Every finding on record at Llanfair House Care & Rehabilitation Center

Based on observation and interview, the facility failed to ensure food was served under sanitary conditions which included proper glove use for one of one kitchen. This failure placed 113 census residents at risk for food borne illnesses. Findings include:During an observation and interview on 06/03/26 at 11:42 AM, a [NAME] was observed with gloves on preparing the plates for each food tray. As the [NAME] was preparing specialized plates, the [NAME] was touching other items in the kitchen (opening and closing the warmer, touching other surfaces away from the tray line) with the same gloved hands. The [NAME] then went back to tray line and started preparing plates for residents and touched the food on the plate with the same gloved hands used when starting to prepare resident food plates. The [NAME] stated gloves needed to be changed when they touched other things before they went back to touching food on tray line. During an observation on 06/03/26 at 12:45 PM, the Dietary Manager (DM) was assisting with tray line preparing plates for the residents. A meal slip showed a resident requested a hamburger for lunch. The DM stepped away to prepare the hamburger. With the same gloved hands, the DM touched the hamburger bun, opened the warmer door to get the hamburger, and then touched the bun again to place the hamburger on the bun. During an interview on 06/03/26 at 1:26 PM, the DM stated he/she would expect his/her staff to change their gloves when they moved away from the tray line to do other things and put on clean gloves when they came back to the tray line. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure female residents had facial hair removed for two of four residents (Resident (R) 43 and R70) and fingernails were kept clean and trimmed for two of four residents (R65 and R92) reviewed for activities of daily living (ADL) of 35 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility. Findings include: Findings include: 1. Review of R43's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and lack of coordination. Review of R43's Care Plan located under the Care Plan tab of the EMR, dated 02/15/24, revealed R43 had ADL self-care performance deficiencies related to dementia, disease process related to Parkinson's disease and limited mobility. R43 required total staff assistance of one staff with personal hygiene. Review of R43's annual Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/21/26, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating severe cognitive impairment. The MDS indicated impairment of upper extremity on one side and required substantial/ maximal assistance with personal hygiene. Review of R43's Progress Notes located under the Progress Notes tab of the EMR, dated 05/04/26 through 06/03/26, revealed the resident did not refuse care. Review of R43's Hygiene Task located under the Task tab of the EMR, dated 05/05/26 through 06/01/26, revealed the resident did not refuse the tasks. During an observation on 06/01/26 at 3:05 PM, R43 had hair on his/her face near the corners of his/her mouth/ upper lip. During an observation on 06/02/26 at 10:50 AM, R43 had hair on his/her face near the corners of his/her mouth/ upper lip and slight stubble to chin area. During an observation on 06/02/26 at 4:27 PM, R43 had hair on his/her face near the corners of his/her mouth/ upper lip and slight stubble to chin area. During an observation on 06/03/26 at 8:55 AM, R43 had hair on his/her face near the corners of his/her mouth/ upper lip and slight stubble to chin area. During an interview on 06/03/26 at 2:18 PM, Registered Nurse (RN) 3 confirmed, while at R43's wheelchair, the resident had facial hair near the corners of his/her mouth/ upper lip and stubble on his/her chin. He/she stated it was a dignity issue and should be removed. During an interview on 06/03/26 at 3:12 PM, Unit Clerk confirmed, while at R43's wheelchair, the resident had facial hair near the corners of his/her mouth/ upper lip and stubble on his/her chin. He/she stated it was a hygiene and dignity concern and should be removed. 2. Review of R70's admission Record located under the Profile tab of the EMR revealed R70 was admitted on [DATE] with a diagnosis of dementia. Review of R70's Care Plan located under the Care Plan tab of the EMR, dated 11/06/22, revealed R70 had an ADL self-care performance deficit related to aggressive behavior, dementia and required limited assistance with personal hygiene. Review of R70's significant change MDS located under the MDS tab of the EMR with an ARD of 02/22/26 revealed a BIMS score of four out of 15 indicating severe cognitive impairment. The assessment revealed the resident required partial/ moderate assistance with personal hygiene. Review of R70's Progress Notes located under the Progress Notes tab of the EMR, dated 05/04/26 through 06/01/26, revealed R70 did not refuse any care. Review of R70's Personal Hygiene Task located under the Task tab of the EMR, dated 05/04/26 through 06/02/26, revealed R70 did not refuse any hygiene related care. During an observation on 06/01/26 at 2:08 PM, R70 had facial hair on his/her chin. During an observation on 06/02/26 at 4:28 PM, R70 had facial hair on his/her chin. During an observation on 06/03/26 at 8:59 AM, R70 had facial hair on his/her chin. During an interview on 06/03/26 at 2:18 PM, RN3, at R70's wheelchair, confirmed the resident had facial hair on his/her chin. He/she confirmed it was a dignity issue and should be removed. During an interview on 06/03/26 at 3:12 PM, Unit Clerk, at R70's wheelchair, confirmed the resident had facial hair on his/her chin. He/she stated it was a hygiene and dignity concern and should be removed. 3. Review of R65's admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE] with a diagnosis of type two diabetes mellitus with complications. Review of R65's Care Plan located under the Care Plan tab of the EMR, dated 04/23/25, did not indicate fingernail care. Review of R65's annual MDS located under the MDS tab of the EMR with an ARD of 04/20/26 revealed a BIMS score of 13 out of 15 indicating cognitively intact. The MDS indicated upper extremity impairment on one side and set up or clean up assistance with personal hygiene. Review of R65's Nail Care Task located under the Task tab of the EMR, dated 05/04/26 through 06/02/26, revealed the resident had not refused nail care. Review of R65's Hygiene Task located under the Task tab of the EMR, dated 05/04/26 through 06/02/26, revealed the resident had not refused the task. During an interview on 06/01/26 at 11:10 AM, R65 stated he/she was unable to trim his/her fingernails himself/herself due to the arthritis in his/her hands and that staff would not trim them. R65's fingernails were observed to be approximately one fourth inch long. During an observation 06/02/26 at 10:54 AM, R65's fingernails were approximately one fourth inch long. During an interview on 06/03/26 at 3:11 PM, RN3 confirmed, while at R65's bedside, the residents' fingernails were approximately one fourth in length and needed to be trimmed to prevent injury. He/she confirmed a nurse needed to be the one to trim R65's fingernails as he/she was diabetic. 4. Review of R92's admission Record located under the Profile tab of the EMR revealed R92 was admitted on [DATE] with diagnoses of Parkinson's disease, Alzheimer's disease, and dementia. Review of R92's Care Plan located under the Care Plan tab of the EMR, dated 05/12/22, revealed R92 had ADL self-care performance deficit related to dementia and impaired balance. R92 was totally dependent on staff for personal hygiene. Review of R92's annual MDS located under the MDS tab of the EMR with an ARD of 03/20/26 revealed a BIMS score of zero out of 15 indicating severe cognitive impairment. The assessment also revealed the resident had an upper body impairment on one side and was dependent for personal hygiene. Review of R92's Personal Hygiene Task located under the Task tab of the EMR, revealed from 05/05/26 through 06/03/26, R93 did not refuse any personal hygiene care. During an observation on 06/01/26 at 11:25 AM, R92's fingernails were approximately one fourth inch long with a black substance underneath them. During an observation on 06/02/26 at 10:47 AM, R92's fingernails were approximately one fourth inch long with a black substance underneath them. During an observation on 06/02/26 at 4:25 PM, R92's fingernails were approximately one fourth inch long with a black substance underneath. During an interview on 06/03/26 at 2:18 PM, RN3, at R92's bedside, confirmed the resident's fingernails were approximately one fourth inch long with a black substance underneath them. He/she confirmed the resident's fingernails should be cleaned and trimmed for hygiene purposes. Review of the facility's policy titled, ADL Care Policy, updated on 11/25, noted It is the policy and procedure of this facility for the CNA's [Certified Nurse Aide] to adequately provide ADL care to the residents. Procedure: 1. ADL care, including assisting residents with daily bathing, dressing, grooming, dental care, ear/ eye care and toileting. 2. Reviewing and following the resident Plan of Care. NJAC 8:39-4.1(a)22 NJAC 8:39-27.1(a) NJAC 8:39-27.2 (g)

Based on interview, record review, and facility policy review, the facility failed to ensure medications were evaluated with clinical indications for use documented for as needed (PRN) psychotropic medication (lorazepam) beyond 14 days for one of five residents (Resident (R) 10) and ensure target psychotropic behavior monitoring was conducted for one of five residents (R4) reviewed for unnecessary medications of 35 sample residents. This failure had the potential to place the residents at risk of adverse consequences. (Cross Reference F756)Findings include:1. Review of R10's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 10/20/25, with a diagnosis of unspecified dementia, unspecified severity, with agitation. Review of R10's EMR Care Plan located under the Care Plan tab, dated 12/09/25, indicated that the resident was placed on hospice care and the goal was to provide the resident with comfort care. Review of R10's EMR Treatment Plan & Informed Consent for Psychotropic Medications located under the Misc. (Miscellaneous) tab, dated 12/12/25, indicated that R10's representative signed the consent for the use of lorazepam since the medication was initiated. Review of R10's EMR physician Orders located under the Orders tab, dated 12/12/25, revealed an order for lorazepam 0.5 milligrams (mg) to be administered every four hours for anxiety PRN. There was no 14-day stop date. Review of R10's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/17/26, located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed that the resident was severely cognitively impaired. The assessment indicated that R10 had no behaviors that would indicate harm to self or to others. The resident was in hospice care. Review of R10's EMR Medication Administration Record (MAR) located under the Orders tab for the months of 12/25, 01/26, and 02/26 indicated the resident was not administered PRN lorazepam 0.5 mg during these months. Review of R10's EMR MAR located under the Orders tab for the month of 03/26 indicated the resident was administered PRN lorazepam 0.5 mg on 03/06/26. Review of R10's EMR MAR located under the Orders tab for the month of 04/26 indicated the resident was administered PRN lorazepam 0.5 mg on 04/05/26 and 04/07/26. Review of R10's EMR MAR located under the Orders tab for the month of 05/26 indicated the resident was administered PRN lorazepam 0.5 mg on 05/02/26. Review of R10's EMR MAR located under the Orders tab for the month of 06/26 indicated that the resident was not administered PRN lorazepam 0.5 mg. During an interview on 06/02/26 at 1:24 PM, Registered Nurse (RN) 1 stated that the lorazepam was to ease R10's anxiety and that hospice ordered the medication. RN1 stated he/she never alerted the physician or hospice to review the pharmacy recommendations. During an interview on 06/02/26 at 2:18 PM, the Pharmacy Owner/Pharmacist stated that it was his/her understanding that all PRN psychotropic medications were to have an initial 14-day end date and then to be re-evaluated by the prescriber, ordered, and another end date (it could go beyond the 14 days). During a subsequent interview on 06/03/26 at 11:08 AM, Pharmacy Owner/Pharmacist stated that R10 was re-evaluated on 04/08/26; however, record review revealed that the prescriber documented a clinical rationale but did not have duration for continued PRN use beyond 14 days. During an interview on 06/03/26 at 12:33 PM, Pharmacy Owner/Pharmacist stated that the original order for the lorazepam 0.5 mg to be administered every four hours as needed was from hospice. Review of a facility's policy titled, Psychotropic Medication & Management & Pharmacy Review dated 11/25, indicated .To ensure that each resident's drug regimen is free from unnecessary medications, including psychotropic medications (Psychoactive) drugs, and to guarantee that these medications are only used to treat medically diagnosed conditions.PRN (As-Needed) orders for psychotropic medications (excluding antipsychotics) are strictly limited to 14 days. Prolonging PRN use beyond 14 days requires the prescriber to document a clinical rationale and duration in the medical record. 2. Review of R4's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnosis including unspecified dementia with behavioral disturbance. Review of R4's quarterly MDS with an ARD of 4/14/26 and located in the EMR indicated a BIMS score of three out of 15, which indicated R4 was severely cognitively impaired. Further review revealed R4 received antipsychotic medications routinely. Review of R4's Physician Order Report, dated 06/02/26 and found in the EMR under the Orders tab, indicated R4 was to receive Quetiapine 100 milligrams (mg), one tablet by mouth twice a day and Seroquel 100 milligrams (mg), one tablet at bedtime for dementia with behaviors. Review of R4's MAR dated January 2026, February 2026, March 2026, April 2026, May 2026, and June 2026 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific target behaviors were associated with the administration of the resident's antipsychotic medications and required routine monitoring. Review of R4's ''Nurse's Notes'' located in the EMR under the ''Notes'' tab for January 2026 through June 2026 revealed no documented target behaviors related to a diagnosis of dementia with behaviors. During an interview on 06/03/26 at 10:55 AM, Licensed Practical Nurse (LPN) 1 said he/she was unsure what specific behaviors R4 was prescribed antipsychotic medications for. He/she stated he/she would assume it was any behavior like acting out or being combative and refusing care. But agreed a new nurse who was not familiar with the resident would not know what the resident's baseline was or what specific behaviors to look for. LPN1 stated the target behaviors should be specific to each resident. During an interview on 06/03/26 at 12:39 PM, RN2 said the MAR would have the target behaviors listed for staff to observe and document throughout the shift. He/she stated R4's was not specific target behaviors and that it should be specific to the person. RN4 said staff would need to ask someone to know which target behaviors they needed to monitor for R4's antipsychotic medication. During an interview on 06/04/26 at 9:49 AM, the Director of Nursing (DON) said psych evaluated all residents that were on antipsychotic medications and made sure it was appropriate use for the medications. He/she stated they made sure there was also an appropriate diagnosis and why they were on the medication. He/she stated he/she expected staff to monitor target behaviors which was the reason why they required medication. He/she stated the behaviors should be specific for each resident. NJAC 8:39-4.1(a)6 NJAC 8:39-5.1

Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency (SSA) for one of one resident (Resident (R) 66) reviewed for abuse out of 35 sampled residents. This failure increased the risk of other vulnerable residents being abused. Findings include:Review of R66's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 06/06/26. Review of R66's EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) located under the MDS tab, dated 05/13/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which revealed that the resident was cognitively intact. During an interview on 06/01/26 at 10:36 AM, R66 stated he felt like he/she was being mentally abused since the facility held his/her mental health medications. There was no documentation related to this allegation. During an interview on 06/03/26 at 1:35 PM, the Administrator and Director of Nursing (DON) were present. The Administrator stated that he/she did not report the allegation of mental abuse to the State Survey Agency (SSA) since it was his/her understanding that the allegation was associated with R66's medications. The Administrator stated he/she typically reported all allegations of abuse to the SSA timely. Review of a facility's policy titled, Abuse, Neglect, and Mistreatment of Residents Policy, dated 05/26, indicated .MENTAL ABUSE: Includes but is not limited to humiliation, harassment, threats of punishment or deprivation.This facility will ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property will be reported immediately to the Administrator/ Designee of the facility and to other officials in accordance with State law through established procedures (including the State survey and certification agency). NJAC 8:39-9.4(f)

Based on observation, record review and staff interview, the facility failed to ensure residents were appropriately screened and had documentation to support the use of wander guards for one of two residents (Residents (R) 4) reviewed for wander guards of 35 sample residents. This failure had the potential to affect all residents with wandering behaviors. Findings include:Review of R4's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, muscle weakness, and cognitive communication deficit. Review of R4's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/07/25, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Further review of MDS along with previous MDS assessments completed on 01/13/26 and 10/14/25 revealed no wandering behavior was exhibited. Review of R4's Care Plan located under the Care Plan tab of the EMR, dated 10/02/24, revealed the resident was care planned for risk of wandering and elopement. Interventions in place were to place wander guard on resident right wrist, implement toileting schedule, provide care in a calm and reassuring manner, and provide clear, simple instructions. Further review revealed no updates to care plan since 10/02/24. Review of R4's Physician Orders located under the Orders tab in the EMR, dated 05/28/25, revealed wander guard on right wrist, check placement and function Q [every] shift. Review of R4's Elopement Risk Assessment located under the Observations tab in the EMR, dated 03/26/26, 12/27/25, and 09/28/25, revealed R4 scored an eight indicating R8 was at risk for elopement. Review of R4's General Notes located under the Notes tab of the EMR, dated 09/01/25 through 06/01/26, revealed no documentation of any wandering or exit seeking behaviors. Observations of R4 on 06/01/26 at 1:30 PM and 06/02/26 at 8:30 AM during the survey revealed wander guard on right wrist. R4 observed in room and walking down the hallway. During an interview on 06/03/26 at 10:55 AM, Licensed Practical Nurse (LPN) 1 stated R4 liked to walk around. He/she stated the resident was alert but also confused and was noncompliant from redirection. LPN1 stated R4 liked to focus on other people and repeat what they said and he/she could be accusatory towards staff. LPN1 stated R4 did not always have purpose when he/she walked around the unit but sometimes he/she did. He/she stated that R4 had the tendency to wander but did not exit seek. He/she stated R4 walked by the elevators but agreed all residents would have to pass by them to get to the dining room. LPN1 said any behavior of wandering or exit seeking was supposed to be documented in progress notes but staff didn't always get around to doing that. He/she stated that documenting these behaviors were important to show a history of behavior or a current concern. During an interview on 06/03/26 at 11:10 AM, Certified Nurse Aide (CNA) 1 stated R4 liked to walk around the unit, but he/she was unaware of any exiting seeking behavior. He/she stated he/she has never seen R4 do anything like that. CNA1 Stated R4 walked by the elevators but all residents passed by to get to the dining room. CNA1 said R4 was not an elopement risk and never tried to get out of the facility or ever talked about wanting to leave or get out. During an interview on 06/03/26 at 11:20 AM, LPN2 said she was one of the unit managers. He/she said unit managers completed the elopement assessment for residents on admission and quarterly. LPN2 stated all the information used to complete the forms was documented in the residents' medical chart. LPN2 stated if staff were observing wandering or exit seeking behaviors that should be documented in progress notes or in behavior charting. LPN2 stated the wander guard was not indefinite, and staff should be assessing if there were current documented risks to reconsider for the wander guard use. LPN2 stated a resident should not have a wander guard if there was no documented risk. During an interview on 06/03/26 at 11:33 PM, CNA2 stated R4 was very particular and staff would have to talk to him/her a certain way. CNA2 stated R4 liked to walk back and forth between rooms and would go down the hallway and come back up the hallway. He/she said R4 was not exiting seeking, and he/she was redirectable, but they had to know how to talk to him/her. He/she said R4 never tried to leave and never talked about wanting to leave but if he/she did that would have to be reported to the nurse. During an interview on 06/04/26 at 9:30 AM, the MDS Coordinator (MDSC) stated he/she doubled checked and R4 had no wandering behaviors from October 2025 to present as indicated on the last three completed assessments. During an interview on 06/04/26 at 9:49 AM, the Director of Nursing (DON) said there should be ongoing evaluation for wander guard use and see if it's an appropriate use. The DON stated it would be helpful if staff were documenting wandering or exit seeking behavior but that he/she did not expect them to. He/she said staff discussed the residents' behaviors during care plan meetings. The DON stated was unsure how anyone would know what staff were observing and if wandering or exit seeking was occurring if that wasn't documented since the DON said that not all staff were present during these meetings. NJAC 8:39-4.1(a) NJAC 8:39-5.1(a) NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for two of three residents (Resident (R) 12 and R54) reviewed for side rails out of 35 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include:1. Review of R12's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia and lack of coordination. Review of R12's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/26 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R12 was severely cognitively impaired. Review of R12's Care Plan located under the Care Plan tab of the EMR, dated 07/21/25, revealed R12 was not care planned for side rail use. Review of R12's Physician Orders located under the Orders tab in the EMR, dated 07/22/25, revealed half side rail use for positioning. Review of R12's [Name] Admission/readmission located under Assessments tab in the EMR, dated 07/21/25, revealed side rail assessments were not indicated at that time. Review of R12's admission [Name] Summary-Bed Rail located under Assessments tab in the EMR, dated 02/03/26, revealed side rail assessment not completed at that time. Further review of quarterly assessment, dated 10/27/25, revealed no documentation that alternates were explored prior to bed rail/side rail use. Observation on 06/02/26 at 9:14 AM revealed R12 was in bed, head of bed (HOB) upright, and side rails were up on both sides. Side rails on both sides. 2. Review of R54's Face Sheet located under the Profile tab in the EMR, revealed the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including muscle wasting and atrophy. Review of R54's discharge return anticipated MDS with an ARD of 05/12/26 and located under the MDS tab in the EMR, revealed a BIMS score of zero out of 15 indicating severe cognitive impairment. The MDS revealed R54 had severe impairment with cognitive skills for daily decision making. Review of R54's Care Plan located under the Care Plan tab of the EMR, initiated on 04/14/26, revealed the resident used side rails as an enabler with interventions including use side rails for aiding in turning and repositioning within the bed. Review of R54's Physician Orders, last reviewed on 06/01/26 and located under the Orders tab of the EMR, did not reveal a current order for bed rail use. Observation on 06/03/26 at 2:17 PM revealed R54 was resting in bed with side rails on both sides at the top portion of the bed. During an interview on 06/03/26 at 11:20 AM, Licensed Practical Nurse (LPN) 2 said he/she was one of the unit managers. LPN2 stated all residents were reviewed for side rails on admission. He/she stated residents and family would verbalize if they wanted to use side rails for getting up from the bed. He/she stated it was also discussed during the care plan meeting. He/she said that all the residents wanted side rails. He/she stated they did not attempt alternatives prior to bedrail use. LPN2 stated most of the beds already had side rails attached. During an interview on 06/04/26 at 9:49 AM, the Director of Nursing (DON) said side rail assessments were completed the same day the resident admitted to the facility. The DON stated staff should be completing alternatives to bedrail use and looking at the least restrictive measure. He/she stated they should not use bedrails if they had not looked at alternatives first. He/she stated that many of their beds already had side rails attached and he/she was unsure if they could be removed. Review of the facility's policy titled, SIDE RAILS, updated 11/25, revealed it is the policy of this facility to provide residents with side rails as an enabler for bed mobility. Residents may request the use of side rails for their own personal reasons. It is the residents' right that this decision must be honored. NJAC 8:39-5.1(a) NJAC 8:39-27.1(a)

