Every finding on record at Manahawkin Health and Rehabilitation Center

Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 03/05/2026, 03/09/2026, and 03/10/2026, it was determined that the facility failed to provide a safe environment for its residents. The facility failed to ensure that a resident (Resident #9) who had smoked inside the facility against facility policy on four previous occasions since 08/02/2025 did not have smoking materials in their possession or smoke in the facility and in the presence of a resident (Resident #16) who was receiving oxygen therapy on 01/28/2026. The facility failed to provide adequate supervision to prevent smoking in the resident's room on 12/18/2025 when the resident refused to surrender their smoking materials; and on 01/28/2026, when Resident #9 was discovered smoking indoors, in the presence of a roommate who was receiving oxygen therapy and refused to surrender their smoking materials. The facility also failed to investigate and implement interventions to prevent smoking against policy when Resident #9 was found smoking on 08/02/2025, 08/07/2025, 10/29/2025, 12/18/2025, and 01/28/2026; and when Resident #8 was observed smoking an electronic cigarette indoors on 09/15/2025. This deficient practice was identified for 2 of 3 residents (Resident #8 and Resident #9) reviewed for smoking. On 03/05/2026, the surveyor observed Resident #9 smoking in the facility smoking area. On 03/05/2026, the surveyor observed what appeared to be burn holes in the sleeves of a blue and white fleece jacket worn by Resident #9. Review of the Progress Notes (PN) revealed that Resident #9 was found smoking in their room on the following dates: 08/02/2025, 08/07/2025, 10/29/2025, 12/18/2025, and 01/28/2025. Further review of the PNs revealed that Resident #9 refused to surrender their smoking materials after they were observed smoking inside on 01/28/2026. An interview was conducted with Resident #9 on 03/05/2026 at 1:30PM. Resident #9 stated that when they smoked in their room in January their roommate (Resident #16) was using oxygen but turned it off so that the resident could smoke in the bathroom. During a follow up interview on 03/09/2026, Resident #9 stated in reference to the 01/28/2026 smoking incident, that they had matches but refused to give them up and that they were not placed under any additional supervision by the facility that day. On 03/10/2026 at 9:15 AM, the facility smoke alarm sounded, and the alarm panel indicated that the source was on the 2nd floor East Wing. The surveyor reported to the unit and determined that the alarm was from Resident #8's room. Upon arrival to Resident #8's room there was no odor of smoke but the room smelled of air freshener. There was no smoking paraphernalia observed but a Febreeze Plug In (an electrical outlet, air freshening device) was noted resting on the heater. The residents denied smoking in the room. The PNs for Resident #8 were reviewed. The PN revealed that on 09/15/2025, Resident #8 was observed smoking an electronic cigarette (e cigarette) indoors at the nurse's station. The PN did not reveal that the resident's e cigarette was removed and stored per facility policy or that the resident received additional supervision. An interview was conducted with the Licensed Nursing Home Administrator (LNHA) on 03/10/2026 at 4:41 PM. The LNHA stated that even without piped-in oxygen improper smoking could cause the whole facility to blow up. The LNHA further stated that vapes (electronic cigarettes) were just as combustible as regular cigarettes. The facility's failure to a.) ensure that Resident #9, who had smoked cigarettes 5 times inside the facility did not have smoking materials in their possession or smoke in the facility in the presence of oxygen and b.) ensure that Resident #8 had their e cigarette properly secured after they were observed smoking at the nurses station placed all residents at risk for serious harm, injury, or death from accidental explosion or fire from unsafe smoking. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 08/02/2025, after Resident #9 was observed smoking in their room. The facility was notified of the IJ on 03/09/2026 at 5:41 PM. The facility submitted an acceptable Removal Plan (RP) on 03/23/2026 at 3:37PM. The surveyor verified the implementation of the RP during the on-site survey on 03/25/2026 and determined that the immediacy was removed as of 03/20/2026 at 7:00 PM. The facility further failed to c.) provide adequate supervision to prevent medication misuse by a resident with moderate cognitive impairment who had a history of opioid abuse (Resident #20), who brought outside medication into the facility, and crushed and snorted it together with another resident who had a history of substance abuse (Resident # 19).Complaint #: 2806068, 2789654, 2789700, 2794269, 2679147, 2639889, 2588899, 2806341The facility policy Resident Smoking with a revised date of 03/01/2025 was reviewed. Under Explanation and Compliance Guidelines, the policy revealed that smoking was prohibited in all areas expect the designated smoking area; all residents and family members would be notified of the policy as part of the admission process and as needed; and e-cigarettes can catch fire or explode if not handled and stored safely, use e-cigarettes in designated smoking area only. This section of the facility policy revealed, 12. A resident does not have the right to put others at risk within or on grounds of the facility [.] 15. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures and may include a Smoking Contract. This section of the facility policy further revealed that the Activities Director and Nursing Supervisor were jointly responsible for ensuring compliance with the Resident Smoking policy; all staff must immediately report residents smoking in rooms or non-designated areas; and incident reports will be completed and reviewed by administration.Part AThe facility policy Incidents and Accidents with a revised date of 07/01/2024 was reviewed. Under Guideline,' the facility policy revealed that staff were to use the electronic medical record (EMR) to report, investigate, and review any accidents or incidents that occurred on facility property and involved residents. The facility policy defined accidents as an unintentional incident which results in or may result in injury or illness to a resident. The policy defined incident as an occurrence or situation that is not consistent with routine care of a resident or routine operation of the organization. Under Explanation, the policy revealed that the purpose of incident reporting included assuring that appropriate and immediate interventions were implemented and corrective actions were taken to improve resident care and prevent recurrences. This section of the facility policy further revealed that the purpose of incident reporting also included conducting a root cause analysis to determine causative and contributing factors. Under Compliance Guidelines, the facility policy revealed that licensed staff should use the EMR to report incident and accidents and to assist with completion of investigative information to identify the root cause; documentation should include date, time, and nature of the incident, initial findings, immediate interventions, and notifications, orders, and follow-up interventions. This section of the policy further revealed that if the accident or incident was witnessed by other people written documentation of the event should be obtained from those people and submitted to the Director of Nursing (DON) or LNHA. No incident/accident reports, investigation findings, or statements related to the smoking incidents by Resident #9 on 08/02/2025, 08/07/2025, 10/29/2025, 12/18/2025, and 01/28/2026; or the for the smoking incident by Resident #8 on 09/15/2025 were provided. According to the admission Record (AR), Resident #8 was admitted to the facility with diagnoses that included but were not limited to: chronic embolism and thrombosis of unspecified vein; localized edema; post-traumatic stress disorder, chronic; opioid abuse with intoxication, uncomplicated; paranoid schizophrenia; and unspecified asthma, uncomplicated. A review of Resident #8's quarterly Minimum Data Set (MDS), an assessment tool dated 12/17/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Review of a PN dated 09/15/2025 at 2:33 AM, revealed that staff observed Resident #8 smoking their e-cigarette while standing at the nurse's station and that the resident was educated on facility policy and designated smoking area. No incident report, investigation findings, or root cause analysis were provided related to this incident. Review of the Care Plan (CP) for Resident #8 revealed that no smoking related foci, goals, or interventions were included in the resident's CP after the resident smoked inside the facility on 09/15/2025 and prior to 03/09/2026. On 03/05/2026 at 10:22 AM, the surveyor observed Resident #9 smoking in the facility smoking area. On the same day at 10:57 AM, the surveyor observed what appeared to be burn holes in the sleeves of the resident's jacket. According to the AR, Resident #9 was admitted to the facility with diagnoses which included but were not limited to: osteomyelitis, unspecified; type 2 diabetes mellitus with hyperglycemia; major depressive disorder, recurrent, unspecified; anxiety disorder; obesity, unspecified; and opioid abuse with intoxication, uncomplicated. A review of Resident #9's comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #9 had impaired range of motion to their lower extremities on both sides, used a manual or electric wheelchair, and required the assistance of two or more helpers to transfer from bed to a chair. A review of the PNs for Resident #9 revealed that the resident was found smoking in the facility as follows: On 08/02/2025 at 10:40 AM, found smoking in their room with a cup full of cigarettes by their bedside. On 08/07/2025 at 10:40 PM, the room was, filled with smoke, and a cup full of used cigarette butts, was observed. On 10/29/2025 at 6:26 AM, the resident was observed smoking in their room and was educated that they were endangering themself and everyone in the building. The resident expressed that they wanted to continue smoking in the room. Facility staff informed the resident that communication with management was the responsibility of all staff. On 12/18/2025 at 7:21 AM, resident was received in bed, non-compliant with the smoking policy and refused to stop smoking or surrender their smoking materials. On 01/28/2026 at 5:26 AM, the resident was found smoking in their bedroom and refused to surrender their smoking materials. There was no facility documentation provided to indicate that the facility Administration was notified of any of the incidents prior to 01/28/2026. Review of the Care Plan (CP) for Resident #9 revealed a Focus, related to smoking initiated on 07/21/2023. The Goal was for the resident to remain compliant with the facility smoking procedure and restrictions. Interventions included completing smoking assessments of the resident, and notifying the resident, family, and physician of the results; informing the resident and/or their responsible party of facility smoking policy; and maintaining and or monitoring all smoking materials in the designated smoking area; and completing periodic smoking evaluation/assessment per policy, or as needed for change in condition. The focus, goals, and interventions were created on 07/21/2025. No interventions were added or adjusted after the five documented smoking episodes in the facility after 08/02/2025. On 03/05/2026 at 1:30 PM, an interview was conducted with Resident #9. Resident #9 confirmed that they had smoked in their room in January. The resident further stated that their roommate at the time (Resident #16) was receiving oxygen but had turned it off when resident #9 informed them that they were going to smoke in the bathroom. On 03/09/2026 at 10:50 AM, a follow-up interview was conducted with Resident #9. The resident confirmed that they had smoked in their bathroom on 01/28/2026 and on that date they had matches in their possession which they refused to surrender to facility staff. The resident stated that they did not have extra supervision by facility staff while they remained in possession of the matches. Resident #9 further confirmed that the holes in their jacket were burn holes that resulted from falling asleep while smoking a cigarette in the facility smoking area. Resident #16 was no longer in the facility; a closed record review was conducted. A review of the AR for Resident #16 revealed that the resident was admitted with diagnoses including but not limited to: borderline personality disorder; hypertensive heart disease without heart failure; alcohol abuse, uncomplicated; and mild intermittent asthma, uncomplicated. A review of Resident #16's admission MDS dated [DATE], revealed that the resident had a BIMS score of 15 out of 15 which indicated that the resident's cognition was intact. A review of the PNs for Resident #16 revealed the following: On 01/27/2026 at 11:05 PM, the resident arrived at 8:46 PM, and the resident had oxygen therapy in place via a nasal cannula at a rate of 2 liters per minute. On 01/28/2026 at 12:06 PM, the resident was receiving oxygen via nasal cannula at a rate of 2 liters per minute. An interview was conducted with the Certified Nursing Assistant (CNA #1) on 03/05/2026 at 10:31AM. CNA #1 stated that residents smoked in their rooms all of the time. CNA #1 stated that if she saw or suspected resident smoking in the facility, she would notify the Unit Manager (UM). An interview was conducted with Registered Nurse (RN) #1 on 03/05/2026 at 1:15 PM. RN #1 stated that if a resident was found smoking, she would try to stop them and report the incident to the UM. RN #1 further stated that smoking incidents should be included on that resident's CP. An interview was conducted with the Activities Director (AD) on 03/05/2026 at 2:01 PM. The AD stated that she was aware that residents smoked inside the facility. The AD stated that the facility smoking policy has been revised twice but residents did not take it seriously, break the smoking policy, and trade cigarettes. The AD stated that she was informed that an Activities Aide (AA#1) buys tobacco products and gives them directly to residents. The AD further stated that she reported this concern to the facility's former LNHA (FLNHA #1) and nothing was done. The AD further stated that she reported the concern to FLNHA #2 as well and she was not sure what was done, but AA #1 was still working at the facility. A call was placed to AA #1 on 3/9/2026 at 11:54 AM. Unable to speak with as phone was not in service. An interview was conducted with UM #2 on 03/09/2026 at 2:04 PM. UM #2 stated that residents in possession of smoking materials would create a big safety issue for the whole building due to possible presence of oxygen, fire, and smoke concerns. UM #2 stated that it was her expectation that if staff observed a resident smoking in the facility, they would stop the resident from smoking and report the incident to a UM. The UM would then be expected to collect the resident's smoking materials and escalate the issue to the Director of Nursing (DON) and Social Worker (SW). UM #2 stated that it was her expectation that an incident report was completed after each smoking incident and there should be a discussion with the Interdisciplinary Team (IDT) to determine interventions geared toward resident and facility safety. UM #2 stated that the interventions should then be documented in the incident report and on the resident's CP. During the same interview UM #2 confirmed that there were no incident reports, no investigations, and no CP updates related to the aforementioned smoking incidents involving Resident #8 and Resident #9. An interview was conducted with the Township Fire Official (TFO) on 03/10/2026 at 9:50 AM. The TFO had responded to the facility because a smoke alarm was triggered in Resident #8's room that morning. The TFO stated that she was aware of residents smoking inside the facility and that smoking around oxygen and laundry chemicals could cause an explosion and non-ambulatory residents may not be able to get out of the facility. The TFO further stated This place has the potential for mass loss of life. An interview was conducted with the DON on 03/10/2026 at 1:19 PM. The DON stated that 107 people (the facility census) could be put at risk by smoking inside the facility. The DON stated that residents should smoke only in the designated outdoor area, not inside the facility. The DON stated that if a resident was found smoking inside, they should be educated on the policy, and staff should try to get the resident to surrender their smoking materials. Staff should notify the supervisor, DON, and LNHA. The DON stated that residents who refused to surrender the smoking materials should be put on a smoking contract, and the physician should be contacted per the smoking policy. The DON further stated that it was her expectation that an incident report be completed so that everyone was made aware of the incident and it could be discussed in morning meetings. The DON stated that CP should be updated with what happened and education, and interventions could be established with the goal of preventing smoking inside. The DON stated that she did not know if any investigation was done after the resident's 01/28/2026 smoking incident and that the lack of investigations after resident smoking incidents did not meet her expectations. During the same interview the CP for Resident #9 was reviewed with the DON. The DON stated that there were no updates to the CP interventions after the aforementioned five smoking incidents, only the goals section was revised on 03/02/2026. An interview was conducted with the LNHA on 03/10/2026 at 4:41 PM. The LNHA stated that even without piped-in oxygen improper smoking could cause the whole facility to blow up. The LNHA further stated that vapes (electronic cigarettes) were just as combustible as regular cigarettes. An acceptable RP was received on 03/23/2026 at 3:37 PM, indicating the actions the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: a facility-wide smoking evaluation audit was done for residents who were smokers on 03/10/2026; residents who were smokers were re-evaluated using the facility-approved smoking assessment tool and appropriate supervision level was assigned; resident care plans were updated to reflect smoking status and safety interventions; residents identified as unsafe to smoke independently were placed on supervised smoking status; staff was provided written guidance on completing the facility smoking evaluation and the required follow-up; residents who are found with smoking paraphernalia in their rooms will be placed on 1:1 monitoring until the smoking materials are given to staff; and staff received re-education. The surveyor verified implementation of the RP on-site on 03/25/2026 and determined that the immediacy was removed as of 03/20/2026 at 7:00PM. Part B A Facility Reportable Event (FRE), a form used by facilities to report events to the New Jersey Department of Health, dated 03/17/20206 was reviewed. The FRE, submitted by the facility's LNHA revealed that Resident #19 was observed by a Certified Nursing Assistant (CNA) in Resident #20's room with a small piece of paper rolled into a cylinder. Resident #19 was observed snorting a white powdery substance up their nose. According to the AR, Resident #19 was admitted to the facility with diagnoses which included but were not limited to: anxiety disorder, unspecified; multiple sclerosis (chronic condition which causes nerve damage and results in problems with vision, balance, muscle control, and other basic body functions), unspecified; other psychoactive substance dependence, uncomplicated; and other seizures. A review of the comprehensive MDS dated [DATE] revealed that Resident #19 had a BIMS score of 15 out of 15 which indicated that the resident's cognition was intact. A review of the CP for Resident #19 revealed a Focus, that the resident was at risk for substance abuse due to current or historical drug use. The focus was initiated on 02/05/2026. Interventions related to this focus included but were not limited to: contacting emergency services for signs of overdose; educating the resident on coping skills; and physician notification of suspected substance use. The interventions were initiated on 03/14/2026. A facility incident report with Resident #19's name at the top dated 03/13/2026 at 6:30 PM, was reviewed. The incident report revealed under, Incident Description, that Resident #19 was observed in Resident #20's room and a white powdery substance was observed on the bedside table. The incident report further revealed that Resident #20 was trying to share medication with Resident #19. A PN dated 03/13/2026 at 11:57 PM, revealed that Resident #19 was observed with slurred speech and closed eyes. The resident also had low blood pressure (92/58). Resident #20 refused to go to the hospital for evaluation. According to the AR, Resident #20 was admitted to the facility with diagnoses which included but were not limited to: neuropathy (damage to nerves outside the brain and spinal cord, causing pain, numbness, or weakness), unspecified; unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement); anxiety disorder; and opioid abuse, unspecified. A review of the MDS dated [DATE] revealed that Resident #20 had a BIMS score of 12 out of 15 which indicated that the resident had moderate cognitive impairment. A review of the CP for Resident #20 revealed no foci, goals, or interventions addressing their history of opioid abuse prior to the 03/13/2026 incident. The PNs for Resident #20 were reviewed. A PN dated 03/13/2026 at 9:22 PM revealed that Resident #20 was observed in their room attempting to share a white powdery substance with another resident. The PN revealed that the substance was confiscated, and it was determined to be medication that the resident brought from the hospital that had not been reported to facility nursing staff upon readmission. The PN further revealed that the police were contacted. A police Investigation Report (IR) dated 03/13/2026 at 7:53 PM was reviewed. The IR revealed that Resident #19 had taken medication provided to them by the hospital back to the facility and was hiding it for further personal use. The IR further revealed that Resident #19 admitted to crushing the pills prescribed to them and snorting them. An interview was conducted with Resident #20 on 03/18/2026 at 9:36 AM. Regarding the 03/13/2026 incident of snorting a powdery substance, the resident stated that they were opening their gabapentin pills and snorting them. The resident further stated that the pills were from the hospital, and they brought the pills into the facility when they were readmitted several days earlier. Resident #20 stated that Resident #19 was their significant other and was in the room to keep them company. An interview was conducted with Resident #19 on 03/18/2026 at 10:45 AM. Resident #19 stated that Resident #20 was their significant other. Resident #19 stated that they were aware that Resident #20 snorted gabapentin for pain control. Resident #19 denied being present in Resident #20's room on 03/13/2026 and denied snorting medication. An interview was conducted with the DON on 03/28/2026 at 1:40 PM. The DON stated that when Resident #19 and Resident #20 were observed with the powdery substance, Resident #20 handed pills to the nurse that were wrapped in a napkin. The DON stated that she identified the pills using an online resource and determined that they were not medications that were provided to the resident in the facility. The DON stated that only Resident #19 was observed snorting the powder. During the same interview the DON stated that no residents in the facility were allowed to self- administer medications. The DON stated that in order to self-administer medication, an assessment should be completed, and a resident's medication would need to be locked away in order to keep it out of access to other residents. The DON further stated that when residents were admitted to the facility, their possessions were inventoried. Documentation of a personal item inventory for Resident #20's recent re-admission was requested by the surveyor. During exit conference on 03/18/2026, the DON stated that there was no documentation that the Resident #20's possessions were inventoried when the resident returned from the hospital. The facility policy, Resident Personal Belongings, with a review/revised date of 07/01/2025 was reviewed. Under, Explanation and Compliance Guidelines: the policy revealed that all resident personal items would be inventoried by social services or a designee on admission and documentation would be maintained in the medical record. This section of the facility policy further revealed, 5. The facility may refuse to allow a resident to retain his or her personal possession(s) due to the following reasons: [.] b. As protection of health and safety. N.J.A.C. 8:39-27.1(a), 31.6(e)

