Every finding on record at Merry Heart Nursing Home

Based on observation, interview, record review and policy review, it was determined that the facility failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 06/22/26 at 11:04 AM, in the presence of the Food and Nutrition Supervisor (FNS) Supervisor, and the Registered Dietitian (RD), the surveyor observed the following:In the food preparation area, on a shelf, the surveyor observed two shallow full sized steam table pans which were stacked with water between them. The FNS stated that these pans should have been air dried before they were stacked. The FNS stated that the porter is responsible for washing the steam table pans.At 11:16 AM, the surveyor interviewed the porter, [NAME], who stated that he washed the pans and placed them on a rack near the dishwasher. The porter pointed to two deep 1/4 sized steam table pans, which he stated were just washed, and then the surveyor observed that those were also stacked with water between them.The surveyor reviewed the Dishwashing Procedures policy with a review date of 4/29/26, which revealed that the dishes are left in the racks to dry and then stored. On 6/24/26 at 1:24 PM, the surveyor discussed the above concerns with the Assistant Licensed Nursing Home Administrator and the Director of Nursing. No further information was provided.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service (education) training annually, for 4 of 5 CNA (CNA #1, #2, #3, and #4) education reviewed.On 6/25/26 at 8:57 AM, the surveyor reviewed the provided in-service education for five randomly selected CNAs for the year 2025 to 2026, which revealed the following:CNA #1 hired on 3/18/21, had 11.5 hours of in-service training from date of hire anniversary dates for 2025 to 2026.CNA #2 hired on 4/11/12, had 8 hours of in-service training from date of hire anniversary dates for 2025 to 2026.CNA #3 hired on 1/11/21, had 9.5 hours of in-service training from date of hire anniversary dates for 2025 to 2026.CNA #4 hired on 5/13/19, had 8.75 hours of in-service training from date of hire anniversary dates for 2025 to 2026.On 6/25/26 at 11:20 AM, the surveyor informed the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Assistant Administrator (AA) about the concern that 4 of 5 CNA 12-hour in-service education training was not completed. On 6/26/26 at 10:55 AM the DON stated the identified CNAs were called in to complete their education. The DON acknowledged the 12-hour education was expected to be completed from hired anniversary dates annually. The DON stated Human Resources (HR) was responsible for ensuring education was completed and did not know why HR did not call in the CNAs earlier to complete their education.The surveyor reviewed the facility provided policy titled, Certified Nurse Aide (CNA) Education and Training Policy last revised 1/10/19. The policy revealed: .Each CNA must receive 12 hours of in-service education annually, based on performance reviews, with at least 6 hours covering OBRA [Omnibus Budget Reconciliation Act] requirements.[Online Learning] training program is the program that we use to complete the 12-hour mandatory education requirement. There will be assigned topic per month.N.J.A.C. 8:39-43.17(b)

Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 2 of 20 residents (Resident #1 and #88) reviewed for comprehensive care plans. 1. On 6/22/26 at 10:37 AM, the surveyor observed Resident #88 in bed, awake, sitting up with knees bent towards their chest. The resident had incoherent speech and could not answer simple questions. Resident #88 was calm and observant. There were no concerns observed. On 6/23/26 at 9:31 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #88. The admission Record (a summary of important information about a resident) revealed that Resident #88 had diagnoses that included, but were not limited to, dementia, mood disorder, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, with an Assessment Reference date (ARD) of 4/19/26, indicated the facility attempted to assess the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #88 was rarely/never understood and the BIMS test could not be completed. A physician's order dated 11/4/25 indicated for escitalopram 5 milligram (mg) to give one tablet one time a day for depression. A physician's order dated 5/1/26 indicated for Depakote delayed release 125 mg to give one capsule by mouth one time a day for mood disorder. The order was discontinued on 6/14/26. A review of progress notes revealed the resident's behaviors were being monitored with no recent episode documented. A review of the resident's care plans revealed there was a care plan for antidepressant medication. The care plan did not indicate any exhibited behaviors or interventions related to resident behaviors. On 6/23/26 at 11:38 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who was assigned to care for Resident #88. The LPN stated that Resident #88 previously exhibited mood and aggressive behaviors towards others. The LPN explained Resident #88 no longer exhibited aggressive behaviors and the Depakote medication was recently discontinued after a GDR (gradual dose reduction). The LPN stated that Resident #88 still had occasional behavioral episodes of resistance with care. The surveyor asked the LPN about behavior monitoring and care planning. The LPN stated she did not complete care plans and that it was the Assistant Administrator (AA) who did. The LPN acknowledged that if the resident exhibited behaviors including resistance to care, then it should be care planned. Further review of Resident #88's care plans revealed there was no care plan related to the resident exhibiting any behaviors, including resistance with care. Additionally, there were no care plans which included interventions to address the resident's behaviors or their monitoring. On 6/23/26 at 12:13 PM, the surveyor interviewed the AA, who was also a Registered Nurse (RN). The AA stated the care plan was a team effort and responsibility. The AA explained that the nurses, the Director of Nursing (DON), and the interdisciplinary team were responsible for initiating and updating care plans. The AA stated if behaviors were no longer recurring, a care plan could be resolved. The AA acknowledged if a resident had a history of exhibiting behaviors and occasional episodes recurred it should be included in the care plan. The AA acknowledged if a resident had episodes of resisting care, then it should be documented and care planned. The surveyor discussed with the AA about concern for Resident #88's care plan not including behaviors. The AA stated she would review with the team to provide additional information. On 6/24/26 at 1:08 PM, the surveyor informed the Director of Nursing (DON) and the AA of the above concern for Resident # 88's care plan. On 6/25/26 at 10:00 AM, the AA and the DON provided an updated care plan for Resident #88. They acknowledged the care plan was incomplete and should have included resident behaviors to reflect a comprehensive and individualized care plan. 2. On 6/22/26 at 10:30 AM, and on 6/23/26 at 8:50 AM, the surveyor observed Resident #1 awake, alert, and able to answer the surveyor's inquiry. On 6/22/26 at 12:50 PM, the surveyor reviewed the electronic medical record of Resident #1, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #1 was admitted with diagnoses that included but were not limited to (a response to unfamiliar situations) and adjustment insomnia (unable to sleep). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 5/22/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the residents had moderately impaired cognition. A review of the Physician Order (PO) with the start date of 6/17/26, an order of alprazolam 0.25 mg (milligram) by mouth every 8 hours as needed for anxiety for 14 days. A review of the care plan (CP) report on Resident #1 did not reflect the use of anti-anxiety medication. On 6/24/26 at 11:07 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the CP should be initiated because it needs to monitor the effectiveness of the anti-anxiety medication and the nursing intervention. On 6/24/26 at 11:12 AM, the surveyor interviewed the assistant administrator/Registered Nurse (AA/RN), who stated that the CP should be done by the nurses assigned to the resident. All the nurses should be doing the CP. Anti-anxiety medication should be added at the CP to monitor the effectiveness of the medication, if the non-drug intervention is effective or not working. The nurses should at least initiate it. On 6/25/26 at 10:40 AM, the team of surveyors met with the AA/RN and the Director of Nursing (DON) for the above concern. The DON stated that the CP for anxiety medication should be initiated when the medication is started, and to monitor the effectiveness of treatment. On 6/25/26 at 10:41 AM, the surveyor reviewed the facility policy that was given by the AA/RN with the reviewed date on 1/28/26 titled, Interdisciplinary Plan of Care, which revealed under Procedures: Care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan, and development of goals for the resident that are reasonable and measurable. NJAC 8:39-11.2(d)

