned. He further stated he was not sure if there was a log to track the wheelchairs and geri-chairs. HK #2 stated we was unsure if the chairs in the hallway were from the hospice company but that he cleaned anything he saw which would include the geri-chairs in the hallway. At 10:48 PM, the surveyor showed HK #2 the pictures that were taken on 10/8/24 and 10/9/24. At that time, HK #2 stated the drippings were hard to get off the IV pole and machine. He acknowledged they should have been cleaned. On 10/10/24 at 11:50 AM, the surveyor interviewed the Maintenance Director (MDR) in the presence of the survey team. The MDR stated the maintenance department was responsible for changing the AC filters and the housekeeping cleaned the exterior. On 10/15/24 at 2:36 PM, the surveyor conducted a follow up interview with the MDR in the presence of the survey team. The MDR stated that for the AC units, the maintenance department was responsible for preventive maintenance, to clean the filters, and if any issues were found to address them immediately. He stated that the filters were cleaned monthly and that housekeeping generally wiped the AC units down, but if maintenance saw them dusty, we do not mind cleaning them. At 2:40 PM, the surveyor showed the MDR the pictures of the AC unit in the [NAME] Unit activities/dining room. He stated that he noticed it today, 10/15/24, and placed a cover over it immediately. He further stated he generally toured each unit once a week. The MDR stated the last time he rounded on the [NAME] Unit was last Monday, 10/7/24 or Tuesday, 10/8/24. He stated that it stuck out today [10/15/24] and jumped right on it. He further stated that no one brought it to his attention. The MDR stated the cover was temporary because the vents needed to be replaced. He stated that when the maintenance department inspected the AC units, they checked to ensure they were in place and if they needed to get replaced, it was done immediately. The MDR stated that he generally conducted visual rounds, but there was no official documentation for the environmental rounds. On 10/15/24 at 3:06 PM, the surveyor interviewed the Director of Housekeeping (DHK) and the Regional DHK (RDHK) in the presence of the survey team. The DOK stated the housekeepers (HK) were responsible for cleaning the resident's rooms, the wheelchairs, equipment, and the spa/shower rooms daily. She stated the HK had a check list on their cart on what to clean, but that there was nothing official to check off daily. She further stated that her and the Assistant DHK conducted weekly and monthly audits. The DHK stated that housekeeping was responsible for cleaning the windowsill and the front of the AC unit daily. She further stated that the maintenance department was responsible for changing the filters. The DHK stated that the AC units should be cleaned because it could cause effects for residents with respiratory issues. At 3:15 PM, the RDHK stated that the [NAME] Unit was the most difficult to clean. He stated there was more movement and upkeep of the unit and that it was harder to get clean with the clientele in that vicinity. At 3:18 PM, the surveyor showed the DHK and the RDHK the pictures from 10/8/24 and 10/9/24. The DHK stated that the expectation was that it should definitely be better than that. A review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, (revised September 2022), reflected that resident care equipment, including items and durable medical equipment will be cleaned and disinfected according to Current CDC recommendations for disinfection and OSHA Bloodborne pathogens Standard. The [NAME] Classification System is used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g. urinary catheters) or vascular system (e/g intravenous catheters) are considered critical items and must be sterile. b. Semi -critical items consist of items that may come in contact with mucous membranes or non- intact skin ( e.g. respiratory equipment). c. Non-critical items are those that come in contact with intact skin but not mucous membranes, include resident care items such as bedpans, blood pressure cuffs, crutches and computes. Non- critical environmental surfaces include bed rails, bedside tables, etc. The policy further revealed that reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment (DME)). Single residents use items are cleaned and disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans, urinals). A review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces, (revised August 2019), revealed that environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and OSHA blood borne pathogens standard. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the residents environment: A. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g. urinary catheters) or vascular system (e/g intravenous catheters) are considered critical items and must be sterile. B. B. Semi -critical items consist of items that may come in contact with mucous membranes or non- intact skin ( e.g respiratory equipment). C. Non-critical items are those that come in contact with skin but not mucous membranes. (1), non- critical environmental surfaces include bedrails, some food utensils, bedside tables, furniture, and floors. The policy further reflects that housekeeping surfaces (e.g. floors . tabletops, will be cleaned on a regular basis (e.g. daily, three times per week) and when visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times a week) and when surfaces are visibly soiled. Wall, blinds, and window curtains in resident rooms will be cleaned when these surfaces are visibly contaminated or soiled. A review of the facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022, included, Resident-care equipment will be cleaned and disinfected A review of the facility's policy, Homelike Environment (Revised February 2021) revealed the following: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; . A review of an undated facility policy, Maintenance Rounds Policy revealed the following: Maintenance Staff will conduct daily rounds to ensure the center's environment is safe and free of any harm throughout the center. These rounds will occur every 2-3 hours while work orders checked on the .platform. Procedures: Maintenance staff will conduct rounds throughout the center daily to address any emergencies and work orders. .The Maintenance Director or designee will check for work orders prior to leaving for the day to assure all items were addressed or have plan in place to complete timely . The weekly .summary will be reviewed by the NHA (nursing home administrator) and Maintenance Director to identify any outstanding issues or trends that are occurring within the facility. NJAC 8:39- 4.1(a)11

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 5 of 5 refrigerators designated for resident food, and was evidenced by the following: On [DATE] from 9:30 AM to 10:45 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen and observed the following: In the refrigerator identified as the Korean Refrigerator: 1. Two sealed bags of cooked rice with a use-by date of [DATE]. The FSD removed the two bags from refrigerator and discarded them. On [DATE] at 10:36 AM, the surveyor, accompanied by the Registered Nurse/Unit Manager (RN/UM) observed the following in the refrigerator designated for resident food in the East unit pantry: 1. Single-serving size containers of cranberry cocktail juice that had a use-by date of: -,d+[DATE] (1 container) -,d+[DATE] (1 container) -,d+[DATE] (1 container) -,d+[DATE] (1 container) -,d+[DATE] (3 containers) -,d+[DATE] (12 containers) -[DATE] (1 container) 2. Single-serving size containers of apple juice with a use-by date of: -,d+[DATE] (8 containers) -,d+[DATE] (2 containers) -,d+[DATE] (8 containers) 3. Single-serving size containers of orange juice with a use-by date of: -,d+[DATE] (1 container) 4. Single-serving size container of fat-free lactose-free milk with a use by date of: -[DATE] (2 containers) -Undated (1 container) The RN/UM removed and discarded the expired beverages. 5. Two blue reusable tote bags with containers of unlabeled, undated food. One tote bag was stuck to the shelf of the refrigerator and was leaking a sticky, syrup-like liquid. The RN/UM stated the tote bags contained food brought in by visitors. During an interview at that time, the RN/UM stated she was unsure who was supposed to maintain the unit pantry. On [DATE] at 10:48 AM, the surveyor, accompanied by Licensed Practical Nurse (LPN) #1, observed the following in the refrigerator designated for resident food on the Central unit: 1. There was no thermometer inside the refrigerator, nor a temperature log posted on the outside of the refrigerator to monitor refrigerator temperatures. 2. Two unlabeled, undated plastic beverage cups that were covered with a lid. One cup contained an opaque white liquid, and the other cup contained a clear, yellow liquid. 3. A single-serving size container of vanilla yogurt and strawberry parfait which had a use-by date of [DATE]. During an interview at that time, LPN #2 stated she would discard the expired/undated items, but was not sure who was responsible for maintaining the refrigerator. At that time, Licensed Practical Nurse/Unit Manager (LPN/UM) #4 entered the nurses' station and stated the refrigerator thermometer must have been misplaced, and that the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shift nurses were responsible for checking the refrigerator temperatures. On [DATE] at 10:57 AM, the surveyor, accompanied by LPN/UM #2, observed the following in the refrigerator designated for resident food in the [NAME] Unit pantry: 1. The temperature of the refrigerator was 22 degrees Fahrenheit. The LPN/UM adjusted the refrigerator thermostat. 2. A single-serving size container of creamy strawberry Glucerna (nutritional supplement) that was in the back of the refrigerator and frozen. LPN/UM #2 removed the supplement to discard. 3. Five single-serving size containers of apple juice that had no use-by date. LPN/UM #2 removed the juice containers to discard. 4. A plastic wrapped peanut butter and jelly sandwich that had a use-by date of [DATE]. LPN/UM #2 removed the sandwich to discard. During an interview at that time, LPN/UM #2 stated the nurses were responsible for maintaining the unit pantry and refrigerator temps. On [DATE] at 11:08 AM, the surveyor, accompanied by LPN/UM #3, observed the following in the refrigerator designated for resident food in the North 2 unit pantry: 1. A single-serving size fat-free lactose-free milk with a use-by date of [DATE]. LPN/UM #3 removed the milk to discard. During an interview at that time, LPN/UM #3 stated housekeeping maintained the unit pantry and nursing staff monitors the refrigerator temperatures. On [DATE] at 11:19 AM, the surveyor, accompanied by LPN/UM #1, observed the following in the refrigerator designated for resident food in the North 1 unit pantry: 1. Two sealed cheese sticks without a use-by date. LPN/UM #1 stated the cheese sticks could have belonged to staff, but removed them from the refrigerator to discard. 