Every finding on record at Morris View Healthcare Center

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of staff-to-resident physical abuse to a cognitively intact resident (Resident # 194) who reported the abuse allegation to the Registered Nurse (RN #1) on 01/01/26. This deficient practice was identified for 1 of 5 residents (Resident # 194) reviewed for abuse. On 1/28/26 at 1:00 PM, the surveyor interviewed Resident # 194, who stated that during the 11 PM to 7 AM shift on 12/31/25, the resident was in the day room with Resident # 158 watching the ball drop before midnight. Resident # 194 stated they got into a physical altercation with the Licensed Practical Nurse (LPN #1), which included LPN #1 yelling and poking their finger in Resident # 194's face, and stomping on the resident's right foot. Resident # 194 stated that the next morning on 01/01/26, they reported what happened to the Registered Nurse (RN #1). The facility processed the resident's concern as a grievance allowing LPN #1 continue working having access to Resident # 194, as well as other residents without conducting a thorough investigation. The facility's failure to implement their abuse policy by thoroughly investigating all allegations of abuse placed Resident # 194, as well as all residents, at risk for abuse. This posed the likelihood of serious physical and emotional harm, or impairment, and resulted in an Immediate Jeopardy (IJ) situation. The IJ began 01/01/26, after Resident #194 made an allegation of staff-to-resident physical abuse. The facility was notified of the IJ on 01/28/26 at 11:15 PM. The facility submitted an acceptable Removal Plan (RP) on 01/30/26 at 3:14 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 01/30/26 at 8:21 PM. The evidence was as follows: Refer to F 600A review of the facility's policy titled Abuse Investigation and Reporting, dated revised 01/26, revealed .If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Upon conclusion of the investigation, the investigator will record the results of the investigation and provide the completed documentation to the Administrator. On 01/28/26 at 1:00 PM, the surveyor interviewed Resident # 194, who stated that during the 11 PM to 7 AM shift on 12/31/25, the resident was in the day room with Resident # 158 watching the ball drop before midnight. Resident # 194 went to the medication cart where Licensed Practical Nurse (LPN #1) was standing and requested medication for a headache. Resident # 194 stated that LPN #1 yelled at them and said, Don't you know not to bother me when I'm at the medication cart. Resident # 194 returned to the day room and forty minutes later LPN #1 went into the day room and handed Resident # 194 a cup with medication in it. Resident # 194 threw the medication over their shoulder and told LPN #1 it would be ineffective now since it took so long for it to be administered. Resident # 194 stated LPN #1 got down in the resident's face and started poking their finger in the resident's face, eye and forehead. Resident # 194 further stated that LPN #1 began yelling close enough that the resident felt the nurse's spit on their face and LPN #1 stomped on Resident # 194's right foot. Resident # 194 stated that the next morning they reported what happened to the Registered Nurse (RN #1). Resident # 194 further stated that LPN #1 did it right in front of the cameras. Resident # 194 stated the Administrator in Training (AIT) and another head nurse came in and talked to Resident # 194 and apologized for what happened and told Resident # 194 that should not have happened and that they were going to review the video from the camera in the day room. Resident # 194 stated LPN #1 continued to work and gave medications to the residents during the 11 PM to 7 AM shift last night. Resident # 194 stated they did not like LPN #1 being their nurse, and the resident did not understand why the facility did not at least assign LPN #1 to another hall. Resident # 194 stated they did not trust LPN #1, and Resident # 194 didn't take their eyes off LPN #1. Resident #194 further stated they watched LPN #1 get medications out of the cart before the resident ingested them. Resident # 194 stated they no longer went into the day room to watch television with their fellow residents because it had bad memories for them now since the incident happened. A review of Resident # 194's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident # 194's quarterly Minimum Data Set (MDS), an assessment tool with an Assessment Reference Date (ARD) of 12/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the Facility Summary, signed and dated 01/02/26, by the Director of Nursing (DON) and provided by the facility, revealed that the facility received a grievance from an alert and oriented resident (Resident # 194) alleging that a nurse was not being nice and failed to administer requested medication. Resident # 194 reported feeling dismissed when asking for medication assistance. An investigation was initiated promptly in accordance with facility policy. Interviews were conducted with the involved nurse, staff present on the unit, and multiple alert and oriented residents who were in the immediate area at the time of the incident. A further review of the Facility Summary, revealed a typed unsigned statement dated 01/01/26, taken by Infection Preventionist (IP) from Resident #194 with no time, revealed Last night I felt a migraine starting so I went to ask [LPN #1] for my Topiramate [anticonvulsant medication]. [LPN #1] asked me to wait until they were done counting and to move away from the cart, so [LPN #1] doesn't make a mistake. I told [LPN #1] I needed it immediately otherwise it won't work. [LPN #1] said I needed to wait until they were finished. [Resident # 242] asked [LPN #1] for Tylenol and [LPN #1] told [Resident # 242] to wait also. I went back into the dayroom, me, [Resident #158] and [Resident # 242] were watching TV, we like to do that in the evening. [LPN #1] came in later and gave [Resident # 242] medicine and gave me my pill. I was upset and threw it over my shoulder. I called [LPN #1] some nasty names, even used the N word. I feel bad, I have never used that word before. [LPN #1] was telling me about how PRN [as needed] medicine is given and that it's not scheduled for an exact time. [LPN #1] bent down and was talking to me close to my face. I even picked up my hand in front of my face. [LPN #1] told me she has to find the pill and throw it away so nobody else can take it. I saw [LPN #1] find it on the floor and leave the dayroom. [LPN #1] came back later to clean up the table and went around my chair, bumping my foot. [LPN #1] left the room again and I stayed watching TV with [Resident # 158] and [Resident # 242]. A further review of the Facility Summary, revealed a typed unsigned statement dated 01/01/26, taken by the IP from Resident # 158, revealed [LPN #1] was counting medicine at the cart and [Resident # 194] went to [LPN #1] asking for medicine for a headache. The nurse asked [Resident # 194] to wait a few minutes until [LPN #1] finishes so [LPN #1] doesn't make a mistake. [Resident #194] came back into the dayroom and was upset. [Resident # 242] asked the nurse for Tylenol, [LPN #1] asked [Resident # 242] also to wait a few minutes until [LPN #1] finishes counting. I tried to calm [Resident #194] down and told [Resident # 194] why are you making such a fuss to wait a few minutes, but [Resident # 194] didn't want to listen to me. [Resident # 194] told me I'm gonna throw it away if [LPN #1] brings it to me now. A few minutes later the nurse came in with medicine for [Resident # 242] and [Resident # 194] and some water. [Resident # 242] took [theirs] and [Resident # 194] threw [theirs] over their shoulder and started saying rude things to the nurse, calling her racial slurs. The nurse tried to explain to [Resident # 194] that their medicine is not scheduled for a specific time and it's dangerous to throw pills on the floor that other residents can find, but [Resident # 194] didn't want to listen. I saw the nurse look on the floor for the medicine, found it, and went to throw it away. She came back later to collect the dirty cups from the table. The three of us stayed watching TV, we wanted to watch the ball drop. A review of the Facility Summary, included a typed unsigned statement dated 01/01/26, taken by the IP from RN #1 which revealed, [RN #1] came to let me know that [Resident #194] stated they were upset about what happened last night with [LPN #1] and [Resident # 194] didn't get their migraine medicine. [RN #1] said [Resident # 194] told [RN #1] the nurse bumped [Resident # 194's] foot when walking by their wheelchair and that [LPN #1] was also talking to very close to [Resident # 194's] face. I told [Resident # 194] I will let the DON know immediately and I will go speak with [Resident #194]. I told [RN #1] to complete a full skin assessment to make sure there is no injury. On 1/28/26 at 6:06 PM, the surveyor interviewed RN #1, who stated they entered Resident # 194's room to pass medications the morning of 01/01/26, between 9 AM and 10 AM, and Resident # 194 told her they had an altercation with LPN #1. RN #1 stated that Resident # 194 reported that LPN #1 was yelling and said some nasty things to them and stomped on their foot, poking the resident in the forehead which made Resident # 194 call LPN #1 a racial slur. RN #1 stated she was told that they were going to review the cameras because they had issues with Resident # 194 making false allegations in the past. RN #1 stated she never heard the outcome of the investigation and was never interviewed or asked to write a statement. RN #1 stated she just assumed they completed their investigation since [LPN #1] was still working at the facility. RN #1 stated she's been waiting for someone to speak to her about the allegation and that she would be happy to write a statement. On 1/28/26 at 4:15 PM, the surveyor interviewed Resident # 158, who confirmed Resident # 194's allegation of staff-to-resident physical altercation. Resident # 158 stated that LPN #1 started yelling at Resident # 194 and poked her finger in Resident # 194's face. Resident # 158 stated they were unable to see if the nurse's finger actually touched the resident's skin. Resident # 158 stated that Resident # 194 called LPN #1 a derogatory name and LPN #1 said to Resident # 194 guess what? You're not getting your 7 AM medication from this [derogatory name]. Resident # 158 further stated that LPN #1 stomped on Resident # 194's foot and that Resident # 194 was only wearing flip flops. Resident # 158 stated that LPN #2 and RN #2 came and asked about what happened and that Resident # 158 told them everything they observed. On 01/28/26 at 6:55 PM, the surveyor interviewed the DON, who stated their process when an allegation was made, they interviewed residents or staff who may have witnessed the incident or were in the area where the incident occurred. The DON stated they have a conversation with their regional person to determine if it's a reportable or a grievance, but they did not report all allegations. The DON stated if they did report an allegation of staff-to-resident abuse, the staff member would be removed from the building and not allowed to return until the investigation was completed. The DON confirmed they did not report the allegation that Resident # 194 made. The DON stated they determined it was a grievance and not something that needed to be reported. The DON stated they interviewed other residents and staff who were present at the time the incident occurred, but she did not know which staff or residents were interviewed and was unable to provide any documentation of these interviews and stated they would be provided the next day. The DON stated they were in a locked cabinet that nobody currently in the building had access to and was unable to state why the interviews were not in the folder with the grievance form that was completed related to the allegation. During a follow-up interview on 01/29/26 at 12:10 PM, Resident #194 re-told the same allegations that they initially reported on 01/28/26, and denied reporting the information that was written in the above statement for them by the IP. On 01/29/26 at 4:10 PM, the surveyor interviewed the Licensed Nursing Administrator Home (LNHA), who stated that the facility met quarterly for quality assurance and performance improvement (QAPI). The LNHA stated their last meeting was 12/02/25, for the 3rd quarter, and they had not identified any system failures. The LNHA stated he was the point person for all allegations of abuse and was the facility's abuse coordinator. The LNHA stated any allegations of abuse were discussed by the team, and they would collect statements and do their due diligence to find out what happened. The LNHA stated that he honestly felt they came to the right conclusion. The LNHA stated looking back maybe they should have suspended LPN #1, but they still did not feel the allegation warranted that response. On 01/30/26 at 8:17 AM, the surveyor interviewed the IP, who stated that on 01/01/26, she was the only nursing supervisor working since it was a holiday. The IP stated they were made aware of the staff to resident altercation by RN #1 and that Resident # 194 was upset about an incident that occurred during the night shift with LPN #1. The IP stated she was asked by the DON to get statements from the staff and residents who were working or in the area when the incident occurred. The IP stated she had never been trained on investigating, and this was the first time she completed one. The IP stated she did not allow the residents or staff that she spoke with to write their statements, and she documented what they told her. The IP stated the statements were not provided to the DON or the LNHA after it was completed so they would not have copies of them, so they were unable to provide them when they were requested the night before. The IP stated she put them in her filing cabinet and forgot about them. The facility submitted an acceptable Removal Plan (RP) on 01/30/26 at 3:14 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the immediacy including; on 01/28/26, the staff member [LPN #1] identified in the allegation was immediately removed from the schedule and an investigation was initiated in accordance with facility policy. On 01/28/26, Resident # 194 was assessed by nursing staff for any signs of injury or distress, and was provided with a trauma screen, emotional support, and a psychiatric consultation on 01/29/26. All alert and oriented residents who received care from LPN #1 between 01/01/26 through 01/28/26, will be interviewed beginning on 01/30/26, to assess for any concerns and confirm resident safety. The facility's Abuse Investigation Policy was revised on 01/29/26, by the DON and the LNHA to clarify that any allegation regardless of severity level, triggers an immediate investigation, and facility wide training on Investigation of Abuse was initiated on 01/28/26, by the DON. The survey team verified the implementation of the RP on-site during the continuation of the survey on 01/30/26 at 8:21 PM. NJAC 8:39-4.1(a)(5)

Based on record review, interview, and policy review, it was determined that the facility failed to implement their abuse policy to ensure residents were protected from abuse including physical and verbal abuse. During the 11 PM to 7 AM shift on 12/31/25, the Licensed Practical Nurse (LPN #1) got into a witnessed physical altercation with Resident # 194, which included yelling and poking their finger in Resident # 194's face and stomping on the resident's right foot. The resident reported after the altercation, they did not trust LPN #1 and they had to watch LPN #1 get their medications out of the cart before Resident # 194 ingested them, and the resident stated they could no longer go to the day room to watch television with their fellow residents because it had bad memories. This deficient practice was identified for 1 of 5 residents (Resident # 194) reviewed for abuse, and was evidenced by the following:A review of the facility's policy titled Abuse Investigation and Reporting, dated revised 01/26, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. Allegations of abuse/neglect will be reported to local, state, and federal agencies (as defined by current regulations). If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Upon conclusion of the investigation, the investigator will record the results of the investigation and provide the completed documentation to the Administrator. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. A review of the facility's policy titled Abuse and Neglect-Clinical Protocol, date revised 01/26, revealed the definition of Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. On 1/28/26 at 1:00 PM, the surveyor interviewed Resident # 194, who stated that during the 11 PM to 7 AM shift on 12/31/25, the resident was in the day room with Resident # 158 watching the ball drop before midnight. Resident # 194 went to the medication cart where Licensed Practical Nurse (LPN #1) was standing and requested medication for a headache. Resident # 194 stated that LPN #1 yelled at them and said, Don't you know not to bother me when I'm at the medication cart. Resident # 194 returned to the day room and forty minutes later LPN #1 went into the day room and handed Resident # 194 a cup with medication in it. Resident # 194 threw the medication over their shoulder and told LPN #1 it would be ineffective now since it took so long for it to be administered. Resident # 194 stated LPN #1 got down in the resident's face and started poking their finger in the resident's face, eye, and forehead. Resident # 194 further stated that LPN #1 began yelling close enough that the resident felt the nurse's spit on their face and LPN #1 stomped on Resident # 194's right foot. Resident # 194 stated that the next morning they reported what happened to the Registered Nurse (RN #1). Resident # 194 further stated that LPN #1 did it right in front of the cameras. Resident # 194 stated the Administrator in Training (AIT) and another head nurse came in and talked to Resident # 194 and apologized for what happened and told Resident # 194 that should not have happened and that they were going to review the video from the camera in the day room. Resident # 194 stated LPN #1 continued to work and gave medications to the residents during the 11 PM to 7 AM shift last night. Resident # 194 stated they did not like LPN #1 being their nurse, and the resident did not understand why the facility did not at least assign LPN #1 to another hall. Resident # 194 stated they did not trust LPN #1, and Resident # 194 didn't take their eyes off LPN #1. Resident #194 further stated they watched LPN #1 get medications out of the cart before the resident ingested them. Resident # 194 stated they no longer went into the day room to watch television with their fellow residents because it had bad memories for them now since the incident happened. A review of Resident # 194's Face Sheet, located in the electronic medical record (EMR) under the Profile, tab revealed the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident # 194's quarterly Minimum Data Set (MDS), an assessment tool with an Assessment Reference Date (ARD) of 12/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the Facility Summary, signed and dated 01/02/26, by the Director of Nursing (DON) and provided by the facility, revealed that the facility received a grievance from an alert and oriented resident (Resident # 194) alleging that a nurse was not being nice and failed to administer requested medication. Resident # 194 reported feeling dismissed when asking for medication assistance. An investigation was initiated promptly in accordance with facility policy. Interviews were conducted with the involved nurse, staff present on the unit, and multiple alert and oriented residents who were in the immediate area at the time of the incident. A further review of the Facility Summary, revealed a typed unsigned statement dated 01/01/26, taken by Infection Preventionist (IP) from Resident #194 with no time, revealed Last night I felt a migraine starting so I went to ask [LPN #1] for my Topiramate [anticonvulsant medication]. [LPN #1] asked me to wait until they were done counting and to move away from the cart, so [LPN #1] doesn't make a mistake. I told [LPN #1] I needed it immediately otherwise it won't work. [LPN #1] said I needed to wait until they were finished. [Resident # 242] asked [LPN #1] for Tylenol and [LPN #1] told [Resident # 242] to wait also. I went back into the dayroom, me, [Resident #158] and [Resident # 242] were watching TV, we like to do that in the evening. [LPN #1] came in later and gave [Resident # 242] medicine and gave me my pill. I was upset and threw it over my shoulder. I called [LPN #1] some nasty names, even used the N word. I feel bad, I have never used that word before. [LPN #1] was telling me about how PRN [as needed] medicine is given and that it's not scheduled for an exact time. [LPN #1] bent down and was talking to me close to my face. I even picked up my hand in front of my face. [LPN #1] told me she has to find the pill and throw it away so nobody else can take it. I saw [LPN #1] find it on the floor and leave the dayroom. [LPN #1] came back later to clean up the table and went around my chair, bumping my foot. [LPN #1] left the room again and I stayed watching TV with [Resident # 158] and [Resident # 242]. A further review of the Facility Summary, revealed a typed unsigned statement dated 01/01/26, taken by the IP from Resident # 158, revealed [LPN #1] was counting medicine at the cart and [Resident # 194] went to [LPN #1] asking for medicine for a headache. The nurse asked [Resident # 194] to wait a few minutes until [LPN #1] finishes so [LPN #1] doesn't make a mistake. [Resident #194] came back into the dayroom and was upset. [Resident # 242] asked the nurse for Tylenol, [LPN #1] asked [Resident # 242] also to wait a few minutes until [LPN #1] finishes counting. I tried to calm [Resident #194] down and told [Resident # 194] why are you making such a fuss to wait a few minutes, but [Resident # 194] didn't want to listen to me. [Resident # 194] told me I'm gonna throw it away if [LPN #1] brings it to me now. A few minutes later the nurse came in with medicine for [Resident # 242] and [Resident # 194] and some water. [Resident # 242] took [theirs] and [Resident # 194] threw [theirs] over their shoulder and started saying rude things to the nurse, calling her racial slurs. The nurse tried to explain to [Resident # 194] that their medicine is not scheduled for a specific time and it's dangerous to throw pills on the floor that other residents can find but [Resident # 194] didn't want to listen. I saw the nurse look on the floor for the medicine, found it, and went to throw it away. She came back later to collect the dirty cups from the table. The three of us stayed watching TV, we wanted to watch the ball drop. A review of the Facility Summary, included a typed unsigned statement dated 01/01/26, taken by the IP from RN #1 which revealed, [RN #1] came to let me know that [Resident #194] stated they were upset about what happened last night with [LPN #1] and [Resident # 194] didn't get their migraine medicine. [RN #1] said [Resident # 194] told [RN #1] the nurse bumped [Resident # 194's] foot when walking by their wheelchair and that {LPN #1] was also talking to very close to [Resident # 194's] face. I told [Resident # 194] I will let the DON know immediately and I will go speak with [Resident #194]. I told [RN #1] to complete a full skin assessment to make sure there is no injury. On 1/28/26 at 4:15 PM, the surveyor interviewed Resident # 158, who confirmed Resident # 194's allegation of staff-to-resident physical altercation. Resident # 158 stated that LPN #1 started yelling at Resident # 194 and poked their finger in Resident # 194's face. Resident # 158 stated they were unable to see if the nurse's finger actually touched the resident's skin. Resident # 158 stated that Resident # 194 called LPN #1 a derogatory name and LPN #1 said to Resident # 194, guess what? You're not getting your 7 AM medication from this [derogatory name]. Resident # 158 further stated that LPN #1 stomped on Resident # 194's foot and that Resident # 194 was only wearing flip flops. Resident # 158 stated that LPN #2 and RN #2 came and asked about what happened and that Resident # 158 told them everything they observed. On 1/28/26 at 6:06 PM, the surveyor interviewed RN #1, who stated they entered Resident # 194's room to pass medications the morning of 01/01/26, between 9 AM and 10 AM, when Resident # 194 told RN #1 that they had an altercation with LPN #1. RN #1 stated that Resident # 194 reported that LPN #1 was yelling and said some nasty things to them and stomped on their foot, poking the resident in the forehead which made Resident # 194 call LPN #1 a racial slur. On 01/28/26 at 6:55 PM, the surveyor interviewed the DON, who stated their process when an allegation was made, they interviewed residents or staff who may have witnessed the incident or were in the area where the incident occurred. The DON stated they have a conversation with their regional person to determine if it's a reportable or a grievance, but they did not report all allegations. The DON stated if they did report an allegation of staff-to-resident abuse, the staff member would be removed from the building and are not allowed to return until the investigation was completed. The DON confirmed they did not report the allegation that Resident # 194 made. The DON stated they determined it was a grievance and not something that needed to be reported. On 1/29/26 at 11:49 AM, the surveyor interviewed the Mental Health Professional (MH #1), who stated they spoke with Resident # 194 on 1/13/26, and that the resident reported that LPN #1 put their hands on them and stomped on their foot. During a follow-up interview on 01/29/26 at 12:10 PM, Resident #194 re-told the same allegations that they initially reported to the surveyor on 01/28/26, and denied reporting the information that was written in the above statement for them by the IP. On 01/30/26 at 8:17 AM, the surveyor interviewed the IP, who stated that on 01/01/26, they were the only nursing supervisor working since it was a holiday. The IP stated they were made aware of the staff-to-resident altercation by RN #1 and that Resident # 194 was upset about an incident that occurred during the night shift with LPN #1. The IP stated that Resident # 194 told them that they were upset that the resident did not get their migraine medication when the resident requested it from LPN #1 and that LPN #1 was counting medication and asked Resident # 194 to wait. The IP further stated that when the nurse came to give them their medication, the resident said it was too late and threw the medication and called LPN #1 racial slurs. Resident # 194 also told LPN #1 they did not know what they were doing. The IP further stated that Resident # 194 said that LPN #1 bent down to try to retrieve the medications and that LPN #1 was talking so close to Resident # 194 that the resident had to put their hand in between their face. The IP said that Resident # 194 also told them that LPN #1 bumped the resident's foot when the nurse went around the table to get the pill. The IP acknowledged that it was inappropriate for a staff member to be that close to a resident's face when speaking. The IP stated that it could be intimidating to someone. The IP further stated that they had not thought about it that way until now when it was put that way. The IP stated it was not said any different than how Resident # 194 reported it when it was first reported to the IP. On 01/29/26 at 4:10 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the facility met quarterly for quality assurance and performance improvement (QAPI). The LNHA stated their last meeting was on12/02/25, for the 3rd quarter, and they had not identified any system failures. The LNHA stated he was the point person for all allegations of abuse and was the facility's abuse coordinator. The LNHA stated any allegations of abuse were discussed by the team, and they would collect statements and do their due diligence to find out what happened. The LNHA stated that he honestly felt they came to the right conclusion. The LNHA stated looking back maybe they should have suspended LPN #1, but they still did not feel the allegation warranted that response. NJAC 8:39-4.1(a)(5) NJAC 8:39-9.4(f) NJAC 8:39-13.4