Complaint #2729626Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a resident who was cognitively impaired and high risk for falls received adequate supervision to prevent accidents. This deficient practice was identified for 1 of 4 residents (Resident #122) reviewed for falls.On 6/24/26 at 9:15 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #122. The resident no longer resided at the facility.The admission Record (a summary of important information about a resident) documented that the resident had diagnoses that included but were not limited to, hydrocephalus (a medical condition where excess cerebrospinal fluid builds up within the brain's cavities), mild cognitive impairment of uncertain origin, restlessness and agitation, history of a transient ischemic attack ( mini stroke), and difficulty walking.A comprehensive Minimum Data Set (MDS) assessment, a tool use to facilitate the management of care, with an assessment reference date of 12/24/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #122 scored 6 out of 15, which indicated the resident had severe cognitive impairment.Under Section GG (Functional Abilities) of the MDS assessment, Resident #122 was coded as needing substantial/maximal assistance for toileting hygiene. The resident was coded as needing partial/moderate assistance for showering/bathing self; upper body dressing, lower body dressing; putting on/taking off footwear; and personal hygiene (including combing hair, shaving, washing/drying face and hands). For mobility, Resident #122 was coded as needing substantial/maximal assistance for sitting to lying. The resident was coded as needing partial/moderate assistance with chair/bed to chair transfer; toilet transfer; tub/shower transfer; and walking 10 feet.A review of progress notes revealed the following:A nurse progress note dated 12/24/25 at 12:15 AM revealed at 11 PM (on 12/23/25) during rounds Resident #122 was found lying on the floor in their room. The resident did not know what happened. The resident sustained a laceration to left side of head and hematoma on left eyebrow. The staff called 911and at 11:20 PM the resident was transported to an emergency room (ER) for further evaluation. A follow-up progress note dated 12/24/25 at 1:40 AM indicated a call from the ER nurse was received, a computed tomography (CT) scan (an imaging test) was done with negative results, and the resident would be returning to the facility. The resident's representative (RR), the primary physician, and the Director of Nursing (DON) were made aware of the incident.A nurse's progress note dated 1/1/26 at 6:45 PM revealed at 5 PM the nurse was notified Resident #122 had an unwitnessed fall incident in the bathroom; the resident was sitting on the floor. Resident #122 stated they were trying to clean themself up and were not hurt. RR #2, and a nurse practitioner (NP) were made aware of the incident.A nurse's progress note dated 1/6/26 at 11:21 AM revealed at 10:30 AM another nurse notified the assigned nurse that Resident #122 had an unwitnessed fall inside room [ROOM NUMBER]'s bathroom and was found sitting on the floor. room [ROOM NUMBER] was two doors down and across from Resident #122's room. The resident was assessed with no apparent injuries, the call bell was not activated, and their pants were soiled. The RR and a NP were made aware of the incident.A nurse's progress note dated 1/8/26 at 11:11 AM revealed at 10:15 AM the nurse was informed by a Certified Nurse Aide (CNA) that Resident #122 had an unwitnessed fall inside their room. The resident stated they were trying to get up. The resident was assessed with no apparent injuries, call bell not activated, they were not soiled and wore socks. The RR and a NP were made aware of the incident.A nurse progress note dated 1/24/26 at 4:33 PM revealed at 3:45 PM the CNA notified the nurse that Resident #122 had an unwitnessed fall inside 224 bathroom and was found lying on the floor. The resident stated they were going to the bathroom and were not hurt. The resident was assessed with no apparent injuries, the call bell was not activated, and the resident was not soiled. The RR and a NP were made aware of the incident.A nurse's progress note dated 1/26/26 at 11:25 PM revealed at 7:38 PM in a hallway Resident #122 was sitting on the floor and grabbing the handrails. The resident was assessed with no apparent injuries, and the resident was not soiled. Resident #122 was assisted back to their wheelchair with two-person assist. The primary physician, the DON and the RR were made aware of the incident. A nurse progress note dated 1/27/26 at 1:23 PM revealed Resident #122 was discharged via wheelchair in stable condition for a routine home discharge. On 6/24/26 at 10:40 AM, the surveyor requested from the DON fall investigations for Resident #122.On 6/24/26 at 9:30 AM, the DON provided the surveyor with the fall investigations for Resident #122. The investigations included a summary, evaluation of potential contributing factors, staff statements as needed, and conclusion of the investigation. The investigations revealed the following:For the 12/23/25 fall at 11 PM, the intervention to prevent future falls was to check Resident #122 around 10:30- 11 PM for safety and care needs. Staff were provided with education on new care plan intervention.For the 1/1/26 fall at 5 PM, an aide was in the bathroom assisting the resident. The resident's pants were soiled, and the aide left the resident in the bathroom to retrieve a clean pair of pants. Upon their return, the resident was found sitting on the floor. The intervention to prevent future falls was to ensure that the resident was not left unattended in the bathroom. Staff were provided with education on new care plan intervention.For the 1/6/26 fall at 10:30 AM, an empty chair was observed outside of room [ROOM NUMBER] by a nurse. Upon looking in the room, Resident #122 was found sitting on the bathroom floor. The intervention to prevent future falls was to check Resident #122 for safety and needs, including offering toileting between 10 to 10:30 AM. Staff were provided with education on new care plan intervention.For the 1/8/26 fall at 10:15 AM, during rounds the resident was found lying on the floor in their room. The intervention to prevent future falls was upon waking up, Resident #122 would be assisted with getting ready for the day and closely monitored outside their room, by the nurses' station. Staff were provided with education on new care plan intervention.For the 1/24/26 fall at 3:45 PM, it was revealed that the resident was found lying on the floor in their bathroom. The intervention to prevent future falls was to remind visitors to notify staff once they were leaving to closely monitor Resident #122. Staff were provided with education on new care plan intervention.For the 1/26/26 fall at 7:38 PM, indicated the resident was assisted with toileting one hour prior to the fall and last seen by staff at 7:30 PM sitting in their wheelchair in the hallway. The planned intervention to prevent future falls was to ensure Resident #122 was in front of the nursing station for closer supervision. Staff were provided with education on new care plan intervention.On 6/24/26 at 10:55 AM, the surveyor interviewed a Registered Nurse (RN) who cared for Resident #122. Fall prevention interventions for high fall risk residents included a low bed position, making sure personal items were within reach, and frequent monitoring of a resident which may include putting them closer to the nurses' station. The RN also explained care plans were reviewed and updated with resident centered interventions after a fall to prevent further incidents. The RN recalled Resident #122 who she stated was very confused at times, and a very high risk for falls due to having multiple falls. The RN stated Resident #122 used a wheelchair and was able to propel themself. The RN further explained that the resident was able to feed self with set up but required assistance by staff with other activities of daily living (ADLs). The RN could not recall details of the resident fall incidents or specific interventions.The surveyor asked about assisting cognitively impaired and high fall risk residents in the bathroom. The RN stated that residents should be monitored and not left unattended. The RN added residents who required closer supervision would be placed by the nurses' station as there would be more staff to monitor them. Recreational activities, depending on a resident's preferences, would be provided.On 6/25/26 at 11:20 AM, the surveyor informed the DON, the Licensed Nursing Home Administrator (LNHA), and the Assistant Administrator (AA) about the concern of the provision of appropriate supervision to prevent falls for Resident #122 and the resident continuing to have multiple falls despite interventions implemented.On 6/26/26 at 11:14 AM, the DON stated that Resident #122 moved quickly and was impulsive. The DON explained that the resident was care planned after each fall and staff did their best to try to prevent falls. The DON stated for the 1/1/26 fall in which the resident was left in the bathroom for the aide to retrieve another pant, in-service education was provided to the staff. The DON stated for the concern with the 1/6/26 fall in which Resident #122 was found in another room, that the room was across from the resident's room and the resident entered the room in error. The surveyor discussed that a tour of the floor was done and the room the resident was found was two doors down and across from their assigned room as well as further away from the nurses' station. Additionally, the resident's empty wheelchair was found by the door, the resident made their way inside of the room and was found on the bathroom floor of the room. There was no additional response provided by the facility.A review of the facility's Preventing Falls policy, last reviewed on 1/28/26, revealed an objective To be able to reduce incidence of falls and injuries resulting from falls. Under Procedures revealed, 9. Residents will be observed closely, kept occupied with activities and needs will be anticipated to prevent falls (e.g., in front of nursing station, toileting, kept occupied with activities, ambulated, etc).NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen (O2), according to the standard of clinical practice specifically not administering O2 therapy as ordered by the physician for 2 of 2 residents (Resident #1 and #126) and the posting of cautionary and safety signs indicating the use of O2 were utilized for resident that received O2 therapy for 1 of 2 residents (Resident #1) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 6/22/26 at 10:15 AM, the surveyor entered the room of resident #126. The resident appeared alert and oriented, seated in a wheelchair. The surveyor observed an oxygen concentrator with the tubing stored in a properly dated bag attached to the machine. The machine was not operating, and the resident stated, I only use it at night. On 6/22/26 at 11:15 AM, the surveyor conducted a review of Resident #126's electronic health record (EHR). The EHR reflected a physician's order for oxygen continuously via nasal canula at a flow rate of two liters per minute (LPM) every shift with a start date of 6/20/26. The EHR reflected that the resident was admitted to the facility with diagnoses including, but not limited to, pneumonia and chronic obstructive pulmonary disease. On 6/23/26 at 10:15 AM, the surveyor made a second observation of Resident #126's oxygen running and not connected to the resident. The resident acknowledged again that they use the oxygen mostly at night. On 6/23/26 at 11:40 AM, the surveyor interviewed Registered Nurse (RN) #1. The RN# 1 confirmed the resident had an order for oxygen continuously at a flow rate of 2 LPM. The RN #1 acknowledged that the resident used oxygen only overnight. A review of the resident records revealed that there was no documentation in the EHR that the resident refused to wear the oxygen as prescribed. There was also no communication with the physician to update the resident's status and change, update, or eliminate the oxygen order. On 6/23/26 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged that nurses should follow orders for oxygen therapy as written or contact the physician to discuss the resident's status and obtain new orders prior to changing the administration of oxygen. The DON acknowledged that the resident was ordered continuous oxygen, via nasal canula at 2 liters per minute. On 6/24/26 at 1:05 PM, the surveyor and survey team met with the DON and the Assistant Licensed Nursing Home Administrator (ALNHA) and discussed concerns with oxygen therapy for Resident #126. Both acknowledged that the resident's oxygen therapy was not administered as ordered. Reference: The National Institutes of Health defines O2 as a colorless, odorless, and tasteless gas. It will support life. It is noncombustible but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. 2. On 6/22/26 at 10:30 AM, and on 6/23/26 at 8:50 AM, the surveyor observed Resident #1 awake, with a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 flows) on both nostrils attached to a concentrator (a device that supplies O2) running at 1.5 to 2 LPM. The surveyor observed on both days that the entrance to their room did not have an O2 in use sign. On 6/22/26 at 12:50 PM, the surveyor reviewed the EHR of Resident #1, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #1 was admitted with diagnoses that included but were not limited to acute and chronic respiratory failure with hypoxia (low O2 level in the blood). A review of the Minimum Data Set (MDS), (an assessment tool used to facilitate the management of care) dated 5/22/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the residents had moderately impaired cognition. Further review of the A/MDS, as reflected in section O-Special Treatments, Procedure and Program, revealed that Resident #1 was using continuous O2 while a resident in the facility. A review of the Physician Order (PO) with the start date of 5/15/26, O2 continuously at 3 LPM via NC. A review of the care plan (CP) report initiated on 5/18/26 focused on Resident #1, who had acute on chronic respiratory failure. Intervention included, but was not limited to, administering O2 as ordered. On 6/23/26 at 8:53 AM, the surveyor interviewed the RN # 2, who was assigned to the resident, and stated that the resident should have been receiving O2 at 3 LPM continuously. The RN # 2 added that there should be signage for the residents outside the door since the resident is receiving O2. On 6/23/26 at 11:25 AM, the surveyor interviewed the DON regarding the concern above. The DON acknowledged that it should have signage for O2 use, and the nurse should check the resident's oxygen order. On 6/25/26 at 10:05 AM, the surveyor reviewed the facility policy given by the DON titled Medication Administration with the reviewed date on 1/16/24 revealed under Procedure: O2 Saturation Monitoring 3. For residents receiving O2 therapy, the nurse verifies the prescribed oxygen delivery device and flow rate, ensures the oxygen is being administered as ordered, and documents the O2 saturation reading and oxygen setting as applicable. On 6/23/26 at 12:30 PM, the surveyor reviewed the facility policy titled Administration of Oxygen with the reviewed date on 1/28/26 revealed under Procedure: 6. i. Alert the staff, visitors, and residents with an O2 sign by the door of the resident's room. NJ 8:39-25.2(c)3