2. Two unlabeled, undated plastic beverage cups that were covered with a lid that were in the freezer portion of the refrigerator and contained frozen liquids. LPN/UM #1 stated the cups belonged to staff and left them in the freezer. During an interview at that time, LPN/UM #1 stated the nursing staff maintained the unit pantry. During an interview with the surveyor on [DATE] at 1:59 PM, the FSD stated nursing staff should be checking the unit pantries for expired food and monitoring the refrigerator temperatures daily. The FSD further stated that food brought in by visitors should be labeled and dated with a use-by date since it would only be good for three days. The FSD added that staff members should not be storing their personal food in the refrigerators designated for resident food. During an interview with the surveyor on [DATE] at 4:12 PM, the Licensed Nursing Home Administrator (LNHA) stated her expectations were that dietary staff should inspect all food items in the kitchen to ensure food is within date and to discard any expired foods. The LNHA further stated that the nursing staff and the FSD should have checked the nursing unit pantries to ensure all food items were stored properly, expired foods were discarded, staff were not storing personal food items in resident refrigerators, and the refrigerator temperatures were monitored. Review of the facility's Refrigerators and Freezers policy, revised ,d+[DATE], included, Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees Fahrenheit and freezers keep frozen foods solid, and, Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Further review of the policy included, Supervisors are responsible for ensuring food items in the pantry, refrigerators, and freezers are not past 'use by' or expiration dates. Review of the facility's Foods Brought by Family/Visitors, undated, included, Food brought in by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food, and, The nursing staff will discard perishable foods on or before the 'use by' date. NJAC 8:,d+[DATE].2(g)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing, and b.) maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for and 5 out of 5 nursing units, and was evidenced by the following: Refer to F584, F645, F657, F689, F758, and F812 A review of the Administrator's job description provided by the facility revealed the following: The Administrator's primary purpose is to direct the day-to-day functions of the center in accordance with current federal, state, and local standards, guideline, and regulations that govern nursing centers to assure that the highest degree of quality care can be provided to the residents at all times. Duties and Responsibilities included but not limited to: plan, develop, organize, implement, evaluate, and direct the center's programs and activities. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the center. Review the center's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations. Ensure that all employees, residents, visitors, and the general public follow the center's established policies and procedures. Delegate administrative authority, responsibility, and accountability to other staff personnel as deemed necessary to perform their assigned duties. Ensure that all Center personnel, residents, visitors, etc., follow established safety regulations, to include fire protection/prevention, smoking regulations, infection control, etc. Ensure that the building and grounds are maintained in good repair. Ensure that the Center is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. During the entrance conference on [DATE] at 9:45 AM, the LNHA stated that she started at the facility five (5) days ago and the Director of Nursing (DON) started at the facility three (3) months ago. At that time, the LNHA stated the facility had residents who identified as smokers. 1.) On [DATE] at 12:27 PM, the surveyor entered Resident #144's room and smelled a cigarette-like smoke scent. The resident was observed lying in bed with the fan on and the window open. At that time, the surveyor interviewed the resident who stated they were not allowed to smoke in their room, but they had to wait for hours for the staff to come into the room to assist them. The resident stated that the staff did not take them out to smoke, so they smoked tobacco in their room. A review of Resident #144's incident reports revealed that the resident was observed smoking cigarettes in their room on [DATE], [DATE], and [DATE]. Interventions included that the individualized comprehensive care plan (ICCP) was updated. During an interview with the surveyor on [DATE] at 1:30 PM, the DON stated that the resident was assessed as an independent smoker and was allowed to hold their cigarettes and lighter. When asked did the resident smoke in their room, the DON stated that the resident informed them that they had smoked in their room. The surveyor conducted a telephone interview on [DATE] at 8:48 AM, with the Medical Doctor (MD), who stated that he had a problem with Resident #144 smoking since they had been caring for the resident. The MD stated that the resident had been resistant to care and that the staff bend over backward. The MD stated that the facility had done everything to keep the lighter and cigarettes from the resident, and the facility was going to do better with the smoking residents and the other residents. 2.) During the tour of the facility throughout the survey, it was determined that the facility failed to maintain the residents' environment, equipment and living areas in a safe, sanitary, and homelike manner on all five nursing units (East, West, Central, North 1, and North 2). During an interview with the surveyor on [DATE] at 3:06 PM, the Director of Housekeeping (DHK) stated in the presence of the the Regional DHK (RDHK) and survey team, that the floor mats and mattresses should be cleaned. On [DATE] at 3:07 PM, in the presence of the survey team, the DHK stated that the air conditioner (AC) vents were supposed to be wiped daily and deep cleaned weekly. The DHK stated that she did not expect to see a thick coating of dust on the outside of the air-conditioning units. The DHK further stated that it could cause health issues in residents with respiratory problems. On [DATE] at 3:15 PM, the RDHK stated that the [NAME] Unit was the most difficult to clean. He stated there was more movement and upkeep of the unit and that it was harder to get clean with the clientele in that vicinity. During an interview with the surveyor on [DATE] at 4:14 PM, in the presence of the survey team, the LNHA stated that housekeeping and maintenance should ensure the AC units were cleaned and remained dust free weekly. 3.) On [DATE] from 9:30 AM to 10:45 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen and it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. During an interview with the surveyor on [DATE] at 1:59 PM, the FSD stated the nursing staff should be checking the unit pantries for expired food and monitoring the refrigerator temperatures daily. The FSD further stated that food brought in by visitors should be labeled and dated with a use-by date since it would only be good for three days. The FSD added that staff members should not be storing their personal food in the refrigerators designated for resident food. 4.) On [DATE] at 10:08 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #97. A review of the PASARR level I Screening Tool dated [DATE], and signed by the facility's social worker (SW), indicated the following: Section II- Intellectual Disability/Developmental Disability/Related Conditions Screen (ID/DD/RC) indicated a positive screening, which required a level II PASARR to be completed. Further review of the EMR revealed there was no evidence of a level II PASARR was completed. During an interview with the surveyor on [DATE] at 4:51 PM, the LNHA stated in the presence of the [NAME] President of Clinical (VPCS), Regional Director of Clinical Services (RDCS), the Regional Director of Operations (RDO), DON, and the survey team that the expectation was that the level II PASARR would be completed prior to admitting the resident. The LNHA acknowledged that the level II PASARR should have been completed. 5.) A review of Resident #73, #102 and #198 individualized comprehensive care plan (ICCP) revealed conflicting interventions related to smoking. A review of Resident #198's ICCP included a focus, created [DATE], of I smoke. Interventions included two conflicting interventions: store all smoking materials in my room, and that, the facility will safely secure all smoking materials. A review of Resident #102's ICCP, with revision dated of [DATE], included a focus area of I smoke cigarettes. Interventions included: I understand that for my safety, the facility will store my nicotine products and my lighter, I understand that the facility will store my lighter and cigarettes for safety reason, I am able to smoke safely independently (initiated [DATE]), and I use a smoking apron (initiated [DATE]). A review of Resident #73's ICCP included a focus, revised [DATE], of I smoke. Interventions included two conflicting interventions: I am able to smoke independently and store all smoking materials in my room, and that, for my safety, the facility will safely secure all smoking materials. During an interview with the surveyor on [DATE] at 4:20 PM, in the presence of the survey team, the DON stated that the smoking care plan was auto populated by the responses on the Smoking Safety Evaluation and that any conflicting interventions should have been corrected the next day by nursing management. 