Based on observations, interviews, and facility policy review, the facility failed to ensure that food was not expired according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 256 census residents.Findings include:During initial observations of the kitchen on 01/27/26 beginning at 9:47 AM, the following was observed:-In the dry storage, three one-quart bottles of food dye displaying a manufactures expiration date of 03/27/25. The Director of Dietary (DOD) stated that those bottles should have been discarded.During an interview on 01/27/26 at 10:35 AM, the DOD stated that the three one-quart bottles were passed the use by date. The DOD stated that there was an audit of the food items completed to ensure no other food items were passed the use by date.During an interview on 01/28/26 at 9:45 AM the Registered Dietitian (RD) stated that the kitchen should not have had food items in stock that were beyond the use by date.Review of the facility's policy titled, Operation Manual-Dietary Services, dated 07/25, revealed that the policy did not address food storage policies and procedures. NJAC 8:39-17.2(g)

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) protecting all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident physical abuse; and b.) thoroughly investigating an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 5 residents (Resident #194) reviewed for abuse, and was evidenced by the following: Refer F 600 and F 610 A review of the facility's Administrator Job Description, dated 12/2018, revealed the Administrator should lead and direct overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objective. Monitor company identified Key Performance Indicators and addressed issues that affect performance of the facility. Responsible for the QA (Quality Assurance) program. Maintain a working knowledge of and confirm compliance with governmental regulations. A review of the facility's policy titled Abuse Investigation and Reporting, dated revised 01/26, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. Allegations of abuse/neglect will be reported to local, state, and federal agencies (as defined by current regulations). If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. Upon conclusion of the investigation, the investigator will record the results of the investigation and provide the completed documentation to the Administrator. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. On 01/28/26 at 1:00 PM, the surveyor interviewed Resident # 194, who stated that during the 11 PM to 7 AM shift on 12/31/25, the resident was in the day room with Resident # 158 watching the ball drop before midnight. Resident # 194 went to the medication cart where Licensed Practical Nurse (LPN #1) was standing and requested medication for a headache. Resident # 194 stated that LPN #1 yelled at them and said, Don't you know not to bother me when I'm at the medication cart. Resident # 194 returned to the day room and forty minutes later LPN #1 went into the day room and handed Resident # 194 a cup with medication in it. Resident # 194 threw the medication over their shoulder and told LPN #1 it would be ineffective now since it took so long for it to be administered. Resident # 194 stated LPN #1 got down in the resident's face and started poking their finger in the resident's face, eye, and forehead. Resident # 194 further stated that LPN #1 began yelling close enough that the resident felt the nurse's spit on their face and LPN #1 stomped on Resident # 194's right foot. Resident # 194 stated that the next morning they reported what happened to the Registered Nurse (RN #1). Resident # 194 further stated that LPN #1 did it right in front of the cameras. Resident # 194 stated the Administrator in Training (AIT) and another head nurse came in and talked to Resident # 194 and apologized for what happened and told Resident # 194 that should not have happened and that they were going to review the video from the camera in the day room. Resident # 194 stated LPN #1 continued to work and gave medications to the residents during the 11 PM to 7 AM shift last night. Resident # 194 stated they did not like LPN #1 being their nurse, and the resident did not understand why the facility did not at least assign LPN #1 to another hall. Resident # 194 stated they did not trust LPN #1, and Resident # 194 didn't take their eyes off LPN #1. Resident #194 further stated they watched LPN #1 get medications out of the cart before the resident ingested them. Resident # 194 stated they no longer went into the day room to watch television with their fellow residents because it had bad memories for them now since the incident happened. On 01/28/26 at 4:15 PM, the surveyor interviewed Resident # 158, who confirmed Resident # 194's allegation of staff-to-resident physical altercation. Resident # 158 stated that LPN #1 started yelling at Resident # 194 and poked their finger in Resident # 194's face. Resident # 158 stated they were unable to see if the nurse's finger actually touched the resident's skin. Resident # 158 stated that Resident # 194 called LPN #1 a derogatory name and LPN #1 said to Resident # 194, guess what? You're not getting your 7 AM medication from this [derogatory name]. Resident # 158 further stated that LPN #1 stomped on Resident # 194's foot and that Resident # 194 was only wearing flip flops. Resident # 158 stated that LPN #2 and RN #2 came and asked about what happened and that Resident # 158 told them everything they observed. On 01/28/26 at 6:06 PM, the surveyor interviewed RN #1, who stated they entered Resident # 194's room to pass medications the morning of 01/01/26 between 9 AM and 10 AM, when Resident # 194 told RN #1 that they had an altercation with LPN #1. RN #1 stated that Resident # 194 reported that LPN #1 was yelling and said some nasty things to them and stomped on their foot, poking the resident in the forehead which made Resident # 194 call LPN #1 a racial slur. On 01/28/26 at 6:55 PM, the surveyor interviewed the DON, who stated their process when an allegation was made, they interviewed residents or staff who may have witnessed the incident or were in the area where the incident occurred. The DON stated they have a conversation with their regional person to determine if it's a reportable or a grievance, but they did not report all allegations. The DON stated if they did report an allegation of staff-to-resident abuse, the staff member would be removed from the building and not allowed to return until the investigation was completed. The DON confirmed they did not report the allegation that Resident # 194 made. The DON stated they determined it was a grievance and not something that needed to be reported. The DON stated they interviewed other residents and staff who were present at the time the incident occurred, but she did not know which staff or residents were interviewed and was unable to provide any documentation of these interviews and stated they would be provided the next day. The DON stated they were in a locked cabinet that nobody currently in the building had access to and was unable to state why the interviews were not in the folder with the grievance form that was completed related to the allegations. On 01/29/26 at 4:10 PM, the surveyor interviewed the LNHA, who stated that the facility met quarterly for quality assurance and performance improvement (QAPI). The LNHA stated their last meeting was on12/02/25, for the 3rd quarter, and they had not identified any system failures. The LNHA stated he was the point person for all allegations of abuse and was the facility's abuse coordinator. The LNHA stated any allegations of abuse were discussed by the team, and they would collect statements and do their due diligence to find out what happened. The LNHA stated that he honestly felt they came to the right conclusion. The LNHA stated looking back maybe they should have suspended LPN #1, but they still did not feel the allegation warranted that response. NJAC 8:39-9.2(a) NJAC 8:39-9.3(a) NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) in the implementation of enhanced barrier precautions, for one of one resident (Resident (R) 12) reviewed for enhanced barrier precautions during a nephrostomy dressing change. In addition, the facility failed to ensure the proper sanitization of a glucometer used to obtain blood glucose results for one of one resident (Resident (R) 90) of three residents reviewed during medication administration observation. This failure had the potential to lead to serious illness and death related to the transmission of blood borne pathogens from resident to resident via the un-sanitized glucometer.Findings include:Findings include: 1.Review of R12's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R12 was admitted to the facility on [DATE] and re-admitted on [DATE]. R12's diagnoses included renal and perinephric abscess, malignant neoplasm of unspecified kidney, obstructive and reflux uropathy, and type two diabetes mellitus. Review of R12's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 01/06/26 and 11/20/25 revealed a Brief Interview of Mental Status score (BIMS) score of zero out of 15 which indicated R12 was severely cognitively impaired. The MDS indicated R12 was dependent on staff for toileting hygiene, bathing, and personal hygiene. Review of the most recent Comprehensive Care Plan located in the resident EMR under the Care Plan tab, initiated 09/01/25, indicated R12 was at risk for infection requiring enhanced barrier precautions related to nephrostomy. The interventions included enhanced barrier precautions: use gown and glove during high contact activities, dressing, hygiene, toileting, transferring, bathing/showering, changing linens, device care, wound care, therapy. And perform hand hygiene prior to and after providing care to resident. Review of active Orders located in the EMR under the Orders tab revealed the following order, dated 01/13/25: enhanced barrier precautions. Further review indicated an order for a right nephrostomy tube site cleanse and application of a Tegaderm dressing. During an observation on 01/28/26 at 7:15 PM, Unit Manager (UM) 2 did not perform hand hygiene and did not don (put on) the required PPE (gown, face shield, mask) prior to entering R12's room and removing R12's right nephrostomy dressing. During an interview on 01/28/26 at 7:15 PM, UM 2 stated oh yes, I forget to put on the PPE. UM2 further stated he/she should have donned the PPE prior to doing the nephrostomy dressing change. UM2 stated that he/she forgot to don PPE prior to performing the nephrostomy dressing change. He/she further acknowledged that PPE should have been worn and that he/she should have performed hand washing hygiene, including washing hands with soap and water before and after the dressing change and sanitizing hands. During an interview on 1/29/26 at 10:30 AM, the Infection Preventionist (IP) stated that staff were expected to perform hand hygiene and don appropriate PPE when caring for residents on enhanced barrier precautions. The IP further stated that staff received training on proper PPE use and enhanced barrier precautions. Review of the facility's policy titled, Enhanced Barrier Precautions, revised 10/25, indicated under Definition Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDRO] that requires staff to wear a gown and gloves while performing high contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO. Under Policy Interpretation and Implementation revealed Enhanced barrier precautions will be applied to: .b. Residents with indwelling medical device including central venous catheter, urinary catheter. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 07/25, indicated This facility considers hand hygiene the primary means to prevent the spread of infections. Under Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 2. During a blood glucose monitoring observation on 01/30/26 at 8:10 AM, Licensed Practical Nurse (LPN) 8 received a new glucometer, he/she took the glucometer to the med cart and then into the R90's room. LPN8 then performed a fingerstick blood glucose check for R90. LPN8 performed a handwash but never cleaned the glucometer. LPN8 picked up the glucometer, proceeded back to the B1 hall medication cart where the glucometer was put into the top cart and into its case and placed into the med cart drawer. During an interview on 01/30/26 at 8:25 AM, LPN8 came to the medication cart and at that time was asked about the proper way to clean the glucometer, he/she stated, to use the purple top Santi wipes that are on the cart, pointing to the container and to clean it before and after using the machine. LPN8 stated that it was a new machine, which was why he/she did not clean it. LPN8 stated, it should have been cleaned anyway. All machines were observed for individual residents and not used on other residents. During an interview on 01/30/26 at 3:00 PM, the IP was asked about how to clean the glucometer machine. He/she answered by using the purple Santi wipes that they have on their carts, wash, let dry for three min before and after each use, and they were for individualized use, and each resident has their own that are marked. Review of the facility's policy titled, GLUCOMETERS, reviewed/revised 01/26, revealed 6. Quality controls will be performed on a daily basis - results will be kept in a binder at the nurse's station. 7. Glucometer control solutions and all supplies are to be assessed on a daily basis for signs of contamination and for expiration date. 8. Each glucometer must be wiped down with a sanitizing agent after each use and returned to individual storage. NJAC 8:39-19.4

Based on record review, interview, and facility policy review, the facility failed to complete grievances with resolution related to missing personal items after he/she was moved on 08/21/25 by the facility for one of three residents (Resident (R) 133) reviewed for missing items of 40 sample residents. This failure had the potential to affect the resident ability to obtain resolution to grievances.Findings include:Review of R133's undated admission record provided by the facility revealed R133 was admitted on [DATE]. Review of R133's quarterly Minimum Data Set, (MDS) with an Assessment Reference Date (ARD) of 05/26/25, located under the MDS tab of the EMR, indicated the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 01/28/26 9:59 AM, R133 was asked about an incident that happened on third floor, when he/she moved to second floor on 07/29/25, He/she stated that all of his/her things were to be moved to his/her new room. R133 stated while he/she was out of the facility at dialysis, staff moved her/his belongings. He/she stated when he/she returned, he/she had several items missing. He/she felt at first the items were just not moved down to his/her new room. R133 stated the following items were missing perfume, lotion, two bottles of baby power from second drawer, phone charger, t-shirt with the number 60 on it that he/she got for their birthday to sleep in, in the bottom drawer, two head turbans- one burgundy and one gold. R133 stated he/she talked to the Director of Admissions (DOA)and the Administrative Assistant (AA) about the missing items. R133 stated both had looked for the items but none of the missing items could be located. Review of the Social Service Note dated 05/27/25 at 3:00 PM., indicated the Social Service Director met with the resident to inquire about personal items. The resident indicated something was missing, however, they already know. The resident was offered a lock box to secure her valuables, but he/she declined. R133 presented at her baseline without signs or symptoms of emotional distress. During an interview on 01/30/26 at 10:58 AM, AA was interviewed about the missing items of R133. AA stated they went to the Laundry Supervisor or Supervisor to see if it could be found, wrote a grievance, and gave to the Laundry Supervisor (LS). The AA was asked if this was done with R133's items. The AA stated No, no grievance was written, I went and asked and we looked, but no grievance was written. When asked what happened to R133's items. AA stated the unnamed Certified Nurse Assistants (CNA's) moved his/her items from room, on the third floor and took them to R133's new room on 08/21/25. During an interview on 01/30/26 at 10:15 AM, The DOA stated that R133 refused to allow him/her to pay for items. When asked if there was documentation to this statement, DOA stated he/she had none. The DOA stated neither the DOA nor AA filed out grievance and/or reported this incident per the policy. DOA stated, he/she was asked yesterday 01/29/26 about this incident by the Director of Nursing (DON). He/she stated no grievance was found or filled out by DOA or the AA. When asked what she should have been done at the time it was reported to them, both the DOA and AA stated that a grievance should have been filled out. The DOA stated that when she did not want to pay for the items there should have been documentation of that. AA made the statement we dropped the ball on this report. Review of the facility's policy titled, Resident Grievances Policy, revealed The Facility advises residents and their representatives (including family, legal representatives, and advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. The Facility ensures that there is no retaliation for filing a grievance or complaint and ensures that there is a prompt review, investigation, and response to and resolution of grievances and complaints. 4. Grievances and/or complaints may be submitted orally or in writing and can be made anonymously.5. Duties and Obligations of Staff a. When a Facility Staff member receives a complaint from a resident, a resident's representative, or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the Facility Staff member is encouraged to advise the resident that the resident may file a complaint or grievance without fear of reprisal ordiscrimination. NJAC 8:39-4.1(a)35

Based on observation, document review, and interview, the facility failed to ensure assistive devices were provided for one of one resident (Resident (R) 32) reviewed for assistive devices out of 40 sample residents. This had the potential to cause a decrease in the residents' dietary intake. Findings include:Review of R32's Activity Log Report, provided by the facility, dated 12/09/24 at 11:44 AM, revealed R32 was to have a metal tablespoon only Do not send small teaspoon. On 01/08/25 at 11:56 AM, it was noted in the Activity Log Report that he/she was to have no plastic utensils, 2 Large tablespoons only.During an observation and interview on 01/27/26 at 4:40 PM, Certified Nurse Assistant (CNA) 4 was observed feeding R32 and there were two regular spoons (regular dining spoon) on the tray. CNA4 stated this was the way it had been for about a week. CNA4 stated he/she had gotten the two regular spoons on his/her tray. The tray tag notes on it revealed Assist with feeding***Only the circular spoon***.During an observation on 01/28/26 at 4:51 PM, CNA4 was observed feeding R32 with two regular spoons on the tray. CNA4 stated it was the same tonight as last night. The tray tag notes on it revealed Assist with feeding***Only the circular spoon***. The spoon was not on the tray. During an observation on 01/30/26 at 11:20 AM, R32's tray was in his/her room and on the tray was noted to have two regular spoons. The new spoons that were noted to have arrived on 01/29/26 at 3:30 PM were not on his/her tray. During an interview on 01/28/26 at 5:10 PM, the Assistant Director of Dietary (ADOD) stated that the spoon was a soup spoon, and he/she showed a picture of the spoon that he/she was to use. The ADOD stated they ordered them about a week ago. ADOD stated that he/she would get the order sheet, where the spoons were ordered. ADOD stated that with the dishwasher it was not working correctly so they had been sending regular plastic spoons on his/her tray. The dietary tray tag, dated Wednesday Dinner 01/28/26 from his/her supper tray at 4:51 PM, revealed Assist with feeding***Only the circular spoon***. NJAC 8:39-27.5(b)