Based on interviews, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure a safe discharge for a resident. This deficient practice was identified for 1 of 18 residents reviewed (Resident #18).Resident #18, who had a history of intravenous (IV) drug use and was admitted to the facility with endocarditis to receive IV antibiotics, was discharged from the facility with their Peripherally Inserted Central Catheter (PICC) in place. The PICC is thin, flexible tube inserted into a large upper arm [NAME] and guided to the large [NAME] near the heart. Resident #18 had documented complications of up to 9 dislodgements of their PICC line. During an interview on 3/10/26, with the Director of Nursing (DON), the DON confirmed that a resident with a history of IV drug use discharged with a PICC line in place had the potential for harm or death. During an interview on 3/10/26 with the Licensed Nursing Home Administrator (LNHA), the LNHA confirmed that Resident #18's discharge was not safe.The facility's failure to ensure Resident #18 was safely discharged from the facility placed Resident #18, as well as all residents being discharged from the facility, at risk for an unsafe discharge. This posed the likelihood of serious harm, injury, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation.The IJ began 10/27/25 at 4:05 P.M., when Resident #18 was discharged from the facility. The facility was notified of the IJ on 3/10/26 at 5:44 P.M. The facility submitted an acceptable Removal Plan (RP) on 3/23/26 at 3:37 P.M. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 3/25/26 and determined that the immediacy was removed as of 03/20/2026 at 7:00PM.Complaint #: 2806068, 2789654, 2789700, 2794269, 2679147, 2639889, 2588899, 2806341 The deficient practice was evidenced by the following: A review of the facility's policy titled Discharge Planning Process with a date reviewed/revised of 5/12/2025, included It is the guideline of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Under Procedure: 4. In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a. Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location.b. Offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussion related to the options presented.c. Document refusals of other options that could meet the resident's needs.d. At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect), as necessary. 5. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented on (list facility-specific form, comprehensive care plan, etc). 6. An active individualized discharge care plan will address, at a minimum: a. Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. b. Identified needs, such as medical, nursing, equipment, educational, or psychological needs. c. Caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care. d. Resident's goals of care and treatment preferences. 7. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. 8. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. 9. The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. The surveyor reviewed the closed medical record for Resident #18. According to the admission Record (AR), Resident #18 was admitted to the facility with diagnoses which included but were not limited to: generalized anxiety disorder and acute and subacute endocarditis (infection often caused by bacteria on normal heart valves, resulting in high fever and significant destruction). According to the discharge Minimum Data Set (MDS), an assessment tool dated 10/27/25, Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. While not included under Resident #18's AR, Resident #18 also had diagnoses which included but were not limited to: alcohol use disorder, severe, in early remission and opioid use disorder, severe, in sustained remission. These diagnoses were in the discharge paperwork provided to the facility by the hospital from which Resident #18 was transferred. A review of the Electronic Medical Record (EMR) revealed the following: Resident #18's Care Plan (CP) included the following: Under Focus date initiated 9/8/25: The resident is on antibiotic therapy related to (r/t) endocarditis. Under Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Under Interventions: Administer ANTIBIOTIC medications as ordered by physician and Monitor/document/report PRN (as needed) adverse reactions to ANTIBIOTIC therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat). Under Focus date initiated 9/8/25: The resident is on pain/opioid medication therapy (SPECIFY medication) r/t. Under Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Under Focus date initiated 9/9/25: [Resident #18] has endocarditis and is on oxacillin 12g (grams) daily til 10/02/2025 and requires enhanced barrier precautions r/t indwelling medical device. Under Goal: The resident will be free from complications related to infection through the review date. Under Interventions: Administer antibiotic as per MD (medical Doctor) orders and Monitor/document/report to MD s/sx (signs and symptoms) of delirium: Changes in behavior, Altered mental status, Wide variation in cognitive function throughout the day, Communication decline, Disorientation, Periods of lethargy, Restlessness and agitation, Altered sleep cycle. Under Focus date initiated 9/29/25: The resident has infection of the (SPECIFY) Under Goal: The resident will be free from complications related to infection through the review date. Under Interventions: Follow facility policy and procedures for line listing, summarizing and reporting infections. Under Focus date initiated 10/16/25: Resident at risk for injury r/t PICC line dislodging. Under Goal: Resident will notify nursing of any changes in condition of PICC line site. Under Interventions: Monitor site Q-shift [every shift] for s/s (signs and symptoms) of infection and infiltration. Resident #18's CP did not include any focus, goals, or interventions for Resident #18's discharge or discharge planning. A review of Resident #18's Progress Notes (PN) showed that Resident #18's PICC had documented complications of up to 9 dislodgements on the following dates: 10/22/25, 10/16/25, 10/15/25, 10/7/25, 9/21/25, 9/20/25, 9/14/25, 9/11/25, and 9/10/25. A review of Resident #18's PN dated 10/27/25 created at 3:46 PM by the Licensed Practical Nurse (LPN) that discharged Resident #18 home stated that Resident #18 had met all goals for discharge home. A review of Resident #18's PN dated 10/27/25 created at 4:11 PM by the Director of Nursing (DON) #3 at the time revealed that Resident #18 was discharged from the facility with their PICC line after Resident #18 refused to allow the facility to remove the PICC due to concerns for possible excess bleeding. The PN created by DON #3 was the last PN for Resident #18 and there was no documentation that the facility notified the MD related to Resident #18 leaving the facility with a PICC line or further efforts to ensure Resident #18's safety after discharge. There were no PNs by the Social Worker (SW) related to Resident #18's discharge from the facility. A review of Resident #18's Discharge Instructions and Review of Systems for Resident (DIRSR) under Discharge Location indicated that Resident #18 was being discharged home.The DIRSR under Current Physical Status (Therapy/Nsg [Nursing]) stated that Resident #18 required set up or clean-up assistance for personal hygiene, shower/baths, dressing, and transfers. It also stated that Resident #18 was dependent when it came to bed mobility. Resident #18's weight bearing status was partial, but no equipment was ordered for discharge. The DIRSR under Follow-Up Physician Care (Nsg) revealed that Resident #18 had no follow up appointments. The DIRSR under Person Receiving Instructions (Nsg) revealed that Resident #18's girlfriend was the one receiving instructions for discharge. On 3/9/26 at 2:45 PM, the surveyors interviewed the Unit Manager (UM) of the second floor. UM #2 stated that if a resident has a PICC line in place, typically the PICC is removed before discharge. She stated that if a resident was being discharged home and refused to have their PICC line removed she would reach out to the MD and notify them of the refusal. She further stated she would inform her DON as well and escalate the situation because it would be an infection and safety concern for the resident. On 3/9/26 at 3:02 PM, the surveyors interviewed UM #1 who stated that she had not heard of a resident being discharged with a PICC or IV and stated it would be a concern because a PICC is a direct line to their heart. On 3/10/26 at 10:30 AM, the surveyors interviewed the Social Worker (SW) regarding what the typical process is for discharging a resident from the facility. The SW responded that she does the discharge summary, and discussions are held regarding resident therapy, equipment, and scripts with staff. The SW could not recall participating in an Interdisciplinary Team (IDT) meeting related to Resident #18's PICC dislodgements and admitted an IDT should have been held. The SW also stated that as a SW, if a resident was being discharged with antibiotic therapy that was to continue out of the facility, she would have set up home care services. The SW confirmed she did not set up home care services for Resident #18. She then stated that when she informs the nurses that a resident with a PICC is being discharged , the nurses call the doctors and the PICC line is typically removed before discharge. On 3/10/26 at 1:19 PM, the surveyors interviewed DON #2 who stated that discharge planning starts when a resident enters the facility. She stated that discharge should be a part of a resident's CP. DON #2 was handed Resident #18's CP and reviewed it. She confirmed that Resident #18's CP did not include discharge planning and that there was no documentation to confirm that the MD had been notified that Resident #18 left the facility with a PICC line. On 3/10/26 at 2:10 PM, the surveyors asked DON #2 why a resident with a history of drug use should not leave a facility with a PICC. She replied that the resident could leave the facility and go shoot something from the street into the PICC and die. She further stated that the facility would not want to be responsible for death, let alone an infection. Referring to Resident #18, DON #2 stated if antibiotics were completed there was no need for line access and that it was an inappropriate discharge. On 3/10/26 at 4:41 PM, the surveyors interviewed LNHA regarding discharging residents. The LNHA stated that a discharge must be safe for residents. When asked if Resident #18's discharge was safe she stated, No, it is not a safe discharge. In the same interview with the LNHA, the surveyors requested the LNHA review the Order Summary Report (OSR) for Resident #18. After reviewing, the LNHA confirmed there was no discharge order for Resident #18 and that there should have been because discharge documentation starts from the day of admission. NJAC 8:39-5.4(c); 39.1

Complaints:2794269, 2679147, 2588899, 2639889, 2789654, 2789700 Based on interviews, review of medical records, and review of pertinent facility documents on 03/05/2026, 03/09/2026 and 03/10/2026, it was determined that the facility failed to a.) ensure that physician ordered medication was obtained and available to be administered and b.) maintain records of, receipt, accountability, and removal from inventory of controlled drugs, for 4 out of 5 residents (Resident #9, Resident #10, Resident #15, and Resident #18) reviewed for methadone (opioid medication that treats severe, chronic pain and substance use disorder). The deficient practice was evidenced by the following:A. According to the admission Record (AR), Resident #9 was admitted to the facility with diagnoses which included but were not limited to: major depressive disorder (mood disorder that causes persistent sadness and loss of interest), recurrent, unspecified; anxiety disorder (condition that causes excessive, uncontrollable worry); and opioid abuse with intoxication, uncomplicated. A review of Resident #9's quarterly Minimum Data Set (MDS), an assessment tool dated 01/24/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A review of Resident #9's physician orders (POs) revealed the following: An order for methadone HCl (hydrochloride) oral concentrate 10 milligrams (MG) per milliliter (ML), give 100 ML by mouth daily in the morning for opioid dependence. The order start date was 12/27/2025. The order end date was 02/21/2026. An order for methadone HCl oral concentrate 10 MG per ML, give 100 MG daily in the morning for opioid dependence. The order start date was 02/22/2026. The order end date was 03/09/2026. A review of the Care Plan (CP) for Resident #9 revealed a Focus, that the resident was, on pain/opioid medication therapy (METHADONE). Goals related to this focus included administering medication as ordered by the physician and monitoring for side effects. Review of the Medication Administration Record (MAR) for Resident #9 revealed that the code 4 was used for methadone HCl oral concentrate 10 MG per ML, give 100 ML by mouth daily in the morning on the following dates: 01/20/2025, 01/28/2026, and 02/16/2026. Review of the Chart Codes/Follow Up Codes, section of the MAR revealed that the code 4 meant Other/See Nurses Note. Review of the Progress Notes (PNs) for Resident #9 revealed the following related to the resident's methadone doses: A PN dated 01/20/2026 at 1:44 PM, revealed, medication unavailable. A PN dated 01/28/2026 at 9:53 AM, revealed, being delivered later. A PN dated 02/16/2026 at 12:01PM revealed awaiting delivery. The MARs and PNs for Resident #9 revealed no documentation that 01/28/2026 and 02/16/2026 methadone doses were administered. B. According to the AR, Resident #10 was admitted to the facility with diagnoses which included but not limited to opioid dependence, uncomplicated; depression, unspecified; and pain in left knee. A review of the MDS for Resident #10 revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. A review of Resident #10's POs revealed the following: An order for methadone HCl oral solution 10 MG per 5 ML, give 110 MG by mouth daily in the morning for history of substance abuse. The order start date was 11/23/2026. The order end date was 03/09/2026. An order for Tylenol tablet 325 MG, give two tablets by mouth every 4 hours as needed for mild to moderate pain or fever above 100. The order start date was 01/06/2025. A review of the CP for Resident #10 revealed a Focus, that the resident was, on pain/opioid medication therapy (Methadone) [related to] pain management. Goals related to this focus included administering medication as ordered by the physician and monitoring for side effects. A review of the MAR for Resident #10 revealed that the code 4, was used for methadone HCl oral solution 10 MG per 5 ML, give 110 MG by mouth daily in the morning on the following dates: 01/01/2026, 01/02/2026, 01/05/2026, 01/12/2026, 01/20/2026, 01/21/2026, 02/02/2026, and 02/16/2026. Further review of the MAR revealed that Resident #10 received Tylenol for pain on the days that they did not receive their methadone as follows: On 01/01/2025 at 10:13 AM for a pain level of five out of 10. On 01/05/2026 at 5:32 PM, for a pain level of six out of 10. Review of the PNs for Resident #10 revealed the following related to the resident's methadone doses: A PN dated 01/01/2026 at 10:10 AM, revealed, on order. A PN dated 01/02/2026 at 9:56 AM, revealed, Awaiting delivery. A PN dated 01/05/2026 at 10:30 AM, revealed, Awaiting delivery. A PN dated 01/12/2026 at 11:13 AM, revealed, none on hand. A PN dated 01/20/2026 at 9:55 AM, revealed, on order. A PN dated 01/21/2026 at 10:13 AM, revealed, Awaiting delivery. A PN dated 02/02/2026 at 10:41 AM, revealed, Awaiting delivery. A PN dated 02/16/2026 at 10:07 AM, revealed, awaiting delivery. The MARs and PNs for Resident #10 revealed no documentation that the 01/01/2026, 01/02/2026, 01/05/2026, 01/12/2026, 01/20/2026, 01/21/2026, 02/02/2026, and 02/16/2026 methadone doses were administered. C. According to the AR, Resident #15 was admitted to the facility with diagnoses including but not limited to: Parkinsonism, unspecified (neurological syndrome characterized by slowed movement, tremors, stiff muscles, and postural instability); schizoaffective disorder (chronic mental illness that causes dramatic changes in thoughts, moods, and behaviors); nicotine dependence, unspecified, uncomplicated; alcohol abuse with alcohol-induced anxiety disorder; and opioid dependence, uncomplicated. According to the quarterly MDS, dated [DATE], Resident #15's BIMS score was 15 out of 15, which indicated that the resident's cognition was intact. A review of Resident #15's POs revealed the following: An order for methadone HCl oral solution 10 MG per 5 ML, give 50 MG by mouth one time a day for opioid withdrawal. The order start date was 04/24/2025. An order for acetaminophen (generic name for Tylenol) tablet 325 MG, give two tablets by mouth every four hours as needed for pain. The order start date was 07/15/2025. A review of the CP for Resident #15 revealed no foci, goals or interventions related to the resident's history of opioid abuse. A review of the MAR for Resident #15 revealed that the code 4, was used for methadone HCl oral solution 10 MG per 5 ML, give 50 MG by mouth one time a day for opioid withdrawal order on the following dates: 01/01/2026, 01/02/2026, and 02/25/2026. Further review of the MAR revealed that Resident #15 received acetaminophen for pain on the days that they did not receive their methadone as follows: On 01/01/2026 at 1:26 PM, for a pain level of three out of 10 pain. Review of the PNs for Resident #15 revealed the following related to the resident's methadone doses: A PN dated 01/01/2026 at 1:02 PM, revealed, Not on hand. A PN dated 01/02/2026 at 8:28 AM, revealed, out of medication. A PN dated 02/25/2026 at 10:52 AM, revealed no documentation of the reason the medication was not given. The MARs and PNs for Resident #15 revealed no documentation that the 01/01/2026, 01/02/2026, or 02/25/2026 methadone doses were administered. D. Resident #18 was no longer at the facility. A closed record review was conducted. According to the AR, Resident #18 was admitted to the facility with diagnoses which included but were not limited to: generalized anxiety disorder; and acute and subacute endocarditis (infection caused by bacteria on normal heart valves, resulting in high fever and significant destruction).According to PNs from the transferring hospital but not included on Resident 18's AR was the resident's history of IV (intravenous) drug use. According to the discharge MDS dated [DATE], Resident #18 had BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. A review of Resident #18's POs revealed the following: An order for methadone HCl oral solution 10 MG per 5 ML, give 50 MG by mouth one time a day for substance use disorder. The order start date was 09/11/2025. The order end date was 09/26/2025. An order for methadone HCL 10 MG per 5 ML, give 50 MG by mouth one time a day for substance use disorder. The order start date was 10/11/2025. The order end date was 11/18/2025. A letter dated 09/08/2025, provided by the facility and signed by Resident #18 was reviewed. The letter revealed that Resident #18 wanted the facility to pick up and administer their methadone during the resident's stay at the facility. Review of the MARs for Resident #18 revealed the code, 4 was used for methadone HCl oral solution 10 MG per 5 ML, give 50 MG by mouth one time a day on the following dates: 09/24/2025, 10/14/2025, 10/15/2025, and 10/22/2025. Review of the PNs for Resident #18 revealed the following related to the resident's methadone doses: A PN dated 09/24/2025 at 10:19 AM, revealed, Awaiting delivery. A PN dated 10/14/2025 at 10:09 AM, revealed, On order. A PN dated 10/15/2025 at 9:33 AM, revealed, Awaiting delivery. A PN dated 10/22/2025 at 9:30 AM, revealed, Awaiting delivery. The MARs and PNs for Resident #18 revealed no documentation that the 09/24/2025, 10/14/2025, 10/15/2025, or 10/22/2025 methadone doses were administered. Further review of the PNs for Resident #9, Resident #10, Resident #15, and Resident #18 revealed no documentation indicating the residents' physicians were notified of the aforementioned unavailable methadone doses. An interview was conducted with Resident #10 on 03/05/2025 at 10:05 AM. Resident #10 stated that recently they went three days without their methadone, which caused the resident to have hot flashes, vomiting, and body aches. The resident stated that they were given Tylenol, but it did not help. Resident #10 further stated that Unit Manager (UM) #2 was responsible for picking up the methadone from the clinic. An interview was conducted with Resident #9 on 03/05/2026 at 10:57 AM. Resident #9 stated that approximately one month prior they had missed their methadone dose twice. Resident #9 stated that they had chills and were in pain. Resident #9 further stated that not receiving their methadone affected their state of mind, made them consider using illicit drugs again and did not make them feel secure at the facility. An interview was conducted with Resident #15 on 03/09/2026 at 10:40 AM. Resident #15 stated they remembered missing methadone doses around the new year. The resident stated that they felt sick, had sweats, and had pain when the methadone doses were missed. Resident #15 stated that their doses were late because the facility failed to pick them up from the methadone clinic on time. An interview was conducted with UM #2 on 03/05/2025 at 12:22 PM. UM #2 stated that around the new year, Resident #9 and Resident #10 did not receive their methadone. UM #2 stated that the residents did not receive their methadone because she did not pick it up. UM #2 stated that she thought the residents would have enough medication to carry them through, but they did not. UM #2 stated, that was my mistake. UM #2 stated that either she or the facility Infection Preventionist (IP) pick up the methadone for the residents. UM #2 further stated that there was not a system in place to ensure that the methadone was picked up if she or the IP were not available. During the same interview UM #2 stated that she was not aware that Resident #18 wanted the facility to pick up and administer their methadone. UM #2 further stated that she could not produce documentation of declining counts for methadone for Resident #18. An interview was conducted with the facility's Pharmacy Consultant (PC) on 03/09/2026 at 12:46 PM. The PC stated that he would be involved in ensuring that there was a facility process in place related to methadone. The PC stated that he was not aware that residents had missed doses of methadone. The PC further stated that declining counts should be kept by the facility for any controlled substances (drugs and medications with a risk of misuse and dependence) in order to maintain chain of custody and to allow the facility to look into any concerns. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 03/18/2026 at 12:13 PM. LPN #3 stated that the process for giving methadone included both the nurse and the resident signing the declining count sheet at the time of administration. LPN #3 stated that he was aware of times that Resident #10 did not receive their methadone. LPN #3 stated that Resident #10 experienced pain and he medicated the resident with Tylenol. NJAC 8:39- 29.7 (c)

