Every finding on record at Masonic Village at Burlington

Complaint #405694Based on interviews, review of medical records, and review of other pertinent facility documents on 1/22/26 and 1/28/2026, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) of an injury of unknown origin, specifically an alleged unwitnessed fall resulting in a hip fracture, as required.This deficient practice was identified for 1 of 4 residents reviewed (Resident #2), as evidenced by the following:According to the admission Record (AR), Resident #2 was admitted with diagnoses that included, but were not limited to, Nontraumatic chronic subdural hematoma.According to the Minimum Data Set (MDS), an assessment tool dated 12/6/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment.A review of the Progress Notes (PN) dated 12/11/2025 11:00 P.M., revealed that on 12/11/25 at approximately 2:30 P.M., Resident #2 was found on the floor. The incident was unwitnessed. Further review revealed that on 12/11/25 at approximately 9:30 P.M., Resident #2 was sent to the hospital for further evaluation.A review of the PN dated 12/12/25 at 2:23 A.M., revealed Resident #2 was admitted to the hospital with a left hip fracture. A review of a facility document titled Full QA [quality assurance] Report with a date of 12/11/25 at 2:30P.M. revealed the fall was unwitnessed.During a telephone interview with the RN #2, on 1/28/26 at 10:40 A.M., RN #2 stated the resident #2 was experiencing leg pain, which prompted the physician to order pain medication and an x-ray.Review of facility documentation revealed that an internal incident report was completed; however, there was no evidence that the facility reported the injury of unknown origin to the NJDOH, as required.During an interview on 1/28/2026 at 11:42 A.M., the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), stated the facility did not report the incident because it was a fall and was not abuse and therefore did not require reporting to the NJDOH. The LNHA stated that the fall wasn't suspicious in nature and did not need to be reported to the NJDOH.A review of the facility's policy titled Abuse and Neglect with a reviewed date of 3/25/2025, revealed under REPORTING AND RESPONSE 'ABUSE' POLICY REQUIREMENTS: The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation.are reported immediately, but not later than 2 hours after the allegation is made.NJAC 8:39-4.1(a)8

Complaint # 405694Based on interviews, review of medical records, and review of other pertinent facility documents on 1/22/26 and 1/28/2026, it was determined that the facility failed to honor and communicate a cognitively intact resident's expressed preference regarding personal care providers, resulting in the resident receiving care inconsistent with their stated preferences. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1), as evidenced by the following:According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: left shoulder fracture.According to the Minimum Data Set (MDS), an assessment tool dated 5/7/2025, revealed that resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. A review of the document titled Verbal Coaching/Education dated 5/23/25 addresses Registered Nurse (RN)#1 and revealed REASON FOR Coaching/Education: Team member was notified by resident [Resident #1] that [they] would not like any male caregivers on 5/18/25. Nurse informed [Resident #1] she would ensure [Resident #1] did not receive any male caregivers.Review of Resident #1's medical record revealed no documentation of Resident #1's preferences and the preference was not reflected in the care plan on 5/18/25 or relayed in shift-to-shift communication. As a result, on 5/19/25, a male Certified Nursing Assistant (CNA)#1 provided care to Resident #1. During an interview on 1/28/2026 at 11:43 A.M., with the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), the LNHA states we were unaware of the preference request until the investigation occurred.the nurse did not follow [Resident #1's] preferences at the time she was notified. The LNHA confirmed that the failure to communicate the resident's preference occurred at the nursing level and acknowledged that the facility's policy states residents are allowed to choose providers of healthcare services consistent with their interests, values and personal care needs. A review of the facility's policy dated August 2022, titled Resident Self Determination and Participation reveals under Policy Interpretation and Implementation 1. Each resident is allowed to choose .healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: b. personal care needs. d. providers of healthcare services.

Complaint #: NJ 174085 Refer to F 610 Based on observation, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to protect a cognitively impaired resident from physical abuse and ensure all other residents were protected from potential abuse. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #51). A review of an abuse investigation revealed on 5/23/24 at 9:45 PM, on the Dementia Unit, a Licensed Practical Nurse (LPN #1) was informed by a Certified Nurse Aide (CNA #1) that a cognitively impaired resident (Resident #51) had a 7 centimeter (cm) left forearm skin tear that required several steri-strips (wound bandage) from the resident (Resident #51) scratching themself and had a 3 cm by 4 cm right posterior hand discoloration. Observation of video footage from the time of the incident revealed that on 5/23/24, CNA #1 was observed forcibly restraining Resident #51 in their wheelchair to prevent the resident from standing and blocked the resident's wheelchair from moving with a chair and the CNA's body. The video footage identified a second resident, Resident #36, witnessed the incident and self-propelled themself away from the situation. Interview on 3/24/25, with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) revealed that the incident was not initially investigated as abuse until the former LNHA reviewed the video footage two days later (5/25/24) and identified that CNA #1 abused Resident #51. The administration confirmed that CNA #1 finished working their shift on 5/23/24, and had access to all the residents on the locked unit. Resident #36 was not assessed after the incident to rule out psychosocial harm. The facility's failure to ensure all residents were free from abuse by not investigating the injuries of unknown origin or assessing Resident #36 who was present at the incident, posed a likelihood of serious harm including psychosocial to Resident #36 and Resident #51. The facility's failure to immediately remove CNA #1 from resident care to protect all fourteen residents who resided on the Dementia Unit posed the further risk of abuse for all residents with likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ situation began on 5/23/24 at 9:33 PM, when CNA #1 was observed holding Resident #51 down. The facility's Administration were notified of the IJ on 3/25/25 at 2:54 PM. An acceptable Removal Plan (RP) was received on 3/27/25 at 2:22 PM. The RP was verified on-site by the survey team on 3/28/25 at 9:20 AM, during the continuation of the survey. The evidence was as follows: A review of the facility's policy in effect the date of the incident, Abuse and Neglect, dated 5/4/23, included Policy: the [facility] will not permit residents to be subjected to any form of abuse/neglect .Abuse definition is the willful infliction of injury .intimidation, .mental anguish. Injuries of unknown source - classified .when both of the following conditions are met a.) source of the injury was not observed or the source could not be explained by the resident. AND b.) the injury is suspicious because of the extent, location, .Identification/Investigation/Protection: 1. The [facility] will identify all types of events including .bruising of residents .that may constitute abuse. 2 .appropriate action will be taken to safeguard the resident from harm while the incident is fully investigated. Actions to include .team member placed on fact finding leave pending investigation. Social Worker referral. Psychology consultation as appropriate. Response: all reported occurrences will be fully investigated .to determine what actions are necessary and what changes are needed to policies and procedures to prevent further occurrences. Abuse Training: to ensure proper training of new and existing team members on abuse/neglect prevention, identification and protection of residents. 6. Characteristics of the resident population at risk for abuse .cognitively impaired, psychological medical problems, communication disorders, those who require extensive nursing care. 7. Training on identifying suspicious bruising . A review of the facility's policy Incident Reporting-Injuries of Unknown Origin/Source dated revised 5/16/16, included Procedure: B. all injuries of unknown origin/source shall be investigated by the nurse on duty and/or Supervisor .E. the nurse will ask the resident how the injury occurred and document their answer. F. the nurse shall obtain statements from everyone on the shift .also from team members for 24 hours prior to the discovery of the injury. G. The nurse shall contact the Supervisor and notify them. On 3/23/25 at 2:30 PM, the surveyor reviewed the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) by the former Licensed Nursing Home Administrator (LNHA) on 5/25/24, for Date/Time of Event: 5/23/24 at 9:35 PM. The location of the incident was the memory care Bistro and the type of incident was staff-to-resident abuse. The Description of the Event included: CNA #1 stated she asked Resident #51 to remain seated and she observed [Resident #51] scratch their own arm causing a skin tear. As this is unusual behavior for the resident we requested camera footage of the Bistro for that time period. The video was obtained today (5/25/24) and viewed by the LNHA (former). The video showed [CNA #1] physically restraining [Resident #51] from behind with her hands pushing down on [Resident #51's] shoulders causing [Resident #51] to become increasing[[NAME]] agitated. [Resident #51] was attempting to get free from [CNA #1] and struggling against [CNA #1]. [CNA #1] grabbed [Resident #51's] arm and hand. This is likely the cause of the skin tear and bruising. [Resident #51] showed [CNA #1] the left arm skin tear and [CNA #1] stopped holding [Resident #51's] arm and pushed the resident out of the bistro to the nurse. Others notified: [name redacted] Police Department after video review. A review of the Incident Investigation submitted with the FRE included: Staff to Resident Abuse Date: 5/23/24, and signed by the former LNHA and Director of Nursing (DON) on 5/29/24. A statement summary from LPN #1 revealed .[CNA #1] told her that she asked [Resident #51] to remain seated and then observed [Resident #51] scratch their own arm causing a skin tear. Investigational Findings: .[Resident #51] can communicate needs but had significant cognitive impairment and had poor safety awareness. At approximately 9:40 PM on 5/23/24, [CNA #1] reported to LPN #1 that [Resident #51's] arm was bleeding and stated that she observed [Resident #51] scratch their own arm. Upon review of the camera footage in the Bistro, the resident attempted to rise from their wheelchair and [CNA #1] grabbed [Resident #51's] arm above the left elbow and hand, and appeared to be talking to resident to sit down (no audio). A few minutes later, the resident again tried to stand. CNA #1 had the resident sit down and moved [Resident #51's] wheelchair using her body and chair as a restraint. As the resident attempted to stand, [CNA #1] pushed down on [Resident #51's] shoulders. That caused increased agitation to [Resident #51]. [Resident #51] struggled to free themselves and swung their arms and hands around their body attempting to hit [CNA #1]. [Resident #51] picked up plastic cups from the table and attempted to throw them behind them at [CNA #1]. [CNA #1] continued to hold [Resident #51] down. During the struggle between the resident and [CNA #1], the skin tear to the arm occurred. During that time, [CNA #1] did not make any attempts to distract the resident by ambulating or engaging in activities. A review of the Incident Investigation Conclusion revealed that It has been determined after gathering statements and watching footage of the incident that [CNA #1] . used unnecessary restraint on [Resident #51] which resulted in a skin tear and bruising . The surveyor reviewed Resident #51's medical record. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia, anxiety, depression, and the need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 5/15/24, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that the resident had severe cognitive impairment. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area initiated on 11/16/22, that the resident was at risk for skin tear and discolorations with an intervention dated 8/22/23, to apply protective arm sleeves or long sleeves. An additional focus area initiated on 11/20/23, for personalized care, included an intervention that the resident preferred a 9:00 PM bedtime. The ICCP also included a focus area revised on 2/20/23, for impaired cognitive function/dementia with an intervention dated 12/14/23, that if the resident becomes agitated at a team member, have another team member try to de-escalate the situation. A review of a skin evaluation dated 5/20/24, indicated Resident #51 had no skin issues. A second skin evaluation dated 5/24/24, indicated the resident had discoloration of the right hand and a skin tear of their forearm. On 3/23/25 at 1:54 PM, the LNHA provided two surveyors access to the video surveillance of the abuse incident that occurred on 5/23/24. The surveyors observed the following occurred on 5/23/24: At 9:33 PM, the footage showed the back of Resident #51 in their wheelchair (w/c) seated at a table in the Bistro. The resident was wearing a long sleeve shirt. To the right of the resident, Resident #36 was observed seated in their w/c at the same table next to Resident #51. CNA #1 was observed to the left of Resident #51 with her right hand on the left shoulder of Resident #51 who was trying to stand up. CNA #1 was holding the resident down and preventing the resident from standing up. At 9:34.16 PM, CNA #1 stood and walked behind Resident #51. CNA #1 pushed Resident #51's w/c into and underneath the table and locked the left wheel of the w/c. Then CNA #1 moved her chair to be positioned directly behind Resident #51 and CNA #1 had both of her hands on the resident's back. CNA #1 appeared to be speaking in Resident #51's ear. Resident #36 was observed at that time backing away from the table slightly. At 9:35.19 PM, Resident #36 was moving their w/c back and forth and started to slowly move back distancing themselves from the table. At 9:36.07 PM, Resident #51 attempted to stand up twice and each time was forcibly pushed back down into the w/c by CNA #1. CNA #1 was positioned behind the resident and was holding the resident down in the w/c. At 9:36.13 PM, Resident #51 was observed trying to push CNA #1 away by moving left to right with no success. CNA #1 again forcibly pushed Resident #51 towards the back of the w/c. The resident attempted to stand up again, and then CNA #1 pushed the resident down into the w/c. CNA #1 then placed Resident #51 in a hold by placing their left hand close to the resident's neck and their right hand in a hook motion by the right side of the resident's neck. At 9:36.22 PM, CNA #1 was observed with both of her hands pushing down on Resident #51's shoulders preventing Resident #51's movements. At 9:36.56 PM, CNA #1 was still positioned behind Resident #51 and observed to be pushing the resident down again with both hands pressed against Resident #51's shoulders. At 9:37.25 PM, CNA #1 was observed with her hands still holding the resident down by their shoulders. The resident began to struggle by moving left to right and attempted to get away from CNA #1 and threw a cup. Resident #51 next swung towards the right to break free but was unsuccessful. CNA #1 continues to forcibly restrain the resident. Resident #36 self-propels back and leaves the room. CNA #1 again holds Resident #51 down by the back and shoulders as the resident attempts to break away. At 9:37.37 PM, Resident #51 attempts to stand and CNA #1 was observed placing both hands on the resident's shoulders and pushing the resident back into their w/c. At 9:38.08 PM, CNA #1 stands, unlocked the w/c and pushed the w/c with the resident into the hall. At 9:39.31 PM, LPN #1 was observed in the hallway and wheeling Resident #51 down the hall. The video revealed that CNA #1 forcibly pushed and restrained Resident #51 eight times in the five minutes of video footage. Resident #36 who was observed in the video witnessing CNA #1 forcibly push and restrain Resident #51 was not identified in the facility's investigation or assessed by the facility for potential psychosocial abuse after observing the abuse by [CNA #1] against [Resident #51] on 5/23/24. The surveyor reviewed Resident #36's medical record. A review of the quarterly MDS dated [DATE], revealed that Resident #36 had a BIMS score of 03 out of 15, which indicated that the resident had severe cognitive impairment. A review of the Admission Record face sheet revealed Resident #36 had diagnoses which included but were not limited to; dementia and aphasia (a disorder that affects communication). A review of the ICCP included a focus area dated 4/18/24, that the resident had potential to be a victim of abuse with interventions including to provide emotional support if feeling uneasy or nervous. An additional focus area dated 1/24/24, for dementia with an intervention to monitor for signs of acute confusion. The ICCP also included a focus area dated 1/24/24, for impaired ability to be understood or express ideas with an intervention to explain all procedures and speak slowly and clearly. A review of the Progress Notes (PN) revealed a Late Entry dated 5/24/24, that Resident #36 was seen for a follow up Depression/anxiety and did not include the incident observed on 5/23/24. The surveyor reviewed the PNs through 6/19/24, and there was no documented evidence that referenced Resident #36 witnessing the incident of abuse on 5/23/24. On 3/24/25 at 12:15 PM, the LNHA and the DON were interviewed by two surveyors. The LNHA stated he was the Assistant DON at the time of the incident and confirmed that he and the DON were both working at the facility when the incident occurred. The DON stated the skin tear had to be investigated to figure out what happened so the video was reviewed, and they found CNA #1 was inappropriate. When asked about signs of potential abuse, the DON stated there could be injuries, skin tears, bruising, broken bones, and emotional distress. The DON stated that LPN #1 was still working at the facility. When asked what was determined regarding Resident #51's bruise, the DON stated, I do not remember. When asked what the expectation would be, the DON stated, We would try to figure out what caused the bruise. When asked the procedure upon discovery of a bruise of unknown origin, the DON stated it should be reported to the Nursing Supervisor. The DON further stated that CNA #1 reported that the resident had a scratch. The DON stated that a CNA who identified an injury, should notify the nurse and the nurse investigates. There would be an incident report completed. The DON stated CNA #1 reported the resident scratched themselves so we (the facility) would not question her. When asked about the bruise, the DON stated they would look at the type of bruise such as a hand print. The LNHA stated that when they viewed the video, they observed that the incident was abuse and not what CNA #1 had reported. When asked about the investigation process and if an LPN would be responsible to make the determination of abuse for the bruise of unknown origin, the DON stated the LPN would report to the Nursing Supervisor, but that there would not be a statement from the Nursing Supervisor unless there was additional information to add. The DON added that the Nursing Supervisor would have to assess the bruise at that time but would not necessarily document the assessment. The DON stated she would look for any additional information. On 3/24/25 at 2:16 PM, during an interview with the LNHA in the presence of the survey team, the surveyor asked the LNHA if any other residents were assessed to rule out abuse since CNA #1 proceeded to work two hours after the bruises of unknown origin were identified on Resident #51. The LNHA stated, we were looking at the event and, did not check any other residents on the neighborhood. The LNHA stated they assumed that it was an isolated incident. When asked if Resident #36 was assessed, the LNHA stated, I do not know. There was no change [regarding Resident #36] reported in their behavior. On 3/25/25 at 1:05 PM, during a telephone interview in the presence of the survey team, LPN #1 was asked about the incident. LPN #1 stated, I do not even recall the bruise, but I remember the skin tear clearly. LPN #1 stated she asked CNA #1 what happened, and she thought it was a mishap like an accident. LPN #1 stated that she did not know about Resident #51 but that residents get agitated all the time and that it would be for a reason and that if CNA #1 could not redirect the resident, she should have called for help. LPN #1 acknowledged that no supervisor came to assess Resident #51. LPN #1 stated she was later informed of the abuse, but she was not provided any education after the incident. When asked what constituted abuse, LPN #1 stated forcibly handled resident, neglect, deprived of anything, and isolation. When asked about being barricaded between a table and a staff member, LPN #1 stated, oh certainly that would be abuse if they [residents] are held in any way. LPN #1 stated she asked Resident #51 what happened but that the resident was unable to say. On 3/27/25 at 9:55 AM, the DON acknowledged that an LPN could not do an assessment and that there was no documentation that the Registered Nurse Supervisor came to assess Resident #51 or Resident #36. On 3/27/25 at 2:01 PM, the LNHA and DON were in the conference room with the survey team. They confirmed that Resident #36 was only coincidentally seen on 5/24/24, but not specifically to address witnessing the abuse of Resident #51. A review of the facility provided transcript revealed that LPN #1 had completed an Annual Abuse review on 3/21/24. A review of the facility provided Team Member Handbook Acknowledgment signed and dated 3/14/22, by CNA #1, included but was not limited to; Abuse Policy .will not permit residents to be subjected to abuse by any person. Physical abuse included the infliction of injury including but not limited to pulling, twisting, restraints, controlling behavior through the use of forcibly handling a resident. A review of the facility provided education and performance records revealed the following: CNA #1 had completed Annual Abuse review on 3/12/24; Restraints and Alternatives training on 4/24/24; Resident Rights and Abuse training on 4/30/24; and Restraint-Free Environment training on 3/13/24. The Performance Evaluation dated 2/4/24, noted that CNA #1 was noted as Improvement Needed with comments that included: does not do well with change and continues to do things as she always has. An acceptable Removal Plan (RP) was received on 3/27/25 at 2:22 PM, which indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; on 3/27/25 Resident #51 and Resident #36 was assessed by the psychiatry Nurse Practitioner (NP) to confirm no physical or emotion injury related to the 5/23/24 incident, all nurse managers and supervisors would be required to respond to all reported incidents and accidents, and the Abuse Policy was amended to include any staff involved with an injury of unknown origin to a resident must be removed immediately from resident contact and all residents that had contact with the alleged perpetrator would be assessed and/or interviewed to ensure no physical or psychosocial harm had occurred. The survey team verified the implementation of the RP during the continuation of the on-site survey on on 3/28/25 at 9:20 AM. NJAC 8:39-4.1(a)(5)

Complaint #: NJ 174543 Repeat Deficiency Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure special dietary instructions were implemented for a cognitively impaired resident who was identified as being at risk for choking and aspiration (inhaling food into the lungs) and required nectar thick liquids (liquid thickened with an agent for a nectar-like consistency), did not receive a straw. This deficient practice was identified for 1 of 2 residents review for food (Resident #3), and it was previously cited during a complaint visit. During a breakfast observation on 3/25/25, the surveyor observed Resident #3 in the Lilac Bistro eating their meal and the resident began to forcibly cough. The surveyor observed Resident #3 had a half-filled plastic cup with a straw inserted through the lid. At that time, the Licensed Practical Nurse (LPN #1) proceeded to the resident and removed the straw from the lid, and LPN #1 then approached the Certified Nurse Aide (CNA #1) to inform her that the resident could not have a straw. An interview 3/25/25, with the Speech Therapist (ST), revealed that Resident #3 had dysphagia (difficulty swallowing) and straws had been discontinued because the resident had bad oral control, so the fluid goes back causing the resident to cough, and the resident could choke. The facility's failure to ensure that a cognitively impaired resident with a special dietary instruction of no straw did not receive a straw. Resident #3 was provided a straw which posed the likelihood of choking and aspiration which result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/25/25 at 8:30 AM, when Resident #3 was observed forcibly coughing with a straw in their drink. The facility's Administration were notified of the IJ on 3/25/25 at 2:54 PM. The facility submitted an acceptable Removal Plan (RP) on 3/27/25 at 11:31 AM. The survey team verified the implementation of the RP on-site on 3/28/25 at 9:20 AM. The evidence was as follows: A review of the facility provided policy Thickened Liquids dated 11/10/24, included but were not limited to; Residents with .altered-liquid consistency will receive thickened liquids at the level ordered .to safely maintain hydration. Purpose: to reduce or prevent the risk of aspiration. 6. Commercial thickened .juice will be provided for meal service and for nursing staff . A review of the facility provided policy Checking Accuracy of Meal Tickets dated 10/15/24, included but were not limited to; maintains a mechanism to ensure the safe and accurate .distribution of food items .Procedure: 6. Meals are placed on the counter for nursing to check for accuracy and special instructions . A review of the facility provided policy Meal Service dated 10/15/24, included but were not limited to; Procedures: B.10. A nurse will monitor the dining room during meals. C.3. Trained individuals will review the .diet slip .and serve the .beverages . On 3/25/25 at 8:30 AM, the surveyor observed Resident #3 in the Lilac Bistro eating their meal who began to forcibly cough. The surveyor observed Resident #3 had a half-filled plastic cup with a straw inserted through the lid. At that time, LPN #1 proceeded to the resident and removed the straw from the lid. LPN #1 then approached CNA #1 and informed her that the resident could not have a straw. The surveyor observed the resident's meal ticket that was located next to the resident, and the ticket indicated Special Instructions: NO STRAWS that was highlighted in orange. On 3/25/25 at 8:31 AM, the surveyor interviewed LPN #1, who stated that Resident #3 should not have any straws. On 3/25/25 at 8:32 AM, the surveyor interviewed CNA #1, who provided Resident #3 with the straw. CNA #1 stated she was agency (staff) and the process was that she was supposed to check the meal ticket, but she did not see the ticket. CNA #1 stated, I should have looked, and confirmed that she provided the straw to Resident #3. On 3/25/25 at 8:35 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1), who stated that the nurses and CNAs should check all meal tickets, and stated Resident #3 could have choked on fluids. On 3/25/25 at 9:11 AM, the surveyor interviewed the ST, who stated that Resident #3 had a dysphagia (difficulty swallowing) evaluation, and straws had been discontinued. The ST stated the resident had bad oral control, so the fluid goes back causing the resident to cough, and the resident could choke. On 3/25/25 at 9:30 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the facility used agency staff, and the Staffing Coordinator educated agency staff on the facility's policies. The LNHA stated, I would have expected that [the special instructions for not having straws] to have been caught prior to the resident receiving the straw. The LNHA confirmed that per the prior Plan of Correction, the agency staff should have been educated. On 3/25/25 at 9:44 AM, the surveyor reviewed the electronic medical record for Resident #3. A review of the Admission Record face sheet (an admission summary), reflected that Resident #3 had diagnoses which included but were not limited to; dysphagia (difficulty swallowing). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/2/25, reflected a Brief Interview for Mental Status (BIMS) score of 06 out of 15, which indicated the resident had a moderately impaired cognition. A review of Section GG for self-care, reflected that Resident #3 was coded as 04, which indicated the resident needed supervision or touching assistance while eating. The MDS further documented that the resident received a mechanically altered diet for both food and liquids. A review of the Order Summary Report reflected the following orders: a diet order dated 2/21/25, for mechanical soft ground texture and nectar thick liquids; acknowledge that appropriately ordered diet was provided and an order dated 2/23/25, for Speech Therapy Screen evaluate and/or treat consultation related to diet, chewing food, and spitting out. A review of the individual comprehensive care plan (ICCP) included a focus area dated 4/28/23, and revised 2/28/25, that the resident was at nutritional risk and had a mechanically altered diet. The goal was for the resident to remain comfortable. One intervention included was to provide diet as ordered, regular, mechanical soft with nectar thickened liquids. A review of the Speech Therapy Evaluation and Plan of Care note dated 2/21/25, included but was not limited to; dysphagia. The reason for referral was that the resident reported fear of swallowing. Medical factors included aspiration precautions. A review of the Nutrition Significant Change Assessment note dated 2/28/25, included but was not limited to; diet: regular, mechanically soft (downgraded .on 2/21) with nectar thick liquids. No straws. A review of the undated facility Handbook provided to agency staff included but were not limited to; Explanation of Diets . Dysphagia and why it is important: affects the muscle used for chewing and swallowing which become weak or uncoordinated. As a result, food and drink can go into the lungs instead of the stomach .can cause serious chest infections. Understanding and implementing the diet types are essential .to improve a resident's quality of life and address specific health challenges they may face. When a patient is not given the diet they are ordered one of three things may happen: 1) they may choke . 2) they may spend excess time chewing and may stop eating because they are tired resulting in weight loss, 3) they could aspirate leading to pneumonia or death . The acceptable Removal Plan on 3/27/25 at 11:31 AM, indicated 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 which included; on 3/25/25 at 8:30 AM, LPN #1 immediately removed the straw from Resident #3's cup and explained to CNA #1 the resident's special dietary instructions, the nurse auscultated (listened to) the lung fields for Resident #3 and their lungs were clear; on 3/25/25 at 8:17 PM, the Medical Director assessed the resident, Resident #3 was ordered a chest x-ray to rule out aspiration and vitals were ordered every shift for three days to monitor for signs and symptoms of aspiration, all nursing and dining staff were educated on the facility's policy for checking the meal ticket against what was being served to our residents with emphasis placed on the need to look at any printed special instructions. The survey team verified the implementation on-site during the continuation of the survey on 3/28/25. NJAC 8:39-17.4(a)1; 27.1(a)