Based on record review, interview, and policy review, the facility failed to ensure two of three residents (R) 254 and R230) and their resident representatives reviewed for emergent hospital transfer out of a total sample of 40 residents were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include:1.Review of R254's admission Record located under the Profile tab in the electronic medical record (EMR) revealed the resident admitted to the facility on [DATE]. Review of R254's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R254 was cognitively intact. Review of R254's Progress Note, dated 12/26/25 and located under the Progress Note tab of the EMR, revealed R254 had a change in condition. New order received to send to hospital for evaluation and treatment. Transfer sheet and face sheet provided to Emergency Medical Services (EMS). Review of Notice of Emergency Transfer, dated 12/26/25 and provided by the facility for R254, revealed that the document did not include the appeal process as indicated in the facility's policy. During an interview on 01/30/26 at 3:59 PM, the Social Worker (SW) said the Ombudsman was notified and the Ombudsman information was provided on the transfer form. He/she stated a copy of the transfer form was not provided to the residents because they knew they were going out. He/she stated nothing was documented in their medical record about notification after a transfer and nothing was explained to the residents because they knew they were going out. Review of the facility's policy titled, Transfer or Discharge Notice, revised 04/25, revealed The resident and./or representative (sponsor) will be notified in writing of the following information, A statement of the resident's rights to appeal the transfer or discharge, including: the name, address, email and telephone number of the entity which receives such requests; information about how to obtain, complete and submit an appeal form; and how to get assistance completing the appeal process. 2. Review of R230's quarterly MDS with an ARD of 11/13/25 and located under the MDS tab of the EMR, revealed an admission date of 09/15/21. The quarterly MDS revealed a BIMS score of 15 out of 15 which indicated R230 was cognitively intact; and diagnoses which included coronary artery disease, hypertension, peripheral vascular disease (PVD), diabetes mellitus, other fracture, anxiety disorder, depression, and tobacco use. Review of a nursing note, located under the Notes tab of the EMR, dated 08/14/25, indicating that R230 was sent to the local hospital for evaluation and treatment after a fall in his/her room. Review of the emergency transfer notice, dated 08/14/25 and provided by the facility for R230, revealed the ombudsman office information as the entity for appeals. During an interview on 01/29/26 at 4:35 PM, the Director of Nursing (DON) stated that was the form for transfers that the facility always used. NJAC 8:39-4.1(a)31,32

Based on record review, interview, and policy review, the facility failed to implement their abuse policy and report an allegation of staff to resident abuse for one of five residents (Resident (R) 194) reviewed for abuse out of 40 sample residents. This had the potential to affect residents in the facility who were at risk for abuse.Findings include: Review of R194's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD). Review of R194's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R194 was cognitively intact. During an interview on 01/28/26 at 1:00 PM, R194 stated during the 11 PM to 7 AM shift he/she was in the day room with R158 and R242 watching the ball drop before midnight. His/her head started hurting so he/she went to the nurse cart where Licensed Practical Nurse (LPN) 1 was standing and requested medication. He/she said that LPN1 yelled at him/her and said, Don't you know not to bother me when I'm at the medication cart, so he/she went back into the day room with the other two residents. About forty minutes later LPN1 came into the day room and handed him/her the cup with the medication and R194 said he/she threw it over his/her shoulder and told LPN1 it would be ineffective now since it took so long for it to be administered. At that time LPN1 got down in his/her face and started poking his/her face with his/her fingers on his/her eye and forehead, yelling at him/her and spit was going on his/her face and stomped on his/her right foot. R194 said he/she did it right in front of the cameras. The next morning, he/she reported what happened to Registered Nurse (RN) 1. He/she stated the Administrator in Training (AIT) and another head nurse came in and talked to him/her and apologized for what happened and told him/her that should not have happened and that they were going to review the video from the camera in the day room. During an interview on 01/28/26 at 4:15 PM, R158 (BIMS of 15) confirmed the allegation of R194, stating LPN1 started yelling at R194 and poked his/her finger in R194's face. He/she said LPN2 and RN2 came and asked him/her about what happened and he/she told them everything he/she observed LPN1 do to R194. During an interview on 01/28/26 at 6:06 PM, RN1 said when he/she went into R194's room to pass his/her medications on the morning of 01/01/26 between 9 AM and 10 AM R194 told him/her he/she had an altercation with an evening nurse. RN1 stated he/she immediately notified the in-house supervisor/RN supervisor, and he/she spoke with the Infection Preventionist (IP) who told him/her to complete a skin assessment on R194 which he/she did. During an interview on 01/28/26 at 6:55 PM, the Director of Nursing (DON) stated their process included when an allegation was made, to interview residents or staff who may have witnessed the incident or were in the area where the incident occurred and have a conversation with their regional person and determine if it's a reportable or a grievance, but they did not report all allegations. The DON stated if they did report an allegation of staff to resident abuse, the staff member was removed from the building and not allowed to return until the investigation was completed. He/she confirmed they did not report the allegation that R194 made. He/she said they determined it was a grievance and not something that needed to be reported. During an interview on 01/30/25 at 8:17 AM, the IP said on 01/01/26 he/she was the only nursing supervisor working since it was a holiday. The IP stated he/she was made aware by RN1 that R194 was upset about an incident that occurred during the night shift with LPN1. The IP stated he/she reported after he/she became aware and he/she contacted his/her DON and made him/her aware. Review of the facility's policy titled, Abuse Investigation and Reporting, revised 01/26 revealed .If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual.An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: two (2) hours if the alleged violation involves abuse. NJAC 8:39-9.4(f)

Complaint#s: NJ00179392, NJ00184406, NJ00184468, NJ00180247 Based on interviews, medical record review, and review of other pertinent facility documentation on 05/06/2025 and 05/12/2025, it was determined that the facility failed to: (a) update the care plan (CP) with interventions for a resident [Resident #7] when the diet consistency of was observed changed by a family member and (b) implement and revise care plan (CP) interventions for a resident (Resident #1) who was a smoker while in the facility and had history of smoking incidents. This deficient practice was identified for 2 of 8 residents reviewed for care plans and was evidenced by the following: According to the admission Record [AR] Resident #7 was admitted to the facility with the diagnoses which included, but were not limited to Cerebral Palsy [a group of disorders that affect movement, posture, and muscle coordination due to the abnormal brain development or damage to the developing brain], Aphasia [impairment in person's ability to comprehend or formulate language because of damage to specific brain region], and Quadriplegia [paralysis that affect all a person's limbs and body from the neck down.] According to the Quarterly Minimum Data Set [MDS] an assessment tool dated 03/20/2025 Resident #7 was not able to complete the assessment. Staff assessment indicated Resident #7 had short-term and long-term memory problems. According to Resident #7's CP regarding the father interferes with his/her care that on 11/12/2024 he was noted pouring thin liquid s into thickened liquids from kitchen tray and yelling at staff stating, this is too thin. The CP revealed that there were no new interventions related to the tampering of the consistency of the liquids. On 05/06/2025 at 3:54 P.M., the surveyor interviewed the Director of Nursing [DON], who stated that It would be best practice to update interventions post incident. The DON explained that the care plans are updated as needed and quarterly. The DON also stated that the Nursing Supervisor [NS] would update a care plan post incident. When the surveyor asked the DON if Resident #7's care plan looked updated post incident she stated, I would have to update myself on that. According to Resident #1's admission Record (AR), Resident was admitted to the facility with the following diagnoses which included but not limited to: Achalasia of cardia [swallowing disorder], narcolepsy with cataplexy [loss of muscle tone associated with excessive sleepiness], anxiety disorder, post-traumatic stress disorder, major depression, and bipolar disorder. Review of Resident #1's CP with Date Initiated:08/21/2023 revealed: Focus: [Resident #1 name] is a smoker: - Resident #1 [name] was observed smoking in a restricted area on 10/09/23. Smoking privileges has been suspended for 1 day. Privileges will be reinstated on 10/11/23 with date initiated on 08/21/2023 and revision on 06/29/2024. Resident #1's CP interventions included but not limited to the following: -Smoking supplies are stored according to facility policy; staff hold and distribute. Date Initiated: 08/21/2023. On 08/10/2024, Resident #1 was missing four vapes from the bedside table and allegedly accused a staff to have taken it according to Resident #1's room mate (Resident #8) who was in the room and witnessed the incident. On 08/11/2024, Resident #1 called the local Police Department (PD) to report the incident. The allegation was known to the facility on [DATE] and the facility investigated. On 05/06/2025 at 1:41pm, the Surveyor interviewed the Social Worker (SW) regarding Resident #1. SW affirmed that Resident #1 was a smoker and utilized vapes. On 05/06/2025 at 4:27pm, the Surveyor interviewed the Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA). Both LNHA and ADON affirmed that Resident #1 was a smoker and utilized electronic cigarettes [vapes]. On 05/12/2025 at 4:21pm, the Surveyor interviewed the ADON who stated the Recreation Department held the lighters for the smokers. ADON further stated the smoking area was the back patio and other place than that would be considered a restricted area. Review of the facility's policy Care Plans, Comprehensive, Person-Centered reviewed /revised 02/2025 revealed under Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation, 8(g)-incorporate identified problem areas, 8(h)-incorporate risk factors associated with identified problems, and 10-Identifying problem areas and their caused and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. NJAC8:39-11.2 [e] [1][2]

Complaint #: NJ00180247 Based on interview, record review, and review of facility documents on 05/06/2025 and 05/12/2025, it was determined that the facility failed to report an allegation of misappropriation on 08/10/2024 to the New Jersey Department of Health (NJDOH) being made for a resident (Resident #1) missing items [four vapes]. This was observed in 1 of 1 resident reviewed for misappropriation. This deficient practice was evidenced as follows: According to Resident #1's admission Record (AR), Resident was admitted to the facility with the following diagnoses which included but not limited to: Achalasia of cardia [swallowing disorder], narcolepsy with cataplexy [loss of muscle tone associated with excessive sleepiness], anxiety disorder, post traumatic stress disorder, major depression, and bipolar disorder. Review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify residents' health problems, dated 03/06/2025, the Resident showed a Brief Interview of Mental Status (BIMS) of 14 indicating that Resident's cognition was intact. Review of the facility's documentation Investigational Summary (IS) completed and signed by Director of Nursing (DON) and Administrator on 8/12/24. The IS has the Resident #1's name [redacted] and Date of 8/10/2024; Overview: Missing Item: 4 vapes. The IS reflected the Description of the Event as follows: on 8/10/24 [Resident #1's roommate (Resident #8)] informed Resident #1 that Licensed Practical Nurse (LPN #1) entered the room, Resident #8 unsure of the exact time. Resident #8 stated that LPN #1 came into the room [number] and went to Resident #1's side of the room. She [Resident #8] was able to see LPN #1 in the mirror. Resident #8 stated that LPN #1 went to Resident #1 nightstand and black plastic organizers and opened them. Then exited the room. Resident #1 notified [local town] Police Department (PD) who came to the facility and interviewed Resident #1. Resident #1 informed them that her vapes were missing from her personal belongings. Resident #1 did not notify staff at that time. Sunday 8/11/24 approximately 10:45am [local town] PD arrived at the facility. Obtained a statement from LPN#1. She denied taking the vapes. Monday 8/12/24 at approximately 7am LPN #1 found missing vapes in the soiled utility room in a plastic bag. LPN #! Notified Social Services that the missing items were found. She [LPN #1] turned the vapes into the Social Worker (SW) [name redacted]. SW secured the vapes in a safe place and informed Resident #1 that they were found. Resident #1 accused LPN #1 of stealing the vapes from her room. The DON [name redacted] instructed LPN #1 that she will no longer be the nurse assigned to [room number] to minimize the potential of future accusations. Resident #1 informed of the plan moving forward and affirmed understanding. Video footage reviewed by the DON and Administrator, Licensed Nursing Home Administrator (LNHA), the video reveals on 8/10/24 at approximately 12:50pm LPN #1 entered room [number] where she remained until 12:54pm. LPN #1 exited room [number] with both hands visible with no items in either hand. LPN #1 walked down the hallway and went to the nurse's station. At the nurse's station LPN #1 obtained her personal bag. Unable to see if any items were put in or removed from her bag. 8/12/24 at approximately 6:35am video reveals LPN #1 enter the [ID] Unit and begin to do rounds of the low hall rooms. LPN #1 dropped her personal belongings at the desk and took soiled plastic bags from her morning rounds in the soiled utility room to dispose them. LPN #1 exited the soiled utility room with a plastic bag and went to nurse's station. The IS further revealed that interview with LNHA, DON, and LPN #1: LPN #1 stated Resident #1 asked her about her inhaler versus aerosol orders while at the nursing station. LPN #1 stated she advised she would reached out to Resident #1's MD [doctor][name redacted] which LPN #1 did and communication was verified. Resident #1 came back to LPN #1 because LPN #1 followed up on receiving orders for her on Friday. LPN #1 further stated she went to Resident #1's room to inform her that she was still waiting for MD to callback. Resident #1 was not in her room. Her roommate [Resident #8] was lying in bed. Resident #1 at times had headphones on so LPN #1 looked behind the curtain to see if she was there and possible did not hear LPN #1 enter. While walking out, Resident #1 roommate [Resident #8] was asking LPN #1about her remote and channels. When LPN #1 left the room, she saw Resident #1 in the hallway (high side) providing her with the update. Resident #1 said thank you. The IS revealed under Intervention: Notifications: Primary nurse, MD [name redacted], Resident, [local town] PD; Staff nurse will not be assigned to room [number]; Staff interviews; Resident interviews. In the IS, the Summary of Investigation was documented as follows: Investigation reveals there is no physical or visual evidence of vapes being taken or possessed by LPN #1. Vapes were found in the soiled utility room amongst soiled linens and given to Social Services on Monday 8/12/24. Resident #1 was informed the vapes were located and secured by Social Services. Social Services will follow up with Resident #1 as needed. LPN #1 will not be assigned to room [number] to minimize the potential of any future accusations. LPN #1 affirmed understanding. Review of Resident #1's progress notes (PN) did not contain documentation of the said incident of allegation of misappropriation against LPN #1 as indicated in the IS made by the facility on the above-mentioned dates. On 05/06/2025 at 4:27pm, the Surveyor interviewed the Assistant Director of Nursing (ADON) and the LNHA. The ADON was the acting DON at present. The LNHA affirmed the allegation of misappropriation incident was not reported to the New Jersey Department of Health (NJDOH) by the previous administration. LNHA further stated that the incident was an allegation and the vapes were found afterwards. The ADON stated that according to previous DON the investigation result was not substantiated even the Court dropped it. When asked by Surveyor to provide documentations to support their statement, though the ADON stated in their inquiry with the local town PD that they sent result of investigation to Resident #1, the facility was unable to provide pertinent documentations or video footages. Review of the facility's policy titled, Abuse Prevention Program, revised 01/2025, under their Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation, this includes but not limited to . Under Policy Interpretation and Implementation: .6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirement . NJAC 8:39-9.4(f)

Complaint #: NJ00178065 Based on observation, interview, and review of pertinent facility documentation on 10/24/2024, it was determined that the facility failed to protect the confidentiality of residents' health related information when the facility introduced to the residents the Newave Care, an external medical practice that specializes in preventive care for geriatric patients, which involved data collection and disclosure of residents' PHI (Protected Health Information). This deficient practice was identified in 2 of 4 residents (Resident #7 and Resident #8) and was evidenced by the following: On 10/24/2024, the Surveyor requested a review of the Newave Care program from facility staff. The Newave Care program documents titled, [New Wave]: Working with Your Nursing Home to Provide Extra Care provided by the facility, [New Wave ] is an external medical practice that specializes in preventive care for geriatric patients .At [New Wave ], we leverage advanced technology, including artificial intelligence (AI), machine learning (ML), and data analytics, to deliver the best .These tools allow us to continuously monitor your clinical data, identify patterns, and predict potential health risks . 1. According to Resident #7's Admission Record (AR), Resident #7 was admitted to the facility with the following diagnoses that included but not limited to the following: Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, Diastolic (Congestive) Heart Failure, and Hypertension. According to Resident #7's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated 08/15/2024, revealed Resident #7's Cognitive Skills Patterns showing her/his Brief Interview of Mental Status (BIMS) score of 15 indicating that Resident #7's cognition was intact. On 10/23/2024 at 1:08 p.m. [afternoon], the surveyor interviewed Resident #7 in her/his room. Resident #7 stated the facility had a new care program [New Wave] they were introducing for several weeks already knocking on the door they said it is preventative care, I do not like solicited care, but it seems like there was no warning from the administration [administrator, social worker, unit manager] telling me of [New Wave] group before coming here. They said my doctor approved it as per their list, but it was not my doctor who approved it, it was the DON [Director of Nursing] or administrator who approved it. Somebody went into my records because to be eligible in the [New Wave] program as they said it requires 2 criteria of 2 major diseases. I did not allow it. That's a HIPAA violation. A review of Resident #7's Order Summary Report (OSR) dated Active Orders As Of: 10/24/2024 under Order Summary, showed a phone order entry of Refer to [New Wave] to evaluate and follow patient for the following programs if eligible: CCM, PCM, BHI, RPM, RTM, with Order Status: Active and Order Date of 07/17/2024. The OSR further indicated the order entry was made by the [name of] facility Administrator. 2.According to Resident #8's AR, Resident #8 was admitted to the facility with the following diagnoses that included but not limited to the following: Idiopathic Peripheral Autonomic Neuropathy, Hyperlipidemia, Non-ST Elevation (NSTEMI) Myocardial Infarction, Dementia, and Hypertension. According to Resident #8's MDS dated [DATE], Resident had a BIMS of 15 indicating Resident's cognition was intact. On 10/23/2024 at 12:36 p.m., the surveyor interviewed Resident #8. Resident stated the [New Wave] was persistent. They came to me, and I told them I was not interested, and they said, let us talk to your daughter. They have been calling my daughter and I told them not to call as I was capable of deciding. If they know my daughter's info, they must have known my medical info. A review of Resident #8's OSR dated Active Orders As of: 10/24/2024 under Order Summary, showed a phone order entry of Refer to [New Wave] to evaluate and follow patient for the following programs if eligible: CCM, PCM, BHI, RPM, RTM, with Order Status: Active and Order Date of 07/17/2024. The OSR further indicated the order entry was made by the [name of ] facility Administrator. On 10/23/2024 at 2:57 p.m., the Surveyor interviewed the Social Worker (SW). SW stated she received emails [electronic mail] from the head officer [name] regarding the New Wave program. The SW further stated, I was told they are going to see residents with BIMS of 12 or more. I assume they had PCC [point click care], electronic chart of residents, access from someone before they went to the residents. On 10/23/2024 at 3:19 p.m., the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON). The LNHA affirmed he made the order entry of the New Wave program in the residents' charts. It was referrals only, the residents and the MD [doctors] were educated, all residents are eligible. The facility's corporate has the contract. When asked if they were given access to PCC right away, LNHA stated, Yes, they do. N.J.A.C. 8:39-4.1(a)(18)