Based on interview, record review, and policy review, the facility failed to ensure medication irregularities were responded to after the Consultant Pharmacist identified that there was a required stop date for one of six residents (Resident (R) 10) reviewed for medication regimens of 35 sampled residents. The Consultant Pharmacist identified that there was a required end date for an as needed (PRN) psychotropic medication (lorazepam) and the facility failed to respond and correct the order. This placed the residents at risk for unnecessary prolonged use of psychotropic medication. Findings include:Review of R10's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 10/20/25, with a diagnosis of unspecified dementia, unspecified severity, with agitation. Review of R10's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference date of 03/17/26, located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed that the resident was severely cognitively impaired. Review of R10's EMR physician Orders located under the Orders tab, dated 12/12/25, revealed an order for lorazepam 0.5 milligrams (mg) to be administered every four hours for anxiety PRN. There was no 14-day stop date. Review of a document provided by the facility Nursing Summary Report, dated 01/02/26, indicated the Consultant Pharmacy alerted the facility of inconsistencies of the resident's medication. Specifically, the document indicated that a .duration must be specified for PRN psychoactive medications. The first order is limited to only 14 days. The next duration may be longer, i.e., 30, 60, or 90 days, if the prescriber documents the rationale to continue the order. Review of a document provided by the facility Nursing Summary Report, dated 02/04/26, indicated the Consultant Pharmacy alerted the facility of inconsistencies of the resident's medication. Specifically, the document indicated that a .duration must be specified for PRN psychoactive medications. The first order is limited to only 14 days. The next duration may be longer, i.e., 30, 60, or 90 days, if the prescriber documents the rationale to continue the order. Review of a document provided by the facility Nursing Summary Report, dated 03/04/26, indicated the Consultant Pharmacy alerted the facility of inconsistencies of the resident's medication. Specifically, the document indicated that a .duration must be specified for PRN psychoactive medications. The first order is limited to only 14 days. The next duration may be longer, i.e., 30, 60, or 90 days, if the prescriber documents the rationale to continue the order. Review of a document provided by the facility Nursing Summary Report, dated 04/06/26, indicated the Consultant Pharmacy alerted the facility of inconsistencies of the resident's medication. Specifically, the document indicated that a .duration must be specified for PRN psychoactive medications. The first order is limited to only 14 days. The next duration may be longer, i.e., 30, 60, or 90 days, if the prescriber documents the rationale to continue the order. Review of a document provided by the facility Nursing Summary Report, dated 05/08/26, indicated the Consultant Pharmacy alerted the facility of inconsistencies of the resident's medication. Specifically, the document indicated that a .duration must be specified for PRN psychoactive medications. The first order is limited to only 14 days. The next duration may be longer, i.e., 30, 60, or 90 days, if the prescriber documents the rationale to continue the order. During an interview on 06/02/26 at 2:18 PM, Pharmacy Owner/Pharmacist stated if the Consultant Pharmacist could not obtain an end date on a PRN psychotropic medication, they will escalate the issue to the Director of Nursing (DON). The Pharmacy Owner/Pharmacist stated he/she did not know the reasons for not receiving a response from the facility. During an interview on 06/03/26 at 12:33 PM, Pharmacy Owner/Pharmacist stated that the original lorazepam was from hospice and wanted to do the best for R10. An interview was conducted on 06/04/26 at 9:03 AM with the Administrator and the DON. The DON stated that the facility addressed clinical issues each morning to ensure that physician orders were signed on the pharmacy reports. Review of a facility's policy titled, Psychotropic Medication & Management & Pharmacy Review, dated 11/25, indicated .Consultant Pharmacist: Conducts monthly and targeted drug regimen reviews, identifies unnecessary drug usage, and submits irregularity reports to clinical leadership. NJAC 8:39-29.3

Based on observation, interview, and facility policy review, the facility failed to ensure three of three medication storage rooms and one of four medication carts were free of expired medications, syringes, collections tubes for specimens, and COVID-19 test for 113 census residents. This practice had the potential to affect medications and biologicals efficacy.Findings include:During an observation on 06/02/26 at 10:28 AM, alongside the Licensed Practical Nurse (LPN) 2, revealed all three medication storage rooms had Medline industries, sterile foam tipped applicators, expired on 05/26 and Medline industries, safety syringe 25Gx1.0 (139 syringes), expired 11/26/25. Observation of the first and second floor medication storage rooms revealed Osang Heatlhcare, (OHC), covid-19 antigen self-test expired 05/05; One a day vitamin, two bottles expired 04/26; and Cyclosporine ophthalmic emulsion 0.05%, two bottles expired 05/26. Observation of the first-floor medication cart revealed morphine oral 5mg (milligram) (25 syringes Predose) expired on 03/24. LPN2 confirmed at this time that the syringes, collection tubes, and covid-19 tests expired. During an interview on 06/03/2026 at 3:56 PM, Central Supply (CS) 1 stated it was not acceptable to have biologicals expired in the facility, especially in that amount. During an interview on 06/02/26 at 10:56 AM, the Administrator stated it was not acceptable to have biological and/or medications expired in the facility. Review of the facility's policy titled, Medication storage, reviewed 02/26, revealed under procedure 3. If the facility has discontinued, outdated or deteriorated mediations or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. check that medication are labeled with open date and not expired before administrating. Review of the facility's policy titled, Medication administration, reviewed 11/25, under procedure: .2. No expired or discontinued medications in the medication cart. Under Medication Administration (General).2. Check expiration date of all medications being administered. NJAC 8:39-29.4(h)

Based on observations, interviews, and policy reviews, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in rooms with enhanced barrier precautions (EBP) for one of one resident (Resident (R) 83) reviewed for infection control of 35 sample residents. These deficient practices had the potential to affect all residents and increase the risk for cross contamination and the spread of infections throughout the facility. Findings include: Observation on 06/02/26 at 9:13 AM of room [ROOM NUMBER]-D revealed signage on the outside of door which indicated EBP. Registered Nurse (RN) 2 was administering medications to R83 in bed A by the door and checking the resident's percutaneous endoscopic gastrostomy (peg) tube. RN2 was observed wearing gloves but no gown and was observed pulling back the residents' blankets. RN2 was observed leaning across R83 contacting the residents' stomach area while he/she touched the residents' peg tube with his/her hand. RN2 removed gloves and disposed of them and put another pair on but did not sanitize his/her hands prior to putting on the new pair of gloves. RN2 removed the gloves and exited the room and walked to medication cart outside the door. At that time, he/she was observed sanitizing his/her hand. During an interview on 06/03/26 at 9:15 AM, RN2 stated he/she was an agency nurse. He/she stated that he/she had not received any training by the facility or his/her agency related to infection control or EBP. RN2 stated he/she did not need to wear a gown since he/she was not changing the residents peg tube. He/she was unable to provide an explanation for why the sign on the door indicated staff should wear gowns when providing close contact care. During an interview on 06/04/26 at 8:24 AM, the Infection Preventionist (IP) stated whenever staff were providing a patient care who had a g-tube, staff must gown and glove up before they provided care. He/she also expected them to wash their hands before and after changing gloves and entering and exiting the room. During an interview on 06/04/26 at 9:49 AM, the Director of Nursing (DON) said staff providing care to a resident on EBP and providing close contact care must gown and glove and should practice hand hygiene between glove changes and when they were done. Review of the facility's policy titled, Infection Control Policy and Procedure, revised 01/26, revealed To help prevent the development and transmission of communicable diseases and infections in the Facility and to ensure that the Facility: Enhanced Barrier Precautions (EBP) a. Enhanced Barrier Precaution means an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. b. EBPS are used in conjunction with standard precautionsand expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms 'MDRO' to staff hands and clothing. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. NJAC 8:39-19.4

Based on interviews, record review, and facility assessment review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for two of two staff (Registered Nurse (RN) 2 and Certified Nurse Aide (CNA) 1) reviewed for training with the potential to affect 113 census residents. This failure had the potential to lead to increased spread of infection. Findings include: Review of the Facility Assessment, updated 01/02/26 and provided by the facility, revealed the facility provided staff training/education and competencies that were necessary to provide care and support for their resident population. The training/education and competencies/skill checks were generally provided upon hire, during monthly in-service/training, whenever an area of concern was identified, or new areas were identified based on resident diagnosis and/or clinical condition. Review of RN2's employee Personnel Training File, provided by the facility, revealed no documentation of pre-employment training or in-service related to infection control or enhanced barrier precautions (EBP). During an interview on 06/03/26 at 9:15 AM, RN2 stated he/she was an agency nurse. He/she stated that he/she had not received any training by the facility or his/her agency related to infection control or EBP. During an interview on 06/03/26 at 11:10 AM, CNA1 stated he/she was an agency staff. CNA1 stated upon hire the facility would check their skills online. But he/she said the facility did not provide any training because he/she was already trained. CNA1 stated he/she had not been trained on the facility's infection prevention program. During an interview on 06/04/26 at 8:24 AM, the Infection Preventionist (IP) stated that staff received training quarterly or as needed. The IP stated when agency staff came he/she would speak with them verbally, but he/she did not have them sign anything indicating they received any formal training. He/she would ask when what they knew or would explain something that was going on in the building. He/she would only have them demonstrate if they were in specific area that required that type of knowledge. He/she said they did not do comprehensive training because they were only at the facility for a day or so and he/she felt that was adequate. During an interview on 06/04/26 at 9:49 AM, the Director of Nursing (DON) said staff providing care to a resident on EBP and providing close contact care must gown and glove and should practice hand hygiene between glove changes and when they were done. The DON said he/she expected all staff to receive appropriate training as a new hire and ongoing. NJAC 8:39-13.4

Complaint #'s: NJ175457, NJ175482 Based on observation, interview, and record review, it was determined that the facility failed to report a newly developed pressure ulcer (PU) and implement a physician's order (PO) for wound care to treat a facility acquired PU for 1 of 3 residents reviewed for PU's, (Resident #110). The PU worsened from an excoriation (wearing off the skin) that was identified on 6/20/24 to an unstageable PU ( covered with slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) or eschar (a layer of dry, dead tissue that forms over a deep wound) and cannot be staged which are caused by prolonged pressure, shear and friction and can lead to infection and complications). This deficient practice was evidenced by the following: On 12/5/24 at 10:30 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #110, which revealed the following: A review of the Admission Record (an admission summary) reflected that Resident #110 was admitted to the facility with diagnoses that included but were not limited to; Peripheral Vascular Disease (PVD-blocked blood vessels) and type 2 Diabetes Mellitus (high blood sugar level) with diabetic neuropathy (nerve damage). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 6/9/24, reflected that the resident had a Brief Interview for Mental Status score of 3 out of 15, indicating that the resident had severely impaired cognition. A review of Resident #110's December 2024 Order Summary Report, revealed a PO for 40% Zinc Oxide cream to be applied to the right and left buttocks every shift for excoriation related to moisture, dated 2/15/2023. A review of the document that was provided by the facility's Director of Nursing (DON) on 12/9/24, which included the timeline of Resident #110's PU, revealed that on 6/20/24, the resident was observed with an excoriation at the sacral area and was treated with 40% Zinc Oxide cream according to the PO dated 2/15/23. A review of the form titled, Skin/Wound Note documented by wound doctor (WD) reflected that on 6/21/24 and 6/28/24, there was no documented evidence that Resident #110's had a facility acquired PU observed to the right and left buttocks, which were initially identified as excoriation to the sacral area on 6/20/24. A review of the Progress Notes (PN) dated 6/26/24 at 12:34 PM did not reflect that the resident was observed with a PU to the sacral area. A review of the paper form titled Skin Only Evaluation dated 6/26/24 and 7/3/24 revealed under 1. Skin No skin issues were checked. A review of the PN dated 6/30/24 at 11:14 AM reflected that Resident #110 had a new PO for Triple cream ointment indicated for worsening excoriation in the buttocks. A review of the PN dated 7/1/24 at 12:36 PM documented an increased excoriation to the buttocks and sacral area. A review of the PN dated 7/3/24 at 3:21 PM documented the resident was observed with excoriation to bilateral buttocks and was awaiting to be seen by a WD. A review of the December 2024 Order Summary Report revealed a PO dated 6/30/24 to apply Lidocaine/Nystatin/Zinc cream two times a day after cleaning with normal saline for excoriation to buttocks. A review of the PN dated 7/6/24 at 16:41 (4:41 PM) indicated that Resident #110 was transferred to the hospital as ordered by the resident's physician. A review of the PN dated 7/7/24 at 7:20 AM documented by the facility nurse who called the hospital and had spoken to the emergency room Nurse who stated to her that Resident #110 was admitted to the hospital with diagnosis of Partial Injury of Sacral Region Unstageable. A review of the form titled Pressure Ulcer Flow Sheet (PUFS) dated 7/3/24 reflected that the right buttock was now classified as an unstageable wound and the left buttock was now classified as a Deep Tissue Injury PU (a pressure ulcer related injury to subcutaneous tissues under intact skin). Both PU sites were confirmed by the wound doctor on 7/5/24. Further review of all the PUFS for Resident #110 did not reflect any documentation for the excoriation that was identified on 6/20/24. A review of the form provided by the DON on 12/12/24 at 1:00 PM, documented the list of residents with a facility-acquired wounds ([NAME]), which did not include Resident #110 to reflect the [NAME] of the sacral area which was identified on 7/5/24. Further review of the medical records which included any documentation from the nurses, Certified Nursing Assistants, including the notification of Resident #110's physician, were not found in the hybrid medical records to reflect that the [NAME] to the right and left buttocks was observed by the WD on 7/5/24. On 12/9/24 at 10:53 AM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, and the Infection Prevention/Assistant DON (IP/ADON) to discuss the above concern. On 12/11/24 at 09:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to Resident #110. The LPN stated the resident had been treated with Zinc Oxide to both buttocks according to the PO. The LPN acknowledged the excoriation to both buttocks were not reported immediately to the WD to prevent worsening of the excoriation. A review of the facility policy, with a revised date of 2024, titled Subject: Pressure Ulcer Prevention & Management Policy, under Policy: It is the policy of this facility to assess all resident upon admission; re-admission and quarterly thereafter for risk factors associated with Pressure Ulcer development and the necessary precautions to prevent formation. Appropriate interventions will be utilized to prevent pressure ulcer development and to promote healing when pressure ulcer present. A review of the facility policy title, Subject: Skin Check Policy, with no revised date stated under Procedure: 1. Nursing will conduct skin checks to assure all residents with skin breakdowns are identified and treated promptly. 5. Skin checks include inspection of all areas including removal of dressings (unless non removal is ordered by the MD) to assess the progress of any open areas present and to look for new areas. 7. Weekly Pressure/Other Wound Tracking Report will be updated to include the residents with new open areas found. NJAC 8:39-27.1(a,e)

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to: a.) follow a physician's order (PO) for a bolus feeding (method of giving tube feeding where large doses of formula are administered several times a day) in one (1) of two (2) residents (Resident #51) reviewed for tube feeding (TF) and b.) failed to document for accountability of medications and treatments administered for 4 of 5 residents (Resident #28, #83, #88 and #110) reviewed for unnecessary medication. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 or 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 a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed Resident #51 in bed with their eyes closed. A review of the Admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence of a surgical opening into the stomach, also known as a gastrostomy which can be temporary or permanent. A review of the Significant Change in Status Assessment Minimum Data Set (SCSA/MDS), an assessment tool used to facilitate the management of care, dated 09/26/24, reflected that the resident had a Brief Interview for Mental Status score of 3 out of 15 indicating that the resident had severely impaired cognition. A review of the December 2024 Order Summary Report (OSR) revealed a physician order (PO), dated 9/16/24 for Peg Bolus feeding Jevity 1.2 (237 ml (milliliter carton) give 2 cartons, 474 ml. Total volume for each feeding, QID (four times daily) total volume of formula = 1896 ml daily total volume of formula + flushes = 2466 four times a day for supplement. A review of the November 2024 and December 2024 electronic Medication Administration Record (eMAR) revealed a PO dated 9/16/24 for a Peg Bolus Jevity 1.2 (237 ml carton) give 2 cartons, 474 ml. Total volume for each feeding QID total volume of formula = 1896 ml daily total volume of formula + flushes=2466 ml four times a day or supplement scheduled 0600 (6:00AM), 1200 (12:00 PM), 1800 (6:00 PM) and 0000 (12:00 AM). A further review of the November 2024 eMAR revealed that a nurse documented every 0000 (12:00AM) indicating that a 237 ml of Jevity 1.2 (one carton) was administered 27 out of 30 times (11/1/24, 11/2/24, 11/4/24, 11/5/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/12/24,11/13/24, 11/14/24, 11/15/24, 11/16/24, 11/17/24, 11/19/24, 11/20/24, 11/21/24, 11/22/24, 11/23/24, 11/24/24,11/26/24, 11/27/24, 11/28/24, 11/29/24, and 11/30/24.) A further review of the December 2024 eMAR revealed that a nurse documented every 0000 (12:00AM) indicating that a 237 ml of Jevity 1.2 (one carton) was administered 10 of 11 times (12/1, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, and 12/11/24.) On 12/11/24 at 11:00 AM, the surveyor interviewed the facility's Registered Dietician (RD) who stated that Resident #51 was tolerating the TF well. The RD further stated that the nurses should administering the bolus feeding according to the PO. On 12/11/24 at 12:50 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that the resident was receiving one-carton (237 ml) of Jevity every 12:00AM daily. In the presence of the surveyor, LPN #1 reviewed the resident's PO for the TF who acknowledged that Resident #51 was supposed to receive 2 cartons (474 ml) of Jevity 1.2 at 12:00 AM. The surveyor attempted to contact the nurse who administered the incorrect quantity but was unable to reach her. On 12/11/24 at 1:30 PM, the surveyor discussed the above concern to the Licensed Nursing Home Administrator, Director of Nursing (DON), and Infection Preventionist/Assistant DON (IP/ADON). On 12/12/24 at 10:20 AM, the DON stated to the surveyor that the resident's weight has been stable. On 12/12/24 at 12:30 PM, the facility's IP/ADON and the Regional Dietician met with the survey team. The IP/ADON further stated that she spoke with the nurse who acknowledged that she did not document the correct amount on the eMAR. The IP/ADON acknowledged that the nurse should have followed the PO which indicated 474 ml of Jevity 1.2 was supposed to be administered. A review of the facility's policy with a revision date of 9/2024, titled, Medication Administration provided by the DON, revealed the following: Compare medication (bubble pack, vial, etc) with MAR to verify resident name, medication name, form, dose, route and time. 46889 2. On 12/04/24 at 9:57 AM, the surveyor observed Resident #28 in bed with eyes closed. On 12/4/24 at 11:16 AM, the surveyor reviewed the hybrid medical records of Resident #28, which revealed the following: A review of the AR reflected that Resident #28 was admitted in the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). A review of the quarterly MDS (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/13/24, reflected that the resident had a BIMS score of 2 out of 15, indicating that the resident had severely impaired cognition. A review of Resident #28's November 2024 eMAR revealed a PO dated 11/22/23 for Levothyroxine Sodium 100 microgram (mcg) give one tablet orally daily on the evening shift (3:00 PM - 11:00 PM). Further review of the November 2024 eMAR revealed that the nurse failed to sign on 11/20/24 at 4:00 PM when the medication was scheduled to be administered. A review of the November 2024 electronic Treatment Administration Record (eTAR) revealed the following PO: Passive ROM (Range of Motion) (PROM)/Active ROM (AROM) daily dated 6/16/20; apply heel booties to both heels while in bed & check every shift for placement dated 4/21/22; bilateral upper side rails up while in bed as an enabler every shift dated 1/31/17 and half-side rail padding while in bed every shift dated 6/16/20. Further review of the November 2024 eTAR revealed that the day shift (7:00 AM - 3:00 PM) nurse failed to sign to indicate the PO was rendered to Resident #28 on 11/18/24 and 11/27/24. 3. On 12/4/24 at 9:40 AM, the surveyor observed Resident #83 awake in bed and was unable to answer the surveyor's inquiry. On 12/12/24 at 12:49 PM, the surveyor reviewed the hybrid medical record of Resident #83, which revealed the following: A review of the AR reflected that Resident #83 was admitted in the facility with diagnoses that included but were not limited to unspecified Dementia. A review of the SCSA/MDS, an assessment tool used to facilitate the management of care, dated 11/16/24, reflected that Resident #83 had a BIMS score of 3 out of 15, indicating that the resident had severely impaired cognition. A review of Resident #83's November 2024 eMAR revealed the following PO: a. Active Liquid Protein 30 ml (milliliters) PO (by mouth) two times a day for wound healing daily dated 11/1/24. Further review of the November 2024 eMAR revealed that the nurse failed to sign on 11/1/24 at 5:00 PM when the medication was scheduled to be administered. b. Betadine external solution, apply to left heel topically every day and night shift dated 10/25/24; Zinc Oxide external, apply to right buttock topically every day and night shift dated 10/25/24 and Zinc Oxide external, apply to sacrum topically every day and night shift dated 10/25/24. Further review of the November 2024 eTAR also revealed that the nurse (11:00 PM - 7:00 AM) failed to sign on 11/2/24 when the treatment was scheduled to be administered. c. Evaluate for COVID-19 signs and symptoms every shift dated 3/22/24. Further review of the November 2024 eMAR revealed the nurse failed to sign to verify that the monitoring was done on 11/18/24. d. Tylenol 325 milligram (mg) give two tablets by mouth every 8 hours for pain dated 9/25/24. Further review of the November 2024 eMAR revealed the nurse failed to sign that the medication was scheduled to be administered on 11/20/24 at 6:00 AM. A review of the November 2024 eTAR revealed the following PO: a. Medihoney wound/burn dressing, apply to right buttock every day shift dated 11/2/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 when the treatment was scheduled to be administered. b. Medihoney wound/burn dressing, apply to sacrum every day shift dated 11/22/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 when the treatment was scheduled to be administered. c. Medihoney wound/burn dressing .apply to left heel every day shift dated 11/27/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 when the treatment was scheduled to be administered. d. Medihoney wound/burn dressing .apply to right heel every day shift dated 11/2/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 when the treatment was scheduled to be administered. e. Low Air Loss (LAL) mattress every shift dated 9/26/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 to verify the use of LAL mattress. f. Place mattress on floor to bed for safety while in bed dated 11/10/24. Further review of the November 2024 eTAR revealed the nurse failed to sign on 11/18/24 and 11/27/24 to verify the placement of the mattress on the floor. 4. On 12/4/24 at 9:40 AM, the surveyor observed Resident #88 in bed with eyes closed. On 12/13/24 at 11:21 AM, the surveyor reviewed the hybrid medical records of Resident #88, which revealed the following: A review of the AR reflected that Resident #88 was admitted in the facility with diagnoses that included but were not limited to unspecified Dementia. A review of the Q/MDS, an assessment tool used to facilitate the management of care, dated 11/17/24, reflected that Resident #88 had a BIMS score of 0 (zero) out of 15, indicating that the resident had severely impaired cognition. A review of Resident #88's November 2024 eMAR revealed the following PO: a. Protonix tablets 40 mg by mouth once daily at 6:00 AM dated 10/11/23. Further review of the November 2024 eMAR revealed the nurse failed to sign that the medication was administered to the resident on 11/20/24 at 6:00 AM. b. Lorazepam 0.5 mg one tablet by mouth every 8 hours dated 6/19/24. Further review of the November 2024 eMAR revealed the nurse failed to sign that the medication was administered to the resident on 11/20/24 at 6:00 AM and 2:00 PM. A review of Resident #88's November 2024 eTAR revealed the following PO: a. Bilateral bolster in place every shift dated 8/13/24. Further review of the November 2024 eTAR revealed the nurse failed to sign to verify that the bilateral bolster was in place on 11/18/24 and 11/27/24. b. Bilateral floor mats check every shift dated 8/13/24. Further review of the November 2024 eTAR revealed the nurse failed to sign to verify that the bilateral floor mats were in place on 11/18/24 and 11/27/24. c. Bilateral side rail pad check every shift dated 8/13/24. Further review of the November 2024 eTAR revealed the nurse failed to sign to verify that the bilateral side rail pad was in place on 11/18/24 and 11/27/24. d. Low Air Loss (LAL) mattress every shift dated 9/26/24. Further review of the November 2024 eTAR revealed the nurse failed to sign to verify that the LAL mattress was in place on 11/18/24 and 11/27/24. e. Zinc oxide ointment to bilateral buttocks every shift dated 10/5/24. Further review of the November 2024 eTAR revealed the nurse failed to sign to indicate that the zinc oxide was administered on 11/18/24 and 11/27/24. 5. On 12/5/24 at 10:30 AM, the surveyor reviewed the hybrid medical record of Resident #110, which revealed the following: A review of the AR reflected that Resident #110 was admitted with diagnoses that included but were not limited to peripheral vascular disease (PVD-blocked blood vessels) and type 2 diabetes mellitus (high blood sugar level) with diabetic neuropathy (nerve damage). A review of the Q/MDS date of 6/9/24 indicated that the facility assessed the residents' cognitive status using a BIMS score of 3 out of 15, which indicated that the resident had a severe impairment in cognition. A review of Resident #110's June 2024 eMAR revealed the following PO: a. Evaluate for Covid-19 signs and symptoms every day shift dated 3/23/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the COVID-19 signs and symptoms were evaluated on 6/12/24 during the day shift. b. Simvastatin 40 mg. 1 tablet by mouth at bedtime dated 4/24/24. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/12/24, 6/19/24, and 6/25/24 at 9:00 PM. c. Apixaban 5 mg. 1 tablet by mouth every 12 hours dated 11/12/22. Further review of the June 2024 eMAR revealed that the nurse failed to sign the medication given on 6/12/24, 6/19/24, and 6/25/24 at 9:00 PM. d. Midodrine HCl (hydrochloride) 5 mg. 1 tablet by mouth three times a day, dated 1/13/22. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/12/24 at 9:00 AM, 6/12/24, and 6/25/24 at 1:00 PM. e. Active liquid protein sugar-free one time a day dated 4/9/24. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. f. Metformin HCl 850 mg. 1 tablet by mouth two times a day dated 6/13/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 4:00 PM. g. Potassium Chloride 10 meq. Give 2 capsules by mouth one time a day dated 4/27/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. h. Acidophilus capsule. Give 1 capsule by mouth two times a day, dated 11/8/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. i. Furosemide 20 mg. Give 1 tablet by mouth two times a day, dated 1/29/24. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. j. Gabapentin Capsule 300 mg. Give 1 capsule by mouth two times a day dated 7/10/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. k. Magnesium Oxide Tablet 400 MG Give 1 tablet by mouth one time a day dated 3/14/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. l. Seroquel 25 mg. Give 1 tablet by mouth two times a day dated 12/7/23. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication was given on 6/25/24 at 5:00 PM. m. Resident is on apixaban. Monitor anticoagulant complications every shift dated 11/7/22. Further review of the June 2024 eMAR revealed the nurse failed to sign the medication monitoring on 6/25/24 in the evening shift and 6/26/24 in the evening and night shift. n. Resident is on Seroquel every shift. Monitor for side effects dated 3/21/24. Further review of the June 2024 eMAR revealed the nurse failed to sign that the medication monitoring on 6/25/24 in the evening shift and 6/26/24 in the evening and night shift. o. Resident is on Seroquel every shift. Observed for target behavior dated 3/21/24. Further review of the June 2024 eMAR revealed that the nurse failed to sign the medication monitoring on 6/25/24 and 6/26/24 in the evening and night shifts. p. Resident is on Lexapro every shift. Monitor for side effects dated 11/29/22. Further review of the June 2024 eMAR revealed that the nurse failed to sign the medication monitoring on 6/25/24 in the evening and 6/26/24 in the evening and night shifts. q. May crush medications and administer them every shift dated 3/23/23. Further review of the June 2024 eMAR revealed that the nurse failed to sign that the medication was crushed on 6/25/24 in the evening and 6/26/24 in the evening and night shifts. r. 24-hour chart check every night shift dated 10/4/23. Further review of the June 2024 eMAR revealed the nurse failed to sign the chart check on 6/26/24 in the night shift. On 12/11/24 at 9:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the MAR/TAR should be signed after giving medication and treatment. She added that she could not speak for other nurses about not signing the orders. On 12/13/24 at 1:37 PM, the surveyor team met with the LNHA, DON, and the IP/ADON regarding the above concern. No information was provided. A review of the facility's policy titled Medication Administration with a revised date of September 2024 is indicated under Policy Explanation and Compliance Guidelines 17. Sign MAR after administered A review of the facility's policy titled Treatment Competency with a revised date of November 2024 is indicated under Procedure: Sign Treatment Administration Record. NJAC 8:39-11.2(b), 29.4(a)(b)