Complaint: 2639889Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/5/26, 3/9/26, 3/10/26, and 3/18/26, it was determined that the facility failed to develop and implement a comprehensive, person-centered Care Plan (CP) for residents: with a Peripherally Inserted Central Catheter (PICC) line, methadone use, oxygen use, smoking and a history of substance abuse. The CPs lacked foci, goals and interventions addressing proper line integrity, monitoring dislodgement, safe administration of methadone, safe utilization of oxygen, addressing residents who were found smoking in their rooms, and for residents with history of substance abuse. This failure resulted in the residents experiencing multiple PICC dislodgements without clear staff directions for response, placing the residents at risk for improper handling and monitoring which could have led to potential harm. This deficient practice was identified for 5 of 20 residents reviewed for resident records (Resident #8, Resident #9, Resident #15, Resident #18 and Resident #20), and was evidenced by the following:Complaint #: 2806068, 2789654, 2789700, 2794269, 2679147, 2639889, 2588899, 2806341 1. During the survey, the surveyor reviewed Resident #18's CP which did not address Resident #18's documented complications of up to 9 dislodgements for their PICC nor had interventions in place for clear staff direction to respond.According to the admission Record (AR), Resident #18 was admitted to the facility with diagnoses which included but were not limited to: generalized anxiety disorder and acute and subacute endocarditis (infection often caused by bacteria on normal heart valves, resulting in high fever and significant destruction).According to the discharge Minimum Data Set (MDS), an assessment tool dated 10/27/25, Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.While not included under Resident #18's AR, Resident #18 also had diagnoses which included but were not limited to: alcohol use disorder, severe, in early remission and opioid use disorder, severe, in sustained remission. These diagnoses were in the discharge paperwork provided to the facility by the hospital that Resident #18 was transferred from.Resident #18's CP included the following:Under Focus date initiated 9/8/25: The resident is on antibiotic therapy related r/t (related to) endocarditis. Under Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Under Interventions: Administer ANTIBIOTIC medications as ordered by physician and Monitor/document/report PRN (as needed) adverse reactions to ANTIBIOTIC therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat).Under Focus date initiated 9/8/25: The resident is on pain/opioid medication therapy (SPECIFY MEDICATION) r/t. Under Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the review date.Under Focus date initiated 9/9/25: [Resident #18] has endocarditis and is on oxacillin 12g (grams) daily til 10/02/2025 and requires enhanced barrier precautions r/t indwelling medical device. Under Goal: The resident will be free from complications related to infection through the review date. Under Interventions: Administer antibiotic as per MD (Medical Doctor) orders and Monitor/document/report to MD s/sx (signs and symptoms) of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle.Under Focus date initiated 9/29/25: The resident has infection of the (SPECIFY) Under Goal: The resident will be free from complications related to infection through the review date. Under Interventions: Follow facility policy and procedures for line listing, summarizing and reporting infections.Under Focus date initiated 10/16/25: Resident at risk for injury r/t PICC line dislodging. Under Goal: Resident will notify nursing of any changes in condition of PICC line site. Under Interventions: Monitor site Q-shift [every shift] for s/s (signs and symptoms) of infection and infiltration.Resident #18's CP did not include proper foci, goals, or interventions for Resident #18's line integrity or monitoring for dislodgement of their PICC. The facility did not specify which infection Resident #18 had.2. During the survey, the surveyor reviewed Resident # 15 and Resident #18's CP for safe administration and use of methadone.According to the AR face sheet, Resident #15 was admitted to the facility with diagnoses including but not limited to: Parkinsonism (an umbrella term for a neurological syndrome characterized by motor symptoms similar to Parkinson's disease, including bradykinesia [slowed movement], resting tremor, muscle rigidity, and postural instability), Chronic Obstructive Pulmonary Disease (COPD) (a progressive, treatable lung disease that causes long-term breathing problems by damaging airway tissue, leading to inflammation and blocked airflow) and mild intermittent asthma.According to the MDS, dated [DATE], Resident #15's BIMS was a score of 15 out of 15, which indicated the resident was cognitively intact.Resident #15's CP did not address the resident's administration of or use of methadone.Resident #18's CP did not address the resident's administration of or use of methadone. 3. During the survey the surveyor reviewed Resident #15's and Resident 18's CP for safe monitoring and utilization of oxygen.Resident #15's CP did not address the resident's safe monitoring and utilization of oxygen.Resident #18's CP did not address the resident's safe monitoring and utilization of oxygen. 4. During the survey, the surveyor reviewed, Resident #8 and Resident #9's CPs which did not address the residents who were found smoking in their rooms. According to the AR face sheet, Resident #8 was admitted to the facility with diagnoses including but not limited to: chronic embolism and thrombosis of unspecified vein (to the presence of a blood clot in a vein that has persisted for an extended period, leading to potential complications and requiring medical management), localized edema (abnormal accumulation of fluid in a specific area of the body), and an anxiety disorder, unspecified. According to the MDS, dated [DATE], Resident #8's BIMS had a score of 15 out of 15, which indicated the resident was cognitively intact. Resident #8's CP did not include any foci, goals, or interventions for Resident #8's smoking or addressing the documented occurrences of Resident #8 being caught smoking in their room on 9/15/2025. According to the AR face sheet, Resident #9 was admitted to the facility with diagnoses including but not limited to: osteomyelitis (a serious infection and inflammation of the bone caused by bacteria or fungi, which can destroy bone tissue), type 2 Diabetes Mellitus with hyperglycemia (a chronic metabolic condition where the body resists insulin and fails to produce enough to manage blood sugar, resulting in persistently high glucose levels), and hypertensive heart disease with heart failure (a condition where long-term high blood pressure forces the heart to work harder, causing the left ventricle to thicken, stiffen, and eventually weaken). According to the MDS, dated [DATE], Resident #9's BIMS had a score of 15 out of 15, which indicated the resident's cognition was cognitively intact. Resident #9's CP included the following: Under Focus date initiated 7/21/23: Smoking: Under Goal: Resident #9 will remain compliant with facility smoking procedure and smoking restrictions. Under Interventions: Inform [Resident name] and/or responsible party of facility smoking policy and document accordingly, Nursing to maintain/monitor all smoking materials in designated smoking area, and Report Resident #9's non-compliance with facility smoking policy or unsafe smoking practices to supervisor as indicated. Resident #9's CP did not include proper foci, goals, or interventions for any of Resident #9's five documented occurrences of being caught smoking in their room on 08/02/2025, 08/07/2025, 10/29/2025, 12/18/2025, and 01/28/2026. 5. During the survey, the surveyor reviewed Resident # 20's care planAccording to the AR face sheet, Resident #20 was admitted to the facility with diagnoses including but not limited to: opioid abuse, neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), and mixed hyperlipidemia (inherited disorder characterized by elevated levels of both bad cholesterol and triglycerides in the blood, increasing the risk of cardiovascular disease).According to the MDS, dated [DATE], Resident #20's BIMS had a score of 12 out of 15, which indicated the resident's cognition was moderately impaired.Resident #20's CP did not include any foci, goals, or interventions for Resident #20's history of opioid abuse. On 3/9/26 at 1:32 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), LPN #2 stated that residents with a PICC should have a CP for it. LPN #2 further stated that if issues occur with a resident's PICC, she would document the issue, and then take the proper steps to fix it and then go over the process with the Director of Nursing (DON) to see if anything else needed to be done.On 3/9/26 at 2:45 PM, the surveyor interviewed the Unit Manager (UM) of the 1st floor who stated that the UM is responsible for updating the CP for residents with PICCs.On 3/9/26 at 3:43 PM, the surveyor interviewed the UM of the 2nd floor who stated that residents should have care plans specific to methadone if they are taking methadone. She agreed that care plans are the plan of care for residents.On 3/9/26 at 5:29 PM, the surveyor interviewed the UM of the 1st floor who stated if residents are on oxygen they should have a CP for it. She also stated that if residents are on methadone they should also have a CP for it.On 3/10/26 at 1:19 PM, the surveyor interviewed the DON. DON #2 stated that the CP should be revised for safety measures for residents who smoke and are caught smoking in their rooms. DON #2 further stated that she expects the CP to list interventions and anything pertaining to smoking such as education if the smoking policy is not followed. She stated that interventions are put in place so that staff and residents are aware of their own CP. DON #2 also said that if residents have a physician order for oxygen or methadone, they should also have a CP for it.On 3/10/26 at 4:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that CP for all residents should be kept updated. The LNHA also stated that a CP could be generalized but must be inclusive to the resident's orders and plan of care.A review of the facility's policy titled Baseline Care Plan with a revision date of 5/12/25, included the following information under Guideline:The facility will develop and implement a baseline care plan for each resident that include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Under Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders. ii. Physician orders. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified need for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis or wound care. A review of the facility's policy titled Comprehensive Care Plans with a revision date of 5/12/25, included the following information under Guideline:It is the guideline of this facility to develop and implement a comprehensive person-centered care plan for reach resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Under, Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.d. The resident's goals for admission, desired outcomes, and preferences for future discharge.f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity.NJAC 8:39-11.2 (e)

Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/5/26, 3/9/26, 3/10/26, and 3/18/26, it was determined the facility failed to ensure residents medical records were complete, accurate and readily accessible as evidenced by: a.) the facility not being able to provide surveyors with Activities of Daily Living (ADL) logs, b.) the facility not being able to provide surveyors with declining sheets for residents on methadone, c.) the facility not being able to provide surveyors with complete and correctly documented 1:1 logs, and d.) the facility not being able to provide surveyors with a personal belongings log for a resident that was being admitted to the facility. This deficient practice resulted in incomplete and unavailable clinical records, which had the potential to impact the facility's ability to ensure appropriate care, monitor resident conditions, ensure accountability of services provided, and protect residents. This deficient practice was identified for 8 of 21 residents (Resident #3, Resident #4, Resident #9, Resident #10, Resident #14, Resident #15, Resident #18, and Resident #20) and was evidenced by the following:Complaint #: 2806068, 2789700, 2679147, 2639889 The facility was unable to provide ADL documentation to reflect the care and services delivered to Resident #14.According to the admission Record (AR) face sheet, Resident #14 was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia, restlessness, and agitation.A review of Resident #14's quarterly Minimum Data Set (MDS), an assessment tool dated 1/13/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired.During the survey, surveyors requested a copy of Resident #14's ADL logs and the facility was unable to provide them.The facility was unable to provide declining sheets or monitoring documentation for residents receiving methadone until January of 2026, to demonstrate ongoing assessment and response to the medication regimen.According to the AR, Resident #9 was admitted to the facility with diagnoses which included but were not limited to: osteomyelitis, unspecified; type 2 diabetes mellitus with hyperglycemia; major depressive disorder, recurrent, unspecified; anxiety disorder; obesity, unspecified; and opioid abuse with intoxication, uncomplicated.According to the MDS, dated [DATE], revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact.According to the AR Resident #10 was admitted to the facility with diagnoses which included but were not limited to: morbid obesity due to excess calories, opioid dependence and depression.According to the MDS, dated [DATE], it revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact.According to the AR, Resident #15 was admitted to the facility with diagnoses including but not limited to: Parkinsonism (an umbrella term for a neurological syndrome characterized by motor symptoms similar to Parkinson's disease, including bradykinesia (slowed movement), resting tremor, muscle rigidity, and postural instability), Chronic Obstructive Pulmonary Disease (COPD) (a progressive, treatable lung disease that causes long-term breathing problems by damaging airway tissue, leading to inflammation and blocked airflow) and mild intermittent asthma.According to the MDS, dated [DATE], Resident #15's BIMS was a score of 15 out of 15, which indicated the resident's cognition was intact.According to the AR, Resident #18 was admitted to the facility with diagnoses which included but were not limited to: generalized anxiety disorder and acute and subacute endocarditis (infection often caused by bacteria on normal heart valves, resulting in high fever and significant destruction).According to the MDS, dated [DATE], Resident #18 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact.During the survey the surveyors requested declination sheets for these residents who were on Methadone and were informed that declination sheets were unable to be provided prior to the end of January of 2026.The facility was unable to provide complete and accurately documented 1:1 observation records for residents (Resident #3 and Resident #4), including missing or incomplete entries necessary to verify continuous monitoring.According to the AR, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: depression and chronic painAccording to the MDS, dated [DATE], Resident #3 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact.According to the AR, Resident #4 was admitted to the facility with diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (neurological deficits caused by left-brain damage, resulting in paralysis (hemiplegia) or weakness (hemiparesis) on the right side of the body), type 2 Diabetes Mellitus, and low back pain.According to the MDS, dated [DATE], Resident #4 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact.During the survey the surveyors requested the 1:1 observation records for Resident #3 and Resident #4 and the facility was unable to provide complete and accurately documented records and records that matched their policy such as both the residents' Electronic Medical record (EMR) Electronic Treatment Administration Record/Electronic Medication Administration Record (eTAR/eMAR).The facility was unable to provide a personal belongings inventory for a resident upon admission, to account for resident property (Resident #20).According to the AR face sheet, Resident #20 was admitted to the facility with diagnoses including but not limited to: opioid abuse, neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), and mixed hyperlipidemia (inherited disorder characterized by elevated levels of both bad cholesterol and triglycerides in the blood, increasing the risk of cardiovascular disease).According to the MDS, dated [DATE], Resident #20 had a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired.During the survey the surveyors requested a personal belongings inventory for Resident #20 when they were re-admitted into the facility on 3/6/26 which the facility was unable to provide. Surveyors requested this inventory as Resident #20 was alleging to have brought pills back from the hospital that they were inhaling via their nostril. This was observed by staff and reported to the Department of Health (DOH).On 3/5/26 at 12:22 PM, the surveyors interviewed the Unit Manager (UM) on the second floor regarding the declining sheets for methadone. UM #2 stated that she did not keep records of the residents who were on methadone until the end of January of 2026.On 3/9/26 at 10:40 AM, the surveyor interviewed Resident #15 who reported that they do not receive their methadone on time and that caused them to feel sick.On 3/9/26 at 10:50 AM, the surveyor interviewed Resident #9 who reported missing methadone doses and having an inadequate supply of methadone.On 3/9/26 at 1:01 PM, the surveyors interviewed Certified Nursing Assistant (CNA) #2 who confirmed that the care that he provides for residents he documents in the Point of Care (POC) for the facility and that the POC should be completed by the end of his shift. CNA #2 also confirmed that there should not be blanks on 1:1 record as that would indicate that the CNA filling out the 1:1 record is not paying attention to their documentation.On 3/9/26 at 1:32 PM, the surveyors interviewed Licensed Practical Nurse (LPN) #2 who stated that documentation for residents should be complete and accurate so that all personnel would be able to know what care is being provided for a resident. LPN#2 was shown the 1:1 record for Resident #3 and Resident #4 and stated that the forms were filled out incorrectly because there were blanks. When asked why there should be no blanks on the 1:1 record, the LPN stated because the observer is not doing their job correctly if there are blanks.On 3/9/26 at 2:14 PM, the surveyors interviewed UM #2 who stated that Resident #3 and Resident #4's 1:1 record were not filled out per facility policy or her expectations for her staff. UM #2 also stated that the 1:1 log should be able to be provided to surveyors and up to date because it informs all personnel that the facility is properly implementing their own interventions related to 1:1 observation.On 3/10/26 at 2:10 PM, the surveyors interviewed the Director of Nursing (DON) #2 who stated that documentation is what properly allows the facility to care for residents. She further stated that documentation is the driving force for residents, their family, and the facility as it allows everyone to be aware of the care being provided for the residents.On 3/10/26 at 4:41 PM, the surveyors interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed there were errors on the 1:1 logs and that they were not done correctly. The LNHA also confirmed that the facility could not produce declination sheets for methadone. On 3/18/26 at 1:40 PM, DON #2 was interviewed and stated that when residents are admitted to the facility an inventory of their belongings is completed. When asked why inventorying a resident's belonging was important DON #2 stated to know what a resident has when they come in and so that belongings don't get misplaced. She also stated that that typically she does not check a resident's pockets or performs a body check when performing an inventory of a resident's belongings. Surveyor requested Resident #20's inventory of belongings from re-admission in March of 2026.On 3/18/26 at 2:14 PM, DON #2 stated she was unable to provide surveyors with the inventory log for Resident #2.A review of the facility's policy titled Documentation in Medical Record with a revision date of 5/12/25 included the following information under Guideline:Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Under, Explanation and Compliance Guidelines: Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation may be performed manually or as per the facility's specific electronic medical record software program. A review of the facility's policy titled One to One Supervision with a revision date of 12/11/25 included the following information under Purpose:One-to-one observation/supervision is implemented when a resident's clinical assessment indicated a one on one necessary based on an increased safety necessity. Implementation of one-to-one supervision is reserved for extreme situations where they may be a significant risk to the safety and well-being of a resident or other residents.Under, Procedure: 1. One-to-one supervision requires that a resident is always never out of sight of the assigned staff member.a. The resident is always accompanied by the designated staff member (including bathing, showering, shaving, and toileting), unless care plan indicates otherwise. 5. Residents on a one-to-one status will be evaluated at least every shift by a Licensed Nurse.a. In addition, the Interdisciplinary Team (IDT) will reassess the resident every 24 hours or as needed to ensure that one-to-one staff supervision continues to be necessary.b. One-on-one will be added to the EMR (eTAR/eMAR), and the nurse assigned to ethe resident will sign off each shift, verifying supervision is in place and current.c. The patient will be on Alert/Shift-to shift charting every shift for the duration of one-to-one supervision to document the patients activities and both effective and ineffective interventions utilized.d. The designated staff member who is providing one-to-one supervision will utilize the Safety Check Log & Data Collection (One-to-One) form to document resident activity throughout the observation period.A review of the facility's policy titled Resident Personal Belongings with a revision date of 7/12/25 included the following information under Guideline:It is the guideline of this facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. The facility will ensure that personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative, in the event of the resident's death or discharge from the facility.Under, Explanation and Compliance Guidelines: 3. All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. 5. The facility may refuse to allow a resident to retain his or her personal possession(s) due to the following reasons:b. As protection of health and safety.c. The facility determines through observation that a resident may have access to illegal substances that they have [NAME] into the facility or secured from an outside source. The facility does not act as an arm of law enforcement. Rather, in accordance with state laws, the facility will determine if a referral to local law enforcement is warranted. The facility may choose to provide additional monitoring and supervision determined on a case by case basis. If facility staff identify items or substances that pose risks to residents' health and safety and are in plain view, they may confiscate them.d. To maintain and prevent the infringement of other resident rights.N.J.A.C. 8:39-35.2

Based on interviews and review of facility documents, it was determined that the facility failed to develop and maintain a comprehensive facility assessment that accurately identified the mental and behavioral health needs of its resident population and the resources necessary to provide appropriate care.On 2/11/26 at 11:54 AM, the surveyor requested a copy of the Facility Assessment (FA).On 2/11/26 at 1:25 PM, the surveyor reviewed the FA dated 7/22/25.The FA under Purpose Statement: The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies.The FA under, Scope identified: The facility's resident population, including but not limited to: the number of residents and the facility's resident capacity. The care required by the resident population using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments. The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population.The FA under, Scope identified: The facility's resources, including but not limited to: Services provided such as physical therapy, pharmacy, behavioral health and specific rehabilitation therapies; All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/ or training and any competencies related to resident care.The FA under, Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care: Psychiatric/Mood Disorders listed schizophrenia, depression, anxiety.The FA under, Resident Acuity Affecting Licensed Nurses (include facility specifics not already listed here): Behavioral/Mental Health listed vendor retained to provide services psych and psychological.The FA under, SERVICES AND CARE WE OFFER BASED ON OUR RESIDENT'S NEEDS: Behavioral and Mental Health listed psychological psychiatric, and pess [Psychiatric Emergency Screening Services] unit.The FA under, INFORMATION ABOUT OUR STAFF: Social Services listed Mental Health Professional as contracted. The contracted party was not identified.The FA under, INFORMATION ABOUT OUR STAFF: Behavioral/Mental Health Providers listed Psychiatrists, Psychologists, Licensed Counselors. None of the providers were identified and the areas to identify the behavioral and mental health providers were left blank.The FA under, INFORMATION ABOUT OUR STAFFING PATTERNS: Behavioral Health Services listed staffing is adequate for caring for residents with dementia, mental health conditions, or history of trauma as evidenced by: . No evidence was listed.The FA under, Reassessment: This assessment will be reviewed and updated, as necessary, and at least annually. Whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment, the Administrator will ensure that all relevant elements of the assessment is reviewed and updated. Additionally, the facility will consider specific staffing needs for each shift. and for each resident unit in the facility based on changes to the resident population. Any changes to this assessment will be documented, along with a revision history.On 2/11/26 at 1:31 PM, the surveyor conducted an interview with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Director of Operations (DOO). The surveyor gave the copy of the FA that was received for review and requested that staff point out the areas of the FA that covered psychiatric and behavioral issues.The LNHA pointed out that the FA included under SERVICES AND CARE WE OFFER BASED ON OUR RESIDENT'S NEEDS: Behavioral and Mental Health listed psychological psychiatric, and pess unit. She also stated that under INFORMATION ABOUT OUR STAFF: Social Services listed Mental Health Professional as contracted. The LNHA then stated that information for mental health providers was not available. She also acknowledged that no evidence was listed under INFORMATION ABOUT OUR STAFFING PATTERNS: Behavioral Health Services.On 2/11/26 at 1:41 PM, the surveyor asked if the FA that was reviewed would be a fully complete FA. The DON stated no. The surveyor then asked if the facility has a large population of residents who have mental health, behavioral and psychiatric issues. The DON stated yes. The surveyor then reiterated the missing components that were reviewed by the LNHA and received acknowledgement from the LNHA and DON that several components necessary for the FA were missing. The LNHA stated she did try to review the FA but did not have a chance to.A review of the facility's policy titled Facility Assessment, with a last revised date of 12/12/24, included the following information under Guideline: this facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operation (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. Under, Explanation and Compliance Guidelines: 1. The facility assessment will, at a minimum, address or include:a. The facility's resident population, including but not limited to:i. Number of residents and the facility's capacity;ii. The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments;iii. The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;b. The facility's resources, including but not limited to;iii. Services provided, such as physical therapy, pharmacy, behavioral health and specific rehabilitation therapies;iv. All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;3. The facility will use the facility assessment to:b. Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process.5. The completed facility assessment will be organized according to resident population, staffing, physical resources, and risk assessments.8. Based on the assessment of resident characteristics, the facility will determine what care/services, staff competencies, and staffing needs are required to meet the needs of our residents. This will be compared to the specific care/services, including by contract, and training that we provide. Action plans will be implemented as necessary.10. The facility assessment will be reviewed and updated as necessary and at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population. Any changes to the assessment will be documented, along with a revision history.NJAC 8:39-5.1(a)

Based on interview and review of Nurse Staffing Report (NSR) it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 4 of 14 days reviewed. This deficient practice was evidenced by the following: 0n 2/3/26, the surveyor requested the NSR to be completed for the 2 weeks of staffing prior to survey from 01/18/2026 to 01/31/2026.A review of the NSRs completed by the facility for the above requested weeks revealed the facility had no RN coverage for all shifts on 1/18/26, 1/21/26, 1/28/26 and 1/31/26. On 2/11/26 at 8:06 AM, during a telephone conversation, the Licensed Nursing Home Administrator confirmed she was aware there was no RN coverage for the above mentioned dates. She stated, It was due to call outs. NJAC 8:39-25.2(h)

Complaint #2731638 Based on interviews and review of facility provided documents, it was determined that the facility failed to provide residents with their breakfast meal at a regular time comparable to normal mealtimes, with no more than 16 hours elapsing between the evening meal and the breakfast meal the following day. This deficient practice was identified for one of one breakfast meal (1/31/26) reviewed and was evidenced by the following: On 2/3/26 at 11:48 AM, the surveyor interviewed the second floor Licensed Practical Nurse (LPN) who stated breakfast usually was delivered to her residents between 7:45 AM and 8:15 AM. She further stated that on Saturday (1/31/26) breakfast was not delivered until approximately 11 AM. The LPN stated she provided some of her residents with snacks from the pantry while they were waiting for breakfast that morning. She stated she did not know the reason for the delay in breakfast being served but continued to provide her morning care as usual until breakfast arrived. She further stated the nursing staff did not have a key to the kitchen. She acknowledged she did not notify a supervisor or manager about the delay in the breakfast meal. On 2/3/2026 at 12:05 PM, the surveyor interviewed the second floor Certified Nursing Assistant (CNA) who stated breakfast was usually served by 8:30 AM. She stated that on Saturday morning (1/31/26), breakfast was not delivered to the residents until approximately 10:30 or 11 AM. She stated some residents asked for food and she offered them what was available in the pantry. On 2/3/26 at 1:22 PM the surveyor interviewed the Food Service Director (FSD) who stated the cook was scheduled to work on Saturday (1/31/26) at 5:30 AM. The FSD stated the following timeline: The cook called him at 4 AM that morning to report having car trouble, but that he would attempt to get to work on time. The FSD further stated he received a call from the dietary aide at 6:30 AM who reported he was at work but unable to get into the kitchen because the door was locked. The FSD stated that two cooks, the FSD (himself), and the director of maintenance had keys to the kitchen. He acknowledged the dietary aides did not have a key to the kitchen. He was unable to speak to whether the nursing department was provided with a key to the kitchen. The FSD stated he received a call from the night shift cook at 9:30 AM who stated he had arrived at the facility with the key to the kitchen. The FSD further stated there were four dietary aides who waited at the facility for a cook to arrive with the key. The FSD stated he himself went to the facility at 10:45 AM to assist with breakfast service. The FSD acknowledged there was a delay in serving the breakfast meal that day. He further acknowledged that 17 hours elapsed between dinner served at 5:45 PM on 1/30/26 and breakfast served at 10:45 AM on 1/31/26. On 2/3/2026 at 11:53, the surveyor interviewed the Licensed Nursing Home Administrator, who stated the dietary aide arrived at 630 to prep breakfast but the kitchen was locked so he sat in lobby waiting for the cook to arrive. She stated he did not tell anyone he couldn't get into the kitchen. The LNHA stated the night supervisor had a key but was unaware of the problem. She stated she was made aware of the problem at 9:40 AM and at that time she called the Manager on Duty who was already on the way to the facility. A review of the facility policy provided by the FSD titled Serving a Meal dated 11/29/23 which reflected that the policy of the facility was to serve meals that meet the nutritional needs of residents. The policy explanation and compliance guidelines reflected 14 items related to the proper way to serve a meal to a resident (ie. open all cartons and give the napkin to the resident. etc). The policy did not reflect a process to ensure meals were provided at regular times and not more than 16 hours elapsed between meals. The surveyor inquired regarding additional policies or procedures with regard to meal times. No further information was provided prior to the end of the survey. NJAC 8:39 - 17.2 (f)