Complaint #: NJ 174085 Refer to F 600 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #51). A review of an abuse investigation revealed on 5/23/24 at 9:45 PM, on the Dementia Unit, a Licensed Practical Nurse (LPN #1) was informed by a Certified Nurse Aide (CNA #1) that a cognitively impaired resident (Resident #51) had a 7 centimeter (cm) left forearm skin tear that required several steri-strips (wound bandage) from the resident (Resident #51) scratching themselves and had a 3 cm by 4 cm right posterior hand discoloration. Observation of video footage from the time of the incident revealed that on 5/23/24, CNA #1 was observed forcibly restraining Resident #51 in their wheelchair to prevent the resident from standing and blocked the resident's wheelchair from moving with a chair and the CNA's body. The video footage identified a second resident, Resident #36, witnessed the incident and self-propelled themselves away from the situation. An interview on 3/24/25, with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) revealed that the incident was not initially investigated as abuse until the former LNHA reviewed the video footage two days later (5/25/24) and identified that CNA #1 abused Resident #51. The administration confirmed that CNA #1 finished working their shift on 5/23/24, and had access to all the residents on the locked unit. Resident #36 was not assessed after the incident to rule out psychosocial harm. The facility's failure to implement their abuse policy by immediately conducting a thorough investigation to ensure all residents are free from abuse posed a likelihood of serious harm including psychosocial, injury, impairment, or death to all residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ situation began on 5/23/24 at 9:33 PM, when CNA #1 was observed holding Resident #51 down. The facility's Administration were notified of the IJ on 3/25/25 at 2:54 PM. An acceptable Removal Plan (RP) was received on 3/27/25 at 2:22 PM. The RP was verified on-site by the survey team on 3/28/25 at 9:20 AM, during the continuation of the survey. Findings include: A review of the facility's policy in effect the date of the incident, Abuse and Neglect, dated 5/4/23, included Policy: the [facility] will not permit residents to be subjected to any form of abuse/neglect .Abuse definition is the willful infliction of injury .intimidation, .mental anguish. Injuries of unknown source - classified .when both of the following conditions are met a.) source of the injury was not observed or the source could not be explained by the resident. AND b.) the injury is suspicious because of the extent, location, .Identification/Investigation/Protection: 1. The [facility] will identify all types of events including .bruising of residents .that may constitute abuse. 2 .appropriate action will be taken to safeguard the resident from harm while the incident is fully investigated. Actions to include .team member placed on fact finding leave pending investigation. Social Worker referral. Psychology consultation as appropriate. Response: all reported occurrences will be fully investigated .to determine what actions are necessary and what changes are needed to policies and procedures to prevent further occurrences. Abuse Training: to ensure proper training of new and existing team members on abuse/neglect prevention, identification and protection of residents. 6. Characteristics of the resident population at risk for abuse .cognitively impaired, psychological medical problems, communication disorders, those who require extensive nursing care. 7. Training on identifying suspicious bruising . A review of the facility policy, Incident Reporting-Injuries of Unknown Origin/Source, revised 5/16/16, included but was not limited to; Procedure: B. all injuries of unknown origin/source shall be investigated by the nurse on duty and/or Supervisor . E. the nurse will ask the resident how the injury occurred and document their answer. F. the nurse shall obtain statements from everyone on the shift . also from team members for 24 hours prior to the discovery of the injury. G. The nurse shall contact the Supervisor and notify them. On 3/23/25 at 1:54 PM, the LNHA provided a copy of the completed Facility Reportable Event (FRE) reported to the New Jersey Department of Health (NJDOH), Incident Investigation dated 5/23/24, for Resident #51 including all documentation and statements which revealed the following: A review of the FRE, included Date/Time of Event: 5/23/24 at 9:35 PM. The location of the incident was the memory care Bistro and the type of incident was staff-to-resident abuse. The Description of the Event included: CNA #1 stated she asked Resident #51 to remain seated and she observed [Resident #51] scratch their own arm causing a skin tear. As this is unusual behavior for the resident we requested camera footage of the Bistro for that time period. The video was obtained today (5/25/24) and viewed by the LNHA (former). The video showed [CNA #1] physically restraining [Resident #51] from behind with her hands pushing down on [Resident #51's] shoulders causing [Resident #51] to become increasing[[NAME]] agitated. [Resident #51] was attempting to get free from [CNA #1] and struggling against [CNA #1]. [CNA #1] grabbed [Resident #51's] arm and hand. This is likely the cause of the skin tear and bruising. [Resident #51] showed [CNA #1] the left arm skin tear and [CNA #1] stopped holding [Resident #51's] arm and pushed the resident out of the bistro to the nurse. Others notified: [name redacted] Police Department after video review. A review of the Incident Investigation submitted with the FRE included: Staff to Resident Abuse Date: 5/23/24, and signed by the former LNHA and Director of Nursing (DON) on 5/29/24. A statement summary from LPN #1 revealed .[CNA #1] told her that she asked [Resident #51] to remain seated and then observed [Resident #51] scratch their own arm causing a skin tear. Investigational Findings: .[Resident #51] can communicate needs but had significant cognitive impairment and had poor safety awareness. At approximately 9:40 PM on 5/23/24, [CNA #1] reported to LPN #1 that [Resident #51's] arm was bleeding and stated that she observed [Resident #51] scratch their own arm. Upon review of the camera footage in the Bistro, the resident attempted to rise from their wheelchair and [CNA #1] grabbed [Resident #51's] arm above the left elbow and hand, and appeared to be talking to resident to sit down (no audio). A few minutes later, the resident again tried to stand. CNA #1 had the resident sit down and moved [Resident #51's] wheelchair using her body and chair as a restraint. As the resident attempted to stand, [CNA #1] pushed down on [Resident #51's] shoulders. That caused increased agitation to [Resident #51]. [Resident #51] struggled to free themselves and swung their arms and hands around their body attempting to hit [CNA #1]. [Resident #51] picked up plastic cups from the table and attempted to throw them behind them at [CNA #1]. [CNA #1] continued to hold [Resident #51] down. During the struggle between the resident and [CNA #1], the skin tear to the arm occurred. During that time, [CNA #1] did not make any attempts to distract the resident by ambulating or engaging in activities. A review of the Incident Investigation Conclusion revealed that It has been determined after gathering statements and watching footage of the incident that [CNA #1] . used unnecessary restraint on [Resident #51] which resulted in a skin tear and bruising . A Progress Note dated 7/9/24 at 2:00 PM, written by LPN #1, included: Incident Date: 5/23/24/ 9:45 PM; Individual that discovered incident: CNA #1, Location of skin issue: Left forearm, right posterior hand; Type of skin issue: Skin tear- left forearm discoloration, right posterior hand; Notifications: (Physician, Family/Sponsor, Nursing Supervisor: List contact name and time notified): Info [information] placed in MD's [physician] book. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia, anxiety, depression, and the need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 5/15/24, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that the resident had severe cognitive impairment. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area initiated on 11/16/22, that the resident was at risk for skin tear and discolorations with an intervention dated 8/22/23, to apply protective arm sleeves or long sleeves. An additional focus area initiated on 11/20/23, for personalized care, included an intervention that the resident preferred a 9:00 PM bedtime. The ICCP also included a focus area revised on 2/20/23, for impaired cognitive function/dementia with an intervention dated 12/14/23, that if the resident becomes agitated at a team member, have another team member try to de-escalate the situation. A review of a Nursing Progress Note (NPN) dated 5/23/24 at 9:45 PM, by LPN #1, documented a skin integrity note that identified a skin tear to the left forearm measuring 7 cm and discoloration of the right posterior hand measuring 3 cm by 4 cm. The NPN further noted that the resident was unable to state what happened due to memory impairment. A review of a typed statement signed by LPN #1, dated 5/23/24, documented that CNA #1 reported that while she was observing the resident in the Bistro for safety, Resident #51 was observed to be anxious and rising from the wheelchair (w/c). CNA #1 reported the resident had to go get the boys and observed Resident #51 had scratched [their] own arm causing a skin tear. (There was no documentation that CNA #1 had reported a bruise on the resident's hand or the possible causal factor of the bruise to the right hand.) A statement on an Accident/Incident Statement/Interview Form dated 5/23/24, from CNA #1, documented .Resident #51 was sitting at the table with me (and all of a sudden, [Resident #51] stood up and almost tipped their w/c backwards. I jumped up to protect the resident and they yelled at me .had things to do .Then all of a sudden, temper went ballistic and tried throwing things at us, trying to scratch [CNA #1] with their long nails and [the resident] thought had my [CNA #1's] arms but in reality had own arms and digging into own skin on own arms, but scratched themselves. [Resident #51] was out of control. She further documented that she kept yelling for LPN #1 and that she was in the office and when LPN #1 finally did come, I showed her the skin tear on Resident #51's left forearm- [Resident #51] did it to themselves. There was a picture drawn on the page of a figure with two hands together in front and I was behind [Resident #51] trying not to let the wheelchair tip over. The statement section for a Manager/Supervisor signature was left blank and undated. A review of the facility provided Skin Injury report dated 5/23/24 at 9:45 PM, completed by LPN #1, included but was not limited to; . CNA #1 stated she asked Resident #51 to stay seated and observed the resident scratch their own arm causing a skin tear. When asked how the incident happened, Resident #51 replied fix it. The Witnesses section revealed no witnesses found. A review of a typed statement signed by the Assistant Director of Nursing (ADON), who was now the LNHA, and dated 5/25/24, documented that when LPN #1 asked Resident #51 what happened, the resident replied, Fix it which contraindicated LPN #1's statement. A statement on the facility Accident/Incident Statement/Interview Form dated 5/23/24, from CNA #2 on the unit, documented that the resident did not have any skin tears prior to the incident. CNA #2 did not indicate if CNA #1 was yelling out for LPN #1. (There was no statement or assessment provided from the Nursing Supervisor who the facility stated had been made aware.) At the same time and date (3/23/25 at 1:54 PM) that the LNHA provided the investigation, the LNHA provided two surveyors access to the video surveillance of the abuse incident that occurred on 5/23/24. The surveyors observed the following occurred on 5/23/24: At 9:33 PM, the footage showed the back of Resident #51 in their wheelchair (w/c) seated at a table in the Bistro. The resident was wearing a long sleeve shirt. To the right of the resident, Resident #36 was observed seated in their w/c at the same table next to Resident #51. CNA #1 was observed to the left of Resident #51 with her right hand on the left shoulder of Resident #51 who was trying to stand up. CNA #1 was holding the resident down and preventing the resident from standing up. At 9:34.16 PM, CNA #1 stood and walked behind Resident #51. CNA #1 pushed Resident #51's w/c into and underneath the table and locked the left wheel of the w/c. Then CNA #1 moved her chair to be positioned directly behind Resident #51 and CNA #1 had both of her hands on the resident's back. CNA #1 appeared to be speaking in Resident #51's ear. Resident #36 was observed at that time backing away from the table slightly. At 9:35.19 PM, Resident #36 was moving their w/c back and forth and started to slowly move back distancing themselves from the table. At 9:36.07 PM, Resident #51 attempted to stand up twice and each time was forcibly pushed back down into the w/c by CNA #1. CNA #1 was positioned behind the resident and was holding the resident down in the w/c. At 9:36.13 PM, Resident #51 was observed trying to push CNA #1 away by moving left to right with no success. CNA #1 again forcibly pushed Resident #51 towards the back of the w/c. The resident attempted to stand up again, and then CNA #1 pushed the resident down into the w/c. CNA #1 then placed Resident #51 in a hold by placing their left hand close to the resident's neck and their right hand in a hook motion by the right side of the resident's neck. At 9:36.22 PM, CNA #1 was observed with both of her hands pushing down on Resident #51's shoulders preventing Resident #51's movements. At 9:36.56 PM, CNA #1 was still positioned behind Resident #51 and observed to be pushing the resident down again with both hands pressed against Resident #51's shoulders. At 9:37.25 PM, CNA #1 was observed with her hands still holding the resident down by their shoulders. The resident began to struggle by moving left to right and attempted to get away from CNA #1 and threw a cup. Resident #51 next swung towards the right to break free but was unsuccessful. CNA #1 continues to forcibly restrain the resident. Resident #36 self-propels back and leaves the room. CNA #1 again holds Resident #51 down by the back and shoulders as the resident attempts to break away. At 9:37.37 PM, Resident #51 attempts to stand and CNA #1 was observed placing both hands on the resident's shoulders and pushing the resident back into their w/c. At 9:38.08 PM, CNA #1 stands, unlocked the w/c and pushed the w/c with the resident into the hall. At 9:39.31 PM, LPN #1 was observed in the hallway and wheeling Resident #51 down the hall. The video revealed that CNA #1 forcibly pushed and restrained Resident #51 eight times in the five minutes of video footage. Resident #36 who was observed in the video witnessing CNA #1 forcibly push and restrain Resident #51 was not identified in the facility's investigation or assessed by the facility for potential psychosocial abuse after observing the abuse by [CNA #1] against [Resident #51] on 5/23/24. CNA #1's statement provided in the investigation did not include Resident #36 was at the table with Resident #51 and herself. On 3/24/25 at 12:15 PM, the current LNHA and the DON were interviewed by two surveyors. The DON stated the skin tear had to be investigated to figure out what happened so the video was reviewed. The DON stated signs of abuse could be injuries, skin tears, bruising, broken bones, and emotional distress. When asked what was determined regarding Resident #51's bruise, the DON stated, I do not remember. When asked what the expectation would be, the DON stated, We would try to figure out what caused the bruise. When asked the procedure upon discovery of a bruise of unknown origin, the DON stated it should be reported to the Nursing Supervisor (NS). The DON stated the CNA notifies the nurse and the nurse investigates, and there would be an incident report completed. The DON stated that CNA #1 reported that the resident scratched themselves, so we (the facility) would not question CNA #1 any further. When asked about the bruise, the DON stated they would look at the type of bruise such as a hand print. When asked about the investigation process and if an LPN would be responsible to make the determination of abuse for a bruise of unknown origin, the DON stated the LPN would have to report to the NS regarding the bruise and the NS would not document a statement unless they felt they had something to add. It was not consistently required. The DON added that the NS was responsible to assess the bruise at that time, but would not have to document the assessment. The facility could not provide any documentation from the NS. When asked about what should have happened with the investigation process, the DON stated that the nurse should have investigated the injury and completed an incident report. The DON further stated that the nurse and supervisor should have investigated the incident that night and they should have obtained statements from staff. On 3/24/25 at 2:16 PM, during an interview with two surveyors regarding the incident that occurred on 5/23/24, the LNHA stated, yes this was abuse, and confirmed that the Social Worker (SW) did not visit with any residents after the incident. The LNHA stated, we were looking at the event and did not go further to check other residents. I believe we thought it was isolated to this event. The LNHA confirmed that CNA #1 finished her shift after the abuse occurred on 5/23/24, and stated CNA #1 physically restrained Resident #51. The LNHA stated they were looking at the event and did not check any other residents on the neighborhood and stated we assumed that it [the abuse] was isolated. The LNHA was unable to provide any documentation or confirm that all 14 residents were assessed to ensure they were not physically or psychosocially abused. When asked if Resident #36 was assessed, the LNHA stated, I do not know. There was no change [regarding Resident #36] reported in their behavior. On 3/24/25 at 2:58 PM, the surveyor interviewed LPN #3, who stated that if there was a resident with an injury of unknown origin, the nurse first saw what care the resident needed, then asked the resident if they were able to explain what happened, and then informed the supervisor. LPN #3 further stated that she documented the description of the injury. LPN #3 stated that if it looked like a scratch, she checked the resident's nails and checked the CNA's nails. LPN #3 stated if the injury was of unknown origin, the supervisors initiated the investigation and looked back about 72 hours to obtain statements. On 3/24/25 at 2:59 PM, during an interview with LPN #2 regarding the investigation process, she stated that if a CNA reported a bruise or any injury, the protocol was to inform the supervisor and notify the physician and the family. If abuse was suspected the supervisor had to report it. On 3/24/25 at 3:06 PM, during an interview with a Unit Manager (UM), who stated the process when an injury of unknown origin was identified, it was investigated by speaking to all the staff involved with the resident's care. The UM stated she tried to find out what happened and completed an incident report. The UM stated if abuse was suspected, the DON and LNHA were notified, and the police were notified as well. On 3/25/25 at 1:05 PM, during a telephone interview in the presence of the survey team, LPN #1 was asked about the incident. LPN #1 stated, I do not even recall the bruise, but I remember the skin tear clearly. LPN #1 stated she asked CNA #1 what happened, and she thought it was a mishap, like an accident. LPN #1 stated if a resident had an injury of unknown origin, she would ask a witness what happened and would document what they had said happened. LPN #1 stated she notified the supervisor after she attended to any injuries. LPN #1 further stated she was not present during the incident and she documented what had been told by CNA #1. LPN #1 stated she had not observed Resident #51 being agitated. LPN #1 stated that if she felt a resident was injured maliciously she would have addressed it immediately. LPN #1 further stated that if there was an injury of unknown origin, there needed to be good documentation, meaning she would ask for statements and inform the supervisor. LPN #1 acknowledged that no supervisor came to the assess Resident #51. LPN #1 stated she asked Resident #51 what happened, and the resident was unable to say what occurred. On 3/27/25 at 9:55 AM, the DON acknowledged that LPN #1 was not permitted to complete an assessment (outside the scope of practice for an LPN) and that there was no documentation that the Registered Nurse Supervisor investigated and assessed either Resident #51 or Resident #36 after the incident occurred on 5/23/24. An acceptable Removal Plan (RP) was received on 3/27/25 at 2:22 PM, which indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented corrective action plan to remediate the deficient practice including; an amended Abuse Policy to ensure: staff involved with any incident or accident of unknown origin must remove the involved staff member immediately and that person must leave the clinical area, and not have further contact with residents until the investigation was completed, all other residents who are on the alleged perpetrator's assignment or have had contact with the alleged perpetrator must be assessed and/or interviewed to ensure no physical or psychological injuries existed, a Supervisor or Manager must respond to all accidents and incidents in person to determine if the injury origin is unknown, and the Supervisor/Manager MUST call the Administrator for all cases of injuries/accidents of unknown origin. On 3/27/25, Resident #51 and Resident #36 were assessed by the psychiatry Nurse Practitioner (NP) to confirm no physical or emotional injury related to the 5/23/24, incident occurred; all nurse managers and supervisors would be required to respond to all reported incidents and accidents. The survey team verified the implementation of the RP during the continuation of the on-site survey on on 3/28/25 at 9:20 AM. NJAC 8:39-4.1(a)(5)

Based on observation, interview and record review, it was determined that the facility failed to a) ensure the infection control practices for residents on transmission-based precautions (TBP) were implemented in accordance with accepted national standards, and b) ensure the facility's infection control for TBP policy reflected evidence-based standards of infection control practices. This deficient practice was identified for 3 of 3 residents reviewed on TBP (Resident #22, #8 and Resident #37 and was evidenced by the following: 1. On 3/21/25 at 10:14 AM, the surveyor observed a plastic bin with drawers outside the room for Resident #22. The drawers had personal protective equipment (PPE) including gowns and gloves. A sign affixed to the resident's door indicated the following: Contact Precaution and specified the proper Personal Protective Equipment to wear prior to entering the room. On 3/24/25 at 9:05 AM, the surveyor observed a Certified Nurses Aide (CNA) in the room assisted Resident #22 with care. The CNA was not wearing a PPE gown. The CNA assisted Resident #22 with transfer and changed the bed linens. The CNA washed her hands and exited the room. On 3/24/25 at 9:10 AM, the surveyor interviewed the CNA who stated that she should have used the proper PPE when providing care. The CNA added that the PPE was to be used when physical care, changing and cleaning was being performed. On 3/24/25 at 9:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) caring for Resident #22's PICC line (Peripherally inserted central catheter- a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). The LPN entered the room with the medication and the intravenous tubing, placed them on the bedside table, donned (put on) gloves, hung the medication on the pole, primed the line and removed her soiled gloves. At 9:19 AM, the LPN donned a pair of clean gloves, used an alcohol pad, disinfected the hub of the tubing and removed her gloves. At 9:21 AM, the LPN donned gloves removed the cap from the PICC line and connected the intravenous solution to the PICC line. With the same gloved hands, the nurse adjusted the intravenous tubing to the infusion pump, primed the line and ran the Vancomycin drip (Antibiotic used to treat C-difficile). At 9:30 AM, the LPN donned gloves, adjusted the Foley catheter and placed the Foley catheter in a privacy bag. At 9:33 AM, the LPN failed to wash hands and then used Alcohol Based Hand Rub prior to exiting the room. On 3/26/25 at 11:55 AM, the surveyor interviewed the LPN regarding the observed procedure. The LPN confirmed that she should wash her hands after removing her gloves because it was the protocol. The LPN stated, I did not do it yesterday. When asked what was the recommended hand hygiene for residents on contact precaution for C-diff, she stated, soap and water. On 3/26/25 at 12:45 PM, the surveyor discussed the above observation with the Infection Preventionist (IP). The IP confirmed that staff had received in-service education regarding PICC line and Contact Precautions. The IP stated confirmed that during care for Resident #22 staff should wear the proper PPE and wash their hands after removing their gloves. The IP confirmed that Resident #22 had an infection called Clostridium difficile Colitis (C. difficile, inflammation of the colon caused by the Clostridium difficile). Resident #22 was also on isolation for ESBL (Extended -Spectrum Beta- Lactamase) infection. Resident #22 had also a Foley Catheter and the PPE was only necessary when physical contact rendering care was being performed. A review of Resident #22's Face Sheet (admission summary) indicated Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included acute kidney failure, heart failure, and Extended Spectrum Beta Lactamase (ESBL) Resistance, a carrier or suspected carrier of Cdiff, and Cellulitis of right lower limb. A review of the resident's electronic physician's order dated 3/5/25 indicated the antibiotic Vancomycin was ordered to treat the right lower leg cellulitis A review of the resident's electronic Care Plan initiated 3/05/25, indicated Resident #22 was on Enhanced Barrier precautions (EBP) while PICC line was in place. The interventions included for staff to maintain standards precautions. Hand washing before and after each intervention. 2. On 3/24/25 at 10:46 AM, the surveyor observed the same LPN cleansing the G-Tube (gastrostomy tube that provides direct access to the stomach for feeding, hydration and medication) site for Resident # 44. The LPN failed to set a clean field for the procedure. The LPN donned gloves, removed the soiled dressing and placed it on the bedside table. The then LPN donned gloves, cleansed the G-tube site and placed the soiled dressing directly on top of the bedside table. The LPN did not change her soiled gloves after removing the soiled dressing. The LPN disinfected the table prior to exiting the room, and used ABHR to disinfect her hands. On 3/26/25 at 12:45 PM, the concern was discussed wit the IP. The IP confirmed that the nurse should have had a clean field and should not have placed the soiled dressing on the resident over bed table. On 3/28/25 at 11:27 AM, the survey team met with the Administrator and Director of Nursing (DON). The DON stated that the concerns were brought to her attention and the staff was reeducated. A review of the facility policy for Enhanced Barriers Precautions, dated 4/1/24 revealed the following: Enhanced Barriers precautions are used as an infection control prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBP employ targeted gown and gloves use during high contact resident care activity when contact precautions do not otherwise apply. Example of high contact resident care including: dressing, changing linens, device care or use (central line, urinary catheter ) EPB are indicated for residents infected or colonized with ESBL, Vancomycin-resistant Enterococci. Section D of the policy under Types of Precautions to be used if isolation required: indicated the following under Hand Hygiene When hands are visibly dirty, contaminated or soiled, hands are to be washed with soap and water. If caring for a resident with C. difficile, or Norovirus, do not use alcohol based hand-rubs; instead wash hands with soap and water. The policy further indicated that hands are to be washed before resident contact, before putting on gloves or other PPE. Before initiating residents treatments. 48423 3. On 3/21/25 at 9:29 AM, during the initial tour, the surveyor observed two signs on Resident #37's door. The signs were as follow: Contact precautions (a set of infection control practices used to prevent the transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient's environment) and sequence for putting on Personal Protective Equipment (PPE; clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments). The surveyor observed that the Contact precautions sign indicated Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Put on gown before room entry. The surveyor observed a PPE bin with gowns and gloves at the doorway. The surveyor observed a female CNA who transported a breakfast tray to Resident #37's room and was wearing a N95 mask before entering into Resident #37's room. The CNA was not observed wearing a PPE gown and gloves as the sign on the resident's door indicated that was to be worn before entering into the room. The surveyor observed the CNA exit the resident's room and the CNA did not perform hand hygiene upon exiting the room. The CNA walked to the Bistro area (a casual dining space where they offer meals and snacks) and retrieved food for the resident in a cup and walked back into Resident #37's room. The CNA was not observed performing hand hygiene, when donning the gown and gloves prior to entering the room. The CNA then assisted the resident to cut their food. At 9:34 AM, upon exiting Resident #37's room, the surveyor conducted an interview with the CNA. The CNA informed the surveyor that she was an agency CNA and it was her third time working at the facility. The CNA informed the surveyor that the resident was on isolation for infection in their urine. The CNA further stated she knew if the resident was on contact precautions, she had to put on gown, gloves and mask before entering the resident's room. The CNA stated that she just brought breakfast for the resident, so she did not have to put on gown and gloves because she was not providing care to the resident. On 3/21/25 at 9:42 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated the resident had a Urinary tract infection (UTI) and was on contact precautions for CRE (superbugs: a type of germ that is resistant to most antibiotics. This makes CRE infections very difficult to treat), VRE (enterococcus [bacteria] that has developed resistance to vancomycin [type of antibiotics]) and ESBL (a type of enzyme or chemical produced by some bacteria and make some antibiotics ineffective in treating bacterial infections.) in urine. The LPN/UM stated the staff had to wear a gown, gloves and masks anytime when they entered the resident's room. The surveyor informed the above-mentioned observations for Resident #37 to the LPN/UM. The LPN/UM acknowledged that the CNA should have put on PPE before entering the resident's room for infection control. On 3/21/25 at 9:49 AM, the surveyor observed the Nurse Practitioner (NP) going into Resident #37's room. The NP was not observed wearing a gown and gloves before entering the room. The NP performed hand hygiene after exiting the room. At 9:53 AM, during an interview with the surveyor, the NP stated she was seeing the resident for the first time. The NP acknowledged that she did not see the Contact Precaution signage on the door. The NP pointed towards the PPE bin at the doorway and further stated, this been an indication to put PPE, but I guess I went in the room too fast. At 10:08 AM, they surveyor informed the LPN/UM about the above-mentioned observations. The LPN/UM stated the staff should be donning the gown and gloves when going into Resident #37's room. The LPN/UM further stated that PPE rule applied to everyone going into the room. At 10:15 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified of the above-mentioned concerns. The DON stated, it was a concern and further stated the CNA and the NP were pulled-off of the floor and were sent for education. The DON acknowledged that the staff did not follow facility policy by not donning PPE before entering into the contact precaution room. At 1:07 PM, during an interview, the Infection Preventionist (IP) stated the staff should have put PPE on before entering into resident's room because of resident's history of infections. On 3/25/25 at 10:08 AM, the surveyor reviewed the medical records for Resident #37 which revealed the following: The Admission Record (AR, admission summary) reflected that the resident was admitted to the facility, had diagnoses which included but were not limited to urinary tract infection (UTI), hypertension (high blood pressure) and malignant neoplasm of bladder (bladder cancer). The Annual Minimum Data Set (MDS), a resident assessment tool used by the facility to prioritize care, dated 3/24/2025, revealed that Resident #37 scored 13 out of 15 on their Brief Interview for Mental Status (BIMS), which indicated the resident had a moderately impaired cognition. The March 2025 Physician Order Summary (POS) Report indicated a physician order, dated 3/18/25 for Contact isolation precautions related to CRE, VRE and ESBL in urine every shift. On 3/28/25 at 9:42 AM, the survey team met with the LNHA and DON to present concerns. On 3/28/25 at 11:15 AM, the Medical Director (MD) was notified of the above-mentioned concerns via telephone. The MD acknowledged that it was definitely a concern when the NP went into a contact precaution resident's room and was not observed wearing PPE (gown and gloves). A review of facility provided undated Isolation Procedures, included: D.2.b. Transmission-Based Precautions are to be used in conjunction with Standard Precautions. The 3 basic categories are: a. These precautions are used to stop spread of bacteria via direct contact such as skin to skin contact and indirect contact such as person making contact with contaminated objects such as bed, call bells, etc. b. gloves and gowns are to be worn when making contact with resident's skin or with objects that have been in direct contact with the resident. E.4. CDC's (Center for disease control) recommendations for preventing transmission of ., VRE, ESBLs, consists of Standard Precautions which are used for all resident care as well as Contact Precautions. d. Wear gloves when caring for resident. e. Wear gown during care of resident. NJAC 8:39-19.4(1,2), 27.1(a)