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD #1, MD #4) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 8 of 16 residents, (Resident #41, # 51, #110, #45, #66, #84, and #71). This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:07 AM, the surveyor interviewed Resident #41 in their room. The resident further stated to the surveyor they could not recall the last time they were assessed by their physician. A review of Resident #41's Face Sheet (an admission summary) reflected that Resident #41 was admitted to the facility with diagnoses that included but not limited to Schizophrenia, Chronic Kidney disease, and End Stage Renal Disease. A review of the 5-Day Minimum Data Set (MDS), an assessment tool used to facilitate care management dated 11/23/2024, indicated a Brief Interview for Mental Status (BIMS) scored of 14 out of 15, which indicated that the resident was cognitively intact. A review of the PPN's in the electronic medical record reflected the following Effective Date, Date of Service, and/or LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicated the PPN were not documented on the effective date (Date of service): 1. PPN with an effective date of 12/2/2024, and a date of service of 10/20/2024. 2. PPN with an effective date of 12/2/2024, and a date of service 10/17/2024. 3. PPN with an effective date of 12/2/2024, and a date of service of 10/25/2024. 4. PPN with an effective date of 12/2/2024, and a date of service of 10/23/2024. 5. PPN with an effective date of 12/2/2024, and a date of service of 10/30/2024. 6. PPN with an effective date of 12/2/2024, and a date of service of 11/2/2024. 7. PPN with an effective date of 12/2/2024, and a date of service of 10/18/2024. 8. PPN with an effective date of 12/2/2024, and a date of service of 11/9/2024. 9. PPN with an effective date of 10/9/2024, and a date of service of 8/25/2024. 10. PPN with an effective date of 10/2/2024, and a date of service of 10/9/2024. 11. PPN with an effective date of 8/10/2024, and a created date of 9/6/2024. 12. PPN with an effective date of 8/8/2024, and a created date of 9/6/2024. 13. PPN with an effective date of 8/1/2024, and a created date of 9/6/2024. 14. PPN with an effective date of 7/31/2024, and a created date of 9/6/2024. 15. PPN with an effective date of 7/25/2024, and a created date of 9/6/2024. 16. PPN with an effective date of 7/22/2024, and a created date of 9/6/2024. 17. PPN with an effective date of 7/11/2024, and a created date of 9/6/2024. 18. PPN with an effective date of 7/10/2024, and a created date of 9/6/2024. 19. PPN with an effective date of 6/26/2024, and a created date of 7/15/2024. 20. PPN with an effective date of 6/21/2024, and a created date of 9/10/2024. 37791 2. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed Resident #51 in bed with their eyes closed. The surveyor reviewed the HMR for the Resident #51 which revealed that the resident's primary physician had inaccurately dated 10 PPN's documented from 1/31/24 through 12/3/24. A review of the resident's FS reflected that Resident #51 was admitted to the facility with diagnoses that included but were not limited to epilepsy, nontraumatic subdural hemorrhage, and type II diabetes mellitus. A review of the Significant Change in Status Assessment MDS (SCSA/MDS), an assessment tool used to facilitate the management of care, dated 09/26/24, indicated a BIMS score of 3 out of 15 which indicated that the resident had severely impaired cognition. A review of the PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry) designation which indicated that the PPN's were not written on the date of service (effective date): 1. PPN effective date of 10/21/2024, and a created date on 12/3/2024. 2. PPN effective date of 09/23/24, and a created date on 10/10/24. 3. PPN effective date of 09/17/24, and a created date on 10/10/24. 4. PPN effective date of 8/28/24, and a created date on 10/10/24. 5. PPN effective date of 7/31/24, and a created date on 09/06/24. 6. PPN effective date of 6/26/24, and a created date on 07/15/24 7. PPN effective date of 5/22/24, and a created date on 07/09/24. 8. PPN effective date of 4/29/24, and a created date on 07/09/24. 9. PPN effective date of 4/24/24, and a created date on 07/09/24. 10. PPN effective date of 2/29/24, and a created date on 04/17/24. 11. PPM effective date of 1/31/24, and a created date on 1/31/24. 46889 3. On 12/5/24 at 10:30 AM, the surveyor reviewed the HMR of Resident #110, which revealed the following: A review of the FS reflected that Resident #110 was admitted to the facility with diagnoses that included but were not limited to peripheral vascular disease (PVD-blocked blood vessels) and type 2 diabetes mellitus (high blood sugar level) with diabetic neuropathy (nerve damage). A review of the Q/MDS, an assessment tool used to facilitate care management dated of 6/9/24, reflected a BIMS score of 3 out of 15, which indicated that the resident had severely impaired cognition. A review of Resident #110's PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated that the PPN's were not written on the date of service; 1. PPN effective date of 5/27/24, 5/31/24, 6/24/24, 6/28/24 and a date of service on 7/15/24. 2. PPN effective date of 2/27/24, 3/31/24, 4/30/24 and with a date of service on 7/9/24. 3. PPN effective date of 1/31/24 and a date of service on 7/8/24. 37175 4. On 12/4/24 at11:15 AM, the surveyor interviewed Resident #45 in their room. Resident #45 could not recall the last time they saw their physician. The surveyor reviewed the HMR for the Resident #45 which revealed that the resident's primary physician (MD #1) had inaccurately dated 14 PPN's written on 12/3/24,10/10/24, 9/6/24 and 7/15/24. A review of the resident's FS reflected that Resident #45 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (a central nervous system autoimmune disease), Major Depressive Disorder (a mental health disorder with persistent depressed mood), and chronic kidney disease (progress damage and loss of functions of the kidneys). A review of the Annual MDS (A/MDS), an assessment tool used to facilitate care management dated 7/23/2024, reflected a BIMS score of 9 out of 15, which indicated that the resident had moderate cognitive impairment. A review of Resident #45's PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated that the PPN's were not written on the date of service: 1. PPN effective date of 11/15/2024, and a created date on 12/3/2024. 2. PPN effective date of 11/12/2024, and a created date on 12/3/2024. 3. PPN effective date of 11/14/2024, and a created date on 12/3/2024. 4. PPN effective date of 11/6/2024, and a created date on 12/3/2024. 5. PPN effective date of 11/4/2024, and a created date on 12/3/2024. 6. PPN effective date of 10/30/2024, and a created date on 12/3/2024. 7. PPN effective date of 10/28/2024, and a created date on 12/3/2024. 8. PPN effective date of 10/25/2024, and a created date on 12/3/2024. 9. PPN effective date of 10/23/2024, and a created date on 12/3/2024. 10. PPN effective date of 10/20/2024, and a created date on 12/3/2024. 11. PPN effective date of 9/23/2024, and a created date on 10/10/2024. 12. PPN effective date of 8/28/2024, and a created date on 10/10/2024. 13. PPN effective date of 7/31/2024, and a created date on 9/6/2024. 14. PPN effective date of 6/26/2024, and a created date on 7/15/2024. 5. On 12/4/24 at12:02 PM, the surveyor observed Resident #66 in the dining room. The surveyor interview Resident #66 who stated they could not recall the last time they saw their physician. The surveyor reviewed the HMR for the Resident #66 which revealed that the resident's primary physician (MD#1) had inaccurately dated 40 PPN's written on 12/3/24,10/10/24, 9/6/24, 7/15/24 and 7/8/2024. A review of the resident's FS reflected that Resident #66 was admitted to the facility with diagnoses that included but were not limited to dementia (loss of memory, thinking, and social abilities), diabetes (too much sugar in the blood), and chronic kidney disease (progress damage and loss of functions of the kidneys). A review of the A/MDS, an assessment tool used to facilitate care management dated 11/19/2024, reflected a BIMS score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. A review of Resident #66's PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated that the PPN's were not written on the date of service: 1. PPN effective date of 10/20/2024, and a created date on 12/3/2024. 2. PPN effective date of 10/17/2024, and a created date on 10/10/2024. 3. PPN effective date of 9/9/2024, and a created date on 10/10/2024. 4. PPN effective date of 9/6/2024, and a created date on 10/10/2024. 5. PPN effective date of 9/4/2024, and a created date on 10/10/2024. 6. PPN effective date of 9/2/2024, and a created date on 10/10/2024. 7. PPN effective date of 8/30/2024, and a created date on 10/10/2024. 8. PPN effective date of 8/28/2024, and a created date on 10/10/2024. 9. PPN effective date of 8/25/2024, and a created date on 10/10/2024. 10. PPN effective date of 8/21/2024, and a created date on 9/6/2024. 11. PPN effective date of 8/19/2024, and a created date on 9/6/2024. 12. PPN effective date of 8/16/2024, and a created date on 9/6/2024. 13. PPN effective date of 8/14/2024, and a created date on 9/6/2024. 14. PPN effective date of 8/12/2024, and a created date on 9/6/2024. 15. PPN effective date of 8/10/2024, and a created date on 9/6/2024. 16. PPN effective date of 8/8/2024, and a created date on 9/6/2024. 17. PPN effective date of 8/5/2024, and a created date on 9/6/2024. 18. PPN effective date of 8/1/2024, and a created date on 9/6/2024. 19. PPN effective date of 7/31/2024, and a created date on 9/6/2024. 20. PPN effective date of 7/29/2024, and a created date on 9/6/2024. 21. PPN effective date of 7/25/2024, and a created date on /6/2024. 22. PPN effective date of 7/24/2024, and a created date on 9/6/2024. 23. PPN effective date of 7/22/2024, and a created date on 9/6/2024. 24. PPN effective date of 7/18/2024, and a created date on 9/6/2024. 25. PPN effective date of 7/17/2024, and a created date on 9/6/2024. 26. PPN effective date of 7/15/2024, and a created date on 9/6/2024. 27. PPN effective date of 7/14/2024, and a created date on 9/6/2024. 28. PPN effective date of 7/11/2024, and a created date on 9/6/2024. 29. PPN effective date of 7/10/2024, and a created date on 9/6/2024. 30. PPN effective date of 6/26/2024, and a created date on 7/15/2024. 31. PPN effective date of 6/24/2024, and a created date on 7/15/2024. 32. PPN effective date of 6/20/2024, and a created date on 7/15/2024. 33. PPN effective date of 6/19/2024, and a created date on 7/15/2024. 34. PPN effective date of 6/17/2024, and a created date on 7/15/2024. 35.PPN effective date of 6/14/2024, and a created date on 7/15/2024. 36. PPN effective date of 6/13/2024, and a created date on 7/15/2024. 37. PPN effective date of 6/10/2024, and a created date on 7/15/2024. 38. PPN effective date of 6/6/2024, and a created date on 7/8/2024. 39. PPN effective date of 6/5/2024, and a created date on 7/8/2024. 40. PPN effective date of 6/3/2024, and a created date on 7/8/2024. 6. On 12/5/24 at 12:55 PM, the surveyor observed Resident #71 in their room and was not able to be interviewed. The surveyor reviewed the HMR for the Resident #71 which revealed that the resident's primary physician (MD #1) had inaccurately dated 31 PPN's written on 12/3/24,10/10/24, 9/6/24, and 7/15/24. A review of the resident's FS reflected that Resident #71 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and makes it difficult to breath), heart failure (a chronic condition in which the heart does not pump blood as well as it should) and diabetes (too much sugar in the blood). A review of the A/MDS, an assessment tool used to facilitate care management dated 9/25/2024, reflected a BIMS score of 00 out of 15, which indicated that the resident had severe cognitive impairment. A review of Resident #71's PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated that the PPN's were not written on the date of service: 1. PPN effective date of 10/28/2024, and a created date on 12/3/2024. 2. PPN effective date of 9/23/2024, and a created date on 10/10/2024. 3. PPN effective date of 9/2/2024, and a created date on 10/10/2024. 4. PPN effective date of 8/30/2024, and a created date on 10/10/2024. 5. PPN effective date of 8/21/2024, and a created date on 9/6/2024. 6. PPN effective date of 8/19/2024, and a created date on 9/6/2024. 7. PPN effective date of 8/16/2024, and a created date on 9/6/2024. 8. PPN effective date of 8/14/2024, and a created date on 9/6/2024. 9. PPN effective date of 8/12/2024, and a created date on 9/6/2024. 10. PPN effective date of 8/10/2024, and a created date on 9/6/2024. 11. PPN effective date of 8/5/2024, and a created date on 9/6/2024. 12. PPN effective date of 8/1/2024, and a created date on 9/6/2024. 13. PPN effective date of 7/31/2024, and a created date on 9/6/2024. 14. PPN effective date of 7/29/2024, and a created date on 9/6/2024. 15. PPN effective date of 7/25/2024, and a created date on 9/6/2024. 16. PPN effective date of 7/24/2024, and a created date on 9/6/2024. 17. PPN effective date of 7/22/2024, and a created date on 9/6/2024. 18. PPN effective date of 7/18/2024, and a created date on 9/6/2024. 19. PPN effective date of 7/17/2024, and a created date on 9/6/2024. 20. PPN effective date of 7/15/2024, and a created date on 9/6/2024. 21. PPN effective date of 7/14/2024, and a created date on 9/6/2024. 22. PPN effective date of 7/11/2024, and a created date on 9/6/2024. 23. PPN effective date of 7/10/2024, and a created date on 9/6/2024. 24. PPN effective date of 6/26/2024, and a created date on 7/15/2024. 25. PPN effective date of 6/24/2024, and a created date on 7/15/2024. 26. PPN effective date of 6/20/2024, and a created date on 7/15/2024. 27. PPN effective date of 6/19/2024, and a created date on 7/15/2024. 28. PPN effective date of 6/17/2024, and a created date on 7/15/2024. 29.PPN effective date of 6/14/2024, and a created date on 7/15/2024. 30. PPN effective date of 6/13/2024, and a created date on 7/15/2024. 31. PPN effective date of 6/10/2024, and a created date on 7/15/2024. 7. On 12/4/24 at12:02 PM, the surveyor observed Resident #84 in the dining room. Resident #66 could not recall the last time they saw their physician. The surveyor reviewed the HMR for the Resident #84 which revealed that the resident's primary physician (MD #1) had inaccurately dated 7 PPN's written on 12/3/24,10/10/24, 9/6/24, and 7/15/24. Per the guidelines, (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) S483.30(b) Physician Visits The physician must- S483.30(b)(2) Write, sign, and date progress notes at each visit. A review of the resident's FS reflected that Resident #84 was admitted to the facility with diagnoses that included but were not limited to vascular dementia (decreased blood flow to the brain causing memory problems), diabetes (too much sugar in the blood), and seizures (abnormal electrical activity in the brain). A review of the SCSA/MDS, an assessment tool used to facilitate care management dated 2/22/2024, reflected a BIMS score of 9 out of 15, which indicated that the resident had moderate cognitive impairment. A review of Resident #84's PPN's in the EMR revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated that the PPN's were not written on the date of service: 1. PPN effective date of 10/20/2024, and a created date on 12/3/2024. 2. PPN effective date of 9/23/2024, and a created date on 10/10/2024. 3. PPN effective date of 9/9/2024, and a created date on 10/10/2024. 4. PPN effective date of 8/30/2024, and a created date on 10/10/2024. 5. PPN effective date of 7/31/2024, and a created date on 9/6/2024. 6. PPN effective date of 7/17/2024, and a created date on 9/6/2024. 7. PPN effective date of 6/26/2024, and a created date on 7/15/2024. On 12/11/24 at 10:55 AM, the survey team conducted a telephone interview with MD #1, who stated they come to the facility a few times a week and enter multiple PPN's into the EMR at one time because they were busy. MD #1 also stated it was not the best practice on when to enter their PPN documentation in the EMR. On 12/11/24 at 12:15 PM, the Licensed Nurse Home Administrator (LNHA) provided the surveyor with a copy of the facility policy titled, Physician Visits and Delegation, with a revision date of September 2022. Under the policy, Explanation and compliance guidelines of the policy reflected 1. The Physician should: d. Date, write and sign a progress note for each visit. On 12/11/24 at 1:34 PM, the survey team met with the Licensed nurse Home Administrator (LNHA and Director of Nursing (DON) to discuss the above review concerns. The DON stated they were aware of the MD documentation error. and that it is not professional by the MD. No further comments made information was provided. NJAC 8:39-23.2(b)

Based on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 3 of 3 residents (Resident #30, Resident #83, and Resident #13) reviewed. This deficient practice was evidenced by: The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. On 12/9/24 at 9:45 AM, the facility provided the surveyor with a list of residents who were discharged from the facility within the last 6 months and should have received the SNF ABN form. The surveyor reviewed Resident #30, Resident #83 and Resident #27 who were listed discharged from Medicare Part A coverage stay and were documented that they remained in the facility. 1. Resident #30 was admitted to the facility on [DATE]. The last documented covered day from Medicare Part A service was 5/28/24. A review of the form titled, SNF Beneficiary Notification Review that was filled out by the facility's Director of Social Services (DSS) indicated the SNF ABN was not provided to the resident. There was no additional documentation about the communication of these forms to the resident or the resident's representative. 2. Resident #83 was admitted to the facility on [DATE]. The last documented covered day from Medicare Part A service was 1/23/2023. A review of the form titled, SNF Beneficiary Notification Review that was filled out by the facility's DSS indicated the SNF ABN was not provided to the resident. There was no additional documentation about the communication of these forms to the resident or the resident's representative. 3. Resident #27 was admitted to the facility on [DATE]. The last documented covered day from Medicare Part A service was 4/30/2024. A review of the form titled, SNF Beneficiary Notification Review that was filled out by the facility's DSS indicated the SNF ABN was not provided to the resident. There was no additional documentation about the communication of these forms to the resident or the resident's representative. On 12/12/24 at 11:50 AM, the surveyor interviewed the DSS who stated to the surveyor he was not aware that a SNF ABN form were supposed to be issued to the resident when they remain in the facility after Medicare A's last covered day service. The DSS acknowledged that he did not issue the form SNF ABN to the residents nor the resident's representatives. On 12/12/24 at 1:31 PM, the surveyor discussed the above concerns with the facility's Licensed Nursing Home Administrator and the Director of Nursing and Assistant Director of Nursing. There was no additional information provided. NJAC 8:39-4.1(a)(8)