Complaint #: 2701205 Based on interviews, review of medical records, and review of other pertinent facility documents on 12/29/2025, it was determined that the facility failed to create a safe environment and provide adequate supervision to prevent the elopement of a resident (Resident #2) with poor decision-making abilities. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #2). During the survey a finding that constituted Immediate Jeopardy (IJ) was identified under CFR 483.12(a)(1) F689. The facility failed to: a) provide adequate supervision to prevent the elopement of a resident with poor decision-making abilities (Resident #2), b) develop appropriate interventions to prevent elopement, and c) follow their elopement and wandering policy. On 12/24/2025 at approximately 1:40 AM, Resident #2 was seen by Certified Nursing Assistant (CNA) #2 walking in the hallway. Resident #2 eloped from the facility by watching staff type a code into a pin-pad near the exit door and waiting for a light on the door's locking mechanism to turn green to exit the building. The resident stated that they went out of the facility to get coffee at a convenience store, but got tired during the walk, so they accepted a ride to the store from a stranger. Resident #2 was returned to the facility by police on 12/24/2025 at approximately 2:00 AM. The facility's failure to a.) provide a safe environment and adequate supervision to prevent the elopement of a resident with poor decision-making abilities and b.) follow their elopement and wandering policy placed Resident #2 as well as all residents at risk for elopement and posed a likelihood of serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 12/24/2025, when Resident #2 eloped from the facility. The facility Administration was notified of the IJ on 12/29/2025 at 5:50 PM. The facility submitted an acceptable Removal Plan (RP) on 12/31/2025 at 1:05 PM. The surveyor verified the implementation of the RP during the continuation of the on-site survey on 01/05/2026. The evidence was as follows: The facility policy Elopements and Wandering Residents, with a review/revision date of 04/22/2025 was reviewed. Under Guideline, the policy revealed that the guideline ensured that residents who exhibited wandering behavior or were at risk for elopement received adequate supervision to prevent accidents and received care according to their individualized care plan. Under Definitions, the policy revealed that elopement occurs when a resident leaves the premises or a safe area without authorization or the necessary supervision to do so. Under Explanation and Compliance Guidelines, the facility policy revealed that the facility would utilize a systematic approach to monitoring and managing residents at risk for elopement which included identification and assessment of risk. A review of the Facility Reportable Event (FRE) dated 12/24/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that at approximately 2:00 AM on 12/24/2025, Resident #2 eloped from the facility by waiting for others to enter the door code. The FRE revealed that Resident #2 stated that they waited for a light to turn green, then exited the building. The FRE further revealed that the police returned Resident #2 to the facility. An undated Summary of investigation, document with Elopement: [Resident #2], and Date of incident: 12/24/2025, at the top was reviewed. The Overview and description of event: section of the document revealed that at approximately 2:00 AM police arrived at the facility with Resident #2 and stated that the resident was picked up from a local convenience store. This section of the facility document revealed that Resident #2 stated that they went out of the facility to get coffee. A handwritten statement by CNA #2 dated 12/24/2025 was reviewed. The statement revealed that on 12/24/2025 she saw Resident #2 at 1:30 AM or 1:40 AM. The statement further revealed that approximately 30 minutes later the police came to the building and stated that a facility resident was at a convenience store nearby and returned the resident to the facility. A handwritten statement by Licensed Practical Nurse (LPN) #1 dated 12/24/2025 was reviewed. The statement revealed that Resident #2 said goodnight to LPN #1 at 1:00AM on 12/24/2025. The statement further revealed that at 2:00 AM, the police brought Resident #2 back to the facility from a convenience store. No additional staff statements were provided on 12/29/2025. A Incident Detail Report, provided by the responding police department was reviewed. The report revealed that on 12/24/2025 at 1:40 AM, a caller reported that an elderly person with no jacket and pajama pants was observed on the side of the roadway. The elderly person identified themself to the caller with Resident #2's first name and was wearing an identification bracelet. The caller took Resident #2 to the convenience store and gave them two dollars and then left. The report further revealed that Resident #2 was picked up from the store by police at 2:00AM and returned to the facility staff 2:08AM. An interview was conducted with Resident #2 on 12/29/2025 at 11:24 AM. Resident #2 stated that they were only allowed to leave the facility with their family. Resident #2 stated that they exited the facility five or six days ago by watching staff exit, then going through the door while a light on the door remained green. Resident #2 stated that they wanted to walk to a convenience store to get coffee but became tired along the way. Resident #2 stated that a guy, gave them a ride to the store and three or four dollars. Resident #2 stated that the police then arrived at the convenience store and brought the resident back to the facility. Resident #2 stated that they were wearing pajamas, rubber clog-style shoes, and no coat when they left the facility. Resident #2 further stated that they forgot their cane. A telephone interview was conducted with CNA #2 on 12/29/2025 at 12:22 PM. CNA #2 stated that at approximately 1:45AM or 2:00AM, on 12/24/2025, she saw Resident #2 walking around the facility, which was their usual behavior. CNA #2 stated that later, a police officer rang the doorbell and informed staff that Resident #2 was found at the convenience store and returned the resident to the facility. A telephone interview was conducted with the Nursing Supervisor (NS) #1 on 12/29/2025 at 1:09 PM. NS #1 stated that she was the NS on duty on 12/24/2025 when Resident #2 eloped. NS #1 stated that Resident #2 told her that they knew the door code. NS #1 also stated the lock on the facility's front door did not lock right away when the door was closed and it was possible for a someone to get out when the door was that way. NS #1 further stated that Resident #2 had, poor judgement on making safe decisions. An interview was conducted with the Unit Manager (UM) #1 on 12/29/2025 at 1:32 PM. UM #1 stated that if the resident was found outside of the facility it was considered an elopement. UM #1 stated that elopements allow residents to get hurt and it was the job of the facility to keep residents safe and secure. UM #1 further stated that it was not safe for Resident #2 to go to the convenience store and that she would not advise that Resident #2 was safe to go out of the facility independently. An interview was conducted with the DON on 12/29/2025 at 2:17 PM. The DON stated that an elopement is when no one knows that a resident has left the facility or the expected safe areas in the facility. The DON stated that when residents eloped, they could fall, be attacked, or anything could happen. The DON stated that after an elopement the expectation was that the resident was assessed by the charge nurse or NS, a risk management form was completed in the computer, staff statements were collected, and the resident's family and physician were notified. The DON stated that the process allowed the facility to do a thorough investigation, determine the root cause of the elopement, and prevent it from happening again. A review of the medical record for Resident #2 revealed the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses including but not limited to: diabetes mellitus due to underlying condition with diabetic mononeuropathy (diseases that affect how the body uses blood sugar); schizoaffective disorder (mental health condition marked by a mix of symptoms such as hallucinations and delusions, and mood disorder symptoms); bipolar disorder, current episode depressed, severe with psychotic features (mental health condition that causes extreme mood swings, paranoia, delusions, or hallucinations); muscle weakness; and difficulty walking, not elsewhere classified. A review of Resident #2's Elopement Risk Review (ERR) dated 03/27/2025 at 12:05 PM, revealed that Resident #2 was at low or no risk for elopement. A review of Resident #2's ERR dated 12/24/2025 at 2:46 AM, revealed that Resident #2 verbalized the desire to, or plans to leave the facility without authorization or supervision. Further review of the facility document revealed that the resident was cognitively impaired, had decreased safety awareness, had disturbances in judgement or had a history/risk of wandering. The resident was assessed as at risk of elopement. No ERRs dated between 03/27/2025 and 12/24/2025 were provided. A review of Resident #2's Care Plan (CP) revealed a focus initiated on 10/28/2022 and revised on 12/06/2022, that Resident #2 had a self-care deficit related to cognitive deficits and confusion. Interventions included but were not limited to watching the resident for fatigue, encouraging rest periods and segmenting tasks. Resident #2's CP revealed a focus initiated on 11/21/2024 and revised on 12/24/2025 that the resident was at risk for falls, accident, and incidents. Interventions included but were not limited to keeping the resident's call bell in reach and responding promptly to requests for assistance. The Progress Notes (PN) for Resident #2 were reviewed. A PN written by NS #1 on 12/24/2025 at 2:42 AM, revealed that at 2:00 AM, on the same day a police officer arrived at the facility and informed NS #1 that Resident #2 was picked up by a passerby on a nearby road and driven to a convenience store to get coffee. The passerby then called the police. The PN revealed that another officer brought Resident #2 back to the facility. The PN further revealed that Resident #2 told NS #1 that they knew the code to the facility door but refused to further discuss the elopement. An acceptable Removal Plan (RP) was received on 12/31/2025 at 1:05 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: On 12/24/2025 Resident #2 was safely returned to the facility and placed on one-to-one supervision. On 12/24/2025 Resident #2 had a wander guard applied and its functionality verified, was placed on enhanced supervision, and was moved to a room closer to the nurse's station. On 12/24/2025 Resident #2's CP was updated. On 12/24/2025 Resident #2 was reassessed for elopement risk. On 12/24/2025 a facility headcount was conducted. On 12/24/2025 facility exit doors, keypads, alarms, and wander guard system were inspected to validate proper functioning. On 12/24/2025 the facility's front door was updated to eliminate delay in opening and closing. On 12/26/2025 the facility elopement policy was reviewed. On 12/26/2025 facility-wide staff were re-educated on elopement prevention and emergency protocols was completed and competency was validated. On 12/26/2025 reassessments of at-risk residents were completed. During an interview on 01/05/2026 at 1:41 PM, the DON stated that the facility's elopement binder was revised to contain only residents at risk for elopement on 12/30/2025. The surveyor verified the implementation of the Removal Plan on-site on 01/05/2026, and determined the immediacy was removed as of 12/30/2025. NJAC 8:39-27.1 (a)

Complaint #: 2701205Based on observations, interviews, medical record reviews, and review of other pertinent facility documentation on [DATE], it was determined that the facility failed to a.) obtain a physician order for a resident (Resident #4) to go out of the facility on pass (OOP) or take leave of absence (LOA) from the facility, and b) update care plans for two residents (Resident #4 and Resident #6) with focuses and interventions related to the residents going OOP or LOA from the facility. This deficient practice was identified for 2 of 6 residents reviewed for care plans and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. 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 medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. On [DATE] at 9:30 AM and 12:23 PM, the surveyor observed both sampled and unsampled residents in the facility lobby and interacting with the Receptionist (who operated the button to unlock the facility's front door). An interview was conducted with the Receptionist on [DATE] at 12:23 PM. The Receptionist stated that only one resident (Resident #4) in the facility was able to leave independently. The Receptionist stated that when Resident #4 wanted to go out, the nursing staff would call her and tell her that the resident was on their way to the lobby to go out. The Receptionist stated that she would then assist the resident in getting their wheelchair out of the facility's front doors. The medical record for Resident #4 was reviewed. According to the admission Record (AR), Resident #4 was admitted to the facility with diagnoses including but not limited to: person injured in unspecified motor-vehicle accident, traffic, initial encounter; and polyneuropathy (damage or disease affecting the nerves and resulting in weakness, numbness, and burning pain). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. The MDS also indicated that Resident #4 used a motorized wheelchair or scooter for mobility. A review of the Resident Responsibility/Sign Out Sheet, for Resident #4 revealed that Resident #4 had signed out of the facility with self listed as the responsible party on the following dates in November and December of 2025: [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of the Order Summary Report (OSR) for Resident #4 revealed no physician order (PO) indicating whether the resident could go OOP or for LOA, or what level of supervision the resident required. A review of the Care Plan Report, (CPR) for Resident #4 revealed no focus, goals, or interventions related to Resident #4 going OOP or for LOA. The medical record for Resident #6 was reviewed. According to the AR, Resident #6 was admitted to the facility with diagnosis including but not limited to cellulitis of unspecified part of limb (infection of the skin and soft tissue underneath); benign neoplasm of meninges, unspecified (tumor that grows from the membranes that surround the brain and spinal cord); unspecified cirrhosis of liver (condition in which scar tissue gradually replaces healthy liver cells); muscle weakness (generalized); and difficulty walking, not elsewhere classified. According to the Comprehensive MDS dated [DATE], Resident #6 had a BIMS score of 14, which indicated that the resident's cognition was intact. A review of the OSR for Resident #6 revealed the following POs: May go out on LOA with medications. The PO had a start date of [DATE]. May go out on LOA with a responsible party. The PO had a start date of [DATE]. A review of the CPR for Resident #6 revealed no focus, goals, or interventions related to Resident #6 going OOP or for LOA. An interview was conducted with Resident #6 on [DATE] at 12:41 PM. Resident #6 stated that they had gone out of the facility with their family in the past. An interview was conducted with Resident #4 on [DATE] at 1:09 PM. Resident #4 stated that they go out of the facility independently on their motorized scooter once or twice a week. Resident #4 stated that the usual process was for them to notify a nurse and sign out in a logbook at the nurse's station. Resident #4 stated that the Nurses would then call and notify the Receptionist, who would let the resident out through the front door. An interview was conducted with the Director of Nursing (DON) on [DATE] at 2:46 PM. The OSR and CPR were reviewed with the DON. The DON confirmed that Resident #4's OSR did not contain a PO indicating if Resident #4 could go OOP or LOA. The DON stated that the resident should have had an order so that staff would know if the resident could go out. The DON stated that a resident's OOP or LOA status should have been included in the resident's CP because CPs were how nurses knew how to care for residents and what residents could do. The facility policy, Comprehensive Care Plans, with an implemented date of [DATE], and a reviewed/revised date of [DATE], was reviewed. Under Guideline: the facility policy revealed that it was the guideline of the facility to develop and implement comprehensive person-centered care plans for each resident that were consistent with resident rights. The policy revealed that the CP should include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and meet professional standard of quality. Under Definitions, the facility policy revealed that person-centered care meant to focus on the resident and support them in making their own choices and having control of their own lives. The same section of the facility policy revealed that Professional standard of quality, meant that care and services were provided according to accepted standards of clinical practice. NJAC 8:39-23.2 (a)

Complaint #: 2701205 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that facility staff failed to document interventions intended to prevent elopement that were provided to a resident with a history of elopement from the facility (Resident #2). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: On [DATE], at 11:24 A.M., the Surveyor conducted an interview with Resident #2 and observed a wandeguard (system that uses wearable tags to limit access to areas of the facility) tag on the resident's ankle. Resident #2 explained that they wore the tag because they had escaped, from the facility 5 or 6 days prior. The Surveyor reviewed the medical record for Resident #2. According to the admission Record, Resident #2 was admitted to the facility with diagnoses including but not limited to: diabetes mellitus due to underlying condition with diabetic mononeuropathy (diseases that affect how the body uses blood sugar); schizoaffective disorder (mental health condition marked by a mix of symptoms such as hallucinations and delusions, and mood disorder symptoms); bipolar disorder, current episode depressed, severe with psychotic features (mental health condition that causes extreme mood swings, paranoia, delusions, or hallucinations); muscle weakness; and difficulty walking, not elsewhere classified. A review of the Minimum Data Set, an assessment tool, dated [DATE], revealed that Resident #2 had a Brief Interview for Mental Status score of 15, which indicated that the resident's cognition was intact. A review of Resident #2's Elopement Risk Review, (ERR) dated [DATE] at 2:46 AM, revealed that Resident #2 verbalized the desire to, or plans to leave the facility without authorization or supervision. Further review of the ERR revealed that the resident was cognitively impaired, had decreased safety awareness, had disturbances in judgement or had a history/risk of wandering. The resident was assessed as at risk of elopement. A review of Resident #2's Care Plan (CP) revealed a focus initiated on [DATE], and revised on [DATE], that Resident #2 was at risk for elopement related to their attempts to leave the facility and an incident, on [DATE]. Interventions related to this focus included but were not limited to the use of a wanderguard tag for the resident. The Order Summary Report, (ORS) for Resident #2 revealed the following physician orders (POs): Check placement of the wanderguard every shift for safety and elopement. The PO had a start date of [DATE]. Check skin integrity under the wanderguard on the resident's left ankle every shift for safety and elopement. The PO had a start date of [DATE]. Check skin integrity, function, placement and expiration of wanderguard every shift and replace the wanderguard immediately if expired, in ill repair, or not functioning. The PO had a start date of [DATE]. Review of Resident #2's Treatment Administration Record (TAR) revealed blank boxes for the aforementioned orders on night shift of [DATE]. The Progress Notes (PN) for Resident #2 were reviewed. A PN written by NS #1 on [DATE] at 2:42 AM, revealed that at 2:00 AM, on the same day a police officer arrived at the facility and informed NS #1 that Resident #2 was picked up by a passerby on a nearby road and driven to a convenience store to get coffee. The passerby then called the police. The PN revealed that another officer brought Resident #2 back to the facility. The PN further revealed that Resident #2 told NS #1 that they knew the code to the facility door but refused to further discuss the elopement. The PNs revealed no documentation indicating that the skin integrity, placement, or function related to Resident #2's wanderguard were checked. The Surveyor attempted to contact the Licensed Practical Nurse (LPN #2) who cared for Resident #2 during the night shift on [DATE] but was unsuccessful. An untitled and undated facility document was reviewed. The top of the document revealed, To ensure that all entries in the Medication Administration Record (MAR) and Treatment Administration record (TAR) are signed promptly and accurately after each medication or treatment is administered. Review of the document further revealed that proper documentation is essential for supporting accurate medical records and promoting resident safety. The document revealed that all records should be reviewed for completeness at the end of that shift. Under. Acknowledgement, the document revealed. I acknowledge that I have read and understand the contents of this memo regarding timely and accurate signing of MAR and TAR documentation. This section of the document further revealed the name and signature of LPN #2 and the date [DATE]. An interview was conducted with the Director of Nursing on [DATE] at 1:41 PM. The DON stated that nurses were in-serviced regarding checks of Resident #2's wanderguard and documentation in the TAR. The DON stated that the resident's wanderguard should have been checked every shift, which meant every eight hours. The DON confirmed that there was no documentation indicating the checks of Resident #2's wanderguard were performed according to the POs on the night shift of [DATE]. During a follow up interview on [DATE] at 2:46 PM, the DON stated that blank spaces on the TAR meant that there was no way to know if the care was provided. The DON further stated, I tell the nurses that if they didn't document something, it didn't happen. NJAC 8:39-35.2 (d)