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to identify the causal factor and implement appropriate interventions to prevent recurrence and consistently follow fall prevention interventions documented on the Care Plan. This deficient practice was identified for 1 of 2 residents (Resident # 76) reviewed for falls and accidents and was evidenced by the following: On 3/24/25 at 9:49 AM, the surveyor observed Resident #76 in bed, the head of the bed was elevated. A fall mat was observed on the left side of the bed and the call light and blanket were observed on the floor. The resident could not answer the surveyors questions. On 3/25/25 at 11:30 AM, the surveyor reviewed the Admission Record which reflected that Resident #76 was admitted to the facility with diagnoses which included but were not limited to; Personal history of traumatic brain injury, other fracture of left lower leg, subsequent encounter for closed fracture with routine healing, mood disturbance, and unspecified abnormality of gait and mobility. On 03/27/25 at 9:48 AM, the surveyor again observed the call light, the phone was not within reach of the resident and alerted the staff. Resident was observed on the bed without socks. The Quarterly Minimal Data Set (MDS) an assessment tool dated 2/17/25, reflected that Resident #76 had a BIMS (Brief Interview for Mental Status) score of 03 out of 15 indicative of severe cognitive impairment and had communication deficits due to the diagnoses of progressive aphasia. The MDS also reflected that Resident #76 required total assistance of one person assist for bed mobility and transfer. A review of the comprehensive care plan revealed that Resident #76 sustained multiple falls at the facility. The care plan also reflected that Resident #76 was to have mats on both sides of the bed, phone on the bedside table, and personal items within reach. On 3/25/25 at 9:30 AM, the surveyor requested all investigations for Resident #76. On 3/26/25 the facility provided the following investigations which revealed the following falls: 1. On 1/16/24 at 10:24 AM, fell in the room. Upon inquiry, Resident #76 informed staff that they were going to the bathroom. Intervention: Ask resident if they need to use the bathroom at the end of the shift. 2. On 1/26/24 at 4:50 PM, Resident #76 slid out of the bed to the floor. Intervention: none were documented as implemented. 3. On 3/16/24 timed 9:49 PM, Resident #76 was found on the floor by the door in their room calling for help. Observed with visible trauma to the face, abrasions seen from forehead down the chin. Resident was transferred to the Emergency Department for evaluation. The intervention was to turn the television off at night as the resident stated they attempted to get out of bed to turn off the television. 4. On 3/18/24 at 3:00 AM, observed on the floor with back against the bed. Intervention: was to ask the resident to call for assistance. 5. On 5/14/24 at 6:55 PM, fell in the room while attempted to transfer self from the chair to the bed. Intervention: Ask the resident to call for assistance with transfers. 6. On 5/17/24 at 12:00 PM, Resident fell from the bed to the floor while attempted to reach for personal items on the floor. Intervention: Do not leave the resident in wheelchair unsupervised. The resident fell from the bed not while sitting in the chair. 7. On 5/17/24 at 11:35 PM, Resident #76 was found on the floor in the room. The intervention was to have the floor mat at bedside while resident was in bed. 8. On 6/6/24 at 8:20 PM, Resident #76 found on the floor in the hallway yelling for help. Resident stated they fell of the bed and crawled on the floor. Interventions: Make rounds more often to ensure safety. 9. On 6/15/24 at 12:41 PM, Call light on, resident stated that they had to go to the bathroom. The resident had the light on at 9:00 and per the Certified Nurses Aide (CNA) was assisted to the bathroom at 9:00 AM. At 12:41 PM, resident was assisted to the bathroom and had a bowel movement. Interventions: Hourly rounds for incontinence care. 10. On 7/4/24 at 7:45 PM. The note reflected that Resident #76 informed the staff that they were trying to reach the phone and slipped down. The intervention was to have all personal items within reach. Place the phone on the bedside table. [The phone was not observed within reach on 3/27/25 at 9:47 AM]. 11. On 8/10/24 at 11:50 AM, found on the floor in the room. Resident reported that they were trying to go to the bathroom, slide out of the bed, rang the bell but nobody came. Interventions: Assist with transfer as per physical therapy recommendations. 12. On 8/19/24 at 9:50 AM, Resident #76 call light was on, CNA found the resident on the floor mat. Sustained abrasions to left big toe and right pinky toe. Intervention: Assist resident in listening to audio books during room visits. 13. On 8/20/24 at 1:33 PM, CNA found Resident #76 on the floor on their knees beside their bed in the room. Intervention: Assist resident with ambulation and transfers utilizing therapy recommendations. Determine resident's ability to transfer. 14. On 8/20/24 at 12:40 AM, Resident #76 was found on the floor in the bathroom. There was no intervention for the fall. Staff could not determine who assisted the resident to the bathroom or how long Resident #76 was on the floor. 15. On 10/9/24 at 1:30 PM, Resident #76 slid from the chair while being assisted by a family member. Intervention: Monitor and provide assistance with transfers if needed. 16. On 10/18/24 at 10:25 PM, Resident #76 fell while being transferred by the CNA to the toilet. Intervention: Use wheelchair when taking to the bathroom. 17. On 10/21/24 at 6:14 PM, Resident #76 fell while being assisted in the shower by the CNA. Intervention: Anticipate spontaneous transfer. Have all necessary items within reach. Give resident simple and direct instructions before and during transfers. 18. On 10/30/24 at 12:32 PM, Resident #76 was found on the floor in front of the bed. Intervention: Remind resident to call for assistance. 19. On 11/2/24 at 7:01 PM, Resident #76 found on the floor in front of the bathroom door. Interventions: Have the resident wears hipsters to prevent injury. 20. On 11/22/24 at 1:33 PM, resident found on the floor mat covered with feces, no gripper socks on. Resident stated they fell of the bed. Intervention: Use proper assisted device wheelchair/walker as needed. The incident report did not indicate when the resident was last toileted. 21. On 1/1/25 at 8:50 PM, the Resident Representative (RR) assisted Resident #76 to the bathroom, the resident fell while being transferred from the toilet. Intervention: Educate RR to ask for assistance with transfer as part of the routine. 22. On 2/9/25 at 2:25 PM, during rounds the resident was noted on the floor on the side of the bed. Interventions: Fall mat on both sides of the bed. 23. On 2/23/25 timed 11:05 PM, Resident #76 was found between the bed and the radiator in the room. Intervention: Move bed to another wall away from the radiator. 24. On 2/16/25 at 9:17 PM, RR called and informed the staff that the resident slide out of bed. The RR informed staff that the resident wanted to go to the bathroom. Intervention: Frequent checks when family is visiting. 25. On 3/18/25 at 3:00 AM, observed the resident sitting on the floor with their back against the bed. Observed with a reddish color abrasion on the left ankle measuring 1 centimeter (cm) x 1 cm. The resident stated that they fell . Intervention: Bedside table within reach. On 3/27/24 at 9:48 AM, the surveyor observed Resident #76 in bed, the call light was underneath the bed. The phone was on the dresser and was not within reach. On 3/28/25 at 10:47 AM, the surveyor visited the resident, and observed the call light underneath the bed and the phone on the dresser. The phone was to be on the bedside table for easy reach. The surveyor accompanied the nurse to the room where we both observed the call light underneath the bed and the phone not within reach. The nurse told the surveyor that he was an agency staff and did not know much about the resident's routine. On 3/27/29 at 1:15 PM, the surveyor interviewed the Unit Manager (UM) regarding the falls. The UM stated that Resident #76 refused to get out of the bed and would not get dressed unless they had an appointment. The UM added that staff were to check on the resident frequently while in bed. On 3/27/25 at 1:35 PM, the surveyor discussed the falls with the Director of Nursing (DON) and asked for a timeline of the falls. On 03/28/25 at 10:47 AM, the surveyor observed Resident #76 in bed. The call light was observed underneath the bed, the phone was on the dresser and not on the bedside table, out of the resident's reach. On 03/28/25 at 9:41 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor informed the DON and LNHA of the observations regarding Resident #76 multiple falls, observations of socks not worn and pattern of falls related to toileting and a timeline of the falls was requested. On 3/28/25 at 11:15 AM the DON stated that interventions were added on the care plan after each fall. A review of the timeline provided failed to indicate that the causal factor was identified after each fall and specific interventions were added to prevent recurrence. On 3/28/25 at 11:30 AM, the surveyor reviewed the facility policy titled, Incident Reporting revised 1/6/25. The policy indicated that All accidents and incidents shall be investigated by the nurse on duty and/or Neighborhood Manager/Supervisor and documented in Risk Management (on the electronic medical record system). If the incident involves a resident fall, the fall investigation Worksheet should also be completed. Interventions based on the assessment of causal factors will be documented on the resident's care plan. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits, and documented progress notes at least every 60 days. This deficient practice was identified for 3 of 3 residents (Resident #8 and #22, #76) reviewed for physician care and was evidenced by the following: 1. On 3/22/25 at 10:30 AM, the surveyor observed Resident #8 in bed, the resident requested to speak with the surveyor. The resident informed the surveyor that they had not seen their assigned physician for nine months. The resident stated that the Nurse Practitioner (NP) visited monthly for 5 minutes, and then charged for a 30 minute visit. The surveyor reviewed Resident #8's medical records. Resident #8 was admitted to the facility with diagnoses which included, but were not limited to; adrenal insufficiency, glaucoma, and acromegaly (abnormal increased growth of bones and tissues). A review of the Physician Progress Notes revealed that from January 2024 to October 2024, the Nurse Practitioner documented that she had seen Resident #8 and written the Progress Notes. 1/15/24, 2/7/24,3/1/24,3/21/24, 4/2/24, 5/3/24. Review of the medical record revealed that the physician wrote a progress notes on 7/24/24. There was no documentation that Resident #8's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the Nurse Practitioner's visits. 2. Resident #22 was had diagnoses which included but were not limited to; acute kidney failure, heart failure, and Extended Spectrum Beta Lactamase (ESBL) Resistance, a carrier or suspected carrier of Clostridium difficile (C. Diff - a bacterium infection) and Cellulitis of right lower limb. A review of the Physician Progress Notes from January 2024 to November 2024, reflected that the Nurse Practitioner documented that she had seen Resident #22 almost weekly and written the following Progress Notes. A physician note was written 11/8/24 1/28/25, 3/7/25. There was no documentation that Resident #22's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the Nurse Practitioner visits. 3. Resident #76 was admitted to the facility with diagnosis which included, but were not limited to Dementia, left ankle fracture and frequent falls. Resident #76 had delayed speech and could not communicate clearly with the surveyor. A review of the Physician Progress Notes from November 2023 to March 2025, reflected that the Nurse Practitioner documented that she had seen Resident #76 almost weekly and documented Progress Notes. The physician completed the history and physical on 11/17/23 and there was no documented physician progress notes in the clinical record regarding that the physician alternating the visits with the Nurse Practitioner. On 3/28/25 at 11:18 AM, the Licensed Nursing Home Administrator (LNHA) provided the facility policy titled, Medical Service Physician Visits last revised 10/30/2024. The following were documented: A physician or advanced practice nurse shall visit each resident at least every 30 days. Following the initial visit, alternate 30-day visits may be delegated by physician to a Nurse Practitioner who possesses current licensure from the New Jersey State Board of Nursing in accordance with Home policy. Sick visits will be scheduled as needed. On 3/28/25 at 11:45 AM, the surveyor informed the Administrator and Director of Nursing regarding physician visits for Resident #8, #22 and #76. There was no additional information provided by the facility. NJAC 8:39-27.1

Based on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to provide a mechanically altered diet as the physician prescribed for 1 of 4 sampled resident (Resident #2), on 9/29/24, who had a Physician's Diet order for Mechanical Soft Ground texture. Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 their lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. CNA #2 responded to Resident #2's call light and observed the resident was blue and choking. The CNA #2 called the nursing staff who intervened by performing the Heimlich maneuver (abdominal thrust) which dislodged the hot dog from Resident #2's throat. This deficient practice created an Immediate Jeopardy (IJ) situation to the health and well-being of Resident #2 and the potential to affect all residents on a therapeutic diet at risk for serious injury or death if not served with the correct diet consistency. The IJ was identified on 10/10/24 at 8:13 p.m. and the IJ template was presented to the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON). The IJ began on 9/29/24 and continued through 10/11/24 when an acceptable removal plan was implemented and continues to run at a D level for no actual harm. A care plan initiated on 8/2/24 identified a problem of history of cerebral vascular accident (stroke) and dysphagia was updated on 10/8/24. An update was to supervise the resident during meals. On 10/10/24, the surveyor entered the resident's room with the assigned nurse (RN #1), and observed resident with the meal in front of him/her unsupervised and meal was partially eaten. The facility provided an acceptable Removal Plan on 10/11/24. On 10/15/24, the surveyor conducted a Removal Plan visit and verified that the Removal Plan was implemented. On 10/11/24, the facility implemented the Removal Plan, which included the following: The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident. Thirty six residents were identified that required assistance with meals. On 10/11/24, the Facility policies and procedures Therapeutic Diets were reviewed/revised. On 10/11/24, education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided. Mandatory in service was held on 10/11/24. All staff who could not attend was not be permitted to work until they completed the mandatory in service. The mandatory in service was added to the new hire orientation and for all future nursing and dietary personnel. On 10/11/24, a member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. A minimum of two managers were assigned at lunch time. On 10/11/24, the Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident. On 10/11/24, The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs. On 10/11/24, residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms. On 10/11/24, a member of the IDT team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. On 10/11/24, the Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. On 9/29/24, Certified Nursing Assistant (CNA) gave Resident #2 a regular consistency hot dog on a bun, who had a history of Dysphagia (difficulty swallowing) and Cerebral Infarction (stroke), and a physician's order for Mechanical Soft Ground textured diet. This caused the resident to choke, putting the resident at risk for serious harm or death which resulted in an immediate jeopardy (IJ). The Administrator and Director of Nursing (DON) were notified of the IJ on 10/10/24 at 8:15 p.m. and was provided the IJ template. The IJ began on 9/29/24 and continued thru 10/11/24. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Cerebral Infarction (stroke), and Dysphagia (difficulty swallowing). According to the Minimum Data Set (MDS), an assessment tool dated 8/8/24, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated that the Resident's cognition was moderately impaired. The MDS also indicated that the Resident was on a mechanically altered diet and required Partial/moderate assistance with eating. Review of the Care Plan (CP) initiated on 8/2/24, revealed under problem documented, Resident #2 has diagnosis (DX) Dysphagia - set up meals, needs cueing (refers to a signal or a stimulus that results in an action). Further review of the CP included an intervention of Diet as ordered: regular, ground texture . Review of the Order Summary Report (OSR) dated 10/8/24, revealed an active order for Mechanical Soft Ground texture for Resident #2. Review of Resident #2's Progress Notes (PN) dated 9/29/23 at 14:00 confirmed that Resident #2 had a choking episode. Further review of the PN, dated 9/29/24 at 14:00 revealed that the resident was blue and choking on his/her lunch. The aide called for help, all nurses helped performed upward compressions to chest to dislodge food, supervisor made aware and helped. A nursing student performed the Heimlich, helping to relieve what was stuck in his/her throat. Nursing narrative PN by nursing supervisor at 14:09 (2:09 p.m.) noted that chest x-ray (CXR) was ordered to rule out (r/o) aspiration and rib fractures status post (s/p) chest compressions due to choking on food. Review of the Facility Reportable Event (FRE) submitted to NJDOH (New Jersey Department of Health) for Resident #2, dated 9/29/24, indicated that on 9/29/24, CNA gave Resident #2 a hotdog on a bun that was inconsistent with resident's diet, which caused Resident #2 to choke, and airway was blocked. The nurses provided Heimlich Maneuver, suctioned Resident #2, and oxygen was initiated. The nursing staff was able to successfully remove the contents. Provider was made aware, and a chest x-ray was ordered. Review of statement from the FRE dated 9/29/24 from the Bistro staff (DS #3) indicated that the CNA asked for a hot dog, and he gave it to her. CNA did not ask him to chop it up, and she did not ask or told him who it was for. Review of a statement from the FRE dated 9/29/24 given by the assigned CNA (CNA #2) revealed that CNA chopped the hotdog that she received from the Bistro staff and gave to Resident #2 who was on a mechanical soft ground diet, then left Resident #2 to assist another resident. CNA was alerted by Resident #2's call bell and found Resident #2 blue and was choking on hot dog that he/she gave to Resident #2. In an interview with CNA #2 on 10/18/24 at 3:04 p.m., CNA stated that if a resident asked for an item on the alternative menu, he/she was to verify with the nurse or dietician. CNA #2 confirmed that he/she did not verify with the dietician because it was a weekend and the dietician was not at the facility, and that he/she also did not verify with the nurse. CNA #2 further stated that he/she was aware of Resident #2's diet, saw pictures in the nursing documentation room, was in-serviced on types of diet, had access to verify on Point of Care (POC), and was aware of what a mechanical soft ground consistency diet looked like. CNA #2 admitted that the consistency of the hot dog given to Resident #2 was not the consistency the doctor ordered, and further stated that Resident #2 should not have been given the chopped hot dog because he/she was unable to chew it properly, and it was a choking hazard. In an interview with the Bistro staff (DS #3) on 10/21/24 at 11:45 a.m., DS #3 stated he received the hot dog in a plastic container labeled with Resident #2's information on it. DS #3 stated that he saw that the resident was on a regular diet but did not saw that resident was on a mechanical soft ground textured diet. DS #3 further stated that he was the only staff working in the Bistro on 9/29/24. DS #3 stated that the Bistro staff does not alter any items that was sent up from the kitchen. According to an Incident Investigation form dated 9/29/2024 the facility indicated that residents who were on mechanically altered diets were to be encouraged to eat in the Bistro and if they declined and ate in their room, they would be supervised during their meal. In an interview with Resident #2 on 10/8/24 at 12:46 p.m., Resident #2 stated, I could not breathe, I felt like I was going to pass out. Now I look the food over before I eat it and make sure it is not too big. Now I am apprehensive each time I have to eat, because I am worried it's going to be too big of pieces that I can't swallow. On 10/10/24 at 10:33 a.m., surveyor observed along with Resident #2's assigned nurse (RN #1), Resident #2 in his/her room in bed with bedside table across bed in front of Resident #2 with a plate of scrambled egg (mashed) and ground sausage link (ground), and Resident #2 was unsupervised. In an interview with RN #1 on 10/10/24 at 10:58 a.m., RN #1 stated that she had not received in-service since Resident #2's choking incident on 9/29/24. In an interview with the Administrator on 10/10/24 at 12:24 p.m., the administrator stated that the Bistro staff and CNA should have confirmed which resident the meal was for, and that the Bistro staff should have verified which resident was getting the hot dog, so the resident got the appropriate diet to prevent choking. Further interview with the administrator at 1:13 p.m. confirmed that residents who were on an altered diet who did not go to the Bistro must be supervised. Administrator stated that Resident #2 should not have been in his/her room with tray table with breakfast in front of him/her unsupervised. Administrator also stated that Resident #2 had a choking event and should not have had a breakfast plate in front of him/her unattended. In an interview with the Education Manager on 10/10/24 at 11:55 a.m. revealed that the emergency in-service on dietary orders and types was given with focus on nursing staff for 7:00 a.m. - 3:00 p.m. shift and 3:00 p.m. - 11:00 p.m. shift. The Education Manager stated that she has not done an in-service with the 11:00 p.m. - 7:00 a.m. shift. The Education Manager stated that the nursing staff that was not present for the in-service post incident, has not received in-service as of today 10/10/2024. The Education Manager further stated that the possibility existed that an 11 p.m. - 7:00 a.m. staff could work 7:00 a.m. - 3:00 p.m. or 3:00 p.m. to 111:00 p.m. Review of a document titled, 'Orientation Checklist' for CNA #2 dated 7/17/24, showed that CNA #2 met the understanding of Resident Nutrition including food consistency. Review of the LCS Operations Procedures & Quality Standards Manual dated LCS 2015, below Therapeutic Menu Planning, displayed that Mechanical soft: this diet offers food that are easily chewed and often recommended for patients with digestive problems or chewing and swallowing difficulties. In the same manual below Guidelines for Observing Meal Services, in Posted Mealtimes displayed, Therapeutic diets served correctly - check tray card/menu slip versus menu on board next to steam table versus food served, and Mechanically altered diets served correctly. Review of the undated policy named, Food and Nutrition Services revealed: Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, and If an incorrect meal is provided to a resident ., nursing staff will report it to the food service manager so that a new food tray can be issued. Review of the undated policy named Ordering off of the Alternate Menu, showed that if a resident ordered an item off the always available menu, their food is then checked against their diet order, texture order, and all allergies. 8:39-17.4(a)(1)

Based on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to provide a therapeutic diet for 1 of 4 sampled residents (Resident #2) on 9/29/2024, who had a Physician's Diet order for Mechanical Soft Ground texture. Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 with lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. CNA #2 responded to Resident #2's call light and observed the resident was blue and choking. The CNA #2 called the nursing staff who intervened by performing the Heimlich maneuver (abdominal thrust) which dislodged the hot dog from Resident #2's throat. This deficient practice created an Immediate Jeopardy (IJ) situation to the health and well-being of Resident #2 and the potential to affect all residents on a therapeutic diet at risk for serious injury or death if not served with the correct diet consistency. The IJ was identified on 10/10/24 at 8:13 p.m. and the IJ template was presented to the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON). The IJ began on 9/29/24 and continued through 10/11/24 when an acceptable removal plan was implemented and continues to run at a D level for no actual harm. A care plan initiated on 8/2/24 identified a problem of history of cerebral vascular accident (stroke) and dysphagia was updated on 10/8/24. An update was to supervise the resident during meals. On 10/10/24, the surveyor entered the resident's room with the assigned nurse (RN #1), and observed resident with the meal in front of him/her unsupervised and meal was partially eaten. The facility provided an acceptable Removal Plan on 10/11/24. On 10/15/24, the surveyor conducted a Removal Plan visit and verified that the Removal Plan was implemented. On 10/11/24, the facility implemented the Removal Plan, which included the following: The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident. Thirty six residents were identified that required assistance with meals. On 10/11/24, the Facility policies and procedures Therapeutic Diets were reviewed/revised. On 10/11/24, education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided. Mandatory in service was held on 10/11/24. All staff who could not attend was not be permitted to work until they completed the mandatory in service. The mandatory in service was added to the new hire orientation and for all future nursing and dietary personnel. On 10/11/24, a member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. A minimum of two managers were assigned at lunch time. On 10/11/24, the Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident. On 10/11/24, The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs. On 10/11/24, residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms. On 10/11/24, a member of the IDT team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. On 10/11/24, the Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. Review of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) for resident [Resident #2], dated 9/29/24, indicated that on 9/29/24, Resident #2 was given a meal tray during lunch service, that consisted of hotdog on a bun by the assigned CNA [CNA #2]. The CNA then left Resident #2, and later saw the call light on, went to Resident #2's room, and saw Resident #2 choking. CNA #2 called nursing staff who intervened by performing the Heimlich Maneuver (abdominal thrust), which dislodged the hot dog from Resident #2's throat. According to the Admission Record Face Sheet, Resident #2 was admitted to the facility on [DATE], with diagnosis that included but were not limited: Cerebral Infarction (stroke) and Dysphagia (difficulty swallowing). The Minimum Data Set (MDS), an assessment tool dated 8/8/24, showed that the Resident had a Brief Interview for Mental Status (BIMS) score of 09/15, which indicated that the Resident had moderate impairment in cognition. The MDS also indicated that the Resident was on a mechanically altered diet and required Partial/moderate assistance with eating. According to Resident #2's Care Plan initiated on 8/02/2024, Resident #2 had a history of Cerebral Vascular Accident (CVA) [Stroke], left sided weakness, and diagnosed with Dysphagia - set up for meals, needs cueing. Interventions included but not limited to Diet as ordered, monitor for signs and symptoms (s/s) aspiration. Care Plan initiated on 08/06/2024 showed Resident #2 is at nutritional risk as evidenced by mechanically altered diet due to but were not limited to Cerebral Infarction and Dysphagia. Interventions included but not limited to Diet as ordered: regular, ground textured with thin liquids. A review of the Physician's Orders on Order Summary Report dated 10/8/24, showed an order for Mechanical ground Soft Ground texture. It further showed, Diet order - Resident receives physician ordered diet every shift. Regular diet, Mechanical Soft Ground texture. Review of Resident #2's Progress Notes (PN), dated 9/29/23 at 14:00, revealed that Resident #2 had a choking episode. Resident placed call light on, when aide entered room, resident was blue and choking on her lunch. The aide called for help, all nurses helped perform upward compressions to chest to dislodge food, supervisor was notified and helped as well. One of the student nurses performed the Heimlich, helping relieve what was stuck in her throat. Further review of progress notes at 14:09 revealed that chest x-ray (CXR) was ordered to rule out (r/o) aspiration and rib fracture (fx) status post (s/p) chest compressions due to choking on food. During an interview with the Registered Dietician/Clinical Nutrition Manager on 10/8/24 at 10:14 a.m., she confirmed that Resident #2's was ordered ground diet and that a mechanical soft ground diet should have been delivered to resident. During an interview with Resident #2 on 10/8/24 at 12:46 p.m., Resident #2 stated, I could not breathe, I felt like I was going to pass out. Now I look the food over before I eat it and make sure it is not too big. Now I am apprehensive each time I have to eat, because I am worried it's going to be too big of pieces that I can't swallow. During an interview with the Speech Therapist on 10/8/24 at 1:42 p.m., she stated that Resident #2 had a Fiberoptic Endoscopic Evaluation Swallow (FEES) [procedure used to assess how well you swallow] test was done at facility while in subacute and maintained same diet when transferred to Long Term Care (LTC), mechanical soft ground. Speech Therapist stated that speech therapy became involved about 4 weeks ago when Resident #2 requested to eat a higher texture which included cereal and blueberry. Speech Therapist stated Resident #2 was evaluated and it was determined that it was not safe for Resident #2's diet to be upgraded. Speech Therapist further stated that there was an always available menu and that the items are not readily available in modified textures. She also stated that the CNA should have also checked to make sure the resident received the appropriate diet. During an interview with the Administrator on 10/8/24 at 3:30 p.m., he confirmed that the hot dog was whole and that it was not the consistency per doctor order. During an interview with the Executive Director of Dining Services (DS#6) on 10/10/24 at 9:31 a.m., he stated, Residents are offered what is on the menu. For alternative/everyday menu, resident may request from nursing staff any item off the alternate menu. The nursing staff should go to the Bistro staff and ask them to call the kitchen to order item. If an order is requested for mechanical soft ground, it would be prepared as ordered. DS#5 further stated that Resident #2 should not have received a whole hot dog as it is a choking hazard, could choke, and was on a therapeutic diet. During an interview with Resident Experience Manager - Dining Services (DS # 5) on 10/10/24 at 9:48 a.m., he stated that Resident #2 should not have received a whole hot dog because he/she could choke. During observation of a whole hot dog processed into mechanical soft ground texture, on 10/10/24 at 9:59 a.m., the Lead [NAME] - Dining Services (DS #4) placed hot dog in a steamer for 5 minutes, temperature checked for doneness, temperature was 178.5 degrees, then placed in robot coupe, pulse mode used for proper consistency, then transferred to 8 size pan to be transported to the Bistro. During the meal observation in the presence of Resident #2's assigned nurse (RN #1) on 10/10/24 at 10:33 a.m., the surveyor observed that Resident #2 was served a breakfast tray which consisted of scrambled egg (mashed) and ground sausage link (ground), and no staff was in the room with resident during meal. During interview with LEA Dining Services (DS #2) on 10/10/24 at 10:45 a.m., she stated, If a CNA asked for a regular hot dog, which is not on a regular menu, I call the kitchen and request the hot dog. I need to know the name of the resident and I know the type of diet. DS #2 also stated, It is not normal practice for Dining Room Services staff to hand a CNA a hot dog without verifying which resident gets it, because they all have different diets. If a resident who is on a mechanical soft ground diet, received a regular hot dog that is not on regular, the resident can choke on it. DS #2 further stated that Resident #2 should not have received this hot dog. During an interview on 10/10/24 at 10:58 a.m. with RN #1, she stated that CNA should never have given Resident #2 who is on a mechanical soft ground textured diet, a whole hot dog. RN #1 also confirmed that today, Resident #2 had a breakfast tray in front of him/her and no staff was supervising resident during breakfast in Resident #2's room. RN #1 further stated that she was not in-serviced since Resident #2's choking incident on 9/29/24 and is not aware of any new instruction regarding resident eating in his/her room. During an interview with the Administrator, on 10/10/24 at 11:44am, he stated that an emergency in-service was completed with the 7:00 a.m. - 3:00 p.m. shift and 3:00 p.m. - 11:00 p.m. shift, and not 11:00 p.m. - 7:00 a.m. The administrator also stated that not all nursing staff was in-serviced since the incident on 9/29/24. During a follow up survey with the Administrator on 10/10/24 at 12:14 p.m., the Administrator stated that there was no ticket for always available menu, and that the nursing staff should have confirmed which resident the meal was for. The Administrator further stated that the Bistro staff should have verified which appropriate diet to prevent choking. During an interview with the Education Manager on 10/10/24 at 11:55 a.m., she stated that she had not trained or in-serviced the 11:00 p.m. - 7:00 a.m. shift. The Education Manager confirmed that there is a possibility that the 11:00 p.m. - 7:00 a.m. shift could work on 7:00 a.m. - 11:00 p.m. and 3:00 p.m. - 11:00 p.m. shift. The Education Manager further stated that no 11:00 p.m. - 7:00 a.m. nursing staff was in-serviced since incident occurred on 9/29/24. During a follow up interview with the Administrator on 10/10/24 at 1:13 p.m., he stated that residents who were on altered diet who do not go to the Bistro, must be supervised. The Administrator stated that Resident #2 should not have been in his/her room with tray table with breakfast in front of him/her unsupervised as observed by surveyor on 10/10/24 at 10:33 a.m. The administrator further stated that Resident #2 had a choking event and should not have had a breakfast plate in front of her unattended. During an interview with Certified Nurse Aide (CNA #2) on 10/18/24 at 3:04 p.m., CNA #2, who was assigned to Resident #2 on 9/29/24, stated that she did not remember the name of the Bistro staff and that she was not a regular staff who gave her the lunch tray for Resident #2 prior to serving the tray to the Resident. CNA #2 stated that when resident requested an item from the alternative, meal, it should be verified by a nurse or dietician. CNA #2 confirmed that she asked neither nurse nor dietician for verification. CNA #2 stated that she used the Point of Care (POC), which guided the care of the residents and had the diet type included. CNA #2 stated that she had been in-serviced on types of diet, and that pictures of the types of diet were in the nursing charting room and was aware of the consistency for Resident #2 as ordered by the doctor. The CNA stated that she received a note with Resident #2's tray to chop hotdog, so she chopped up the hot dog, and gave to Resident #2. CNA #2 confirmed the chopped consistency was not the consistency that was ordered by the doctor for Resident #2 but was mechanical soft ground. When asked, CNA #2 confirmed that Resident #2 should not have received the hot dog in a chopped consistency because it was not safe for the resident, he/she could not properly chew, which was a choking hazard and could aspirate on it. During an interview with the Bistro staff (DS #3) on 10/21/24 at 11:45 a.m., DS #3 stated he was the only staff working in the Bistro on 9/29/24. DS #3 stated that the hot dog was already sent up from the kitchen in an isolation box/ plastic container with resident's name on it. DS #3 further stated that the Bistro staff does not alter any items sent up from the kitchen. A review of the policy titled, Bistro Dining with a Revision date of 11/14, showed, All food is prepared in the main kitchen and delivered to the Bistro kitchens for services. It further stated under Residents who are Unavailable for Bistro Dining, that for residents who are unable to attend scheduled bistro meal service, a tray will be made in the Bistro kitchen according to the Resident's dining slip, and that trays will be delivered by the nursing staff. A review of the policy titled, Therapeutic Diets, with procedure effective date of 8/2/19 and procedure review date of 9/30/24, showed under Policy: A therapeutic diet must be prescribed by the resident's attending physician. It further stated that a therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. If mechanically altered diet is ordered, the provider will specify the texture modification. The following dietary consistencies are available: Regular diet - normal everyday foods of soft/tender texture. Mechanical soft ground - meat and other foods diced to 1/8 inch or restricted to make the food easier to chew and/or swallow. A review of the undated policy titled, Food and Nutrition Services showed: Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, and If an incorrect meal is provided to a resident ., nursing staff will report it to the food service manager so that a new food tray can be issued. A review of the undated policy titled Ordering off of the Alternate Menu, showed that if a resident ordered an item off the always available menu, their food is then checked against their diet order, texture order, and all allergies. The order is then plugged into an excel spreadsheet for consistency and transparency for the staff. Any questionable items will be emailed to the dietician to be approved or denied before the list goes to the cooks. The final order is then delivered to the cafe for preparation of regular texture items and to the back of the house cook who prepares textures for any modified items. Our lead cooks validate the consistency of any modified texture items. A review of the LCS Operations Procedures & Quality Standards Manual dated LCS 2015, under Therapeutic Menu Planning, showed that Mechanical soft: this diet offers food that are easily chewed and often recommended for patients with digestive problems or chewing and swallowing difficulties. Also, under the same manual under Guidelines for Observing Meal Services, under Posted Mealtimes displayed, Therapeutic diets served correctly - check tray card/menu slip versus menu on board next to steam table versus food served, and Mechanically altered diets served correctly. NJAC 8:39 17.4 (a) (1)(2) 8:39 27.1(a)