REPEAT DEFICIENCY Complaints # NJ175457, NJ175482 Based on observations, interviews, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 28 residents reviewed (Resident #51 and #110). This deficient practice was identified by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records. A review of the Admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence of a surgical opening into the stomach, also known as a gastrostomy which can be temporary or permanent. A review of the Significant Change in Status Assessment Minimum Data Set (SCSA/MDS), an assessment tool used to facilitate the management of care, dated 09/26/24, reflected that the resident had a Brief Interview for Mental Status score of 3 out of 15 indicating that the resident had severely impaired cognition. A review of the December 2024 Order Summary Report (OSR) revealed a physician order (PO), dated 9/16/24 for Peg Bolus feeding Jevity 1.2 (237 ml (milliliter carton) give 2 cartons, 474 ml. Total volume for each feeding, QID (four times daily) total volume of formula = 1896 ml daily total volume of formula + flushes = 2466 four times a day for supplement. The surveyor reviewed Resident #51's comprehensive CP which reflected a CP titled, [Resident's name] is a NPO (Not by Mouth), requires tube feeding for nutrition and hydration R/T NPO status. Resident #51 had the following intervention which was undated, Four times a day Via PEG (percutaneous endoscopic gastrostomy). Jevity 1.5 as follows: 2, 8-ounce cartons (474 ml) at 6 AM; 2, 8-ounce carton (474 ml) at noon/12 PM; 2, 8-ounce carton (474 ml) at 6 PM, and 1, 8-ounce carton at 12 AM. On 12/12/24 at 11:45 AM, the surveyor interviewed the facility's Registered Dietician (RD) who stated it was her responsibility to update the CP of the residents nutritional CP. The RD acknowledged that the PO for Jevity formula should have been updated on the resident's CP to reflect the current PO dated 9/16/24. On 12/12/24 at 1:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Infection Preventionist/Assistant DON (IP/ADON). No further information was provided to the surveyor. A review of the facility's policy dated 3/2024 titled Medical Nutrition Therapy (MNT) Documentation that was provided by the Regional Dietician revealed the following: Under Person Centered Plan of Care Each time an MNT assessment or re-assessment is completed, a care plan or care plan revision should be completed as appropriate. Care plans are to be completed, and update according to the facility policy, state and federal guidelines, and as needed due to any significant changes (i.e. weight status, food intake, diet order, etc.) 46889 2. On 12/5/24 at 10:30 AM, the surveyor reviewed the hybrid medical records of Resident #110, which revealed the following: A review of the AR reflected that Resident #110 was admitted with diagnoses that included but were not limited to Peripheral Vascular Disease (PVD-blocked blood vessels) and type 2 Diabetes Mellitus (high blood sugar level) with Diabetic neuropathy (nerve damage). A review of the quarterly MDS, an assessment tool used to facilitate the management of care, dated 6/9/24, reflected that the resident had a BIMS score of 3 out of 15 indicating that the resident had severely impaired cognition. A review of the December 2024 OSR revealed a PO dated 2/15/23 for Zinc Oxide cream 40 % (percent) to be applied to right buttocks and left buttocks every shift for excoriation related to moisture. Further review of the December 2024 OSR revealed a PO dated 6/30/24 for Lidocaine/Nystatin/Zinc cream two times a day for excoriation to buttocks after cleaning with normal saline. A review of the Skin/Wound progress note documented by the wound doctor (WD) reflected that on 7/5/24, the WD identified an unstageable pressure ulcer (PU) to the right and left buttocks. A review of Resident #110's comprehensive CP did not reflect a CP for the newly identified PU to the right buttocks and left buttocks. On 12/12/24 at 10:22 AM, the survey team met with LNHA, DON, and IP/ADON. The DON stated the nurses were responsible for updating and initiating the residents CP. A review of the facility policy with a revised date of 9/2024, titled, Reviewing and Revising Care Plan, reflected under 3. d. The care plan will be updated with the new and modified interventions, e. Staff involved in the care of the resident will report the resident's response to new or modified interventions, and g. The unit manager or other designated staff members will conduct an audit on all residents experiencing a change in status at the time the change in status is identified to ensure care plans have been updated to reflect current resident needs. NJAC 8:39-11.2(e)2(i)

Based on observation, interview, and record review, it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for a resident who was receiving continuous oxygen (O2). The deficient practice was identified for 1 of 1 resident (Resident #95) reviewed for respiratory care. The deficient practice was evidenced by the following: On 12/4/24 at 11:46 AM, the surveyor observed Resident # 95 in bed with eyes closed with O2 in use via nasal cannula (a medical device used for delivering O2) at 4 Liters Per Minute (LPM.). The surveyor further observed the O2 tubing was dated 11/5/24. A review of the Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but not were not limited to Pneumonia, Chronic Respiratory Failure, and Pulmonary Fibrosis. A review of the quarterly Minimum Data Set Assessment (Q/MDS), an assessment tool, used to facilitate the management of care, dated 9/2/24, reflected that the resident had a Brief Interview for Mental Status score of 14 out of 15 indicating that the resident was cognitively intact. A review of Resident #95's December 2024 Order Summary Report revealed a physician's order (PO) dated 10/28/2024 to Change oxygen and/or nebulizer administration set up (tubing, nasal cannula/mask, etc.) weekly, every night shift every Monday. On 12/5/24 at 09:51 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who acknowledged Resident #95's O2 tubing was not changed according to the PO. On 12/9/24 at 10:54 AM, the surveyor interviewed the Infection Preventionist/Assistant Director of Nursing (IP/ADON) who stated Resident #95's O2 tubing must be changed weekly according to the PO. IP/ADON unable to provide further information why the O2 tubing has not been changed. On 12/11/24 at 12:15 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Oxygen Administration, with a revised date of 9/2024. Under the policy explanation and compliance guidelines it states, 5 .b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 12/11/24 at 1:34 PM, the survey team met with the LHNA, Director of Nursing (DON) and IP/ADON to discuss the above concern. There was no further information provided. NJAC 8:39- 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every 30 days for Medicaid recipient residents and once every 60 days for Medicare recipient residents. This deficient practice was identified for 2 of 22 residents (Resident #95 and Resident 103), reviewed for physician visits and was evidenced by the following: 1. On 12/04/24 at 11:46 AM, the surveyor observed Resident # 95 with eyes closed. The surveyor reviewed the hybrid medical records (paper and electronic) (HMR) for the Resident #95 which revealed that the resident's primary physician (PP) (MD#2) no Physician Progress Notes (PPN) since Resident #95 was admitted to the facility on [DATE]. The surveyor reviewed Resident 95's Face Sheet (an admission record) which revealed that the resident was admitted to the facility with diagnosis that included but not limited to pneumonia, chronic respiratory failure, and pulmonary fibrosis. A review of the Quarterly Minimum Data Set Assessment (MDS), an assessment tool, used to facilitate the management of care, dated 9/2/24, revealed that the resident had a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was cognitively intact. On 12/05/24 at 9:51 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manger (UM) who stated, MD#2 would come into the facility on ce a month. The UM added that MD #2 was no longer the PP for Resident #95. The UM further stated the PP for the resident was changed to MD#1 on effective 11/15/24. In the presence of the surveyor, UM confirmed there were no PPN's found in the resident's paper or electronic chart. On 12/11/24 at 10:36 AM, the surveyor interviewed MD#2, who stated the last time he came into the facility was October 2024. MD#2 further stated they would write their PPN's in the paper chart. MD #2 was unable to provide information as to why Resident #95 did not have any PPN's in their HMR. On 12/11/23 at 12:15 PM, the Licensed Nurse Home Administrator (LNHA) provided a copy of the facility policy titled, Physician Visits and Delegation, with a revision date of September 2022. Under the policy revealed, 1. The Physician should: a. See resident within 30 days of initial admission to the facility. B. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate as appropriate by state law. On 12/11/24 at 1:34 PM, the survey team met with the LNHA and Director of Nursing (DON) to discuss the above concerns. The DON stated, they were aware of the PPN's documentation concern. No further information was provided. 37791 2. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #103 which revealed that the resident's primary physician (MD#2) had not written any Physician Progress Notes (PPN) since Resident #103 had been admitted into the facility. The surveyor reviewed the Face Sheet (an admission record) which revealed that the resident had been admitted to the facility on [DATE] with diagnosis that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus and hypertension . A review of the Admission Minimum Data Set Assessment (MDS), an assessment tool, used to facilitate the management of care, dated 10/9/24, revealed that the resident had a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was cognitively impaired. A review of the resident's progress notes (PN) revealed a physician's admission note dated from 10/2/24. A further review of the resident's hybrid medical records revealed no further phyiscian PN for Resident #103. NJAC 8:39-23.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for 1 of 22 residents (Resident #51) reviewed. The deficient practice was evidenced by the following: On 12/04/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid medical records. A review of the Admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence of a surgical opening into the stomach, also known as a gastrostomy which can be temporary or permanent. A review of the Significant Change in Status Assessment Minimum Data Set, an assessment tool used to facilitate the management of care, dated 09/26/24, reflected a Brief Interview for Mental Status score of 3 out of 15, which indicated that resident had severely impaired cognition. A review of the December 2024 Order Summary Report (physician's order sheet) revealed a physician order (PO) dated 9/24/24 for Sucralfate oral tablet 1GM (Gram), give 1 tablet via G-Tube (Gastrostomy tube) three times a day for GERD (gastroesophageal reflux disease). A review of the CP - Medication Regimen Review revealed the following recommendations: On 9/04/24 the surveyor reviewed the facility's Nursing Summary Report (Consultant pharmacist monthly recommendation) which reflected the CP recommended not to crush Carafate (Sucralfate) tablets. It can be dissolved into a slurry (For patients with difficulty swallowing whole or halved sucralfate tablets, a slurry may be prepared just prior to administration by placing a 1-gram tablet in a 30 mL medicine cup without crushing and adding 15 mL to 30 mL of water, preferably warm water but room temperature is adequate.) or the order change to the suspension. formulation. A further review of the form revealed the facility's response to the CP's recommendation to discontinue the above PO on 9/12/24. The resident's PO for Sucralfate was again re-ordered on 9/24/24 which did not reflect any changes according to the CP's recommendations. On 11/4/24, the CP recommended Sucralfate (Carafate) is best administered on an empty stomach, preferably 1 hour before or 2 hours after meals. The CP further recommended to evaluate the use of Carafate with feedings. There is a risk of bezoar formation (solid mass in the gastrointestinal tract) when sucralfate is combined with enteral feeding. A review of Resident #51's HMR revealed no response from the facility regarding these two CP's recommendations. On 12/12/24 at 9:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the preparation of the PO for Carafate (Sucralfate) via G-tube administration. The LPN stated that when she prepared Carafate to be administered via G-tube, she would crush the tablet and dilute it with water. She will then pour it down the G-tube. The LPN added that after the medication administration, she would flush the G-tube with 5 to 10 milliliters of water. The surveyor asked the LPN who was responsible for reviewing the CP recommendation who stated, either the Unit Manager, the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). On 12/12/24 at 10:25 AM, the survey team met with the Licensed Nursing Home Administrator, DON, and the Infection Preventionist/Assistant Director of Nursing to discuss the above concerns. The DON stated that she did not understand the CP's recommendation which stated Carafate could be crushed. No further information was provided. A review of the facility's policy Consultant Pharmacy provided by the DON with a revision date 3/2024, did not include a time frame for the facility's response to the CP recommendations pertaining to medication irregularities. NJAC 8:39-29.3

Based on observation, interview, and record review, it was determined that the facility failed to properly label, dispose and secure medications in one (1) of five (5) medication carts and one (1) of five (5) treatment carts inspected. This deficient practice was evidenced by the following: On 12/9/24 at 9:15 AM, the surveyor during observation of medication administration observed the 1st floor long-side treatment cart that was unlocked and unattended. The treatment cart contained ointments and creams. The surveyor did observe any residents near the treatment cart. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who acknowledged that the treatment cart was unlocked and further stated that the treatment cart must always be locked when unattended. On 12/12/24 at 11:35 AM, the surveyor inspected the 1st floor short-side medication cart in the presence of LPN#2. The surveyor observed an opened bottle of blood glucose test strips that was not dated. The surveyor also observed an unopened and undated Humalog insulin pen. At that time, the surveyor interviewed LPN#2 who acknowledged that once a bottle of blood glucose test is opened, it should have been dated. LPN #2 also stated the surveyor that once a Humalog vial was removed from the refrigerator, it should have been dated. LPN #2 further stated the Humalog pen should have been removed because the resident was no longer on this medication. A review of the manufacturer's specifications for the following medications revealed that the bottle of blood glucose test strips had an expiration date of 90 days once opened and Humalog Insulin Pen had an expiration date of 28 days once opened. On 12/12/24 at 1:30PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Infection Preventionist/Assistant DON to discuss the above concerns. There was no additional information provided. A review of the facility's policy titled Medication Storage that and a revision date of 9/2024 and was provided by the DON revealed the following: Policy: Medications housed on our premises are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. All medications are stored in designated areas which are sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 4. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and each medication room. NJAC: 8:39-29.4(a)(h)(d)

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PPN). This deficient practice was identified for 2 of 22 residents reviewed, Resident #5 and #51, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records (HMR). A review of the Admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence of a surgical opening into the stomach, also known as a gastrostomy which can be temporary or permanent. A review of the Significant Change in Status Assessment Minimum Data Set (SCSA/MDS), an assessment tool used to facilitate the management of care, dated 09/26/24, reflected that the resident had a Brief Interview for Mental Status score of 3 out of 15 indicating that the resident had severely impaired cognition. The SCSA/MDS further indicated that the resident was on Hospice. A review of the December 2024 Order Summary Report revealed a physician's order dated 09/12/24 for Hospice to evaluate and treat. On 12/11/24 at 12:45 PM, in the presence of the 2nd floor Licensed Practical Nurse (LPN#1), the surveyor reviewed the resident's hospice care binder (HCB). The HCB revealed a form where the hospice staff signed in their daily log (which was filled out with signatures and dates) and a hospice care plan. The surveyor observed no progress notes (PN) from the hospice nurses or the hospice aides. At that time, the surveyor interviewed LPN #1 who acknowledged that the PN from hospice nurses and hospice aides must be placed in the HCB. LPN#1 acknowledged to the surveyor that they were no PN found in the HCB. On 12/12/24 at 12:10 PM, the surveyor conducted a telephone interview with the Hospice Registered Nurse/ Director of Operation (RN/DO) who explained the operation and the process of care for the hospice company. The RN/DOO acknowledged that hospice nurses and hospice aides would enter their PN using the hospice' electronic computerized system, and they would only print them and file them in the HCB if the hospice nurse needed something to be addressed by the facility. The RN/DO further stated that the facility can request copies from them at any time. On 12/12/24 at 1:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Infection Preventionist/Assistant DON (IP/ADON). No additional information provided. A review of the facility policy titled Coordination of Hospice Services which was provided by the DON with the revised date of 9/2024, revealed the following: The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by Hospice and the facility. 44605 2. On 12/4/24 at 11:12 AM, the surveyor interviewed Resident #5 in the dayroom. The resident stated they do not recall the last time they saw their primary physician (PP). A review of the resident's FS reflected that Resident #41 was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, schizoaffective disorder, and adjustment disorder. On 12/11/24 at 12:29 PM, the surveyor reviewed the HMR for Resident #5 which revealed that the resident's PP was MD#3. A further review of the HMR did not reflect any MD admission assessment (process that involved assessing a patient's current vital signs, laboratory values, changes in condition, medical history and recommending care. It is performed during the admission to a facility). A review of the recent quarterly MDS, an assessment tool used to facilitate care management dated 9/17/24, reflected a BIMS score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. On 12/11/24 at 12:14 PM, the surveyor interviewed the Licensed Practical Nurse first-floor unit manager (UM) who stated, MD#3 would come in at least once a week, but she was not sure where they write or document their PPN. UM confirmed the MD admission assessment were not found in the HMR. On 12/12/24 at 11:17 AM, the surveyor conducted a telephone interview with MD#3 who stated, they come in at least once a week and would document their PPN's on paper in their office. MD #3 further stated they had Resident #5's admission assessment in their office. No additional information was provided. On 12/12/24 at 1:30 PM, the survey team met with the facility's Licensed Nursing Home Administrator (LNHA) and DON to discuss the above concern. The DON stated, they would expect their MDs to have all their physician's assessment for the residents in the HMR. On 12/13/24 at 9:31 AM, MD#3 provided a copy of Resident #5's admission assessment dated , 3/16/24. MD#3 stated resident assessment must be in the resident's HMR. On 12/13/24 at 10:58 AM, the LNHA provided the surveyor a copy of the facility policy titled, Maintenance of Medical Records with a revised date of 9/2022. Under the policy, explanation, and compliance guideline it stated, 2. In accordance with accepted professional standards of practice, the facility must maintain records on each resident that are .c. readily accessible. 3. The clinical records will contain at least, but not limited to .b. A record of the resident's assessments. NJAC 8:39-35.2 (d)(5)