6.) A review of 5 of 5 residents (Resident #17, #40, #109, #167, and #358) for psychotropic medications revealed the following was not addressed: recommendations for a gradual dose reduction (GDR) of psychotropic medications (mood altering medications); ensure as needed (PRN) psychotropic medications were prescribed with a 14-day duration and re-evaluated for continued use; and adequately monitor target behaviors for the use of psychotropic medications. A review of Resident #17's Psychiatric Evaluation (psych eval), dated [DATE], revealed the resident reported they had been refusing bupropion (an anti-depressant medication) because it gave them hallucinations and that they requested to stop olanzapine (an anti-psychotic medication). Further review of the psych eval included recommendations of a GDR by stopping bupropion and olanzapine. A review of Resident #17's June through [DATE] Medication Administration Records (MARs) revealed there were no physician's orders to monitor target behaviors related to psychotropic medication use prior to [DATE]. A review of Resident #40's June, July, August, September, and [DATE] MARs and Treatment Administration Record (TARs) did not include any PO for targeted behavior monitoring related to anxiety or depression. A review of Resident #358's [DATE] Physician Order Summary Report (OSR) reflected that the resident was on the following psychoactive medications: A physician's order (PO), dated [DATE], for Xanax (alprazolam), oral tablet 0.25 milligram (mg); give one tablet by mouth every 12 hours as needed for anxiety/agitation/restlessness. There was no stop date indicated. A review of Resident #358's July, August, September, and [DATE] MARs and TARs did not include any PO for behavior monitoring related to anxiety, depression or bipolar medications. A review of Resident #109's OSR dated as of [DATE], included the following PO: A PO dated [DATE], for Risperdal 1 mg; administer one tablet by mouth two times a day for psychosis. A review of Resident 109's [DATE] MAR did not include any behavior monitoring or monitoring of side effects of psychotropic medications prior to surveyor inquiry. A review of Resident #167's PO revealed that the resident had an order for quetiapine fumarate tablet 100 mg; give one tablet by mouth at bedtime for mood disorder. There was no evidence that the resident's behavior was being monitored. During an interview with the surveyor on [DATE] at 3:45 PM, in the presence of the LNHA, the Director of Clinical Services, the [NAME] President of Clinical Services and the survey team, the DON stated that a PO for Xanax would need a 14-day stop date on the order. During an interview with the surveyor on [DATE] at 3:57 PM, in the presence of the survey team, the DON stated the facility utilized a batch order set to create physician's orders for behavior monitoring. The DON further stated that behavior monitoring should be documented on the MAR every shift. During an interview with the surveyor on [DATE] at 4:18 PM, in the presence of the survey team, the DON stated that psych recommendations should be verified and implemented according to the provider. The DON further stated that the provider should document in the resident's medical record when recommendations were reviewed. On [DATE] at 10:26 AM, the LNHA acknowledged the concerns that were brought to her attention in the presence of the DON and the survey team. NJAC 8:,d+[DATE].2(a); 9.3(a); 27.1(a)

Based on interviews, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of 1 resident (Resident #97) reviewed for level II PASARR and was evidenced by the following: On 10/15/24 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #97. A review of the Admission Record face sheet (an admission summary) reflected that the resident had diagnosis that included, intellectual disability, schizophrenia and generalized anxiety. A review of the PASARR level I Screening Tool dated 2/7/24 and signed by the facility's social worker (SW), indicated the following: Section II - Mental Illness Screen showed the resident had diagnosis or evidence of a major mental illness and the screen was negative. Section II- Intellectual Disability/Developmental Disability/Related Conditions Screen (ID/DD/RC) indicated a positive screening, which required a level II PASARR to be completed. Step 2: Determine Final Level I Screening Outcome revealed a positive screening and to refer to Division of Development Disabilities (DDD). Section VIII - PASRR level Screening Outcome and Certification of Screening Professional Completing Level I form revealed a negative screen: admit to nursing facility (NF). A review of the Notice of Referral for Level II Preadmission Screening and Resident Review (PASARR) Evaluation dated and signed on 2/7/24 by the SW reflected a referral was made for a level II PASARR evaluation and determination for placement in a Medicaid certified nursing facility. Further review of the EMR revealed there was no evidence of a level II PASARR was completed. On 10/15/24 at 10:29 AM, the surveyor interviewed the SW and the Director of Social Work (DSW). The DSW stated that their role regarding the PASARR included that upon admission the PASARR was uploaded into the electronic medical record (EMR) and that she kept a spreadsheet to ensure she had one for every resident. She further stated that she reviewed the PASSARs, updated the PASSAR's every year, and then uploaded them into the EMR. The DSW explained if the resident came from the hospital and was in subacute rehab and had a positive level I and level II it would be a part of the admission records. She further explained if the resident was in long term care she would review the level I and level II and they would update the PASARR every year. When asked about Resident #97's negative level I and the notification for referral for level II PASARR evaluation completed by the SW on 2/7/24. Both the SW and the DSW stated they would need to review it and then they could provide the clarification for the negative level I and notice of referral for level II. On 10/15/24 at 11:00 AM, the DSW provided the level I PASARR and stated that it was corrected to reflect a positive level I. When asked about the referral of the notification for the level II and was a level II completed, the DSW stated she would have to look into it. During an interview with the surveyor on 10/15/24 at 11:17 AM, the DSW stated the full level II application will not be completed until Thursday 10/17/24 by the psychiatrist and then it would be filled out and submitted that day. When asked when it should be completed? The DSW stated she would have to get the answer from the regional SW to see when the level II should be completed. The DSW confirmed the resident had a positive level I screening and a level II should have been completed prior to surveyor inquiry. On 10/15/24 at 11:20 AM, the DSW provided another level I PASARR. At that time, the DSW stated that the level I that was originally in the EMR was uploaded by error and that it was modified and the second copy she provided was accurate of the positive PASARR. When asked for the clarification on Section II a positive screening but the outcome of level I was negative. The DSW stated that she would get clarifications on the PASARR. On 10/15/24 at 11:30 AM, the SW provided a third copy of the level I PASARR. At that time, the SW stated that she just modified the level I PASARR in the EMR. She stated that she would have to speak to the supervisor to see when the positive screening should have been reflected on the level I and after the notification of the referral for level II when the level II should be completed. During a follow up interview with the DSW on 10/15/24 at 12:01 PM, the DSW stated once the notification of referral was submitted then the state would review it and complete the level II. She was unable to speak on when they should follow up if there was no response for the completion of the level II. The DSW emphasized the resident would have the level II completed and acknowledged it should have been completed prior to surveyor inquiry. On 10/15/24 at 4:51 PM, the Licensed Nursing Home Administrator (LNHA) stated in the presence of the [NAME] President of Clinical (VPCS), Regional Director of Clinical Services (RDCS), the Regional Director of Operations (RDO), Director of Nursing (DON) and the survey team the expectation was that the level II would be completed prior to admitting the resident. The LNHA acknowledged that the level II PASARR should have been completed. A review of the facility's policy Admission Criteria revised March 2019, included 8b. If the level I screen indicates that the individual may meet the criteria for a MD [mental disorder], ID [intellectual disabilities], or RD [related disorders, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process. 8d. The state PASARR representative provides a copy of the report to the facility. NJAC 8:39-11.2(i), 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individualized comprehensive care plan (ICCP) related to smoking for 3 of 6 residents (Resident #73, #102 and #198) reviewed for accidents. This deficient practice was evidenced by the following: 1.) On 10/9/24 at 1:52 PM, the surveyor observed Resident #102, awake and alert, sitting in a chair at a table in the outside smoking patio. The surveyor observed a red pack of cigarettes with a black lighter on top of the pack of cigarettes on the patio table. The resident confirmed the cigarettes and lighter were his/hers and that he/she did not use a smoking apron anymore. Resident #102 further stated that he/she can come out to smoke anytime between 8:00 AM and 8:00 PM, and there was no supervision by the staff. Resident #102 stated that they kept their cigarettes in the drawer in their room. A review of the Admission Record face sheet (an admission summary) reflected that Resident #102 was admitted to the facility with diagnoses which included, but were not limited to, Parkinsons Disease (a disorder of the central nervous system that affects movement, often tremors), chronic pain syndrome, chronic obstructive pulmonary disease, and muscle weakness. A review of the annual comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 03/01/24, revealed a Brief Interview for Mental Status score of 14 out of 15, which indicated the resident's cognition was intact and currently used tobacco. A review of the Smoking Safety Evaluation, dated 9/2/24, revealed that Resident #102 was able to smoke independently, follow facility policy, and safely secure all smoking materials in their room. The interventions included: I will adhere to the facility smoking policy through the review date, that for my safety the facility will store my nicotine products and my lighter, and the facility will store my lighter and cigarettes for safety reasons. The interventions did not include a smoking apron was needed. A review of Resident #102's ICCP, with revision date of 9/2/24, included a focus area of I smoke cigarettes, with interventions that included: I understand that for my safety, the facility will store my nicotine products and my lighter, I understand that the facility will store my lighter and cigarettes for safety reasons, I am able to smoke safely independently (initiated 06/08/24), and I use a smoking apron (initiated 05/22/24). 