Based on observation, interviews and record review, as well as review of pertinent facility documents on 10/08/24 and 10/10/24, it was determined that the facility failed to implement a care plan dated 8/06/2024 that identified a nutritional risk. The care plan revised on 8/6/24 listed a ground texture diet with thin liquids as an intervention. On 9/29/24, Resident #2, with a diagnosis of Dysphagia (difficulty swallowing) and Cerebral Infarction (Stroke), had a Physician's Diet order for Mechanical Soft Ground texture, was served a regular consistency hot dog on a bun by the assigned Certified Nursing Assistant (CNA #2). After serving Resident #2 their lunch tray, CNA #2 left and went to assist another resident. On her way out of assisting the other resident, CNA #2 observed Resident #2's call light on. CNA #2 responded to Resident #2's call light and observed the resident was blue and choking. The CNA #2 called the nursing staff who intervened by performing the Heimlich maneuver (abdominal thrust) which dislodged the hot dog from Resident #2's throat. This deficient practice created an Immediate Jeopardy (IJ) situation to the health and well-being of Resident #2 and the potential to affect all residents on a therapeutic diet at risk for serious injury or death if not served with the correct diet consistency. The IJ was identified on 10/10/24 at 8:13 p.m. and the IJ template was presented to the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON). The IJ began on 9/29/24 and continued through 10/11/24 when an acceptable removal plan was implemented and continues to run at a D level for no actual harm. A care plan initiated on 8/2/24 identified a problem of history of cerebral vascular accident (stroke) and dysphagia was updated on 10/8/24. An update was to supervise the resident during meals. On 10/10/24, the surveyor entered the resident's room with the assigned nurse (RN #1), and observed resident with the meal in front of him/her unsupervised and meal was partially eaten. The facility provided an acceptable Removal Plan on 10/11/24. On 10/15/24, the surveyor conducted a Removal Plan visit and verified that the Removal Plan was implemented. On 10/11/24, the facility implemented the Removal Plan, which included the following: The Director of Nursing conducted an audit to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray card information for each resident. Thirty six residents were identified that required assistance with meals. On 10/11/24, the Facility policies and procedures Therapeutic Diets were reviewed/revised. On 10/11/24, education was provided to the staff by the Staff Educator or designee regarding applicable facility policies and procedures titled Therapeutic Diets, diet consistency, compliance with resident-specific dietary interventions, supervision and food preparation consistent with each resident's dietary order including when a mandatory snack or alternative meal is provided. Mandatory in service was held on 10/11/24. All staff who could not attend was not be permitted to work until they completed the mandatory in service. The mandatory in service was added to the new hire orientation and for all future nursing and dietary personnel. On 10/11/24, a member of the Interdisciplinary Team (IDT) team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. A minimum of two managers were assigned at lunch time. On 10/11/24, the Director of Nursing or Designee audited all new admissions to ensure the dietary orders/recommendations/documentation were accurate in the medical record and matched the dietary department's tray card information for that resident. On 10/11/24, The Dietary Manager or designee monitored food preparation at all three meals and compared the meal and or snacks being prepared to the physician order/documentation for each resident's dietary needs. On 10/11/24, residents requiring assistance and or supervision with meals were encouraged to eat in the bistro, and residents who preferred to eat in their room were noted on the resident Kardex. A staff member was assigned to assist these residents during mealtime in the bistro and or resident rooms. On 10/11/24, a member of the IDT team and or nurse was assigned to each floor to monitor staff compliance with supervision at mealtimes. On 10/11/24, the Administrator implemented a Quality Assurance and Performance Improvement (QAPI) Performance Improvement Projects (PIP) in order to gather and process information from the audits/monitoring processes and findings to be reported at the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with diagnoses that included but were not limited to Cerebral Infarction (stroke), and Dysphagia (difficulty swallowing). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/8/24, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated that the Resident's cognition was moderately impaired. The MDS also indicated that the Resident was on a mechanically altered diet and required Partial/moderate assistance with eating. Review of Resident #2's Care Plan (CP) initiated on 8/2/24, identified the followings as problems: History of (H/O) CVA left sided weakness, Diagnosis (DX) of Dysphagia - set up meals, needs cueing (refers to a signal or a stimulus that results in an action). Under Interventions, section of the CP, revealed the following interventions including but not limited to: Encourage rest periods as needed, Diet as ordered: regular, ground texture . Resident #2 CP initiated on 8/02/2024 with a problem of history of cerebral vascular accident was revised post incident on 10/08/2024. The revision included the following interventions including but not limited to: Ensure resident is sitting upright during meals, monitor resident for any coughing during meals, and supervise the resident during meals. Review of the Order Summary Report (OSR) dated 10/8/24, showed an active order for Mechanical Soft Ground texture for Resident #2. Review of Resident #2's Progress Notes (PN), dated 9/29/23 at 14:00, revealed that Resident #2 had a choking episode. Resident placed call light on, when aide entered room, resident was blue and choking on her lunch. The aide called for help, all nurses helped perform upward compressions to chest to dislodge food, supervisor was notified and helped as well. One of the student nurses performed the Heimlich, helping relieve what was stuck in her throat. Further review of progress notes at 14:09 revealed that chest x-ray (CXR) was ordered to rule out (r/o) aspiration and rib fracture (fx) status post (s/p) chest compressions due to choking on food. Review of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) for resident [Resident #2], dated 9/29/24, indicated that on 9/29/24 Resident #2 was given a meal tray that consisted of hotdog on a bun by the assigned CNA [CNA #2]. A short time after tray was delivered to Resident #2, she was observed Resident #2 choking. CNA #2 made nursing staff aware that Resident #2 was choking and responded immediately. The nurses performed the Heimlich Maneuver (abdominal thrust), suctioning, and applied oxygen. The nursing staff successfully dislodged the hot dog from Resident #2's throat. Provider was made aware, and a chest x-ray was ordered. Review of the FRE statement dated 9/29/24 from the Bistro staff (DS #3) indicated that the CNA (CNA #2) asked for a hot dog, and he gave it to her. DS #3 further stated that CNA #2 did not ask him to chop up the hotdog, and she did not ask or told him who it was for. Review of the FRE statement dated 9/29/24 from the assigned CNA (CNA #2) revealed that CNA #2 chopped up the hotdog that she received from the Bistro staff and gave it to Resident #2 who was on a mechanical soft ground diet. CNA #2 stated that she then left Resident #2 to assist another resident, was alerted by Resident #2's call bell, and found Resident #2 blue and was choking on hot dog that she gave to Resident #2. In an interview with Resident #2 on 10/8/24 at 12:46 p.m., Resident #2 stated, I could not breathe, I felt like I was going to pass out. Now I look the food over before I eat it and make sure it is not too big. Now I am apprehensive each time I have to eat, because I am worried it's going to be too big of pieces that I can't swallow. In an interview with Resident #2's assigned CNA (CNA #2) on 10/18/24 at 3:04 p.m., revealed that if a resident asked for an item on the alternative menu, it should be verified with the nurse or dietician. CNA #2 confirmed that she did not verify with the dietician because it was a weekend and the dietician was not at facility, and she also did not verify with the nurse. CNA #2 stated that she was aware of Resident #2's diet, saw pictures in the nursing documentation room, was in-serviced on the various types of diet, had access to verify resident's diet on the Point of Care (POC) system, and was aware of what a mechanical soft ground consistency diet looked like. CNA #2 admitted that she received a regular hot dog from the Bistro staff (DS #3), she chopped up the hot dog. CNA #2 confirmed that it was not the consistency the doctor ordered when she gave it to Resident #2. CNA #2 stated that Resident #2 should not have been given chopped hot dog because Resident #2 was unable to chew it properly, and it was a choking hazard. In an interview with the Bistro staff (DS #3) on 10 /21/24 at 11:45 a.m., he stated that he received the hot dog from the kitchen in a plastic container labeled with Resident #2's information on it. DS #3 stated that he saw that the resident was on a regular diet but did not saw that resident was on a mechanical soft ground textured diet. According to an Incident Investigation form dated 9/29/2024, the facility indicated that residents who were on mechanically altered diets were to be encouraged to eat in the Bistro area. If a resident with mechanically altered diet refused to eat in the Bistro, this must be reflected in the care plan. Those residents and if they declined and ate in their room, they would be supervised during their meal. On 10/10/24 at 10:33 a.m., the surveyor entered the Resident #2's room with the assigned Registered Nurse (RN), and Resident #2 was observed with his/her meal in front of him/her unsupervised. The resident stated that he/she had eaten some of the meal. In an interview with the assigned nurse for Resident #2 (RN #1) on 10/10/24 at 10:58 a.m., RN #1 confirmed with surveyor that she had not received any in-service since Resident #2's choking incident on 9/29/24. In an interview with the Administrator on 10/10/24 at 11:44 a.m., the Administrator confirmed that Resident #2 should not have been in his/her room with tray table with breakfast in front of him/her unsupervised. Administrator also stated that Resident #2 had a choking event and should not have had a breakfast plate in front of him/her unattended. A review of the 'Orientation Checklist' for CNA #2 dated 7/17/24, indicated that CNA #2 met the understanding of Resident Nutrition including food consistency. A review of an undated policy named, Food and Nutrition Services showed, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, and If an incorrect meal is provided to a resident ., nursing staff will report it to the food service manager so that a new food tray can be issued. A review of an undated policy called Ordering off of the Alternate Menu, showed that if a resident ordered an item off the always available menu, their food is then checked against their diet order, texture order, and all allergies. NJAC 8:39-11.1

Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to a.) ensure respiratory equipment was kept in a clean and sanitary condition to prevent infection and ensure a portable oxygen tank was stored in accordance with facility policy and b.) develop an individualized care plan for the administration and treatment of oxygen. This deficient practice was identified for 1 of 1 residents reviewed for respiratory equipment (Resident #66), and the evidence was as follows: According to the facility's Admission Record face sheet (an admission summary), Resident #66 was admitted to the facility with diagnoses that included but were not limited to heart failure (ineffective heart pumping resulting in fluid build-up in lungs), ischemic cardiomyopathy (weakened heart muscles due to heart disease), and asthma. A review of a the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 5/29/23, revealed the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. A further review revealed the resident received oxygen. A review of the resident's Order Summary Report revealed an order dated 11/20/22 for continuous oxygen (O2) at three liters per minute (3 lpm) via nasal cannula (NC, the part of the tubing that rests in the nose); check pulse oximeter (POX, measures oxygen saturation in the blood) every shift. A review of Resident #66's corresponding June 2023 Treatment Administration Record (TAR) included the above physician's order and was documented as administered. A review of Resident #66's individualized comprehensive care plan (ICCP) did not include oxygen care and usage. On 6/21/23 at 9:50 AM, during the initial tour of the New Hope Unit, the surveyor observed a portable oxygen tank in a black bag hanging from the wheelchair in Resident #66's room. The undated oxygen tubing was observed connected to the tank and the NC was observed resting on the floor. On 6/22/23 at 9:19 AM, in Resident #66's room, the surveyor observed a portable oxygen tank in a black bag resting on the floor in front of the wheelchair. The undated oxygen tubing was connected to the tank and the NC was resting on the floor. On 6/26/23 at 11:15 AM, in Resident #66's room, the surveyor observed a portable oxygen tank in a black bag resting on the floor in front of the wheelchair. The undated oxygen tubing was connected to the tank and was rolled up and hung on top of the tank. The resident acknowledged that it was the tank that he/she used when they left the facility for their appointment on 6/23/23 and stated, The bag slips over the handle of the wheelchair. 1. On 6/26/23 at 11:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) caring for Resident #66 who stated that the resident was ordered oxygen to be worn at all times, and that when he/she left the building that they wore oxygen from the portable tank that hung in a black bag off the back of the wheelchair. Together, the surveyor and the LPN observed a portable oxygen tank on the floor in the resident's room and the LPN acknowledged that it was the tank that the resident had left the facility with on 6/23/23. The LPN stated the tank should not have been resting on the floor, and that she was unsure how old the NC tubing was because it was not dated. The LPN stated it was important to keep the equipment off the floor to keep it as clean as possible because it could have gotten dust, dirt, or germs on it. She then removed the tank and tubing from the room. On 6/26/23 at 12:26 PM, the surveyor interviewed the Neighborhood Manager (NM) who stated that NC tubing was dated and changed weekly and that portable oxygen tanks were stored in an oxygen closet in a stand. The surveyor informed the NM of Resident #66's portable oxygen tank observations. The NM acknowledged that the portable oxygen tank should not have been stored on the ground in a resident's room and that it was important for infection control to keep the NC tubing off the ground. On 6/26/23 at 12:40 PM, the surveyor interviewed the Director of Nursing (DON) who stated that portable oxygen tanks were kept in a storage closet on each unit and that once a tank was used, that it would be replaced to the closet. The surveyor informed the DON of Resident #66's portable oxygen tank observations. The DON acknowledged that there should not have been an unused portable oxygen tank left in a resident's room. The DON stated that for safety purposes, the oxygen tank should have been secured and that for infection control, the NC tubing should have been dated and should not have been resting on the floor. 2. On 6/27/23 at 12:12 PM, the surveyor interviewed the Registered Nurse (RN) caring for Resident #66. The RN stated that an ICCP was put together for each resident with their diagnosis, plans for care, assessments and evaluations and that the nurse was able to add or update the ICCP at any time. The RN acknowledged that she would expect to see oxygen on an ICCP, and that it was important to include on the ICCP how many liters of oxygen were ordered and any oxygen treatments for the resident in case of shortness of breath. In the surveyor's presence, the RN reviewed Resident #66's ICCP and stated she did not see oxygen listed. On 6/27/23 at 12:20 PM, the surveyor interviewed the NM who stated that an ICCP was a resource used to provide the desired care and a picture of the resident's needs. He stated that it was created and updated by the interdisciplinary team and that every discipline was able to update it. The NM stated that he would have expected to see a respiratory ICCP that mentioned oxygen therapy or an actual order that the resident was on oxygen. The NM acknowledged that Resident #66 wore oxygen continuously. In the surveyor's presence, the NM reviewed Resident #66's ICCP and stated he did not see oxygen listed, and that oxygen should have been on the ICCP. He further stated that it was important to include oxygen on the ICCP so that everyone could have made sure the resident was provided appropriate care. On 6/27/23 at 12:26 PM, the surveyor interviewed the DON who stated that an ICCP listed the care that the resident required and that the nurse should have been familiar with each resident's ICCP and should have reviewed the ICCP for any updates. The DON stated that if a resident was on oxygen, that she would have expected to see oxygen on the ICCP. In the surveyor's presence, the DON reviewed Resident #66's ICCP and acknowledged she it did not include oxygen, and that oxygen should have been included. She further stated that it was important for oxygen to be on the ICCP so that everyone would have known what the plan was for the resident's oxygen usage. On 6/28/23 at 11:09 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that oxygen tanks were stored in the oxygen closets and that if a resident needed portable oxygen, that the nurse retrieved a portable tank from the closet and placed it in a sling bag on the resident's wheelchair, or may use the rollator (metal bracket on wheels that holds the portable oxygen tank). The LNHA stated the portable oxygen tanks should not have been stored in resident's rooms, the tanks should have always been in a holder off the floor and the NC tubing should not have been resting on the floor. The surveyor informed the LNHA of Resident #66's portable oxygen tank observations. The LNHA acknowledged that the portable oxygen tank should not have been stored on the floor in the resident's room and that it should have been in the oxygen closet, and that the NC tubing should have been dated and secured in a plastic bag. During the same interview, the LNHA stated that an ICCP was a plan of care provided to each resident while at the facility. She stated that the ICCP was completed by the interdisciplinary care team, that everyone contributed based on the needs of the resident, and that it was used by all clinical team members. The LNHA stated that if a resident was ordered continuous oxygen, that she would have expected to see oxygen on the ICCP. She further stated that it was important for oxygen to be included on the ICCP so that the team was made aware that the resident was on oxygen, any breathing issues would have been monitored, it would have been used to confirm the correct amount of oxygen was being administered, and that if the resident were to go out to an appointment that they would have been aware that the resident would have needed continuous oxygen. A review of facility's Oxygen, policy dated revised 8/6/22, included A. Storage, Oxygen is to be kept in designated areas on the nursing units except when in use . 2. Portable O2 (oxygen) tanks will be available and secured in a rack .C. Safety .2. Oxygen must be kept in a stand or cart . D. Method of Delivery, O2 will be administered via nasal cannula unless otherwise specified by physician order. Nasal cannula to be changed weekly and PRN (as needed) . A review of facility's Care Planning, policy dated revised 8/1/21, included .I. Procedure .B. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. C. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .e. Reflect treatment goals, timetables and objectives in measurable outcomes .g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels . E .the care plan outlines those individualized interventions to specifically address the resident's issues . NJAC 8:39-11.2(e), 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) clarify and accurately transcribe a physician's order for an enema (a medication used to relieve constipation); b.) document the administration of the enema; c.) obtain physician's orders in accordance with professional standards of practice for tube feeding for the flushing of water before and after medication pass and checking residual to ensure accountability and consistency. The deficient practice was identified for 2 of 20 residents reviewed for professional standards of practice (Resident #43 and #778) 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 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 prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 6/21/23 at 10:23 AM, the surveyor observed Resident #43 sitting in their chair eating breakfast. At this time, Resident #43 advised that they were admitted to the facility on a Thursday and went back to the hospital that Saturday for a bowel impaction. The resident reported to the surveyor that they informed the facility upon admission they have not had a bowel movement and was told that it was a result of the pain medication. The surveyor reviewed the medical record for Resident #43. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in May of 2023, with diagnoses which included closed fracture of the left hip. A review of the admission Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the Physician Progress Notes included a note dated 5/5/23 at 9:18 AM, that indicated no [bowel movement] since 4/29 give enema (medication used for constipation) [one time] today. The note did not include if the enema was administered. A review of the May 2023 Physician Summary Report did not include the one time order for the enema ordered by the Physician on 5/5/23. A review of the corresponding May 2023 Treatment Administration Record (TAR) and Medication Administration Record (MAR) did not include the administration of the enema on 5/5/23 or 5/6/23. On 6/26/23 at 10:24 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who confirmed that the nurses were responsible for putting in physician orders. On 6/25/23 at 12:47 PM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #1) who confirmed there was documentation that the order for the enema was entered, reconciled, or even that the order was relayed to the nurse and administered. When asked who had the responsibility for transcribing physician orders, the UM/LPN #1 stated everyone had the responsibility to make sure orders were transcribed. On 6/26/23 at 1:38 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that there was no documentation that the order for the enema was carried out. When asked who had the responsibility for transcribing physicians orders the DON stated, the nurse that is assigned typically. On 6/28/23 at 10:40 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, stated that the resident received the enema on 5/5/23, as ordered by the Physician, but the nurse forgot to input the physician order into the medical record as well as document the administration of the enema. The LNHA further stated that she spoke to the resident who confirmed the enema was administered as ordered, as well as the resident requested to be transferred to the hospital instead of receiving a second enema on 5/6/23. On 6/30/23 at 9:30 AM, LNHA in the presence of the DON, Administrator in Training, and survey team confirmed that the nurse who received the verbal order was responsible for putting into the medical record. The LNHA continued anytime a verbal order was taken it should be documented, input on the MAR and TAR, and documented as administered. A review the facility's Telephone and Verbal Orders policy dated 1/5/21 and last reviewed on 1/9/23, included .2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe order on his or her behalf. 4. The individual receiving the verbal order must write it on the physicians order sheet as v.o. (verbal order) or t.o. 43308 2. On 6/22/23 at 9:30 AM, the surveyor observed Resident #778 lying in bed watching television and who stated that he/she was doing okay, and everything was fine. At that time, Licensed Practical Nurse (LPN #1) informed the surveyor and the resident that the tube feeding was completed and would go back up at 3:00 PM. LPN #1 then took down the empty bottle of Jevity 1.5 (nutrition formula); and placed a clean white towel on top of the resident's abdomen near the feeding tube (FT; tube inserted into the stomach for nutrition) to prevent any leakage. LPN #1 took out her stethoscope and used a disinfectant wipe to clean it. She informed the resident she was going to listen for the placement of the FT. She then used a syringe and checked the gastric residual volume. She then informed the resident she was going to administer the medication gabapentin (treat seizures and nerve pain) 300 milligrams (mg). LPN #1 grabbed a four ounce (4 oz) plastic cup filled with water and poured some of the water down the FT and informed the resident she was flushing the FT with water. She then administered the gabapentin crushed mixed with water into the FT. LPN #1 then grabbed the 4 oz plastic cup again and poured some more water into the FT. LPN #1 stated that she was flushing with water again. She then informed the resident she was going to change her gown and gloves to change the FT dressing. The surveyor reviewed the medical record for Resident #778. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility June of 2023, with diagnoses which included dysphagia (difficulty swallowing) and gastro-esophageal reflux disease (GERD; stomach acid back flow into esophagus). A review of the Order Summary Report (OSR) for June 2023 included the following physician's orders (PO) for enteral feeding (feeding tube): A PO dated 6/16/23, to administer Jevity 1.5 at a rate of 75 milliliter per hour (75 mL/hr) for twenty hours for a total volume of 1500 mL; hang up at 3:00 PM. A PO dated 6/16/23, to administer a water flush of 250 mL of water every six hours. The OSR did not in PO for the checking of residual as observed by LPN #1 or the water flush administered with medication administration. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated 6/16/23, that the resident was at nutritional risk as evidenced by diagnosis of chronic obstructive pulmonary disease, GERD, dysphagia, and FT regimen. Interventions included to monitor gastric residuals (the amount of liquid drained from a stomach following administration of enteral feed) after each scheduled feeding as resident will allow and to administer Jevity 1.5 at a rate of 75 mL/hr for a total volume of 1500 mL with 250 mL water flushes every six hours. The ICCP did not include the amount of residual to monitor for or to notify the physician of a certain amount of residual. The ICCP also did not include the water flushes observed during medication administration. On 6/23/23 at 10:41 AM, the surveyor interviewed LPN #1 who stated that the process for tube feeding included performing hand hygiene, putting on a pair of gloves, using a syringe to check the residual and the placement which was a physician's order (PO). She then stated that the nurses flushed the FT with water with the amount specified in the PO which was given before and after each medication. She stated that if the medication was appropriate to be crushed, it would be mixed with water and flushed again with the ordered amount of water. LPN #1 stated that she believed there was a PO in the electronic medical record (EMR) as she thought she signed off on it. She further stated it would have to be a PO to show it was done. On 6/23/23 at 10:44 AM, LPN #1 and the surveyor reviewed the EMR together. LPN #1 stated that there were orders to flush 250 mL of water every six hours and for the Jevity 1.5 at 75 mL/hour for 20 hours only. LPN #1 confirmed the EMR did not include a PO for how much water to flush between medications, for monitoring the residual, and checking the placement. LPN #1 stated that the residual and placement she just did automatically. At that time, LPN #1 continued to review the EMR and confirmed she did not see any active orders or discontinued orders for water flushes before and after medications, monitoring the residual, and checking the placement. LPN #1 stated that there should be orders for the water flushes before and after medication administration, monitoring the residual, and checking the placement. LPN #1 stated that it was important to ensure the nurses were not over flushing the resident and gave the ordered amount of water, in addition to checking for placement to ensure the FT was in the proper place, and the residual to ensure the resident was appropriately digesting the feeding. On 6/23/23 at 10:54 AM, the surveyor interviewed UM/LPN #2 who stated that the process for tube feeding included to ensure the tubing was patent (unobstructive). UM/LPN #2 stated that they flushed with 10 mL of water before and after each medication. She further stated that the nurse had to first check placement as you want to hear a whoosh sound that assured the tube was in place. UM/LPN #2 stated you then checked for any residual to ensure the feeding was working. She confirmed a PO was needed to check residual and placement as well as for water flushes before and after a medication. She stated that it was important to ensure there were POs for these to ensure the tubing was functioning like it was supposed to. She further stated that the POs were important so everyone knew what to do for that resident. UM/LPN #2 emphasized you have an order for everything. The surveyor continued to review the medical record. A further review of the OSR after surveyor inquiry revealed the following after surveyor inquiry: A PO dated 6/23/23, to check placement of the FT before beginning a feeding and before administering medications. Notify MD if placement is not confirmed every shift. A PO dated 6/23/23, to flush FT with 30 mL warm water prior to all medication administrations to check correct placement of tube every shift. The PO did not include to administer water flushes after medication administration or between each medication. On 6/23/23 at 12:18 PM, UM/LPN #2 stated in the presence of the survey team, that the facility followed the [company's name redacted] manual for new hires which was located on each nursing unit. She stated that all of the unit managers had one, and that the facility conducted in-services when things changed and provided the surveyor with in-service conducted on 5/22/23 to 5/29/23. UM/LPN #2 acknowledged that there should have been orders for water flushes before and after medication administration and checking the residual. UM/LPN #2 confirmed she had entered the PO in the EMR after surveyor inquiry. On 6/26/23 at 10:55 AM, the surveyor interviewed the DON who stated that the process for tube feeding included that they referred to the facility's policy and procedures in following the steps. She stated that the steps included checking for placement, checking for residual, and flushing the tube with 30 mL to 60 mL of water before and after the mediation administration. She then stated that you would mix the medication in water and ensure it was thin enough to be administered through the feeding tube. She further stated that they used gravity to administer the medications, but occasionally they would push with a 60 mL syringe if needed. The DON again stated they referred to the policies and some of it was simply nursing judgement as we all learned it in nursing school. She further stated unless it was something different than normal or unexpected, then they needed an order such as if the resident was on a fluid restriction or different quality of gastrointestinal issues. When asked would you need a physician's order for checking the placement, checking the residual, and flushes before and after the administration of medication? The DON stated, it would be a good reminder to have an order, but I would expect the nurses to know the standard of practice with feeding tubes. She again stated she would not expect to have a physician's order for the water flushes before and after medications; checking the residual and placement as that was all a standard of practice. On 6/26/23 at 11:04 AM, the surveyor asked the DON about UM/LPN #2 entering a physician's order after surveyor inquire. The DON stated after the surveyor talked to UM/LPN #2, they thought that moving forward it would be good to add those orders in and to show it was done. On 6/26/23 at 11:27 AM, the surveyor interviewed the LNHA who stated that physicians had to provide orders for anything that we are doing to the residents. The surveyor asked did they need a physician's order for the checking the placement of the FT, checking the residual of the FT, and water flushes before and after medication administration with a FT. The LNHA stated that if they deemed necessary, they would obtain a physician's orders but that it was nursing standard of practice to make sure they were checking the placement and that it was intact, flushing the tube checking for patency and checking the residual to ensure we are not over feeding the resident and they are tolerating the feeding. The LNHA emphasized that they just considered that checking placement, checking residual and flushes before and after medication as nursing standard of practices and did not need a physician's order. On 6/27/23 at 11:26 AM, the surveyor interviewed the Medical Director (MD) via telephone who stated that the nursing staff should be following the protocol for tube feedings which included checking the placement, checking the gastric residual, and flushing the tube. He stated that it was important to follow the protocol as it would let the physician know if the resident tolerated the feeding, the placement to ensure it was not dislodged, and the flushes to ensure it was not clogged. He further stated following those protocols ensured there were no issues with the tube. When asked was a physician's order required, the MD replied that he was not sure if a PO was needed. The MD again stated it was important to know and follow the protocol. The MD stated that for the free water flushes, there should be a PO. He further stated that the POs varied from each resident based on their needs when it came to the flushes. The MD then stated that the flushes before and after medication was a small amount of 10 to 20 mL to ensure the tube was not clogged. When asked was an order required for the before and after medications, the MD again stated he was not sure if a PO was needed as that was a nursing practice. He further stated that checking for placement and residual was part of the examination, and when they documented it that would be their accountability. The MD concluded everyone worked together for the care of the resident. The surveyor asked for clarification on if a PO was needed to ensure there was accountability, and the MD was unable to provide clarification. On 6/27/23 at 11:37 AM, the surveyor interviewed the DON again who stated if it was not in a PO, then they did not have to document to ensure accountability. The DON stated, as professional nurses we need to make the assumption that it is getting done and that there needs to be an understanding that the nurses are doing the job they are trained for. The DON confirmed that if care was not documented then there would be no way to ensure accountability. She then stated that if a resident on was on fluid restrictions, then there would a PO for the specific amount, but a resident was not on fluid restrictions then they would base it off their policy which indicated to flush the tube with 30 to 60 mL before and after medications. The DON emphasized I would hope they are following the policy. She then stated that if a resident was not on fluid restrictions, then they would not be concerned about tracking the fluid amount. On 6/28/23 at 9:33 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she was out on leave for three months, and it was her first week back. She stated that prior to her leave, she had the nurses complete an in-service on tube feedings she thought in January or February of 2023. The surveyor continued to interview the CP regarding residents that required tube feedings. The CP stated that if a resident was on a tube feed, she looked to ensure that there were actual orders of tube feeding as well as water flushes. She further stated that some facility had orders for flushes 30 mL before and after medications with a minimal of five (5) mL between each medication being administered. The CP stated that it was standard of practice to flush the tube with 30 mL before and after medication administration and should be reflected in the facilities' policies. The CP stated that based on her understanding, some facilities did not require an order because it was considered a standard of practice. She stated that during her in-service, she informed her nurses to flush the tube before and after medication administration with the 30 mL of water unless the resident was on fluid restrictions. The CP further stated that if there was no specific order for it, then they should be following the protocol standard of practice for checking the placement, checking the residual and the flushes. The CP then stated that it would be best practice if they had an order to ensure accountability but again stated that not all facilities required to have orders in place for the standard of practice. The CP stated, it would be nice to have those orders in place. The CP stated she did not discuss a lot with the nurses regarding tube feed as the facility did not have a lot of residents on tube feedings. The CP stated that if there was not a PO, then there would be no way to ensure accountability. The CP acknowledged there should be a way to ensure accountability in a form of a PO or documentation regarding the checking of the placement, residual and flushes. At that time, the CP was unable to speak on any additional information and stated that there should be some type of way to ensure accountability. On 06/28/23 at 10:03 AM, the surveyor interviewed the Registered Dietician (RD) who stated that with the tube feeding she made sure the weights were stable, the residents were tolerating the feed, that there was no residual, and that they were tolerating the formula. She further stated that with the tube feedings she monitored those residents monthly instead of quarterly. The surveyor continued to interview the RD who stated that the nurses monitored the residual. She stated that the nurses documented in the progress note how the resident was tolerating the feeding that she reviewed, or the nurses informed her. She further stated that they discussed it during the morning meeting. The RD stated that she did not believe there were physical orders and that it was just a standard of practices for the nurses. The RD stated that the water flushes were an order as she wrote the orders for the formula and the water flushes which were for additional fluids to ensure the residents were meeting their hydration needs which was typical 250 mL every six hours. The RD stated that the nursing generally entered the orders for the flushes before and after medications. She stated that it would 30 mL before and after medications. She explained she just addressed the formula rate, the resident's calorie, and fluid needs. The RD stated that to her knowledge if the residual was over 200 mL, the nurses held the feeding for at least four hours, and if over 300 mL, the feeding would be stopped and the physician would be notified. The RD concluded there was no formal order as for the checking the residual. On 6/28/23 at 10:25 AM, the surveyor interviewed LPN #2 who stated the process for the FT included checking the placement, checking the residual, but she was unsure of the amount for residual. She further stated that the nurses flushed the FT with 30 mL before and after medication administration and five (5) mL between each medication. She stated that it was rare that they had residents with FT. She further stated they were educated on when Resident #778 arrived to ensure everyone remembered the appropriate steps. The surveyor asked did they need a physician's order to ensure accountability, and LPN #2 replied they needed an order to document for checking the placement, the residual, and the water flushes. LPN #2 stated that it was important to have physician's orders because sometimes things could be overlooked if there is no order and you can forget because being on the floor can be crazy and having the order is necessary as it shows accountability of what we did. She stated she had Resident # 778 three times, and she documented in the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for checking of the placement and the water flushes, but was unsure of the residual. She stated that with her experience any residual over 200 mL, she would inform the physician. She further stated that if she was unsure of the residual amount and the steps, she would just ask questions, but that was just her. On 6/28/23 at 11:09 AM, the surveyor asked the DON about the monitoring of the residual that was listed on the resident's care plan. The DON in the presence of the survey team stated that anything over 30 mL, she would hold the feeding and call the physician. She then stated that was a low amount [30 mL], and she would have to review to confirm. The surveyor asked if there was no order on when to hold the feeding, and multiple staff members gave different answers, how would you know when to hold the feeding and notify the physician? The DON stated that she did not have an answer. The DON acknowledged that there was no way to ensure accountability if there was no PO. On 6/30/23 at 9:36 AM, the LNHA in the presence of the DON, and the survey team stated that there should be an order for when to hold and notify the physician on a certain amount of residual. The LNHA acknowledged there should be orders for accountability. On 6/30/23 at 10:32 AM, the LNHA provided a copy of the Adult Gastric Residual Monitoring which she stated it was what the RD provided to staff when they had residents on a tube feeding. She stated that she did not believe this was listed in their policy for guidance. A review of the facility provided Adult Gastric Residual Monitoring form undated included, measure gastric residual volumes (GRV) use at least a 60 mL syringe. For continuous pump feedings check every six (6) hours. If GRV< [less than] 200 mL re-instill gastric residual contents and continue with feeding. If the GRV was > (greater than) 200 mL, re-instill gastric residual contents and hold the feedings for one (1) hour than recheck. If residual > (greater than) 300 after rechecking hold the feeding and contact the medical doctor. A review of the facility provided in-service Tube Feeding Update from 5/22/23 to 5/29/23, included review of the enteral feeding connector and basic feeding tube procedures. In addition, it reflected per the [company's name redacted] Nursing Procedures Manual to verify tube placement, aspirate (to draw) contents from the tube with an enteral syringe, flush the enteral tube with 30 mL of water before and after feedings if ordered, assess every four hours for gastrointestinal intolerance by assessing abdominal distention, monitoring for complaints of abdominal pain, do not monitor gastric residual volume routinely. A further review did not include water flushes before and after medications. A review of the facility's Policy Enteral Nutrition dated reviewed 8/08/22, included .3. The dietician will input from the provider and nurse d. calculates fluid to be provided (beyond the free fluids in formula .11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include f. instructions for flushing (solution, volume, frequency, timing and 24-hour volume). 12. The provider will consider the need for supplement orders, including: a. confirmation of tube placement and g. checks for gastric residual volume (GRV). It further revealed for procedure, to refer to the [company's name redacted] Nursing Procedure Book . A review of the Medication Orders - Receiving and Recording policy date reviewed 1/10/23, included .4. Enteral Orders - when recording orders for tube feedings, specify the type of feeding, amount, frequency of feeding and rationale if prn [as needed]. The order should always specify the amount of flush following the feeding . NJAC:8:39-11.2(b); 27.1(a); 29.2(d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to appropriately label and date two Tubersol (tuberculin purified protein derivative [PPD]; a clear, colorless solution injected into the skin of the forearm that aides in the detection of tuberculosis). This deficient practice was identified in 1 of 2 medication storage rooms inspected in the facility (Magnolia nursing unit), and was evidenced by the following: On 6/21/23 at 11:30 AM, the surveyor inspected the medication storage room by the Magnolia nursing unit in the presence of the Registered Nurse (RN). At that time, the surveyor observed two opened and undated Tubersol solutions in the refrigerator. On 6/21/23 at 11:34 AM, the surveyor interviewed the RN who stated that the Tubersol was to be dated when it was opened. The RN then told the surveyor that she was not sure if the Tubersol was supposed to be dated upon opening, and wanted to ask another staff member. The RN then exited the medication storage room. On 6/21/23 at 11:36 AM, the RN re-entered the medication storage room and informed the surveyor that her Unit Manager/Registered Nurse (UM/RN) told her the medication was supposed to be dated upon opening. On 6/21/23 at 11:39 AM, the surveyor interviewed the UM/RN who confirmed the Tubersol should have been dated upon opening and stored in the refrigerator. The UM/RN further stated that it was important to date the medication, for expiration purposes. On 6/23/23 at 11:43 AM, the surveyor conducted an interview over the telephone with the facility's Consultant Pharmacist (CP) who stated that upon opening the medication Tubsersol, the medication was required to be dated. The CP explained after the medication was opened, it was only good for usage for 28 - 30 days per the manufacturer' specifications for usage. On 6/23/23 at 12:36 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Tubsersol needed to be dated upon opening because the medication was only good for 30 days. The DON acknowledged it was important to date the medication, so the nursing staff knew when the medication was going to expire. A review of the undated Tubsersol package insert from the Food and Drug Administration included .A vial of Tubersol which has been entered and in use for 30 days should be discarded . A review of facility's pharmacy, Medication Storage Guidelines dated 2022, included Tubersol was required to be dated upon opening and the unused portion was to be discarded after 30 days . A review of the facility's, Medication Storage Policy dated 10/6/22, included .medications were labeled accordingly . NJAC 8:39-29.6(b)1