Based on observation, interview, and record review, it was determined that the facility failed to ensure high blood pressure medication with parameters, a defined set of conditions was followed as ordered by the physician, and in accordance with professional standards of practice and the facility policy of medication administration. The deficient practice was identified for 1 of 4 residents (Resident #130), administered by 1 of 4 nurses observed during the medication administration 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 and potential physical and emotional health problems, through such services as casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 6/25/25 at 8:14 AM, the surveyor observed Licensed Practical Nurse (LPN) prepare 5 medications for Resident #130 which included a physician's order for Metoprolol Succinate Extended Release (ER) 25 milligram (mg), to be given one (1) tablet by mouth one (1) time a day for hypertension (high blood pressure) and held for systolic blood pressure (SBP) less than 110 and heart rate (HR) less than 60. The order was started on 6/24/26 and scheduled for administration at 8:00 AM.At that time, LPN stated that she had previously taken Resident #130's blood pressure (BP) and heart rate (HR) measurements at 7:33AM, pointed to the documented recording of the BP and HR (vitals) that reflected the recorded time of 7:33 AM on the electronic Medical Record (eHR).At 8:20 AM, the LPN confirmed she was ready to administer the medications to Resident #130, turned, knocked on the resident's door and entered the room. At that time, the surveyor requested to speak with LPN outside of the resident's room.At 8:21 AM, the surveyor and the LPN reviewed the eHR together. At that time, LPN stated she knew Resident #130 had parameters and a diagnosis of congestive heart failure (inability of the heart to pump enough blood). LPN also stated that she should have taken the BP and HR before administration because both BP and HR could have changed from when she first took the vitals to the time of administration [47 minutes]. At that time, the surveyor discussed the concerns and the LPN stated she would re-check the vitals prior to administration.On 6/25/26 at 1:05 PM, during a meeting with the survey team, the Assistant Licensed Nursing Home Administrator, and the Director of Nursing (DON), the surveyor discussed the concern with the LPN who did not take Resident #130's BP and HR immediately prior to administration of a high blood pressure medication in accordance with the physician's orders.At that time, the DON stated that the BP and HR should have been taken immediately before the administration of the high blood pressure medication. No further information was provided.A review of the provided facility policy, Medication Administration dated/revised 4/29/26, included the following: Medications are administered as prescribed, in accordance with good nursing principles and practices.No additional information was provided. NJAC 8:39-11.2(b), 27.1 (a) 29.2(d)

Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility staff members failed to ensure infection control practices were implemented by not properly handling the soiled linens to prevent the spread of infection, as reviewed for infection control tasks. This deficient practice was evidenced by the following: On 6/23/26 at 10:40 AM, the surveyor observed the dietary aide (DA) who dropped off a plastic bag of soiled linen inside the laundry room on the floor. The DA stated that they usually put the plastic bag of laundry on the floor, and the laundry aide will take it. The surveyor observed that there is a bin of soiled mops, but nothing for soiled linen. On 6/23/26 at 10:43 AM, the surveyor interviewed the Food Nutrition Supervisor (FNS), who stated that they put the soiled laundry on top of the washing machine or the other side on the floor, and the laundry aid will take care of it. She added that there is no provided bin for soiled linen inside the laundry room. On 6/23/26 at 10:50 AM, the surveyor interviewed the Infection Preventionist (IP) who was with the surveyor inside the laundry during observation. The IP stated that soiled linen should not be on the floor, and there should be a system for handling the soiled linens. On 6/23/26 at 11:09 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concern, and the DON stated that there should be a bin to put the soiled laundry linens, and added that she will look into it. On 6/25/26 at 10:05 AM, the surveyor reviewed the facility policy given by the DON titled, Infection Prevention and Control - Handling and Laundry of Soiled Dietary Linens (Napkins, Aprons, and Dining Room Tablecloths) with the implemented date on 6/23/26, revealed under Procedure: B. Handling of Soiled Napkins and Dietary Aprons by the Dietary department, 5. Upon arrival at the laundry room, place the bagged soiled napkins and aprons into the designated laundry hamper/bin for washing. NJAC 8:39-19.1

Based on observation, interview, and record review, it was determined that the facility failed to maintain the dignity of two unsampled residents. This deficient practice was found with 2 of 5 staff (Certified Nursing Assistant) (CNA) and Hospice Aide (HA) observed during dining observations on the 1st- floor. The deficient practice was evidenced by the following: On 1/10/25 at 12:10 PM, during a lunch meal dining observation in the 1st-floor dining room, the surveyor observed the lunch trays being distributed to the residents by five staff members. At 12:15 PM, the surveyor observed the HA standing while feeding an unsampled resident. On 1/10/25 at 12:20 PM, the surveyor observed the CNA standing while feeding an unsampled resident. On 1/14/25 at 12:10 PM, during a lunch meal dining observation in the 1st-floor dining room, the surveyor observed the HA standing while feeding an unsampled resident. On 1/14/25 at 12:35 PM, the surveyor interviewed the HA who acknowledged that she should sit while feeding the residents as it was a dignity concern. On 1/14/25 at 12:39 PM, the CNA was unavailable to be interviewed. On 1/14/25 at 12:49 PM, the above concerns were discussed with the Director of Nursing (DON), Administrator, Assistant Administrator, and Administrator in training. The DON confirmed that the staff should be seated when feeding the residents. No further information was provided. NJAC 8:39-4.1(a)12