Complaint #s: NJ00176773 Based on observation, interview, and review of medical records on 10/23/24, it was determined that the facility failed to ensure Licensed Registered Nurse (LPN) #1 followed: a) a physician order for a mist humidifier (a device that adds moisture to the air by releasing a fine mist or vapor) for a resident (Resident #1), b) acceptable standards of nursing practice when LPN #1 signed and initialed [indicating it was administered] on the above mentioned order in Resident #1's electronic Medication Administration Record (eMAR) while the order was not carried out. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. This deficient practice was observed in 1 of 3 residents reviewed for respiratory orders and was evidenced as follows: On 10/23/24 at 11:27 a.m. [morning], the surveyor observed Resident #1 in her/his room in her/his wheelchair while Certified Nursing Assistant (CNA) #1 was feeding the Resident. The surveyor noted Resident #1's mist humidifier [colored blue] was on top of the TV stand/cabinet. Furthermore, it was observed the mist humidifier was empty, dry, and not plugged in. The surveyor asked CNA #1 where the mist humidifier of Resident #1 and CNA #1 pointed at the device and stated, Nurse takes care of that. On 10/23/24 at 11:52 a.m., the surveyor interviewed and requested LPN #1, while in front of her medication cart, to open Resident #1's eMAR for that day and shift, 10/23/24 7-3 shift [dayshift]. Resident #1's eMAR dated 10/23/24 and 7-3 shift order box for mist humidifier: Turn on Mist Humidifier while resident in the room every shift and fill humidifier with distilled water to appropriate level as indicated on humidifier every shift for Room Humidification, was noted in green color indicating the order was administered. On 10/23/24 at 11:57 a.m., the surveyor in the presence of LPN #1 went to Resident #1's room and asked LPN #1 where Resident #1's mist humidifier. LPN #1 affirmed the Resident's humidifier was not turned on nor was it filled with distilled water to appropriate level as ordered. LPN #1 stated, when surveyor pointed out in the eMAR, the order was in green it indicated the order was done. LPN #1 confirmed she signed the order in eMAR but has not performed the order for Resident #1. According to Resident #1's Admission Record (AR), revealed the Resident was admitted with diagnoses that included but were not limited to Cerebral Palsy, Aphasia, Quadriplegia, Seizures, and Microcephaly. According to Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated 09/26/2024, revealed Resident #1's Cognitive Skills for Daily Decision Making was severely impaired. Furthermore, the Resident's MDS Section GG Functional Abilities and Goals showed Resident #1 was dependent on staff for completion of her/his Activities of Daily Living (ADL). A review of Resident #1's Order Summary Report (OSR) Active Orders as of 10/23/2024, the OSR revealed a physician order of: Turn on Mist Humidifier while resident is in the room every shift and fill humidifier with distilled water to appropriate level indicated on humidifier every shift for Room Humidification with Order and Start Date of 04/25/2022. A review of Resident #1's eMAR dated 10/1/2024 to 10/31/2024 indicated the above-mentioned physician order was signed and initialed by LPN #1 under the column Wed 23 on assigned schedule of Day [dayshift]. NJAC 8:39- 11.2 (b)

Complaint number #169038 Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) timely assess a resident after the resident had an unwitnessed fall on 9/16/23 at 01:20 AM. Subsequently, the resident had increased pain and limited mobility requiring transfer to the emergency roiagnom on [DATE] at 11:54 AM, with a diagnosis of acute fracture of the intertrochanteric portion of the left femur and acute fracture of the left pubic ring; b.) provide adequate pain management; c.) failed to report the injury to the New Jersey Department of Health (NJDOH). This deficient practice was identified for one (1) of five (5) residents (Resident #316) reviewed for accidents and was evidenced by the following: Review of the Admission Record (an admission summary), indicated Resident #316 was admitted to the facility with a diagnosis that included but was not limited to; COVID-19, spinal stenosis, cerebral infarction (stroke), and unsteadiness on feet. Review of the nursing progress note (PN) dated 9/15/23 at 18:40 (6:40 PM), reflected that Resident #316 was admitted to the facility awake, verbally responsive, and denied pain or discomfort. Review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of resident care dated 9/21/23, reflected that Resident #316 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated that the resident was cognitively intact. The MDS also reflected that the resident ambulated once or twice during the assessment reference period and required extensive assistance with activities of daily living. Further review of the MDS reflected that the resident complained of pain frequently and had one fall since admission to the facility. A review of Resident #316's Comprehensive person-centered Care Plan (CP) indicated that the resident was at risk for pain or discomfort associated with the diagnosis of spinal stenosis (the spaces inside the bones of the spine get too small). The interventions included the following: -Administer pain medications (meds) as ordered -Monitor and record pain characteristics every shift and prn (as needed), quality, and severity (0-10 scale). Anatomical location, onset duration, continuous, intermittent, and relieving factors. -Monitor and Report to the nurse resident complaints of pain or request for pain treatments. -Notify the physician if interventions were unsuccessful or if the current complaint is a significant change from the resident's past experience of pain. -Anticipate the resident's need for pain relief and respond immediately. Review of the electronic Medication Administration Record (eMAR) dated 9/15/23, indicated physician ordered pain assessment to be performed every shift, pain scale of 0 indicated no pain, pain scale of 1-3 indicated mild pain, pain scale of 4-6 indicated moderate pain, and pain scale of 7-10 indicated severe pain. Non-pharmacological interventions to be administered prior to prn meds: The following codes were to be documented on the eMAR: 1-repositioning, 2-ice, 3-food, 4-distraction, 5-toileting and 6-relaxation techniques. Review of the Order Summary Report (OSR) showed a physician order (PO) with a start date of 9/16/23, for Physical Therapy (PT) evaluation and treat for 6x/wk (6 times/week) x 12 weeks. Further review of the OSR revealed a PO dated 9/15/23, for Acetaminophen (Tylenol) 325 milligrams (mg) to give two tablets (tabs) [total of 650 mg] to be administered every 6 (six) hours prn for mild pain. The PN dated 9/16/23 at 01:20 AM, indicated that around 12:00 AM, the Registered Nurse (RN) was called to Resident #316's room by the Certified Nursing Assistant (CNA). The resident was observed sitting on the floor next to the bed. The resident stated that they were going to the bathroom, lost their balance, and fell . The PN revealed that the RN conducted a body assessment, and the resident was able to move their upper and lower extremities without difficulty and denied pain. The surveyor reviewed the Incident and Accident investigation (IAI) dated 9/16/23, for an unwitnessed fall. The IAI indicated that the resident was to be monitored for nine shifts post-fall for the decrease in activities of daily living, pain, decrease in range of motion, and any change in the resident's appetite or vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). There was no documented evidence on the report that the PT or occupational therapy (OT) department was notified that the resident had fallen. The PT note dated 9/17/23 at 12:14 PM, reflected that Resident #316 had complaints of pain in their left lower extremity and stated that their lower back hurt with movement of the left lower extremity. There was no documented evidence that the PT notified the nurse that the resident had complaints of pain, nor was there documentation that the PT was aware that the resident had fallen on 9/16/23. The nursing PN dated 9/17/23 at 14:07 (02:07 PM), indicated that the resident told the nurse that they fell on their buttocks the night before and the nurse notified the supervisor. A review of the PN dated 9/18/23 at 14:34 (02:34 PM), indicated that Resident #316 complained of pain on a verbal pain scale level 3 (three) which indicated mild pain. The nurse administered Tylenol 325 mg two tabs (tablets). The PN dated 9/18/23 at 14:53 (02:53 PM), indicated that the resident complained of body pain not relieved by the Tylenol and the chart was to be reviewed by pain management for a pain management plan. There was no documented evidence that the nurse contacted the MD (medical doctor) regarding the residents' complaints of pain that were not relieved by the Tylenol. Furthermore, there was no assessment conducted when the resident began complaining of pain. Review of the Physical Therapy Assistant (PTA) note dated 9/18/23 at 6:26 PM, indicated that the resident's movement was extremely limited by pain in the left groin and the left thigh area. There was no documentation that the PT notified the nurse regarding the resident's complaints of pain, nor was there documentation that the PT was aware that the resident had previously fallen. The surveyor reviewed the Certified Occupational Therapy Assistant (COTA) notes dated 9/19/23 at 12:57 PM, which indicated that Resident #316 reported 7-8 on the pain scale (severe pain). The resident refused to get out of bed or any bed mobility due to pain in the lower back and left lower leg. There was no documented evidence that the COTA notified the nurse that the resident had complaints of severe pain and there was no documentation that the COTA was aware that the resident had fallen on 9/16/23. According to the eMAR, the resident complained of pain on 9/19/23 on the 3-11 PM shift. The nurse documented on the eMAR that the resident complained of pain at a pain scale of 4 (four) indicating moderate pain. The documentation showed that the resident was not provided with non-pharmacological interventions, nor was the resident offered a prn pain med. The eMAR reflected that the resident was not provided with prn Tylenol for mild pain. A review of the PN dated 9/19/23 at 14:56 (02:56 PM), indicated that the resident complained of full body pain that was not relieved by Tylenol and the MD was aware. There were no new PO and there was no documentation that the resident was reassessed for post-fall injury due to increased complaints of pain. The PTA note dated 9/19/23 at 5:56 PM, indicated that the resident continued to loudly express pain with all movements and even with the anticipation of movement. The note indicated that the resident refused to move the left lower extremity due to pain. There was no documented evidence that the PT notified the nurse regarding the residents' complaints, nor was there documentation that the PT was aware that the resident had previously fallen. According to the eMAR dated 9/20/23 on the 3-11 PM shift, the resident had complaints of pain at a pain scale of 6 which indicated moderate pain, and was offered non-pharmacological interventions included repositioning, food, and distraction to help relieve that pain. There was no documented evidence that pain med was provided. The PN dated 9/20/23 at 17:36 (5:36 PM), indicated that the resident had groin pain not relieved by pain management and was ordered stat (immediate) bilateral hip x-rays. A review of the PTA notes dated 9/20/23 at 5:54 PM indicated that Resident #316 continued to report pain in the left lower extremity. The note also revealed that it took 2 (two) staff with maximum assist if the resident allowed them to touch the resident. The note did not contain any information that the PT informed the nurse about the resident's complaints of pain. There was also no documentation that the PT was aware that the resident had previously fallen, and x-rays of the bilateral hips were ordered. The PN dated 9/20/23 at 18:24 (6:24 PM) revealed that the resident was unable to turn on their back due to pain and was not able to have the x-ray completed. The PN indicated that the MD and family were aware. No further MD orders or assessments were documented, and the resident was not provided with any additional prn pain meds when they continued to complain of pain. The PN dated 9/20/23 at 10:56 AM, indicated that the rehabilitation physician (Physiatrist) examined Resident #316 and documented that the resident refused to get out of bed (OOB) or perform any bed mobility due to pain in their lower back and left lower extremity. There was no documentation within the note that indicated that the MD was aware that the resident had fallen on 9/16/23. There was also no documented evidence that the physician was aware that the resident could not have the bilateral hip x-rays performed due to increased complaints of pain not relieved by Tylenol, and Lidocaine patch. There were also no additional pain meds ordered at this time and there were no interventions or treatments ordered for the resident. Review of the eMAR dated 9/21/23, indicated that the Resident complained of pain at a level of 6 which indicated moderate pain on 7am-3pm (day shift), 3pm-11pm (evening shift) and 11 am-7am (night shift). The day shift and evening shift provided non-pharmacological pain interventions however, the night shift did not provide any pain management intervention. At no time, on all shifts, did the resident receive any prn Tylenol. On 9/21/23 at 14:56 (02:56 PM), the nurse documented that the resident had complaints of full body pain not relieved by prn Tylenol. The note also indicated that the MD was aware. There were no new POs obtained for alternate pain management. The PTA note dated 9/21/23 at 4:28 PM, indicated that the resident had complaints of pain in the groin area when the PTA tried to move the left hip. There was no documented evidence that the PTA notified the nurse regarding the residents' complaints of pain. The Physician's PN dated 9/22/2023 at 12:13 PM, indicated that the Nurse Practitioner (NP) examined Resident #316. The NP documented that the resident was lying in bed and had complaints of body pains on and off. There was no documented evidence that the NP was aware that the resident had a fall on 9/16/23, or that the resident did not have bilateral hip x-rays completed due to pain. Review of the eMAR dated 9/25/23, for the Dayshift indicated that Resident #316 had complaints of severe pain at a level 7 and was provided with non-pharmacological interventions such as food, distraction, and relaxation. There was no documented evidence that the MD was notified of the resident's severe pain. Further review of the PN, indicated a late entry note dated 9/25/23 at 13:03 (01:03 PM) from the Social Worker that the MD was in to see the resident that morning that the resident agreed to take the med Tramadol and that the resident did not want to be touched because of pain. The note also indicated that the resident had an active range of motion to the ankle (did not specify which one) but would not move their upper leg. The PTA note dated 9/25/23 at 5:39 PM, indicated that the resident continued to complain of pain in the left groin and the left knee. There was no documented evidence that the PTA notified the nurse regarding the resident's continued complaints of pain. According to the eMAR, the resident had a new PO dated 9/26/23 for Tramadol HCL (hydrochloride) 50 mg one tab once a day for pain. The resident did not receive a PO for the Tramadol HCL (a controlled med that can treat moderate to severe pain) 50 mg, until 10 days after resident fell and seven days after the resident had complained moderate to severe pain. According to the PTA notes dated 9/26/23, 9/27/23, 9/28/23, 9/29/23, and 9/30/23, the resident continued to receive PT despite resident's complaint of pain. A review of the PO dated 9/20/23, revealed an order for bilateral hip x-ray stat (immediately). A review of the radiology report showed that the test for bilateral hips with pelvis two views was done on 9/29/23, and was reported to the facility on [DATE], with the impression of acute femur fracture. Review of the PN dated 9/30/2023 at 11:54 AM, indicated that the resident had an x-ray and the results reflected that the resident had an acute fracture of the intertrochanteric portion of the left femur (bony protrusions on the femur (thighbone)) and acute fracture of the left pubic ring (a ring of bones located at the lower end of the trunk - between the spine and the legs). The MD was notified, and the resident was sent to the hospital emergency room for evaluation. On 7/09/24 at 11:38 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who explained that when a resident complained of pain, the resident's pain level needed to be documented and the pain med was to be administered as ordered by the MD. She stated that the nurse was responsible to document the location of the pain if the resident had pain with range of motion (ROM) and the resident's facial expression. She stated that if the pain was not relieved by the current pain med, the MD should be notified and that something different should be ordered to manage the resident's pain. She stated that if the resident still complained of pain and had limited ROM after getting the pain med changed, the MD and family should be notified, and the resident should be sent out to the hospital for evaluation. On that same date and time, the LPN reviewed Resident #316'2 eMAR and stated that when the resident had complained of pain above the pain scale of mild (1-3) and that the Tylenol was not effective in managing the resident's pain then the MD should have been notified so that they could get the appropriate pain med for moderate pain and severe pain. The LPN reviewed Resident #316's medical record in the presence of the surveyor and stated that if the resident refused to have an x-ray due to pain, the resident should have been sent to the hospital or evaluation. On 7/10/24 at 9:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been employed by the facility since 2020. The DON explained that the pain scale that the facility used was the numerical scale 0 no pain, scale 1-3 mild pain, scale 4-6 moderate pain, scale 7-10 severe pain. The DON stated that if Resident #316's pain was higher than a 3 level per indication of the Tylenol order then the staff should have notified the MD for a possible change in pain med. On that same date and time, the DON reviewed the PN and stated that the staff was monitoring the resident's pain and notified the MD on 9/20/23, 9/21/23, 9/22/23, 9/25/23. She stated that she could not speak as to why a different pain med was ordered or why the resident was not sent to the hospital after the resident refused to have the x-ray due to pain. She then stated that she could not speak to how the MDs conducted their decision-making. At that same time, the DON reviewed the IAI that was conducted after Resident #316 fell on [DATE], and stated that she did include factors that contributed to the resident's fall. The DON stated that she did not complete a summary or conclusion related to the fall and that was something she did not normally do. The DON stated that she did not know that if a fracture sustained during a fall had to be reported to the NJDOH. The DON stated that the facility followed the PO and felt that they followed protocol related to Resident #316 pain. Furthermore, the DON stated that the resident's fall was discussed with the nursing staff at the time of the fall, and then it was discussed with the supervisors on the coming shift. She explained that the Interdisciplinary Team (IDT) team, which consisted of the DON, Administrator, unit managers, assistant DON, Director of Rehabilitation, and Social Worker, meet every day at morning meetings except weekends. She stated that if the resident fell on the weekend, then it was communicated to the DON by the supervisor. She stated that she was not sure why it was not determined earlier that the resident's increase in pain was attributed to the fall that occurred on 9/16/23, and was not sure why the resident pain med was not effective in managing pain or why the resident was not sent to the hospital after refusing to have the x-ray due to pain. On 7/10/24 at 10:05 AM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that she had been employed in the facility for eight years. She stated that the treating PT and PTA that treated Resident #316 from 9/17/23-9/30/23 were no longer employed in the facility. The DOR explained that the PT evaluation was done prior to the fall on 09/16/23, OT evaluation was conducted on 9/16/23, after the resident fell . The DOR reviewed the documentation from both the COTA and PTA and confirmed that the therapist had documented that the resident was complaining of pain. The DOR continued to review the PT and OT notes and confirmed that OT documented that she notified the nursing staff on 9/29/23, regarding the resident complaints of pain and that nursing was going to get an x-ray. The DOR could not find any additional documentation during therapy sessions that the OT or PTA notified the nursing staff that the resident continued to have complaints of pain and was refusing to be touched due to the pain. On that same date and time, the DOR stated that the evaluating and treating therapist did not document that they were aware that the resident had fallen on 9/16/23. The DOR further stated that she could not remember that far back, however if it was not documented that the resident had a fall prior to rehabilitation treatment then she could not speak to why the staff did not document that they were aware of the resident's fall. On 7/10/24 at 10:26 AM, the surveyor interviewed the COTA who confirmed that she documented on 9/23/23 that she provided OT services to Resident #316. The COTA stated that the resident refused to reposition secondary to pain. The COTA stated that she could not remember the resident, but upon reviewing her documentation she should have been more specific in her documentation regarding notification of the CNA and nurse regarding the resident's complaints of pain and refusal of OT services. On 7/10/24 at 10:45 AM, the surveyor interviewed the NP who stated that pain management was usually done by the physiatrist, however if Resident #316 was admitted with the diagnoses of spinal stenosis and chronic lower back pain the use of Tylenol and Lidoderm patches would have been sufficient pain treatment for that type of condition. The NP stated that he could not remember if he was notified that the resident had fallen or that the resident had increased complaints of pain not relieved by the Tylenol or the Lidoderm patches. At that time, the NP reviewed the resident's pain management and stated, It does look bad. If the resident told him he would have ordered additional pain management or x-rays. He stated that he did not remember if the nurses reported to him that the resident refused an x-ray that was ordered and stated that it should have been followed up on. He stated that would have to review his notes and get back to the surveyor. On 7/10/24 at 11:12 AM, the surveyor interviewed the facility's Physiatrist (physician of rehabilitation and pain management) who stated that she could not recall if she was told by therapy or the nursing staff that the resident had fallen on 9/16/23. She stated that if there was no documentation in her notes that she was aware that the resident had fallen, then she probably did not know that the resident had fallen. She stated that the therapist would let her know that a resident had fallen and was having increased pain. The Physiatrist further stated that Probably that the resident had pain from spinal stenosis and left-sided weakness from a stroke. She stated that she did not order any X-rays while the resident was a patient. She stated that she was not in the facility for five days a week, however, when she had come in the 9/25/24, she had ordered the resident Tramadol for pain. She continued to explain that resident care was an interdisciplinary approach and that communication was key to providing care to residents. On 7/15/24 at 11:53 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor notified the facility management of the above findings. On 7/16/24 at 02:11 PM, the survey team met the LNHA, DON, Chief Nursing Officer, Corporate Compliance Officer, and Regional Administrator for an Exit Conference. The facility did not provide any additional information. A review of the facility policy titled, Managing Falls and Fall Risk dated 01/2024, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling. The policy also indicated that the staff and/or physician would document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The facility policy titled, Pain Assessment and Management dated 01/2024, reflected that pain management program is based on a facility-wide commitment to resident comfort. Pain management is a multi-disciplinary care process that include the following: -Assessing the potential for pain. -Effectively recognizing the presence of pain. -Identifying the characteristics of pain. -Addressing the underlying cause of the pain. -Monitoring for effectiveness of interventions. -Modifying approaches as necessary. Identify the causes of pain and review the resident's clinical record to identify conditions or situations that may predispose the resident to pain including Muscular Skeletal conditions: fractures. The policy indicated that the following information was to be reported to the physician or practitioner: significant changes in the level of the resident pain and prolonged unrelieved pain despite care plan interventions. The facility policy titled, Accidents and Incidents-Investigating and Reporting dated 01/2024, indicated that all accidents or incidents involving residents, employees, visitors, vendors etc., occurring on the facilities premises shall be investigated and reported to the Administrator. The policy did not specify a timeframe or documentation on reporting to the Department of Health (DOH). A review of the facility's Policy and Procedure: Physician Responsibilities, Signatures, and Visits with reviewed/revised date of 01/2024, that was provided by the LNHA revealed: I. Responsibilities a. General Responsibilities i. Physicians are responsible for providing comprehensive medical care to residents, including diagnosis, treatment, and ongoing management of chronic and acute conditions. ii. Physicians should ensure continuity of care by coordinating with other healthcare providers and specialists as necessary. iii. Physicians must comply with all relevant federal, state, and local regulations and adhere to the standards set by accrediting bodies. 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.) to maintain proper kitchen sanitation practices in a manner to prevent food borne illness, and b.) discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/08/24 at 9:34 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The juice dispenser machine which was attached to several large juice boxes to be dispensed included: -An Unsweetened black iced tea juice box had a manufacturing label with a Best if Used by date of 5/20/2024. -A Cranberry Juice Fusion juice box had a manufacturing label with a Best if Used by date of 11/28/2023. -A thickened water nectar consistency juice box with a manufacturing label with a Best if Used by date of 4/19/2024. The FSD acknowledged the boxes should have been disposed of and could not explain why they were still in use. The boxes were disposed. 2. Dietary Aide (DA) #1 wearing drop earrings hanging more than an inch from her ear. The surveyor interviewed DA#1 who stated she was not sure of the facility policy regarding earrings worn in the kitchen. The surveyor observed DA #2 wearing medium hoop earrings hanging down from her ears almost one inch. The surveyor interviewed DA#2 who stated she thought the earrings were okay as they were not large hoop earrings. The FSD was asked about earrings observed being worn in the kitchen by DA #1 and DA#2. The FSD stated servsafe guidelines indicated it shouldn't be worn. The FSD did provide further verbal response on the policy for jewelry in the kitchen. The surveyor requested the facility's policy on kitchen staff attire. On 7/09/24 at 10:45 AM, the survey toured the kitchen in the presence of the FSD. The surveyor observed DA#3 who had hair on his chin which was exposed and not covered. The FSD stated DA #3 should have his facial hair covered with a beard restraint (cover) and instructed DA #3 to put on a beard cover. On 7/10/24 at 9:03 AM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the above concerns. There was no additional information provided by the facility. The surveyor reviewed the facility's policy titled, Food/Chemical Storage with a reviewed date of 5/01/24. The policy indicated that all foods should be covered, labeled, and dated and should be consumed within their use by dates. The surveyor reviewed the facility's policy titled Food Preparation and Service with a revised date of July 2024. Under the section Food Service/Distribution indicated Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so hair does not contact food. The policy also indicated .Jewelry shall be worn minimally . NJAC 8:39-17.2(g)