Complaint: 2564823Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain refrigerated potentially hazardous foods at appropriate temperatures to prevent potential microbial growth, b.) discard foods that were past their date of expiration and showed signs of spoilage, c.) maintain the kitchen in a sanitary manner, e.) accurately record appropriate cooking and holding temperatures, and f.) accurately record refrigeration temperatures. This deficient practice was evidenced by the following: 1.) On 07/18/2025 at 9:30 A.M., the surveyor and the [NAME] toured the kitchen and observed the needle of the dial type external thermometer on the chest refrigerator was resting in the lowest possible position (below -40 degrees Fahrenheit (F)). The thermometer did not appear to be functioning. The internal thermometer read 50 degrees F. There was cloudy liquid pooled at the bottom of the chest refrigerator. During a follow up tour and interview on 07/18/2025 at 12:00 P.M., the Food Service Director (FSD) confirmed that the exterior thermometer of the chest refrigerator was not functioning, and that the internal thermometer read 50 degrees F. The FSD confirmed the presence of cloudy liquid at the bottom of the chest refrigerator. The FSD attempted to calibrate two digital probe thermometers which belonged to the facility, but was unsuccessful. The surveyor calibrated a digital probe thermometer in an ice bath to 32 degrees F and obtained the following temperatures from products that were held in the chest refrigerator:A single serving carton of fat free milk was 44.2 degrees F.A single serving carton of whole milk was 48.5 degrees F. The following temperatures were obtained from food items stored inside of the double-door reach-in refrigerator:A peach flavored yogurt cup was 41.9 degrees F.A butterscotch pudding was 43.3 degrees F. 2.) On 07/18/2025 at 9:44 A.M., the surveyor and the [NAME] toured the kitchen and observed on the shelving unit directly outside of the FSD's office door, a cardboard box containing bags of long rolls. The rolls were dotted with circles of a blue-green fuzzy substance. The cook stated, that is mold. The cook removed the two bags of rolls containing the blue/green fuzzy substance from the cardboard box. During a follow up tour and interview on 07/18/2025 at 12:19 P.M., the surveyor returned to the shelving unit outside of the FSD's office with the FSD. The FSD looked in the cardboard box and confirmed the presence of a blue/green fuzzy substance on an additional six packs of long rolls. The FSD stated that the substance was mold. The FSD confirmed that the expiration date of the rolls was 07/15/2025. The FSD stated that they should have been discarded on that date. 3.) On 07/28/2025 at 9:15 A.M., the surveyor and the FSD toured the kitchen. The surveyor observed on the wall next to the walk-in refrigerator and walk-in freezer, multiple spots of a black fuzzy substance extending approximately two feet up the metal wall. The floors outside of the walk-in refrigerator and walk-in freezer had standing cloudy water with small, black items in it. The FSD stated that the standing water could have been rain from outside or water left over from power-washing that occurred two or three days prior. The FSD further stated that the black substance on the wall may have been mold and the black items in the water on the floor may have been fruit flies. During the kitchen tour on 07/28/2025 at 9:15 A.M., the FSD stated that cleaning was done according to a cleaning matrix. The FSD stated that cleaning tasks were documented on a sanitation checklist by the person who completed the task. The FSD stated that completed sanitation checklists were kept in a binder in the kitchen. The FSD was unable to provide a completed sanitation checklist for the previous week. 4.) On 07/28/2025 at 8:15 A.M., the surveyor and the facility's Director of Nursing (DON) entered the kitchen, and the DON informed the [NAME] that the surveyor intended to check food temperatures. The [NAME] informed the surveyor that he did not have a thermometer, and that the facility's steam table was not working. The remaining breakfast food were disposed of by the [NAME] at that time. During an interview on 07/28/2025 at 9:10 A.M., the FSD stated that the facility's process for checking food temperatures was to take the temperatures food was finished cooking on the stove or in the oven. The FSD stated when the food was then transferred to the steam table for serving, the temperatures were checked again. The FSD acknowledged that temperatures should have been checked with a thermometer prior to service. During a follow-up interview on 07/28/2025 at 11:04 A.M., the FSD stated that food temperatures were recorded on a log that was kept in a binder in the kitchen. A review of the SERVICE LINE CHECKLIST (SLC)document with 7/28, written at the top was reviewed with the FSD. The document revealed the following under, BREAKFAST: Milk 38 degrees F, coffee 150 degrees F, [orange juice]/cereal 38 degrees F, oatmeal 160 degrees F, oatmeal 160 degrees F, bacon 175 degrees F, sausage 175 degrees F, sausage 175 degrees F, and French toast 170 degrees F. The FSD stated that food temperatures were not taken for the breakfast meal on 07/28/2025, and he filled in the SLC for the breakfast meal that day. The FSD further stated that the temperatures that were entered on the SLC for breakfast that day were based on average temperatures and not the temperatures of the food items for that day. The FSD confirmed that prior to 07/28/2025, that last entry in the SLC was made on 07/21/2025. On 07/28/2025 at 11:20 A.M., in the presence of the Licensed Nursing Home Administrator (LNHA), the [NAME] confirmed that the temperatures in the breakfast column of the SLC for 07/28/2025, were not taken by him and were entered by the FSD around 9:30 A.M., when breakfast service was complete, and no food was present. 5.) On 07/28/2025 at 3:17 P.M., the surveyor reviewed the following documents with, July 2025 written at the top with the FSD: REFRIGERATOR TEMPERATURE RECORD with the unit description, 2 Door, written at the top; REFRIGERATOR TEMPERATURE RECORD with the unit description, Milk Box, written at the top; REFRIGERATOR TEMPERATURE RECORD with the unit description, Walk-In, written at the top; and FREEZER TEMPERATURE RECORD. The surveyor obtained these logs from the kitchen during an 8:15 A.M. tour on 07/28/2025, prior to the FSD's arrival to the facility. The FSD confirmed that the last temperature entered for the refrigerator described as 2 Door, was the P.M. temperature on 07/24/2025. The FSD confirmed that the last temperature entered for the refrigerator described as Milk Box, was the A.M. temperature on 07/25/2025. The FSD confirmed that the last temperature entered for the refrigerator described as Walk-In, was the P.M. temperature on 07/26/2025. The FSD confirmed that the last temperature entered for the freezer was the P.M. temperature on 07/26/2025. The FSD confirmed that his initials appeared next to the entries for the walk-in refrigerator and freezer for 07/26/2025. The FSD stated that he did not work on that date or on 07/27/2025. The FSD further stated that he was unsure how his initials got onto the temperature logs. A review of the undated facility's Food Storage, policy included POLICY, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Under, PROCEDURE, the policy revealed, 16. Refrigerator temperatures: a. Temperature for refrigerators should be 41 degrees F and below. They must be recorded daily. The policy further revealed, 17. Freezer Temperatures: Temperatures for freezer should be 0 degrees or below and must be recorded daily . A review of the facility's Record of Food Temperatures guideline with a reviewed/revised date of 03/26/2025, included It is the guideline of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Under, Explanation and Compliance Guidelines: the guideline revealed, 1. Food temperatures will be checked on all items prepared in the dietary department. 2. Hot foods will be held at 135 degrees Fahrenheit or greater [.] 4. Potentially hazardous cold food temperatures will be kept at or below41 degrees Fahrenheit [.] 6. Measure and record the temperatures for each food product and milk at all meals. Record the temperature on the temperature log. 7. When holding hot foods for service, food temperature should be measured when placing it on the steam table [.] 14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. A review of the facility's Cook job description included Overview: the job description revealed, .prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policies and procedures [.] to assure that quality food service is provided at all times. Under, Essential Functions: the job description revealed, Perform administrative requirements such as completing necessary forms, reports, etc., and submit to the Director of Food Services. [.] Ensure that all food procedures are followed in accordance with established policies and procedures. A review of the facility's Food Service Manager, job description included Overview: the job description revealed, .assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Service Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility [.] to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Under, Essential Functions: the job description revealed, Interpret the department's policies and procedures to employees [.] Perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of equipment and supplies. [.] Inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control. NJAC 8:39-17.2(g)

Complaint # 2564823 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and comfortable room temperature levels in residents' shower rooms and in the facility elevator. This deficient practice was identified in 2 of 4 resident shower rooms and in 1 of 1 facility elevator (elevator car 1). This deficient practice was evidenced by the following:On 07/18/2025 at 10:23 A.M., the surveyor checked temperatures in different locations throughout the facility in the presence of the Maintenance Person (MP) and the following were obtained: The second-floor East shower room has room temperature of 84.4 degrees Fahrenheit (F). which is above the required temperature range of 71 to 81 F. There were no residents present at this time.The second-floor [NAME] shower room had room temperature of 84.4 degrees F in the shower stall and 84.2 degrees F outside of the stall. No residents were present in the shower room.In the Elevator car 1, the air temperature was 84.6 degrees F. No residents present in the elevator. After the temperature checks, the surveyor observed residents, visitors, and staff using the elevator Car 1throughout the day.On 07/18/2025 at 3:06 P.M., the surveyor interviewed the facility Maintenance Director (MD). The MD stated that the air conditioning had been working properly since the power was restored after a brief outage on 07/16/2025. The MD further stated that he was not aware of any work orders related to room temperatures. On 07/18/2025 at 4:36 P.M., the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed that the facility had a power outage on 07/16/2025. The LNHA stated that the facility's generator switched on and functioned properly. The LNHA further stated that the facility did not have an interruption in air conditioning during the power outage. The LNHA also stated that as far as she knew, the air conditioning system was functioning properly. NJAC 8:39 -31.6(p)4

Based on record review, interview, and facility policy review, the facility failed to ensure a family member's concern regarding missing clothing and personal items were filed as a grievance and investigated for one of nine sample residents (Resident (R) 3) reviewed for grievances. This had the potential for residents' rights not being supported, to have their lost belongings searched for, and/or reimbursed.Review of the facility's policy titled, Grievance Guideline, revised on 05/31/23, revealed Purpose: To provide a process to voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or resident representative appropriately apprised of progress toward resolution.Grievance Official: Our facility Grievance Official is the Administrator and/or Designee appointed by the Administrator.A grievance or concern may be expressed orally or in writing to the Grievance Official or facility staff. RESOLUTION: The Grievance Official and/or designee will complete a response within 5 days of receipt to the resident and/or resident representative.Review of R3's admission Record located in the electronic medical record (EMR) under the admission tab revealed the resident was admitted to the facility on 07/22 with a diagnosis of dementia without behavior disturbances. The resident was discharged to the hospital in 2/25 and did not return to the facility.Review of R3's Progress Note, dated 01/17/25, located in the EMR under the Progress Note tab, revealed the resident's family was in for a visit and had concerns because the resident's lock was off her closet. The nurse told the family member they would look into it.Review of the facility's Grievances for January 2025 and provided by the facility revealed no evidence of grievance being filed by the facility on behalf of R3's family.During an interview on 07/30/25 at 1:00 PM, the Licensed Practical Nurse (LPN) 2/ Unit Manager (UM) revealed back in January 2025, R3's family member said the facility could cut the lock off the resident's closet so staff could get into the closet and get the resident a change of clothes. LPN2/UM was not aware of the family reporting there was missing clothing and personal items from the closet.During an interview on 07/31/25 at 2:20 PM, the Administrator confirmed R3's family did have concerns that the resident was missing clothing and personal items from her closet back in January 2025 when the lock was removed. She confirmed she did send an email to the family on 01/18/25 stating that she would submit a request for reimbursement in the amount of $200.00 to cover the missing clothing and personal items. She stated, however, that the facility had not sent R3's family $200.00 or followed up with the family. The Administrator confirmed she did not complete a formal grievance or look into the concern. She confirmed a grievance should have been filed in order to complete a thorough investigation, so a resolution could be presented to the family of R3.

Complaint # 2564823 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/18/2025, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3).This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. 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 medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses that included but not limited to: spondylosis (degenerative changes in the spine), depression, unspecified anxiety disorder and other chronic pain. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 05/25/2025, reflected that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview with Resident #3 on 07/18/2025 at 9:55 A.M., the surveyor observed the resident in bed with their head under the covers. The surveyor observed multiple pills of varying shapes, sizes and colors in a medicine cup on top of Resident # 3's overbed table. When interviewed, Resident #3 stated that the nurse handed the medication to them, and that they placed the cup of medication on the table and forgot about them. At that time, the surveyor called the Unit Manager (UM) and showed her the medications left at Resident #3's bedside. The UM removed the medication cup with the pills from Resident #3's bedside. On 07/18/2025 at 1:54 P.M., the surveyor interviewed the Registered Nurse (RN #1), who stated that she was the nurse caring for Resident #3 and confirmed that that during the morning medication administration, she handed a cup containing the resident's morning medications to the resident and left the room without waiting for the resident to take the medications. RN #1 stated that the usual process was to watch the resident take their medications before leaving the room. RN #1 further stated that she was in a rush that morning and did not wait for Resident #3 to take their medications. RN #1 stated that the medications she left with Resident #3 were Gabapentin (medication to treat seizures) along with the resident's other morning medications. RN #1 further stated that it was important for safety to watch residents take their medication in order to prevent accidents and medication diversion. A review of the resident's Medication Administration Record (MAR) revealed that RN #1 prepared for administration to Resident #3 the following medications: Aspirin 81 milligram (MG) delayed release tablet Escitalopram Oxalate 10 MG tablet 9 Meloxicam 15 MG tablet Multivitamin-Minerals tablet Vitamin D3 125 microgram (MCG) tablet Buspirone HCl 10 MG tablet Gabapentin 800 MG tablet (used to treat seizure disorder) An interview was conducted with the UM on 07/18/2025 at 2:30 P.M. The UM stated that that the expectation was for the nurses to watch the residents take their medications to ensure the medication was taken and that it was tolerated well. The UM stated the if the resident was not observed taking their medication, they may not receive the prescribed treatment, or another resident could take the medication. The UM further stated that the administering nurse was responsible to watch the resident take their medications. An interview was conducted with the Director of Nursing (DON) on 07/18/2025 at 4:45 P.M. The DON stated the expectation was that nurses observed the residents take their medications. The DON stated that leaving pills at the bedside did not comply with the facility's policy or his expectations for medication administration. The DON further stated that watching residents take their medications was important to in order to ensure that the resident got their ordered medications and that another resident did not get them. A review of the undated facility policy titled, Medication Administration, revealed under Policy, Medications are administered by licensed nurses [.] as ordered by the physician and in accordance with professional standards of practice. Under Policy Explanation and Compliance Guidelines: the policy revealed, 18. Observe resident consumption of medication. NJAC 8:39-29.2(d)

Based on record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for fungal dermatitis (skin infection) and arterial ulcers for one of three residents (Resident (R) 2) reviewed for skin integrity out of a total sample of nine residents. This had the potential for fungal dermatitis and arterial ulcers to worsen and a potential for infection.Review of the facility's policy titled, Skin Integrity-Incontinence Associated Dermatitis (IAD) with a date implemented 02/14/23, revealed Residents who are incontinent will receive appropriate treatment and services for the prevention and management of IAD.e. For residents with fungal skin infection, apply antifungal products as ordered by the physician.Review of R2's admission Record located in the electronic medical record (EMR) under the admission Record tab revealed R2 was admitted to the facility on 05/25 with diagnoses including peripheral vascular disease (PVD) and gangrene. The resident was discharged from the facility in 07/25.Review of R2's Hospital Record located in the EMR under the Evaluation tab, dated 05/23/25, revealed the resident was being discharged to the facility with a wound infection, osteomyelitis (bone infection), gangrene due to atherosclerosis (buildup of substances in and on the artery walls) of extremity, gangrene of right foot, and sepsis likely due to multiple poor healing lower extremity wounds.Review of R2's Care Plan located in the EMR under the Care Plan tab with an initiated date 05/29/25, revealed the resident had multiple wounds related to PVD. The goal was for the resident to have intact skin free of redness, blisters, or discoloration. Intervention included complete treatments as ordered.Review of R2's Multi Wound Chart Details, dated 05/30/25 located in the EMR under the Evaluation tab and completed by the Nurse Practitioner/Certified Wound Specialist (NP/CWS), revealed R2's fungal dermatitis and arterial ulcers were assessed and treated with the Licensed Practical Nurse (LPN) 3/Unit Manager (UM) at the bedside. The resident's following arterial ulcers and fungal dermatitis with treatment orders included the following:1.Arterial ulcer of the right medial (inner edge of foot) extending to the great toe measuring 20.0 centimeters (cm) by 8.0 cm with no depth and 100 percent (%) necrotic (dead or dying tissue), with an order to paint the wound with betadine, apply abdominal dressing pad (ABD), and wrap with Kling (bandage) daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.2.Arterial ulcer of the right fourth toe measuring 5.0 cm by 4.0 cm with no depth and 100% necrotic with an order to paint the wound with betadine, apply ABD pad, and wrap with Kling daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.3. Arterial ulcer of the right lateral foot measuring 15.0 cm by 3.0 cm with no depth and 100% necrotic with an order to paint the wound with betadine, apply an ABD pad and wrap with Kling daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.4. Arterial ulcer of the right dorsal (back) ankle measuring 2.0 cm by 1.0 cm with no depth and 100% necrotic with an order to paint the wound with betadine, apply and ABD pad and wrap with Kling daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.5.Arterial ulcer of the right distal posterior lower leg measuring 7.0 cm by 9.0 cm by 0.2 cm in depth and between 25% and 50% necrotic with an order to apply honey gel with a dressing of calcium alginate and apply an ABD pad and wrap with Kling. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.6.Right groin fungal dermatitis with measurements of 15.0 cm by 11.0 cm with no depth with erythematous (redness) with an order to cleanse the area with soap and water with a primary dressing of zinc and antifungal, dry well after cleansing, apply 1:1 nystatin powder and zinc oxide, to be completed twice a day. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.8. Left groin fungal dermatitis with measurements of 15.0 cm by 11.0 cm with no depth with erythematous (redness) with an order to cleanse the area with soap and water with a primary dressing of zinc and antifungal, dry well after cleansing, apply 1:1 nystatin powder and zinc oxide, to be completed twice a day. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.9. Sacrum extending to bilateral buttocks fungal dermatitis with measurements of 30.0 cm by 20.0 cm with no depth with erythematous, macerated (red moist area) with an order to cleanse the area with soap and water with a primary dressing of zinc and antifungal, dry well after cleansing, apply 1:1 nystatin powder and zinc oxide, to be completed twice a day. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.Review of R2's Treatment Administration Record (TAR) for May 2025 located in the EMR under the Orders tab, revealed no evidence the treatments ordered by the NP/CWS for R2's three areas of fungal dermatitis were on the TAR to be completed on 05/31/25.Review of R2's TAR for June 2025 located in the EMR under the Orders tab, revealed only one combined entry for all of R2's arterial ulcers, the treatment for all of R2's arterial ulcers were to cleanse right lower extremity wounds with Dakin's solution, pat dry, and wrap with Kling. This was documented as completed from 06/01/25 through 06/23/25. However, the treatment documented as completed was not the specific orders that were ordered by the NP/CWS on 05/30/25 for the arterial ulcers. The TAR for June 2025 further revealed the specific orders received by the NP/CWS on 05/30/25 for R2's arterial ulcers were not started until 06/26/25. There was no evidence that any treatments were completed on the resident's arterial ulcers on 06/24/25 and 06/25/25.Further review of R2's TAR for June 2025 located in the EMR under the Orders tab, revealed the treatments to the residents three fungal dermatitis areas that were ordered on 05/30/25 to be completed twice a day were not started until 06/26/25 and were only completed once a day.Review of the weekly Multi Wound Chart Details, dated 06/06/25, 06/13/25, 06/20/25, and 06/27/25, located in the EMR under the Assessment tab, revealed the NP/CWS completed the treatments to R2's fungal dermatitis and arterial ulcers once a week, and completed assessments. The status of the resident's right and left groin remained unchanged. The status of the sacrum fungal dermatitis had improved. The status of the resident's right dorsal ankle arterial ulcer increased in size to 7.0 cm by 9.0 cm by 0.3 cm in depth.During an interview on 07/31/25 at 9:30 AM, the Director of Nursing (DON) confirmed the documentation of R2's arterial ulcers completed by the facility from 06/01/25 to 06/23/25 were not according to the specific orders received by the NP/CWS on 05/30/25. He confirmed there was no evidence treatments were completed on 06/24/25 and 06/25/25. The DON confirmed the only time R2's arterial ulcer treatments were completed per order was when the NP/CWS came to the facility once a week (06/06/25, 06/13/25, and 06/20/25) and completed them as well as assessed the arterial ulcers. He further confirmed there was no evidence that R2's fungal dermatitis treatment orders were completed by the facility until 06/26/25 and they were only completed once a day, however, were ordered to be completed twice a day.During a telephone interview on 07/31/25 at 10:15 AM the LPN3/UM of the unit R2 resided on, revealed she did not know why the treatments to R2's arterial ulcers, and fungal dermatitis were not completed as ordered by the NP/CWS.