41260 2.) On 10/9/24 at 1:35 PM, the surveyor observed Resident #198 outside smoking in the smoking area. On 10/9/24 at 1:46 PM, the surveyor observed Resident #198 return to his/her room. At that time, the resident stated he/she had been smoking since admission to the facility and kept smoking materials in his/her bedside drawer. The surveyor observed three boxes of cigarettes in a brown bag on the resident's chair and the resident patted his/her pocket when the surveyor asked where he/she kept the lighter. A review of the most recent admission Minimum Data Set (MDS), an assessment tool, dated 9/12/24, included the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident's cognition was intact. A review of the resident's Smoking Safety Evaluation, dated 9/19/24, included the resident smoked and two conflicting interventions that the resident was to store all smoking materials in my room, and that, the facility will safely secure all smoking materials. A review of the resident's ICCP included a focus, created 9/19/24, of I smoke, with two conflicting interventions: store all smoking materials in my room, and that, the facility will safely secure all smoking materials. During an interview with the surveyor on 10/15/24 at 11:53 AM, Certified Nursing Assistant (CNA) #2 stated she was made aware of the smokers on her assignment through verbal report. The CNA further stated that residents should not have smoking materials in their rooms and that smoking materials were locked up by the nurse. During an interview with the surveyor on 10/15/24 at 12:01 PM, Licensed Practical Nurse (LPN) #4 stated that the Smoking Safety Evaluation determined if a resident was allowed to keep smoking materials in their room. The LPN further stated that all nurses were responsible for reviewing and revising the resident care plans so that all staff would know the resident's current status. During an interview with the surveyor on 10/15/24 at 12:26 PM, the Registered Nurse/Unit Manager (RN/UM) stated that residents who smoke were assessed upon admission to determine whether the resident could hold onto their own smoking materials or if smoking materials would be kept by the facility. The RN/UM further stated that the nurses were responsible for reviewing and revising the resident care plans to reflect the most current information about the resident. When asked about Resident #198, the RN/UM stated that the resident kept his/her own smoking materials in his/her room. At that time, the surveyor reviewed the resident's ICCP with the RN/UM and asked how someone reading the ICCP would know where the resident's smoking materials should be kept. The RN/UM stated, You wouldn't. The Care Plan would have to be clarified. The RN/UM further stated it was important to accurately document where the resident's smoking materials should be kept to make sure the residents are safe. 43308 3.) On 10/9/24 at 11:31 AM, the surveyor observed Resident #73 lying in bed, resting with their eyes closed. A review of the Admission Record reflected that the resident had diagnoses that included, diabetes, high cholesterol, and tobacco use. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 10/6/24, included the resident had a Brief Interview for Mental Status score of 7 out of 15, which indicated a severely impaired cognition. A review of the resident's Smoking Safety Evaluation, dated 10/8/24, included, the resident smoked, and two conflicting interventions that the resident was to store all smoking materials in my room, and that, the facility will safely secure all smoking materials. A review of the resident's ICCP included a focus, revised 7/8/24, of I smoke with two conflicting interventions: I am able to smoke independently and store all smoking materials in my room, and that, for my safety, the facility will safely secure all smoking materials. During an interview with the surveyor on 10/9/24 at 12:00 PM, LPN #8 stated that she worked per diem but was given report that the resident was a smoker and generally went out to smoke after lunch. LPN #8 stated that the cigarette pack was kept in the medication cart. At that time, she looked in the medication cart and showed the surveyor the pack of cigarettes. When asked where the lighter was kept, LPN #8 stated she was not sure who kept the lighter. During an interview with the surveyor on 10/9/24 at 12:03 PM, CNA #9 stated the resident was a smoker and generally smoked in the afternoon. CNA #9 stated the nurse kept the cigarettes and the lighter and that the aide went out with the resident to the courtyard when he/she wanted to smoke. She further stated the resident did not need an apron they were just supervised. During an interview with the surveyor on 10/9/24 at 12:09 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated the resident was a smoker. LPN/UM #2 further stated that the cigarettes and the lighter were kept in the medication cart. During a follow up interview with the surveyor on 10/15/24 at 2:17 PM, LPN/UM #2 stated she was responsible for completing the ICCP to ensure that it was done. She further stated that anyone could do it, but it was her responsibility. LPN/UM #2 stated the care plan was updated quarterly and as needed. She explained the care plan was generally discussed during the care conference which was done quarterly and anything new would be updated on the ICCP. LPN/UM #2 stated that if things were contradicting on the ICCP, she would try to review it and resolve it. On 10/15/24 at 2:20 PM, LPN/UM #2 reviewed the ICCP in the electronic medical record (EMR) and stated that the resident was not on the west unit at that time the ICCP was created. She stated because the resident was on the memory care unit which had wandering residents, she wanted the cigerrettes and the lighter to be stored on the medication cart. She further stated that she updated the ICCP to include that all items were stored at the nurse's station. Further review of the ICCP, reflected it was revised on 10/14/24 by the Director of Nursing (DON) and LPN/UM #2 to include intervention I am able to smoke with supervision, and store all smoking materials at the nurse's station after surveyor's inquiry on 10/9/24. During an interview with the surveyor on 10/15/24 at 4:20 PM, in the presence of the survey team, the Director of Nursing (DON) stated that the smoking care plan was auto populated by the responses on the Smoking Safety Evaluation and that any conflicting interventions should have been corrected the next day by nursing management. A review of the facility's Care Plans, Comprehensive Person-Centered policy, revised 03/2022, included, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) address recommendations for a gradual dose reduction (GDR) of psychotropic medications (mood altering medications), b.) ensure as needed (PRN) psychotropic medications were prescribed with a 14-day duration and re-evaluated for continued use, and c.) adequately monitor target behaviors for the use of psychotropic medications for 5 of 6 residents (Resident #17, #40, #109, #167, and #358) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1.) On 10/9/24 at 12:36 PM, the surveyor observed Resident #17 lying in bed. The resident was in a pleasant mood and had no complaints. A review of the Admission Record (an admission summary), Resident #17 had diagnoses which included, but were not limited to, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, and panic disorder. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/03/24, included the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had no behaviors and received antipsychotic and antidepressant medications (types of psychotropic medications). A review of the individualized comprehensive care plan (ICCP), initiated 6/27/24, included that the resident used anti-psychotic and anti-depressant medication with interventions to consult with physician to consider dosage reduction when clinically appropriate. A review of the Psychiatric Evaluation (psych eval), dated 9/19/24, revealed the resident reported he/she had been refusing bupropion (an anti-depressant medication) because it gave him/her hallucinations and that he/she requested to stop olanzapine (an anti-psychotic medication). Further review of the psych eval included recommendations of a GDR by stopping bupropion and olanzapine. A review of the Nurse Practitioner (NP) note, written by NP #2 and dated 9/20/24, included, anxiety: pending psych eval and treat. Further review of the note did not indicate whether NP #2 addressed the psych eval recommendations for a GDR that were made the day prior. A review of the September 2024 Medication Administration Record (MAR) included the following physician orders: -Bupropion XL (extended release) 300 mg (milligrams) by mouth once a day for depression with an order date of 09/08/24 - 10/08/24. -Olanzapine 5 mg by mouth at bedtime for mood disorder with an order date of 09/09/24 - 10/08/24. A review of the October 2024 MAR included the following physician orders: -Bupropion XL (extended release) 300 mg (milligrams) by mouth once a day for depression with an order date of 09/08/24 - 10/08/24. The medication was last administered on 10/08/24. -Olanzapine 5 mg by mouth at bedtime for mood disorder with a start date of 10/08/24. The medication was administered 10/08/24 through 10/14/24. During an interview with the surveyor on 10/15/24 at 11:50 AM, Certified Nursing Assistant (CNA) #2 stated Resident #17 did not have any behaviors. During an interview with the surveyor on 10/15/24 at 11:55 AM, Licensed Practical Nurse (LPN) #4 stated the psychiatrist came to the facility weekly and if recommendations were made, the nurse would follow-up with the physician. The LPN further stated that psych recommendations should be addressed immediately to see if the medications are working and keep the resident safe. During an interview with the surveyor on 10/15/24 at 12:09 PM, the Registered Nurse/Unit Manager (RN/UM) stated when a resident was on a psychotropic medication, a psych eval was ordered to see if the resident was appropriate for a GDR. The RN/UM explained that when the psychiatrist made a recommendation, the physician would review the psych eval in the resident's EMR and address the recommendations as soon as possible. When asked about Resident #17, the RN/UM confirmed the resident was still ordered the olanzapine and that if NP #2 saw the resident after the psych eval, the NP should have addressed the recommendations. The RN/UM further stated that it was important to address psych recommendations to decrease the amount of time the resident is on psych meds if they are not appropriate. During an interview with the surveyor on 10/15/24 at 4:18 PM, in the presence of the survey team, the Director of Nursing (DON) stated that psych recommendations should be verified and implemented according to the provider. The DON further stated that the provider should document in the resident's medical record when recommendations were reviewed. 40041 2.) On 10/08/24 at 9:31 AM, the surveyor observed Resident #167 in his/her room. A review of the Admission Record (admission summary) reflected the resident had diagnoses which included, but were not limited to, anxiety disorder, depression, and bipolar disorder (mental illness that causes unusual shifts in mood). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 9/4/24, revealed the resident had a Brief Interview for Mental Status score of 15 which indicated that the resident's cognition was intact. A review of Resident #167's Physician's orders located in the Electronic Medical Record (EMR) revealed an order for Lorazepam (medication used for anxiety) 0.5 milligram tablet to by given by mouth every 6 hours as needed for anxiety disorder, with a start date of 08/29/24. The active order did not include a duration for use or stop date. A review of the Pharmacy Consultant Report, dated 8/30/24, revealed the following documentation: Resident has a PRN (as needed) order for Lorazepam as needed. PRN psychotropic medications should be ordered for a duration of 14 days, then reassessed, reordered for a specific duration, scheduled routinely, or discontinued. CMS (Center for Medicaid Service) 14 Day Rule MEGA RULE. During an interview with surveyor on 10/15/24 at 3:57 PM, in the presence of the survey team, the Director of Nursing (DON) stated that typically after 14 days, the provider would be contacted and would determine if the medication should be extended or discontinued. The DON further stated that if the PRN was ordered beyond 14 days, then there should be documentation in the medical record. During an interview with the surveyor on 10/16/24 at 8:56 AM, the Medical Director (MD) stated the PRN order of Ativan (Lorazepam) should have been time-limited for 14 days and then re-evaluated. He further stated that when the PRN psychotropic was continued, there should be a progress note in the medical record with a rationale. A further review review of Resident #167's PO revealed that the resident had an active order for Quetiapine Fumarate tablet 100 MG give 1 tablet by mouth at bedtime for mood disorder. There was no evidence in the EMR that the resident's behavior was being monitored. During an interview with the surveyor on 10/15/24 at 3:57 PM, in the presence of the survey team, the DON stated that typically the behavior monitoring was done every shift and it would be documented on the Medical Administration Record (MAR). 41072 3.) On 10/8/24 at 10:43 AM, during the initial tour of the North 2 Unit, the surveyor observed Resident #358, awake and alert, lying in bed. During the observation, the resident started to cry and stated I lost my apartment, and I don't know if my sister can keep my cat for me. I may need to have an amputation of my leg. I was receiving therapy, but I had refused therapy, so they discontinued it. A review of the Admission Record revealed that Resident #358 was admitted to the facility with diagnoses including, but not limited to, acute embolism and thrombosis (blood clots) of the right lower extremity, difficulty walking, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The surveyor reviewed the residents October 2024 Physician OSR which reflected that Resident #358 was on the following psychoactive medications: A PO, dated 9/25/24, for Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 12 hours as needed for Anxiety/agitation/restlessness. NO STOP DATE. A PO, dated 7/9/24, for Aripiprazole Oral Tablet 5 MG (Abilify) Give 1 tablet by mouth in the morning for bipolar. A PO, dated 7/9/24, for Latuda Oral Tablet 40 MG (Lurasidone HCl) Give 1 tablet by mouth at bedtime for Bipolar. A PO, dated 7/9/24, for Latuda Oral Tablet 20 MG (Lurasidone HCl) Give 1 tablet by mouth in the morning for Bipolar disorder. A PO, dated 7/9/24, for Duloxetine HCl Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times a day for depression. A PO, dated 7/9/24, for Amitriptyline HCl Oral Tablet 25 MG (Amitriptyline HCl) Give 5 tablet by mouth at bedtime for Anxiety Take 5 tablets (125mg). A review of Resident #358's admission MDS, dated [DATE], included the resident had a BIMS score of 15 out of 15 which indicated the resident's cognition was intact. The MDS further revealed that the resident was on an anti-psychotic, hypnotic, and antidepressant medications and had not had any behaviors. A review of the resident's ICCP, included a Focus, created 7/9/24, I use anti-depressant medication, with interventions that included: Monitor/document/report to physician PRN (as needed) signs and symptoms (s/sx) of depression unaltered by antidepressant medication or worsening s/sx of depression. A review of the ICCP included a focus, created 7/9/24, I use antipsychotic medication related to bipolar and interventions did not include behavior monitoring. Further review of the ICCP included a focus, created 10/2/24, I use anti-anxiety medication, and interventions did not include behavior monitoring. A review of the psychiatry notes, dated 9/26/24, revealed that resident appeared anxious and stated that his/her mood was down after being transferred to his/her new room. A low dose Xanax was ordered to help with the anxiety. A GDR was not recommended. A review of the progress notes, dated 9/15/24 through 10/15/24, revealed a progress note date by LPN #3 dated 10/8/24 which included the resident was tearful, his/her house was sold, that encouragement was given, and the resident refused to get out of bed or go to activities. The resident told the NP that he/she was feeling manic and psychiatry and psychosocial was ordered. No other documentation of behaviors was noted in the progress notes. A review of the July, August, September and October 2024 MARS and TARs did not reveal any PO for behavior monitoring related to anxiety, depression or bipolar medications. On 10/15/24 at 10:37 AM, the surveyor interviewed LPN #3 who stated that when a resident was placed on a new psychotropic medication, behavior monitoring would be documented for 14 days every shift, either in the progress notes or in the MAR. LPN # 3 further stated that the facility does not do monthly psychotropic monitoring or daily behavior monitoring for residents on long term use of psychotropic medications. If the staff saw any change in the resident's behavior, then they would notify the doctor or Nurse Practitioner and have them seen by the psychiatrist. LPN#3 further stated that psychotropic medications ordered as a PRN (as needed), such as Xanax, should be ordered for 14 days and would need a stop date on the PO. On 10/15/24 at 10:52 PM, the surveyor interviewed the LPN/UM #3 who stated that if a new psychotropic medication was ordered or a resident's psychotropic medications were changed, then a 14-day behavior monitoring would be completed. LPN UM #3 further confirmed that a new PO for PRN Xanax should have a 14 day duration and a stop date on the order. The behavior monitoring would be documented in the progress notes or the MAR. The LPN/UM #3 stated it was important to conduct behavior monitoring so that they know that the resident was on the appropriate behavior management and appropriate dosages of medications. When asked how the psychiatrist or psychologist would know what behaviors the resident was presenting, LPN/UM #3 stated the psychiatrist would look at the PO to see what medications were ordered, review the progress notes, and would discuss with the nurses. During an interview with the surveyor on 10/15/24 at 3:57 PM, in the presence of the survey team, the Director of Nursing (DON) stated the facility utilized a batch order set to create physician's orders for behavior monitoring. The DON further stated that behavior monitoring should be documented on the MAR every shift. On 10/15/24 at 3:45 PM, in the presence of the LNHA, the Director of Clinical Services, the [NAME] President of Clinical Services and the survey team, the Director of Nursing (DON) stated that a PO for PRN Xanax would need a 14-day stop date on the order. 4.) On 10/9/24 at 9:20 AM and 10/10/24 at 12:45 PM, the surveyor observed Resident #40 in his/her room. The resident did not display any behaviors at that time. A review of the Admission Record revealed that Resident #40 was admitted to the facility with diagnoses including, but not limited to, major depressive disorder and generalized anxiety disorder. The surveyor reviewed the residents October 2024 Physician Order Summary Report (OSR) which reflected that Resident #40 was on the following psychoactive medications: -A physician's order (PO), dated 7/23/24, for Xanax (anti-anxiety medication) 0.25 milligrams (MG); Give 1 tablet by mouth every 12 hours for anxiety. -A PO, dated 4/22/24, for Zoloft (anti-depressant) 100 mg: Give 2 tablets by mouth at bedtime for antidepressant. A review of the resident's Significant Change MDS, dated [DATE], included the resident had a Brief Interview for Mental Status score of 14 out of 15 which indicated the resident's cognition was intact. The MDS further revealed that the resident was on an antianxiety and an antidepressant and had not had any behaviors. A review of the resident's ICCP included a focus, created 1/3/23, of I use anti-anxiety medication related to anxiety. The interventions did not include any monitoring of target behaviors. The ICCP included a focus, dated 2/3/23, of: I use anti-depressant medication related to depressive disorder. The interventions did not include any monitoring of target behaviors. A review of a psychiatrist note, dated 8/7/24, revealed that the resident has a history of anxiety and depression and had been on Xanax 0.25 mg twice a day (BID) for the last 3 years. On 10/15/24 at 10:37 AM, the surveyor interview LPN #3 who stated that Resident #40 was currently on Xanax and Zoloft, but had no change in his/her behavior lately. LPN #3 stated that Resident #40 did not have any behavior monitoring and if there were any changes in the resident's behavior, a behavioral note would be written in the progress note and the psychiatrist would be notified. LPN #3 stated that the importance of behavior monitoring was to see if the resident needed an increase or decrease in their medications. On 10/15/24 at 10:52 AM, the surveyor interviewed LPN/UM #3 who stated that Resident #40 was not on any behavior monitoring, his/her behaviors included attention and medication seeking, and his/her medication had not been adjusted in a while. LPN/UM #3 confirmed that the last behavior monitoring documentation in the EMR was August 2023. A review of Resident #40's progress notes dated 6/1/24 through 10/15/24 did not reveal documentation of behavior monitoring. A review of the June, July, August, September and October 2024 MARs and TARs did not reveal any PO for targeted behavior monitoring related to anxiety or depression. 