C#: NJ 4 Based on interviews, medical record review, and review of other permanent facility documents on 8/23/2021 and 9/1/2021, it was determined that the facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow its policy titled Medication Administration for 1 of 3 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) were as follows: According to the Resident Face Sheet, Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimal Data Set (MDS), an assessment tool dated 6/23/2021, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS also showed that Resident #2 needed assistance with Activities of Daily Living (ADLs) and received IV (Intravenous) medications. Review of Resident #2's Care Plan (CP) dated 6/16/2021, showed under Focus: Resident #2 receives IV medication for CHF ([CONDITION(S)]). Under Goals, Resident #2 will be free from complications of IV medications. Under Interventions: Change the battery on Milrinone and pump Q (every) 3 days. Change Milrinone administration bag weekly. Milrinone via (route) IV as ordered. A review of Resident #2's nursing Progress Notes (PN) dated 7/1/2021 at 3:40 PM revealed that the resident had 2+ plus [CONDITION(S)] (swelling caused by excess fluid build-up in the body). Further review of Resident #2's PN dated 7/1/2021 at 5:34 PM revealed the resident did not receive his/ her bag of Milrinone as prescribed by the Physician. According to the PN, the IV bag of Milrinone was noted to be full during the weekly bag change, and only a quarter of the bag was infused. The PN also showed that a message was left for the doctor (Cardiologists) to notify him of the missed doses. The attending Physician was also notified, and there were no new orders. A review of Resident #2's PO's dated 6/2021 were as follows: Milrinone 1 mg/ml (milligrams/milliliters) infused 0.25 micrograms by intravenous (IV) route every shift continuously. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitoring daily weights every day at 7:00 AM, dated 6/16/2021. Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's weight sheet showed no documentation of the above missing weights. Further review of the weight sheet showed from 6/23/2021 through 7/1/2021, during the time of the resident not receiving his/her Milrinone; the resident had an eleven-pound weight gain as follows: 6/23/2021 149.3 6/28/2021 154.2 7/1/2021 160.4 Review of Resident #2's Accidents/Incidents Report dated 7/1/2021, revealed under Pertinent Health Status Information: End Stage HF (Heart failure). The Accident/Incident Report also revealed that the IV Milrinone was due for its weekly change when the bag was noted to be full, resulting in missed doses of the medication. Review of Resident #2's Medication Error Incident Report dated 7/1/2021, indicated under Description of Incident: Medication IV bag changed on 6/30/2021, was noted to have multiple doses that were not infused over a week timeframe from 6/23/2021 through 7/1/2021. During an interview on 8/23/2021 at 11:06 AM, the Assistant Director of Nursing (ADON) stated, Resident #2 has end-stage heart failure and is on a Milrinone continuous drip. The ADON also stated the Milrinone runs continuously 24 hours a day, and it's a continuous drip needed for the heart, which the resident will need for the rest of his/her life. The ADON explained that on 7/1/2021, we noticed that the pump wasn't working when the resident's family member came in and noticed that the resident had some of the medication left over. According to the ADON, the IV pump did not alarm, which would have indicated the pump was not infusing. The ADON also explained that the resident had some extra weight gain. Hence, the doctor adjusted the resident's diuretics (medications to help the kidneys produce more urine to get rid of excess fluids). During an interview on 8/23/2021 at 12:46 PM, the Director of Nursing (DON) stated, Resident #2's weight gain could have been from the resident not receiving the medication. The DON also stated Milrinone increases the contractility of the heart and helps with cardiac output. The surveyor made multiple attempts to contact the staff assigned to Resident #2 when the medication errors occurred. However, there were no responses. Messages were also left with Resident #2's Cardiologist receptionist on 9/1/2021, but the surveyor received no return calls. A review of the facilities policy titled Medication Administration dated 10/5/2019 indicated the following: Under Policy Statement,: Medications shall be administered in a safe and timely manner and as prescribed. Under Policy Interpretation and Implementation #3. Medications must be administered in accordance with orders, including any required timeframe. #7 The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dose, right time, and right method (Route) of administration before giving the medication. N.J.A.C.: 8:39-27.1

Complaint # NJ 1 Based on interview and review of the medical record's (MR) and other facility documentation, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJ DOH) for 1 of 5 residents reviewed for incidents and accidents (Resident #5). This deficient practice is evidenced by the following: According to the Resident Face Sheet, Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #5's Quarterly Minimum Data Set (MDS), an assessment tool, dated 12/4/19, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 6, which indicated that the resident had severe cognitive impairment. A review of the Care Plan, dated 1/28/20, revealed a focus of skin discolorations related to [MEDICATION NAME] (a blood thinner) with discoloration to the resident's right cheekbone. Interventions included encouraging the resident to not sleep with the face against the bed enabler (side rail) and gentle handling of the skin. A review of a Progress note dated 1/28/20 at 12:17 PM, written by a Nurse Practitioner, revealed that the resident had swelling and discoloration to the right cheek below the right eye with no reported recent falls or other trauma to the face. The resident was unable to give any information related to the facial bruising and swelling. A review of a Progress Note dated 1/28/2020 at 2:43 PM revealed, During morning care, CNA noticed and reported to nurse a skin discoloration to the right cheekbone. Resident denies having been hurt by anyone, denies fallen, denies having hurt (themselves). Head trauma protocol initiated. A review of Resident #5's Accident/Incident Report (IR) dated 1/28/2020, revealed at 8:00 AM, a certified nursing assistant (CNA #1) reported to the nurse that the resident had skin discoloration under the right cheekbone. The resident denied being hit, hurt, falling, or hurting themselves. The resident was assessed, and the nurse practitioner was notified. The IR indicated that the incident was unobserved. A statement from CNA #1 revealed that when the CNA entered the resident's room, the resident rolled over, and the resident had a black eye. The CNA asked the resident what happened if someone hit the resident, and if the resident was in pain, the resident replied nothing was wrong with their eye and that the resident was not hit or in pain. Attached to the report was a summary completed by the Registered Nurse Unit Manager (RN UM) dated 1/31/20, which revealed that CNA #1 reported the discoloration to the RN UM. Upon assessment, the discoloration was 6 centimeters (cm) by 5cm. The resident denied injury. The NP assessed the resident. The summary indicated that the resident had been observed sleeping on the right side with the resident's face next to the bed enabler. The summary further reflected that the resident's face might have touched the enabler causing a discoloration. The resident's laboratory results indicated that the resident's PT/INR (test that detects how long it takes for blood to clot) was elevated, which could increase bruising. It was concluded that, Upon review of issue with DON (Director of Nursing) and Administrator, it is our opinion that the discoloration was caused by pressure from the enabler on the right side of (Resident #5's) face and the elevated PT/INR. The resident denies any injury by a team member. During an interview with the surveyor on 8/27/20 at 12:30 PM, the Director of Nursing stated the facility did not report the injury because the facility felt that in their investigation that they knew the source of how it happened and didn't suspect abuse. The DON stated that the facility reports abuse or an injury of which a cause could not be determined. During an interview with the surveyor on 8/27/20 at 1:23 PM, the Administrator stated the injury was not reported to the NJDOH because the facility determined how the injury occurred. A review of the facility's policy titled, Abuse and Neglect revised 1/18/17, included but was not limited to; Injuries of known source- an injury should be classified of unknown source when both of the following conditions are met; (a) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, AND (b) the injury is suspicious because of the extent of the injury, or the location of the injury, (injury located in an area not generally vulnerable to trauma) . E. Reporting 6 b. See Reporting Grid, Unexplained Injury, Division of Long Term Care Systems. NJAC 8:39-9.4(e)

Based on observation, interview and record review, it was determined that the facility failed to follow appropriate respiratory and isolation precautions and perform appropriate hand hygiene to minimize the potential of infection transmission. This deficient practice was identified for 4 of 6 nursing units, (Magnolia Lane, North Cape May, New Hope, and White Birch Boulevard) reviewed for infection control practices and was evidenced by the following: 1. During the entrance conference on 7/11/19 at 9:49 AM, the Administrator stated that the Magnolia Lane and North Cape (MONTH) units were on respiratory precautions due to an upper respiratory outbreak. The precautions included the requirement to wear a face mask and use hand hygiene. On 7/11/19, during the initial tour of Magnolia Lane, the surveyor observed four signs that were posted on the entrance doors to the unit. One sign had a red hexagon shape with the word STOP in capital letters inside and beneath the hexagon the sign indicated, You must use hand gel and put on a mask before entering this neighborhood (unit). The second sign also had a red hexagon shape with the words STOP in capital letters, on the sign and beneath the hexagon the sign indicated, PPE (Personal Protective Equipment) located just inside the door, follow instructions on the table. The third sign posted on the door indicated,We're under the weather. If you need to visit our neighborhood, please make sure to wash your hands before and after your stay! Masks are available at the nursing station! A fourth sign posted on the door had a red hexagon shape with the word STOP in capital letters inside and beneath the hexagon the sign indicated,DO NOT pass through this neighborhood. Please walk around. The door entering the neighborhood had a window which enabled the surveyors to clearly observe the PPE table from outside of the entrance doors. Upon entering the neighborhood the surveyor observed a table against the right side of the wall with a trash can next to it. There was a box on the table that contained face masks and two plastic containers that contained wipes for hand hygiene. There were also three laminated papers on the table, one with instructions for how to put on and remove a face mask, the second with instructions how to remove a face mask and the third included, but was not limited to, symptoms of a common cold and handwashing instructions. On 7/17/19 at 12:24 PM, in the presence of two surveyors, a Guest Services Representative (GSR) was observed entering the neighborhood/unit through the doors with the posted signs. The GSR was observed donning a face mask without performing hand hygiene. Upon exit from the neighborhood, the GSR removed the mask without performing hand hygiene. On 7/17/19 at 12:26 PM, in the presence of two surveyors, Certified Nursing Assistant (CNA #1) was observed entering into the neighborhood through the doors with the posted signs. CNA #1 did not perform hand hygiene or don a face mask. She was observed walking past the table containing the PPE and entering a bathroom in the neighborhood/unit. On 7/17/19 at 12:27 PM, in the presence of two surveyors, a pharmacy delivery staff was observed entering into the neighborhood through the doors with the posted signs. The pharmacy delivery staff did not perform hand hygiene or don a face mask. During an interview on 7/17/19 at 12:25 PM, CNA #1 stated that she had to use the bathroom and didn't think she had to use the face mask and hand gel if she didn't go past the PPE table. On 7/17/19 at 1:40 PM, in the presence of three surveyors, a housekeeping employee was observed entering the neighborhood/unit through the doors with the posted signs. The housekeeping staff was observed donning a face mask without performing hand hygiene. During an interview with the Infection Control Preventionist (ICP) on 7/17/19 at 1:20 PM, the ICP stated that the precautions are in place in the Magnolia neighborhood/unit because 8 out of 17 residents have or have had the human rhino [MEDICATION NAME] (cold). She further stated that the process when entering the neighborhood is to clean your hands and then put on a face mask and when leaving remove the face mask and clean your hands. The ICP stated that all employees including contracted employees are expected to follow the facility policy and procedures. 2. During the initial tour of North Cape (MONTH) on 7/11/19, the surveyor observed a table that contained PPE positioned directly outside of the unit. The surveyor observed that the unit was under respiratory precautions and required everyone to don a face mask before entering the unit. On 7/11/19 at 11:48 AM, the surveyor observed a corporate staff member enter the dining room area of North Cape May. The surveyor observed that the corporate staff member did not have on a face mask while on the unit. On 7/11/19 at 11:52 AM, the surveyor observed CNA #2 assisting residents during the lunch meal service. The surveyor observed that CNA #2's face mask was pulled down exposing her nose and mouth. The surveyor observed CNA #2 walk around the dining room area and assist multiple residents with her face mask pulled down. During an interview on 7/18/19 at 12:44 PM, CNA #2 stated the facility provided an in-service to the staff on the correct way to wear the face mask while on the unit. CNA #2 stated the face mask should cover both the nose and mouth and should not be taken off or pulled down at any time while on the unit. CNA #2 further stated she had not pulled down her mask while on the unit. During an interview on 7/18/19 at 1:25 PM, the Director of Nursing (DON) stated CNA #2 had been removed from the unit due to noncompliance with the face mask. 3. During the initial tour of the New Hope Unit on 07/11/19 at 11:44 AM, the surveyor observed a three (3) drawer plastic container that contained PPE (yellow disposable gowns, and gloves), with a red hexagon shaped sign that indicated to Please see Nurse before entering located outside of Resident #326's room. The Unit Manager stated Resident #326 was on isolation for a urinary tract infection. On 7/12/19 at 10:20 AM, the surveyor observed a psychologist sitting in Resident #326's room wearing a gown and gloves. On the same day at 10:32 AM, the surveyor observed the psychologist exit Resident #326's room wearing a gown and gloves and walked down the hallway to speak with a nurse. The psychologist then re-entered Resident # 326's room without changing the gown, gloves or perform hand hygiene. According to the Electronic Medical Record (EMR), Resident #326 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #326's Physicians Order form revealed an order to maintain isolation for [MEDICATION NAME]-Resistant [MEDICATION NAME] (VRE) (a type of bacteria that have developed resistance to many antibiotics, especially [MEDICATION NAME]) in the urine. During an interview on 7/16/19 at 12:32 PM, the ICP stated that staff are to remove the gloves, gown and perform hand hygiene upon leaving an isolation room. The ICP confirmed that no one should be walking up and down the hallway wearing a gown and/or gloves. The ICP stated that all staff, including outside providers, are expected to follow the facility's procedures for isolation precautions. During an interview on 7/17/19 at 11:17 AM, Licensed Practical Nurse (LPN #1) stated that isolation precautions for VRE include to wear a gown and gloves upon entering a resident's room and to remove the gown, gloves and wash hands prior to leaving a resident's room. The LPN confirmed that no one should leave the room wearing a gown and gloves. A review of the Centers for Disease Control's (CDC) guideline titled, Sequence For Removing PPE, provided by the facility's ICP, indicated that all PPE, except for a respirator, is to be removed at the doorway or in anteroom and to perform hand hygiene immediately after removing all PPE. 4. During a tour of the White Birch Boulevard unit, on 7/16/19 at 9:10 AM, the surveyors observed the Registered Nurse (RN #1) administer medication to the first of six residents of the medication pass. On 7/16/19 at 9:15 AM, the surveyors observed RN #1 proceed to a second resident without performing hand hygiene. RN #1 administered two injections of insulin, with two different insulin pens, which consisted of one injection in each of the resident's upper arms without using gloves and did not perform hand hygiene after providing the injections. On 7/16/19 from 9:25 AM to 9:51 AM, RN #1 administered medication to a third, fourth, fifth, and sixth resident, and did not consistently perform hand hygiene prior to preparing medications and after medication administration. On 7/16/19 at 10:00 AM, RN #1 then returned to the second resident and administered oral medications, without performing any hand hygiene. During an interview on 7/16/19 at 10:19 AM, the surveyors interviewed RN #1 regarding the facility's hand hygiene policy. RN #1 stated she thought that it was okay to use alcohol-based gel to clean the hands and that hands should have then been washed after every third or fourth resident. In addition, RN #1 confirmed that hand hygiene should have been performed between contact with each resident. When asked why hand washing did not occur within the confines of administering medication to six different residents, the RN stated that it was likely due to being in a hurry. During an interview on 7/16/19 at 1:50 PM, the DON, in the presence of the Administrator and the survey team, stated that her expectations would be that nursing staff would wash their hands typically after the fifth time medications are administered and that handwashing should have occurred, as opposed to using alcohol-based gel. Review of the facility Infection Control and Prevention (#KC18) document, dated effective 1/18/17, indicated, under Handwashing, hands must be washed before and after resident contact or contact with items contaminated with blood or body fluids/substances. Under Gloves, the document indicated that gloves reduce the likelihood that mircoorganims present on the hands of personnel will be transmitted to residents during resident-care activities, procedures, and invasive procedures. Under Hand Hygiene, the document indicated hands are to be washed before patient contact and after contact with a person's skin. NJAC 8:39 - 19.4(a)(1)