REPEAT DEFICIENCY Based on observation, interview, and review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices during dining observation for one (1) of three (3) dining rooms, and for one (1) of two (2) staff (Housekeeper #1 [HK#1]) and b.) follow transmission-based precautions (TBP) to prevent the potential spread of infection for two (2) of two (2) residents (Residents #41 and #111) and not utilizing personal protective equipment (PPE) for a resident on contact precautions for two (2) of two (2) staff (Attending Physician and HK#2) reviewed for TBP, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient Before and after eating Before performing an aseptic task 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 the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 7/08/24 at 11:34 AM, the surveyor observed HK#1 wearing gloves while cleaning the toilet room of room [ROOM NUMBER]. After cleaning the toilet room, HK#1 went outside the room without removing used gloves and did not perform hand hygiene. HK#1 with used gloves pushed her cleaning cart in the middle of the hallway between rooms [ROOM NUMBERS]. The surveyor then asked HK#1 if that was appropriate for her to have the gloves on while in the hallway. HK#1 immediately removed her used gloves and then pushed her cleaning cart in front of room [ROOM NUMBER]. HK#1 went inside room [ROOM NUMBER]'s toilet room and immediately left the room, donned (applied) a new pair of gloves without performing hand hygiene. There was no resident inside room [ROOM NUMBER]. On 7/08/24 at 11:48 AM, the surveyor notified Registered Nurse #1 (RN#1) of the above concern regarding HK#1. The RN stated that she would notify the Housekeeping Director about it. The RN further stated that HK#1 should have removed gloves and performed hand hygiene prior to leaving the room and not wear gloves in the hallway. A review of the provided Handwashing/Hand Hygiene Policy that was provided by the Licensed Nursing Home Administrator (LNHA) with a reviewed/revised date of 01/2024 showed: Policy Interpretation and Implementation: #7 Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: -before donning gloving gloves; -after contact with objects in the immediate vicinity of the resident; -after removing gloves; #8 Hand hygiene is the final step after removing and disposing of PPE. #9 The use of gloves does not replace hand washing/hand hygiene. 2. On 7/08/24 at 11:40 AM, the surveyor observed a lunch food truck parked in front of the nursing station of the 3 D unit. The Concierge Staff (CS) took the lunch food truck into the dining room wherein there were five residents inside the room. There was a container of hand wipes inside the dining room. The residents were not offered or provided hand hygiene. Certified Nursing Aide #1 (CNA#1) distributed lunch trays to four residents. On 7/10/24 at 8:57 AM, the surveyor interviewed CNA#1 in front of the 3 D nursing station. The surveyor notified the CNA of the above concerns regarding no hand hygiene provided to the residents in the dining area on 7/08/24 during lunch observation. The CNA stated that one of the residents in the dining room on 7/08/24 was assigned to her and she did the hand hygiene of the resident in the morning prior to going to the dining room and not before lunch. CNA#1 acknowledged that she was unsure if hand hygiene was provided to five residents in the dining room on 7/08/24 before and after lunch. On 7/10/24 at 9:06 AM, the surveyor interviewed RN#1. The RN acknowledged that she did not observe that the facility staff during lunch at the dining room provided hand hygiene to the residents prior to lunch. She further stated that she would reinforce it to the staff. On 7/12/24 at 10:27 AM, the survey team met with the LNHA and Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns regarding HK#1 and dining observation. On 7/12/24 at 12:41 PM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN). The surveyor notified the above concerns regarding HK#1 and dining observation. The IP/RN stated that the residents in the dining area should have been offered hand hygiene by staff. She further stated that HK#1 should remove used gloves before exiting the resident's room and staff should not wear PPE including gloves in the hallway for infection control. A review of the facility's Handwashing/Hand Hygiene Policy with a reviewed/revised date of 01/2024 that was provided by the LNHA revealed: Policy Interpretation and Implementation: . #7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . o. before and after eating or handling food; p. before and after assisting a resident with meals . On 7/15/24 at 11:53 AM, the survey team met with LNHA and DON. The LNHA stated that we in-service the staff in the 3 D unit and HK#1 about hand hygiene. 48423 3. During initial tour on 7/08/2024 at 10:10 AM, the surveyor observed an Enhanced Barrier Precaution (EBP; infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) signage above the name plate of Resident #111's room. The surveyor did not observe any additional signage and there was no PPE bin observed at the doorway. On 7/09/2024 at 11:56 AM, the surveyor observed a Contact Precaution (used for patients with infections that can be transmitted by direct or indirect contact) sign above the name plate of Resident #111's room. There was also PPE bin by the door which had blue disposable gowns and face shields. The surveyor observed that the Contact Precaution sign at the door indicated Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Put on gown before room entry. The surveyor reviewed the medical records for Resident #111 which revealed the following: According to the Admission Record (AR; an admission summary), Resident #111 was admitted to the facility with acute kidney failure, unspecified (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), retention (failure to eliminate a substance from the body) of urine, unspecified, and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) without complications. The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 5/16/24, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. A review of Order Summary Report (OSR), included a physician order (PO), dated 7/08/2024 at 15:00 (3:00 PM) which read, Contact Precaution r/t [related to] MRSA [methicillin-resistant staphylococcus aureus, a type of bacteria that is resistant to several antibiotics] in the urine (gown & gloves) every shift for Infection control until 7/14/2024 23:59 (11:59 PM). A review of a nursing progress note (PN) dated 7/07/2024 at 8:51 AM indicated Resident #111 had a positive result for MRSA infection and needed antibiotic treatment. On 7/12/24 at 11:19 AM, the surveyor conducted an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated she would contact the physician and IP/RN immediately once a resident had a new positive result for MRSA. The LPN/UM further stated a resident would be placed on contact precautions. Contact precaution isolation signage and a PPE bin would be placed at the door of the room. The LPN/UM further stated that it was important to place a contact precaution signage to prevent the spread of infection. On 7/15/24 at 11:01 AM, the surveyor conducted an interview with the IP/RN who explained that as soon as nursing staff found out that a resident had an infection, they would notify the IP/RN and if it was an infection that required isolation precautions, it would be implemented by nursing staff. The IP/RN stated that the PO for isolation precautions and a care plan would be entered in the EMR (Electronic Medical Record). A PPE bin and a contact isolation sign would be posted above the name plate at the resident's door. The IP/RN further explained that We do not need PO and nurses can initiate contact isolation. She stated that it was important to place contact precaution signage and PPE bin at the door to prevent the spread of MRSA. On 7/15/24 at 12:00 PM, the survey team met with LNHA and DON. The surveyor notified the facility management of the above findings. On 7/16/24 at 02:11 PM, the survey team met the LNHA, DON, Chief Nursing Officer (CNO), Corporate Compliance Officer (CCO), and Regional Administrator (RA) for an Exit Conference. The facility did not provide any additional information. 4. On 7/09/2024 at 11:56 AM, the surveyor observed a Contact Precaution sign above the name plate of Resident #111 and Resident #91's room. On the sign, there was a small round sticker at the middle-bottom with #1 written in black, which indicated that resident in bed 1 (Resident #111) was on Contact Isolation. The surveyor reviewed the medical records for Resident #91 which revealed the following: The AR documented Resident #91 was admitted to the facility with gout (a painful type of arthritis that usually affects one joint at a time), chronic (continuing for a long time) embolism (is a blockage in one of the arteries of the body due to a blood clot that has broken off from another location in the body) and thrombosis (a blood clot) of other specified veins; and tooth fracture. A comprehensive MDS (CMDS) dated [DATE], reflected a BIMS score of 8 out of 15, which indicated that Resident #91 had moderate cognitive impairment. Further review of the MDS in Section G for functional status, indicated that Resident #91 was independent with toilet hygiene and toilet transfer. Section H for bladder and bowel, indicated that Resident #91 was always continent of bowel and bladder. A review of OSR and nurse progress notes revealed Resident #91 was not on contact precautions. On 7/12/24 at 11:19 AM, the surveyor conducted an interview with the LPN/UM who stated that she would immediately remove a resident out of the room if she found out one (1) of the two (2) residents needed to be placed on contact isolation in the room. The LPN/UM confirmed Resident #111 was on isolation and their roommate, Resident #91 was not on isolation. On 7/15/24 at 10:34 AM, the surveyor conducted an interview with CNA#2 who was assigned to care for Resident #91 and Resident #111. The CNA stated Resident #111 had a foley catheter and she emptied their urine in the bathroom toilet of the resident's room. The CNA stated that Resident #91 was independent with bladder and bowel and was also using the same bathroom in the room. On 7/15/24 at 11:01 AM, the surveyor conducted an interview with the IP/RN who stated that she had discussed with the Infectious Disease (ID) physician regarding Resident #91 who was not on contact precautions and Resident #111 who was on contact precautions for MRSA in the urine being in the same room. The IP/RN continued that the ID physician said it was okay for the residents to share a room as Resident #111 had a urinary catheter, would not be using the bathroom and was being treated with an antibiotic. The IP/RN stated that when the staff dumped the urine in the toilet, if anything splashed, they were to make sure the toilet was wiped off with sani-wipes [a disposable wipe that destroys harmful microorganisms] as standard precautions. On 7/15/24 at 12:00 PM, the survey team met with the LNHA and DON. The surveyor informed the facility management of the above findings. There was no verbal response by the facility at this time. On 7/15/24 at 01:40 PM, the surveyor conducted an interview with CNA#2 who stated that after disposing the urine in the toilet, she flushed the toilet and did not wipe the toilet. The CNA further stated that we don't clean the bathroom. That's not part of our job. On 7/16/24 at 02:11 PM, the survey team met the LNHA, DON, CNO, CCO, and RA for an Exit Conference. The facility did not provide any additional information. 5. On 7/12/24 at 11:13 AM, the surveyor observed the Contact Precaution Signage above the name plate of Resident's room and PPE bin was at the doorway. The surveyor observed a HK#2 wearing gloves and entered Resident #111's room. The housekeeper was observed in the resident's room without wearing a PPE gown, which was indicated on the signage to be worn while inside the room. The surveyor conducted an interview with HK#2 after she exited Resident #111's room. HK#2 stated the Contact Precaution sign above the name plate was an infection sign and that a Gown is not compulsory for housekeeping staff when entering into this room. The surveyor reviewed the medical records for Resident #111 and revealed in the OSR, included a PO, dated 7/08/2024 at 15:00 (3:00 PM) which read, Contact Precaution r/t [related to] MRSA in the urine (gown & gloves) every shift for Infection control until 7/14/2024 23:59 (11:59 PM). On 7/12/24 at 11:19 AM, the surveyor conducted an interview with the LPN/UM who acknowledged that Resident #111 was on contact precautions and staff were required to don (put on) gloves and gown before entering Resident #111's room. On 7/12/24 at 12:42 PM, the surveyor conducted an interview with the IP/RN who stated that any staff entering a contact precaution isolation room was required to don gown and gloves. The IP/RN acknowledged that the HK#2 should have donned a gown and gloves before entering the resident's room. On 7/15/24 at 12:00 PM, the survey team met with LNHA and DON. The surveyor notified the facility management of the above findings. A review of the facility provided Isolation- categories of TBP policy revised on 12/2023 included: Policy Statement 1. Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. TBP shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others. Policy Interpretation and Implementation: 1. TBP will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Contact Precautions 1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. 5. Gown: a.) Wear a disposable gown upon entering the Contact Precautions room or cubicle. 8. Signs- The facility will implement a system to alert staff to the type of precaution resident requires a.) This facility utilizes the following system for identification of Contact Precautions for staff and visitors: _____STOP SIGN-- SEE NURSE BEFORE ENTERING ROOM___. On 7/16/24 at 02:11 PM, the survey team met the LNHA, DON, CNO, CCO, and RA for an Exit Conference. The facility did not provide any additional information. 49078 6. On 7/12/24 at 12:18 PM the surveyor observed the Enteric Contact Isolation (an infection control intervention used to control diseases that can be transmitted through direct or indirect oral contact with infected feces or contaminated articles) signage above the room number name plate outside Resident #41's room and a bin of PPE. The bin contained disposable gowns, disposable gloves, masks, and face shields. The Enteric Contact Isolation signage reflected that prior to entering the room to clean the hands, put on a disposable gown, put on disposable gloves and to clean hands with soap and water on exit. The surveyor also observed at the same time, a male individual with a stethoscope exit Resident #41's room and proceed directly to another resident room. The surveyor asked the Registered Nurse/Unit Manager (RN/UM) who was present in the hallway to identify the individual. The RN/UM stated that he was the Attending Physician (AP) for Resident #41 and Resident #103 which resided in the same room. The surveyor did not observe the AP remove and dispose of any PPE including a gown, gloves, or mask before exiting Resident #41's room and the surveyor did not observe the AP perform any hand hygiene including hand washing prior to exiting the resident's room. The surveyor asked the RN/UM if the AP should follow the procedure for Enteric Contact Isolation. The RN/UM stated yes, he should have. The surveyor observed the RN/UM approach the AP and inform him of the observation and of the Enteric Contact Isolation signage. The surveyor asked the RN/UM the procedure for visitors who would want to enter a room with Enteric Contact Isolation. The RN/UM stated that a visitor would be advised to use PPE and hand hygiene, as well as disposal of PPE in receptacle at the doorway. If the visitor refused, they would be advised of the risks. On 7/12/24 at 12:55 PM, the surveyor interviewed the IP/RN. The surveyor asked what the expectation was for all staff and providers when entering and leaving a room that was identified as Enteric Contact Isolation. The IP/RN stated that the expectation for staff and physicians to use PPE, wear and remove it appropriately and use hand hygiene upon entry and exit for any Isolation room including Enteric Contact Isolation. On 7/15/24 at 10:00 AM, the surveyor interviewed the LNHA. The surveyor asked the LNHA if physicians were expected to follow the same infection control practices and policies as the other staff. The LNHA stated, yes, they should and that they should be educated and informed of those policies and procedures for infection control. The facility provided no further information pertinent to this observation. 7. On 7/12/24 at 12:18 PM the surveyor observed the Enteric Contact Isolation signage posted outside the room for Resident #41 and Resident #103. The surveyor reviewed the medical record for Resident #41 which revealed the following: According to the AR, the resident was admitted to the facility with diagnoses including but not limited to Multiple sclerosis (a disease that affects the central nervous system), paraplegia (a paralysis of the legs and lower body), and anemia (low red blood cell count). The CMDS dated [DATE], reflected a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Section H of the MDS, Bowel and Bladder, reflected that Resident #41 had an indwelling suprapubic catheter (a tube inserted through the abdomen to the bladder to drain urine into an external bag) and was incontinent of bowel. The resident's OSR for other orders indicated a PO dated 7/10/24 with an end date of 7/15/24 for TBP: Enteric Contact Precautions C-DIFF (gown and gloves). The resident's recent laboratory results revealed a positive result for Clostridium Difficile (C-Diff) (an infection of the lower bowel usually resulting in loose stools) dated 6/20/24. The Physician's Progress notes revealed a Physician encounter note dated 7/12/24 by the resident's AP. The note included a diagnosis of C. Difficile colitis. Further review of Resident #41's medical record revealed the isolation policy was in effect for Resident #41 during the treatment of an infection that could be transmitted. The surveyor reviewed the medical record for Resident #41 which revealed the following: A review of Resident #103's Quarterly MDS dated [DATE] revealed that Section H reflects the resident as always continent of bowel. Further review of Resident #103's medical record revealed the resident did not have an infection that required isolation. On 7/15/24 at 10:07 AM, the surveyor interviewed CNA#3 that provides care for both Resident #41 and Resident #103. The CNA stated that Resident #41 requires total care, was incontinent of bowel and has a catheter with a bag that gets emptied regularly. The CNA stated that Resident #103 also has a catheter and bag and was sometimes incontinent of bowel when they can not get to the bathroom in time. The surveyor asked the CNA if Resident #103 uses the toilet located in the room. The CNA responded, yes, sometimes. The surveyor asked the CNA if both catheter bags are emptied in the toilet located in the resident's room. The CNA stated, yes. On 7/15/24 at 10:43 AM, the surveyor interviewed the IP/RN in the presence of the survey team. The IP/RN was asked why a resident who required isolation procedures in the same room as a resident who did not. The IP/RN stated that as of 7/15/24, Resident #41 was considered no longer positive, will be taken off isolation and a terminal clean of the room will be done. Resident #41's roommate, Resident #103 was offered to change to another room but refused, and Resident #103 was informed of the risks of infection. The IP/RN stated she was not aware that Resident #103 used the toilet and that she thought the resident was incontinent of bowel all the time. The IP/RN could not state why a commode was not offered. She further acknowledged that if she knew that Resident #103 uses the toilet, she could have provided an alternative means of use of toilet which was the commode. A review of the facility's Isolation Policy dated 12/2023 that was provided by the LNHA showed the following: Under the section Contact Precautions, Number 2, line b., Diarrhea associated with Clostridium Difficile. Number 3 Resident Placement, a. Place the resident in a private room if possible. b. If a private room is not available, the Infection Preventionist will assess the various risks associated with resident placement options (e.g., cohorting, placing with a low risk roommate). Number 4 Gloves and Handwashing, line a., In addition to wearing gloves as outlined under Standard Precautions, wear gloves .when entering the room. line c., Remove gloves before leaving the room and perform hand hygiene. Number 5 Gown, line a., Wear a disposable gown upon entering a Contact Precautions room or cubicle. NJAC 8:39-19.4(a)(1)(2)(c)(m)(n), 27.1(a)