5.) On 10/9/24 at 12:36 PM, the surveyor observed Resident #17 lying in bed. The resident was in a pleasant mood and had no complaints. A review of the Admission Record, Resident #17 had diagnoses which included, but were not limited to, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, and panic disorder. A review of the admission comprehensive Minimum Data Set (MDS), an assessment tool, dated 7/3/24, included the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had no behaviors and received antipsychotic and antidepressant medications (types of psychotropic medications). A review of the ICCP, initiated 06/27/24, included the resident was on anti-anxiety, anti-psychotic, and anti-depressant medications (psychotropic medications) with interventions to observe for effectiveness and side effects. A review of the Order Summary Report (OSR), with active orders as of 10/15/24, included the following physician's orders: -Buspirone 5 mg (milligrams) by mouth twice a day for anxiety. -Olanzapine 5 mg by mouth at bedtime for mood disorder. -Trazodone 100 mg by mouth at bedtime for insomnia. A review of the June, July, August, September, and October 2024 Medication Administration Record (MAR) revealed the following physician's orders: -Bupropion XL (extended release) 300 mg (milligrams) by mouth once a day for depression with order dates of 06/28/24 - 08/12/24; 09/08/24 - 10/08/24 -Olanzapine 5 mg by mouth at bedtime for mood disorder with order dates of 06/27/24 - 08/12/24; 09/07/24 - ongoing. -Trazodone 100 mg by mouth at bedtime for insomnia with order dates of 06/27/24 - 08/12/24; 09/07/24 - ongoing. -Buspirone 5 mg (milligrams) by mouth twice a day for anxiety with order dates of 09/08/24 - ongoing. Further review of the June through October 2024 MARs revealed there were no physician's orders to monitor target behaviors related to psychotropic medication use prior to 10/14/24. During an interview with the surveyor on 10/15/24 at 11:50 AM, Certified Nursing Assistant (CNA) #2 stated that if a resident had behaviors, the CNA would notify the nurse and come back later to attempt to provide care. The CNA further stated Resident #17 did not have any behaviors. During an interview with the surveyor on 10/15/24 at 11:55 AM, Licensed Practical Nurse (LPN) #4 stated the Unit Manager (UM) was supposed to evaluate residents monthly related to behaviors and psychotropic medication use. When asked where those assessments were documented, the LPN was unsure. The LPN further stated it was important to monitor behaviors for residents who received psychotropic medications for the resident's safety and to see if there is any change in the resident's status. The LPN added that Resident #17 did not have any behaviors. During an interview with the surveyor on 10/15/24 at 12:09 PM, the Registered Nurse/Unit Manager (RN/UM) stated that residents being monitored for target behaviors would have a physician's order and behaviors, or lack of behaviors, would be documented on the MAR. The RN/UM further stated she was unsure who was supposed to evaluate residents monthly related to behaviors and psychotropic medication use. When asked about Resident #17, RN/UM was unsure if the resident had behaviors, but the behaviors, or lack of behaviors, should have been documented on the resident's MAR. The RN/UM added that it was important to monitor behaviors for residents who received psychotropic medications for effectiveness and side effects. During an interview with the surveyor on 10/15/24 at 3:57 PM, in the presence of the survey team, the Director of Nursing (DON) stated the facility utilized a batch order set to create physician's orders for behavior monitoring. The DON further stated that behavior monitoring should be documented on the MAR every shift. During a follow-up interview with the surveyor on 10/16/24 at 10:43 AM, the DON stated behavior monitoring should have been ordered for Resident #17 when the resident's psychotropic medications were started. 43308 6.) On 10/9/24 at 11:30 AM, the surveyor observed Resident #109 lying in bed sleeping. A review of the Admission Record (an admission summary) reflected that the resident had diagnosis that included major depressive disorder, anxiety, and psychosis (a condition that causes a person to lose touch with reality, making it difficult to distinguish what is real and what is not). A review of the annual comprehensive Minimum Data Set (MDS), an assessment tool, dated 5/6/24, included the resident had a Brief Interview for Mental Status score of 0 out of 15, which indicated a severely impaired cognition. Further review in Section N - Medication included: the resident was on an antipsychotic medication. A review of the Order Summary Report (OSR) dated as of 10/16/24, included the following physician's order (PO): -A PO dated 11/10/23, for Risperdal 1 milligram (mg), administer 1 tablet by mouth two times a day for psychosis. -A PO dated, 5/9/24, for Lexapro 5 mg, administer 1 tablet by mouth in the morning for depression. Further review of the OSR indicated the following PO after surveyor inquiry: -A PO dated 10/11/24, Behavior/interventions - monitor for disorganized thinking with incoherent speech. -A PO dated 10/11/24, Behavior/interventions - monitor for yelling to the point of exhaustion. -A PO dated 10/11/24, Side effects - monitor for side effects of psychotropic medications every shift. A review of the October 2024 MAR reflected no evidence of behavior monitoring and monitoring of side effects of psychotropic medications prior to 10/11/24. A review of the resident's Individual Comprehensive Care Plan (ICCP) included a focus, revised 10/8/24, of potential to demonstrate verbal behaviors. Interventions created 10/13/24, included: monitor and document observed behavior and attempted interventions in behavior log. A review of the Progress Notes (PN) included Psychiatry Progress Note (PPN) which revealed the following: On 7/4/24 at 9:58 PM, the Advanced Practice Nurse (APN) assessed the resident and checked off psychiatric medication requiring management/risk assessment (effectiveness/monitored). During an interview with the surveyor on 10/15/24 at 1:07 PM, Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated the resident had outburst of yelling when placed in a geriatric chair (geri-chair - useful for those with mobility issues and have difficulty sitting upright). She stated they would try to redirect the resident, but it could be difficult to calm him/her down. LPN/UM #2 stated that they would monitor the resident's behavior by documenting in the progress notes. She stated that the resident had not had any behaviors recently. She further stated the nurse did not report any behaviors to her lately and the hospice aide did not mention any recent behaviors. LPN/UM #2 stated the psychiatrist came last week and the last time the resident was seen was 7/4/24. On 10/16/24 at 9:33 AM, the surveyor conducted a telephone interview with the Medical Doctor (MD) in the presence of the survey team. The MD stated that he was not familiar with the standard protocol for behavior monitoring, but that the facility did document behaviors. He further stated if the resident had behaviors they would be seen more frequently. A review of the facility's Psychotropic Medication Use policy, revised 07/2022, included, Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Further review of the policy included, Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and, PRN orders for psychotropic medications are limited to 14 days. The policy also included, Psychotropic medication management includes: . adequate monitoring for efficacy and adverse consequences, and, Consideration for the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised 03/2019, included, When medications are prescribed for behavioral symptoms, documentation will include: . specific target behaviors and expected outcomes; . monitoring for efficacy and adverse consequences. Further review of the policy included, If the resident is being treated for an altered behavior or mood, the IDT [interdisciplinary team] will seek and document any improvements or worsening in the individual's behavior, mood, and function. NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to provide necessary dental care services in a timely manner for 1 of 1 resident (Resident #143) reviewed for dental care services. This deficient practice was evidenced by the following: On 10/8/24 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #143 lying in bed awake with a visitor present at the bedside. The resident stated that he/she was ordered a mechanical soft diet (designed for people who have trouble chewing/swallowing). The resident further stated, I lost my bottom denture a year ago and thought that the facility was going to replace them, but it never happened. A review of Resident 143's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Dysphagia (difficulty swallowing) following cerebral infarction (stroke), muscle wasting and atrophy (waste away), and type 2 (two) diabetes (the body has trouble controlling blood sugar and using it for energy). A review of Resident #143's quarterly Minimum Data Set (MDS), an assessment tool, 9/17/24 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated that the resident was fully cognitively intact. A review of Resident #143's Care Plan revealed an entry dated 3/6/23, with a Focus: I have oral/dental health problems r/t (related to) with no specification provided. The Care Plan Goal included: I will not experience complications of oral/dental health problems through the review date. Interventions/Tasks included: Coordinate arrangement for dental care, transportation as needed/as ordered .Monitor/document/report to physician PRN (as needed) s/sx (signs/symptoms) of oral/dental problems needing attention: .Teeth missing . A review of a Speech Therapy Treatment Encounter Note (s) dated 2/2/24 revealed, Pt (patient) seen in bedroom for skilled dysphagia tx. (treatment) .Mastication (chewing) prolonged, given partial dentition (condition of teeth), yet seen to be functional .A second entry dated 2/6/24, revealed .SLP (Speech Language Pathology) assisting pt to insert upper dentures; pt still awaiting new set of lower dentures . On 10/9/24 at 9:45 AM, the surveyor requested to view a list of those residents who had filed grievances for reimbursement of missing items. The surveyor reviewed the list provided and noted that the resident was not on the list. During an interview with the surveyor on 10/9/24 at 11:24 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that if a resident reported a missing item she immediately searched for the item with resident permission. LPN/UM #1 stated that if the item was not found, she reached out to housekeeping and dietary and all parties were made aware. LPN/UM #1 stated that Social Work filed a grievance and we started an investigation process. On 10/9/24 at 12:51 PM, the surveyor observed Resident #143 lying in bed with their meal tray in front of them. The resident stated that he/she reported the loss of their dentures to the Social Worker, but