C#: NJ Based on interview and record review it was determined that the facility failed to notify and/or inform a resident's family member and/or responsible party about a change in the resident's condition. This deficient practice was identified in 1 of 4 (Resident #1) residents sampled for notification of a responsible party or family member. This deficient practice was evidenced by the following: A review of the medical record revealed that Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the initial Minimum Data Set (MDS), an assessment tool dated 2/1/16 revealed that Resident #1 had a Brief Interview for Mental Status of 13 out 15. This score indicated that the resident had mild cognitive deficits. According to this MDS, the resident required assistance from one staff member for bed mobility and transferring from the bed and into a chair. According to the resident's admission skin assessment dated [DATE], Resident #1 was admitted to the facility with a community acquired blanchable abrasion to his/her buttocks. A review of the Braden Scale, an assessment tool dated 1/18/16 revealed that the resident was identified as being at low risk for the development of a pressure ulcer. A review of a progress noted dated 1/23/18 at 3:54 p.m., revealed that a Certified Nursing Assistant reported to the nurse that Resident #1 had an open area to his/her buttocks. A review of the physician's orders [REDACTED]. According to documentation, the resident was seen by the wound care nurse on 1/27/18. A review of the progress notes titled Wound Consultant revealed that the Wound Care Nurse Practitioner use a scalpel to perform an invasive surgical debridement of the resident sacral wound on 2/1/16; 2/4/16 and 2/10/16. According to these notes, these wound debridement's were done without notifying the resident's family member. A Review of the POS [REDACTED]. Further Review of the POS [REDACTED]. There was no documentation found on the record that the resident or the resident's responsible party were made aware of the implementation of these medications for a wound treatment. When interviewed on 10/15/18 at 1:45 p.m., the Administrator and Director of Nursing (DON) stated that Resident #1 was sent to the hospital but did not return to the facility. The Administrator and the DON stated that it was the wound care nurse's responsibility to notify the resident's responsible party and obtained consent prior to [MEDICATION NAME] the wound. The DON added that this information should have been documented in the resident's record. The DON stated that the doctor and the wound care nurse were not available for interview because they were no longer working at the facility. According to the facility's Notification to Family and/or Responsible Party revised on 6/15 revealed that it was the facility's policy to notify the family, next of kin and/or responsible party with regards to any of the following matter .A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (i.e., a need to discontinue an exiting from of treatment due to adverse consequence, or to commence a new form of treatment). NJAC 8:39-13.1 (c)

Based on observation and interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On [DATE] from 9:04 a.m. to 10:07 a.m., the surveyor, who was accompanied by the Director of Dining Services (DDS), observed the following in the main kitchen located behind the North 1 Bistro: 1.) In Refrigerator #1, a pan with chipped beef was stored on a shelf. The pan was dated [DATE] - [DATE]. When interviewed, the DDS stated that it was considered expired. 2.) In the walk-in refrigerator, a pan with beef sirloin steaks covered with plastic was stored on a shelf. The pan was unlabeled and undated. When interviewed, the DDS stated that the beef sirloin steaks should have been dated when taken out of the original box. 3.) In Refrigerator #3, a pan of hash browns was stored on a shelf. The pan had a use by date of [DATE]. When interviewed, the DDS stated it should have been dated when the package was opened and should have been used or discarded by the use by date. 4.) In Refrigerator #3, the surveyor observed an opened tub of sour cream dated [DATE] stored on a shelf. When interviewed, the DDS stated sour cream lasts one week. The DDS confirmed the sour cream had expired and should not have been in the refrigerator. 5.) In Refrigerator #3, the surveyor observed a tub of chocolate mousse stored on a shelf. The tub was labeled with a preparation date of [DATE] and a use by date of [DATE]. When interviewed, the DDS confirmed the mousse was expired and should not have been in the refrigerator. 6.) In the dry storage room, the surveyor observed a container with Chow Mein noodles stored on a shelf. The container was dated [DATE] and had a use by date of [DATE]. The DDS stated that the Chow Mein noodles shelf life was longer than three days. The DDS added the dates (on the noodles) would indicate that they were expired. 7.) In the dry storage room, an opened and undated box of Craisins was stored on a shelf. When interviewed, the DDS acknowledged the Craisins should have been dated once opened. The DDS further indicated the shelf life was three days after opening. 8.) In the dry storage room, there was a stored box of crushed cookies with an open date of [DATE]. The surveyor observed that the plastic packaging which the crushed cookies were contained in, was left open with the contents exposed to air. When interviewed, the DDS stated he thought it was good for 6 months. The surveyor observed the DDS fold over and close the plastic packaging. 9.) In the dry storage room, a box with semi-sweet chocolate chips was stored on a shelf. The box was opened and undated. The surveyor observed that the plastic packaging that the chocolate chips were contained in, was left open with the contents exposed to air. The surveyor observed the DDS fold over and close the plastic packaging. 10.) In the dry storage room, a box with Hershey cocoa powder was stored on a shelf. The box was labeled with an open date of [DATE]. The surveyor observed the plastic packaging that contained cocoa powder was opened with the contents exposed to air. The surveyor observed the DDS fold over and close the plastic packaging. 11.) In the dry storage room, a box with confectionary curvature disks was stored on a shelf. The surveyor observed the plastic packaging, which contained the confectionary curvature disks, was opened with the contents exposed to air. When interviewed, the DDS stated that they should be closed and air tight. 12.) In the dry storage room, a stack of 32 ounce containers and a stack of portion cups that were stored uncovered directly on a shelf. When interviewed, the DDS stated that all containers should be kept in original packaging and kept covered. 13.) In the dry storage room, two boxes of plastic spoons, one box of plastic knives, one box of plastic forks were stored on a shelf, and one box containing paper baking cups was stored on a shelf. The boxes were opened and exposed to air. 14.) In the dry storage room, the surveyor observed an opened and undated bag of Pasta Bella dried noodles stored on a shelf. The surveyor also observed an opened and undated bag of Barilla dried penne noodles stored on a shelf. When interviewed, the DDS stated that the bags should have been dated when opened. 15.) On the clean storage rack near the 3-compartment sink, there was a stack of food storage bins wet nested. The DDS confirmed the bins should not be stacked until they were completely dry. 16.) In the South 3 satellite kitchen, the surveyor observed an open container of pineapple stored on a shelf in the refrigerator. The pineapple was exposed to air and unlabeled. The food service worker (FSW) revealed she had used it and would cover the pineapple when she was done. 17.) In the North 3 satellite kitchen, the surveyor observed an undated tray with cake slices covered with plastic wrap. When interviewed, the DDS stated if the cakes were being consumed today, they didn't have to be dated. 18.) In the North 3 satellite kitchen, the surveyor observed an opened stack of coffee filters stored directly on top of a coffee machine. The top of the coffee machine was soiled with unknown particles. When interviewed, the DDS confirmed that the coffee filters were stored on the soiled coffee maker. 19.) In the Memory Care kitchen, the surveyor observed an undated pan that contained salad wrapped with plastic. 20.) In the Memory Care kitchen, the surveyor observed an opened stack of coffee filters stored directly on a cabinet shelf. On [DATE] at 10:53 a.m., the surveyor observed an outside vendor (indicated by a Nestle company logo on his shirt) working on the juice machine in the North 3 satellite kitchen. The vendor had his hair pulled back in a ponytail but did not have a hairnet on. When interviewed, the vendor indicated he did not work at the facility, that no one told him about using a hairnet when in the kitchen, and that he was leaving right now. The surveyor observed a sign on the door when entering the kitchen, Hat or hairnet required in this area. On [DATE] at 1:08 p.m., the surveyor entered the main kitchen located behind the North 1 Bistro. The surveyor observed a FSW by the sink area (across from the office and in view of where the DDS was located) actively sipping from a lidded hot beverage cup. When interviewed, the FSW stated he should not eat or drink in the kitchen. The DDS observed the surveyor interviewing the FSW and left the office to join the surveyor. The DDS acknowledged the area was not a designated eating area and stated FSWs should eat or drink in a designated area only. The surveyor continued the kitchen tour and observed that FSW #2 transferred sour cream from a large stock container into a smaller plastic hinged-lid container using a small plastic spoon. The surveyor observed that FSW#2 was not wearing gloves. When interviewed, FSW#2 stated she should have been wearing gloves and immediately applied them. The surveyor observed that FSW#2 did not wash her hands before applying gloves and immediately returned to completing the task using the same spoon in the sour cream container. When interviewed, the DDS stated, If the FSW is putting their hand inside the container, they should wear gloves. The surveyor reviewed the facility's undated Food Storage and Handling policy provided by the DDS. The policy reflected that it is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner. Furthermore, the policy revealed that dry bulk items should be stored in seamless containers with tight fitting lids and clearly labeled. The policy also revealed to always securely cover food items and to write the products name and expiration date clearly. The policy also reflected to check labels daily and discard outdated foods. The surveyor also reviewed the facility's undated HACCP Food Safety Recipe Guidelines, provided by the DDS. The policy reflected, no eating or drinking in food prep areas. The surveyor reviewed the facility's Glove Usage policy, with the revision date of (MONTH) (YEAR), provided by the DDS. The policy revealed that single-use gloves should always be used when preparing and serving Ready-To-Eat-foods (RTE). The policy reflected to always wash and dry hands before and after gloving. The surveyor reviewed the facility's Hair Restraints/(NAME)Guards policy, with the revision date of (MONTH) (YEAR), provided by the DDS. The policy reflected that Hair nets must be worn by all who are in the kitchen production areas. NJAC 8:,[DATE].2 (g)

Based on observation, interview, and record review, it was determined that the facility failed to complete ongoing records of communication between the facility and the [MEDICAL TREATMENT] center for 1 of 1 residents reviewed for [MEDICAL TREATMENT] (Resident #61). This deficient practice was evidenced by the following: Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/10/18 at 9:45 a.m., the surveyor observed the resident in the room, sitting in a wheelchair, with both eyes open. When interviewed at that time, the resident stated that he/she went for [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident stated that he/she went in the morning and returned to the facility in the afternoon. On 7/13/18 at 11:15 a.m., the surveyor interviewed the Unit Manager (UM) regarding the resident's [MEDICAL TREATMENT] schedule. The UM stated that the resident went for [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The UM added that the transportation pick-up was around 8:00 a.m. and the expected return time to the facility was approximately 2:00 p.m. During the interview, the surveyor questioned the UM about how the facility communicated with the [MEDICAL TREATMENT] center. The UM stated that the facility used a communication form titled, [MEDICAL TREATMENT] COMMUNICATION FORM and further stated, the facility initiates and sends the [MEDICAL TREATMENT] communication form, in a red folder, to the [MEDICAL TREATMENT] center to communicate information related to [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center fills out their part and returns the form after each [MEDICAL TREATMENT] treatment. The facility then checks if there was information (like recommendations) that needed to be addressed. On 7/13/18 at 11:15 a.m., in the presence of the UM, the surveyor reviewed Resident #61's [MEDICAL TREATMENT] Communication Forms completed on each [MEDICAL TREATMENT] day. The surveyor noted the top portion of the form was completed by the facility nurse and sent with the resident to [MEDICAL TREATMENT]. The surveyor further observed the bottom portion of the form was to be completed by the [MEDICAL TREATMENT] nurse and returned with the resident to the facility. The surveyor noted the following omissions on the [MEDICAL TREATMENT] Communication Forms: a.) The rehab facility nurses did not complete the top portion of the forms including the Medications administered prior to [MEDICAL TREATMENT] as ordered by the physician, vital signs, examine shunt site, nurse signature, and time left for [MEDICAL TREATMENT]. on the following dates: 5/2/18, 5/4/18, 5/7/18, 5/9/18, 5/14/18, 5/16/18, 5/21/18, 5/23/18, 5/25/18, 5/28/18, 5/30/18, 6/1/18, 6/4/18, 6/6/18, 6/8/18, 6/11/18, 6/13/18, 6/15/18, 6/20/18, 6/22/18, 6/25/18, 6/29/18, 7/2/18, 7/4/18, and 7/6/18. b.) On 5/07/18, 5/21/18, 6/25/18, 7/4/18, and 7/9/18, the [MEDICAL TREATMENT] Communication Forms revealed the [MEDICAL TREATMENT] nurse completed when [MEDICAL TREATMENT] Started, when [MEDICAL TREATMENT] Ended, the Pre-[MEDICAL TREATMENT] weight and the Post [MEDICAL TREATMENT] weight but did not sign the form. c.) On 6/18/18, the facility nurse did not initiate/complete a [MEDICAL TREATMENT] Communication Form between the facility and the [MEDICAL TREATMENT] center. The UM acknowledged some pages were incomplete. The UM stated she would expect the nurse to call the [MEDICAL TREATMENT] center and the nurse should document the conversation with the [MEDICAL TREATMENT] center nurse. On 7/16/18 10:30 a.m., the surveyor reviewed the resident's medical record including the electronic nursing progress notes. The record revealed that there was no documentation that follow-up calls were made to the [MEDICAL TREATMENT] center regarding incomplete information on the [MEDICAL TREATMENT] communication forms. On 7/16/18 at 11:30 a.m., the surveyor reviewed the facility's policy on [MEDICAL TREATMENT] Services, dated 6/15/17, that was provided by the Administrator. The policy revealed that 5. Communication between MVB (Masonic Village at Burlington) and the outpatient [MEDICAL TREATMENT] center will be maintained by a log transported with the resident on [MEDICAL TREATMENT] days. Log will be transported in a red HIPAA compliant envelope. Nurse on receiving unit will review the log upon return to MVB for any recommendations or changes. NJAC 8:39 - 27.1 (a)

A. Based on observation, interview and record review, it was determined that the facility failed to adequately monitor and supervise a cognitively impaired resident identified as having a history of physical and verbal abuse toward residents and staff. The facility staff were aware of the threatening and physically abusive behavior of the resident and failed to consistently conduct investigations of the multiple incidents. Interventions to manage the resident's behavior were not revised to protect both this resident and residents residing throughout the facility to which the resident had access through unsupervised wandering. This deficient practice was identified for 1 of 4 residents identified for abuse, Resident #1, with multiple incidents of assaultive behaviors. The incidents were documented in the medical record from 11/1/10 to 9/28/11 and included 18 incidents of verbal altercations and 10 physical altercations with other residents. This deficient practice constituted an Immediate Jeopardy situation for other residents who resided in the facility. The immediate jeopardy was identified on 10/17/11. An acceptable plan of correction was submitted on 10/17/11 identifying that the jeopardy situation was corrected on 9/28/11 by actions which included that Resident #1 was moved to a locked unit and care plan interventions were developed to address the resident's behavior. The following evidenced the deficient practice: 1). On 10/11/11 at 10 a.m., the surveyor reviewed the medical record of Resident #1 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Clinical Progress (IDCP) Notes from 11/1/10 to 9/29/11 revealed multiple incidents of resident to resident altercations, as well as inappropriate behaviors. Examples are as follows but not limited to: On 11/1/10 at 12 p.m, "threw a spoon across the table at (Resident) after argument." On 2/3/11 at 5 p.m., "very nasty to (Resident), threw bib at this resident." On 2/6/11 at 9:30 a.m, "arguing with (Resident) related to her speaking Italian. Unable to redirect. Resident began cursing at staff." On 2/6/11 at 10 p.m, "wandering in and out of other residents' rooms. Disruptive to other residents in bistro, taking food away, states "you can't eat that, its poison." Arguing with staff and other residents in bistro. Extremely difficult to redirect." On 5/14/11 at 5:30 p.m, "resident was observed approaching another resident. She was observed by a Certified Nurse's Assistant (CNA) hitting (Resident name). When asked why she hit this resident she stated, "he started it." On 5/22/11 at 12:30 p.m, Resident #1 was yelling "shut up" several times to a resident with [MEDICAL CONDITION] who was making repetitive noises. On 6/30/11 at 2 p.m, the resident punched (Resident #20) in the face 2 times. See below. On 7/2/11 at 8:45 a.m, Resident #1 was yelling at (Resident) to "shut up." However, the other resident said nothing to Resident #1 prior to being told to "shut up." On 7/13/11 at 1:10 p.m, a nurse heard Resident #1 say to (Resident),"Don't make me tell you this again." The nurse asked what was going on and the other resident stated that Resident #1 hit her on the arm. Resident #1 said she slapped the other resident because she was sleeping. On the same day, at 4 p.m. and again at 6:30 p.m, Resident #1 was yelling shut up to (Resident) while in television area. Resident #1 stated, "shut up or I will punch you in the chops." On 7/14/11 at 9 a.m, Resident #1 was transferred to another nursing unit (W3). On 7/16/11 during dinner, a nurse overheard Resident #1 say to (Resident) "I'd like to punch you in the face." On 7/17/11 at 6:00 p.m, Resident #1, "was overheard being nasty to other residents at the table." The other residents did not say anything. On 7/22/11 at 6:30 p.m, the resident was wandering the unit, attempting to go into other resident rooms. On 7/24/11 at 10 p.m, "wandered off unit to double elevator, difficult to return with escort. Propelling self about unit in wheelchair." On 7/30/11 at 12 noon, "requires supervision related to wandering off unit and becomes agitated when escorted back." On 8/2/11 at 7 p.m, "wandered to N3, propelled herself in wheelchair." On 8/3/11 at 7 p.m, "Resident threatening staff and other residents in bistro. States, "I'm gonna kick your ass. I'll punch you in the face if you keep that up." Behavior unprovoked but insists other people start arguments, unable to redirect. Resident eventually left bistro and went to room stating, "I can't stand all these idiots." Other residents very upset by behavior." On 8/5/11 at 9 p.m, "verbally abusive to Restorative Aide (RA) while in the television room. Threatened to kill RA when RA tried to keep her from wandering." On 8/6/11 at 4 p.m, Resident #1 was found in another resident's bathroom. On 8/7/11 at 8:30 p.m, "wandered to N3 unit 2 times." On 8/11/11, "continues to wander other wings of the building, and she needs to be constantly reminded and redirected." On 8/13/11 at 8 p.m, "wandering in and out of other residents' rooms. Urinated in another resident's bathroom. Was found on N3 and W2 and returned to unit." On 8/15/11 at 5 p.m, "yelling in bistro and upsetting the other residents." At 6p.m, the same day, "wandering in and out of other residents' rooms and requires constant monitoring." On 8/17/11 at 8 a.m, another resident reported to staff that on 8/15/11 Resident #1 attempted to enter room [ROOM NUMBER]. The other resident was close to the door entrance and would not allow Resident #1 to enter the room. Resident #1 called the other resident,"a [***] ." At 10 p.m, the same day, "continues to wander in and out of other residents' rooms. Supervision required throughout shift." On 8/18/11 at 2 p.m, "continues with disruptive behavior threatening to other residents, wandering in and out of other residents' rooms." At 9p.m, the same day, "continues to go in other residents' rooms, when told to get out, curses at residents." On 8/19/11 at 4 p.m, "wandered off unit, going in and out of rooms on neighboring units. Difficult to redirect, angry at staff bringing her back to unit. Remained agitated/wandering." On 8/24/11at 8 p.m, "increased agitation when she was roaming on unit banging on other resident room doors trying to enter upsetting them." On 8/27/11 at 8 p.m, "argumentative with other residents. Wanders, was brought back from N3 x 1." On 8/28/11 at 1 p.m, Resident #1 had hold of (Resident) wheelchair and stated, "I'll shake you out of this damn thing." At 8 p.m, the same day, "went into other resident rooms, wanders, had to be brought back from S3." On 8/31/11 at 5 p.m, "resident brought back to unit, she had wandered to N3. At 6:45 p.m, Resident was observed opening balcony door to Big West by another resident. At 7 p.m, the same day, Resident #1, "was observed by another resident in elevator. When staff nurse pushed elevator button, door opened, Resident was on elevator had pressed call button and was talking to security. Returned to unit with some increased agitation." On 9/2/11 at 9:45, "Attempting to get off the unit. Redirected several times, Resident took elevator to cafeteria. Brought back to unit by CNA." On 9/6/11 at 8 p.m, "Wandering into other residents' rooms. Residents upset." On 9/11/11 at 8:30 a.m, Resident #1" verbalized to the nurse that she had been raped by a woman from head to toe. She stated that the woman kept something on her mouth so she could not scream." She stated to the nurse,"she won't do it again, I'll strike back again." On 9/13/11 at 10a.m, "Resident became argumentative with (Resident) at bistro time. Stated to resident, don't talk about my husband. Shut up or I'll punch you in the mouth." On 9/16/11at 8 p.m, "continues to wander on unit, in and out of other resident rooms, upsetting some." On 9/23/11 at 1:15 p.m, "resident wander off unit to N3." On 9/24/11, "Resident was struck with cane on left side of face by(Resident)." On 9/28/11 at 1 p.m, Resident #1 was transferred to the locked unit on N1. On 9/29/11 at 5 a.m, Resident #1 attempted to remove the lap tray of (Resident) in the bistro. When the other resident told Resident #1 to hurry up, Resident #1 said she would slap (Resident) in the face. Review of the care plan dated 11/20/10 to 8/23/11 identified verbal and physical abusive behavior and socially inappropriate behavior as a problem. Some of the identified interventions included, "encourage caregivers to participate in activities with Resident #1; remind resident that screaming/cursing is not appropriate; monitor pattern of behavior (time of day, precipitating factors, specific staff or situations). Document behavior problems in the nurse's notes; remove from area if resident is verbally abusive to others; provide [MEDICATION NAME] and [MEDICATION NAME] as ordered." The care plan was not revised following the incidents of resident to resident altercations, and did not address the resident's wandering behavior as a problem. On 10/11/11 at 11 a.m, the surveyor requested the investigations for the above mentioned resident altercations. The documentation that was provided were, "resident incident reports/ resident to resident abuse" forms for the 6/30/11 and 9/24/11 incidents. The reports revealed that both of these incidents were witnessed altercations. However, no statements were obtained regarding the circumstances of the incidents. There were no recommendations identified on the forms to prevent the incidents from recurring. No other investigation/documentation was provided to the surveyor. On 10/12/11 at 1:45 p.m, the DON stated that all resident to resident altercations were to be investigated. She said that when an altercation occurred, the residents were to be immediately separated and the "abuse form" initiated by the nurse. The Nursing Supervisor was to be notified to perform an assessment of the residents. The DON, physician and social service were to be notified. At 2:30 p.m, that same day, the DON stated that she was aware that Resident #1 had some behavior issues, however, she "was not aware of the extent of the resident's behaviors or the numerous resident to resident altercations which had occurred." She stated that the staff may have thought Resident #1's behaviors were,"normal for her," and that may have been the reason the incidents were not reported, therefore, investigations had not been done. She also stated that these incidents had not been reported to the Department of Health. At 2:40 p.m, that same day, the administrator said he was not aware of Resident #1's numerous altercations with other residents. On 10/13/11 at 12 p.m, the social worker stated that she was to be notified regarding resident to resident altercations. She said that the social service documentation was included in the IDCP notes in the medical record. Review of the Social Service documentation for Resident #1 included the following: the 12/15/09 (admission) "social service data" and a 7/13/11 social service referral, following a resident to resident altercation. The referral (completed 7/14/11) revealed that the social worker tried to speak with Resident #1 regarding her unacceptable behavior but she became agitated. It indicated to, "keep me posted as this is the first I've heard." The Social Worker stated that she had not been notified, by the nursing staff regarding any other resident altercations. On 10/11/11, while the survey was in progress, the Social Worker documented in the resident's medical record (IDCP notes). On 10/17/11 at 2:15 p.m., in the presence of the Administrator, and DON and the survey team, the surveyor interviewed the nurse who wrote the above mentioned note of 9/11/11, when the resident alleged that she "was raped by a woman." The nurse told the surveyor that she did not report the allegation to anyone or assess the resident for sexual assault, "because I didn't believe it happened." On 10/13/11 at 10:45 a.m., the surveyor observed Resident #20 seated in a wheelchair in the room. At 12:00 p.m., the surveyor reviewed Resident #20's medical record, which revealed that the resident had [DIAGNOSES REDACTED]. An Interdisciplinary Clinical Progress Notes dated 6/30/11 at 12:00 p.m. read, " Resident got punched two times in the face by another resident, ecchymosis noted on face." On 10/13/11 at 11:30 p.m., the surveyor reviewed a form titled, "Resident to Resident Abuse." Under the section of Investigation of Incident the nurse wrote, "During lunch time resident got punched twice in the face by (Resident #1). Under the section "Recommendations to prevent accidents from reoccurring," the section was left blank. There was no witness statement attached to the incident report although the nurse documented that another resident witnessed the incident. No statements were obtained from the resident who witnessed the incident or the resident who was victimized. The surveyor attempted to interview Resident #20 on 2 occasions 10/13/11 and 10/17/11 was unsuccessful. On 10/13/11 at 12:30 p.m., the surveyor noted another Interdisciplinary Clinical Progress Notes dated 7/13/11 which revealed that Resident #20 was again assaulted by Resident #1. The note dated 7/13/11 at 1:10 p.m. read, " This writer coming down the hall heard (Resident #1) say to (Resident #20), "Don't make me tell you this again." I then approached both residents (Resident #20) stated, " She hit me on the arm." (Resident #1) admitted to hitting (Resident #20) because she was sleeping." On 10/17/11 at 10:30 a.m., the surveyor interviewed the nurse who wrote the first incident report. The nurse revealed that Resident #1 "wandered in the dining room all the time." The surveyor asked the nurse if she was aware of any violent behavior from the resident prior to the incident, she indicated that the staff on the floor was aware of Resident #1's behavior. The nurse further stated when she notified the family,the family was very upset. On 10/17/11 at 1:15 p.m., the surveyor interviewed the nurse who wrote the notes in the clinical record for the second incident. The nurse that Resident #1 slapped Resident #20. The nurse revealed no staff witnessed the incident but she reported the incident to the nursing supervisor and wrote an incident report. When the surveyor asked the nurse to provide the incident report for review, the nurse said she would inform the Director of Nursing. Later that day the DON informed the surveyor that she was not aware of the second incident. The DON further stated there was no incident report for the 7/13/11 incident, nor was there an investigation. On 10/17/11 at 1:30 p.m., the surveyor interviewed the nurse again regarding the 7/13/11 incident, the nurse indicated that Resident #1 slapped Resident #20 in the face. The surveyor showed the nurse Interdisciplinary Clinical Progress Notes which indicated that Resident #1 hit Resident #20 on the arm. The nurse revealed that Resident #1 admitted to slapping Resident #20 later on. The nurse said she wrote everything on the incident report. However, the facility maintained that the incident was not reported or investigated. When the surveyor asked the nurse if she was aware of any behavior prior to the incident, the nurse indicated she was aware of Resident #1's aggressive behavior. The nurse went on to state, "All 3 of the CNA's were probably changing other residents. I made out an incident report, is it the best we can do. I need my other residents to be toileted, I cannot have a staff member sitting there." On 10/12/11 at 11:00 a.m., the surveyor interviewed 2 unsampled, alert and oriented residents who resided near Resident #1, on the W3 unit. One resident stated "she would use foul language and come into my room. I felt she was a threat and this was a terrible way to live." The other resident stated "she would come to my door. I was very cautious of her. She scared me when she came in my room while I was sleeping." Review of the facility's abuse policy included the following: "all reports of abuse shall be reported and thoroughly investigated. An immediate investigation of the incident must be made. All staff members are required to immediately report any suspected or actual reports of abuse to their supervisor. Supervisors are required to immediately report all suspected or actual reports of abuse to the Director of Nursing Services and the Administrator. If not on the premises, the DON and Administration are to be notified by telephone. Suspected or actual resident abuse of residents of any age must be reported to the Department of Health." There was no documented evidence this policy was consistently followed. The Immediate Jeopardy was identified on 10/17/11 at 10:30 a.m. Facility administration was notified and a plan of correction was submitted to the survey team and accepted at 2:40 p.m. which indicated that the jeopardy was corrected on 9/28/11 through actions including: Criteria #1 On 9/24/11 Resident #1 was struck on the head by another resident when she inadvertently entered her room. On 9/28/11 the resident was moved to a locked unit. The resident was reassessed for behavior and the IDC team met and revised her care plan to include the following: encouraging caregivers to participate in activities to promote positive interactions, monitor pattern of behavior, respond in calm voice, maintain eye contact, identify times/approaches/staff that result in least resistance, provide meds as ordered, follow up on psych on PRN basis, assess potential causes and if treatable cause treat as ordered by the physician, maintain continuity with care on each shift as well as with routine, coax and never force to comply with request. Criteria #2 All residents have potential for being affected by this practice. Criteria #3 The twenty four hour report was revised to specifically capture behaviors. Daily clinical review of all incidents and falls to review appropriateness and completeness of plan of care and interventions. Medical staff will review medications/medical conditions to determine if there may be continuing factors to abusive behavior. An educational program will be done for all nursing staff to include: Definition and Types of Abuse, Emphasis on resident to resident abuse, Risk Factors, Identification of Abuse/Neglect. Masonic Home Policy and Procedures, reporting abuse, Investigative Process, Interventions and Documentation. Education will continue to provide all newly employed individuals with training on abuse and neglect during orientation, with special emphasis on resident to resident abuse. Beginning 10/17/11 on 3-11 and all shifts. The DON/Designee will review each individual incident to assess causative factors contributing to the behavior/incident, review of staff/residents statement, Care Plans and interventions, Medical/medication review. Criteria #4 The DON/Designee will continue to review Incident reports to ensure proper interventions have been initiated. Incident reports will be trended and analyzed quarterly. Residents with behavior issues will be closely monitored and supervised by staff and appropriate interventions will be initiated. F223 remains a deficiency at a scope and severity of D, based on the evidence in Part B: B. Based on observation, interview and record review, it was determined that the facility failed to protect residents from abuse/mistreatment from other residents. The facility failed to adequately supervise residents with wandering behavior and histories of altercations with other residents and failed to take measures and develop interventions to protect residents when incidents occurred. This deficient practice was identified for 2 of 4 residents reviewed for abuse Resident #3 and #13 as evidenced by the following: 1. On 10/7/11 at 10a.m, the surveyor reviewed the medical record of Resident #3 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/12/11 Minimum Data Set indicated that the resident usually understands and was usually understood. An IDCP note of 4/28/11 at 1:45p.m, revealed that another resident (Resident) hit her on the right side of the face while sitting in the bistro. On 10/7/11 at 11a.m, the surveyor requested the investigation for the above incident. The DON provided the surveyor with a "Resident Incident Report." However, an investigation regarding the circumstances of the incident and statements from the residents (when applicable) had not been obtained. Review of the care plan dated 1/17/11 to present did not address the resident to resident altercation. There were no identified interventions to prevent recurrence. 2. On 10/7/11 at 9a.m, the surveyor reviewed the medical record of Resident #13 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/3/10 at 10p.m, "while at dinner tonight became argumentative with increased agitation with tablemate. Resident lift knife and fork off table and attempted to throw at resident sitting at table." On 11/4/10 at 12:15p.m, "Resident took (Resident) cupcakes at lunch table. He took back his cupcakes and she (Resident #13) held a butter knife towards the other resident in a threatening manner. Other resident was afraid and moved to another table." On 12/1/10 at 12p.m, "Resident began calling another resident (Resident) names. He put up his arms to keep her away. She smacked him on the right arm." On 12/22/10 at 9p.m, "Resident slapped (Resident) on his hand during dinner. On 10/7/11 at 11a.m, the surveyor requested the investigations for the above incidents. At 11:30a.m, the same day, the Director of Nursing (DON) stated "Investigations should have been done but were not done." Review of the 3/18/11 care plan identified, "displays persistent anger with others. Has a history of being verbally abusive towards others." Some of the identified interventions included, "monitor for side effects of medication; Provide quiet atmosphere/reduce stimulation when behaviors observed; if resident is verbally abusive towards another resident, remind her that it is not appropriate behavior and if the behavior continues remove her from the situation." The care plan was not updated to identify the physically abusive behaviors displayed by the resident, nor were there interventions to prevent recurrence. There was no documented evidence that the facility policy as stated above, was consistently followed. NJAC 8:39 - 4.1(a) 5