Based on record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for pressure ulcers for one of three residents (Resident (R) 2) reviewed for pressure ulcers out of a total sample of nine residents. This had the potential for the pressure ulcers to worsen and a potential for infection. Review of the facility's policy titled, Pressure Injury Prevention and Management with a date implemented 02/14/23, revealed This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/ injuries.2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment.Review of R2's admission Record located in the electronic medical record (EMR) under the admission Record tab revealed R2 was admitted to the facility on 05/25 with diagnoses including peripheral vascular disease (PVD) and gangrene. The resident was discharged from the facility in 07/25.Review of R2's Hospital Record located in the EMR under the Evaluation tab, dated 05/23/25, revealed the resident was being discharged to the facility with a wound infection, osteomyelitis (bone infection), gangrene due to atherosclerosis (buildup of substances in and on the artery walls) of extremity, gangrene of right foot, and sepsis likely due to multiple poor healing lower extremity wounds.Review of R2's Care Plan located in the EMR under the Care Plan tab with an initiated date 05/29/25, revealed the resident had multiple wounds related to PVD. Intervention included complete treatments to the wounds as ordered.Review of R2's Multi Wound Chart Details, dated 05/30/25 located in the EMR under the Evaluation tab and completed by the Nurse Practitioner/Certified Wound Specialist (NP/CWS) revealed R2's wounds were assessed and treated with the Licensed Practical Nurse (LPN) 3/ Unit Manager (UM) at the bedside. The resident's following pressure ulcers with treatment orders included the following:1.Unstageable pressure ulcer of the right heel measuring 8.0 centimeters (cm) by 8.0 cm with no depth and 100% necrotic, with an order to paint the wound with betadine, apply an abdominal dressing (ABD) pad, and wrap with Kling daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.2. A stage IV pressure ulcer of the right medial posterior knee measuring 2.0 cm by 3.0 cm with a depth of 0.5-cm with the tendon exposed. The order revealed to apply honey gel with a dressing of calcium alginate and apply a bordered gauze daily. The treatment was completed by the NP/CWS, and subsequent treatments were to be completed by the staff of the facility.Review of R2's Treatment Administration Record (TAR) for June 2025 located in the EMR under the Orders tab, revealed only one combined entry for all of R2's wounds, the treatment for all of R2's wounds were to cleanse right lower extremity wounds with Dakin's solution, pat dry, and wrap with Kling. This was documented as completed from 06/01/25 through 06/23/25. However, the treatment documented as completed was not the specific orders that were ordered by the NP/CWS on 05/30/25. The TAR for June 2025 revealed the orders received by the NP/CWS on 05/30/25 were not started until 06/26/25. There was no evidence that any treatments were completed on the resident's pressure ulcers on 06/24/25 and 06/25/25.Review of the weekly Multi Wound Chart Details, dated 06/06/25, 06/13/25, 06/20/25, and 06/27/25, located in the EMR under the Assessment tab, revealed the NP/CWS completed the treatments once a week and assessed the residents pressure ulcers. The status of the above pressure ulcers remained unchanged.During an interview on 07/31/25 at 9:30 AM, the Director of Nursing (DON) confirmed the documentation of R2's pressure ulcers completed by the facility from 06/01/25 to 06/23/25 were not according to the orders received by the NP/CWS on 05/30/25. He confirmed there was no evidence treatments were completed at all on 06/24/25 and 06/25/25. The DON confirmed the only time R2's pressure ulcer treatments were completed per order was when the NP/CWS came to the facility once a week (06/06/25, 06/13/25, and 06/20/25) and completed them as well as assessed the pressure ulcers.During a telephone interview on 07/31/25 at 10:15 AM, the LPN3/UM of the unit R2 resided on revealed she did not know why the treatments to R2's pressure ulcers were not completed as ordered by the NP/CWS.

Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed 11/17/2024 through 11/30/2024. Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the week of 11/17/2024 through11/23/2024, revealed the facility had no RN coverage for all shifts on 11/18/2024 and 11/23/2024. During an interview with the surveyor on 12/06/2024 at 2:06 PM, the Director of Nursing (DON) expressed that staffing needs are met to some extent but not fully. When an RN is unavailable to work the required 8 consecutive hours, the DON steps in as a supervisor, rather than fulfilling the DON role. At that time, the Licensed Nursing Home Administrator confirmed that the DON can not be counted as the RN on duty. A review of a facility provided policy undated titled, [facility name] Staffing revealed that, To ensure there are a sufficient number of staff members (RN, Licensed Practical Nurse, Certified Nursing Assistant) with the appropriate competencies and skill sets necessary to care for its residents' needs requirements eight (8) hours per day for RN is required daily. NJAC 8:39-25.2(h)

Repeat deficiency from recertification survey of 09/23/2023 Based on observations, interviews, and review review of other facility documentation, it was determined that the facility failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 3 of 3 meals observed. This deficient practice was evidenced by the following: 1. On 12/03/2024 at 12:12 PM, the surveyor observed the lunch meal on the 2nd floor dining/activity room. The surveyor observed Resident #48 and seven (7) additional residents at the lunch meal. All eight (8) residents were observed to have received diced peaches in a clear plastic portion control cup for dessert at the lunch meal. According to the 12/3/2024 Week 4 cycle menu provided to the surveyor on entry to the facility, residents were to receive yellow cake for the dessert at the lunch meal on 12/03/2024. There was no yellow cake observed. When interviewed the Food Service Director (FSD) told the surveyor that they (kitchen staff) didn't make any. In addition, the lunch menu also included that a dinner roll was to be served. Observation of the 8 residents at the lunch meal revealed that 8 of 8 residents did not receive a dinner roll at the lunch meal. When interviewed the FSD told the surveyor on interview that the facility had run out the previous Friday (11/29/2024) and that they only received a delivery once a week. 2. On 12/04/2024 at 12:07 PM, the surveyor observed the lunch meal on the 2nd Floor dining room. The surveyor observed Resident #84 at the lunch meal being assisted by a staff nurse. Resident #84 received the following menu items: Salisbury steak with gravy, white rice, and mixed vegetables that contained peas, carrots, corn, and green beans (same vegetable that was served on 12/3/2024 at the lunch meal). There was no scalloped corn and there were no dinner rolls served. In addition, the menu revealed that residents were to receive a baked apple as dessert. There were no baked apples. On 12/04/2024 at 12:15 PM, the surveyor went to the kitchen and interviewed the FSD and cook. The surveyor asked the cook why residents had no received scalloped corn at the lunch meal as listed on the menu. The cook told the surveyor that they only had a few cans of corn, so she mixed it with the other vegetables, so we had enough. According to the FSD he did not contact the Registered Dietitian/Nutritionist (RDN) to obtain an approval of menu substitution prior to the lunch meal that day. The FSD told the surveyor that there were no dinner rolls in the facility and told the surveyor that they did not make yellow cake yesterday and substituted diced peaches. When asked if the FSD contacted the RDN for approval of menu substitutions prior to the meal the FSD stated he did not contact the RDN for approval prior to the lunch meal and that he had not contacted her at the time of interview. The surveyor asked the FSD if the facility process was to contact the RDN prior to making menu substitutions. The FSD agreed that he should contact the RDN for menu substitutions and document the substitutions in the meal substitution log. 3. On 12/05/2024 at 11:47 AM, during observation of tray line temperatures in the presence of the FSD, the surveyor observed that the vegetable to be served at the lunch meal on 12/5/2024 was a mixed vegetable that consisted of peas, carrots, corn, and green beans. This was the same vegetable that was observed to be served at the lunch meal on 12/3 and 12/4/2024 lunch meals. The surveyor asked the FSD if he realized that they had served the same vegetable at the lunch meal 3 days in a row. The FSD stated, Well, the menu said mixed vegetable. The FSD responded by saying that he would change the menu. A review of the Week 4 menu provided to the surveyor upon the initial tour revealed that the following vegetable was to be served at lunch meals: On 12/3/2024 the vegetable to be served according to the Week 4 menu was seasoned green peas. Residents received a mixed vegetable as described previously. On 12/4/2024 the Week 4 lunch menu revealed that residents were to receive scalloped corn at the lunch meal. Residents received the same mixed vegetable that they had received at lunch on 12/3/2024. On 12/5/2024 according to the week 4 lunch menu, residents were to receive vegetable blend. The FSD stated to the surveyor that the vegetable served was a mixed vegetable and agreed that the kitchen had served the same mixed vegetable at lunch for 3 days consecutively. On 12/05/2024 at 12:09 PM, the surveyor interviewed the facility Registered Dietitian/Nutritionist (RDN). The surveyor asked the RDN if she had been contacted by the FSD for any menu substitutions. The RDN told the surveyor that yesterday was supposed to be corn. The surveyor corrected the RDN and told her it was supposed to be scalloped corn. The RDN further stated she called yesterday (the FSD), right around 12:30 PM and she asked the FSD if there were any substitutions and he said that he made a substitution for the corn. I called earlier in the week, and I was told that there were no substitutions for the week. I was not contacted for a substitution for the yellow cake on Tuesday 12/3/2024. The surveyor asked if the FSD contacted her before or after the lunch meal to get approval for the corn substitution. The RDN told the surveyor that it was after the lunch meal. 4. On 12/06/2024 at 12:06 PM, the surveyor observed the meal delivery cart outside the 2nd floor dining room prior to the lunch meal. The surveyor observed diced fruit in a clear plastic portion control cup on resident trays. The dessert to be served according to the week 4 menu on 12/0/2024 was sherbet. On 12/06/2024 at 12:40 PM, the surveyor interviewed the facility FSD. The surveyor asked the FSD if he had completed a menu substitution for the lunch meal because the residents received diced, canned fruit as dessert and not sherbet as the menu had indicated. The FSD stated, I'm going to do it right now. The surveyor asked the FSD when the substitution should have been completed and approved. The FSD stated that it should have been done prior to the lunch meal. The surveyor asked the FSD if he had sherbet and the FSD stated, No. The facility was unable to provide the surveyor with a facility policy and procedure for menu substitutions. NJAC 8:39-17.2(b)

Based on observation, interview, and review of there facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/02/2024 at 9:23 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On the top shelf of a multi-tiered rack in the dry storage area, a previously opened pack of coffee filters were removed from their original packaging and left uncovered. The usable surface was exposed to contamination. 2. On a middle shelf of the walk-in freezer contained frozen pizza box previously opened. The lids to the box were open and the plastic bag inside that contained the pizza was opened and the pizza was exposed to the air and contamination. 3. The surveyor observed the kitchen staff operating the high temperature dish machine after the breakfast meal. The staff were actively washing dishes during this observation. The surveyor asked the FSD what the facility process was for operation of the dish machine. The FSD told the surveyor, First we check to assure proper temperatures (wash and final rinse) and record those temperatures on the temperature log prior to initiating dish washing. The surveyor then asked the FSD to provide the surveyor with the December 2024 dish machine temperature log. A review of the December dish machine temperature log revealed that no temperatures had been recorded for the month of December 2024 for the breakfast, lunch, and dinner meals for the dates 12/01/2024 up to and including breakfast on 12/02/2024. On interview the FSD agreed that dish machine temperatures must be at the required minimum temperatures and recorded on the temperature log prior to initiating dish washing. The surveyor attempted to interview the kitchen staff that was observed operating the dish machine, however the staff failed to provide the surveyor with an explanation when asked why the temperatures for the wash and final rinse had not been recorded. 4. A stack of three (3) quarter pans on a middle shelf of the pot and pan storage rack were observed to have a wet liquid substance on the interior and exterior of the pans when the surveyor lifted the top pan on the stack. On the same shelf next to the three quarter pans, a stack of four (4) half pans were observed to have a wet, clear liquid substance on the interior and exterior of the pans when the surveyor picked up the top half pan. On an adjacent rack on the middle shelf, the surveyor observed a sheet pan that was not inverted and was facing in the upward position. The pan was observed to have a clear liquid substance on the food contact surface. On interview, the FSD agreed that all pans should be air dried prior to stacking on top each other. The FSD further stated, That's wet nesting (occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating a condition that is ripe for microorganisms to grow). 5. An industrial can opener was attached to the end of the prep table in the center of the kitchen. The can opener was not currently in use, according to the FSD. When removed out of its receptacle the surveyor observed a brown/black sticky substance on the cutting blade and on the stem of the can opener. The FSD removed the can opener to the dish room to be cleaned and sanitized in the presence of the surveyor. The FSD told the surveyor that he did not have the can opener on the cleaning schedule and stated, I screwed up. On 12/03/2024 at 01:09 PM, the surveyor observed the first floor resident/dietary nourishment room. The surveyor reviewed the November 2024 and December 2024 Nourishment Room Refrigerator Temperature Log for the first floor nourishment room.A review of the temperature logs revealed that refrigerator temperatures had not been recorded from 11/27/2024 up to and including 12/3/2024. The temperature log also revealed that the facility was only monitoring temperatures for the refrigerator and no monitoring of the freezer temperatures was being conducted. observation of the interior of the freezer revealed that there was no internal thermometer present. The surveyor interviewed Licensed Practical Nurse (LPN #2) who told the surveyor that the 11-7 shift was responsible for the recording of refrigeration temperatures on the first floor unit pantry. On 12/05/2024 at 09:35 AM, the surveyor observed the 2nd floor nourishment room/resident pantry, accompanied by the staffing coordinator (SC). On an upper shelf, a clear plastic portion control cup contained what appeared to be apple sauce and a second portion control cup contained what appeared to be diced fruit. The portion control cups had no dates. The SC indicated that it was sent from the kitchen. When interviewed the SC agreed that all foods require dates. On interview with the facility FSD the surveyor was told that staff on the unit must have removed the portion control cups of applesauce and diced fruit from resident trays and placed them in the nourishment refrigerator because all foods that come from the kitchen are dated using a labeling gun. On 12/05/2024 at 11:24 AM, the surveyor, accompanied by the FSD, observed the following in the kitchen: 1. The surveyor told the FSD upon entry to the kitchen that they needed to observe tray line food temperatures for the lunch meal. The FSD told the surveyor that he would be conducting the food temperatures and proceeded to obtain a red digital thermometer and a brown paper hand towel from the hand towel dispenser wall mounted in the designated hand washing area. The FSD then approached the steam table where the lunch meal was waiting to be served from their respective pans. The FSD set the brown paper hand towel on the steam table ledge, proceeded to turn on the digital thermometer and inserted the thermometer into the first food item which was described as baked chicken. The FSD obtained a temperature of 160 F (Fahrenheit). The FSD then removed the digital thermometer from the baked chicken and proceeded to grab the brown paper hand towel. At this point the surveyor told the FSD that they needed to obtain an alcohol wipe to disinfect the probe before taking the temperature of the next food item. The FSD responded, I don't have any and proceeded to wipe the probe of the thermometer in then insert the thermometer into the next food item which was fried rice. After obtaining a temperature of 160.3 F, the FSD removed the thermometer from the rice and proceeded to wipe the probe with the brown paper hand towel previously used to clean the thermometer after the chicken. The FSD repeated this pattern for six additional food items. The digital thermometer probe was never cleaned with an approved sanitizer between foods, presenting a risk of contamination. The surveyor then conducted an interview with the facility Registered Dietitian/Nutritionist (RDN). The surveyor explained the process that the FSD utilized to sanitize the digital thermometer during the observation of lunch tray line temperatures. The RDN told the surveyor, I agree that the thermometer probe should have been cleaned with an appropriate sanitizer between foods. Using a paper towel is unacceptable. The surveyor reviewed the facility policy titled Record of Food Temperatures, undated, revealed under the heading Policy Explanation and Compliance Guidelines: Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy. The surveyor reviewed the facility policy titled Use and Storage of Food Brought in by Family and Visitors, undated, revealed under Policy Explanation and Compliance Guidelines: 2. All food items brought in that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The surveyor reviewed the facility policy titled Dishwasher Temperature, undated, revealed under Policy Explanation and Compliance Guidelines: Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. The facility failed to provide the surveyor a policy/procedure related to wet nesting. NJAC 18:39-17.2(g)