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a.) license verification was checked for three (3) out of seven (7) licensed staff (Staff #1, #3, and #6) b.) criminal background check done for one (1) out of 10 staff (Staff #10) and c.) obtain current and past-employer reference checks for six (6) out of 10 staff (Staff #1, #3, #7, #8, #9, #10). This deficient practice was evidenced by the following: 1. On 7/17/24 at 9:00 AM, two surveyors reviewed ten randomly selected facility employee files and revealed the following: A review of Staff #1 (S#1), the Certified Nursing Assistant (CNA), hired 02/06/24. S#1 file did not have a New Jersey Division Consumer Affairs (NJDCA) license verification printout or the copy of the license. There was no evidence of reference checks from past employers in the file. Review of S#3, the Licensed Practical Nurse (LPN), hired 02/16/23. There was no evidence of the reference checks from past employers in the file. Review of S#5, the Registered Nurse (RN), hired on 3/12/24. The NJDCA license printout was dated 7/09/24. The verification was completed after the staff member was hired. There was no documented evidence that S#5's license was verified prior to the date of hire (doh). 39885 2. On 7/16/24 at 10:28 AM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Review of S#6, a Licensed Practical Nurse, hired on 12/21/23, had a NJDCA license verification printout (used to verify the status of a license for license verification) dated 12/27/23. The verification was completed after the staff member was hired. There was no documented evidence that S#6's license was verified prior to the doh. The review for reference check for four of the five new employees revealed the following: Review of S#7, a Recreation Aide, hired on 3/06/23, did not have documented evidence in their employee that a reference was obtained. Review of S#8, an Occupational Therapist, hired on 12/04/23, did not have documented evidence in their employee that a reference was obtained. Review of S#9, a Registered Nurse/MDS, hired on 6/28/23, did not have documented evidence in their employee that a reference was obtained. Review of S#10, a Unit Clerk, hired on 01/03/23, did not have documented evidence in their employee that a reference was obtained. The review for criminal background check for one of the five new employees revealed the following: Review of S#10, hired on 01/03/23, had a Background Screening Report (BSR) dated 01/05/23. The BSR was ordered and reported after the date of hire. A review of a Time & Attendance-Employee Punch History form in the file indicated S#10 punched in and out on 01/03/23, 01/04/23 and 01/05/23. On 7/16/24 at 10:53 AM, in the presence of the survey team, the surveyor interviewed the Director of Human Resources ([NAME]) via telephone on speaker regarding the process for new employee hire. The [NAME] stated that upon hire for nursing and rehab the license was run through a website to verify or if the employee provided a current license she would take a copy of the license. The surveyor asked the [NAME] when the license was verified. The [NAME] stated that the doh was when she verified the license. She added that the doh was when the employee was entered into the system and that sometimes the employee did not start work for a week or 2 after that. On that same date and time, the surveyor notified the [NAME] that S#6's license verification was done after the doh. The [NAME] confirmed that the license verification should have been done on 12/21/23 and that she was not the person that did the file. The surveyor also notified the [NAME] that S#1's did not have a license verification. The [NAME] stated that she had done an audit of the files and that there was a copy of S#1's physical license in the file. The surveyor then notified the [NAME] that S#5's license verification was done months after their doh. The [NAME] stated that S#5 was a transfer from the agency and that the agency would verify the license and provide it to the facility. The [NAME] did not have the verification. At that same time, the surveyor asked the [NAME] the process for reference checks. The [NAME] stated that she would get two references and that they would be in the file. She added that in some cases if the employee was fresh out of college, they could only provide one. The surveyor asked the [NAME] the process for criminal background check. The [NAME] stated that it should be done upon hire. The surveyor notified the [NAME] that S#10's BSR was dated 01/05/23, two days after the doh. The [NAME] stated that S#10 started in July. The surveyor then notified the [NAME] that documentation in the file had S#10 punched in on 01/03/23. The [NAME] stated that it should have been done prior to the start date. On 7/16/24 at 11:49 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) the concerns that S#1, S#5 and S#6 did not have a license verification prior to their doh, S#10 did not have a BSR done prior to their doh and that S#1, S#3, S#7, S#8, S#9 and S#10 did not have a reference check. The surveyor requested the facility policy for new hire process. On 7/16/24 at 01:29 PM, in the presence of the survey team, the LNHA stated that the facility did not have a policy for the new hire process. On 7/16/24 at 02:02 PM, in the presence of the survey team and Director of Nursing (DON), the LNHA stated that sometimes the doh was not the date the employee started in the facility. A review of the facility provided policy titled, Abuse Prevention Program with a reviewed/revised date of 02/2024, included the following: 1. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The facility did not provide any additional information. N.J.A.C. 8:39-9.3 (a)4,(b); 43.15(a)

Based on interview and record review it was determined that the facility failed to ensure that a.) the residents' Attending Physician signed and dated monthly physician orders for residents under their care for one (1) of 38 residents (Resident #466) reviewed for physician order and b.) the residents Attending Physician visited and documented monthly visits or alternately visited every other month when the Advanced Practice Nurse visited on the subsequent month for five (5) of 38 residents (Resident #18, #80, #227, #257, and #466), reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 7/09/24 at 12:44 PM, the surveyor reviewed Resident #18's electronic medical record (EMR) which revealed that the resident's Attending Physician (AP) did not document any visit for March, April, May or June 2024. The Advanced Practice Nurse (APN), covering for the AP, documented an April and June 2024 monthly visit. There was not a documented AP visit for Resident #18 for the last four months and there was no visit by the APN or AP for May. 2. On 7/10/24 at 12:08 PM, the surveyor reviewed Resident #80's EMR which revealed that the resident's AP physician did not document any visit for March, April, May or June 2024. The APN, covering for the AP, documented only documented one visit which was dated 3/30/24. There was not a documented AP visit for Resident #80 for the last four months and there was no visit by the APN or AP for March, April or June. 3. On 7/09/24 at 11:03 AM, the surveyor reviewed Resident #227's EMR which revealed that the resident's AP physician did not document any visit for April, May or June 2024. The APN, covering for the AP, documented only one visit which was dated 5/26/24. There was not a documented AP visit for Resident #227 for the last three months and there was no visit by the APN or AP for April or June. 4. On 7/12/24 at 10:42 AM, the surveyor reviewed Resident #257's EMR which revealed that the resident's AP physician did not document any visit for May or June 2024. The APN, covering for the AP, documented the visits for May and June 2024. There was not a documented AP visit for Resident #257 for the last two months. On 7/11/24 at 12:08 PM, the surveyor interviewed the Unit Manager of 1A (UM1A) regarding the AP visits. The UM1A stated that the AP visited the residents once a month and that the APN would come visit if the resident needed something sooner and that the visit was documented in the electronic medical record. On 7/12/24 at 10:32 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concerns that the residents did not have an AP visit and that some months did not have an AP or APN monthly visit. On 7/15/24 at 11:55 AM, in the presence of the survey team and DON, the LNHA stated that the AP provided notes. The surveyor asked the LNHA to confirm what date the AP visited. The LNHA confirmed that the AP visited on 7/14/24. The facility did not provide any additional information. 38327 5. On 7/08/24 at 11:34 AM, the surveyor observed Resident #466 lying on the bed. The surveyor reviewed the EMR of Resident #466 and showed the following: The Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included a displaced fracture (broken) of the base of the neck of the left femur (thigh bone) sequela, end-stage renal (kidney) disease, dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from blood when the kidneys are not able to), and chronic obstructive pulmonary disease unspecified (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/05/24 revealed in Section C Cognitive Patterns a brief interview for mental status (BIMS) score of 13 out of 15 which reflected that the resident was cognitively intact. A review of the monthly PO revealed the AP and the APN had not hand-signed or electronically signed monthly orders for June 2024 and July 2024. Further review of the EMR revealed that the resident's AP did not document any visits in June and July 2024. The AP did not document a History and Physical (H&P) and the succeeding monthly visits for June and July 2024. On 7/10/24 at 11:41 AM, the surveyor interviewed and asked the Registered Nurse (RN) where the AP signed orders and how the nurse knew that the AP signed the orders. The RN stated that she was unsure how the AP signs orders or if the AP signs orders because she gets orders via phone call or enters the order of the AP in the EMR. The RN further stated that it would be the Assistant Director of Nursing (ADON) or the DON who could answer the question on where the AP signs orders. On that same date and time, the surveyor asked the RN where the AP documents the H&P and succeeding progress notes (PN) of the AP. The RN then checked the EMR. The RN acknowledged that she could not find the AP's H&P and PN. The RN stated that she would call the ADON and ask about it. On 7/10/24 at 12:20 PM, the surveyor interviewed the DON. The surveyor notified the DON of the above findings and concerns. The DON checked the resident's EMR and was unable to locate the AP's signed monthly orders, H&P, and PN. At that same time, the surveyor asked the DON what the facility's policy and practices on how many days should the AP and the APN sign the orders and how many days should the physician visit and documents for succeeding PN, the DON stated that she would get back to the surveyor. On 7/12/24 at 10:27 AM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above findings. A review of the facility's Policy and Procedure: Physician Responsibilities, Signatures, and Visits with a reviewed/revised date of 01/2024 that was provided by the LNHA revealed: Purpose: to establish guidelines and standards for the responsibilities of physicians, including their signatures and visits, ensuring the highest quality of care for residents. I. Responsibilities: .iii. physicians must comply with all relevant federal, state, and local regulations and adhere to the standards set by accrediting bodies. II. Documentation and signatures: a. all physician orders, progress notes, and other medical documentation must be dated, timed, and signed by the physician .c. physicians must ensure that all documentation is clear, accurate, and complete, and must be recorded in the resident's medical record in a timely manner. d. physicians must sign all medical orders, progress notes, care plans, and other relevant documentation in a timely manner. IV. Visits: a. Initial visit, an initial visit comprehensive visit must be conducted by a physician within 48 hours of a resident's admission to the nursing home. This visit should include a complete physical examination, a review of medical history, and the development of an initial care plan. b. regular visits, a physician must visit residents regularly to monitor their health status, adjust care plans, and address any new medical issues. at a minimum, physicians should conduct visits every 30 days for the first 90 days after admission and then at least once every 60 days thereafter. On 7/15/24 at 11:53 AM, the survey team met with LNHA and DON. The DON stated that the AP entered a late entry for H&P and PN. The DON further stated that the physician orders were signed after the surveyor's inquiry. NJAC 8.39-23.2(b)(d)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) one (1) of three (3) residents' rooms (Resident #32) and b.) two (2) of two (2) common rooms (toilet and chapel room) This deficient practice was evidenced by the following: 1. On 7/15/24 at 10:09 AM, the surveyor met and interviewed Resident#83. The resident requested the follow-up personal meeting after the resident council meeting with another surveyor on 7/10/24. The resident discussed the 1 A/B public toilet room safety railing was loose which Resident #83 had previously reported to the Housekeeping Director (HD) and the Licensed Nursing Home Administrator (LNHA) via email. The resident further stated that the 1 A/B public toilet room was being used by residents. On that same date and time, the resident also mentioned the chapel where residents gather for religious services had an incident/accident a month ago with one resident (Resident #35) who had a cut on their foot and blood was all over the carpet of the chapel. The resident stated that he/she reported the blood in the carpet to the Maintenance Person (MP) who told the resident that they were not responsible for blood spills. Resident #83 further stated that since then the blood stained the carpet and no one cleaned it. On 7/15/24 at 10:44 AM, the surveyor with the LNHA went to the chapel and observed blood stains, and black stains #1, 2, and 3 on the chapel carpet floor. The surveyor notified the LNHA of the concern of Resident #83 about an incident a month ago regarding the blood stain and the LNHA stated that he would get back to the surveyor. The LNHA further stated that it should have been cleaned. On 7/15/24 at 10:55 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN). The IP/RN stated that when there was a blood spill on the floor, the facility uses the blood spill kit by nursing and then housekeeping will clean afterward. At that time, the surveyor with the IP/RN went inside the chapel and showed the blood stain on the carpet. Both the surveyor and the IP/RN observed the two housekeeping personnel cleaning the area where there was a blood stain. Both the housekeeping personnel informed the surveyor and the IP/RN that they did not know that there was a stain on the carpet because no one told them about it and now it was hard to remove. Furthermore, the surveyor and the IP/RN also observed the six ceiling tiles with brownish discoloration which the IP/RN claimed was probably due to condensation. On 7/15/24 at 11:53 AM, the survey team met with LNHA and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns. On that same date and time, the LNHA provided a piece of paper with Resident #35's name on it and the date of the left foot incident that happened on 6/16/24 at the chapel. On 7/16/24 at 10:23 AM, the surveyor and the LNHA both went to the 1 A/B public toilet room and both observed the safety railings were loose when the LNHA attempted to shake it. The LNHA stated that he would call Maintenance immediately to fix it. On 7/16/24 at 12:32 PM, the survey team met with the LNHA, DON, and Chief Nursing Officer (CNO). The LNHA stated that the facility ordered new ceiling tiles for the chapel. 48423 2. On 7/10/24 at 11:33 AM, the unsampled Resident #32 was seen in their room at their request. The resident was sitting in their wheelchair and pointed towards their room floor and walls to show the chipped and faded paint with black colored streaks on the left wall (Bathroom back wall) and back wall left of the headboard. The surveyor observed the floor tiles with brown and black scattered discoloration large markings. The surveyor observed few patches where the paint had come off from the front wall next to the television (TV). The surveyor reviewed the medical records for Resident #32 which revealed the following: According to the Admission Record (an admission summary), Resident #32 was admitted to the facility with obesity, unspecified, osteoarthritis (a common joint condition where the cartilage, which cushions the ends of your bones, wears down over time) of knee, unspecified, osteoarthritis of hip, unspecified and dependence on wheelchair. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/16/24, Section C Cognitive Patterns revealed that Resident #32 had modified independence with decision making regarding tasks of daily life. At 11:50 AM, the surveyor conducted an interview with House Keeping staff (HKS), who looked at the floor and identified that it's (the floor) got to be clean. HKS further stated if the floor needs to be stripped, they contact the HD. HKS acknowledged that It's (the floor) got to be stripped and waxed. The HKS further stated that Maintenance does the painting, repairs, plumbing, fix TV and sinks. At 12:11 PM, the surveyor conducted an interview with Director of Maintenance (DoM) in unsampled Resident #32's room and DoM acknowledged that it was not acceptable the way the room paint looked in that room. The surveyor observed two ceiling tiles with brownish-dried discoloration marks close to the window. DoM identified there was a leak more than a year ago. DoM stated, he fixes worse things first. At that same time, the surveyor and DoM toured the resident's bathroom. DoM was able to lift up the right front leg of the toilet railing. DoM stated, we don't secure it because the toilet is fixed to the wall and incase if the toilet needs to be replaced. On 7/12/24 at 11:01 AM, the surveyor observed the unsampled Resident #32's toilet railing and it was loose. On 7/15/24 at 10:25 AM, two surveyors visited the unsampled Resident #32's toilet railing and it was loose. On 7/15/24 at 12:00 PM, the survey team met with LNHA and DON. The surveyor notified the facility management of the above findings. A review of the facility's undated Safe and Homelike Environment Policy provided by the LNHA revealed: . In accordance with resident's rights, the facility will provide a safe, clean comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Policy Explanation: . #3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment #9. General Considerations: . c. Report any furniture in disrepair to Maintenance promptly. d. Report any unresolved environmental concerns to the Administrator . On 7/16/24 at 02:11 PM, the survey team met for an Exit conference with LNHA, DON, CNO, Corporate Compliance Officer, and the Regional Administrator. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-31.4 (a)(b)(f)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents were served their meals in a dignified manner during meal service. This deficient practice was observed for one (1) of five (5) residents (Resident #105), in one (1) of three (3) dining rooms. The deficient practice was evidenced by the following: On 7/08/24 at 11:40 AM, the surveyor observed the lunch food truck parked in front of the nursing station of 3D unit. The Concierge staff took the lunch truck into the Dining room wherein there were five residents inside the room. At that time, the surveyor observed the Certified Nursing Aide (CNA) enter the 3D dining room and five residents were served lunch trays except for Resident #105. Resident #105 was seated at one table where there were two other residents. On 7/08/24 at 11:45 AM, the surveyor observed in the 3D unit dining area during mealtime the Registered Nurse (RN) came to the dining room. The surveyor asked the RN why Resident #105 had no lunch tray and was not being served at the same time as the other two residents on the same table. The RN stated that the CNA had requested the tray already and was aware that there was no tray in the lunch food truck that was delivered earlier for Resident #105. The RN further stated that she did not know why there was no tray for Resident #105 when the food truck was delivered. On 7/08/24 at 11:54 AM, the surveyor observed the CNA received and set up the lunch tray of Resident #105 in the 3D dining room. On 7/12/24 at 10:27 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The surveyor notified the facility management of the above concerns. On 7/12/24 at 12:41 PM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN). The surveyor notified the IP/RN of the above concerns. The IP/RN stated that the resident at the same table should have served at the same time. A review of the facility's Dining Environment Policy with a reviewed/revised date of February 2024 that was provided by the LNHA, revealed in the Policy Interpretation and Implementation: #6. All residents seated at a table will be served together, when feasible . On 7/16/24 at 02:11 PM, the survey team met the LNHA, DON, Chief Nursing Officer, Corporate Compliance Officer, and Regional Administrator for an Exit Conference. The facility did not provide additional information and did not refute the findings. N.J.A.C. 8:39-4.1(a)12