A. Based on interview and record review, it was determined that the facility failed to inform administration of incidents of resident to resident abuse/mistreatment and failed to conduct investigations when incidents occurred. This deficient practice was identified for 1 of 4 residents reviewed for abuse, Resident #1, which resulted in an Immediate Jeopardy situation which took place from 11/1/10 to 9/28/11. Resident #1 was involved in 18 incidents of verbal mistreatment and 10 incidents of physical altercations with other residents, which were not reported to facility administration and were not investigated. The facility administration was notified of the Immediate Jeopardy on 10/17/11 and a plan of correction was submitted and accepted on 10/17/11 indicating that the jeopardy was corrected on 9/28/11 based on actions taken including moving Resident #1 to a locked unit and educating the nursing staff regarding the Abuse policy. This deficient practice was evidenced by the following: On 10/11/11 at 10 a.m., the surveyor reviewed the medical record of Resident #1 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Clinical Progress (IDCP) Notes from 11/1/10 to 9/29/11 revealed multiple incidents of resident to resident altercations. On 10/12/11 at 1:45 p.m., the Director of Nursing (DON) stated that all resident to resident altercations were to be investigated. At 2:30 p.m., that same day, the DON stated that she was not aware of the multiple resident to resident altercations which had occurred and staff may have thought Resident #1's behaviors were,"normal for her," and that may have been the reason the incidents were not reported to administration. There were no investigations of any of the incidents provided to the surveyor. On 10/13/11 at 10:45 a.m., the surveyor observed Resident #20 seated in a wheelchair in the room. At 12:00 p.m., the surveyor reviewed Resident #20's medical record, which revealed that the resident had [DIAGNOSES REDACTED]. An Interdisciplinary Clinical Progress Note dated 6/30/11 at 12:00 p.m. read, "Resident got punched two times in the face by another resident, ecchymosis noted on face." On 10/13/11 at 11:30 p.m., the surveyor reviewed a form titled, "Resident to Resident Abuse." Under the section of Investigation of Incident the nurse wrote, " During lunch time resident got punched twice in the face by (Resident #1). Under the section "Recommendations to prevent accidents from reoccurring", the section was left blank. There was no witness statement attached to the incident report, however, the nurse documented that another resident witnessed the incident. No statements were obtained from the resident who witnessed the incident or the resident who was victimized. The surveyor attempted to interview Resident #20 on 2 occasions 10/13/11 and 10/17/11 but was unsuccessful. On 10/13/11 at 12:30 p.m., the surveyor noted another Interdisciplinary Clinical Progress Note dated 7/13/11 which revealed that Resident #20 was again assaulted by Resident #1. The note dated 7/13/11 at 1:10 p.m. read, (This writer coming down the hall heard (Resident #1) say to (Resident #20), "Don't make me tell you this again." I then approached both residents (Resident #20) stated, "She hit me on the arm." (Resident #1) admitted to hitting (Resident #20) because she was sleeping.) On 10/17/11 at 10:30 a.m., the surveyor interviewed the nurse who wrote the first incident report. The nurse revealed that Resident #1 "wandered in the dining room all the time." The surveyor asked the nurse if she was aware of any violent behavior from the resident prior to the incident, she indicated that the staff on the floor was aware of Resident #1's behavior. The nurse further stated when she notified the family of Resident #20 they were very upset. On 10/17/11 at 1:15 p.m., the surveyor interviewed the nurse who wrote the notes in the clinical record for the second incident. The nurse stated that Resident #1 slapped Resident #20. The nurse revealed no staff witnessed the incident but she reported the incident to the nursing supervisor and wrote an incident report. When the surveyor asked the nurse to provide the incident report for review, the nurse said she would inform the Director of Nursing. Later that day the DON informed the surveyor that she was not aware of the second incident. The DON further stated there was no incident report for the 7/13/11 incident, nor was there an investigation. When the surveyor asked the nurse if she was aware of any behavior prior to the incident, the nurse indicated she was aware of Resident #1's aggressive behavior. The nurse went on to state, "All three of the CNA's were probably changing other residents. I made out an incident report, is it the best we can do. I need my other residents to be toileted, I cannot have a staff member sitting there." The facility maintained that there was no incident report or investigation. On 10/17/11 at 10:00 a.m., the facility Administrator told the surveyor that he was not aware of any incidents of maladaptive behavior of Resident #1. The Immediate Jeopardy was identified on 10/17/11 at 10:30 a.m. and a plan of correction was submitted at 2:30 p.m. The jeopardy was corrected on 9/28/11 based on documented actions taken by the facility. Refer to F223, to review the full plan of correction. F226 remains a deficiency at a scope and severity of D, based on the evidence in Part B. Findings: B. Based on interview and record review, it was determined that the facility failed to implement its abuse policy and failed to report and investigate incidents of resident to resident abuse/mistreatment. This deficient practice was identified for 3 of 4 residents reviewed for abuse/mistreatment, Resident #3, #13 and #25, as evidenced by the following: 1. On 10/7/11 at 10 a.m., the surveyor reviewed the medical record of Resident #3 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An IDCP note of 4/28/11 at 1:45 p.m., revealed that another resident hit Resident #3 on the right side of her face while sitting in the bistro. On 10/7/11 at 11 a.m., the surveyor requested the investigation for this incident. The DON provided the surveyor with a "Resident Incident Report." The DON stated, that an investigation regarding the circumstances of the incident had not been done. 2. On 10/7/11 at 9 a.m, the surveyor reviewed the medical record of Resident #13 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/7/11 at 11 a.m, the surveyor requested the investigations for the above mentioned incidents. At 11:30 a.m, the same day, the DON stated that," investigations should have been done but were not." 3. On 10/17/11 at 9:30 a.m., the surveyor reviewed the medical record of Resident #25 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Interdisciplinary Clinical Progress Note of 12/11/10 at 5 p.m., revealed that (Resident) was in Resident #25's room and that she (#25) was upset. Resident #25 stated that the other resident was too strong and that she could not do what he wanted her to do. Resident #25 pushed the other resident out of her room with her wheelchair. On 10/17/11 at 2 p.m., the surveyor requested the investigation for the above mentioned incident. The Director of Nursing stated that she was not aware of the incident and that an investigation had not been done. Review of the facility's abuse policy included the following: "all reports of abuse shall be reported and thoroughly investigated. An immediate investigation of the incident must be made. All staff members are required to immediately report any suspected or actual reports of abuse to their supervisor. Supervisors are required to immediately report all suspected or actual reports of abuse to the Director of Nursing Services and the Administrator. If not on the premises, the DON and Administration are to be notified by telephone. Suspected or actual resident abuse of residents of any age must be reported to the Department of Health." There was no documented evidence this policy was consistently followed. NJAC 8:39-4.1(a)(5)

A. Based on observation, interview and record review, it was determined that the facility failed to develop care plan interventions, based on individual assessment, to manage the behavior of a resident who wandered freely throughout the facility with minimal supervision and who was consistently involved in abuse/mistreatment toward other residents. This behavior occurred from 11/1/10 to 9/28/11 and resulted in 18 verbal and 10 physical altercations with other residents. Care plan interventions for the resident's behavior were standardized in nature and lacked an individualized plan for increased supervision, identified behavior triggers, and emphasis on protecting Resident #1 and other residents. Failure to identify and implement interventions to manage Resident #1's behavior resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was identified on 10/17/11 during the survey and a plan of correction was submitted by the facility on 10/17/11. The jeopardy was corrected on 9/28/11, by relocating the resident and developing and implementing careplan interventions to address the residents behavior. This deficient practice was identified for 1, Resident #1, of 4 residents reviewed for careplan interventions for abusive behaviors and was evidenced by the following: 1). On 10/11/11 at 10 a.m., the surveyor reviewed the medical record of Resident #1 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Clinical Progress (IDCP) Notes from 11/1/10 to 9/29/11 revealed multiple incidents of resident to resident altercations, as well as wandering behavior throughout the facility and into other residents' rooms. Review of the care plan dated 11/20/10 to 8/23/11 identified "verbally and physically abusive behavior and socially inappropriate behavior" as a problem. Some of the identified interventions included, "encourage caregivers to participate in activities with (Resident #1); remind resident that screaming/cursing is not appropriate; monitor pattern of behavior (time of day, precipitating factors, specific staff or situations). Document behavior problems in the nurse's notes; remove from area if resident is verbally abusive to others; provide [MEDICATION NAME] and [MEDICATION NAME] as ordered." The care plan was not updated following the incidents of resident to resident altercations, and did not identify the resident's wandering behavior as a problem. There were no interventions to prevent recurrence. On 10/13/11 at 1:30 p.m., the Director of Nurses told the surveyor that she knew Resident #1 had behavior issues, but was not aware of the scope of the behaviors. The DON stated that a behavior plan should have been in place to help manage the resident's behavior. Refer to 223 for documented episodes of behaviors. The Immediate Jeopardy was identified on 10/17/11 at 10:30 a.m. An acceptable plan of correction was received on 10/17/11 at 2:40 p.m. and indicated that the jeopardy was corrected on 9/28/11, with specific action that included: 1. After an incident on 9/24/11 when Resident #1 was struck on the head by another resident after attempting to enter their room, on 9/28/11 Resident #1 was moved to a locked unit. 2. The resident was then reassessed for behavior and the IDC team met and revised her care plan to include the following: encouraging caregivers to participate in activities to promote positive interactions, monitor pattern of behavior, respond in calm voice, maintaining eye contact, identify times/approaches/staff that result in least resistance, provide meds as ordered, followup on psych on PRN basis, assess potential causes and if treatable cause/treat as ordered by the physician, maintain continuity with care on each shift as well as with routine, coax and never force to comply with request. Refer to F223 to review the entire plan of correction. F279 remains a deficiency, at a scope and severity of H, based on evidence in Part B. Findings: B. Based on observation, interview and record review, it was determined that the facility failed to employ an Interdisciplinary approach to develop care plan interventions based on individualized assessment of resident's needs. The facility failed to develop care plan interventions for residents who were at risk to develop pressure ulcers and failed to develop interventions specific to the actual area of skin breakdown. This deficient practice was identified for 3 of 9 residents reviewed for pressure ulcers, Resident #6, #17 and #18, who developed facility acquired pressure ulcers, which were found at advanced stages. The facility also failed to develop and implement interventions for residents to provide supervision and safety to prevent accidents. This deficient practice was identified for 11 of 18 residents reviewed for accidents, Resident #2, #3, #4, #5, #7, #9, #10, #13,#17, #18 and #25, who fell while in the facility and sustained injuries in the form of cuts, bruises, lacerations and multiple fractures. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident #17 on 10/6/11 at 11:00 a.m. Review of the Interdisciplinary Clinical Progress Notes (ICP) notes revealed that on 7/6/11, the resident was lowered to the floor by two CNAs during a transfer in a sit-to-stand lift, when the resident was unable to balance or stand without assistance. Review of the care plan dated 5/24/11 to the present, revealed on the front portion of the care plan, under the section "Ambulation/Mobility," "Hoyer" and "Assist of 2" were checked. As a result of the fall, the resident hit his head while being lowered to the floor. Further review of the ICP notes revealed that on 4/5/11, Resident # 17 developed a Stage III open area to the right elbow. Review of the care plan dated 4/14/11 to present time during survey, identified chronic pressure ulcers of the right elbow. The interventions were not specific to the site and included "assess and record the size, amount and characteristics of exudates, check for incontinence and turn while in bed with each diaper change." 2. The surveyor reviewed the care plan of Resident #18 on 10/6/11 at 1:00 p.m. According to ICP notes the resident sustained [REDACTED]. Review of the care plan dated 5/22/11 to present, revealed on 8/13/11 "At risk for falls, R/T history of falls, poor safety awareness" was added. Interventions were standardized in nature and there was no evidence of progression of interventions, as falls continued to occur. Further review of the notes of Resident # 18 revealed that on 4/24/11, the resident was found to have a left heel Stage III pressure sore. Review of the care plan dated 6/23/11 to present, revealed that a care plan to address the pressure ulcer was not generated until 8/13/11, and was focused on skin breakdown r/t frequently incontinent of urine, occasionally incontinent of bowel. None of the interventions addressed the resident's heel ulcer. 3. On 10/1/11 at 9 a.m., the surveyor reviewed the nurses' notes of Resident #6, who on 7/14/11 was found by her daughter to have a Stage III pressure sore of the sacrum. Review of the care plan dated 3/17/11 to present, revealed that a care plan for the sacral wound was not developed until 8/13/11. The front of the care plan under the section labeled "Skin Care," "Routine Skin Care" and "Float heels" was checked. Although a Roho cushion for the wheelchair and on overlay mattress were ordered by the physician on 9/28/11, these areas were not checked on the care plan to ensure consistent awareness and utilization. 4. On 10/7/11 at 10 a.m., the surveyor reviewed the medical record of Resident #3 which revealed the following: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 9/29/10 physician's orders [REDACTED]. An ICP note of 11/8/10 at 10:30 p.m. revealed the following: "Resident ringing call bell at approximately 7:30 p.m., states, I want to get out of here. When returning with assistance resident on floor. Sensatec to chair (pad) not working- replaced same." Review of the care plan dated 1/17/2011-present, identified falls as a problem. Some of the interventions included: keep in room close to the nurse's station for closer supervision; instruct on safety measures to reduce the risk of falls; to wear non-slick footwear that fits and Sensatec alarm to bed and chair, check for functioning and placement every shift. An interview with the DON on 10/18/11 at 10:00 a.m., revealed that there was no system in place for staff to consistently check safety devises for function and proper application. The DON stated "It is the responsibility of the CNAs to apply safety devices and to make sure they are working." The facility failed to consistently implement care plan interventions for the resident's safety. 5. On 10/11/11 at 1:00 p.m., the surveyor reviewed the medical record of Resident #7 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An ICP note of 3/25/11 at 10 p.m., revealed that the resident was pleasantly confused and fell while ambulating to the bathroom. Following this incident, a physician's orders [REDACTED]. An ICP note of 3/31/11 (admission summary) indicated that Resident #7 was confused with short and long term memory loss and required supervision due to poor safety awareness. On 5/6/11 at 8:05 a.m., a nurses' note revealed that the resident was assisted to the bathroom and placed on the toilet and left alone without supervision. Approximately 10 minutes later, the resident was found on his hands and knees on the floor. On 8/22/11 at 8 p.m., the resident attempted to stand from his wheelchair while in the television room and fell on his right side. The resident sustained [REDACTED]. The Resident Fall Reporting Form for this incident indicated that the resident's chair alarm did not sound at the time of the fall. Review of the 3/28/11 to present care plan identified falls as a problem related to poor safety awareness/balance problems. Some of the interventions included: Assist with all transfers related to balance problems; resident to wear non slick footwear that fits; instruct resident on safety measures and Sensatec alarm to bed and wheelchair. CNA to check for placement and functioning every shift. On 9/15/11, the care plan was updated to include "Increased observation." 6. On 10/7/11 at 9 a.m., the surveyor reviewed the medical record of Resident #13 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ICP notes from 5/22/11 to 9/11/11 revealed the following incidents of wandering/exit seeking behavior: On 5/22/11 after lunch, the resident wandered to the Residential Unit on the 3rd floor. At 2:30 p.m., that same day, Resident #13 was in the lobby looking for a way out. On 8/27/11 at 9 p.m., the resident was wandering the halls, "looking for an elevator because she was going out." On 9/6/11 at 10 p.m., "Resident remains fully dressed and stated she was going home tonight. Attempt to wander off unit looking for exit." On 9/11/11 at 5 p.m., "Resident propelling self in wheelchair. Attempting to leave unit, seeking an exit out of building." Review of the care plan dated 7/2/11to present did not identify the wandering /exit seeking behaviors as a problem. There were no interventions to address these behaviors to prevent recurrence. On 10/7/11 at 9:30 a.m., the surveyor interviewed the ADON on the unit who stated that the care plan should be revised when issues are identified. That same day while the survey was in progress, the resident's care plan was revised. 7. On 10/17/11 at 9 a.m., the surveyor reviewed the medical record of Resident #25, which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The IDCP notes from 1/31/11 - 3/20/11 revealed numerous incidents of wandering behaviors. Some examples are as follows: On 1/31/11 at 12 p.m., the resident wandered most of the shift and went into other resident rooms, through their closets and drawers. On 2/4/11 the resident wandered off the unit 3 times and tried to get on the elevator. On 2/10/11 at 1:15 p.m., the resident was found in the basement by a staff member. On 2/20/11 at 10 p.m., Resident #25 was found sitting in a another resident's room. On 2/23/11 at 9:30 p.m., "continues to wander around unit, at times going into others room." On 3/4/11 at 7 p.m., "Resident wandered off unit, returned from S 3 unit with escort." On 3/5/11 at 8 p.m., "Resident wandering on unit. Oblivious to safety; 1:1 supervision required." On 3/7/11 at 6 p.m., "wandered off floor and brought back to unit." On 3/20/11 at 4:40 p.m, (Resident) reported that Resident #25, "wandered into her room and found her in the closet stroking her fur coat. (Resident) stated she had a difficult time getting her out of her room." Review of the 1/20/10 (admission) care plan identified that, "Resident likes to walk needs to be observed for possible wandering off the unit." Some of the interventions included: "If no activities available staff to check to see where (Resident) whereabouts are frequently throughout the shift; Nursing and activities to keep (Resident) involved on and off the unit and to keep her under close observation; Use wanderguard/location monitor daily." On 3/9/11 the care plan was updated and identified wandering/eloping off the unit as a problem. However, this was approximately 5 weeks after the behaviors had been identified. On 10/17/11 at 2 p.m., the DON stated that the facility did not have a wanderguard system. She was not aware that it had been identified as an intervention on the resident's care plan. 8. The surveyor reviewed the medical record of Resident #5 on 10/13/11 at 9:00 a.m., which revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the ICP notes revealed that Resident #5 sustained falls in the facility on 12/1/10, 12/25/10, 1/1/11 and 6/14/11. On 12/1/10 Resident #5 fell in the bathing spa room while being weighed by a Certified Nursing Assistant (CNA). On 1/1/11 Resident #5 was left unsupervised in the TV area and sustained another fall. On 6/14/11 Resident #5 fell while being transferred by an activity staff member. On 10/14 /11 and 10/17/11 the surveyor reviewed the fall investigative reports. There were no recommendations in place to indicate what interventions would be implemented to prevent further incidents. On 10/17/11 the surveyor reviewed Resident #5's care plan that addressed falls secondary to Dementia with poor short term memory problem/ unaware of safety issues. The care plan initiated 3/2/11 identified Resident #5 at high risk for falls. The care plan identified interventions for a seatbelt as an enabler and restorative nursing for ambulation. The care plan did not address Resident #5's need for supervision during transfer and ambulation. The facility failed to specify in the care plan how the staff would provide the amount of supervision required by the resident to prevent falls and accidents. 9. The surveyor reviewed the medical record of Resident #10 on 10/11/11 at 9:00 a.m., which revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a fall on 12/10/10 and reported to the staff that she slipped off her wheelchair while in the hallway. The resident was assessed to be confused with an altered gait. An intervention as recorded on the incident report, included to "keep under observation." There was no evidence on the current plan of care that increased observation was identified and there were no interventions for how this would be accomplished. 10. The surveyor reviewed the medical record and care plan for Resident #9 on 10/8/11 at 11 a.m., who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan revealed that Resident #9 had a history of [REDACTED]." On 7/27/11 a new problem on the care plan was "fell transferring from bed to wheelchair." The goal was no further falls." The intervention was to change the resident to 4 side rails when available to have something to hold on to with transfer." On 10/8/11 at 11:20 a.m., the side rails were not observed by the surveyor on the resident's bed. The charge nurse told the surveyor that the resident was in a room which was far away from the nursing station and that whenever a closer room became available the resident was going to be moved. The facility failed to consistently revise and implement interventions for the resident's safety. 11. The surveyor reviewed the medical record and care plan for Resident #2 on 10/8/11 at 11:30 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of the care plan revealed that the resident returned from the hospital on [DATE] and a care plan was not initiated to address falls until the 11/29/11. The care plan stated that the resident was at high risk for falls related to use of high risk medications. The goal was that "the resident will maintain current level of mobility with no increase in the incidence of falls and injuries." The interventions included "assist resident to wear non stick foot wear, instruct resident on safety measures to reduce the risk of falls, keep nurse call light within reach. Instruct resident to use call bell or call out for assistance. Provide intermittent supervision to ensure compliance and resident requires constant reminders to ambulate with a walker." There were no interventions to increase supervision for the resident, despite her history of falls. The resident fell again on 10/08/11 and the resident was to have a bed alarm but the presence or absence of the alarm was not addressed on the incident report. There was no evidence to determine if the intervention was in place at the time of the fall. There were no interventions on the care plan to increase supervision for the resident to increase safety. 12. The surveyor reviewed the medical record and care plan of Resident #4 on 10/6/11, at 10:00 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan interventions initiated on 7/25/11 for falls included to "remind resident to call for assistance before moving from bed to chair and from chair to bed, respond promptly to calls for assist to the toilet, provide reminders to use ambulation and transfer assist devices, nursing restorative program for ambulation with walker, staff to provide intermittent supervision and resident will attend supervised activities out of his room to decrease falls-bingo 3 times per week." On 10/6/11 to 10/17/11, when observed by the surveyor, the resident was not seen in a supervised activity. The resident was observed sleeping in a Geri chair in his room, for the majority of the time. On the above mentioned dates, while observed by the surveyor, the resident was alone in his room without supervision or staff interaction. Refer to F314 for Resident #6, #17 and #18, for the facility's failure to develop care plans with interventions specific to the areas of breakdown to promote healing of pressure sores. Refer to F323 for Resident #1, #2, #3, #4, #5, #7, #9, #10, #13, #16,#17, and #18, for the facility's failure to develop and implement interventions to provide safety for the residents. NJAC 8:39-1.2(i)