Complaint # NJ 00178498 Based on observation, interviews, review of medical records, and facility documents, it was determined that the facility failed to follow fall prevention interventions as written on the resident's individual comprehensive care plan (ICCP). This deficient practice was identified for 1 of 3 residents (Resident # 14) reviewed for accidents and was evidenced by the following: On 1/10/25 at 11:09 AM, during the initial tour of the 1st-floor unit, the surveyor observed Resident #14 in a reclining chair in the day room with other residents and staff members. The surveyor reviewed the medical record for Resident # 14. A review of the Admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to osteoporosis, Alzheimer's Disease, hypertension, and Chronic Obstructive Pulmonary Disease (COPD). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/29/24, revealed Resident #14 had a Brief Interview for Mental Status of 1 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident was dependent on staff for Activities of Daily Living (ADL) care and bed-to-chair transfers. A review of Resident # 14's Individual Comprehensive Care Plan (ICCP) revealed a Focus: FALLS . The resident is at risk for falls due to deconditioning, gait, and balance problems On 6/10/24 had a witnessed fall .interventions included Ensuring two-person assistance during transfers. Bed kept in lowest position. A review of Resident #14's Plan of Care (POC), which was completed by their assigned Certified Nursing Assistant (CNA), indicated that Resident #14 required 2 staff and a Hoyer lift for the bed-to-chair transfers. A review of the facility-provided Fall Investigation revealed: On 6/10/24 at 10:35 AM, the CNA did not follow Hoyer Lift transfers policy and procedure and transferred Resident #14 independently, without an assistant. The resident sustained three linear lacerations, one distal to the left eyebrow measuring .8x.1cm, below the left side of the eye measuring .2x.1cm, and below the second laceration measuring .2x.2cm with minimal bleeding. The MD was notified and ordered x-rays of the lumbar spine, left hip, and facial bones. All x-rays were negative for fractures. On 1/15/25 at 1:30 PM, the surveyor interviewed the DON and Assistant Licensed Nursing Home Administrator, who confirmed the facility's policy included that all Hoyer lift transfers required 2 staff members. The DON further stated that the CNA was terminated because the CNA did not follow the facility policy. The surveyor attempted a phone interview with the CNA who had transferred Resident #14 independently without the assistance of a second staff member. The CNA did not return the surveyor's call. On 1/16/25 at 8:55 AM, the surveyor interviewed Resident #14's assigned Licensed Practical Nurse (LPN), who stated that all Hoyer lift transfers required 2 staff assistants. The LPN further stated that the Director of Rehab educated all staff on safe transfers, which included the proper use of the Hoyer lift and two staff during those transfers. On 1/16/25 at 9:00 AM, the surveyor interviewed Resident #14's assigned CNA, who stated that she knew the resident well. She stated that she used a Hoyer lift when transferring the resident from the bed to the chair and always obtained the assistance of another CNA. The CNA further stated that she had received in-services on safe transfers, which included ensuring there were always 2 CNAs when using the Hoyer lift. On 1/16/25 at 9:10 AM, the surveyor interviewed the Director of Rehab (DOR), who stated that he was responsible for in-services for all staff on safe transfers. The DOR provided copies of the in-services completed prior to and after the fall. A review of the facility's Mechanical Lift policy and procedure, reviewed 6/2024, indicated . a mechanical lift allows a resident to be lifted and transferred with a minimum of physical effort. The Hoyer lift needs two caregivers to operate. A review of the facility's Fall Investigation policy and procedure implemented 7/2018, reviewed 7/2024 indicated .the objective of the Fall investigation was to analyze the cause of a fall and implement new initiatives to prevent future falls . The rehab director will screen and give recommendations . No further information was provided by the facility. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.)identify and dispose of expired biologicals in 2 of 3 medication carts, and b.) properly store an unopened biological in 1 of 3 medication carts inspected. This deficient practice was evidenced by the following: 1.) On [DATE] at 11:45 AM, in the presence of the Registered Nurse (RN), the surveyor began the medication cart (med cart) inspection of cart A located on the third floor. During the inspection, the surveyor observed an opened bottle of Latanoprost Solution 0.005% (an eye drop medication used to treat glaucoma) for Resident #56 that was stored in the manufacturer's packaging (box). The box for the Latanoprost was labeled by the facility with an opened date of [DATE], and an expired date of [DATE]. At that time, during an interview with the surveyor, the RN confirmed that the Latanoprost for Resident #56 was expired and that was the only supply of Latanoprost in the med cart for administration to Resident #56. The RN stated that he did not administer the medication to the resident that day. At that time, the surveyor and the RN reviewed the electronic Medication Administration Record (eMAR) of Resident #56 together. The eMAR reflected that Latanoprost was administered every night in [DATE], and was last administered on [DATE] at 8:00 PM. At that time, the RN stated that the night shift nurse was responsible to ensure all the medications in the cart were not expired and that the nurses who administered the doses on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], should have checked the date before the administration of Latanoprost to Resident #56. On [DATE] at 12:53 PM, in the presence of the Licensed Practical Nurse (LPN), the surveyor began the med cart inspection on the first floor. During the inspection, the surveyor observed an opened bottle of Lantus 10 milliliter (ml) (insulin glargine; used to control high blood sugar levels in the blood) for Resident #35 that was stored in a box. The box for the Lantus was labeled by the facility with an opened date of [DATE] and was not labeled with an expiration date. The surveyor and the LPN reviewed the box of Lantus together. The Lantus box reflected the manufacturer's specifications for storage that included the following: Refrigerate until first use. After first use, store at room temperature and discard after 28 days. At that time, the LPN confirmed that the Lantus for Resident #35 expired on [DATE], and that was the only opened Lantus bottle in the cart for administration to Resident #35. The LPN stated that she did not administer the medication to the resident that day. At that time, the surveyor and the LPN reviewed the eMAR of Resident #35 together. The eMAR reflected that Lantus was administered every night in [DATE], and was last administered on [DATE] at 9:00 PM. At that time, the LPN stated that the night shift nurse was responsible to ensure all the medications in the cart were not expired. The nurses who administered the doses on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], should have checked the date before the administration of Lantus to Resident #35. The LPN added that checking for expiration was part of the standard of practice for medication administration and that an expired medication had reduced efficacy. The LPN added that she would remove the expired Lantus from the active inventory, inform the DON and call the pharmacy. 2.) On [DATE] at 12:58 PM, the surveyor continued to inspect the medication cart located on the first floor and observed an unopened/sealed bottle of Lantus for Resident #35. At that time, the LPN confirmed that the unopened bottle of Lantus should have been refrigerated as recommended by the manufacturer. The LPN stated that the nurse who received the medication should have refrigerated the unopened bottle of Lantus to avoid deterioration of effectiveness. On [DATE] at 1:07 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), Assistant Administrator (ALNHA), and the Administrator in Training (AIT), the surveyor discussed the concerns with the expired Latanoprost and Lantus that Resident #56 and #35 received, was stored with the active inventory, unidentified, and the improper storage of the unopened/sealed Lantus, for Resident #35, that was not refrigerated. On [DATE] at 1:34 PM, in the presence of the survey team, the ALNHA, and the AIT, the DON stated that nursing staff were re-educated on medication storage, a process was implemented wherein the last person who used a medication that was about to expire, disposed of the medication before the expired date, label medications that required an opened date and the discard date. All nurses on all shifts were expected to ensure proper labeling and storage of medications. A review of the facility provided Medication Administration policy dated/reviewed on [DATE] included that medications are administered as prescribed in accordance with good nursing principles .The provided policy did not include a process to ensure medications administered were not expired. A review of the facility provided Medical Storage policy included that all medications must be clearly labeled with the resident's name, dosage instructions, and expiration dates. Medications should be stored at appropriate temperatures as specified by the manufacturer. No further information was provided. NJAC 8:,d+[DATE].4 (c) (g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically for 2 of 5 staff (Certified Nursing Assistant (CNA) and Hospice Aide (HA) not following appropriate hand hygiene during meal service. The deficient practice was evidenced by the following: Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces. CDC recommendations for Hand Hygiene: Updated February 27, 2024: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations On 1/10/25 at 12:10 PM, during a lunch meal dining observation in the 1st-floor dining room, the surveyor observed the lunch trays being distributed to the residents. The surveyor observed that there was no hand hygiene done by the CNA or HA while assisting the residents with meal set up. On 1/10/25 at 12:35 PM, the surveyor observed the HA apply soap to her hands, lather outside the stream of water for 2 seconds, and then put her hands under the stream of running water. The HA turned off the faucet with her bare hands. On 1/10/25 at 12:40 PM, the surveyor observed the HA apply soap to her hands and immediately place them under the stream of water without lathering outside the water. On 1/14/25 at 12:10 PM, during a lunch meal observation in the 1st-floor dining room, the surveyor observed the lunch trays being distributed to the residents. The surveyor observed that the HA did not practice hand hygiene while assisting the residents with meal setup. On 1/14/25 at 12:33 PM, the surveyor observed the HA applied soap to her hands and immediately placed them under the stream of water. On 1/14/25 at 12:35 PM, the surveyor interviewed the HA who stated that she was not sure how long she should have washed her hands. She was not aware that she should lather for 20 seconds before placing her hands under the stream of water. On 1/14/25 at 12:39 PM, the CNA was unavailable to be interviewed. On 1/14/25 at 12:49 PM, the above concerns were discussed with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) Assistant LNHA(ALNHA), and Administrator in training (AIT). The DON confirmed that staff were expected to perform hand hygiene before assisting residents with their meals. The DON further stated that staff should wash their hands for a full 20 seconds outside the stream of running water. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to deliver unopened mail in a timely manner for 2 of 5 residents (Resident # 5 and #2) reviewed. This deficient practice was evidenced by the following: On 1/13/25 at 10:57 AM, during the resident council meeting, Residents #5 and #2 stated that they often received their mail opened and then scotch-taped closed. The residents could not recall who had delivered the opened letters that had been addressed to them. The residents were upset and said no one should have opened their mail. Resident #5 stated that she gave her daughter the last 2 opened envelopes yesterday, who was also very upset that someone had opened the resident's mail without permission. The surveyor reviewed the medical record for Resident #5. A review of Resident #5's Admission Record indicated that the Resident was admitted to the facility with diagnoses that included bilateral shoulder pain related to osteoarthritis. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 11/17/24, revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the Resident's cognition was fully intact. The surveyor reviewed the medical record for Resident #2. A review of Resident #2's Admission Record indicated that the Resident was admitted to the facility with diagnoses that included basal cell carcinoma and mild cognitive impairment. A review of the quarterly MDS dated [DATE] revealed that Resident #2 had a BIMS score of 13, which indicated the Resident's cognition was fully intact. On 1/14/25 at 9:34 AM, the surveyor interviewed the Director of Activities (DOA), who stated that the mail was received and sorted by the concierge, and the activities staff delivered it to the residents. The DOA further stated that her activity staff is not allowed to open the mail without the resident's permission. On 1/14/25 at 9:53 AM, the surveyor interviewed the Concierge, who explained that all business mail went to the business office and personal mail was given to the DOA for distribution. On 1/14/25 at 10:32 AM, the surveyor interviewed the Accounts Payable Manager (APM) and confirmed that she sometimes mistakenly opened Residents' mail. The APM further stated that when she opened the mail by mistake, she would tape it closed and give it back to the concierge for distribution. She never personally apologized to the residents for opening their mail. On 1/14/25 at 11:15 AM, the surveyor interviewed Resident #5's daughter, who is also their POA, via telephone. The daughter confirmed that the resident's mail had been opened and stated that the letter was delivered to the resident more than a month after the postmarked date. The facility did not deliver the opened mail to Resident #5 for four weeks after it had been received. On 1/14/25 at 11:21 AM, the surveyor interviewed the APM, who acknowledged that she had accidentally opened Resident #5's two pieces of personal mail. She confirmed that she had kept the mail for more than 4 weeks without delivering it to the resident because she was very busy. She also confirmed that she had not apologized to the resident for opening her mail but should have. On 1/15/25 at 1:30 PM, the survey team discussed the above observations and concerns with the Administration, who confirmed that the APM should not open residents' mail. N.J.A.C. 8:39-4.1 (19)

Based on interviews and review of pertinent facility documentation, it was determined that the facility allowed 2 of 4 Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days. This deficient practice was identified during NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: Facilities are advised as follows: I. TNAs (Temporary Nursing Assistant) A. Individuals who are working as TNAs must pass the nurse-aide written or oral exam and the State-approved clinical skills competency exam by May 11, 2023, or the end of the federal PHE (Public Health Emergency), whichever comes first. B. If a TNA does not pass the exams by the end of the federal PHE, the TNA may not work after May 11, 2023, unless the TNA meets the requirements of Paragraph C below. C. In order to work beyond May 11, 2023, TNAs must, by May 11, 2023: 1. Be enrolled in a NATCEP CNA training program, and 2. Have completed the first 16 hours of training, and 3. Be working in a facility before May 11, 2023. 4. Note that the TNA only has until September 10, 2023 to complete the NATCEP (Nurse Aide Training and Competency Evaluation Program) program and pass the exams. II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing. On 12/27/23 at 10:47 AM, during entrance conference the Director of Nursing (DON) stated that they did not have any Nursing Aides (NAs) working past their 120 days. The DON was given the Nursing Staffing Reports to be completed for the two weeks of staffing prior to the recertification survey. On 1/2/24 at 11:00 AM, the surveyor met with the DON to inquire about the Nursing Staff Reports which did not list any NAs or Certified Aides in training. The DON apologized and stated that the Staffing Human Resource assistant (SHRA)completed them incorrectly. The surveyor requested a list of NAs along with their dates of hire (DOH), and proof of their enrollment in a Certified Nursing Aide (CNA) school. On 1/3/24 at 10:27 AM, the surveyor interviewed the SHRA who stated that the facility does not use NAs for staffing. The surveyor asked for a list of NAs along with their DOH, and proof of their enrollment in a CNA school. On 1/3/24 at 11:00 AM, the DON provided the surveyor with a list of NAs which included the Dates of hire (DOH). The DON stated that Human Resources was responsible for maintaining the records for NAs. On 1/3/24 at 12:00 PM, the surveyor interviewed RN#2 who stated that that NA#1 had her own assignment and was not working alongside or sharing an assignment with the Certified Nursing Assistant. On 1/3/24 at that same time the surveyor interviewed NA#1 who stated that she was working alone, had a full assignment and was still in training. The surveyor asked NA#1 when she started working at the facility. NA#1 replied that she was still in training. The surveyor asked her the date of hire and if she had taken the certification test. NA #1 did not respond. Review of the NA list provided by the facility revealed the following: NA#1, Date of Hire (DOH) 4/4/23, 120 days from date of hire: 8/2/23. NA#2, DOH 7/31/23, 120 days from date of hire: 11/28/23. The surveyor requested the program completion dates several times however the facility did not provide this information to the survey team. On 1/5/24 at 11:18 AM, during an interview the DON stated that she was aware that NAs should be certified within 120 days of hire and that the Staffing Coordinator/HR and LNHA would have to address this concern. The surveyor requested a copy of the formal job offer letters to the above-listed NAs. The DON stated that she would ask HR for a copy of them. On 1/5/24 at 11:50 AM, during an interview the HR assistant/ staffing coordinator stated that she does not include NAs in her staffing, they only shadow the Certified Nursing Assistants. The surveyor told the HR staffing coordinator that on 1/3/24 the surveyor observed that CNA #1 had a full assignment (assignment B) on the memory care unit which included 7 Residents. The HR staffing coordinator replied, I only use NAs if I don't have enough CNAs. The HR assistant/staffing coordinator further stated that she was aware of the 1CNA to 8 resident ratio. The surveyor requested a copy of the document verifying NA enrollment in a CNA training class and the date the Certification Test is scheduled. The HR/staffing assistant replied she is unable to provide the surveyor with the requested documents. She only received confirmation once the NAs have taken the exam. On 1/5/24 at 2:22 PM, during an interview on the 3rd floor, NA#2 stated that she started working at the facility in July 2023 and was enrolled in a training class to become a Certified Nursing Assistant. She further stated that she was aware that she should not have an assignment, but she was given a full assignment regularly. On 1/5/24 at 1:39 PM, the LNHA acknowledged that NAs should be certified within 120 days of hire. Review of the Facility provided Job Description and Performance Standards for Non-Certified Nursing Assistants reflected .Qualifications .Must be currently employed less than 4 months and currently enrolled in a state approved Nurse Aide in Long Term Care Facilities training course and scheduled to complete the competency evaluation program (skills and written/oral exam) within 4 months of employment. No additional information was provided to the survey team. N.J.A.C. 8:39-43.10