C/O: # NJ 710 Based on observation, interviews, and review of medical records and pertinent facility documentation, it was determined that facility staff failed to follow their own policy on Abuse. The facility failed to protect a resident from potential abuse for a period of 48 hours by allowing Resident #1 to continue to have access to Resident #2. In addition, there were nurses and Certified Nursing Assistants (CNA) who witnessed these incidents of abuse and failed to intercede or report the incidents of abuse. This deficient practice was identified for 1 of 4 sampled residents (Resident #2) for an incident of abuse that occurred on 11/13/16. Resident #2 was so fearful of being hurt by Resident #1, he/she called the police for protection. The Immediate Jeopardy which began on 11/13/16 was identified by the surveyor on 11/15/16 at 2:10 p.m. and reported to the Administrator, Executive Director and Director of Nursing at 2:15 p.m. on 11/15/16. The Immediate Jeopardy was lifted on 11/15/16 at 5:20 p.m. based on the implementation of an acceptable plan of correction submitted by the facility staff. This deficient practice was evidence by the following: A review of the medical record revealed that Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident #2's Minimum Data Set (MDS), an assessment tool dated 10/20/16 revealed that Resident #2 had a Brief Interview Mental Status (BIMS) score 15/15 which indicated that the resident had no cognitive deficits. The MDS identified that Resident #2 required extensive assistance from one staff member for bed mobility and transferring from the bed and into a chair. Resident #2 was also identified as having right sided limited range of motion. A review of the medical record revealed that Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review Resident #1's MDS dated [DATE] revealed that Resident #1 had scored a 15/15 on the BIMS assessment. This score indicated that Resident #1 did not have any cognitive deficits. The MDS identified that Resident #1 was independent in all areas of activities of daily living including ambulation. During an interview conducted by the surveyor on 11/15/16 at 9:50 a.m., Resident #1 stated that he/she was involved in a consensual relationship with CNA #1 that began May 2016 and ended in 10/2016. Resident #1 stated that he/she ended the relationship because CNA #1 was now involved with Resident #2. Resident #1 stated that he/she had an argument with Resident #2 about his/her involvement with CNA #1. Resident #1 told the surveyor that he/she could not recall the date the argument occurred. Resident #1 stated that he/she had reported the relationship between him/her and CNA #1 to the facility's Administrator, Executive Director (ED), Unit Manager (UM) and the Director of Nursing (DON.) Resident #1 stated that all of them knew about the relationship between him/her and CNA #1 because he/she had shown them text messages. Resident #1 stated that he saved over 200 text messages as proof of his/her relationship with CNA #1. Resident #1 stated that CNA #1 was now having a relationship with Resident #2 and this made him/her angry. Resident #1 stated that everyone knew about the verbal arguments between them and the resident denied having any physical contact with Resident #2. Resident #1 showed the surveyor the text messages that were exchanged between Resident #1 and CNA #1. The surveyor observed that the most recent text message was dated 10/12/16. When interviewed further, Resident #1 stated that CNA #1 had given him/her their phone number and CNA #1 has changed her cell phone number. A review of a Nurses Note (NN) dated 10/10/16 at 9:00 a.m. revealed that a nurse had informed Resident #1's physician about the residents heightened behaviors. The NN revealed that Resident #1 was yelling out at staff. This same NN revealed that the doctor had recommended for Resident #1 to be seen by the facility's Psychiatrist. According to the documentation in the NN, Resident #1 stated I don't need a psychiatrist and there was no further documentation regarding Resident #1's behaviors in the medical record. During an interview on 11/15/16 at 10:20 a.m., the UM stated Resident #1 had been verbally assaulting staff and had verbal altercations with other residents. The UM stated that she reported Resident #1's behaviors of yelling and cursing at staff and residents to the doctor and the resident's behavior was discussed during the care plan meetings. When interviewed further, the UM stated that she could not give an answer as to why there was only one NN that reflected the resident behavior on the record and why was there no other documentation of Resident #1's behaviors in the medical record. A review of Resident #1's care plan in the presence of the UM revealed there was no care plan developed that addressed the resident's behaviors. The UM stated that she and the nurses were responsible for up-dating the resident's care plans. The UM stated that she could not provide any answers as to why there was no care plan with interventions that addressed the resident's identified behaviors. The UM stated that she reported Resident #1's behavior and incidents involving staff and other residents to the DON. The UM stated that she did not complete an incident report following any of these incidents and confirmed that she had only reported them to the DON. During an interview conducted by the surveyor on 11/15/16 at 10:30 a.m., in the presence of the Administrator, the ED and the DON. The ED stated that CNA #1 had called her at home a few weeks ago and reported that Resident #1 had been harassing her. The ED stated that she made the decision and told the supervisor that was on duty to move CNA #1 from the second floor nursing unit where she normally worked to the first floor nursing unit. The ED stated that she knew Resident #1 had been following CNA #1 around the unit harassing her and making sexual comments towards CNA #1. The ED stated that she believed that by moving CNA #1 to the first floor nursing unit that this would have resolved the issue, but it did not. The ED stated that Resident #1 had began coming down to the first floor unit were CNA #1 was now working and following CNA #1 around and making rude comments to her. The ED stated that she did not believe Resident #1 when he/she had told her that he/she had been in a relationship with CNA #1. The ED stated that she did not do an investigation nor did she complete an incident report after receiving the information from Resident #1. The ED stated that they have tried to move Resident #1 from the unit but he/she refused to move and that they were preparing to discharge Resident #1 soon but were waiting for a proper placement. The ED stated they have tried to schedule Resident #1 for a psychiatric evaluation but the resident had refused to be seen by the Psychiatrist. The ED stated that she was aware that Resident #2 had called the police to file report against Resident #1 on 11/13/16. The ED stated that she did not interview Resident #2 nor did the supervisor on duty when the incident occurred. The ED stated that they did not investigate either incident or complete an incident report. The DON stated that an incident occurred on 11/13/16 between Resident #1 and Resident #2 over the weekend and administration staff was not at the facility. The DON stated that she was informed about the incident during morning meeting on 11/14/16. The DON stated that the supervisor on duty and the nurses were responsible for initiating the investigation and that she was responsible for completing the investigation. The DON confirmed that no investigation was done and she did not offer any explanation as to why an investigation was not done. The DON added she had in-serviced CNA #1 on 10/14/16 when it was discovered that CNA #1 gave her phone number to Resident #1. The DON added that the entire nursing department was in-serviced with regards to the facility's policy that prohibited staff from exchanging phone numbers with residents. When interviewed further, the DON stated that she did not know why the nurses did not document Resident #1's behaviors in the NN or on the care plan. The DON verified that Resident #1's care plan did not address the resident's behaviors. During an interview conducted on 11/15/16 at 10:53 a.m., CNA #2 stated that she had been working at the facility for 1 year. CNA #2 stated that she normally works the 3 p.m.-11 p.m. shift on the second floor with CNA #1. CNA #2 stated that she had heard the rumors that CNA #1 was having a relationship with Resident #1. CNA #2 stated that she had witnessed Resident #1 following CNA #1 and calling CNA #1 derogatory names. CNA #2 stated that she suggested that CNA #1 transfer to another unit because of Resident #1's behavior. CNA #2 stated that Resident #1 had shown her an exchange of text messages between him/her and CNA #1. CNA #2 stated that she believed that there was a facility policy that prohibited staff from exchanging their personal phone numbers with residents. During an interview conducted on 11/15/16 at 11:17 a.m., CNA #3 stated that she also heard that CNA #1 was in a relationship with Resident #1. CNA #3 stated that Resident #1 became angry when CNA #1 was feeding or caring for other residents. CNA #3 stated that Resident #1 would look for CNA #1 in other resident's room on the unit or would call CNA #1 derogatory names in the front of staff and other residents if she did not respond to him/her quickly. CNA #3 stated that Resident #1 would walk down the hallway to Resident #2's room and make mean and/or threatening comments to Resident #2. CNA #3 stated that she did not report the incidents that she witnessed because it was known to everyone about the prior incidents between Resident #1 and Resident #2. CNA #3 stated that Resident #1 did not like Resident #2 because he/she thought Resident #2 was having a relationship with CNA #1. CNA #3 stated that Resident #1 would become angry even when CNA #1 gave Resident #2 a shower or helped him/her in any way. During an interview conducted by the surveyor on 11/15/16 at 12:05 p.m., Resident #2 stated that he/she was having problems with Resident #1. Resident #2 stated that Resident #1 had accused him/her of having an affair with CNA #1. Resident #2 stated that Resident #1 had confronted him/her in the presence of staff and other residents on the elevator one day and told him/her that CNA #1 was his/her girl friend. Resident #2 stated that he/she responded to Resident #1 by saying that there nothing was going on between him/her and CNA #1. Resident #2 stated that after the conversation ended Resident #1 started yelling and screaming that he/she was in relationship with CNA #1 and warned him/her to leave CNA #1 alone. Resident #2 stated Resident #1 even pulled out his/her cell phone and began showing him/her and others on the elevator the text messages that were exchanged between Resident #1 and CNA #1. Resident #2 stated that he/she felt that Resident #1 was showing him/her the text messages to prove that they were in a relationship. Resident #2 stated that he/she told Resident #1 to leave him/her alone and that whatever was going on between them was none of his/her business and it was said in front of staff. Resident #2 stated, Resident #1 started calling him/her names, pointing his/her finger in his/her face and staff did not intervene. Resident #2 stated after that incident on 11/13/16 Resident #1 began making more threatening comments like I'm going to F . you up to him/her. Resident #2 stated that he/she reported this incident to the UM and to administrative staff and nothing was done. When asked, why did he/she believe that nothing was done about his/her complaints, Resident #2 stated because Resident #1 had continued to harass and threaten him/her to this date. Resident #2 told the surveyor that he/she enjoyed going outside to sit underneath the gazebo and read his/her books alone. Resident #2 stated, Resident #1 began following him/her outside to the gazebo and making threatening comments and gestures towards him/her. Resident #2 stated he/she was afraid Resident #2 was going to do something to him/her or hurt him/her in some kind of way. Resident #2 stated that he/she feared that Resident #1 could hurt him/her because he/she could not walk and was stuck in a wheelchair. Resident #2 stated, Resident #1 was able to walk and because of this he/she could not fight off Resident #1 if there was ever a physical altercation between them. Resident #2 stated that he/she reported this incident to the Administrator, ED, DON, supervisors and the UM, and nothing was done. Resident #2 stated that all of this was happening because; Resident #1 believed that he/she was trying steal his/her girlfriend. Resident #2 stated that he/she was so afraid of Resident #1 that on 11/13/16 he/she had called 911 to file a police report against Resident #1 hoping to prevent something serious from happening to him/her. Resident #2 stated that when the police had arrived to the facility they spoke him/her about the incidents that had occurred and the police had instructed him/her to come into the police station and file a formal report. Resident #2 stated that one of his/her family members was coming to pick him/her up and take him/her to the police station to file the report. Resident #2 stated after incident occurred, the supervisor questioned him/her as to why he/she had called the police. Resident #2 stated that he/she had told the supervisor that he/she had been complaining to staff for months about Resident #1's behavior towards him/her and that staff had done nothing to help him/her. Resident #2 stated that the supervisor just walked away. Resident #2 stated that the facility staff has never asked for him/her to provide a verbal or written statement about the incident on 11/13/16 or any of the previously reported incidents. During a follow-up interview on 11/15/16 at 12:20 p.m., Resident #1 confirmed that Resident #2 had called the police to file a complaint against him/her on 11/13/16. Resident #1 refused to answer any more of the surveyor's questions and abruptly left the conference room. During an interview conducted by the surveyor on 11/15/15 at 12:25 p.m., the supervisor on duty on 11/13/16 stated that Resident #2 had complained to her that Resident #1 was threatening him/her. The nursing supervisor stated that she was new to the position of being the supervisor on the weekends. The supervisor stated that she had spoken to Resident #1 and the resident had told her that (he/she) knew how to take care of Resident #2. The supervisor stated that she took Resident #1's statement as being threatening to Resident #2. The supervisor stated that she did not inform administration until 11/14/15 during morning meeting. The supervisor stated that she did not separate the residents and did not call either resident's doctor. When interviewed on 11/15/16 at 1:00 p.m., the Administrator, the ED and DON verified that they all knew about Resident #1's behaviors. They all stated that they knew that Resident #1 was following CNA #1 around the facility and calling CNA #1 derogatory names in the presence of staff and other residents. They all stated that they were aware that CNA #1 had given her personal cell phone number to Resident #1. They all stated that they were made aware by CNA #1 that she was exchanging text messages with Resident #1 during work and off hours. The Administrator, the ED and the DON stated after the incident that occurred on 11/13/16 between Resident #1 and Resident #2, both residents remained on the same nursing unit and no precautions were implemented on the behalf of Resident #2. The Administrator and ED both stated that the residents should have been separated and believed that the supervisor's decision to leave both residents on the same unit was because she did not think there was any danger with leaving them both on the same unit. During an interview conducted by the surveyor on 11/15/16 at 2:45 p.m., CNA #1 stated that she has worked at the facility for a year. CNA #1 denied having a physical relationship with Resident #1 and Resident #2. CNA #1 stated that she gave Resident #1 her cell phone number and they only exchanged text messages and never spoke on the phone directly. CNA #1 stated Resident #1 would text her and ask for her to bring him/her in clothes and cigarettes to work. CNA #1 stated when she broke things off with Resident #1 and stopped responding to his/her texts, Resident #1's behaviors escalated. CNA #1 stated that she never reported Resident #1's behaviors of following her around the unit or the derogatory comments to administration until things became out of control. CNA #1 stated that she thought that she could handle the situation and believed that if she ignored Resident #1 that the harassment would stop. CNA #1 stated that she also witnessed Resident #1 harassing and threatening Resident #2 inside and outside the facility. When interviewed further, CNA #1 stated that she did not report Resident #1 harassing and threatening behavior towards Resident #2 to administration. CNA #1 added that she was ashamed and felt embarrassed about the entire situation. CNA #1 stated that she finally reported Resident #1 to the ED and was moved to the first floor nursing unit over the weekend. CNA #1 stated that Resident #1 still came to the first floor and harassed her on the first floor nursing unit. A review of the facility's Abuse Prevention and Reporting Policy dated January 15, 2000 revealed that the facility does not condone resident abuse by anyone including staff member, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. According to this policy verbal abuse is defined as any use of oral written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance to describe a resident regardless of their age, ability to comprehend or disability .Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. A review of the section titled Resident-to-Resident Abuse revealed that all forms of abuse, including resident-to-resident abuse must to reported immediately to the Nursing Supervisor, the Director of Nurses and to the Administrator. 1. Facility staff will monitor resident for aggressive/inappropriate behavior towards other residents, family members, visitors or to the staff. Occurrences of such incident must be promptly reported to the Nursing Supervisor, Director of Nurses and to the Administrator. 2. Should a resident be observed/accused of abusing another resident, the facility will implement the following actions: a. Remove the aggressor from the situation if the aggressor is still in the area in which the incident occurred. b. If necessary, temporarily separate the resident from other residents, as a therapeutic intervention, to help lower the agitation until the interdisciplinary care planning team can develop a plan of care to meet the needs of the resident. c. Counsel the resident to determine the cause of the behavior. d. Notify each resident's representative (sponsor), attending physician and medical director of the incident. e. Evaluate the circumstances/events leading up to the incident. f. Develop a care plan that includes interventions to prevent the recurrence of such incidents. g. Inform all staff involved in the care of the resident of the care plan and to promptly report behavioral changes to the charge nurse. h. Document in the resident's clinical record all interventions and their effectiveness. The IJ which began on 11/13/16 was lifted on 11/15/16 at 5:20 p.m. when an acceptable plan of correction was implemented. 1. CNA #1 was suspended until an investigation has been completed. Both Resident #1 and Resident #2 were assessed by the DON and counseling and emotional support were provided. Both residents are currently being seen by the Psychology group and placed on Psychology list for continual emotional support/council. Resident #1 is currently on 30 minute checks to ensure safety of all residents. 2. All residents have the potential to be affected by this deficient practice. 3. All staff are currently being in-serviced and this practice will continue quarterly on abuse and proper reporting of abuse. In servicing includes appropriate use of cell phones and texting residents, and inappropriate communication. Education on proper documentation and reporting of incidents regarding resident to resident altercations, what to alert for and immediately inform the supervisor, DON, and the Administrators. Supervisors are being in-serviced by the Administrator to ensure immediate follow-up. 4. The Administrator/designee will review the in-services don. Monthly and Quarterly audits on all residents incident reports will be done. all findings will be submitted to the Quality Assurance committee. NJAC 8:39-27.1(a)