Complaint NJ00157677 Refer F689, and F836 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the policies and procedures were implemented to ensure resident safety and well-being to prevent serious harm, by failing to: a.) identify sufficient staffing numbers to address the population census and needs of their residents, and b.) ensure they were also meeting New Jersey state minimum staffing requirements for 32 of 42 total shifts over a two week period of time from 9/25/22 through 10/08/22, yet the LNHA continued to allow the admission of seven (7) new residents during this two week period prior to survey. The LNHA's failure to identify their sufficient staffing benchmark and include it in the Facility Assessment and the failure to ensure the New Jersey state minimum staffing requirements were being met by a wide margin, all while continuing to admit new residents to the facility places all residents at risk for serious harm, impairment, or death if not corrected. It was determined that the facility's LNHA had not ensured sufficient Certified Nursing Aide staffing for 14 of 14 day shifts in which most days, the facility was only meeting half of the required CNA's for the day shift (CNA's had between 13 to 26 residents each on their assignment when the NJ state requirement is 1 CNA to 8 Residents for the day shift). The Facility was also deficient in staffing the evening (3-11 PM) shift for 4 of 14 evening shifts, and 14 of 14 night (11 PM- 7 AM) shifts. Staff interviews revealed short staffing had impacted resident outcomes, including Resident#47 who had 11 falls over the last six months, and seven of them were unwitnessed despite occurring in common areas. As a result of the falls, Resident#47 developed serious harm including fractures, intracranial hemorrhage with subdural hematoma, and hospitalization . The failure of the LNHA to ensure the facility established and maintained systems that were effective and efficient to operate the facility in a manner to safely meet resident's needs in compliance with federal, state, and local requirements as outlined in the Administrator Job Description, resulted in an Immediate Jeopardy (IJ) situation that began on 5/26/22. The facility's LNHA was notified of the IJ on 10/24/22 at 4:16 PM. The acceptable removal plan was submitted and verified by the survey team on 10/25/22 at 12:55 PM. This deficient practice was evidenced by the following: A review of the facility's Position Title: Administrator, revealed that the Position Summary of the Administrator included but was not limited to: a) Comply with standards of business conduct in accordance with federal, state, and local health and regulatory standards and guidelines, as applicable. b) Must maintain the highest standards in caring and servicing the needs of the residents and residents' family members and loves ones. c) Must adhere to all facility policies and procedures. The Position Title: Administrator, showed that the Responsibilities/Accountabilities of the Administrator included but were not limited to: a) Administrator is responsible for planning and is accountable for all activities and departments subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. b) Concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. c) Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and rights. d) Protects residents from abuse, and cooperates with all investigations. The survey team has identified that due to inadequate supervision and not following protocols, one resident (Resident #47) has had multiple unwitnessed falls in common areas resulting in serious harm with nasal/rib fractures, head trauma, intracranial hemorrhage (brain bleed) with subdural hematoma (bleed under the membrane that surrounds the brain), and hospitalization , due to inadequate supervision and not implementing their systems (investigating and updating care plan) to prevent recurring falls. The LNHA's failure to assess their sufficient staffing par levels, and not following the state minimum staffing requirement while continuing to admit new residents to the facility places all residents at risk for the lack of supervision to prevent serious adverse outcomes, including falls with a major injury. 1. On 10/18/22 at 11:35 AM, the surveyor asked the Director of Nursing (DON) to provide all the supporting documentation related to Resident #47's fall incidents from 5/26/22 through 10/10/22. The DON acknowledged to the surveyor that she gave all the documentation related to the resident's fall investigations except the hospital records. She informed the surveyor that the neuro checks were completed in a paper form titled Neurological Evaluation Flow Sheet, which was attached to the fall reports that were given to the surveyor. On the same day at 12:07 PM, the Regional DON (RDON) and DON met with the survey team. The RDON informed the surveyors that the staff and resident statements for fall investigations were paper documentation. The RDON stated that the statements were part of the fall investigation and should be attached to the fall incident report. He further stated that after obtaining statements, the UM (Unit Manager), DON, and LNHA would do a full investigation which included a fall summary and conclusion. At that same time, the RDON stated that the interim fall investigation report should be electronically entered immediately and completely by the nurse within the shift. He stated that the printed interim fall report would go to the UM to investigate for completion, then the DON and LNHA were made aware of the investigation. The RDON acknowledged the fall incident investigations and reports were not being completed. The DON also agreed and stated the completion of the investigation process was not being done. On 10/18/22 at 12:07 PM, the survey team met with the RDON and DON. The surveyor asked the facility team what is the facility's protocol and standard of practice concerning the investigation/incident/accident reports. The RDON informed the surveyor that as per facility policy and protocol, once the incident/accident was identified by staff, the staff will initiate to document the investigation, and nursing staff will take statements from staff. The RDON stated that for example if the incident was about bruising, the facility will require lookback statements from staff at least 72 hours, a full investigation to be done by the DON, UM, and the LNHA. He further stated that there should be a summary conclusion that will be put together in a separate paper. On that same date and time, the surveyor asked the facility team if the above information, policy, and protocol for an investigation of an incident/accident were being followed for all residents including Resident #47. The RDON stated that he was the interim DON from April through August 2022 and it was not being done according to facility protocol because it was chaos here. At that time, the DON stated that when she became the DON, the policy and protocol for investigating an incident/accident was not followed. Then the surveyor informed the facility team of the above concerns. The survey team reviewed the staffing for the dates and shifts on the unit associated with each fall. The staffing assignment sheets revealed the following: 5/26/22: Census: 44 4 CNA 2 Nurses 6/2/22: Census: 45 3 CNA 2 Nurses 6/7/22: Census: 45 3 CNA 2 Nurses 6/26/22: Census: 53 4 CNA 2 Nurses 7/12/22: Census: 54 5 CNA 2 Nurses 7/17/22: Census: 54 4 CNA 2 Nurses 8/17/22: Census: 57 4 CNA 2 Nurses 8/23/22: Census: 55 4 CNA 2 Nurses 8/29/22: Census: 55 3 CNA 2 Nurses 10/3/22: Census: 51 3 CNA 2 Nurses 10/10/22: Census: 51 3 CNA 2 Nurses On 10/19/22 at 11:32 AM, two surveyors interviewed Licensed Practical Nurse/Unit Manager (LPN/UM). She informed the surveyors that she was responsible for the care plan initiation and revision. She stated that every fall, there should be new intervention. She acknowledged that the resident had multiple falls and his/her fall care plan was not updated on every fall. She stated that the resident's fall care plan interventions should have been adjusted accordingly on each fall to prevent the resident from future falls, but that it wasn't updated. LPN/UM stated that the resident had no safety awareness and needed continuous 1 on 1 observation only when they can due to short staffing. She also acknowledged that the resident's fall investigation reports were incomplete. On 10/24/22 at 11:54 AM, the survey team met with the Regional Registered Nurse (RRN), DON, and LNHA, and were made aware of the above concerns that the facility LNHA was aware of the above investigations of Resident #47's fall incidents with major injuries that the investigation process was not being done, and the care plan was not updated to reflect the interventions that will prevent the further falls and injuries. 2. Upon a review of the Facility Assessment (FA), it was determined that the facility did not assess its benchmark (a standard or point of reference against which things may be compared or assessed) of sufficient staff numbers necessary to serve its resident population based on an average census and specific needs. The Facility Assessment was generic regarding staffing and had only specified that they would provide sufficient staff but there were neither numeric values for staffing nor did it address what sufficient staffing meant. Despite not assessing their sufficient staff numbers within their Facility Assessment (dated October 15, 2021 to October 14, 2022) and in addition, not meeting the state minimum staffing requirements by a significant margin, the facility continued to admit new residents to their facility, particularly seven (7) new residents from 9/25/22 to 10/8/22 during this two week period of time in which staffing was evaluated. The facility continued to admit new residents through 10/21/22. Interviews with the LNHA revealed that they could not speak to why they continued to admit new residents despite their significant staff deficit to care for the residents currently residing there. He was unable to speak to their Facility Assessment and why they had not assessed and documented their sufficient staff numbers/benchmark. The LNHA acknowledged that they were not meeting the State Minimum staffing requirement. On 10/17/22 at 11:45 AM, the surveyor interviewed the LNHA, the DON, and the RDON in the presence of a second surveyor. The RDON stated that instead of getting better the staffing issues have been getting worse. He stated that it had been a struggle to use agencies because they get grabbed up quick. He further stated that when they did hire and orient staff, they did not return. The LNHA stated that they had hired hospitality aides and acknowledged that they were not able to provide direct resident care. On that same date and time, the LNHA could not speak to why the facility continued to admit new residents when they were aware of their inability to provide sufficient staff. He stated that which comes first if there are no admissions, we won't have money to pay for the staff. He further stated that we try not to admit clinically complex residents. The LNHA could not speak to the facility's ability to provide appropriate care to the residents with insufficient staff. At the same time, the RDON stated that we have borrowed staff from other places to come here. The surveyor stated that there was one CNA for 53 residents on the 11 PM -7 AM night shift for the second-floor last night. The LNHA stated that no he was not aware of that. The RDON stated that this should never have happened. The administrative team could not speak to why the facility continued to admit new residents with insufficient staff. In addition, the LNHA stated that I can't provide an adequate answer to that question. Furthermore, the DON stated that there had not been a nursing supervisor for the 11 PM -7 AM night shift for the last nine months and none for the 3 PM-11 PM evening shift since August 2022. The LNHA and the RDON acknowledged the DON's statement. The RDON stated that I agree there should be no admissions . since the staffing was so short. The RDON added, I am going to take care of that. The DON added, I agree. On 10/24/22 at 12:58 PM, the survey team met with the LNHA, the RRN, and the DON about the FA which was provided by the RDON on 10/14/22 at 12:48 PM. The LNHA stated that I completed the FA. The LNHA could not speak to the benchmarks he used or how it was determined that staffing was sufficient. He stated that some of the numbers used for the FA came from the MDS (Minimum Data Set, a tool used to facilitate the needs of a resident) and PBJ (payroll-based journal). He was unable to speak to how he completed the FA, or if anyone else participated. Furthermore, the facility's administrative team including the LNHA could not speak to how the FA was determined and completed and requested the opportunity to review it and would further respond to the survey team. A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks beginning 9/25/22 and ending 10/08/22 revealed the facility was not in compliance with the State of New Jersey minimum staffing requirements of CNAs on 14 of 14-day shifts, deficient in total staff for residents on 4 of 14 evening shifts, and deficient in total staff for residents on 14 of 14 overnight shifts. A review of the list of new admissions from 9/25/22 to 10/08/22 revealed that the LNHA allowed for seven new admissions to the facility despite knowledge of the lack of staff to care for the residents that currently resided at the facility. On 10/24/22 at 4:16 PM , the survey team met with the LNHA, DON, RDON, and the RRN. The failure of the LNHA to assess sufficient staffing benchmark in the FA, identify and provide state minimum staffing requirement while continuing to admit new residents places all residents at risk for serious harm, impairment or death. The LNHA's knowledge according to staff interviews revealed short staffing had impacted resident outcomes, including Resident #47 who had 11 falls over the last six months, and seven of them were unwitnessed despite occurring in common areas, as a result of the falls, Resident #47 developed serious harm including fractures, intracranial hemorrhage with subdural hematoma, and hospitalization . In addition, the failure of the LNHA to ensure the facility established systems that were effective and efficient to operate the facilitate in a manner to safely meet resident's needs in compliance with federal, state, and local requirements as outlined in the Administrator Job Description, resulted in an IJ situation that was identified. On 10/25/22 at 11:30 AM, the surveyor met with the RRN and RLNHA#1. The RRN informed the surveyor that the RLNHA#1 started yesterday (10/24/22) and will oversee the LNHA until the facility's problems will be corrected. RLNHA#1 stated that we understand the staffing concerns and we will make sure to cover and address the concern. On 10/25/22 at 12:55 PM, the survey team met with the RRN, Regional LNHA #1. The facility management provided a copy of the facility's removal plan. The team verified the removal and lifted the IJ. On 10/26/22 12:42 PM, after the survey team interviewed the LNHA and left the conference room, RLNHA#1 entered the room and introduced RLNHA#2 to the survey team. RLNHA#1 stated that her and RLNHA#2 will be covering for the LNHA until the facility find another administrator. A review of the Facility Assessment policy with a revised date of 9/2022, reflected that The facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operation and emergencies. It also reflected that The facility assessment will include but not limited to the following: . The care required by the resident population considering the types of diseases, condition, physical and cognitive disabilities, overall acuity and other pertinent facts that are present within the population. In addition, the policy reflected that The facilities resources, including but not limited to: . All personnel, including manager, staff (both employees and those who provide services under contract) . A review of the facility policy Nursing Services and Sufficient Staff with a revised date of 11/2021, reflected that the facility should provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. In addition, it reflected that The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. This included except when waived, licensed nurses and other personnel including but not limited to nurses aides. NJAC 8:39-13.1(a)(b), 14.2(a), 33.1(d)

Complaint #NJ00157677 Reference F677 and F689 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the facility was meeting New Jersey state minimum staffing requirements, and b.) identify their own sufficient staffing numbers necessary to meet their census population and resident needs. The survey team reviewed the staffing levels for the two weeks prior to the survey (9/25/22 to 10/8/22). It was determined that the facility was significantly deficient in Certified Nursing Aide (CNA) staffing for 14 of 14 day shifts in which most days, the facility was only meeting half of the required CNA's for the day shift (CNA's had between 13 to 26 residents each on their assignment when the NJ state requirement is 1 CNA to 8 Residents for the day shift). The Facility was also deficient in staffing the evening (3-11 PM) shift for 4 of 14 evening shifts, and 14 of 14 night (11 PM- 7 AM) shifts. Upon a review of the Facility Assessment (FA), it was determined that the facility did not identify or assess their benchmark of sufficient staff numbers necessary to serve their resident population based on an average census and specific population needs. The FA was generic regarding staffing and had only specified that they would provide sufficient staff but there were no numeric values. Despite not assessing their own sufficient staff numbers within their FA and in addition was not meeting the state minimum staffing requirements by a significant margin, the facility continued to admit new residents to their facility, particularly seven (7) new residents from 9/25/22 to 10/8/22 during this two week period of time in which staffing was evaluated. The facility continued to admit new residents through 10/21/22. All residents for 2 of 2 units were at risk for serious injury, harm, impairment, or death, which included multiple falls (Resident #47) and elopement (Resident #88). This placed all residents on 2 of 2 resident care units at risk for serious harm, impairment or death from a failure to identify sufficient staffing and failure to meet New Jersey State minimum staffing requirements by almost half on most days. This resulted in an Immediate Jeopardy (I) which began on 5/26/22. The facility's Director of Nursing (DON), Regional DON (RDON), Regional Registered Nurse (RRN) and Licensed Nursing Home Administrator (LNHA) were notified of the IJ on 10/24/22 at 4:06 PM. An acceptable Removal Plan was received on 10/25/22 at 12:55 PM. The IJ was verified by the survey team on 10/25/22 through observation, interview, record review and review of other pertinent facility documents. The evidence was as follows: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties; and (3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum . 1. On 10/13/22 at 10:04 AM, the surveyor conducted an entrance conference with the DON, LNHA, and the Regional Quality Assurance Registered Nurse. The DON reported that the facility census was currently 107 residents, and they were currently holding one additional bed. The surveyor reviewed the list of new admissions to the facility in the last 30 days provided upon entrance to the facility. The list was provided on a matrix list of current residents which indicated that there were a total of seven new residents admitted from 9/27/22 through 10/11/22. At 11:21 AM, the surveyor interviewed the day shift (7 AM-3 PM) Licensed Practical Nurse/Unit Manager#1 (LPN/UM #1) for the second floor. The LPN/UM #1 stated that the unit census (number of residents in a unit) was 54 residents and three CNAs were working; therefore, the CNA-to-Resident ratio calculated to be 1 CNA for 18 residents that shift. The surveyor confirmed this by counting the number of CNA's present on the unit. On 10/13/22 at 11:52 AM, the surveyor observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted in the reception area/lobby area of the facility dated 10/7/22-Night Shift with Current Resident Census: 108, 1 CNA: 32 Residents. The receptionist provided a copy of the 10/7/22-Night Shift NHRCSR that was posted. The staffing report was not posted for the day of 10/13/22 which was six days late. On 10/14/22 at 11:25 AM, the surveyor observed the NHRCSR posted in the reception area/lobby area of the facility dated 10/14/22-Day Shift which indicated a ratio of 1 CNA to 20.3 Residents. (This did not meet the New Jersey state minimum staffing requirement for the day shift of 1 CNA to 8 Residents). On 10/17/22 at 6:11 AM, the surveyor made an observation on the night shift for the first floor. The surveyor observed that there was only one CNA assigned on the unit. The surveyor interviewed LPN #1 who was working the night (11 PM-7 AM) shift on the first floor. LPN#1 stated that the unit census was 52 residents and there was 1 CNA assigned to the residents this shift. LPN #1 acknowledged there was a staffing shortage and stated that We do what we can do. We pitch in. On 10/17/22 at 6:16 AM, the surveyor interviewed CNA #1. She acknowledged that she was the only CNA assigned to the first-floor unit for the current night shift. CNA#1 stated that nurses try to help her out to provide care and assistance to the residents. CNA #1 acknowledged there was a staffing shortage. She further stated that new staff start but leave since it's always short in 11-7 [night shift], that's why they don't stay. In addition, she stated that facility management was aware of the staffing shortage and stated that it had been like this for two years since the start of the pandemic. On 10/17/22 at 6:40 AM, LPN #2 stated to the surveyor that he was one of the two nurses that worked for the 11 PM to 7 AM night shift. He stated that he was aware of the facility's staffing shortage. On 10/17/22 at 7:03 AM, the surveyor interviewed the Registered Nurse (RN) who had worked the 11 PM to 7 AM night shift on the second floor. The RN stated that the census was 53 residents and that there was only one CNA assigned to the unit. On 10/17/22 at 7:37 AM, the surveyor interviewed CNA #2. She stated that she was assigned to work the 7 AM-3 PM day shift but started before 7:00 AM and provided incontinence care to a resident at 6:45 AM. On 10/17/22 at 7:53 AM, the surveyor interviewed the RN who stated that the facility was short-staffed. In addition, she stated that there was no nursing supervisor and that he/she left nine months ago. The RN stated that there was a CNA who came in at 6 AM before the 7 AM-3 PM assigned shift to assist with care. In addition, she stated that she was aware of family complaints of staffing shortages. On 10/17/22 at 10:16 AM, the surveyor interviewed the Hospitality Aide on the second floor. He stated that he has been working at the facility for a few months and assisted residents on the whole unit and was not assigned to specific rooms. He stated that he did not provide direct care to the residents but assisted the CNA's. He stated that they have very few aides. On 10/17/22 at 11:45 AM, the surveyor interviewed the LNHA, the DON and the RDON in the presence of a second surveyor. The RDON stated that instead of getting better, the staffing issues have been getting worse. He stated that it had been a struggle to use agencies because they get grabbed up quick. He further stated that when they did hire and orient staff, they did not return. The LNHA stated that they had hired hospitality aides and acknowledged that they were not able to provide direct resident care. On that same date and time, the LNHA could not speak to why the facility continued to admit new residents when they were aware of their inability to provide sufficient staff. He stated that which comes first if there are no admissions, we won't have money to pay for the staff. He further stated that we try not to admit clinically complex residents. The LNHA could not speak to the facility's ability to provide the necessary care to the residents with insufficient staff. At the same time, the RDON stated that we have borrowed staff from other places to come here. The surveyor stated that there was one CNA for 53 residents on the 11-7 AM night shift for the second-floor last night. The LNHA stated that no he was not aware of that. The RDON stated that this should never have happened. The administrative team could not speak to why the facility continued to admit new residents with insufficient staff. In addition, the LNHA stated that I can't provide an adequate answer to that question. Furthermore, the DON stated that there had not been a nursing supervisor for the 11-7 AM shift for the last nine months and none for the 3 PM-11 PM evening shift since August 2022. The LNHA and the RDON acknowledged the DON's statement. The RDON stated that I agree there should be no admissions if we cannot provide care, I am gonna take care of that. The DON added, I agree. On 10/17/22 at 12:26 PM, the RDON approached the survey team and stated, this should never have happened. On 10/20/22 at 8:59 AM, the surveyor interviewed CNA #3 in the presence of the survey team. He stated that he worked the 3-11 PM evening shift on 10/16/22. He further stated that I probably had more than 20 residents because I had the whole short hall resident plus one room on the long [hall]. The surveyor reviewed the staffing for the two weeks prior to survey and all other pertinent facility staffing documents, which revealed the following: A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks beginning 9/25/22 and ending 10/08/22 revealed the facility was not in compliance with the State of New Jersey minimum staffing requirements of CNAs on 14 of 14-day shifts, deficient in total staff for residents on 4 of 14 evening shifts, and deficient in total staff for residents on 14 of 14 overnight shifts as follows: -09/25/22 had 6 CNAs for 108 residents on the day shift, required 13 CNAs. (18 residents per CNA) -09/25/22 had 10 total staff for 108 residents on the evening shift, required 11 total staff. -09/25/22 had 6 total staff for 108 residents on the overnight shift, required 8 total staff. -09/26/22 had 6 CNAs for 107 residents on the day shift, required 13 CNAs. (17.83 residents per CNA) -09/26/22 had 5 total staff for 108 residents on the overnight shift, required 8 total staff. -09/27/22 had 7 CNAs for 107 residents on the day shift, required 13 CNAs. (15.28 residents per CNA) -09/27/22 had 9 total staff for 107 residents on the evening shift, required 11 total staff. -09/27/22 had 4 total staff for 107 residents on the overnight shift, required 8 total staff. -09/28/22 had 7 CNAs for 106 residents on the day shift, required 13 CNAs. (15.14 residents per CNA) -09/28/22 had 5 total staff for 106 residents on the overnight shift, required 8 total staff. -09/29/22 had 8 CNAs for 105 residents on the day shift, required 13 CNAs. (13.12 residents per CNA) -09/29/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -09/30/22 had 6 CNAs for 105 residents on the day shift, required 13 CNAs. (17.50 residents per CNA) -09/30/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -10/01/22 had 7 CNAs for 105 residents on the day shift, required 13 CNAs. (15 residents per CNA) -10/01/22 had 9 total staff for 105 residents on the evening shift, required 10 total staff. -10/01/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -10/02/22 had 6 CNAs for 105 residents on the day shift, required 13 CNAs. (17.50 residents per CNA) -10/02/22 had 9 total staff for 105 residents on the evening shift, required 10 total staff. -10/02/22 had 6 total staff for 105 residents on the overnight shift, required 7 total staff. -10/03/22 had 5 CNAs for 105 residents on the day shift, required 13 CNAs. (21 residents per CNA) -10/03/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -10/04/22 had 5 CNAs for 105 residents on the day shift, required 13 CNAs. (21 residents per CNA) -10/04/22 had 4 total staff for 105 residents on the overnight shift, required 7 total staff. -10/05/22 had 4 CNAs for 105 residents on the day shift, required 13 CNAs. (26.25 residents per CNA) -10/05/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -10/06/22 had 5 CNAs for 105 residents on the day shift, required 13 CNAs. (21 residents per CNA) -10/06/22 had 6 total staff for 105 residents on the overnight shift, required 7 total staff. -10/07/22 had 6 CNAs for 105 residents on the day shift, required 13 CNAs. (17.50 residents per CNA) -10/07/22 had 5 total staff for 105 residents on the overnight shift, required 7 total staff. -10/08/22 had 5 CNAs for 107 residents on the day shift, required 13 CNAs. (21.40 residents per CNA) -10/08/22 had 6 total staff for 107 residents on the overnight shift, required 8 total staff. Upon a review of the FA dated to cover October 15, 2021 through October 14, 2022, it was determined that the facility did not identify their benchmark of sufficient staff numbers necessary to serve their resident population based on an average census and specific resident needs. The FA was generic regarding staffing and had only specified that they provided sufficient staff but there were neither numeric values for staffing nor did it address what sufficient staffing meant. Despite not assessing their own sufficient staff numbers within their FA, and not meeting the state minimum staffing requirements by a significant margin, the facility continued to admit new residents to their facility, particularly seven (7) new residents from 9/25/22 to 10/8/22 during this two-week period of time in which staffing was evaluated. The facility continued to admit new residents through 10/21/22. On 10/24/22 at 12:58 PM, the survey team met with the LNHA, the RRN, and the DON about the FA which was provided by the RDON on 10/14/22 at 12:48 PM. The LNHA stated that I completed the Facility Assessment. The surveyor and the LNHA reviewed together that there was no evidence that the facility identified sufficient staffing numbers to address their resident population and census data. The LNHA could not speak to why in the FA there were zero categories in which there were insufficiencies, and the FA indicated that there was sufficient staff. He stated that it was probably written before COVID and those challenges. The LNHA could not speak to the dates and time frame indicated on the FA as October 15, 2021 through October 14, 2022, and what that meant for the FA. He stated that the FA was based on observations and looking at data. He stated, We are looking at staffing and staffing patterns, census, and resident diagnoses. The LNHA could not speak to identifying the benchmarks he used or how it was determined that staffing was sufficient. He stated that some of the numbers used for the FA came from the MDS (Minimum Data Set, a tool used to facilitate the needs of a resident) and PBJ (payroll-based journal). He was unable to speak to how he completed the FA, or if anyone else participated. In addition, the LNHA did not have his own copy of FA to review. The RRN stated that she had not yet reviewed the FA. The RRN stated that the FA should be reviewed annually and during the Quality Assurance Performance Improvement (QAPI) committee meetings. She stated that the purpose of the FA was that it will determine the needs of the residents and resident population, so we can provide the services required to take care of the residents. She further stated that if there was an area of concern it should have been discussed at the QAPI meeting. Furthermore, the facility's administrative team could not speak to how the FA for staffing was determined and requested the opportunity to review it and would further respond to the survey team. On 10/26/22 at 9:31 AM, the surveyor interviewed the DON in the presence of a second surveyor. The DON stated that for burnout prevention, she looked at the hours that staff had worked and if they worked other jobs. She further stated in reference to staffing status that it's challenging. The DON stated that the staff tell her I'm tired. They work long hours. They try to kill themselves to deliver the best care for the residents. She further stated that the administration and higher-ups were aware of the possibility of staff burnout. On 10/31/22 at 02:40 PM, the survey team met with a family representative. He/She expressed concerns over staffing shortages that had been noticed. He/She stated that they are very short-staffed and that they do not have enough aides. On 11/03/22 at 11:04 AM, the surveyor interviewed the Nursing Staffing Coordinator (SC). The SC acknowledged staff shortages for all three shifts weekdays and weekends. She stated that she was familiar with minimum staffing requirements but could not speak to numbers off the top of my head but I have them. She also stated that now we are working with four agencies and not previously . we had no agency. At that same time, the SC stated that staffing has been a challenge and that the LNHA and DON were aware. She stated that she participated in weekly meetings with corporate regarding staffing challenges and that they try and provide staff from other buildings, however, I work with sister facilities to solve staffing issues but unfortunately they are in the same boat. 2. On 10/20/22 at 12:37 PM, the surveyor interviewed the DON regarding an elopement which the DON acknowledged took place on 7/6/22. The DON told the surveyor that the resident was seen by the exit door at the end of the hallway on the Front Porch Unit, the second-floor unit during the evening shift. At that time a CNA#4 heard the exit door at the end of the hallway alarm. The exit door led to a stairwell that led to the ground floor. The CNA came out of a room where he was providing care and redirected the resident toward the nursing station. The CNA then reset the door alarm and went back into another resident's room to provide care. At that same date and time, the DON told the surveyor that she believed the alarm went off again and no resident was seen by the door. The DON further stated that LPN#3 who was working on the evening shift just went ahead and reset the alarm without accounting for all the residents. The DON stated, The LPN had just returned from break and heard the alarm, she didn't see a resident at the door, so she reset the alarm and continued to pass medications. At that time, the surveyor asked the DON what should have happened, and the DON stated, the LPN should have checked the exit door and the stairwell to see if any residents were there and then should have done a head count to make sure all the residents were accounted for, which she failed to do. The DON said, she didn't think. On 10/21/22 at 12:07 PM, the surveyor spoke with CNA#4 who was with Resident #88 on the night of an elopement. The CNA told the surveyor that he heard a door alarm while he was in another resident's room. At that time, he went to the door and saw Resident #88 attempting to run down the steps. The CNA said that he grabbed the resident's shirt because he was afraid the resident would fall down the steps. The CNA said that he put the resident back in the room and told the nurse on duty about the incident. On that same date and time, the surveyor asked CNA#4 if he heard the second alarm and the CNA stated, I went on break and the next thing I saw was the cops and I found out that the resident had been found a couple of doors down from the facility. On 10/26/22 at 3:14 PM, the surveyor interviewed LPN#3 who was caring for Resident #88 on the evening of the elopement. The LPN told the surveyor there were, Two nurses working for the entire unit. And we were short with only three aides on a dementia unit. I was responsible for the resident. I saw [him/her], put the resident to bed. I called the CNA when I put [him/her] to bed to do PM care. I then fed some residents, because we were so short-staffed. I then heard the door alarm, I didn't know how to turn it off, so I called the CNA to help me turn it off, I didn't open the door or look for any residents, I thought the resident was still sleeping. I didn't know the resident had a history of leaving. A Police officer called and then I realized [he/she] was missing because the police asked me if I knew the resident. I was shocked. 3. On 10/18/22 at 11:35 AM, the surveyor asked the DON to provide all the supporting documentation related to multiple fall incidents (11), some of which resulted in major injury for Resident #47 from 5/26/22 through 10/10/22. On 10/19/22 at 11:32 AM, two surveyors interviewed LPN/UM#2. She informed the surveyors that the resident had no safety awareness and needed continuous 1 on 1 observation only when they can due to short staffing. The survey team reviewed the staffing for the dates and shifts on the unit associated with each fall. The staffing assignment sheets revealed the following: 5/26/22: Census: 44, 4 CNAs, 2 Nurses 6/2/22: Census: 45, 3 CNAs, 2 Nurses 6/7/22: Census: 45, 3 CNAs, 2 Nurses 6/26/22: Census: 53, 4 CNAs, 2 Nurses 7/12/22: Census: 54, 5 CNAs, 2 Nurses 7/17/22: Census: 54, 4 CNAs, 2 Nurses 8/17/22: Census: 57, 4 CNAs, 2 Nurses 8/23/22: Census: 55, 4 CNAs, 2 Nurses 8/29/22: Census: 55, 3 CNAs, 2 Nurses 10/3/22: Census: 51, 3 CNAs, 2 Nurses 10/10/22: Census: 51, 3 CNAs, 2 Nurses On 10/21/22 at 10:30 AM, the surveyor conducted a follow-up interview with the LPN/UM#2, who acknowledged that Resident #47 had frequent falls. She also stated that the resident can ambulate when he/she wants to and required staff supervision to prevent further falls because of poor balance and safety awareness. She further explained that the staff should have been close enough to the resident to intervene as needed. On the same day at 10:35 AM, the surveyor interviewed CNA#5. CNA#5 acknowledged that the resident had frequent falls. She stated that due to staffing issues, they could not closely supervise the resident. She further stated that they were short staffed and they needed more staffing to monitor the resident due to their impaired cognition and agitated behavior, and to provide for Resident #47's needs. On 10/24/22 at 11:54 AM, the survey team met with the RRN, DON, and LNHA, and were made aware of the above concerns. On 10/26/22 at 11:30 AM, LPN#4 stated, I feel extremely high burnout, no help since COVID. She acknowledged that the resident had multiple falls due to impaired cognition which resulted in major injury. She stated that because they were under staffed, to be realistic, staff needs to observe the resident visually but to be idealistic, staff will observe resident physically to prevent the resident from falling. LPN#4 further stated that the resident required close observation by sitting next to him/her. 4. On 10/17/22 at 6:13 AM, the surveyor observed the RN and CNA#2 providing morning care to Resident #55. The resident's room smelled of urine and the resident's mattress was wet. The surveyor observed that the linen and fitted sheet were saturated wet with yellow and brown colored stains. The resident was positioned to the left side facing toward the window, the sacral area was not reddened, and no wounds were observed. The CNA and the RN both stated that the resident was soaking wet with urine, which soaked through to the mattress, and confirmed that the room smelled of urine. On that same date and time, the RN stated that the census was 53 and CNA#6 was the only aide working for the previous 11 PM-7AM night shift. The RN further stated that CNA#2 came in before 6 AM today to help even though she was not asked to come early and that CNA#2 usually comes in early. At that same time, CNA#2 indicated that she had to help because she was assigned to Resident #55 today for the 7AM to 3PM day shift anyway and I know 11-7 [night shift] are short staffed and I will be busy today because it will be short also today for 7-3 [day] shift. Both the RN and CNA#6 stated, We do what we can here. 5. On 10/17/22 at 6:57 AM, the surveyor observed CNA#6 providing morning care to Resident #19. The resident's room smelled of urine, the resident's mattress was wet, and the linen and fitted sheet were saturated in wetness with a yellow and brownish color. The resident was positioned to the left side of the bed, facing toward the wall, and the sacrum area was exposed with no reddened area and the skin was intact. At that same date and time, CNA#6 stated that the resident was soaking wet with urine including the side of the mattress, linen, and the fitted sheet and that the room smelled of urine. The surveyor observed that the resident was wearing doubled (2) incontinence briefs soaking wet with urine. CNA#6 acknowledged that the doubled brief on the floor which was soaked in urine belonged to the resident, and stated that the resident should not have a doubled brief. She further stated that she did not know who put the doubled brief on the resident because that was the first time she changed the resident's brief since 11:00 PM yesterday (10/16/22; Sunday) because of short staffing. She indicated that she was the only CNA for the 2nd-floor unit for the 11PM-7AM night shift for 53 residents. Furthermore, CNA#6 informed the surveyor that she worked the 3 PM- 11 PM evening shift yesterday (10/16/22; Sunday) and there were two CNAs on the second-floor unit. CNA#6 stated that she was not assigned to the resident on the evening shift and it was CNA#3 who took care of the resident. She further stated that the resident should have been changed and provided incontinence care at least twice per shift. She indicated that there were 53 residents on 10/16/22 and that she can only do so much. On 10/17/22 at 7:07 AM, during the interview with the surveyor, the RN stated that there was no regular CNA for the night shift, the census was 53 residents on 10/16 and 10/17/22. She further stated that only she and CNA #6 worked that night shift. The RN stated that 24 out of 53 residents were offered incontinence care for the night shift, 1 out of 24 refused care, 3 out of 24 were self-care, and 18 out of 24 were incontinent and were provided incontinence care. Both the RN and CNA#6 stated that We do what we can. The RN further stated that We cannot go to everyone to take care of them, I provided care to two residents only, and that she had to administer medications. The facility was notified of the Immediate Jeopardy (IJ) on 10/24/22 at 4:06 PM. The facility's DON, RDON, RRN, and LNHA were informed that for Resident #47 and Resident #88, the failure to a.) ensure the facility was meeting New Jersey state minimum staffing requirements, and b.) identify their own sufficient staffing numbers necessary to meet their census population and resident needs, placed these and all residents on 2 of 2 resident care units at risk for serious harm, impairment or death. On 10/25/22 at 12:55 PM, the facility provided the survey team with an acceptable removal plan. On 10/25/22, survey team verified the removal plan through observation, interview, record review and review of other pertinent facility documents. A review of the facility policy Facility Assessment with a revised date of 9/2022, reflected that The facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operation and emergencies. It also reflected that The facility assessment will include but not limited to the following: . The care required by the resident population considering the types of diseases, condition, physical and cognitive disabilities, overall acuity and other pertinent facts that are present within the population. In addition, the policy reflected that The facilities resources, including but not limited to: . All personnel, including manager, staff (both employees and those who provide services under contract) . A review of the facility policy Nursing Services and Sufficient Staff with a revised date of 11/2021, reflected that the facility should provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. In addition, it reflected that The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. This included except when waived, licensed nurses and other personnel including but not limited to nurses aides. (However, there was no calculation to what the facility's sufficient staffing numbers were or what the information was based on). On 11/03/22 at 12:23 PM, the survey team met with the DON, RRN, RLNHA #1 and RLNHA #2. There was no further information provided during the meeting. NJAC 8:39-5.1(a); 25.2(b); 27.2(h)