Complaint #165021 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health NJDOH) promptly for 1 of 2 residents (Resident #99) reviewed for investigations and was evidenced by the following: A review of Resident #99's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypertension, osteoarthritis, and anxiety disorder. A review of Resident 99's Admission Minimum Data Set (MDS), an assessment tool dated 5/31/23, revealed that the resident had memory problems. Further review revealed that the resident required extensive assistance from one to two people for Activities of Daily Living (ADLs). A review of a nursing progress note dated 6/8/2023 at 2:53 PM revealed on 6/7/23 at 11:30 AM, the nurse was notified by physical therapy that while standing, the resident was observed to have difficulty with weight-bearing activities and to have facial grimacing. Further review of the progress note revealed the doctor was notified and ordered x-rays of both knees and both hips. The staff assisted the resident into bed, and the nurse observed that the left leg was shorter than the right leg. A review of an x-ray report dated 6/7/23 at 7:54 PM, signed by the MD at 10:29 PM, revealed that there was a complete acute femoral neck fracture with a moderate medially displaced fracture of the left acetabulum. Further review of the x-ray revealed there was moderate osteopenia, osteoporosis, and a moderate degree of osteoarthritis. A review of the nursing progress note dated 6/8/23 at 4:02 PM indicated that the resident was transferred to the hospital at 10:50 AM. A review of the Reportable Event Record Report revealed the facility reported the fracture to the New Jersey Department of Health on 6/15/23, eight days after the event happened. On 1/5/23 at 2:40 PM, the survey team met with the administration team. The Director of Nursing (DON) stated the facility should report injuries of unknown origin within 24 hours of the incident. Further, she stated that the facility was still investigating the incident, so the facility did not report the incident sooner. A review of the facility's policy labeled Resident Abuse Prevention/Prohibition with a reviewed date of 9/8/23, under the section heading of Reporting; in the case of an injury involving sutures or fracture of unknown origin, reports are filed with the Office of the Ombudsman and law enforcement immediately or within two hours. Further review revealed under section Reporting section C. that it is the responsibility of the Administrator to immediately (within one business day) report all actual or suspected incidents of abuse, neglect, or exploitation to the Department of Health. NJAC 8:39-4.1(a)(5)

Based on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to follow a physician's order (PO) for the application of heel protectors for 1 of 1resident reviewed, Resident #68. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/2/24 at 10:41 AM, the surveyor observed Resident #68 in bed. The surveyor observed the resident's heels were not offloaded off of the mattress and there were no heel protectors in place. The surveyor observed a dry and intact dressing to the resident's right foot dated 1/1/24. On 1/4/24 at 9:55 AM, the surveyor asked the Registered Nurse to accompany her to resident #68's room. The surveyor observed the resident was in bed. The surveyor asked the RN if the resident had heel protectors in place. The RN removed the residents blanket and exposed their feet. The RN and surveyor observed that the resident's heels were directly on the mattress with no heel protectors on. The surveyor asked to see the residents heels. The RN lifted the residents feet off the bed and the surveyor observed that skin to the bilateral heels was intact. The RN stated that the resident was on a positioning program and that part of that program was to have heel protectors on when in bed and to have both feet offloaded onto a pillow. The RN stated that it was the evening shifts responsibility to apply the booties and the day shift to check and ensure they were in place. The RN found the heel protectors in the resident's closet and put them on. On 1/4/24 at 10:06 AM, the Nursing Assistant who was assigned to provide care to Resident #68 came into the resident's room. The RN asked the NA if the resident had heel protectors on when she provided care this morning. The NA replied that s/he did not have heel protectors on yesterday or today and that she didn't know anything about heel protectors. Review of Resident #68's Admission Record revealed Resident #68 was admitted to the facility in August 2021 and readmitted in August 2023 with diagnoses which included, but not limited to, Right and Left foot drop, Diabetes Mellitus, dementia, and psychosis. A review of the Quarterly Minimum Data Set (MDS) an assessment tool dated 12/3/23, reflected the Resident had a Brief Interview of Mental Status (BIMS) score of 6 of 15 which indicated Resident #68 had a severe cognitive impairment. Section GG documented that Resident #68 had a Functional limitation in Range of Motion on both upper extremities and required maximum assistance with their personal hygiene. A review of the current January 2024 Physician Order Summary Report reflected a Physician's order (PO) for the Positioning Program with interventions to apply protective heel booties while resident in bed and to float heels while in bed with an order date of 12/13/23. A review of the Treatment Administration Record (TAR) reflected the PO had been transcribed onto the TAR and signed by the nurses indicating the heel protectors had been applied on 1/1/24, 1/2/24,and 1/3/24. On 1/4/24 at 1:38 PM, the survey team met with the Administration to discuss the above observations and concerns. The DON stated that Nurses and Nurse Aides were responsible for ensuring that physician's orders are followed and that the heel protectors were in place as ordered. A review of the facility's Nursing Assistant Job Description and Performance Standards undated, included .the purpose of this position is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with facility policies and procedures and report resident needs and concerns to a licensed nurse assist residents with Activities of Daily Living such as: daily mouth care, bath/shower functions, hair care, nail care, shaving and restorative/rehabilitation procedures. NJAC 8:39-19.4 (a) (1)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide nail care to a resident who was dependent on the staff for Activities of daily living (ADL). This deficient practice was identified for 2 of 2 residents (Resident # 68 and #73) reviewed for ADL care. The deficient practice was evidenced by the following: 1.) On 12/27/23 at 11:50 AM, the surveyor observed Resident #68 in the small day room seated in a geri chair. The surveyor observed the resident had bilateral contractures to their hands and that the resident's fingernails were long, jagged, and soiled underneath. On 1/2/24 at 10:41 AM, the surveyor observed Resident #68 in bed with bilateral contractures, nails long, jagged and soiled. On 1/4/24 at 9:55 AM, the surveyor showed the Registered Nurse (RN #1) on the memory care unit the resident's nails and hands. RN #1 moved the resident's fingers which were pressing against their palms and acknowledged that the nails were soiled, long and jagged. RN #1 acknowledged that these jagged nails could have caused a break in the resident's skin integrity. On 1/4/24 at 10:06 AM, RN #1 asked the Nursing Assistant (NA) who was assigned to the care of Resident #68 when she had last cleaned, trimmed, and filed Resident #68's fingernails. The NA replied that the resident's hands were always closed but that she should have cleaned and trimmed them and would try to do it more often. RN#1 stated that the NA should be providing nail care daily. Review of Resident #68's Admission Record revealed Resident #68 was admitted to the facility in August 2021 and readmitted in August 2023 with diagnoses which included, but not limited to Right and Left foot drop, Diabetes Mellitus, dementia, and psychosis. A review of the Quarterly Minimum Data Set (MDS) an assessment tool dated 12/3/23, reflected the Resident had a Brief Interview of Mental Status (BIMS) score of 6 of 15 which indicated Resident #68 had a severe cognitive impairment. Section GG documented that Resident #68 had a Functional limitation in Range of Motion on both upper extremities and required maximum assistance with their personal hygiene. 2.) On 12/27/23 at 11:51 AM, the surveyor observed Resident #73 seated in a wheelchair in the day room. The surveyor observed the resident to be unshaven with long facial hair, and their fingernails long, jagged, and soiled underneath. On 1/3/24 at 11:46 AM, the surveyor interviewed Resident #73 in their room. The surveyor asked the resident if s/he preferred facial hair. Resident #73 felt their face and neck with their hands and replied, no I don't like it. It bothers me. Resident #73 further stated that s/he would prefer their nails to be cleaned and trimmed. On 1/3/24 at 11:51 AM, the surveyor interviewed RN #2 who stated that the Nursing Assistants were responsible for shaving the residents and for providing nail care. RN#2 acknowledged that Resident #73's facial hair was long and unkept and that it appeared the resident had not been shaved in quite a while. RN#2 further stated that it appeared as though the Resident had not received nail care recently, as the resident's nails were soilded, long and jagged. On 1/3/24 at 12:00 PM, RN#2 asked the NA when she had last shaved Resident #73. The NA replied, Yesterday. RN#2 stated that the NA could not possibly have shaved the resident yesterday as the facial hair was too long. The NA replied that she was sorry and didn't remember when she last shaved the resident because s/he scratches. The surveyor asked RN#2 if the NA ever reported this behavior to her. RN#2 replied, no and further stated that she was not aware that Resident #73 had any behaviors of scratching, becoming combative, or refusing care. RN#2 showed the NA Resident #73's nails. The NA acknowledged that the nails were long, jagged, and soiled underneath. The NA stated she was sorry and should have cleaned, trimmed, and filed Resident #73's nails. A review of the resident's Admission Record reflected Resident #73 had diagnoses that included but were not limited to, Diabetes Mellitus, Dementia, anxiety, depression, and psychotic disorder. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #73 had a BIMS score of 3 out of 15 which indicated the resident had a severe cognitive impairment. Section E of the MDS revealed that the resident did not have any behaviors of hitting, pushing or scratching others and no behaviors of rejecting care. Section GG assessed the resident required limited assistance of one staff member for personal hygiene. On 1/4/24 at 1:38 PM, the survey team met with the Administration to discuss the above observations and concerns. The DON stated that the Nurse Aides were responsible for providing nail care daily and as needed and that Resident #73 should be shaved daily. The DON further stated that if a resident refused care the Aides should notify the nurse. A review of the facility's Nursing Assistant Job Description and Performance Standards undated, included .the purpose of this position is to provide direct care to residents, under the supervision of a licensed nurse, in accordance with facility policies and procedures and report resident needs and concerns to a licensed nurse assist residents with Activities of Daily Living such as: daily mouth care, bath/shower functions, hair care, nail care, shaving and restorative/rehabilitation procedures. NJAC 8:39-27.1(a), 27.2(g)