Complaint# NJ00174351 Based on interview and record review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify and notify the facility of a medication irregularity for a resident. On 1/11/2024, a nurse documented a Physician order in the medical record for Resident #2 for Warfarin Sodium,( Coumadin) a blood thinner. This medication order was for another resident. Resident #2, was already on a Xarelto, a blood thinner. Resident #2 was administered the Coumadin for eighteen (18) doses from 1/12/2024 to 1/29/2024. On 1/15/2024, the CP conducted an on-site visit and had reviewed Resident #2 chart, however, there was no documented evidence for the recommendations for Coumadin and Xarelto in the report. The administration of both blood thinners caused Resident #2 to become symptomatic and decline in health. The resident eventually needed to be admitted to a acute care hospital. This deficient practice was identified in one (1) of four (4) residents reviewed for medication regimen review and was evidenced by the following: On 6/6/2024, the surveyor reviewed the hybrid medical record (paper and electronic) for Resident #2. According to the ADMISSION RECORD (AR), Resident #2 was admitted with diagnoses including but not limited to Chronic Kidney Disease, Paroxysmal Atrial Fibrillation, Neuromuscular dysfunction of Bladder, Hypertension, Congestive Heart Failure, and Atherosclerotic Heart Disease. A review of the Minimum Data Set (MDS), an assessment tool dated 03/28/24, showed that Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident had intact cognition. Resident #2's MDS further revealed he/she required assistance in Activities of Daily Living (ADL). A review of Resident #2 electronic Medication Administration Record (eMAR) from 1/1/2024 - 1/31/2024 reflected Xarelto Tablet 15MG (Rivaroxaban) Give 1 tablet by mouth one time a day for A Fib [atrial fibrillation] - Start Date- 12/29/2023 1700 -Hold Date from 01/30/2024 1008 to 02/01/2024 0000. The eMAR further showed that the above-mentioned medication was checked, initialed, and administered from 01/01/24 to 01/29/24 to Resident #2. Further review of Resident #2's [DATE] eMAR revealed Warfarin Sodium Tablet Give 7 milligram by mouth at bedtime for treating/preventing blood clots - Start Date -01/12/2024 2100 and was-D/C [discontinued] Date- 01/30/2024 1024. The eMAR indicated Warfarin Sodium was checked, initialed, and administered at 2100 on the following dates: 01/12/2024; 01/13/2024; 01/14/2024; 01/15/2024; 01/16/2024; 01/17/2024; 01/18/2024; 01/19/2024; 01/20/2024; 01/21/2024; 01/22/2024; 01/23/2024; 01/24/2024; 01/25/2024; 01/26/2024; 01/27/2024; 01/28/2024, and 01/29/2024. A review of the report submitted by the CP to the facility between 1/1/2024 and 1/31/2024 revealed a Recommendation to Nursing Services - [DATE] under [Resident #2] name and as follows: clarify Mg [magnesium] order is it only on Tues, Thurs, Sat and Sunday. No parameters on [Carvedilol] no need to do BP/P [blood pressure/ pulse] prior to administration. The above report was a response dated 1/17/24 and signed by [Nurse]. A review of the Progress Notes (PN) dated 02/5/2024 14:53 documented by Licensed Practical Nurse (LPN) #1, that at 11:15am [morning] Called into resident room upon rounds .stating he [Resident #2] feels too weak to go back to bed .Staff unable to transfer safely back to bed, slowly the resident [Resident #2] started to become more lethargic, unit manager is present with other staff members .MD [physician] notified and orders to send to [hospital] for eval [evaluation] and treat [treatment]. 911 called. 12pm [afternoon] Taken to [hospital] via stretcher . A further review of the PN dated 02/05/2024 16:54 documented by Nurse Unit Manager (NUM) revealed .resident has been admitted to [hospital]. Dx [diagnosis] Upper GI [gastrointestinal] bleed, Diarrhea. During the surveyor's interview with the CP via phone on 06/06/24 at 4:11 pm [afternoon], the CP stated she did drug regimen review once a month in the facility, kept a copy, and emailed it to the DON, Administrator, Assistant Director of Nursing (ADON), Nursing Supervisors (NS), and the Unit Managers (UM)s, on the day I did it and before I left the facility. CP further stated she would do the monthly review of residents' medications around the 15th until the 25th of the month. CP confirmed that she did Resident #2's January monthly drug review. The surveyor asked the CP if she saw the new medication order of Warfarin (Coumadin) for Resident #2. CP stated that she did see the new medication order. The CP stated I thought it was a short period of time; I did not ask nurses or confirm with the DON. When the facility notified me on 1/30/24 of what happened to Resident #2, I looked back on my notes, and I did not write any notes. I normally would order to stop it, but I did not. During the surveyor's exit conference with the DON and Administrator on 6/6/24 at 5:18 pm, DON and Administrator were made aware of CP statements about Resident #2 review of medications during visit at the facility. A review of the facility's policy titled, ADVERSE CONSEQUENCES AND MEDICATION ERRORS, under Policy Interpretation and Implementation 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as .or decline in an individual's mental or physical condition or functional or psychosocial status. 4. The staff and practitioner shall strive to minimize adverse consequences by: .c. Determining that the resident: . (2) Is not taking other medications .that would be incompatible with the prescribed medication. 7. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. 8. When a resident receives a new medication, the medication order is evaluated for the following: .e. The resident is not taking other medications . that would be incompatible with the prescribed medication. NJAC 8:39-29.3 (a)1

Complaint# NJ00174351 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident (Resident #2) who was currently being administered daily Xarelto, a blood thinner, was incorrectly transcribed a new medication Coumadin (Warfarin Sodium), another blood thinner by Registered Nurse #1 (RN). The Coumadin medication was prescribed by a Physician for another resident (Resident #1). Resident #2 remained on prescribed daily dose of Xarelto and also received daily doses of the Coumadin from 1/12/2024 to 1/29/2024 for 18 days for a total of eighteen (18) doses . This resulted in Resident #2 to become symptomatic and decline in health. The resident eventually needed acute inpatient hospitalization . This deficient practice was identified in one (1) Resident #2 of four (4) residents reviewed for medication order transcription and administration, and was evidenced by the following: According to the ADMISSION RECORD (AR), Resident #2 was admitted with diagnoses including but not limited to Chronic Kidney Disease, Paroxysmal Atrial Fibrillation, Neuromuscular dysfunction of Bladder, Hypertension, Congestive Heart Failure, and Atherosclerotic Heart Disease. A review of the Minimum Data Set (MDS), an assessment tool dated 03/28/24, showed that Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident had intact cognition. Resident #2's MDS further revealed he/she required assistance in Activities of Daily Living (ADL). A review of the Progress Notes (PN) dated 02/5/2024 14:53 documented by Licensed Practical Nurse (LPN) #1, that at 11:15am [morning] Called into resident room upon rounds .stating he [Resident #2] feels too weak to go back to bed .Staff unable to transfer safely back to bed, slowly the resident [Resident #2] started to become more lethargic, unit manager is present with other staff members .MD [physician] notified and orders to send to [hospital] for eval [evaluation] and treat [treatment]. 911 called. 12pm [afternoon] Taken to [hospital] via stretcher . A further review of the PN dated 02/05/2024 16:54 documented by Nurse Unit Manager (NUM) revealed .resident has been admitted to [hospital]. Dx [diagnosis] Upper GI [gastrointestinal] bleed, Diarrhea. The resident was discharged from the hospital and back to the facility on [DATE]. A review of Resident #2 electronic Medication Administration Record (eMAR) from 1/1/2024 - 1/31/2024 reflected Xarelto Tablet 15MG (Rivaroxaban) Give 1 tablet by mouth one time a day for A Fib [atrial fibrillation] - Start Date- 12/29/2023 1700 [5 pm] -Hold Date from 01/30/2024 1008 to 02/01/2024 0000 and Warfarin Sodium Tablet Give 7 milligram by mouth at bedtime for treating/preventing blood clots - Start Date -01/12/2024 2100 [9 pm] and was-D/C [discontinued] Date- 01/30/2024 1024. The eMAR further indicated the abovementioned medications were checked, initialed, and administered at the following administration times and dates: 01/12/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7mg at 9 pm - checked, initialed, and administered by LPN #2 01/13/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #3 01/14/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #4 01/15/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #4 01/16/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #4 01/17/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/18/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/19/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #5 01/20/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #6 01/21/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/22/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #7 01/23/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/24/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/25/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/26/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by RN #1 01/27/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #3 01/28/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #6, and 01/29/2024 Xarelto 15 mg at 5 pm and Warfarin Sodium 7 mg at 9 pm - checked, initialed, and administered by LPN #4 A review of Resident #1's [DATE] eMAR revealed Warfarin Sodium Tablet Give 7 milligram by mouth at bedtime for treating/preventing blood clots -Start Date- 01/11/2024 2100 -D/C Date- 01/17/2024 1647. The eMAR indicated Warfarin Sodium was checked, initialed, and administered at 2100 [9 pm] as ordered on 01/11/2024. During the surveyor's interview with Resident #2 at 10:37 am (morning) on 06/06/24, Resident stated I went to hospital on February 5, 2024, ER emergency it was 911; what they discovered while I was waiting for the ambulance before sending me out, I was on Xarelto and on January 12 a doctor called in a prescription for Coumadin for another resident and a nurse put it in my record. My blood pressure was low, and I was bleeding all over. During the surveyor's interview with the DON and facility's Administrator at 1:49 pm on 06/06/24, the DON stated she did an investigation on the incident. DON affirmed that a medication transcription error with the medication Coumadin (Warfarin Sodium) occurred and was transcribed by Registered Nurse (RN) #1 on 01/11/24 in Resident #2 chart in error. DON stated Resident #2 was on Xarelto and that the transcription error was found out on 01/30/24. DON further stated upon investigation she asked RN #1 regarding the Warfarin Sodium transcription error and DON stated RN #1 was not able to recall the specific incident and was not able to provide an explanation about the medication error. A review of the Investigation Summary (IS) provided by the facility on 06/06/24, completed and signed by the Director of Nursing (DON) and the Administrator on 1/30/24, under Description of event: On Tuesday, January 30th, 2024 at approximately 8:25 am [morning], [Resident #2] was observed with bleeding from suprapubic catheter site and dark liquid stools [feces] .He [Resident #2] complained of feeling lightheaded; under Involved resident's pertinent medical data: Medications include [but not limited to]: .Xarelto, Morphine Sulfate, Detrol .; under Investigation/chart review: >1/11/24: New order- Coumadin [warfarin sodium] 7 mg [milligram] po [by mouth] at bedtime to start 1/12/24. (Received a total of 18 doses - 1/12 to 1/29); >1/15/24 pharmacist note: see nursing report. Report recommendations: consider gdr [kidney filtration rate] [medication], reeval [reevaluation] need both [Detrol/Mybetriq- bladder medications] duplicate tx [treatment], .clarify Mg[magnesium] order is it only on Tue, Thur, Sat, and Sun and no parameters on Coreg [heart medication]- no need to do bp [blood pressure] prior to administration; >1/30/24 Nurses note: At 8:25 AM [morning], resident was noted to have large amount of [NAME] [fresh] bleeding from his SP [suprapubic] tube site .Call placed to Optum NP [nurse practitioner] who came in to see resident. Orders received .; >1/30/24 Optum note: Pt [Resident #2] seen in AM [morning] after nurse called to report he [Resident#2] had a large amount of bleeding from his SPC [suprapubic catheter] as well as hypotension [low blood pressure] and dark liquid stool .Upon chart review, it was found that an order for warfarin 7 mg was entered on 1/12/24 in error and he [Resident #2] is also on Xarelto 15 mg daily . Conclusion: On January 11th, 2024, [RN#1] ordered Coumadin 7 mg po at bedtime to start on 1/12/24 for [Resident #2]. Order was intended for another resident on the unit. [Resident #2] had a current order for Xarelto (a blood thinner) .Further assessment indicated hypotension and c/o [complaint of] feeling lightheaded .He [Resident #2] refused to be transferred to [hospital] ER [emergency room ] for evaluation but agreed to some in house treatments such as labs and medications. During the survey on 06/06/2024 at 5:11 pm, the surveyor placed a phone call to RN #1 who transcribed the medication in error into Resident #2's medical record. RN #1 did not answer nor return surveyor's phone call. The other nurses who signed off on the medication error for Resident #2 LPNs #2, #4, #5, #6, and #7 no longer work in the facility. A review of the facility's policy titled, ADVERSE CONSEQUENCES AND MEDICATION ERRORS, under Policy Interpretation and Implementation 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as .or decline in an individual's mental or physical condition or functional or psychosocial status. 4. The staff and practitioner shall strive to minimize adverse consequences by: .c. Determining that the resident: . (2) Is not taking other medications .that would be incompatible with the prescribed medication. 5. A medication error is defined as thee preparation or administration of drugs .which is not in accordance with physician's orders . or accepted professional standards and principles of the professional (s) providing services. 8. When a resident receives a new medication, the medication order is evaluated for the following: .e. The resident is not taking other medications . that would be incompatible with the prescribed medication. NJAC 8:39-29.2(d)