PART A Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that Resident #47 who was at risk for falls and with a diagnosis of Dementia was supervised, assessed, evaluated, and monitored to determine the cause of each fall and to prevent future falls, including a fall that resulted in serious injury. This deficient practice was identified for 1 of the 3 residents reviewed for falls. Resident #47 sustained 11 falls from 5/26/22 through 10/10/22 over a six month period of time. Seven (7) of the 11 of the falls were unwitnessed falls with most of the falls reoccurring in common areas (hallways and dining room). A review of the Investigation reports for the 11 falls revealed that they were incomplete and did not conclude possible causes/root cause of the falls. Further the investigations did not evaluate what interventions were in place at the time of the falls, nor did it address interventions or appropriate interventions to be put in place as a result of each fall, and the resident's care plan was not appropriate or specific to the resident's individualized needs to prevent falls. After multiple falls, the resident had another fall and suffered nasal fracture, rib fracture, intracranial hemorrhage with subdural hematoma, head trauma and was hospitalized for approximately two weeks. After having the fall with serious injury and returning from the hospital, the facility still did not update the resident's care plan to prevent future falls. Interviews with staff (CNA's, Nurses, Therapy) revealed inconsistent theories on what they believed close observation meant to prevent falls for Resident #47. They confirmed it was unclear and was not measurable or resident-specific. The CNA, Unit Manager, and DON were aware of the resident's cognitive impairment and reported that supervision of residents was very challenging because they were so short staffed. There was no Interdisciplinary Team (IDT) meeting or quarterly review note to review the resident's falls and evaluate interventions. The physician progress notes or Physician orders did not address the frequency of the falls or a plan to address the falls. There was no neurology/other physician consults or other medical work up to rule out if the falls were occurring due to a medical change in condition. The facility's failure to reassess after each fall, thoroughly investigate each fall to determine possible root causes, evaluate interventions and update the care plan with new, resident-centered/specific inventions after each fall in an effort to mitigate future falls, or rule out a medical change in condition, and the failure of staff to verbalize or provide evidence of what they are actively doing to prevent falls for Resident #47, when this resident already had a fall with serious injury. This places this resident and all other residents at risk for the likelihood of serious harm, impairment or death as a result of recurring falls if this practice was not immediately corrected. The Immediate Jeopardy (IJ) situation began on 5/26/22. The facility was notified of the IJ on 10/21/22 at 3:21 PM. An Acceptable Removal Plan was received on 10/24/22 at 3:53 PM. The immediacy continued through 10/26/22. The survey team verified the implementation of the Removal Plan on 10/27/22. The evidence was as follows: On 10/13/22 at 10:39 AM, the surveyor observed Resident #47 seated in a wheelchair, awake and alert. The resident was able to maintain eye contact and smiled at the surveyor; however, he/she did not respond to the surveyor's inquiry. The surveyor reviewed Resident #47's medical records. The Admission Record (an admission summary) reflected that Resident #47 was admitted to the facility with diagnoses that included Unspecified dementia with behavioral disturbance, generalized anxiety disorder, and major depressive disorder. The Annual Minimum Data Set (AMDS), an assessment tool with an assessment reference date (ARD) of 8/11/22 and Quarterly MDS (QMDS) with an ARD of 5/11/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which reflected a severely impaired cognition. Both MDS assessments revealed that the resident required staff supervision for transfer, walk-in room and corridor, locomotion on the unit, and limited assistance of one-person physical assist for locomotion off the unit. The Fall Risk Evaluation (an assessment tool) reflected that anytime there was a total score of 10 or greater, the resident should be considered at HIGH RISK for potential falls. It also indicated that a prevention practice should be initiated immediately and recorded on the resident's care plan. A review of Resident #47's medical records reflected that the resident sustained 11 falls from 5/26/22 through 10/10/22, specifically on the following dates: 5/26/22, 6/2/22, 6/7/22, 6/26/22, 7/12/22, 7/17/22, 8/17/22, 8/23/22, 8/29/22, 10/3/22, and 10/10/22. The following were the reported and documented fall incidents: 1.) The 5/26/22 at 11:07 AM fall incident revealed unwitnessed fall without injuries. Documentation reflected that a nurse that passed by observed the resident lying with the back of his/her head at the base of the scale. The printed form Change in Condition Evaluation (an evaluation tool for a resident change in condition) dated 5/26/22 included that the resident wanders alone. The Fall Risk Evaluation dated after the fall on 5/27/22 revealed a score of 10 which classified the resident at high risk for falls. 2.) The 6/2/22 at 11:07 AM fall incident reflected that another resident witnessed that #47 ambulated and tripped over a buffing machine's electrical cord which was laying across the floor while Housekeeping (HK) was conducting a room cleaning. The resident sustained injuries related to the fall: an abrasion to the back right hand, a bruise to the back left hand, a laceration to the face, and a pain level of 5 as shown in the Pain Assessment Advanced Dementia (PAINAD) tool. The Advanced Practice Nurse (APN) Physician Progress Note dated 6/02/22 at 9:29 PM, authored by the Advanced Practical Nurse (APN) included Accidental fall in her assessment and included a plan to implement fall prevention and neuro monitoring. The fall incident report indicated that the witness was a resident, but it did not specify that this resident was a reliable source. In addition, the incident report did not include documented statements from the witness and HK staff. The Fall Risk Evaluation dated 6/02/22 revealed a score of 11 which classified the resident at high risk for falls. 3.)The 6/7/22 at 9:26 PM fall incident revealed that the resident had an unwitnessed fall and was found on the floor in the short hallway without injuries. The fall report did not specify who found the resident on the floor nor include documented evidence of witness statements that surrounded the occurrence of the fall. In addition, the incident report included Notes dated 6/16/22 which indicated that the staff continues to observe and redirect the resident. It did not reflect specific interventions on what to observe or when and how to redirect the resident. The Fall Risk Evaluation dated 6/07/22 revealed a score of 17 which classified the resident at high risk for falls. 4.) The 6/26/22 at 10:45 AM fall incident reflected that the resident had an unwitnessed fall in which it was indicated that the resident hit their head, was bleeding, and had a 5 numerical level of pain at the time of the incident. The electronic Health Status Note (HSN) dated 6/26/2022 at 11:39 PM, indicated that the resident was sent to the hospital and returned to the facility the same day with no recommendations received. The Change in Condition Evaluation dated 6/26/22 under the Evaluations tab in the resident's electronic medical record (EMR) reflected an In Progress status, which was initiated but incomplete. It was included in the Employee Statement report authored by the Nursing Supervisor that a CNA found the resident lying on the floor by the hallway towards the dining room door. However, there was no documented evidence of statements from this CNA. 4.) The 7/12/22 at 5:55 PM fall incident revealed that the resident had a witnessed fall in which the resident tripped and landed on his/her knees and faced forward down to the floor while ambulating in the short hallway. The resident sustained a small laceration on the nose and a scratch mark on the right knee from the fall. The Change in Condition Evaluation dated 7/12/22 in the resident's EMR reflected an In Progress status, which was initiated but incomplete. There was no documented evidence that a Fall Risk Evaluation related to the 7/12/22 fall incident was completed. The Physical Therapy (PT) Discharge Summary indicated the date of service started on 6/03/22 and the discharge on 7/15/22. It indicated that the resident had poor safety awareness and poor ability to navigate obstacles and busy hallways. It also included recommendations to provide the resident with close supervision for ambulation without assistive devices to reduce the risk of falls. The care plan was not updated related to the 7/12/22 fall incident to implement interventions to ensure resident safety and reduce the risk of further falls. It also did not include or address the PT's discharge recommendations. 5.) The 7/17/22 at 02:33 PM fall incident revealed that the HK staff reported that the resident was found lying flat on the floor in the hallway. The report included that the resident cried out and was holding on to his/her right knee and hip, at the time of the incident. It also indicated that the resident sustained a bruise on the right knee from the fall. The APN Physician Progress Note dated 7/18/22 at 04:23 PM reflected that she included Accidental fall in her assessment and included a plan to implement fall prevention and neuro monitoring. The facility Neurological Evaluation Flow Sheet form (used to assess the neurological status of the resident) was initiated on 7/17/22 but was incomplete. There was no documented evidence that a Fall Risk Evaluation related to the 7/17/22 fall incident was conducted. 6.) The 8/17/22 at 8:29 PM fall incident reflected that the resident had an unwitnessed fall in which Resident #47 sustained a laceration on the left eyebrow. It included that the staff were at the nursing station, heard a sound, looked up, and found the resident on the floor in the long hallway near room [ROOM NUMBER]. There was no documented evidence that a Fall Risk Evaluation related to the 8/17/22 fall incident was conducted. The electronic HSN dated 8/17/2022 at 23:43 (11:43 PM) indicated that the resident was transferred and admitted to the hospital within the same day with a diagnosis of Intracranial Hemorrhage (brain bleed). The hospital records dated 8/17/22 revealed a Problem List for the current admission to the hospital that included a diagnosis of Acute on Chronic Intracranial Subdural Hematoma (a serious condition where blood collects between the skull and the surface of the brain). It also included those diagnostic tests that were performed on the resident during hospitalization and showed results of posterior left third rib fracture and bilateral nasal bone fractures. The electronic HSN dated 8/22/22 at 7:12 PM was readmitted to the facility from the hospital via ambulance via stretcher. The Readmission Fall Risk Evaluation dated 8/22/22 revealed a score of 12 which classified the resident at high risk for falls. 7.) The 8/23/22 at 5:20 PM fall incident revealed that Licensed Practical Nurse#1 (LPN#1) was called by another resident from room [ROOM NUMBER]W to see Resident#47 on the dining room floor. It did not indicate that the resident who reported the fall was a reliable source nor include a documented statement from this resident. Furthermore, the incident report indicated that LPN#1 was accompanied by Physician#1 who assessed Resident#47 with an order to send him/her to the hospital for evaluation following a fall with head trauma. The fall report did not reflect the identification of the causal factor that influenced the resident's fall. CNA#1's statement dated 8/23/22 reflected that she did not witness the resident's fall. She indicated that another resident notified her of Resident #47's fall in the dining room. The 8/23/22 incident report did not identify the resident who reported the fall to CNA#1 nor indicate whether this resident was a reliable source. There was no documented evidence of a statement from the resident who reported the fall to CNA#1. Additionally, CNA#2's statement dated 8/23/22 reflected that she did not witness the resident's fall in the dining room. She indicated that an activity staff was also in the dining room serving dinner to the residents. There was no documented evidence of a statement from the activity staff that was in the dining room, which was mentioned in CNA#2's statement. CNA#1 and #2's statements did not reflect whether the resident was supervised by staff in the dining room when the fall occurred. The Fall Risk Evaluation dated 8/23/22 revealed a score of 17 which classified the resident at high risk for falls. The facility-provided hospital records dated 8/23/22, After Visit Summary, reflected Fall for Reason for Visit and Diagnosis of Fall, initial encounter. The hospital records indicated the list of imaging tests conducted during the resident's visit. However, there was no documented evidence of the results that were included in the hospital records. The HSN dated 8/24/22 at 6:06 AM, reflected that the resident returned to the facility from the hospital at around 12:40 AM. The APN Physician Progress Note dated 8/24/22 at 13:06 (01:06 PM), reflected that the resident was readmitted to the facility from the hospital where he/she was diagnosed with Acute on Chronic Subdural Hematoma and Nasal Fracture. In the same notes, the APN included in the Plan for neurological monitoring and closed monitoring. However, there was no documented evidence of accountability in the resident's medical records that the neuro monitoring was conducted. Close monitoring was not defined. 8.) The 8/29/22 at 12:40 PM fall incident revealed that the resident had a witnessed fall in which the resident was sitting in a chair at the nursing station and attempted to rise from the chair which caused Resident #47 to fall on the floor. It was indicated that the resident had a pain level of 5 at the time of the incident. It also reflected that the resident's mobility assessment was ambulatory without assistance. In the incident report, LPN#2's statement dated 8/29/22 reflected that she was in the short hall where she witnessed the resident fall to the floor. She indicated that the resident had poor balance and attempted to ambulate which caused him/her to land on the buttocks and then hit his/her head possibly on the floor. The Fall Risk Evaluation dated 8/29/22 revealed a score of 16 which classified the resident at high risk for falls. The APN Physician Progress Note dated 8/29/22 at 01:32 PM, indicated that the APN was notified of the resident's fall. She included that the resident had no apparent injury on examination other than minor bruising on the forehead. She included in the Plan that for neuro monitoring should be conducted. However, there was no documented evidence of accountability in the resident's hybrid medical records that the neuro monitoring was completed. 9.) The 10/3/22 at 5:28 PM fall incident indicated that the resident had an unwitnessed fall in which the resident was heard screaming, crying, and laying on the dining room floor. The incident report included Notes dated 10/07/22 which indicated that the resident had a history of falls, no safety awareness, and being very spontaneous. It also included that the staff distantly observes the resident and anticipates his/her needs. A written statement from the Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1) dated 10/03/22, reflected that she was called to the dining room where she observed the resident sitting on the floor in front of the wheelchair, crying, grimacing, and holding his/her head. The printed form Change in Condition Evaluation dated 10/03/22 under interventions specified Frequent monitoring. It was also indicated that the primary care clinician was notified on 10/03/22 at 17:16 (2:16 PM) with recommendations for Neuro checks and Monitoring. The PT Discharge Summary indicated the date of service started on 8/23/22 and the discharge on 10/03/22. It included that the resident was discharged on a Supervision or touching assistance level for sit-to-stand transfer and gait with rehab recommendations for use of a wheelchair for mobility due to impaired safety and HHA/CGA (handheld assist/contact guard assistance) for all ambulation with staff as tolerated. There was no documented evidence that the PT discharge recommendations mentioned above were updated in the resident's care plan interventions during the surveyor's record reviews. The fall care plan was inappropriately updated on 10/5/22 related to the 10/3/22 fall, which included non-resident-centered interventions. Furthermore, there was no documented evidence that the intervention indicated in the 10/3/22 incident report which included that the staff distantly observed the resident, was recorded in the fall care plan interventions. The Fall Risk assessment dated [DATE] revealed a score of 16 which classified the resident at high risk for falls. 10.) The 10/10/22 at 02:19 PM fall incident revealed that the resident had a witnessed fall in which he/she was in the day room, stood up from the wheelchair, and took a few steps before falling and hitting his/her head on the foot of the table and the resident had a pain level of 5 at the time of the incident. The printed form Change in Condition Evaluation dated 10/10/22 indicated that the primary care clinician was notified on 10/10/22 at 14:00 with recommendations to continue to monitor and initiate neuro checks (an assessment that detects brain, spinal cord, and nerve injuries or disorders). Furthermore, the fall care plan intervention that was created on 10/10/22 included Staff to provide close observation. It did not identify what close observation meant for Resident #47, when or how often it close observation occurs, nor did it specify if it meant the proximity between the observing staff and the resident to be considered close observation. The Fall Risk assessment dated [DATE] revealed a score of 14 which classified the resident at high risk for falls. The above fall investigations showed the following: On 5/26/22, 6/26/22, 7/12/22, 7/17/22, and 8/17/22 fall incidents, there was no documentation of a root cause analysis written in the summary and conclusion of the fall investigation reports to evaluate what interventions were in place at the time of the fall and whether they were effective or not. There was no determination as to whether the falls were avoidable or unavoidable. There was no documentation in the resident's medical record that the neurological check orders were implemented or immediate actions were taken on 5/26/22, 6/02/22, 7/17/22, 8/23/22, 8/29/22, 10/03/22, and 10/10/22 in accordance with the fall incidents that were initiated. There was no documented evidence in the resident's hybrid medical records that the resident was seen and evaluated by a clinician following the falls that occurred on 5/26/22, 6/7/22, 6/26/22, and 10/03/22. There was no documented evidence that the Interdisciplinary team met to discuss the resident's falls that occurred on 5/26/22, 6/02/22, 6/07/22, 6/26/22, 7/12/22, 7/17/22, 8/17/22, 8/23/22, 8/29/22, and 10/10/22. In addition, there was no evidence that these fall occurrences, including those with major injury, were updated on the resident's care plan related to the incident and interventions to prevent further falls. There was no documentation that the resident was screened by the Rehabilitation Department following the 5/26/22, 7/17/22, and 10/10/22 fall incidents to determine if the resident could benefit from rehabilitation services or screen for the use of other durable medical equipment. There was no documentation that the staff received education, training or in services on the residents' safety and prevention of further falls following the 11 fall incidents. On 10/18/22 at 11:35 AM, the surveyor asked the DON to provide all the supporting documentation related to the resident's fall incidents from 5/26/22 through 10/10/22. The DON acknowledged to the surveyor that she provided the surveyor with all the documentation related to the resident's fall investigations except the hospital records. The DON stated that the neurological checks were completed on a paper form titled Neurological Evaluation Flow Sheet, which was attached to the fall reports that were given to the surveyor. On the same day at 12:07 PM, the RDON and DON met with the survey team. The RDON informed the surveyors that the staff and resident statements for fall investigations were paper documentation. He also stated that the statements were part of the fall investigation and should be attached to the fall incident report. Furthermore, he stated that after obtaining statements, the UM, DON, and LNHA would do a full investigation which included a fall summary and conclusion. During the interview, the RDON stated that the interim fall investigation report should be electronically entered immediately and completely by the nurse within the shift. He stated that the printed interim fall report should go to the UM to be reviewed for completion, then the DON and LNHA would be made aware of the investigation. The RDON acknowledged that the fall incident investigations and reports were not being completed. The DON also agreed and stated that the completion of the investigation process was not being done. On 10/18/22 at 01:33 PM, the surveyor had a follow-up interview with the DON in the presence of the survey team. The DON stated that the fall care plan should be updated by the UM within 24-72 hours of the fall occurrence, depending on when the fall occurred. She further stated that the fall care plan should have included appropriate interventions related to each fall. On that same date and time, the DON reviewed the resident's care plan and acknowledged that Resident #47's fall care plan was not appropriately updated and stated, You probably won't find the care plan updated. At that same time, during the interview with the DON, the DON informed the surveyors that the LPN/UM#1 did not update the fall care plan because she was not aware that she was supposed to update the resident's care plan to include appropriate interventions for each fall occurrence. On 10/19/22 at 11:32 AM, two surveyors interviewed LPN/UM#1. LPN/UM#1 informed the surveyors that she was responsible for care plan initiation and revision. She stated that with each fall, there should be new intervention. She acknowledged that the resident had multiple falls and his/her fall care plan was not updated for each fall. She stated that the resident's fall care plan interventions should have been adjusted accordingly on each fall to prevent the resident from future falls. The LPN/UM#1 stated that the resident had no safety awareness and needed continuous 1 on 1 observation only when they can due to short staffing. She also acknowledged that the resident's fall investigation reports were incomplete. On 10/20/22 at 10:41 AM, the surveyor interviewed the Director of Rehabilitation (Rehab) (DOR). The DOR informed the surveyor that the Rehab Department conducted Rehab screenings for residents every quarter, annually, for each new admission and readmission, and with a change in status. She stated that Rehab screenings were also initiated by staff or family referrals as needed, which included residents who had fallen to determine any decline in mobility, cognition, and communication that warrant rehab evaluation, treatment, and services. She informed the surveyor that the resident was referred for Rehab due to her multiple falls. On that same date and time, the surveyor asked the DOR if the resident was screened and evaluated after each fall incident. The DOR stated that she was not sure and would verify after reviewing the rehab notes. She also stated that she would provide the surveyor with a copy of the resident's rehab notes. In addition, she stated that the communication with the nursing department would be documented in the rehab daily notes. On 10/20/22 at 12:09 PM, the DOR met with the survey team. She stated that the nursing department would send a referral to the rehab department for each fall occurrence. The DOR further stated that the resident had a decline since his/her readmission from a hospitalization after a fall incident. She stated that the resident was discharged from PT on 10/3/22 with recommendations for use of a wheelchair for mobility and Handheld Assist (HHA) or Contact Guard Assist (CGA) for all ambulation with staff as tolerated due to his/her impaired safety awareness. During the interview, the surveyor also reviewed the PT Discharge Summary dated 7/15/22 in the presence of the DOR. It was documented by Rehab staff a recommendation that the resident required close supervision for ambulation without an assistive device to reduce the risk of falls. Furthermore, the DOR stated that she expected that the rehab recommendations be included in the resident's care plan. The surveyor asked the DOR for documented evidence of accountability that the rehab recommendations were relayed to the nursing department. The DOR stated that the rehab recommendations were discussed in the weekly Utilization Review (UR) meeting with the nursing department. The surveyor asked the DOR to provide a copy of the accountability of the rehab discharge recommendations dated 7/15/22 and 10/3/22 in the UR meeting. The DOR did not provide further information at this time. On 10/21/22 at 10:30 AM, LPN/UM#1 acknowledged that Resident #47 had frequent falls. She also stated that the resident could ambulate when the resident wants to and that the resident required staff supervision to prevent further falls because of poor balance and safety awareness. She further explained that the staff should be close enough to the resident to intervene as needed. On the same day at 10:35 AM, the surveyor interviewed CNA#3. She acknowledged that the resident had frequent falls. She stated that the resident always needed to be closely supervised by staff due to the resident's confusion and safety unawareness to prevent him/her from future falls. At that same time, CNA#3 further stated that due to staffing issues, they could not closely supervise the resident. She informed the surveyor that they were short staff and they needed more staffing to monitor the resident due to her impaired cognition and agitated behavior, and to provide for the resident's needs. The surveyor asked the CNA what close supervision meant. She stated that she sat by the resident so she can prevent her from falling. The surveyor reviewed the staffing assignment sheets associated with the dates and shifts of each fall for the unit. The assignment sheets revealed insufficient staff during the times of the falls in accordance with New Jersey State minimum staffing requirement. Review of the staffing patterns for the days and shifts that Resident #47 falls occurred were as follows: 5/26/22: Census: 44, 4 CNAs, 2 Nurses 6/2/22: Census: 45, 3 CNAs, 2 Nurses 6/7/22: Census: 45, 3 CNAs, 2 Nurses 6/26/22: Census: 53, 4 CNAs, 2 Nurses 7/12/22: Census: 54, 5 CNAs, 2 Nurses 7/17/22: Census: 54, 4 CNAs, 2 Nurses 8/17/22: Census: 57, 4 CNAs, 2 Nurses 8/23/22: Census: 55, 4 CNAs, 2 Nurses 8/29/22: Census: 55, 3 CNAs, 2 Nurses 10/3/22: Census: 51, 3 CNAs, 2 Nurses 10/10/22: Census: 51, 3 CNAs, 2 Nurses On 10/21/22 03:14 PM, the survey team met with the LNHA, DON, and RDON. The surveyor informed the facility's management that the facility's failure to ensure that Resident #47 who is at risk for falls and with diagnosis of dementia prevent the serious injury by failing to ensure that the resident was supervised, assessed, evaluated, and monitored to determine the cause of falls and to prevent future falls placing all residents at risk for serious injury, harm or death. From 5/26/22 through 10/10/22, for a period of six months, the facility failed to ensure Resident #47's safety who is at risk for falls and cognitively impaired by preventing falls, and including falls with major injuries (resident had lacerations, subdural hematoma with intracranial hemorrhage, fractures in the nose, and rib, and head trauma). This resulted in an IJ situations. The surveyor notified the facility management that the facility had to provide an acceptable removal plan, and an IJ template was provided to the facility. On 10/21/22 at 3:22 PM, the surveyor interviewed the Regional RN (RRN) in the presence of the survey team. The surveyor asked the RRN to define close supervision and close observation. The RRN responded that they both meant the same. She further explained that when the resident was in the staff's line of sight they would be able to see the resident and attend to his/her as needed. The surveyor asked the RRN to interpret the line of sight and what was the expected distance between the resident and the staff providing observation. The RRN could not provide further information. On 10/24/22 at 11:01 AM, the surveyor interviewed the resident's primary attending Physician#2. Physician#2 acknowledged that Resident # 47 was his resident. He stated that the resident had a decline and was frail due to Dementia. He informed the surveyor that he or his NP were notified and made aware of the resident's falls. However, he stated that he did not see and evaluate the resident after every fall. At that same time, the surveyor asked Physician#2 if he had meetings with the IDCP team that discussed the resident's falls. Physician#2 stated that he did not have a formal actual meeting with the IDCP team and stated, I wouldn't go to the meeting and that he went directly to the UM. The surveyor asked the physician about what he had done when he kept getting notified of the resident's falls. He stated that he included recommendations for CNA observation of the resident. He further stated, they can use the alarm if necessary to prevent the resident from future falls. He further stated, As far as I know, the facility told me we cannot use an alarm for the resident because it's against the resident's rights. On 10/24/22 at 11:54 AM, the survey team met with the RRN, DON, and LNHA. The RRN informed the survey team that 1:1 will never prevent falls. She further stated that the facility did not use a personal alarm to prevent residents from falling. She also stated that they did not try to use an alarm for Resident#47. Additionally, she stated that alarms will not deter the resident from falling. The RRN acknowledged that the resident's fall investigations were reviewed for completion after the surveyor's inquiry which included checking the root cause analysis, interviews, and care plan revision and updates, and written statements related to the resident's falls. An Acceptable Removal Plan was received on 10/24/22 at 3:53 PM. The survey team attempted to verify the implementation of the Removal Plan on 10/26/22. However, the immediacy could not be lifted on 10/26/22. On 10/26/22 at 11:30 AM, LPN#3 stated, I feel extremely high burnout, no help since COVID. LPN#3 acknowledged that the resident had multiple falls due to her imp [TRUNCATED]