Based on observations, interviews, and record review it was determined that the facility failed to change the oxygen tubing as directed by the Physician order and follow the facility policy. This deficient practice was identified for 1 of 1 resident (resident #40), which was reviewed for Oxygen therapy. This deficient practice was evidenced by the following: On 12/27/23 at 11:00 am, the surveyor entered resident's #40 room and observed an oxygen concentrator (a device which provides supplemental oxygen) and a plastic drawstring bag which was dated 10/23/23 on the outside of the bag. The plastic drawstring bag was hung from the oxygen flow meter (an equipment used to control oxygen flow delivery) and inside the plastic drawstring bag was a nasal cannula tubing with the date of 10/22/23. On 12/28/23 at 12:00pm, the surveyor entered resident's #40 room and observed a plastic drawstring bag with the date of 10/23/23 on the outside of the bag. The plastic drawstring bag was on the oxygen concentrator and was hung from the oxygen flow meter. Inside the plastic drawstring bag was a nasal cannula tubing dated 10/22/23. The resident was observed in bed without oxygen and appeared comfortable. The surveyor reviewed the medical record of resident #40. Review of the Admission Record (an admission summary) reflected that resident #40 was admitted to the facility with diagnoses which included but are not limited to: Palliative Care(specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), Cerebral Infarction due to embolism(occurs when a blood clot forms in part of the body and travels through the blood to the brain), and Chronic Obstructive Pulmonary Disease(a group of lung diseases that block airflow and make it difficult to breath). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. Revealed that resident #40, had a Brief Interview for Mental Status (a tool used to identify the cognitive condition) scored a 3 out of 15, which indicated that the resident was severely cognitively impaired. In section (I) of the MDS active diseases number I6200 Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Chronic Lung Disease was checked (indicated that this was an active disease) during the observation period (a time period which the resident's condition or status is captured by the MDS assessment). In section O of the MDS (Special Treatments, Procedures and Program) number O0110 section titled Respiratory Treatments. Oxygen Therapy is not checked for the following continuous (receiving oxygen therapy continuously), intermittent (not continuous oxygen therapy, oxygen administered for symptom relief), high concentration (respiratory support that delivers a flow of medical gas to a patient of up to 60 liters per minute and 100% oxygen) while a resident. This section indicated that resident #40 was not on oxygen therapy during the observation period. A review of the November 2023 Order Summary Report revealed a Physician Order dated 07/14/2023 for Oxygen 3L(liters) per minute as needed via nasal cannula to maintain O2 Sat(saturation) above 88-90% every 1 hours as needed. Further review of the Physician Order also revealed a Physician order dated 1/19/23 to CHANGE and date oxygen concentrator/nebulizer pump tubing weekly on Sunday 11-7 shift every night shift every Sun (Sunday) for as per protocol with a physician order. A review of the November 2023 Treatment Administration Record revealed the order to change and date oxygen concentrator/nebulizer pump tubing weekly on Sunday 11-7 shift every night shift every Sun (Sunday) for as per protocol. Indicated that the physician order was signed as completed on 11/5/23;11/12/23;11/19/23 and 11/26/23. A review of the December 2023 Order Summary Report (OSR) revealed a Physician Order dated 07/14/2023 for Oxygen 3L(liters) per minute as needed via nasal cannula to maintain O2 Sat(saturation) above 88-90% every 1 hours as needed. Further review of the Order Summary Report revealed a Physician Order dated 1/19/23 to CHANGE and date plastic drawstring bag for O2, nebulizer weekly on Sunday, 11-7 shift DATE AND INITIAL EACH BAG. Every night shift every Sun (Sunday). A review of the December 2023 Treatment Administration Record revealed the order to change and date plastic drawstring bag for O2, nebulizer weekly on Sunday, 11-7 shift had been signed which indicated as completed on 12/3/23;12/10/23; 12/17/23; and 12/24/23. On 12/29/23 at 12:00pm the surveyor interviewed the Registered Nurse (RN) (floor nurse), who stated that all respiratory equipment is changed weekly and as needed. This surveyor showed her the plastic drawstring bag which was dated 10/23/23 and asked should the respiratory bag have been changed, and the Registered Nurse stated that resident #40 does not use oxygen. The surveyor responded should the respiratory equipment have been discarded since she is not wearing oxygen all the time and the Registered Nurse responded yes. On 12/29/23 at 12:25pm, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that resident #40 has never worn oxygen. Review of the facility's policy Oxygen, Administration of which was implemented 3/2010 and reviewed 12/12/23 revealed under the section face mask administration, #24 for intermittent therapy, wash cannula, mask, tubing, and catheter weekly with mild soap, rinsing with warm water. Allow to air dry on paper toweling or hang on towel rack and #25, for continuous therapy, replace cannula, mask, tubing, and catheter weekly. NJAC 8:39-11.2(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store, label, and date potentially hazardous foods to prevent food-borne illnesses. This deficient practice was evidenced by the following: On 12/27/23 at 10:13 AM, the surveyor, in the presence of the Assistant Supervisor of Dietary (ASD), toured the kitchen and observed the following: 1. In the walk-in freezer, an opened box of fully cooked flame-broiled beef patties in a plastic bag that was opened to air and was not labeled or dated as to when they were opened. 2. In the walk-in freezer, there were 20 beef patties in a plastic bag in a box labeled for an artificial sweetener. The plastic bag or the box was not labeled or dated. 3. In the walk-in freezer, there was a plastic bag with 12 chicken patties identified by the ASD that were not labeled or dated. 4. In the walk-in refrigerator there was a plastic resealable bag with 11 hotdogs dated 11/29/23. The ASD stated that if eaten, someone could get sick and removed the hotdogs. On 12/29/23 at 1:19 PM, the surveyor met with the contracted dietitian, who stated that she works 10-15 hours per week and provided supervision of the food service staff. She stated that the facility labeling policy is after five days open, the staff should discard from the refrigerator. The food in the freezer should be labeled and dated when opened. On 1/4/23 at 1:38 PM, the survey team met with the administration and was informed of the findings. A review of the facility's policy Storing and Dating of Food Policy with a reviewed date of 2/23/22 indicated to date food when they are received with the received date. Label opened or site-prepared ready-to-eat potentially hazardous foods that are held for more than 24 hours, with the discard date after the 5th day or per manufacturer's guideline indicated on the package [ .] Store food in original packaging[ .] label the new container with the name of the food and the original use by or expiration date. NJAC8:39-17.2(g)

Based on observation, interview and record review it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/3/21 at 9:34 AM, in the presence of the Food Service Director, Registered Dietitian (FSD, RD), the surveyor observed the following: 1. In the free-standing refrigerator, the surveyor observed an undated and wrapped 1/4 slab yellow sliced cheese and an undated and wrapped 1/2 slab of yellow sliced cheese. The surveyor also observed an undated and covered 1/4 sheet pan filled with spaghetti and meatballs. The FSD, RD stated that these should have been dated once opened. 2. In the walk-in refrigerator, the surveyor observed an undated opened ½ full bag of shredded mozzarella cheese, an undated opened 1/2 full bag of parmesan cheese open, an undated opened 1/2 full bag of opened prunes, an undated opened 1/2 full seven-pound container of Cole slaw, an undated opened 1/2 full container of orange juice, an undated opened 1/4 full milk and undated opened 1/2 full milk. The manufacturer specifications on the two milk containers indicated use within 14 days of opening. The surveyor also observed an undated opened 1/2 full container of almond milk. The manufacturer specifications on the two milk containers indicated use within 14 days of opening. 3. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - A #10 sized can of sweet potatoes with a 2-inch dent on the body of the can, - A #10 sized can of mushrooms with a 2-inch dent on the body of the can, -A #10 sized can of pineapples with a ¼ inch dent on the upper lip of the can. The surveyor reviewed the facility's policy titled, Storing and Dating of Food Policy dated 3/11/21. The policy indicated that all food is to be labeled and dated. The surveyor reviewed the facility's undated policy titled, Dented Cans. The policy indicated that dented or damaged cans will be placed in designated area labeled, Dented Cans. On 11/3/21 at 01:30 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. NJAC 8:39-17.2(g)

Based on observation, interview, review of the medical records and other pertinent facility documents, it was determined that the facility failed to ensure that medications were administered according to physician's orders [REDACTED].#17), reviewed which occurred over a period of four months. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board. The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/31/19 at 10:42 AM, the surveyor observed Resident #17 lying in bed with eyes open; however, the resident did not respond to the surveyor. There was a tube feeding pump at the bedside, and unopened honey thickened apple juice on the resident's overbed table. The surveyor reviewed Resident #17's medical record that revealed the following: The Facesheet Admission Record for Resident #17 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Order Recap Report (printed physician's orders [REDACTED]. And [MEDICATION NAME] Tablet 2.5 MG; Give one tablet by mouth one time a day every Tuesday, Wednesday, Friday, Saturday, and Sunday. The 7/2019 through 11/2019 Electronic Medication Administration Record [REDACTED]. Resident #17's Care Plan, under special instructions, revealed that medications should be administered via PEG ([DEVICE]). The Progress Notes reviewed from 7/3/19 through 11/7/19 revealed no further documentation related to the oral administration route of [MEDICATION NAME] administration. On 11/7/19 at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who worked full time on the 3-11 PM shift. The LPN stated that on the 3-11 PM shift, he administered three medications to Resident #17, including the [MEDICATION NAME], all of which were administered via the [DEVICE]. The surveyor asked the LPN if he was aware that the [MEDICATION NAME] orders specified by mouth administration. The LPN reported that when he received the original telephone order from the physician on 7/18/19, it should have been for administration via [DEVICE] and that he must have input accidentally by mouth administration into the computer. The LPN reported that he had been assigned to Resident #17 for a long time and automatically knew to administer all medications via [DEVICE]. The LPN admitted that he did not notice the physician's orders [REDACTED]. The LPN stated that he was not reading the entire physician's orders [REDACTED]. On 11/7/19 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the nurses who had been signing the EMAR for the by mouth administration of [MEDICATION NAME] should have read the entire physician's orders [REDACTED]. The DON was not sure why this had not been done since 7/18/19 when the order was initially received. On 11/8/19 at 12:56 PM, the DON reported that she had interviewed all of the nurses that had documented by mouth administration of [MEDICATION NAME] on the EMAR from 7/18/19 through 11/6/19. The DON further stated that all the nurses had administered the [MEDICATION NAME] via the [DEVICE] and not by mouth, as the nurses had not realized that the order specified by mouth administration. A review of the facility's policy titled, Prescriber Medication Orders under Procedure B. revealed that Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. NJAC 8:39-27.1(a)