did not recall when the report was made. During an interview with the surveyor on 10/9/24 at 12:54 PM, the Social Worker stated that when someone lost their dentures she put a grievance into the portal and assigned it to both housekeeping and the laundry and then rerouted the grievance to the business office if they were not found. The Social Worker stated that there was a grievance filed on behalf of Resident #143 on 09/08/23, after the residents dentures were not found. The Director of Social Services (DSS) was present and stated that once the grievance was filed it went to everyone's email and the matter was discussed in morning meeting. The DSS stated that she did not remember if there was any follow up. The Social Worker stated that she spoke with the resident yesterday and he/she mentioned that he/she wanted their dentures replaced due to weight loss. The SW stated that she communicated that to both the Unit Manager and the Unit Clerk. The surveyor asked the Social Worker if she ever followed up with the grievance filed on 09/08/23 prior to yesterday and she stated that when the resident brought it up to her previously, she informed the resident that the facility was still looking for them. The surveyor asked the Social Worker if she documented when the resident asked about the status of his/her missing dentures and she stated, No. At that time, the DSS stated that the Social Worker should have documented the resident's concerns about their missing dentures and followed up. The DSS further stated that the delay could have been prevented if there was follow up with both the business office and the administrator. The DSS stated that there have been a few different Administrators and Business Office Officials since that time. On 10/9/24 at 4:15 PM, the surveyor reviewed a physician's order dated 10/9/24, within Resident #143's Electronic Health Record (EHR) for a Dental Consult RE: Bottom dentures, that was placed after surveyor inquiry. During an interview with the surveyor on 10/10/24 at 11:05 AM, the Business Office Manager (BOM) stated that she had worked at the facility since the end of July 2024. She stated that when a grievance was filed in the portal a notification email was sent that informed the recipient, A grievance has been assigned to your department. The BOM stated that the grievance should live in the system historically, but there may have been a discrepancy, as she did not see a grievance related to Resident #143's missing denture and could not speak to that. The BOM stated that this happened fairly recently with another resident and it was identified that it was the facility's liability and we received an invoice from the resident's dentist and paid the dentist directly. The BOM stated that she was informed yesterday that Resident #143's dentures were missing and spoke with the resident's spouse to initiate the process. During an interview with the surveyor on 10/10/24 at 11:52 AM, the surveyor interviewed the Regional Director of Operations (RDO) who stated that he was not the Licensed Nursing Home Administrator (LNHA) on record when Resident #143's grievance for missing dentures was reportedly filed. The RDO stated that a grievance was assigned to a party, and an email was sent out to all parties, and the LNHA was responsible to drive the investigation at that moment. The RDO stated the communication was well connected, but there was no answer on the grievance related to the missing dentures from September 2023. The RDO sated that he would have liked to have thought that the Social Worker followed up. The RDO stated, The grievance investigation starts and stops with the administrator. The RDO stated, There was certainly a lapse and delay there. The RDO further stated that the Social Worker did not follow up with the new administrator or it would have been taken care of. During an interview with the surveyor on 10/10/24 at 12:52 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #4 stated that Resident #143 was set up to go and see the dentist for denture replacement after surveyor inquiry. LPN/UM #4 further stated that he did not think that the resident reported the missing dentures to him prior. During an interview with the surveyor on 10/15/24 at 10:51 AM, the Director of Nursing (DON) stated that when a resident's denture was missing and could not be found we contacted the family to verify and if we can not find it, we consult with dental and get an impression and pay for the service if we found out that we were at fault or the denture was lost. The DON stated, My expectation was for the service to be provided sooner. During an interview with the surveyor in the presence of the survey team on 10/16/24 at 10:33 AM, the DON stated that Resident #143's dental appointment was scheduled and the Business Office would pay for dentures. The DON provided the surveyor with an updated physician's order dated 10/15/24 at 20:51 (8:51 PM) for a Dental consult for replacement dentures. A review of an undated facility policy, Grievances/Complaints, Recording and Investigating revealed the following: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve grievances (s). The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. .The Resident Grievance/Complaint Investigation Report will be filed with the administrator within five (5) working days of the incident. The Resident, or person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended. .Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. NJAC 8:39-15.1(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's psychological needs specifically by failing to implement a care plan for a resident diagnosed with anxiety on admission. The deficient practice was identified for 1 of 6 residents (Resident #167) reviewed for unnecessary medication. This deficient practice was evidenced by the following: On 10/8/2024 at 9:31 AM, during the initial tour, the surveyor observed Resident #167 in their room. A review of Resident 167's Admission Record face sheet (an admission summary) revealed that they had a diagnosis that included but not limited to; major depressive disorder, bipolar disorder, and generalized anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/5/2024, under Section I- revealed an active diagnosis of anxiety. A review of the physician orders (PO) revealed the following: lorazepam (a medication used to treat anxiety) oral tablet 0.5 milligrams (mg), Give one (1) tablet by mouth every six (6) hours as needed for anxiety. A review of the Individualized Comprehensive Care Plan (ICCP) did not include a focus area and interventions that addressed that Resident #167 had anxiety. During an interview with the surveyor on 10/15/24 at 12:28 PM, the Director of Nursing (DON) stated that if a resident had a diagnosis of anxiety and was being treated for it, he would expect it to be on the resident's care plan. A review of the facility's policy titled Care Plans, Comprehensive Person Centered, date revised March 2022, revealed, 7. The Comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, metal, and psychosocial well-being . NJAC 8:39-11.2

Complaint #: NJ176224 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) a resident was assessed by a Registered Nurse (RN) after sustaining a fall and b.) a resident was evaluated by a physical therapist as per a physician's order. This deficient practice was evidenced for 1 of 6 residents (Resident #305) reviewed for accidents and 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. A review of the Admission Record (an admission summary) reflected Resident #305 was admitted to the facility with diagnoses which included, but not limited to; seizures, muscle wasting and atrophy, hemiplegia and hemiparesis, and legal blindness. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/20/24, revealed that Resident #305 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS included in Section GG-Functional Abilities and Goals that the resident required partial assistance with activities of daily living (ADLs). A review of the individualized comprehensive care plan (ICCP), initiated on 11/6/23, included a focus area of I am at risk for falls related to impaired mobility, unsteady gait, weakness. Interventions included: Create a safe environment. A review of the facilty's Full QA (quality assurance) Report revealed, on 12/20/23 at 10:00 AM, Resident #305 sustained a fall during a transfer from the bed to the wheelchair. CNA #13 reported, I was transferring the patient and as [he/she] got in the chair, the cushion [he/she] has on the chair slide making [him/her] slide and I assisted as [he/she] slide to the floor . There was no evidence that a Registered Nurse (RN) assessed Resident #305 after the fall on 12/20/23. A review of the Nurse Practitioner's (NP) progress note, dated 12/21/23 at 6:32 PM, revealed, the NP assessed the resident and recommneded a follow-up with Physical Therapy (PT) for chair safety. There was no evidence that Resident #305 was evaluated by PT as recommended by the NP. During an interview with the surveyor on 10/15/24 at 11:09 AM, the Licensed Nursing Home Administrator (LNHA) confirmed that the PT evaluation was not done. When asked if it should have been done as per the NP's recommendation, she replied, yes. During an interview with the surveyor on 10/15/24 at 12:26 PM, the Director of Nursing (DON) stated that their process was after a PO was written then PT would be notified that the resident needed to be evaluated. During an interview with the surveyor on 10/16/24 at 10:27 AM, the DON stated, yes, an RN assessment was conducted after the fall on 12/20/23. A review of an undated facility policy Investigating Resident Injuries revealed, 1. The director of nursing services or a designee assesses all resident injuries and documents findings in the medical record.6. The medical director or attending physician shall review and verify conclusions about the possibility of a medical or other similar cause of the findings. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to complete a Tracking Record (Discharge) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, for 2 of 38 residents (Resident #108 and Resident #406) reviewed for resident assessments. The deficient practice was evidenced by the following: 1. On 10/11/24 at 1:00 PM, the surveyor completed record review of Resident #108 specific to MDS assessment. Resident #108 was discharged to home on 9/10/24. The Discharge Return Not Anticipated/End of PPS Part A Stay MDS was completed on 10/11/24. The discharge MDS was 17 days overdue. 