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure that Resident #2 was free from physical abuse from a staff Licensed Practical Nurse. On 7/30/22 during the evening shift, Resident #2 was a victim of physical abuse by a Licensed Practical Nurse #1 (LPN#1) when LPN #1 punched Resident #2 on the left side of the face with a closed fist causing the resident to fall to the ground. This incident was witnessed by two facility staff, a Certified Nursing Aide (CNA #1) and a second Licensed Practical Nurse (LPN #2). The resident exhibited pain after the incident. LPN#1's failure to prevent physical abuse by punching Resident #2 with a closed fist causing the resident to fall posed a likelihood of serious harm, impairment or death to that resident on 7/30/22, resulting in an immediate jeopardy (IJ) situation that began on 7/30/22. The facility immediately suspended and terminated LPN #1 and notified all necessary parties and governing agencies and implemented additional measures to protect other residents on the same day 7/30/22. The facility was notified of the past non-compliance IJ on 10/26/22. The immediacy was lifted on 7/30/22. This deficient practice was identified for 1 of 11 residents reviewed for abuse (Resident #2). The evidence was as follows: On 10/13/22 at 9:40 AM, the surveyor observed Resident #2 in bed with his/her eyes closed. The surveyor reviewed the medical record for Resident #2 which revealed the following: A review of the Admission Record face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included: metabolic encephalopathy (a condition caused by a chemical imbalance in the blood and can affect one's mental state.), bipolar disorder (a psychiatric diagnosis that causes changes in a person's mood, energy, and ability to function), anxiety disorder, and chronic pain syndrome. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 7/01/22 reflected a Brief Interview for Mental Status (BIMS) score of 9 out of 12, indicating that the resident's cognition was moderately impaired. A review of the Resident #2's comprehensive individualized care plan included that the resident had a Behavioral Care Plan with an initiation date of 7/26/16 and revised on 8/02/22 with a focus area that Resident #2 had episodes of lashing out, threatening, verbally/physically aggressive to staff/co-residents if the resident did not get what the resident wants instantly. The interventions included allowing the resident to verbalize feelings, anticipate and meet the resident's needs, and caregivers to provide an opportunity for positive interaction, attention, approach/speak in a calm manner, and divert attention. Further review of the resident's care plan revealed another focus area for behavioral if the resident's meals are not delivered to their room prior to the food truck being pulled down the hallway and staff delivering food trays. The interventions included that the staff will deliver the resident's meals to their room before passing trays out in the wing so the resident's food will be delivered hot, two staff members to assist the resident and deliver the food tray; and when the resident gets agitated, to intervene before agitation escalates; if aggressive, staff to walk calmly away, and approach later. A review of the Progress Notes (PN) revealed a health status note dated 7/30/22 at 9:35 PM which indicated, Call received from nurse on duty that there was an incident between this resident and a nurse that resulted in a fall of this resident. The nurse and the resident were arguing over orange juice, food, and medication when the resident hit the nurse with an open hand. The nurse, in turn hit the resident with a closed fist causing the resident to lose balance and fall. Resident was able to move all extremities. Resident denied pain and discomfort. Noted no obvious injury. The facility's investigation report titled, Allegation of Physical Abuse for Resident #2 dated 7/30/22, revealed that LPN#2 was a witness to the incident and heard a loud argument over an orange juice (OJ) and LPN#2 attempted to intervene by providing the OJ to the resident. The investigation report showed that LPN#1 (the perpetrator) and the resident were in each other's personal space (less than an arm's reach) and LPN#2 attempted to place herself in between the resident and LPN#1 to create a physical separation and de-escalate the situation, at the same time Certified Nursing Aide#1 (CNA#1) who was also a witness to the incident overheard the loud argument also went to the hallway where the incident was happening and attempted to help by separating the resident and LPN#1. When the ongoing verbal argument and the proximity of the resident and LPN#1 escalated to a physical altercation when the resident was able to hit LPN#1 in his chest and in response, LPN#1 hit the resident in their face with a closed fist. The hit caused the resident to fall backward, the resident landed on floor hitting his/her head even though CNA#1 was behind the resident on the floor. The facility interviews that were conducted post-incident revealed that LPN#2 and CNA#1 confirmed the above investigational report affirming their statements dated 7/30/22. A written statement dated 7/30/22 from the perpetrator/LPN #1 revealed the following: .Resident #2 asked me for OJ, we were both in the hallway. I told the resident to grab the juice on the cart. The resident was unable to hear me, I said to go in the cart and grab it. The resident starts yelling, as resident started yelling my co-workers came and grab the resident as the resident is starting to approach me, yelling at me, as my coworkers trying to help the resident back to their room he/she hit me in the chest, and I hit him/her back. When the resident starts going to their room, Resident #2 tried to spit on me, and the resident said he/she is going to kill me. The incident narrative of the investigation report dated 7/30/22 showed that the witnessing LPN #2 called the Assistant Director of Nursing (ADON) to report the staff-to-resident physical abuse at about 9:43 PM. The ADON instructed LPN#2 to assess the resident while the ADON was en route to the facility. The ADON reported the incident to the LNHA. When the ADON reported to the facility around 10:26 PM, the ADON re-assessed the resident and initiated an immediate investigation. In addition, before the ADON reported to the facility, the resident and perpetrator/LPN#1 were already separated, then the local police department were notified and arrived to the facility to conduct an investigation, and the responsible party and physician of the resident were notified of the incident. The resident declined medical treatment and transfer to the emergency room at that time, the resident was monitored for any negative outcomes. A review of the local Police Department Incident Report dated 7/30/22 at 10:38 PM revealed: On the above date and time, police officer responded to the facility on the report of an assault. Upon, arrival, .the [ADON] explained a nurse and patient of the facility were involved in an altercation which led to the nurse striking the elderly patient .[LPN #1] stated he was trying to help the resident when he was pushed in the chest by [Resident #2]. [LPN #1] explained, in defense he then struck [Resident#2] in the head with a closed fist. [Resident #2] explained that [LPN #1] was refusing to help [him/her] with [his/her] basic needs. [Resident #2] stated [he/she] asked [LPN #1] for food but was provided food [he/she] can not eat and was told to get something [him/her-self]. [Resident #2] stated that [LPN #1] also gave [him/her] [his/her] medicine late and would not help [him/her] take them. [Resident #2] further stated when [he/she] requested different pills from [LPN #1] he refused to give them to the resident. [Resident #2] stated [he/she] then stood up out of bed and pushed [LPN#1] out of the way. [Resident #2] stated at this time, [LPN #1] struck [him/her] on the left side of the face, with a closed fist. It should be noted, I did not observe any bruising, redness, swelling etc. on [Resident #2's] face and [he/she] only complained of pain. [Resident #2] stated [he/she] did not need medical attention beyond what the nurses provided at the time of the incident . On 10/20/22 at 1:00 PM, the surveyor interviewed the Director of Nursing (DON), who used to be the ADON on the 7/30/22 incident. The DON stated that she suspended LPN#1 after the police left on 7/30/22. She further stated that the 7/30/22 incident was reported to the Department of Health, the Ombudsman office, and the New Jersey Board of Nursing. She indicated that all staff was re-educated regarding the facility's abuse policy right away. The DON provided documented evidence of the same. On 10/24/22 at 10:25 AM, the surveyor interviewed the Director of Social Worker (DSW) who stated that the resident was alert and oriented. The DSW stated that the resident likes female staff who are soft-spoken and the resident doesn't like it when staff say no without an explanation. She further stated that the resident could get agitated if the resident feels that the staff was coming across as rude. The SW stated that these behaviors have been evident and it is in the care plan. She also stated that when you talk calmly with the resident and explained why something can not be done, the resident will understand. On 10/24/22 at 12:20 PM, the surveyor interviewed the DSW regarding any grievances that were filed by the resident. The DSW stated that the resident had filed no grievances. On 10/25/22 at 9:45 AM, the surveyor interviewed Resident #2 who was observed having difficulty with hearing. The resident agreed to be interviewed regarding the incident that occurred on 7/30/22. The surveyor asked the resident if he/she recalled the physical abuse on 7/30/22. The resident stated that he/she was still experiencing headaches after the incident. The resident told the surveyor that he/she had no negative interaction with the nurse before the incident. The resident stated that they interacted with the nurse earlier in the day with no issue but somehow the nurse snapped. On that same date and time, the resident stated that he/she was asking the nurse for orange juice and a snack. The food that was offered was a food that he/she was not allowed to consume. The resident further stated that he/she did not hit the nurse and that the resident put their hand on the nurse's shoulder. The nurse then punched him/her in the face. The resident further stated that he/she had no issues with the facility. In addition, the resident stated that the facility immediately fired the nurse, made sure that he/she was safe, and they assessed the resident for any injuries. The surveyor reviewed the facility provided documents of full staff education on abuse, the immediate notification of all parties and governing agencies and the New Jersey Board of Nursing letter dated 8/1/22 to confirm the immediacy had been lifted. The surveyor reviewed the personnel file for the perpetrator/LPN #1. LPN #1 was hired on 11/15/21 and had a clear background check upon hire, license verification, and reference checks done that were also clear. The LPN #1 had been educated for abuse prevention on 11/18/21 prior to the 7/30/22 incident. On 10/26/22 at 3:52 PM, the survey team met with the facility which included the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse (RRN), DON, and Regional LNHA#1. The LNHA acknowledged the staff-to-resident physical abuse occurred and that it was witnessed by CNA #1 and LPN #2. The surveyor team notified the facility that the failure to ensure Resident #2 was free from staff-to-resident physical abuse. LPN#1's failure to prevent physical abuse by punching Resident #2 with a closed fist causing the resident to fall posed a likelihood of serious harm, impairment or death to that resident on 7/30/22, resulting in an immediate jeopardy (IJ) situation that began on 7/30/22. The LNHA and facility administrative team were made aware that a review of the facility documentation regarding this incident indicated that the immediacy was lifted on the same day 7/30/22. A review of the facility's policy for Abuse, Neglect and Exploitation that was 9/21 and was provided by the RRN indicated the following: by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Under Training topics will include: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents. b. Wandering or elopement-type behaviors. c. Resistance to care. d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. N.J.A.C. 4.1 (a) (3) (5) (12) (15)