C# NJ Cross reference F223 Based on observation, interviews, medical record (MR) review, and review of other pertinent facility documentation on 2/24/17, it was determined that the facility failed to follow their own facility policy and procedure on Abuse Investigations to prevent further potential abuse when the Certified Nursing Assistant (CNA), who was under investigation for allegations of verbal abuse, was allowed to work while the investigation was in progress. This deficient practice placed all residents in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Administrator and Director of Nursing (DON) on 2/24/17 at 10:37 a.m. The IJ was identified as Past Non-Compliance for 2/8/17, for the 11p.m.-7a.m. shift into 2/9/17. The facility provided evidence of an implemented acceptable Plan of Correction (POC) on 2/24/17 at 3:45 p.m. This deficient practice was evidenced by the following: See examples #1, #2, and #3. The Immediate Jeopardy (IJ) was identified as Past Non-Compliance for 2/8/17, and was corrected on 2/24/17 at 3:45 p.m., when an acceptable Plan of Correction (POC) was implemented. The Plan of Correction included: I. 1. All 9 residents that were assigned to CNA on 2/8/17, 11-7 shift were interviewed by the UM and DON for any possible abuse. I. 2. The affected Resident #1 and Resident #2 were assessed and assured of their safety and well-being in the facility. I. 3. The families and the attending Physicians of Resident #1 and Resident #2 were made aware of the incident. I. 4. Care Plan of Resident #1 was updated on 2/7/17 and Care Plan of Resident #2 was updated on 2/8/17. I. 5. The involved CNA was immediately suspended pending investigation. II. 1. All the residents in the facility have the potential to be affected by the same deficient practice. III. 1. Investigation was conducted and the involved CNA was terminated immediately. III. 2. In-service regarding Preventing, recognizing and Reporting of Abuse and Types of Abuse were conducted by the DON, UM and the Supervisors to all the employees of the facility. III. 3. The 3-11 Nursing Supervisor was terminated for failure to follow the direction of the DON. III. 4. All the UM and Nursing Supervisors were give an In-service on Effective Employee Discipline and Termination. III. 5. The DON would communicate with the UM and Nursing Supervisor and would notify them about the disciplinary actions served to the employees and ensure that the employees under investigation were not allowed to work in the facility. III. 6. A communication log book was in place which was endorsed and monitored by all UM and the nurses from shift to shift. IV. 1. All disciplinary action notices served by the Nursing Department would be verified by the Administrator on a monthly basis. IV. 2. The Administrator would forward the disciplinary action notices to the Human Resources immediately. NJAC 8:39-13.4(c)2iii

C# NJ Based on interviews, medical record (MR) review, and review of other pertinent facility documentation on 2/24/17, it was determined that the facility failed to ensure that the residents were free from verbal abuse for 2 of 3 sampled residents (Resident #1 and #2). In addition, the facility failed to prevent further potential abuse when the Certified Nursing Assistant (CNA), who was under investigation for allegations of verbal abuse, was allowed to work while the investigation was in progress. This deficient practice placed all residents in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Administrator and Director of Nursing (DON) on 2/24/17 at 10:37 a.m. The IJ was identified as Past Non-Compliance for 2/8/17, for the 11p.m.-7a.m. shift into 2/9/17. The facility provided evidence of an implemented acceptable Plan of Correction (POC) on 2/24/17 at 3:45 p.m. This deficient practice was evidenced by the following: A review of the medical record on 2/24/17, revealed the following: 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. According to the Minimum Data Set (MDS), an assessment tool dated 1/20/17, Resident #1 scored 9/15 on the Brief Interview for Mental Status (BIMS), which indicated mild cognitive impairment. Resident #1's Care Plan dated 2/7/17, revealed that the resident had expressed . concerns regarding behavior of CNA (CNA#1). The Care Plan included a goal that Resident #1 would feel safe and comfortable with the care provided by the staff. The Care Plan contained interventions that included but were not limited to: resident would be affirmed that he/she is safe, resident's call bell would be answered promptly and courteously, the resident would be monitored for any changes in their mood and behavior, and would be provided with emotional support. A review of the Facility's Reportable Event Record/Report (FRE) dated 2/8/17, revealed that on 2/7/17 at 4:00 p.m., Resident #1 reported an allegation of verbal abuse by CNA #1. The report recorded that Resident #1 requested help from CNA #1 for toileting assistance. CNA #1 took a long time to answer the call bell and yelled at Resident #1. Further review of the report revealed the following interventions implemented after the event: The DON called the New Jersey Department of Health (NJDOH) on 2/7/17 at 4:38 p.m. and reported the incident. CNA #1 was not scheduled to work on 2/7/17, and was suspended pending the outcome of the investigation. The report revealed that during the investigation, another resident (Resident #2) made an allegation of verbal abuse by CNA #1. The report revealed that based on the evidenced gathered by the facility, it was concluded that the verbal abuse was substantiated and that CNA #1 would be terminated on 2/9/17. A review of the written statement signed by Resident #1 dated 2/8/17, untimed, revealed the following: My name is . I felt I was mistreated here as a patient by a specific CNA (CNA#1) . It's the way CNA #1 spoke to me and not answering the call bell timely, CNA #1 made me feel very insignificant. 2. According to the Admission Record, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], Resident #2 scored 13/15 on the BIMS, which indicated intact cognition. Resident #2's Care Plan dated 2/8/17, revealed that the resident had expressed her concerns regarding behavior of CNA (CNA #1). The Care Plan included a goal that Resident #2 would feel safe and comfortable with the care provided by the staff. The Care Plan contained interventions that included but were not limited to: resident would be affirmed that he/she is safe, resident's call bell would be answered promptly and courteously, the resident would be monitored for any changes in their mood and behavior, and would be provided with emotional support. A review of the FRE dated 2/10/17, revealed that on 2/8/17 at 4:00 p.m., Resident #2 reported that they were yelled at by CNA #1 when Resident #2 requested assistance with toileting. The report recorded that Resident #2 stated, CNA #1 made me feel like I did not count. Further review of the report revealed the following interventions implemented after the event: The DON called the NJDOH on 2/9/17, and reported the incident. CNA #1 was not scheduled to work on 2/7/17, and was suspended pending the outcome of the investigation, but worked on 2/8/17. The report revealed that CNA #1 denied the allegation of verbal abuse and stated that he/she was hard of hearing and talked loud. The report also revealed that based on the evidence gathered by the facility, it was concluded that the verbal abuse was substantiated and that CNA #1 was terminated on 2/9/17. A review of the written statement made by Resident #2 dated 2/8/17 at 3:30 p.m., verified that CNA #1 had shouted at me and it makes me feel that I don't count. An interview with Resident #2 was attempted by the surveyor on 2/24/17 at 9:55 a.m., but Resident #2 declined to be interviewed. During an interview with the DON on 2/24/17 at 9:25 a.m., The DON stated that Resident #1 and Resident #2 alleged that CNA #1 was verbally abusive to them. The DON showed the surveyor two Reportable Event Reports/Records for Resident #1 and #2 submitted to the DOH. The DON stated that the verbal abuse allegation was substantiated and that CNA #1 was suspended during the investigation and terminated on 2/9/17. The DON explained to the surveyor that CNA #1 was not scheduled to work on the day the first verbal abuse allegation was reported by Resident #1 on 2/7/17 at 4:00 p.m. The DON stated that they called CNA #1 on their cell phone at least two times and left messages to call the facility, however, the facility did not receive a call back from CNA #1. The DON stated that on 2/8/17 at 4:00 p.m., Resident #2 reported that she was also yelled at by CNA #1. The DON explained to the surveyor that the facility was still not able to reach CNA #1 to discuss the verbal abuse allegation and the suspension, and the facility had not received a return call from CNA #1 as of 2/8/17. The DON also stated that on 2/8/17, that the 3:00 p.m. - 11:00 p.m. (3-11) Nursing Supervisor (RN #1) was informed of the abuse allegations made against CNA #1, and RN #1 was instructed to send CNA #1 home if the CNA showed up to work on 2/8/17. The DON further explained that she gave RN #1 instructions to inform the 11:00 p.m. - 7:00 a.m. (11-7) shift RN (RN #2) to send CNA #1 home and that there was another CNA scheduled to cover CNA #1's assignment. The DON further stated that they were not made aware that CNA #1 worked on 2/8/17 for the 11-7 shift until 2/9/17 at 7:45 a.m. On further interview at that time, the DON stated that there were nine residents under CNA #1's assignment when the CNA worked on 2/8/17, 11-7 shift. The DON stated that the nine residents did not include Resident #1, but included Resident #2, and they had been assessed by the Unit Manager (UM) after and found to be safe and had no concerns. The DON further stated that the facility called CNA #1 again on 2/9/17, immediately after being informed that CNA #1 worked the 11-7 shift and finally was able to talk with the CNA. The DON stated that CNA #1 explained that they had not retrieved the voicemail messages until 2/9/17. The DON stated that CNA #1 was informed of the termination effective 2/9/17, and was instructed to meet with the Director of Human Resources (HR) that day but did not meet with HR until 2/10/17. The DON also stated that RN #1 stated that he/she did not let CNA #1 go home on 2/8/17 because of the snow storm. The DON stated that an In-Service Education on Disciplinary Action was given to all Nurse Managers/Supervisors on 2/9/17, and an In-service Education on Abuse was initiated on 2/8/17, and completed on 2/10/17, for all employees. The DON also stated that it was the facility's policy to suspend any staff member involved in any abuse allegations while under investigation and that the staff member would be terminated if/when the allegation was substantiated. A telephone interview was conducted by the surveyor with CNA #1 on 2/24/17 at 11:45 a.m. CNA #1 stated that they were not aware that there were verbal abuse allegations from Resident #1 and Resident #2 reported against the CNA until 2/9/17. CNA #1 stated that she did not yell at Resident #1 and #2, or at any resident. CNA #1 explained that they had a loud voice and everyone in the facility was aware. CNA #1 verified that he/she received calls from the facility and did not answer the calls. CNA #1 did not state a reason why he/she did not return the facility's calls. CNA #1 stated that RN #1 and RN #2 did not send him/her home and that he/she was not informed of his/her suspension on 2/8/17 and that they would have gone home if they were told to go home. During the interview, CNA #1 stated that she had direct contact with residents under her care on 2/8/17. CNA #1 explained that Resident #1 was not on her assignment but Resident #2 was, but he/she did not have any contact with Resident #2 that night because he/she was on break when Resident #2 called for assistance and another CNA assisted Resident #2. At that time, CNA #1 further stated that he/she received a call from the facility on 2/9/17, and was informed of the verbal abuse allegations, suspension, and immediate termination. CNA #1 stated that he/she met with the HR staff and the Administrator on 2/10/17. An interview was conducted with RN #1 on 2/24/17 at 12:05 p.m. RN #1 stated that on 2/8/17, he/she was informed by the DON that CNA #1 was to be sent home and should not work on 2/8/17, 11-7 shift. RN #1 stated that the DON informed him/her that there was an investigation for verbal abuse in progress which involved CNA #1, Resident #1, and Resident #2. RN #1 stated that CNA #1 was not sent home because they thought that CNA #1's suspension was lifted because of the snow storm. RN #1 stated that a text message was sent to the UM to confirm that CNA #1 was allowed to work, but did not get a response. RN #1 further stated she instructed RN #2 to call HR to confirm CNA #1's disciplinary action, but did not call the DON or the Administrator to ask if CNA#1 was allowed to work nor did RN #1 make them aware of the decision not to send CNA #1 home. RN #1 also stated that it was the facility's policy to remove any staff member being investigated for abuse from their assignment immediately and that any staff member being investigated for abuse would be suspended temporarily until the investigation is completed to protect the residents. RN #1 further explained that he/she did not send CNA#1 home because he/she was fearful of the CNA's safety driving home during the snow storm. RN #1 revealed that he/she did not talk to CNA #1 about his/her suspension and that she did not tell or ask CNA #1 to go home. A post survey telephone interview was conducted with RN #2 on 3/3/17 at 10:57 a.m. RN #2 stated that he/she worked on 2/8/17, 11-7 shift and that before his/her 11-7 shift began, RN #1 informed him/her that CNA #1 was under investigation for verbal abuse and was suspended until the investigation was completed. RN #2 stated that they were surprised when CNA #1 showed up for work hence he called the 11-7 staffing coordinator to ask if CNA #1 was allowed to work. RN #2 stated that the staffing coordinator told him/her that CNA #1 could work that night. RN #2 did not state a reason for not calling the DON and/or Administrator, except that the 11-7 staffing coordinator told him/her that CNA #1 could stay and work on 11-7 shift on 2/8/17. When asked by the surveyor what was he/she supposed to do if/when a staff member was being investigated for abuse, RN#2 stated stated that any staff member under investigation for abuse could not work in the facility until the investigation was completed. RN #2 further explained that he/she spoke with CNA#1 about the verbal abuse allegations and that CNA#1 told him/her that he/she would speak to all the residents kindly. RN #2 further stated that he/she assessed and interviewed all the residents under CNA #1's assignment and found them safe and revealed no concern. A review of the facility's Night Shift Staffing Report dated 2/8/17, revealed that CNA #1's name had been removed from the schedule and replaced with another assigned CNA. A review of the In-service Sign in Sheet dated 2/8/17, and 2/10/17, revealed that an In-Service Education was given to all employees on the facility's Policy and Procedure on Abuse, Recognizing Signs of Abuse, Types of Abuse, and Reporting. A review of the In-Service Sign in Sheet dated 2/9/17, revealed that an In-Service Education was given by the DON and the Administrator on 2/9/17, to all Nurse Managers. The In-Service included the Supervisor's role on how to properly and effectively serve a disciplinary action to an employee, and to follow the facility's Policy and Procedure on Abuse to ensure resident's safety and quality of care. A review of the CNA#1's Disciplinary Action dated 2/7/17, revealed that CNA #1 was suspended pending investigation and was terminated on 2/9/17 for verbal abuse. A review of the facility's Policy titled Staff to Resident Abuse revised on March 2010, revealed an objective that Staff abuse and or neglect of residents would not be tolerated. The Policy revealed procedures which included but not limited to: (c) allegations of abuse or neglect should result in immediate suspension followed by a prompt investigation, (d) employees determined to be responsible for abuse or neglect should be discharged . The Immediate Jeopardy (IJ) was identified as Past Non-Compliance for 2/8/17, and was corrected on 2/24/17 at 3:45 p.m., when an acceptable Plan of Correction (POC) was implemented. The Plan of Correction included: I. 1. All 9 residents that were assigned to CNA on 2/8/17, 11-7 shift were interviewed by the UM and DON for any possible abuse. I. 2. The affected Resident #1 and Resident #2 were assessed and assured of their safety and well-being in the facility. I. 3. The families and the attending Physicians of Resident #1 and Resident #2 were made aware of the incident. I. 4. Care Plan of Resident #1 was updated on 2/7/17, and Care Plan of Resident #2 was updated on 2/8/17. I. 5. The involved CNA was immediately suspended pending investigation. II. 1. All the residents in the facility have the potential to be affected by the same deficient practice. III. 1. Investigation was conducted and the involved CNA was terminated immediately. III. 2. In-service regarding Preventing, recognizing and Reporting of Abuse and Types of Abuse were conducted by the DON, UM and the Supervisors to all the employees of the facility. III. 3. The 3-11 Nursing Supervisor was terminated for failure to follow the direction of the DON. III. 4. All the UM and Nursing Supervisors were give an In-service on Effective Employee Discipline and Termination. III. 5. The DON would communicate with the UM and Nursing Supervisor and would notify them about the disciplinary actions served to the employees and ensure that the employees under investigation were not allowed to work in the facility. III. 6. A communication log book was in place which was endorsed and monitored by all UM and the nurses from shift to shift. IV. 1. All disciplinary action notices served by the Nursing Department would be verified by the Administrator on a monthly basis. IV. 2. The Administrator would forward the disciplinary action notices to the Human Resources immediately. NJAC 8:39-4.1(a)5 NJAC 8:39-13.4(c)2iii