2. On 10/11/24 at 3:00 PM, the surveyor completed record review of Resident #406 specific to MDS assessment. Resident #406 was discharged to the hospital on 7/9/24. The Discharge Return Anticipated MDS was completed on 8/2/24. The discharge MDS was 10 days overdue. Resident #406 was discharged to the hospital on 7/15/24. The Discharge Return Anticipated MDS was completed on 8/2/24. The discharge MDS was four days overdue. Resident #406 was discharged to the hospital on 8/9/24. The Discharge Return Anticipated/End of PPS Part A Stay MDS was completed on 8/28/24. The discharge MDS was five days overdue. Resident #406 was discharged to the hospital on 8/20/24. The Discharge Return Anticipated/End of PPS Part A Stay MDS was completed on 9/12/24. The discharge MDS was nine days overdue. On 10/15/24 at 10:36 AM, the surveyor interviewed the MDS Coordinator, License Practical Nurse (LPN), who has been working in the facility for almost four years. The MDS Coordinator stated, The MDSs get completed on the 14th day, which we try to do. We were behind on completing the MDSs because we had many admissions and discharges. The discharge MDSs for those two residents, yes, they're discharges were all completed late. On 10/15/24 at 12:25 PM, the MDS Coordinator provided the surveyor with the MDS Validation Reports from the Centers for Medicare and Medicaid Services (CMS) data base, which revealed the 9/10/24, 7/9/24, 7/15/24, 8/9/24, and 8/20/24 discharge MDS assessments were all completed late. On 10/15/24 at 1:50 PM, the surveyor in the presence of the Federal surveyor discussed with the facility administrative staff: Regional Director of Clinical Services (RDCS), License Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDO), regarding the concerns with the late MDSs completion. The RDO, who was the previous LNHA acknowledged, I do not recall how long the problem has been, but I know that this was an issue. The surveyor informed the administrative staff that the CMS validation reports verified the late MDSs. A review of the most current facility Policy and Procedure titled MDS Completion and Submission Timeframes, revised in October 2023 revealed, 'Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. NJAC 8:39 - 11.1

Based on interviews, record review and review of other pertinent documentation, it was determined that the facility failed to report timely an allegation of staff to resident abuse to the facility administrator and the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 residents (Resident #173) reviewed for an allegation of abuse. This deficient practice was evidenced by the following: During the initial tour of the facility on 10/08/24 at 1:36 PM, Resident #173 was observed seated on the side of their bed. When interviewed, the resident was tearful at times as they described how they were spoken to by the Nurse Practitioner (NP). The resident stated that the NP told them that they would die if they did not take their potassium. The resident stated that he/she did not want care forced upon them. The resident stated that they preferred to take a more natural approach like eating bananas instead of taking medication such as potassium. The resident stated that they had declined the medication and that was what the NP was mad about. The resident stated that they were most upset about the fact that the NP took away his/her diuretics (water pill) and the resident feared getting fluid build up in their lungs and limbs. The resident stated that they had spoken with both the Social Worker (SW) and psychiatry about the incident. A review of Resident #173's Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to; chronic kidney disease, unspecified, major depressive disorder, heart failure, unspecified, essential (primary) hypertension (high blood pressure), pleural effusion (a build up of fluid between the tissues that line the lungs and chest), and traumatic subarachnoid hemorrhage (results from a medical aneurysmal (an enlargement of an artery caused by a weakening artery wall) rupture or traumatic head injury resulting in bleeding between the subarachnoid (area in the brain) space). A review of Resident #173's quarterly Minimum Data Set (MDS), an assessment tool, dated 09/23/24 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated that the resident was fully cognitively intact. The remainder of the assessment remained in progress. A review of Resident #173's Care Plan included an entry dated 5/7/24 with a Focus of: I have fluid deficit and/or potential fluid deficit related to diuretic use. Fluid restriction. The Goal included: I will be free from s/s/x (signs and symptoms) of fluid deficit by/through the review. Interventions included: Administer medications as ordered. Monitor for side effects and effectiveness. Educate me/RP (responsible party) on the importance of adequate fluid intake .Notify Medical Doctor (MD) of significant abnormalities and/or significant changes from baseline. The resident's Care Plan failed to contain an entry for the resident's refusal of medications or noncompliance with related interventions. A review of Resident #173's Electronic Health Record (EHR) revealed a Nurse Practitioner (NP) Note dated 10/05/24 at 9:32 AM, which indicated, The reason for the visit was: f/u (follow up) hypokalemia (low potassium level)/chf (congestive heart failure)/Pleural effusions.The NP documented that the resident was seen per nursing request. Pur [sic.] nursing the patient is refusing potassium supplementation. The patient is currently on bumex (diuretic), metolazone (diuretic), and acetazolamide (diuretic). The NP documented that the resident refused to talk to this author. reports he/she does not wish to take potassium or medications, attempted to discuss with patient risk for hypokalemia if untreated, risk of low potassium with large amount of diuretics, patient placed head phones back on head and refused to speak. no signs of acute distress noted Psychiatric: Oriented to self, Pleasant, cooperative Oriented to person, Oriented to place, Oriented to year and refused exam or speaking to NP regarding care.Spoke with nursing and will discontinue medications for now due to patient refusing potassium supplementation and high use of diuretics puts patient at risk for low potassium, patient will be at risk for Congestive Heart Failure/pleural effusion will monitor fluid volume status closely if patient will allow .Rx (prescription) to discontinue metolazone placed, rx to discontinue diamox, rx for potassium chloride 40 meq (milliequivalent) in the am only, continue bumex to 1 mg once daily .depression: placed order for psych eval . On 10/9/24 at 11:52 AM, the surveyor interviewed the Nurse Practitioner (NP) who stated that she recalled speaking with Resident #173 and the resident would not listen to me and put headphones on. The NP stated that the doctor was called and he told me to decrease the diuretics if we could not get him/her to take the potassium. The NP stated she asked the resident if there was a reason that they refused to take the potassium? She stated that was when he/she put the headphones on and refused to talk to me. The NP further stated that the resident did not ask to stay on diuretics. During an interview with the surveyor on 10/9/24 at 1:18 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) #4 stated that he had spoken with Resident #173 and the resident did not tell him that he/she was upset, just depressed. LPN/UM #4 stated that the nurses said the resident was refusing medications and we put the resident in to see psychiatry. LPN/UM #4 stated that the resident did not bring it to his attention that he experienced maltreatment from the NP. During a follow-up interview with the surveyor on 10/10/24 at 12:39 PM, the surveyor asked LPN/UM #4 if he reported Resident #173's allegation of abuse by the NP? The LPN/UM #4 stated that sometimes the resident did not take their medications and wanted to do things the natural way. LPN #4 further stated, I am going to report it. On 10/15/24 at 9:44 AM, the surveyor requested all incidents and investigations related to Resident #173 and the Licensed Nursing Home Administrator (LNHA) confirmed that there were none. During an interview with the surveyor on 10/15/24 at 9:47 AM, the surveyor interviewed LPN/UM #4 who stated, I reported the allegation of abuse to the administrator when I was done talking to you and he ordered the Social Worker to talk with the resident directly. He stated that no further investigation was completed on his end. A review of a Social Services note dated 10/08/24 at 4:37 PM revealed that the SW documented, SW rounded on resident and provided active listening and psychosocial support.A psychology referral made for an added layer of mental health support. SW will continue to monitor and remain available. During an interview with the surveyor on 10/15/24 at 10:08 AM, the LNHA stated that LPN/UM #4 had not conveyed any concerns to her regarding Resident #173. The LNHA reconfirmed that no reportable events or investigations were completed for the resident. The Director of Nursing (DON), who was present, stated that while no abuse allegation was made, the SW mentioned to the DON that the resident did not want to follow the NP's recommendations. The DON stated that the Director of Social Services (DSS) came to me last week and stated that, The resident did not want to follow the recommendations of the Nurse Practitioner because he/she has been told what to do all of his/her life and did not want to be told what to do. The DON stated that if abuse were suspected, then it would be reported immediately. At that time, the SW who was present, stated that she did not recall who informed her of a need to speak with Resident #173, and she did not think that it was LPN/UM #4. The SW stated that she was not informed that the resident felt abused prior to seeing the resident. The SW stated that the resident chose not to follow the plan of care or recommendations or abide by their Care Plan. The SW stated the resident was calm and just wanted to do things on their terms and understood the potential risks or dangers of not following medications as prescribed and wanted to do things on their terms as his/her responsible party. At that time, the DON stated that LPN/UM #4 should have reported to him or the LNHA and we should have followed the protocol to report to the Department of Health after an investigation within five days. The DON stated, None of that has been done. The LNHA stated, We will report it now, since we were just made aware. A review of an undated facility policy, Recognizing Signs and Symptoms of Abuse/Neglect revealed the following: All types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. A review of a facility policy, Accidents and Incidents-Investigating and Reporting dated revised July 2017 revealed the following: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. .The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. The director of nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accidents for each occurrence . NJAC 8:39-9.4(f)