Based on observation, interview and record review it was determined that the facility failed to implement an identified care plan intervention to reduce risk for injury from falls for 1 of 6 residents reviewed for falls, Resident #100. The resident sustained [REDACTED]. The Admission Record reflected Resident #100 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment tool dated 2/8/18, Resident #100 had moderate cognitive impairment with long and short-term memory problems, was sometimes understood and usually able to understand. The resident required total dependence of two staff for bed mobility and transfers, total dependence on one staff for toilet use, and did not walk. The resident's vision was assessed as highly impaired with use of glasses and had minimal difficulty hearing. On 3/14/18 at 11:58 AM the surveyor observed Resident #100 in bed, wearing glasses, with padded half side rails in the raised position. A floor mat was on the floor on the right side of the resident's bed. The resident's Responsible Party (RP) was seated in a chair immediately next to the left side of the resident's bed and a floor mat was folded up and stored leaning against the left side of the bed. The resident appeared comfortable but confused and did not respond to the surveyor when greeted. On 3/14/18 at 11:58 AM the surveyor interviewed Resident #100's RP who stated that the resident had been readmitted from the hospital the night before and had been in the hospital because the resident had tried to get out of bed on their own and broke their knee. The RP stated that the resident was not a candidate for surgery, that the primary goal was to provide pain management, and that the RP was considering placing the resident on Hospice Care. On 3/19/18 the surveyor reviewed the medical record for Resident #100 which revealed that the resident had a fall in the facility on 2/24/18 without injury and a fall on 3/7/18 which resulted in a femur fracture and hospitalization . The resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The surveyor reviewed the resident's electronic care plans which revealed an active care plan initiated on 1/11/16 for the problem of Risk for Falls and Injuries Related to Unaware of Safety Needs, Confusion, and Gait/Balance Problems. The Risk for Falls care plan included a current intervention initiated on 11/1/16 to maintain the bed in the lowest position and a current intervention initiated on 1/26/18 for a floor mat to be in place while the resident was in bed. The surveyor reviewed the Investigation Reports provided by the Director of Nursing (DON) for Resident #100's falls of 2/24/18 and 3/7/18 which revealed the following: On 2/24/18 at 10:15 PM Resident #100 was found lying on the floor next to the left side of their bed. The resident was unable to explain what happened and was not injured. The Summary of Investigation completed and signed by the Interdisciplinary Team (IDT) documented that at the time of the fall the resident's bed had been in the lowest position and floor mats were in place. The IDT concluded that staff would continue to ensure that the resident's bed was in the lowest position and that floor mats were in place when in bed. The investigation report concerning the 3/7/18 incident documented the following - On 3/7/18 at 8:40 PM Resident #100 was found kneeling on the floor on the left side of the bed, with both hands holding onto the side rail. The resident was unable to explain what happened but had discoloration of the left knee and complained of upper right leg pain. The nurses' notes revealed that the resident was given Tylenol 650 milligrams (mg) by mouth for pain and then slept through the night. An X-ray obtained on 3/8/18 revealed a [MEDICAL CONDITION] Distal Femur and the physician ordered the resident to be sent to the hospital. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. On 3/20/18 at 10:38 AM the surveyor observed Resident #100 in bed with their eyes closed, padded half side rails in the raised position, and floor mats on both sides of the bed. The resident did not respond to the surveyor. On 3/20/18 at 10:50 AM the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that Resident #100 used to be able to move in bed, was restless at times, was able to make their needs known, and had behaviors like calling out. The resident had a fall out of bed onto their knees, sustained a fracture, went to the hospital but wasn't a candidate for surgery, and returned to the facility. The resident was admitted to Hospice Care and the resident was being kept comfortable with pain medication and positioning techniques. The LPN further stated that, since returning from the hospital, the resident didn't move around much and didn't have behaviors. On 3/22/18 at 7:40 AM the surveyor observed Resident #100 in bed with their eyes closed, padded half side rails in the raised position, and floor mats on both sides of the bed. On 3/22/18 at 3:07 PM the surveyor interviewed Registered Nurse (RN) #1 who stated she was a usual nurse on the evening shift and knew Resident #100 well. RN #1 stated that the resident was known to constantly ask to go home and would constantly ask to use the bathroom even immediately after they had been toileted. RN #1 stated that usually a Certified Nurses' Aide (CNA) sat in the resident's doorway or next to the resident's bed because it comforted the resident to have someone nearby. RN #1 further stated that on 3/7/18, the night Resident #100 fell and sustained a femur fracture, the power had been out because of the snowstorm and only emergency generator power and lights were available so it was dark. RN #1 stated she heard Resident #100 calling out and found the resident at the side of the bed, holding onto the side rail with both hands, with both knees just off the floor. RN #1 further stated that Resident #100 did not have mats on the floor at the time of the fall because that was not on the resident's care plan at that time. The floor mats were put in place after the fall. RN #1 did not recall Resident #100 having a fall prior to the one on 3/7/18. On 3/22/18 at 3:30 PM the surveyor interviewed CNA #1. CNA #1 stated that she usually took care of Resident #100 on the evening shift and that the resident would always ask to go to the bathroom, but that right after being toileted they would ask to go again. The CNA stated that on the evening of 3/7/18 she toileted Resident #100 and put the resident back to bed and went to take care of another resident in another room when she was notified by the nurse that the resident had fallen out of bed. CNA #1 stated she didn't know how the resident fell , didn't know how or why the resident got out of bed, and that the resident did not have mats on the floor that night. On 3/23/18 at 10:12 AM the surveyor observed Resident #100 in bed with their eyes closed, padded half side rails in the raised position, and floor mats on both sides of the bed. On 3/23/18 at 10:25 AM the surveyor interviewed Unit Manager (UM) #1 who stated that if a change in a resident's care plan occurs, the change is communicated to staff verbally and in writing. UM #1 showed the surveyor a binder labeled Activities of Daily Living Care Log which included forms for Resident #100 entitled Visual Bedside Kardex Report and My Daily Rhythm of Life. UM #1 stated these two forms guided the CNAs' care of the residents and were kept in the binder for the CNAs to access. The forms were updated monthly and as needed, and included all instructions for the CNAs directly from the residents' electronic care plans. The surveyor observed that the form entitled My Daily Rhythm of Life for Resident #100 had an undated, handwritten entry for floor mats while in bed and the Visual Bedside Kardex Report had a printed date of 3/23/18 and an intervention for floor mat in place when in bed. UM #1 further stated that Resident #100 had floor mats as an intervention on their care plan but the mats were not in place when the resident fell . The bed was low at the time of the fall, which was another intervention in place. The resident was very frail and elderly and the fracture could have been related to [MEDICAL CONDITION]. The Unit Manager also stated We had everything else in place but we are human and a mistake was made. On 3/23/18 at 1:33 PM the DON, Assistant Director of Nursing (ADON) and Administrator were informed of the surveyor's findings. The DON stated that she had spoken with UM #1 and that UM #1 did not complete education with the staff and the floor mats were not in place. She further stated, we are looking at our communication process, we have these things in place on the other units and I cannot explain what happened. N.J.A.C. 8:39-27.1(a)

C # NJ , C# NJ Based on interview and record review, it was determined that the facility failed to follow a physician's treatment order, the nursing staff performed a wound care treatment to a surgical incision and covered the incision with a dressing. The physician order instructed the staff to leave the incision open to air (uncovered.) In addition, the nursing staff signed the Treatment Administration Record (TAR) indicating that incision was open to air (uncovered.) The facility failed to report signs and symptoms of infection to the physician for 1 of 6 residents sampled (Resident #4.) This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or 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 well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. A review of the medical record revealed that Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/14/16 revealed that Resident #4 was alert and had short and long-term cognitive deficits. The MDS identified that the resident required extensive assistance from 2 staff members for bed mobility and transferring from the bed to the chair. The MDS also identified that Resident #4 was able to ambulate with the use of a rolling walker and the assistance from 1 staff member. The surveyor reviewed the Nurse's notes (NN) dated 6/3/16 at 4:20 p.m. which revealed that Resident #4 was re-admitted to the facility on [DATE] and had 73 staples to his/her left hip/thigh and had a cast on the left arm. The note revealed that the area of the incision closer to the knee was secured with staples and had redness with small amount of bloody drainage. The note also revealed that the nurse cleansed the surgical incision with normal saline solution and covered the surgical incision with a dry dressing on Resident #4's re-admission to the facility. A review of the re-admission Physician's Order Sheet (POS) from the hospital dated 6/3/16 and untimed revealed an order for [REDACTED]. A review of a telephone order dated 6/3/16 at 7:30 p.m. from Resident #4's primary physician revealed an order to monitor Resident #4's left arm with cast for numbness, pain, warmth and discoloration. The order also instructed the nurses to notify the Orthopedic Doctor for any changes to the resident's surgical incision and left arm cast. A review of Resident #4's care plan initiated on 6/3/2016 revealed that the resident was at risk for infection due to left hip/thigh surgical incision. The intervention identified on the care plan was that the surgical incision should be assessed by the nurses every shift for signs and symptoms of infection such as redness, drainage, warmth and tenderness. In addition, the resident was to have follow-up appointment with the orthopedic doctor in two weeks or when needed. A review of the NN dated 6/4/16 at 3:34 p.m. revealed that the resident had left hip/thigh incision with 73 staples and had a dressing on the lower part of the incision. A review of the NN dated 6/5/16 at 2:32 p.m. revealed that Resident #4's left hip/thigh incision with staples were dry and intact and the lower part of the stapled area had redness and a scant amount of bloody drainage. This note also revealed that the nurse cleansed the area with normal saline solution and covered it with a dry dressing. A review of the NN dated 6/8/16 at 1:58 p.m. revealed that the left hip/thigh incision and staples were intact but the dressing was soaked at the lower part of the stapled area and the nurse changed the resident's dressing. There was no indication that the Physician was notified of the increased amount of drainage. A review of the NN dated 6/8/16 at 2:57 p.m. revealed that the resident's left hip/thigh had staples that were intact. The note revealed that there was a small amount of sero-sanguinous (a thin, watery, pink color) drainage coming from the 3 staples near the upper part of the incision site. The nurse cleansed the surgical incision with normal saline solution and covered it with a dry dressing. A review of the Physician order sheet from 6/3/16-6/10/16 revealed that there was no physician orders to clean Resident #4's surgical incision with normal saline solution and/or to cover the incision with a dry dressing. A review of Resident #4's June 2016 Treatment Administration Record (TAR) revealed a treatment order for the surgical incision that contained 73 staples was to be left open to air (uncovered.) In addition, the surgical incision was to be monitored for signs and symptoms of infection. A review of the TAR revealed that from 6/3/16 to 6/10/16 the nurses had signed the TAR indicating that the surgical incision was left open to air however; the documentation in the NN dated 6/3/16, 6/4/16, 6/5/16 and 6/8/16 revealed that the incision was cleansed with normal saline and covered with a dressing. When interviewed by the surveyor on 11/2/16 at 10:40 a.m. LPN #1 stated that she had cleansed Resident #4's surgical wound with normal saline solution and covered it with a dry dressing. LPN #1 stated that she had did this because of the sero-sanguinous drainage that she observed on the lower part of the incision and near the staples. LPN#1 could not recall if there was an order to clean the surgical incision with normal saline solution and to cover it with dry dressing. LPN #1 also stated she could not recall notifying Resident #4's doctor or the orthopedic doctor about the redness or drainage on resident's left hip/thigh surgical incision. When interviewed on 11/2/16 at 2:00 p.m. the DON stated that the facility's Wound Treatment Protocol should be followed by the nurses for any type of wound. The DON stated that the nurses should have informed the doctor if there was a change in Resident #4's surgical incision and that the doctor should have been informed if there was a need for the current surgical incision treatment to be changed. The DON stated that the nurses should not have cleansed the wound with normal saline solution and cover the incision with a dry dressing without a doctor's order. On 6/10/16, Resident #4 went to the Orthopedic Doctor (OD) for a scheduled follow-up appointment. The OD recommended for Resident #4 to be sent to the hospital because the left hip surgical incision was thought to be infected and would possibly need surgical intervention. Resident #4 was sent directly from the OD's office to the hospital. A review of the information received from the hospital dated 6/10/16 revealed that Resident #4 was admitted for surgery of Left hip wound and was in the hospital until 6/18/16. A review of the facility's policy titled Wound Treatment Protocol revealed that the wound treatment protocol will be followed for any identified wound, unless otherwise a physician order existed that established a specific protocol needed for wound treatment. The protocol stated that the licensed nurse will identify wounds not responding to current treatment regimen and that the Physician, the resident and the resident's caregiver will be informed of such findings. NJAC 8:39-27.1 (a) NJAC 8:39-11.2(b)

C # NJ , C# NJ Cross Reference F-323 Based on interview, and record review it was determined that the facility's Certified Nursing Assistant (CNA) transferred a resident from a wheelchair to the bed using a Hoyer lift alone. The resident sustained [REDACTED]. These injuries resulted in the resident having permanent decreased mobility. The CNA used a Hoyer lift to transfer the resident without a physician's orders [REDACTED]. This deficient practice was identified for 1 of 6 residents sampled (Resident #4). This deficient practice is evidenced by the following. Refer to example #1 NJAC 8:39-11.1

C# NJ , C# NJ Based on interviews and record review it was determined that the facility failed to provide a safe transfer consistent with the resident's needs to prevent an injury for 1 of 6 sampled residents (Resident #4.) A Certified Nursing Assistant (CNA) used a Hoyer lift without a physician's orders [REDACTED]. As a result of this transfer the resident sustained [REDACTED]. This deficient practice was evidenced by the following: 1. A review of the medical record revealed that Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated [DATE] revealed that Resident #4 was alert and had short and long-term cognitive deficits. The MDS identified that the resident required extensive assistance from 2 staff members for bed mobility and transferring from the bed to the chair. The MDS also identified that Resident #4 was able to ambulate with the use of a rolling walker and the assistance from 1 staff member. A review of Resident #4's care plan for range of motion and ambulation dated [DATE] and revised on [DATE] with a target date of [DATE] revealed Resident #4 was to be transferred to and from bed, chair and toilet with the use of a rolling walker and staff supervision. A review of the nurse's note (NN) dated [DATE] 3:45 p.m. revealed that Resident #4 complained of left leg pain while being transported from the dining room, back to his/her room. This NN revealed that Resident #4 was assisted back to bed by 2 staff members. The NN also revealed that a Licensed Practical Nurse (LPN #1) had assessed Resident #4's left knee and found that the resident's knee was tender to touch, slightly swollen and had spot of bluish discoloration. LPN #1 documented in the NN that she had administered pain medication on [DATE] at 1:00 p.m. to Resident #4, and the pain was relieved. LPN #1 documented that she notified the doctor about Resident #4's left knee pain. The doctor gave an order for [REDACTED].#4's left knee. A review of Resident #4's Left knee x-ray report dated [DATE] at 5:54 p.m. revealed that Resident #4 did not have a fracture. A review of the NN dated [DATE] 3:16 p.m. revealed that Resident #4's left knee had remained swollen and tender and warm to touch. This NN revealed that a physician order [REDACTED]. Resident #4 was given Ibuprofen on [DATE] at 9:00 a.m., and according to the NN the resident's pain was relieved. In addition, the NN dated [DATE] at 3:16 p.m. revealed that Resident #4's legal representative was made aware of Resident #4's condition (knee pain.) A review of the NN dated [DATE] at 4:30 a.m. revealed that Resident #4 complained of left leg pain. The NN revealed that the nurse assessed the resident's left leg and found that Resident #4's left thigh and knee were painful to touch and swollen. The NN revealed that Resident #4 was given pain medication and slept well. A review of the NN dated [DATE] at 6:32 a.m. revealed that the nurse notified Resident #4's doctor that the resident's left thigh and knee were swollen. The nurse documented that she suggested that an x-ray be done of the resident's left hip and thigh. According to the NN, the doctor told the nurse that she would see Resident #4 on the morning of [DATE]. A review of the NN dated [DATE] at 3:08 p.m. revealed that Resident #4 was seen by the doctor on [DATE]. The doctor ordered for Resident #4 to have an x-ray of the left hip. The nurse notified Resident #4's legal representative about the order for the x-ray. A review of the NN dated [DATE] at 10:59 p.m. revealed that the portable x-ray that was done on [DATE] at 7:32 p.m. showed that Resident #4 had left femoral fracture. The nurse reported the x-ray results to the doctor and the doctor gave an order to send the resident to the hospital. A review of the NN dated [DATE] at 11:44 p.m. revealed that Resident #4 was sent to the hospital by ambulance on [DATE] at 9:30 p.m. Further review of this same NN lacked any documentation that Resident #4's legal representative was informed of Resident #4's transfer to the hospital. A review of the NN dated [DATE] at 1:40 a.m. revealed that the nurse received a verbal report from the hospital and was told that Resident #4 had fractures of left hip, left wrist and left shoulder and might be transferred to another hospital. A review of the Universal Transfer form dated [DATE] and untimed revealed that Resident #4 was transferred to the hospital and then was to another hospital on [DATE]. Resident #4 was admitted and diagnosed with [REDACTED]. A cast was placed on Resident #4's left wrist and his/her shoulder fracture was placed in a sling. A review of the facility's Incident/Accident Report dated [DATE] 12:00 a.m. revealed that on [DATE] Resident #4's left thigh and knee were both swollen and warm to touch. A review of the facility's Investigation Report of Injury of Unknown Origin dated [DATE] revealed that Resident #4 was not able to answer the interviewer's questions, as to what had happened to his/her left thigh and knee. A review of the Certified Nursing Assistant (CNA #1's) written statement dated [DATE] revealed that CNA#1 used a Hoyer lift to transfer Resident #4 from the wheelchair to the bed. CNA#1 wrote that Resident #4 was in the dining room and that she had asked the resident if he/she wanted to go back to his/her room. CNA #1 wrote that she placed the Hoyer lift pad underneath Resident #4 while CNA#2 stood by the door. CNA #1 wrote that she hooked Resident #4 up to the Hoyer lift machine and transferred the resident into bed while CNA#2 stood behind her. A review of a written witness statement from CNA #2 revealed that Resident #4 was already hooked up to the Hoyer lift and was being lifted by the Hoyer lift into bed by CNA#1 when he had arrived to Resident #4's room. During an interview conducted by the surveyor on [DATE] at 9:45 a.m. the Unit Manager (UM)) stated that Resident #4 did not require the use of a Hoyer lift for transfers. The UM stated that Resident #4's plan of care did not identify the resident for the use of a Hoyer lift for transfers. The UM stated that the facility's Hoyer Lift policy required for there to be 2 staff members for transfers. The UM stated that residents were assessed by either the Registered Nurse or screened by a Licensed Rehabilitation prior to the use of Hoyer lift. The UM stated that CNAs were not allowed to make the decision to use a Hoyer lift and transfer a resident by themselves. The UM stated that when a resident has been screened to use a Hoyer lift for transfers, all the nurses and CNAs are informed and that the resident's care plan would reflect the use of Hoyer lift. When further interviewed on the same date, the UM stated that on [DATE] Resident #4 had complained of left knee pain. The UM stated that on [DATE] the nurse assessed that Resident #4's left knee was swollen. The UM stated that she could not recall if the resident's knee was discolored. The UM stated that since the x-ray that was done on [DATE] at 5:54 p.m. of Resident #4's left knee was negative, no investigation was done. The UM stated that it was the facility's policy to investigate any skin discoloration, bruising or any injury of unknown origin. The UM stated that an investigation should have been done since the source of Resident #4's injuries were unknown. When interviewed on [DATE], at 10:18 a.m., CNA #3 and CNA #4 stated that the facility's policy on Hoyer lift transfers required for there to be 2 people to operate the lift. CNA #3 stated that Charge Nurse or UM inform the CNAs of the residents who require the use of a Hoyer lifts for transfers. When interviewed on [DATE] 10:40 a.m. LPN #1 stated that Resident #4 had complained of left knee pain on [DATE]. LPN #1 stated that she could not recall the time when the resident had complained. LPN#1 stated that she assessed Resident #4's left knee and found that the left knee was swollen. LPN #1 stated that she did not remember Resident #4 having had a fall. LPN#1 stated that she notified the resident's doctor and legal representative about the resident's swollen knee. LPN#1 stated the the doctor had given an order for [REDACTED]. LPN #1 stated she was not sure if an investigation was done afterwards to determine the cause of Resident #4's swollen left knee. When interviewed on [DATE] at 11:00 a.m. the DON stated that the facility's Hoyer lift policy required for there to be 2 staff for transfers. The DON stated that a CNA could not make the decision to use a Hoyer lift to transfer a resident on their own. The DON stated that the resident would have to been evaluated by Nursing and Rehabilitation Staff before a Hoyer lift was used. When further interviewed, the DON stated that Resident #4 had no incidents or accidents that required the facility to investigate prior to [DATE]. The DON stated that she did not have any knowledge about the bluish discoloration found on Resident #4's left knee on [DATE]. The DON stated that it was the facility's policy to investigate all injuries of unknown origin including any skin discoloration, bruises, skin tears and injuries of unknown origin. The DON stated an investigation should have been done when the bluish discoloration was found on Resident #4's left knee by LPN #1 on [DATE]. On [DATE] at 12:00 noon, the surveyor interviewed the facility's Medical Director (MD). The MD stated that he had attended the meeting with Resident #4's legal representative to discuss how Resident #4 sustained the fractures. The MD stated that the team concluded that the resident sustained [REDACTED]. The MD stated that Resident #4 was at risk for injury due to his/her age, generalized weakness and impairment in mobility. The MD added that Resident #4 was at an increased risk for injury because of degenerative changes found on the [DATE] x-ray report of Resident #4's left knee. When interviewed on [DATE] at 2:00 p.m., the DON stated that Resident #4's fractures were from an unknown origin. The DON stated that the fractures were discovered on the x-ray that was done on [DATE]. The DON stated that they should have reported Resident #4's injuries to the state agency and completed a reportable event form but they did not. The DON stated that the Administrator was the person who was responsible for making the decision to report or not to report incidents to the state agency. When interviewed on [DATE] at 2:50 p.m. the Administrator confirmed that he should have reported Resident #4's fractures to the state agency. The Administrator stated that he did not report it to the state agency since the facility concluded in their investigation that the fracture that was sustained by Resident #4 were pathological in nature and was caused by improper Hoyer lift transfer. On [DATE] at 10:15 a.m. the surveyor conducted a post survey telephone interview with CNA #1. CNA #1 stated that she did not receive any instruction from a nurse to transfer Resident #4 with a Hoyer lift. CNA #1 stated that she had been transferring the resident with a Hoyer lift before the [DATE] incident had occurred. CNA #1 stated she placed the Hoyer pad underneath the resident and hooked Resident #4 up to the Hoyer lift and transferred the resident to bed in the presence of CNA #2. CNA #1 stated that CNA #2 was inside the room and was standing by the resident's wheelchair when she transferred the resident into bed. CNA #1 stated that Resident #4 did not fall or bumped his/her legs or arms during the Hoyer lift transfer. On [DATE] at 10:23 a.m., the surveyor conducted a post survey telephone interview with CNA #2. CNA #2 stated that that CNA #1 had connected Resident #4 to the Hoyer lift and that the resident was already lifted off the wheelchair when he came to the room. CNA #2 stated that he stood by the door the entire time CNA #1 transferred Resident #4 alone. CNA #2 stated that he did not assist CNA #1 with the transfer. A review of Resident #4's Discharge Report from the hospital revealed that Resident #4 had fractures of left hip, wrist and shoulder. Resident #4 required a surgical revision of left hip (a total hip replacement) on [DATE]. A cast was placed on Resident #4's left wrist and his/her shoulder fracture was found old and it was managed with a sling. A review of the facility's Summary of Investigation Report dated [DATE] revealed that the Interdisciplinary Care Plan (IDCP) committee concluded that the cause of Resident #4's fracture was from the transfer from the chair to the bed by mechanical lift (Hoyer) use. The report identified that there was an unequal distribution of the resident's body weight (180 pounds) during the transfer and application of pressure in different areas of the resident's body. This report also concluded that Resident #4 had no falls prior to this incident. Furthermore, the report identified that Resident #4 had severe Osteoporosis and Degenerative Joint Disease which may have contributed to the resident's fractured hip. Further review of the facility's Investigation Report of Injury of Unknown Origin dated [DATE] revealed corrective action taken prior to the survey. The report revealed that the facility staff were in-serviced on [DATE] and [DATE] on the Hoyer lift policy. In addition, Resident #4's care plan was up-dated on [DATE] to reflect no Hoyer transfers. During a post survey record review, Resident #4 was readmitted to the hospital on [DATE] directly from the Orthopedic Doctor's office for infection of the left hip surgical incision and expired on [DATE] at the hospital. The surveyor reviewed the facility's policy and procedure titled, Safe Movement and Lifting of Residents. The policy revealed that nursing staff, in conjunction with the rehabilitation staff, should assess individual resident's needs for transfer assistance on ongoing basis. The policy required that there should be a minimum of 2 staff were to be use when operating the mechanical lift. The Hoyer Lift Manufacturer's Manual provided to the surveyor from the Administrator revealed that before using the Vander-lift series 450, patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the Vander-lift 450. The manual also revealed that patients must have no injuries or medical conditions that might be aggravated by the Vander Lift Transfer procedure. The surveyor reviewed the facility's policy titled Investigating Unexplained Injuries.The policy revealed that an investigation of all unexplained injuries including bruises, abrasions and injuries of unknown source will be conducted by the Director of Nursing and/or other individual appointed by the Administrator to ensure that the safety of the facility's residents had not been jeopardized. NJAC 8:,[DATE].1 (a)