Based on observation, interview and record review, it was determined that the facility failed to identify and implement measures to prevent pressure sore development and to promote the healing of pressure sores once they developed. This deficient practice was identified for 3 of 9 residents reviewed for pressure sores, Resident #6, #17 and #18, who developed facility acquired pressures sores discovered at advanced stages. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident #6 on 10/11/11 at 9:35 a.m. The resident had [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) of 7/19/11, revealed that the resident was staff dependent for ADL's. The surveyor observed the resident on 10/11/11 at 9:30 a.m. The resident was sitting upright in bed, with her breakfast on an over bed table in front of her. The resident had a pressure relief mattress on the bed. The resident answered "yes" and "no" appropriately when spoken to, but did not engage in meaningful conversation. Further review of the medical record revealed a nurses' note dated 7/14/11 at 9:30 p.m., which reveled that the resident's daughter found an open area to the sacral region of Res. Requesting wedge or softer mattress for Res. Noted in Dr. book for further eval." An additional nurses' note dated 7/15/11 at 2p.m., stated "N/O written treatment to low back boney area, a new [MEDICATION NAME] dsg. applied." Review of the Treatment Administration Records (TAR) revealed that no measurements or staging of the wound occurred until 8/11/11, when the wound was documented as "Sacrum, Stage III, 4 cm x 3cm with 0.2 tunneling." Further review of the medical record revealed that on 8/30/11, a New Wound Consultation Referral was initiated and the wound care specialist documented the wound as "Unstageable sacral ulcer 3.0 x 3.0 x 1.0 cm, with 100% necrosis, with moderate amount of serous purulent drainage." The resident continued to be seen on a weekly basis by the wound care specialist, and the most recent note dated 10/5/11 stated "Stage IV sacral ulcer, 5.0 x 3.4 x 2.0 cm. Tunnel @ 5:00=6.0 cm." Review of the resident's care plan revealed a "Problem" dated 8/13/11, which stated "Sacral wound and potential for additional skin breakdown R/T Incont B&B, decreased mobility." Interventions were standardized in nature and included "Check for incontinence, change if wet. Check skin for areas of redness. Use pads, pillows, or wedges to reduce pressure on heels and pressure points. Use pads/briefs to manage incontinence. Provide treatment to sacral wound as ordered." The front of the care plan marked "Skin Care" had "Routine Skin Care" and "Float Heels" checked. "Air mattress" and "chair cushion" were not checked. Further review of the "TAR" revealed that on 9/28/11, an "overlay mattress to bed" and "Roho cushion to wheel chair" were ordered. On 10/11/11 at 11:00 a.m., the charge nurse told the surveyor that not all mattresses in the facility were "pressure relief." The unit manager stated that she could not remember what kind of mattress the resident had, when the pressure sore was initially found. Further review of the medical record revealed that there was no documentation to indicate if the resident had been assessed to be at risk for skin breakdown or if the resident was using a pressure relief mattress prior to when the pressure sore was discovered by the daughter. 2. The surveyor reviewed the medical record of Resident #18 on 10/11/11 at 10:30 a.m. The resident had [DIAGNOSES REDACTED]. The surveyor observed the resident previously that day at 9:40 a.m., in his room. The resident was in a recliner chair with a pillow behind his back, watching TV. The resident had a dressing and specialized boot on his left foot. Review of the medical record revealed a nurses' note dated 4/24/11 at 2 p.m., which stated "Noted to Lt. heel to have a Stage III with an unstageable area on the center, noted a black area measuring (size of a dime). Surrounded by red area with total size of a quarter then skin redness surrounding; to be evaluated by MD tomorrow AM, a dry dsg applied and will closely monitor." On 4/25/11 at 2:00 p.m., a nurses' note read "Resident was seen by (Dr. name) R/T wound/ulcer on Lt. heel, unstageable. N/O written by (Dr. name) for antibiotic." According to the note, the resident was started on Cipro. Review of the annual MDS dated [DATE], revealed that the resident was dependent on staff for ADL's, and was at risk of developing pressure ulcers. The MDS also indicated that the resident had an unstageable pressure ulcer, which measured 4.0 cm x 3.0 cm, with the presence of necrotic tissue. A quarterly MDS dated [DATE], again indicated that the resident was staff dependent for ADL's and indicated that the resident had a Stage III pressure ulcer, which measured 1.8 cm x 1.8 cm x 0.2 cm, with slough. Further review of the medical record revealed that a Wound Consultation was initiated on 5/11/11. At that time the wound care nurse documented a wound of the left heel, with "eschar soft cap." The wound measured "3.4 x 4.3 x 0.1 cm., with serous drainage oozing from the edges." On 10/11/11 at 10 a.m., the surveyor observed the resident's wound, in the presence of the charge nurse and noted a healing Stage III pressure ulcer. Review of the care plan revealed that on 8/13/11, a "Problem" identified was that the "skin was desensitized to pain of pressure, left heel wound." Interventions for this problem included "check skin for redness, skin tears, swelling or pressure areas. Report any signs of skin breakdown. Perform nutritional screening. Use pillows, pads, wedges to reduce pressure on heals and pressure points. Turn/reposition. Do not massage over pressure areas. Continue with treatment to ulcer on left heel as ordered." Review of the previous care plan for the resident provided by the charge nurse, dated 6/23/10 to the present, revealed that the resident was not identified to be at risk for pressure sores, and the residents heel ulcer which developed on 4/24/11, was not addressed. On 10/12/11 at 11a.m., the surveyor asked the charge nurse "How do you think the resident got the wound on his heel?" The charge nurse replied "From pressure." 3. The surveyor reviewed the medical record of Resident #17 on 10/6/11 at 1:15 p.m. The medical record indicated that the resident was receiving Hospice care and had [DIAGNOSES REDACTED]. The surveyor had observed the resident that same day at 1:00 p.m., sitting in a recliner chair in his room. The resident was sleeping and did not respond when spoke to. The resident was noted to have his right arm elevated on a pillow and an elbow protector was applied. Further review of the medical record revealed a nurses' note dated 4/5/11 at 2:30 p.m., which stated "Noted a Stage III open area to Rt. elbow, two round Stage III open areas, size of a dime and the other size of a nickel." Review of the Treatment Administration Record (TAR) revealed that a treatment to the open areas was initiated on 4/6/11. On 4/14/11, an addition to the TAR to "Apply elbow protectors once daily," was added. On 10/12/11 at 10:00 a.m., the surveyor observed the resident's wound treatment in the presence of the charge nurse. When the nurse removed the elbow protector, a moderate amount of bloody drainage was noted on the outside of the resident's elbow dressing. When the nurse removed the dressing, the wound had a moderate amount of foul smelling bloody drainage. The nurse stated "I better call the doctor about this." The nurse took wound measurements of the elbow, which measured 2 x 2.2 cm. Review of the resident's care plan dated 5/24/11 to present, revealed an identified "Problem" dated 8/14/11, as "Chronic pressure ulcers R elbow and left heel. Potential for additional skin breakdown R/T incont B&B, decrease mobility and skin desensitized to pain/pressure." Interventions for this problem included to "assess and record the size, amount and characteristics of exudates, and pain status. Check for incontinence, clean and dry skin if wet or soiled. Turn while in bed with each diaper change and during care." There were no documented interventions specific to the resident's elbow. During an interview on 10/12/11 at 10:30 a.m., the charge nurse told the surveyor that nurses do initial skin assessments on residents upon admission. After that, it is the responsibility of the CNA's to assess the resident's skin daily during care and to report any findings to the nurse. The nurse further stated that the facility did not utilize any assessment tool or documentation for the daily skin checks by the CNA's. There was no evidence of nursing oversight or evaluation of CNA observation in regard to residents' skin integrity. Review of CNA inservice training on 10/18/11 at 11:00 a.m., revealed that no inservice training regarding skin assessment had been conducted in the past year. On 10/18/11 at 11:30 a.m., the Director of Nurses told the surveyor "I know we have to revise our policy for skin assessments." NJAC 8:39 27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide supervision and assistive devices to residents who were at risk for accidents. The facility failed to consistently apply safety devices to residents who were at high risk for falls. When falls occurred, the facility failed to adequately investigate to determine causal factors, to prevent recurrence. This deficient practice resulted in residents sustaining injuries in the form of fractures, lacerations requiring sutures, cuts and bruises. This deficient practice was identified for 13 of 18 residents reviewed for falls and accidents, Resident #2, #3, #4, #5, #6, #7, #9, #10, #13, #14, #16, #17, and #18. All but Resident #18 sustained varying degrees of injuries including lacerations and fractures requiring medical and/or surgical intervention and is evidenced below. The facility also failed to maintain the resident call system in a manner which would alert staff when residents required assistance. This deficient practice is evidenced below. 1. The surveyor reviewed the medical record of Resident # 18, on 10/11/11 at 9:00 a.m., who had [DIAGNOSES REDACTED]. Review of the Interdiciplinary Clinical Progress Notes (ICP) revealed that the resident had a history of [REDACTED]. Examples included: On 12/13/10, an IDCT Fall Review, (Late Note), stated "(Resident) fell on [DATE] at 6:15 p.m. Resident was found in the bathroom in front of the toilet. Appears he may have tried to toilet himself." The note also stated "Staff continue to observe resident closely. Will toilet resident before and after meals as well as q 2 hrs. Plan of care remains the same." Review of the care plan dated 6/23/10 to the present, revealed that there were no interventions of how staff were going to increase observation of the resident. Review of the incident report provided by the facility dated 11/10/10, revealed a description of the incident which read "Resident went to room after dinner without asking for help. CNA found him sitting on floor in front of wc by the toilet." Areas checked on the incident report included "Confuse/memory impaired," and "Lighting poor, light not on." There was no investigation of the incident or statements by the employees who found the resident. On 12/14/10, an IDCT Fall Review noted " (Resident) fell on [DATE] at 2:15 p.m. States he was reaching for something off of the floor. Has episodes of confusion. Team continues to feel that a w/c alarm would cause additional anxiety and agitation as he can easily become agitated if he is frustrated. Staff will continue increased observation. Plan of care remains the same." Review of the care plan dated 6/23/10 to present, revealed that the resident had a history of [REDACTED]. Review of an incident report provided by the facility for the above 12/7/10 fall revealed that a Hospice nurse was in the vicinity and heard the resident fall. There was no investigation of the incident or statement by the nurse, who heard the resident fall. Under the section of the report entitled "Plan of Care"; it was documented that the resident was to be kept under observation. There was no documented evidence in the medical record of how this was accomplished. A ICP note dated 5/23/11 at 6 p.m., stated "At about 4:30 p.m. aid assigned to resident reported that he was on the floor in bathroom. Resident had his light on when she went to answer the light she found him on the floor of his bathroom. Resident stated he hit his head whilst trying to go to the bathroom." Review of the incident report provided by the facility revealed that there was no investigation of the incident. Under the area marked "plan of care," it was again noted to keep the resident under observation. Review of the care plan dated 6/24/10 to present revealed that here were no interventions in place to increase observation of the resident. Review of an IDCT note dated 6/7/11, under the section "Fall Review" it was noted that the resident fell in the bathroom on 5/23/11 at 4:30 p.m. Further note indicated "He was in the bathroom in his wheelchair and staff needed to attend to something else. Staff educated not to leave resident in bathroom who needs assistance." A nurses' note dated 9/22/11 at 5:30 a.m., revealed "Staff responding to bed alarm. Resident found on the floor on his buttocks sitting next to the bed." Review of the incident report revealed that there was no investigation of the incident. 2. The surveyor reviewed the medical record of Resident #17 on 10/6/11 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident was observed on 10/6/11 at 1:00 p.m., in a geri recliner in his room with his eyes closed and did not respond when spoken to. Further review of the medical record revealed an ICP note dated 7/6/11 at 10:00 p.m., which stated "Resident lowered to floor of bedroom while in sit to stand lift, CNA stated Res hit head on floor while being lowered. Right elbow skin tear re-opened." Review of the incident report provided by the facility revealed that the fall was witnessed by two CNAs and their names were listed on the report. The description of events stated "Resident was positioned in sit to stand lift, unable to balance or stand without assistance, appeared to be slipping out of lift, lowered to floor, head was hit on floor during lowering." There was no investigation of the incident and no statement by the aides who were involved with the transfer. 3. The surveyor reviewed the medical record of Resident # 6 on 10/11/11 at 9:00 a.m, which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor observed the resident that same day at 9:00 a.m. The resident was in bed and noted to have a black left eye and sutures below the eyebrow. The resident answered "yes" and "no" when spoken to, but was unable to engage in meaningful conversation. Review of the ICP notes in the medical record revealed that the resident had several falls. Examples are as follows but not inclusive of: On 4/12/11 at 8p.m., "Staff responded to daughter saying she found resident on floor. Resident placed in bed with no injuries noted." On 4/14/11 at 3 p.m., "Resident was in front of the T.V.- near Bistro and suddenly alarm w/c pad alarm heard and a loud noise, resident fell down on her right side, hit her head on the floor. Assisted up and into w/c, a bump noted to Rt. side of head, a small skin tear to Rt. lower leg." On 4/21/11 at 11:30 a.m., "Thump heard, nurse investigated, found pt. lying on her R side on the floor perpendicular to her w/c. She said she didn't hit her head but c/o R wrist pain-holding R wrist..R knee abraded...skin tear R dorsal hand near thumb." An x-ray was done 4/21/11 at 3 p.m., and showed a "R wrist acute fracture of distal radial metaphysis with impaction." On 10/5/11 at 3:30 p.m., "Resident was found on the floor at 2:15 p.m. by a CNA when passing by heard a loud noise and went in resident fell down as she tried to get out of her rock n go, resident found laying on her Lt. side with head against wall between wall and rock n go, able to move all extremities but noted to have a lg. laceration to her Lt. eyebrow, a skin tear to Lt. top of hand. Resident sent to ER." On 10/5/11 at 9 p.m. "Resident returned from ER around 8 p, dx minor closed head injury. Stiches above L eyebrow, 2 staples on L side of head near ear, skin tear observed on L shoulder, skin tear observed to L hand, covered with gauze." On 10/11/11 at 11:00 a.m., the surveyor asked the Director of Nurses for all fall investigations from 4/12/11 to present. The surveyor was provided with incident reports for only the 4/21/11 and 4/14/11 falls. The incident reports lacked investigations and statements by anyone who found or witnessed the falls. In addition, there was no consistent documentation that safety was readdressed after the falls. 4. The surveyor reviewed the medical record of Resident #2 on 10/8/11 at 1:30 a.m., which revealed that the resident was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. On 10/8/11 at 11:30 a.m., the surveyor observed the resident in the dining room sitting in a wheel chair, with a tab alarm applied. Review of the ICP notes revealed the following: On 8/24/11 the resident was noted to have a fall. The note indicated that the resident was using a walker and was being escorted by a CNA toward her room, when her knees gave out. The resident complained of discomfort in her right hip. On 8/26/11 at 1:40 p.m., the resident was observed to have an ecchymotic area 4 inches by one inch on her right hip, which was tender to touch. The resident was unable to recall if this occurred from the fall. According to the note, the resident was observed ambulating with the walker and dragging her feet, the staff reminded her to pick her feet up while walking. On 9/6/11 the resident was given a chair alarm and a bed alarm for safety. On 9/10/11 the CNA responded to an alarm, and found the resident on the floor in front of her bathroom. The note stated that the resident was unable to recall how she fell . The resident was transferred to the hospital with left hip pain and external rotation of the left foot. The resident was admitted with a [DIAGNOSES REDACTED]. Further review of the ICP notes revealed that on 10/8/11 at 12 noon, the resident was found on the floor, and she stated that she did not know how she got there. Review of the incident reports provided by the facility for the above incidents revealed that there were no investigations of the incidents. During an interview on 10/12/11 at 8:55 a.m., the charge nurse told the surveyor that the resident fractured her right hip in 2008 and that she was using a walker with assistance. She stated that the resident had fractured her left hip on 9/10/11 and that she was now using a walker with assist of two, from the bed to the wheelchair. 5. The surveyor reviewed the medical record of Resident #4 on 10/6/11 at 12:30 p.m., who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. When observed by the surveyor throughout the survey from 10/6/11 to 10/17/11, the resident spent most of the time alone in his room in his recliner. On 10/6/11 at 12:30 p.m. the surveyor reviewed ICP notes of Resident #5, which indicated that on 9/22/11 the resident stated that "he slid on the floor and hit his back. Purplish discoloration observed on back." On 9/24/11 at 2:00 a.m. the resident was "in his recliner complaining of rib pain and was guarding right side. One to one was given for encouragement." A physician note dated 9/22/11, indicated that the resident had a large area of bruising on left lateral side of back which was 10cm x 6cm and that there was no evidence of a fractured ribs. On 9/25/11 on 3-11 shift, the supervisor was called to speak to the resident. According to the note, the resident was very upset, crying and complaining of pain in the right rib cage and an x-ray was ordered. On 9/27/11 the x-ray result showed a slightly displaced fracture of right anterior-lateral 7th and 8th ribs. On 10/13/11 at 12:30 p.m., during an interview, the resident told the surveyor that he hurt his ribs when he fell . On 10/13/11 at 1:40 p.m., the charge nurse told the surveyor that the resident was alert and oriented but that he was hard of hearing. She stated that the resident was usually agitated and that "everything upsets him." She stated that the resident sustained [REDACTED]. The surveyor then requested the investigative reports for the resident's falls from the DON. The incident report of the fall of 9/22/11, in which the resident sustained [REDACTED]. 6. The surveyor reviewed the medical record of Resident #9 on 10/8/11 at 10:30 a.m., which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/6/11 at 9:30 a.m., during the initial tour of the facility, the resident was observed walking out of his bathroom into his room. The charge nurse told the resident that he needed to call for help after which he was assisted back in his wheel chair. On 10/8/11 at 10:30 a.m., the surveyor observed the resident sitting in a wheel chair in his room. The resident told the surveyor that he fell and fractured his ribs. On 10/13/11 at 9:45 a.m. the resident was observed ambulating with a Certified Nursing Assistant in the hall way. On 10/8/11 at 10:30 a.m., the surveyor reviewed the ICP notes which revealed that the resident had fallen three times since his admission to the facility from 5/29/11 to 7/27/11, resulting in a reddened area on his right knee and fractured ribs. Further review of the medical record revealed that the resident sustained [REDACTED]. According to the note, the resident fell on his left side and complained of pain. Minor bruising was noted to his left arm, complained of left sided pain that increased with inhalation and had difficulty breathing while lying flat. The resident was sent to the emergency room where he was diagnosed with [REDACTED]. On 10/8/11 at 11:20 a.m., the charge nurse told the surveyor that the resident used a walker with contact guard and that the resident was in a room which was far away from the nursing station. The charge nurse stated that the resident was going to be moved whenever there was a room available closer to the nursing station. On 10/11/11at 12:30 p.m., the surveyor requested investigations of the falls. For the fall on 5/29/11 there was no evidence of an investigation or statements to determine how the falls had occurred. On the 7/27/11 investigative report, the Assistant Director of Nursing (ADON) wrote a statement on 7/31/11 to the CNA, asking her to write a detailed note on the specifics as to how the resident fell on [DATE]. On 8/10/11 the CNA wrote a note which stated that "she was standing at the back of the wheelchair while the resident was trying to turn and to sit on the chair. I held on to his pants waist to guide him in the chair and somehow on his left side the resident lost his balance and fell ." The CNA further wrote that after the incident, the nurse told her that "the resident had a bad leg which she did not know." On 10/1/11 at 1:00 p.m., the surveyor interviewed the charge nurse to determine how information specific to resident's care was communicated to the CNAs. The charge nurse stated that a daily CNA Work Sheet is printed out and kept in the nurses' station for CNAs to reference. Review of the worksheet on 10/11/11, revealed that under the resident's name, there was no indication that the resident had left sided weakness. On 10/12/11 at 10:30 a.m. this was brought to the attention of the ADON, who reviewed the resident's chart and stated that the resident had a bad leg due to left sided weakness. The ADON and the surveyor reviewed the CNA work sheet. There was no indication on the sheet that the resident had a bad leg or how he should be transferred by the staff. The ADON told the nurse to have the resident assessed and to update his care plan and the CNA work sheet. 7. On 10/12/11 at 9:30 a.m., the surveyor reviewed the medical record of Resident #5, which revealed that the resident had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], revealed that Resident #5 was cognitively impaired and required extensive assistance from staff with Activities of Daily Living. On the Fall Risk assessment dated [DATE] Resident #5 received a score of 10 indicating she was at high risk for falls. On 10/12/11 at 9:00 a.m., the surveyor observed Resident #5 seated in her wheelchair in the TV area. Six others residents were observed in the area and no staff was present. On 10/12/11 at 9:15 a.m., the surveyor reviewed Resident #5's clinical record. A review of the ICP notes from 12/10 to 6/11 revealed that Resident #5 sustained falls at the facility on 12/1/10, 12/25/10, 1/1/11 and 6/14/11. The fall of 12/1/10 resulted in Resident #5 sustaining a right hip, right hand fracture, and head trauma with a laceration. On 10/12/11 at 9:45 a.m., the surveyor reviewed the "Resident Hospital Transfer and Discharge Summary" dated 12/1/10. This document included a notation indicating that the resident had a fall, was transferred to the hospital on [DATE] at 2:00 p.m., had head trauma with a large hematoma, had painful range of motion to the right arm and right hip. The primary [DIAGNOSES REDACTED]. On 10/12/11 at 10:30 a.m., the surveyor reviewed the physician progress notes [REDACTED]. right frontal area above hairline." At 11:30 a.m., that same day the surveyor reviewed Resident #5 "Fall Reporting Form" dated 12/1/10. The form was only an incident report and lacked investigation or statements from the incidents. On 10/13/11 at 1:30 p.m., the surveyor asked the DON for the investigation. The DON indicated there was none. On 10/17/11 at 9:30 a.m., the surveyor interviewed the CNA assigned to Resident #5 on 12/1/10. The CNA indicated that she escorted Resident #5 to the bathing spa room for a monthly weight. The surveyor escorted the CNA to the bathing spa where she could demonstrate what happened. The CNA stood to the left side of the scale. The CNA indicated that after she weighed the resident, she moved in front of the scale. At that time she stated Resident #5 let go of the scale handle, her feet jammed, she stumbled, hit the tub, then fell on the floor. The CNA stated, "I could not catch her." The CNA stated she usually held the resident under the arm and gave the resident the chance to step down from the scale and get out of the room safely, but she indicated that day she did not guide the resident off the scale. On 10/17/11 at 10:30 a.m., the surveyor interviewed the activity staff identified by the CNA. The activity staff revealed that she was in the bistro and heard a loud noise. She went to the bathing spa and observed Resident #5 lying on the floor. The activity staff revealed the CNA was in the bathing spa also. The activity staff revealed she left the room and called for the nurse. The surveyor asked the Activity Staff if she wrote a statement regarding the incident and she replied "no." An interview with the nurse later that day indicated that she was notified of the fall by the CNA. The nurse indicated she went immediately to the bathing spa, assessed the resident, and summoned another staff to call the supervisor. The Nurse said she administered First Aid to the resident, stayed with the resident until the paramedics took over. The nurse stated, "clinical signs of fracture were evident." The nurse went on to state that Resident #5 was complaining of pain and had external rotation of her right leg and arm. The nurse revealed that she did not write a statement because she was not asked to write one. She further indicated that there was no change in interventions to address the safety upon return from the hospital because the resident was in a wheelchair and could not ambulate. Resident #5 returned to the facility on [DATE] with a cast to the right arm. Review of the resident's care plan revealed that it was not revised to include how supervision would be provided following the fall with injury. The Resident Fall Report indicated that on 1/1/11 at 7:00 p.m., Resident #5 sustained another fall. The report noted that the resident "was seen on TV screen standing up and falling down." According to the report, there was no staff present for supervision at the time of the fall. On 6/14/11 at 9:30 a.m., Resident #5 sustained another fall according to the ICP notes. Review of the fall investigative report revealed that it was a witnessed fall. On 10/17/11 at 11:00 a.m., the surveyor interviewed the activity staff who witnessed the fall. The activity staff revealed that Resident #5 was ambulating a few feet ahead of her. She was escorting Resident #5 off the unit along with another resident in a wheelchair and stated she was unable to prevent her from falling. Resident #5 sustained an injury to the left knee and struck her arm. According to the Physical Therapy (PT) report dated 2/22/11, Resident #5 was discharged from PT to restorative nursing. The recommendation was to ambulate with supervision. An interview with the PT staff on 10/17/11 at 11:30 a.m., described supervision as "walking side by side with the patient, not hands on." The PT discharge summary dated 2/22/11 stated, "patient will complete transfers with supervision with verbal cues." On 10/17/11 at 9:30 a.m., the surveyor interviewed the supervisor on duty at time of the 12/1/10 fall. The surveyor asked the supervisor to elaborate on the protocol for weighing the resident in the bathing spa. The supervisor indicated that if a resident is ambulatory it is preferable for the resident to stand and be weighed. The supervisor stated, " I would think anybody in this age group would need guidance to get off the scale." The surveyor asked the nursing supervisor if the CNA was in-serviced following the incident regarding safe transfer technique, and she responded "no. " On 10/18/11 at 9:15 a.m., the surveyor reviewed the fall investigative report with the DON, who indicated that fall interventions should be on the care plan. A review of Resident #5's Care Plan showed that no interventions were added after the falls regarding safe transfer technique. There was no investigation done to identify the causative factors of the accident or identify precautions to prevent recurrence. The surveyor asked the DON if the staff was in-serviced following the incident of 12/1/10 and 6/14/11. The DON revealed that the staff was not in-serviced and stated that the CNA should guide any resident off the scale for safety. 8. The surveyor reviewed the medical record for Resident #10 on 10/11/11 and observed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed a fall incident report provided by the facility and noted that the resident had a fall on 12/10/10. According to the incident report, the resident told the staff that she slipped out of her wheelchair while self propelling in the hallway. The report indicated that Resident #10 was confused and had altered gait and balance. A follow-up plan of care was to "keep under observation." Further review of the medical record revealed that the resident had a fall on 5/29/11. The fall report indicated that the resident was found on the floor between the bed and wheelchair. The resident told the staff that she was getting out of the wheelchair to get into bed and slid out. The report noted that the resident's buttock was reddened but no other obvious injury. Further review of the medical record revealed an ICP note dated 6/4/11 at 8 a.m., which stated that Resident #10 started complaining of pain and was unable to get out of bed. The note stated that staff called the physician and the resident was sent to the hospital for evaluation. The resident was diagnosed with [REDACTED]. There was no investigation into the fall of 5/29/11, and no investigation of this newly discovered compression fracture. There was no evidence that the facility revised the plan of care with interventions for the resident's safety. Further review of the medical record revealed that Resident #10 had another fall on 9/12/11 and sustained a left Ulna fracture and swelling with discoloration to the top of left hand. The facility was unable to provide an investigation for this fall. During an interview with the DON on 10/17/11 at 1:30 p.m., she told the survey team that they would "review their policy and conduct investigations from now on." 9. The surveyor reviewed the medical record of Resident #14 on 10/11/11 at 9:30 a.m. and observed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed the resident's fall incident/accident reports and ICP notes and observed the following: On 1/2/11, staff documented that the resident had "a pale purple area" on her upper right hip On 1/23/11, 3 small ecchymotic areas were observed on the resident's right hip On 5/11/11 a 4 cm x 3 cm abrasion was noted on the resident's left forehead On 7/20/11, a small pink area was noted on the resident's forehead. There was no investigation of any of these injuries. On 8/3/11, according to an incident report, Resident #14 slid out from under the Laptray while in her wheelchair. In response, the facility decided to use a Broda chair instead of the regular wheelchair and also discontinued the Laptray. On 8/3/11 a physician's orders [REDACTED]. According to multiple ICP notes, the resident was observed many times attempting to get up out of the broda chair. On 8/29/11, the resident was found on the floor in the Television room. The resident was unable to recall what happened. According to the incident report, "the alarm did not sound." The surveyor observed another fall report dated 9/5/11 which indicated that another resident pointed out to the staff that Resident #14 was on the floor in the dining room. The resident sustained [REDACTED]. There was no investigation as to why the alarm did not sound and no further evidence was provided to the surveyor. 10. The surveyor reviewed the medical record of Resident #16 on 10/7/11 at 9:00 a.m., and observed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon further review of the medical record, the surveyor noted that the resident suffered the following injuries: On 6/2/11 the resident sustained [REDACTED]. On 7/22/11 a skin tear to the shin was sustained during transfer by the Certified Nursing Assistant (CNA) On 7/24/11 a skin tear to the right arm On 8/2/11 a skin tear to the left forearm On 8/28/11 a skin tear to the left elbow which required a steri strip dressing On 8/30/11 a skin tear to the right forearm measuring 2 cm in size while being positioned by the CNA On 9/22/11 a skin tear measuring 3.5 x 3 when arm was hit while being positioned by the CNA. The incident reports indicated that except for the skin tears sustained during positioning by the CNA, all the other skin tears were from unknown origin. There was no investigation of the skin tears and no evidence that the CNA was inserviced regarding gentle handling of the resident to prevent the possibility of skin tears. The surveyor observed the resident on 10/12/11 at 11:40 a.m., eating lunch. The resident was wearing a short sleeved blouse and no other protection on her arms, and on 10/13/11 at 10:20 a.m., the resident was attending an activity wearing a short sleeve blouse and no protection for the skin. 11. During the initial tour of the facility on 10/6/11 at 9:30 a.m, the surveyor observed Resident #3 sitting in a wheelchair with a chair alarm attached. There was bruising noted on the resident's left forehead, and abrasions on the left side of the resident's nose and forehead. The tour nurse stated that the resident had a recent fall while being transported to the physical therapy department by a volunteer. On 10/7/11 at 10 a.m, the surveyor reviewed the medical record of Resident #3 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 9/29/10 physician's orders [REDACTED]. An ICP note of 11/8/10 at 10:30 p.m. revealed the following: "Resident ringing call bell at approximately 7:30 p.m, states, I want to get out of here. When returning with assistance resident on floor. Sensatec to chair (pad) not working- replaced same." Review of the "Resident Fall Reporting Form" for this incident concurred with the ICP note of 11/8/10 regarding the details of the fall, however, it did not indicate that the chair alarm was not functioning at the time of the resident's fall. There were no recommendations listed on the form to prevent recurrence. An ICP note of 10/4/11 at 11 a.m, revealed, "Resident fell out off the moving wheelchair in the basement hallway. Resident was being taken to Physical Therapy (PT) by volunteer. Resident's feet pedals were not on. Resident has injury to head with soft tissue swelling on left side of forehead. Noted small pink abrasion to left side of nose and left hand ecchymotic area noted. Pink hematoma on left side of forehead." The resident was sent to the hospital for an evaluation and returned to the facility later that same day. Review of the "Resident Incident Report," for the fall revealed "Resident being transferred via wheelchair with volunteer. Volunteer did not ensure pedals present on wheelchair. When pushing resident, resident put down feet and fell forward hitting head." The contributing factor to the incident was identified to be, "no foot pedals." The volunteer was immediately inserviced following the incident. Review of the care plan dated 1/17/2011 to the present, identified falls as a problem. Some of the interventions included: keep in room close to the nurse's station for closer supervision; instruct on safety measures to reduce the risk of falls; to wear non-slick footware that fits and Sensatec alarm to bed and chair, check for functioning and placement every shift. On 10/7/11 at 12 p.m, the nurse stated that the Certified Nurses' assistants (CNAs) were responsible for checking the placement and function of the safety alarms, and documenting on the safety alarm checklist. The nurse was unable to provide Resident #3's safety alarm checklist for 11/8/10 when the safety alarm failed to function properly. 12. On 10/11/11 at 1:00 p.m, the surveyor reviewed the medical record of Resident #7 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the ICP noted revealed the following: On 3/25/11 at 10 p.m, the resident was noted to be pleasantly confused and fell while ambulating to the bathroom. Following the incident, a physician's orders [REDACTED]. On 3/31/11, an admission summary indicated that the resident was confused with short and long term memory loss and required supervision due to poor safety awareness. On 5/6/11 at 8:05 a.m, the resident was assisted to the bathroom and placed on the toilet. Approximately 10 minutes later, the staff responded to the wheelchair alarm and the resident calling out for help. The resident was found on his hands and knees on the floor with bowel movement on the bathroom floor. Review of the "Resident Fall Reporting Form," indicated that the resident was, "confused/ memory