C# NJ Based on interviews, a review of medical records, and pertinent facility documentation, it was determined that the facility failed to consistently provide identified safety devices and/or adequate supervision for an identified fall risk in 1 of 3 sampled residents (Resident #1). Resident #1 was placed in an unsupervised area while her lap tray was not in place, fell and sustained a hip fracture. This deficient practice is evidenced as the following: The medical record was reviewed by the surveyor on 5/10/12 and the following was revealed: 1. Resident #1 was admitted to the facility in 11/10 and readmitted in 4/12 with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), an assessment tool dated 10/20/11, indicated that the resident was cognitively impaired, and totally dependent on staff for activities of daily living (ADLs). The Fall Risk assessment dated [DATE] revealed a score of "11" which indicated that she was a high risk for falls. The Care Plan Activity Report dated 3/6/12, identified the resident as a fall risk. Interventions on the Care Plan included: providing an electronic monitor to the bed or chair, and a Broda chair with lap tray; released every 2 hours and as needed (prn). The Physician order [REDACTED]. Release tray table every 2 hours. A facility Reportable Event Record/Report (AAS-45), dated 4/15/12, and faxed to the Department of Health and Senior Services (DHSS), revealed Resident #1 was found on the floor and that her alarm had sounded. The resident was noted to have complaints of pain in the right leg and slight swelling was noted to the right thigh. Vital signs were stable. The report indicates that the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The Progress Notes dated 4/15/12 indicated that the resident refused to stay in the dining room for dinner and had wheeled herself out of the dining room. "Med alarm went off rsdt (resident) found laying on floor screaming with pain rt (right) leg. Assisted back to chair after vitals ..." and, "Assisted back to bed and c/o (complained) severe rt (right) leg hip pain". The resident's family was present at that time, and the doctor was notified. The progress notes also indicated that the resident was medicated for pain and then transferred to the hospital for evaluation. An addendum note dated 4/16/12 revealed that on assessment, the resident's family member noticed a small palpable lump and slight swelling on the right lower thigh. She was only able to move foot and toes. An undated "Investigative Findings/Conclusion" document provided by the facility with the AAS-45, revealed that on 4/15/12 at 5:30 p.m., the resident's alarm sounded, and that Resident #1 was found on the floor, "screaming with pain". The nurse took her vital signs, and then assisted her to the chair, then to her bed, and gave her medication for pain. The document also reveals that a family member was present and that the physician was notified. The document continues, stating that "resident was left unsupervised in the hallway on her Broda chair without the lap tray. Resident stood up, walked a few steps, and fell (as seen on video camera)". According to the "Investigative Findings/Conclusion" document, "the nurse failed to call the RN (Registered Nurse) on duty for assistance" and that "the nurse failed to call 911 for assistance and transport". The Licensed Practical Nurse (LPN) responsible for the resident was disciplined and inserviced on the facility's policies on Fall Prevention, and Incidents/Accidents. A review of the nurse's employee file indicated that she was inserviced on Incident/Accident and Falls policies on 4/10/12. The LPN's written statement dated 4/16/12, documented that the LPN should have called the RN on duty immediately before moving the resident onto the bed. In addition, she documented that she should not have moved the resident from the floor, and should have called 911 immediately. The surveyor conducted an interview on 5/10/12 at 10:40 a.m., with the Director of Nursing (DON). The DON explained that the resident wheeled herself from the dining room, while in the Broda chair; to the front of the nurse's station and that the resident stood up, walked a little, and then fell . The DON stated that it was the nurse's and Certified Nurse Assistants (CNA) responsibility for ensuring that the lap tray was in place and that the LPN observed the resident leave the dining room without the lap tray in place, and did not apply the lap tray upon recognition. She said that the resident's alarm sounded and she was found on the floor screaming in pain. The surveyor conducted an interview on 5/10/12 at 12:52 p.m., with the LPN. The LPN stated that she was not aware that the resident was at the nurse's station without the lap tray in place. She further explained that she saw Resident #1 with a doll in her arms and assumed that the lap tray was in place. The LPN stated that she had watched a video of the incident and realized then that the resident did not have the lap tray in place. She further stated that she responded to the resident's alarm sounding and that the resident was screaming for help. She stated that the resident was out of her sight when she responded to her and explained that it was the nurses' and the CNAs' responsibility to ensure that the lap tray was in place. The LPN stated that she was inserviced on safety after the incident. A post-survey telephone interview was conducted by the surveyor on 5/11/12 at 10:56 a.m., with the CNA. He explained that he placed the resident at the nurse's station in an unsupervised area to eat dinner. The CNA stated that he informed the aforementioned LPN that resident was at the nurse's station and that when he went to check on her, she was already on the floor. He explained that it was his responsibility to apply the lap tray after she finished eating. He further explained that he was inserviced on safety after the incident. A post-survey telephone interview was conducted by the surveyor on 5/22/12 at 1:13 p.m., with the RN. He explained that the LPN did not call him when the resident was found on the floor. He further explained that he was called by the LPN to assist with transfer paperwork. He stated that he was informed of the fall when he arrived on the unit. He further stated that the resident was already in bed when he went into the room. The hospital records revealed that the resident was admitted on [DATE], [DIAGNOSES REDACTED]. NJAC 8:39-27.1(a)