Complaint, #NJ 1, #NJ 3, #NJ 1 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that on [DATE], the facility failed to ensure: a.) a resident with moderate cognitive impairment, who was at risk for elopement, and had a known history of wandering and exit seeking behavior was appropriately supervised and monitored to ensure safety, prevent elopement, or exiting of the building, and staff failed to follow their facility's policy and procedure on Wandering/Elopement. This deficient practice was identified for one of five residents, (Resident #206) reviewed, who had moderate cognitive impairment, and were at risk for elopement. This placed Resident #206 as well as all other residents with moderate cognitive impairment, who were at risk for or had a known history of wandering and/or elopement in Immediate Jeopardy (IJ). On [DATE], Resident #206 was able to exit the building unsupervised through an unlocked door at 10:12 AM, was found by the police, and subsequently expired on [DATE] at 4:19 PM. The IJ for Resident #206, occurred on [DATE], and was identified on [DATE] at 4:20 PM, when the Facility's Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation. The survey team provided the facility with an IJ template on [DATE]. The facility provided an acceptable Removal Plan (RP), on [DATE] at 10:16 AM to remove the immediacy. The facility further failed to ensure: b.) staff provided a resident who was at risk for aspiration (when food, drink, or a foreign object is breathed into the lungs) with the correct liquid consistency to prevent aspiration pneumonia (an infection caused by a foreign substance entering the lungs), and staff failed to follow the facility's policy and procedure for the administration of thickened liquids. This deficient practice was identified for one of three residents, (Resident #191) reviewed for accidents related to mechanically altered diets. On [DATE], Resident #191 was provided with thin liquids when the resident had a physician's order for thickened liquids. This placed Resident #191 as well as all other residents who received a mechanically altered diet at risk for Immediate Jeopardy (IJ). The IJ for Resident #191 started on [DATE], and was identified by the survey team on [DATE]. The survey team provided the facility with an IJ template on [DATE]. The IJ was identified as past non-compliance from [DATE] through [DATE] when the facility provided the survey team with an acceptable Plan of Correction. This deficient practice was further evidenced by the following: Part A The surveyor reviewed the medical record for Resident #206. The surveyor reviewed the Admission Record (AR), Resident #206 was admitted to the Facility with diagnoses which included but were not limited to: [CONDITION(S)], dementia, [CONDITION(S)], [CONDITION(S)], protein-calorie malnutrition, [CONDITION(S)], injury of the head, anxiety disorder, mood disorder, [CONDITION(S)], depression, dysphasia, rhabdomyolysis, [CONDITION(S)], and essential hypertension. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #206 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that Resident #206 had moderate cognitive impairment. Further review of the MDS in Section G for functional status, indicated that Resident #206 was independent with transfers, locomotion on the unit, and ambulation. Review of the Care Plan (CP), with a documented resolved date of [DATE], revealed a focus area that Resident #206 was at risk for elopement due to wandering related to cognitive impairment, confusion, and dementia. The goal was that Resident #206 would not leave the facility unsupervised. The interventions included: to assess for change in behavior, to observe for unsafe behaviors, to provide with a program of activities that minimize the potential for wandering, wander guard in place left ankle, observe for placement, and proper functioning each shift. This CP was resolved and discontinued with the date of [DATE], which indicated that Resident #206 was no longer at risk for elopement. Review of the Physician's Progress Note (PN) dated [DATE] at 03:48 PM, revealed the resident was on the [CONDITION(S)] medication, [MEDICATION(S)] 125 milligrams two times daily and had dementia with behavioral issues/wandering behavior with gait instability. Review of the Medication Administration Record (MAR) dated ,d+[DATE], revealed the nurses were monitoring Resident #206's behaviors to include; itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], aggression, and refusing care. During a review of a Facility Reportable Event (FRE) form dated [DATE] at 09:13 AM, sent into NJ Department of Health (DOH) from the DON. On [DATE], the Certified Nursing Assistant (CNA #1) assigned to Resident #206 left unit 1A where he/she resided and went on break without giving report or asking someone to monitor their residents. During the break, Resident #206 was able to independently exit the facility unattended, without the staff's knowledge, through an unlocked door in unit 1D, and wandered off the facility grounds onto the main road. Resident #206 made it across the main road and was later found by police at 3:52 PM, laying on the ground at the ,d+[DATE] Memorial. The policeman immediately performed Cardiac Pulmonary Resuscitation (CPR) and Resident #206 was later reported to have expired at 4:16 PM. The last time Resident #206 was observed within the facility was at 10:12 AM on video surveillance walking the hallway and exited through an unlocked door on unit 1D. The Licensed Practical Nurse/Unit Manager (LPN/UM #1) observed an empty wheelchair in the hallway of 1D which had a tag with Resident #206's name on it. This initiated a CODE GREY and all staff started a search of the interior of the facility then moved to the exterior of the facility. When Resident #206 was not found within the facility's grounds, the LPN/UM #2 initiated a call to the police at 12:14 PM on [DATE], to report Resident #206 missing. The facility searched for Resident #206, but was unaware of the whereabouts of Resident #206 until he/she was found by police on [DATE] at 03:52 PM. On [DATE] at 11:53 AM, the surveyors observed Stairwell #4 on the 1st floor in the presence of the facility's Admin, Assistant Admin, and Maintenance Director (MD). The Admin stated this was the door that Resident #206 exited the facility from at approximately 10:10 AM on [DATE], and Resident #206 was not wearing a wander guard. The surveyors observed a horizontal metal bar on the top of the door and a keypad next to the door. The door was observed to be locked. The MD waved a tool by the keypad and an alarm sounded which indicated that the wander guard keypad system was functioning. The Admin stated the door was a delayed egress maglock and either the maglock system malfunctioned or the keypad itself malfunctioned when Resident #206 exited the building. The Admin told the surveyors that since Resident #206 exited the facility, the keypad, and the maglock were both replaced and were now, new. The surveyors exited the door that Resident #206 exited from and observed a parking lot with woods surrounding. The Admin told the surveyors that the office next to the door Resident #206 exited from was closed because it was a Saturday, and no cars were in the parking lot because no one was in the area that day. The Admin further stated that a Dietary Aide (DA) observed Resident #206 trying to open the patio door. Resident #206 had asked the DA to open the door and the DA stated that he/she could not open the door. On [DATE] at 12:53 PM, the surveyors interviewed the DA, who stated that he/she worked at the facility since [DATE], and worked in the kitchen, the day Resident #206 left the facility. The DA stated that when he/she left the kitchen, it was to drop off and pick up meal trays. The DA stated that he/she had observed Resident #206 by the patio trying to open the door. Resident #206 asked the DA to open the door. The DA told Resident #206 that he/she could not, so the resident continued walking toward the unit. The DA told the surveyors that it was not the first time that DA had seen Resident #206 and had observed the resident on 1A when he/she dropped off the meal trays. The DA stated that he/she did not think it was an odd behavior for Resident #206 to ask the DA to open the door because he/she figured Resident #206 wanted to sit outside. The surveyors asked the DA approxiamtely what time he/she saw Resident #206 trying to exit onto the patio. The DA stated that it had to be before 12:00 PM because that was when he/she left the facility for the day. The DA stated that a nurse asked when he/she last saw Resident #206, so the DA provided the nurse with their observation and a statement. The surveyors asked when the DA was last educated on elopement and the DA said they learned about elopement in orientation, but was unable to speak to specifics, and stated that it was common sense to go look for the person, if they went missing. On [DATE] at 1:22 PM, the surveyors reviewed the video surveillance from [DATE] from 10:07 AM to 10:10 AM. There were two cameras which provided the video surveillance. Both cameras were located on the first floor. One of the cameras was in hallway 1D with views of the hallway and patio entrance. The second camera faced the adjoining hallway between the facility and another outside organization. The Admin stated that there were no cameras outside of the facility. On [DATE] at 10:07 AM, the video showed the DA walked to 1D unit. At 10:08 AM, the surveyors observed Resident #206 self-ambulate from 1D unit, pointed at the patio area, observed the DA walk past Resident #206, and then observed Resident #206 ambulate toward the adjoining hallway. At 10:08, the surveyors observed the DA walk towards the kitchen and returned food trays to the kitchen. At 10:09 AM, the surveyors observed the DA leave the dietary area. At 10:10 AM, the surveyors observed Resident #206 walk down the adjoining hallway when the DA was no longer in view of the camera. Resident #206 was observed in the video surveillance, walking toward the double doors that entered the adjoining area. The video ended when Resident #206 exited the door, and was no longer visible on the surveillance video. On [DATE] at 1:55 PM, the survey team interviewed the Admin in the presence of the DON and asked, What should be done if the resident has wandering behavior and was confused? The Admin stated that residents had wandering behaviors, but it did not indicate that the resident was exit seeking. On [DATE] at 1:56 PM, the survey team interviewed the DON in the presence of the Admin and asked, What does it mean when a resident wanders? The DON stated that a definition of wandering meant that a resident did not always remain in one space. The DON further stated that interventions to decrease wandering behavior included; to re-direct the resident, provide diversional activities, provide time in day room, provide the resident with verbal cues as to where they are. The DON told the survey team that if the resident had a history of wandering and displayed that behavior, it should be included in the resident's CP. The DON further stated that a wander guard assessment should be completed for a resident upon admission, quarterly, and annually. On [DATE] at 3:52 PM, the surveyors interviewed the Admin who stated that the cameras were accurately time stamped, could not be edited, and the cameras captured live time. On [DATE] at 3:56 PM, the survey team interviewed Resident #206 's Primary Care Physician (PCP), who stated that they had taken care of Resident #206 while he/she resided at the facility. The PCP did not take care of Resident #206 when he/she lived at home. The survey team asked the PCP to describe Resident #206. The PCP stated Resident #206 had a fair amount of confusion with day-to-day tasks, but was easily re-directed when Resident #206 was confused. The PCP stated that they never knew Resident #206 to have exit seeking behaviors at the facility, however, during the COVID-19 Pandemic there were a lot of room changes and Resident #206 would get confused and needed to be re-directed back to the location of their room, so staff placed a wander guard on Resident #206. The surveyors asked if the PCP knew when the wander guard was discontinued and the PCP could not recall specific dates, however, stated when PO's were discontinued, the nurse performed an assessment and PCP based the determination of discontinuing orders, off the nurse's assessment. The PCP stated that Resident #206 never expressed that he/she wanted to leave the facility. The PCP knew Resident #206's history prior to admission to the nursing facility. The PCP told the surveyors that Resident #206 was the primary caretaker of his/her spouse, the spouse became ill, and went to the hospital, and when the spouse was in the hospital, Resident #206 stayed at home and wandered around their home. The PCP stated that they never observed Resident #206 wandering and did not hear from staff that Resident #206 wandered and would assume that was why the wander guard was discontinued, because for the most part Resident #206 stayed in their room. The PCP stated that Resident #206's behavior of wandering was not exactly a chronic issue, it was an issue Resident #206 had in the past. The PCP gave the example of high blood pressure and stated that if wandering was in a resident's history, just like high blood pressure, that would always be something that should be monitored. The PCP further stated that they thought Resident #206's wandering should have been included in their plan of care because it would make Resident #206 challenging to go home without ,d+[DATE] supervision. On [DATE] at 11:07 AM, LPN/UM #2 unit 1A stated that he/she was working on Saturday when Resident #206 eloped. LPN/UM #2 stated that Resident #206 did not have behaviors. Resident #206 would come out of the room and sit in the doorway and sometimes Resident #206 liked to sit in atrium. The atrium was closed a few weeks ago because it was under construction. Resident #206 would go to the atrium because he/she saw other people there and would just come back to the unit. The LPN/UM #2 stated Resident #206 was confused and could not put a complete sentence together. The LPN/UM #2 stated they had known Resident #206 for about a year and had never observed Resident #206 self-ambulate without an assistive device. The LPN/UM #2 saw Physical Therapist (PT) work with Resident #206 to use a rolling walker and Resident #206 was also assessed for use of a wheelchair. Even when Resident #206 stood in the room, he/she had an unsteady gait. Assistance of one person with care, would always need help. The LPN/UM #2 added that the Psychiatric Nurse Practitioner (PNP) recently decreased Resident #206's [MEDICATION(S)] because he/she was not having behaviors. There were no noted changes in Resident #206's behavior or mood. At one point, Resident #206 did have a wander guard in place, although LPN/UM #2 did not recall when it was removed but stated that they put the wander guard on Resident #206 when he/she was getting acclimated to the facility. Resident #206 and their spouse lived at the facility. Resident #206's spouse always expressed that they wanted to go home. That was why the facility put the wander guard on Resident #206. After Resident #206 was oriented to the facility and had a history of going to different areas on the first floor, Resident #206 never tried to exit the elevator, and was not exit seeking to the LPN/UM #2's knowledge. When asked about Resident #206's confusion, LPN/UM #2 stated when they asked Resident #206 something, he/she had a hard time to gather the words to answer the questions. Resident #206 knew the mealtimes, med times, staff, and other residents, but the resident would not have been safe to live in community based on their cognitive status. Resident #206 needed oversite- direction for showers and from the LPN/UM #2's experience, they did not identify Resident #206 as an elopement risk. On [DATE] at 11:21 AM, the surveyor interviewed the Security Supervisor (SS) who stated that he/she was the head of the security for the facility and was employed by a security company that was subcontracted by the facility. The SS stated that there was no keypad to the left of the stairwell #4 door prior to [DATE], the day the repairs were done. The SS stated that There was not a keypad on that exit door prior to Monday. The SS also stated that The facility had just installed that keypad on Monday. The SS added that prior to [DATE], there was no lock on the door, and you could just walk out. The SS added that the security guards that were assigned to work at the facility had no responsibility of monitoring cameras and thought that the cameras were county property and unsure if they were working. The SS stated that the county personnel and visitors to the county clinic entered the adjoining hallway and used that same exit door to freely access the clinic, which was located on the second floor. On [DATE] at 12:15 PM, the surveyor interviewed Resident #206's PNP who stated that he/she saw Resident #206 last week to follow up on their [CONDITION(S)] medications and laboratory review. The PNP further stated that Resident #206 was first placed under psychiatric care because he/she had behaviors of refusing medications and care. The PNP told the surveyor that Resident #206 had diagnoses of depression, dementia, and mood disorders and was absolutely confused. The surveyor asked the PNP if Resident #206 had cognitive awareness of where they lived. The PNP stated that Resident #206 had periods of knowing where he/she was and at times did not. The PNP stated that he/she remembered that Resident #206 had a past history of wearing a wander guard, but they never verbalized or displayed behavior indicating that Resident #206 wanted to leave the facility. The PNP stated that they were surprised that Resident #206 walked out of the wheelchair because PNP always observed Resident #206 in their wheelchair. On [DATE] at 02:32 PM, the surveyor interviewed the technician (tech) via telephone who stated that he/she provided a service on Monday Labor Day, [DATE]. The tech stated he/she was called on Sunday, [DATE], but could not come and told the facility to call someone else but then he/she was called back and was able to come on Monday. The tech stated he/she was told that the wanderguard keypad was not working meaning that the wanderguard keypad was not keeping the door locked at all times. The tech added he/she was not an expert on wanderguards but had worked with them and knew they had more than one function and confirmed that the wanderguard was not keeping the door locked. The wanderguard was working when a wanderguard was in the vicinity because it would lock the door, but the relay to keep the door locked was not working. The tech referred to the new keypad he/she installed, on the left wall of the door, and a code had to be put in to unlock it. The tech added that there was no keypad on the left wall of the door before they put one in. When asked by the surveyor why the invoice had replaced keypad, the tech stated, I sort of replaced it, you say new and I say replaced, because I sort of replaced the keypad because they had a wanderguard keypad. The wanderguard keypad was on the opposite wall before the door. Review of the document titled Police Department Investigation Report, dated [DATE], revealed that the police were called at 12:20 PM on [DATE]. Once the police received a description of Resident #206, the police requested mutual aid from the sheriff's office, K-9 unit, as well as the utilization of the drone unit. After review of the facility's video, the police concluded that Resident #206 was last seen at approximately 10:12 AM walking down the dietary hallway of the facility, on the first floor, and walking through the exit door but it was undetermined from the video surveillance, which direction Resident #206 continued to walk. The police found Resident #206 on [DATE] at 3:52 PM, and Resident #206 expired at 4:19 PM on the same day. A review of the facility's policy titled; Wandering/Elopement Policy with the revised dated of ,d+[DATE], included; It is the objective of this facility to ensure the safety and protection of wandering residents by preventing their exit from the building. Under Policy Interpretation and Implementation; Section 1. Upon admission, annually, and when there is a significant change in status, resident will be assessed for wandering/elopement using the Elopement risk form. Any resident identified to be a risk for wandering either by preadmission history and/or observed behavior will be provided with a wander-guard and an appropriate plan of care will be developed. Section 6- The Admin or in his/her absence the DON will notify Department of Health (DOH) if the resident is NOT FOUND as per DOH guidelines. The facility's policy also did not indicate a specific time frame to notify DOH after a search for a missing resident that had not been found within the facility or on the facility's grounds. This deficient practice placed Resident #206 and all other residents with moderate cognitive impairment who were at risk for or had a known history of wandering and/or exit seeking behavior, in an Immediate Jeopardy (IJ) situation. The IJ was identified on [DATE] at 4:15 p.m., when the Admin and DON were notified of the IJ situation, which ran from [DATE] until [DATE], when the door was monitored and repaired. The facility provided an acceptable removal plan on [DATE] at 10:16 AM, to remove the Immediacy. The Removal Plan was verified by the survey team on [DATE] at 10:40 AM, the sixth day of the survey. This deficient practice continues at a lower S/S for no actual harm with the potential for more than minimal harm. Part B Refer to F609 On [DATE] at 11:32 AM, the surveyor observed Resident #191 reclining back in his/her reclining chair in their room. The surveyor attempted to interview the resident. The resident was able to communicate his/her name to the surveyor. The surveyor reviewed the medical record for Resident #191. A review of the resident's Admission Record, reflected that the resident had resided at the facility for about a year and had diagnoses which included but were not limited to; [CONDITION(S)] (a congenital disorder that affects movement, muscle tone and posture due to abnormal brain development before birth), lobar pneumonia, unspecified organism, unspecified severe protein calorie malnutrition, [CONDITION(S)], major depressive disorder, anxiety, unspecified intellectual disabilities, essential hypertension, and gastro-[CONDITION(S)] reflux disease without esophagitis (inflammation that damages the tube running from the throat to the stomach). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated [DATE], reflected that the resident had a Brief Interview for Mental Status score of 6 out of 15, which indicated the resident had moderately impaired cognition. A further review of the resident's MDS, Section G - Functional Status for activities of daily living reflected that the resident required supervision and setup for eating and drinking. A review of the resident's Order Audit Report, throughout Resident's #191's stays at the facility, revealed a Physicians Order (PO) dated [DATE], and timed at 10:37 AM, for regular diet puree texture, honey thickened liquid consistency. According to a review of an incident investigation dated [DATE], completed by the facility's DON indicated on [DATE] at 2:30 PM Resident #191 was in the 2D dayroom during snack time. The resident's (Licensed Practical Nurse) LPN was informed by an activity aide that Resident #191 was choking and vomiting. The resident had a PO for honey thickened liquids and was provided thin whole milk by his/her primary CNA2. The resident was immediately evaluated by the LPN. Upon evaluation, the LPN heard crackles throughout the resident's lungs and determined the resident's vital signs were abnormal. The LPN notified the residents (Primary Care Physician) PCP who gave physician orders for the administration of oxygen and nebulizer treatments, quickly came to the unit, assessed the resident, and sent the resident to the hospital for an evaluation. Resident #191 was admitted with aspiration pneumonia and required placement of a peg-tube (a creation of an artificial external opening in the stomach for nutritional support) in the hospital. A further review of the incident investigation dated [DATE], revealed Resident #191 was incorrectly provided regular thin liquids during snack time when his/her current diet order indicated honey thick liquids. The DON further concluded that the incident most likely occurred due to lack of knowledge regarding proper protocols in verifying fluid consistencies. A review of a Progress Note (PN) dated [DATE], and timed at 14:30 (2:30 PM), indicated that while Resident #191 was in the dayroom during snack time, staff informed nursing that the resident was choking and vomiting. The PN further explained that the resident had a PO for honey thickened liquids and was given thin milk by an unknown staff member. The PN revealed that the resident was evaluated by the LPN. Upon evaluation, the LPN heard crackles throughout the resident's lungs, the resident's vital signs were abnormal, and the resident's physician was notified immediately. Upon notification of the physician, the physician provided the LPN with physician orders for the resident to be administered oxygen and a nebulizer treatment. The PN further indicated that the physician came to the unit, assessed the resident, and decided to send the resident to the hospital. A further review of the resident's PN, dated [DATE], and timed at 22:35 (10:25 PM), reflected that the resident was admitted to the hospital with possible aspiration pneumonia. A review of the resident's hospital discharge paperwork from [DATE] through [DATE], reflected a discharge diagnosis of aspiration which was identified on a chest x-ray. A further review of the resident's hospital paperwork indicated that the resident required placement of a peg-tube. The hospital discharge paperwork dated [DATE], by the Speech Language Pathologist (SLP) at the hospital indicated, [Resident arrives via ambulance from [facility] with [blood pressure] ,d+[DATE]. The hospital discharge paperwork further indicated as per Emergency Medical Services the resident was normally on a thickened liquid but was administered unthickened milk at some point, aspirated on it. A review of the facility's Investigation of the incident that took place on [DATE] was dated, [DATE] and signed by the DON. The investigation indicated that video surveillance dated [DATE] and timed at 1426 (2:26 PM), shows [CNA2] passing out snacks in the dayroom. He opens and places what appears to be a milk carton in from of [Resident #191]. [Resident #191] is seen sitting at the table drinking milk. Three other employees are present in the dayroom. [Activity aide] appears to be checking on [Resident #191], leaves the dayroom and returns with [LPN] (pulling the vital sign machine). The Investigation revealed that the DON interviewed the staff members that were present in the dayroom. A review of the interview with the resident's LPN revealed that a staff member saw the resident drinking milk and then start coughing. The LPN went into the dayroom, evaluated the resident, and observed that the resident was coughing and spitting up. The LPN told the DON that she auscultated (listened to the resident's lungs with a stethoscope) and heard crackles. The LPN then notified the resident's PCP who gave her physician orders for oxygen and nebulizer treatments. The LPN interview indicated that the resident's PCP came to the unit and decided to call 911 because the resident's vital signs were abnormal. A review of the interview with the resident's CNA2 indicated that he did not recall passing out the milk to Resident #191 but recalled seeing the resident drinking the milk and being surprised that the resident was on regular milk fluid consistency. The investigative report revealed that the DON asked the CNA2 the process for identifying residents on alternative fluid consistencies, the CNA2 responded that he knew by the dots by the resident's bedroom doors. A review of the interview with the activity aide indicated that she saw the resident drinking milk out of a red carton. The activity aide told the DON that she did not know who gave the resident the milk and the resident was spitting up liquid and coughing. When the DON asked the activity aide the process for identifying residents on alternative fluid consistencies the activity aide stated that she did not know. A review of the interview with the facility's Corporate Food Service Director revealed that on [DATE] at 10:31AM, the kitchen received a PO for honey thick liquids for the resident. A review of the Investigation conclusion indicated the resident was provided regular thin liquids when his/her current diet indicated honey thickened liquids. A further review of the Investigation revealed the DON concluded Resident #191 received the incorrect fluid consistency during snack time and the incident most likely occurred due to lack of knowledge by staff regarding proper protocols in verifying fluid consistencies. A review of Nurse Staffing for the 2D unit on [DATE], revealed that the CNA2 that provided Resident #191 with the thin whole milk was the resident's primary care CNA for that day. A review of the CNA2's personnel file revealed that on [DATE], the CNA2 who provided the resident with thin whole milk received a verbal warning by the facility's DON. The verbal warning indicated that the CNA2 failed to follow instructions. Incorrect Diet was documented on the verbal warning work rule violation. Additionally, a Dietary Inservice was provided to the CNA2 by the DON. The Dietary Inservice indicated, Explained DOT system and importance of checking dietary restrictions prior to feeding. DOT system hanging in nurses station and dayroom. Specific colored DOT placed near resident's name plate by room door. No fluids left at bedside of residents on a tube feeding and with Blue Dot. Residents requiring thickened liquids will receive tray with empty mug and coffee thickener packet. Dietary will send up carafe of hot water for staff to use to make the coffee. Demonstrated how to use Coffee thickener packets- Nectar and Honey thick. Jello and ice cream are considered thin liquids. When unsure- STOP! And ask nurse before giving anything. A further review of the CNA2's personnel file indicated that on [DATE], the CNA2 was terminated due to performance issues, absenteeism, and poor work quality. A review of the resident's Care Plan, revised [DATE], reflected a focus area for nutrition. The goal of the resident's Care Plan was that the resident would follow diet as ordered. Interventions in Resident #191's Nutrition Care Plan included; provide me my diet as ordered and provide me with my supplements as ordered. On [DATE] at 11:42 AM, the surveyor interviewed the facility's Registered Dietician (RD) who stated that a resident was placed on an altered diet or liquid consistency after being evaluated by the SLP. The RD stated that she observed resident's during mealtimes and if she noticed that a resident was having difficulty swallowing or suspected weight loss due to swallowing difficulties she would include the nursing department, SLP, the resident representative, and the PCP in her assessment of the resident. The RD further stated that the [NAME] [TRUNCATED]

Based on observation, interview and record review it was determined that the facility failed to a.) prevent Hospitality Aides (HA's) from feeding residents who were identified to be at risk for aspiration, had complicated feeding issues and who required specific feeding strategies. On 2/28/18 and 3/2/18 during the breakfast and lunch meal, the survey team observed HA's feeding three residents who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56 had specific feeding directions which included the use of a cervical collar at meal times and alternate solids/liquids and pacing. Resident #124 had specific feeding directions which included to alternate solids and liquids, small sips/bites, and allow time between mouthfuls; and Resident #222 had specific feeding directions which included to alternate solids and liquids, small sips/bites, allow time between mouthfuls and provide verbal reminders to swallow. According to the Speech Therapist (ST), Director of Nursing (DON), and facility Registered Nurse (RN) Educator, all stated the HA's were not trained in feeding residents who had swallowing difficulties and/or specialized feeding techniques and should not have been feeding residents. This resulted in an Immediate Jeopardy (IJ) situation identified on 3/2/18 at 3:05 p.m., and communicated to the facility administration. The immediacy was corrected on 3/2/18 at 3:35 PM. The remainder of the elements of the IJ were corrected on 3/5/18 at 4 PM based on an acceptable plan of correction that was implemented by the facility and verified by the team. This deficient practice was identified for 3 of 14 residents (Residents # 56, #124 and #222) reviewed for specialized diets with specialized techniques and was evidenced by the following: 1. On 2/28/18 at 12:20 p.m., the surveyor observed a HA #1 feeding Resident # 124 a pureed diet with nectar thick liquids for lunch. The surveyor reviewed the medical record for Resident #124 who was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2018 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #124's care plan for nutrition initiated on 7/29/15 and revised on 1/15/18 revealed the following interventions: continue to provide regular/Puree consistency/Nectar thickened liquid diet with fortified foods at all meals as ordered. A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 1/12/18 indicated that the resident's cognitive skills for daily decision making was severely impaired. Review of the functional status for eating indicated the resident required extensive assistance of one person for eating. Review of the swallowing/Nutritional status revealed the resident was assessed for mechanically altered diet which required a change in texture of food or liquids. Further review of the resident's medical record, revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Feeding Program Guide and Caregiver Training dated 3/31/16 provided by the ST revealed the following: must be alert, seated at 90 degrees during meal (HOB) [head of bed] fully upright, liquids thickened to consistency of nectar. The following feeding strategies checked indicated to Alternate solids and liquids, small sips/bites, and allow time between mouthfuls. On 3/2/18 at 9:32 a.m., the HA#3 on unit 2D told the surveyor she feeds residents in the day room and she can feed pureed and thickened liquids to residents because she was trained, but cannot remember who trained her. 2. On 3/2/18 at 8:51 a.m., the surveyor observed a HA #1 feeding Resident # 222 breakfast. The resident's breakfast meal ticket indicated puree and honey thicken liquids. The Licensed Practical Nurse (LPN) on the unit told the surveyor that the HA feeding Resident #222 was new and he was allowed to feed the resident. The surveyor reviewed the medical record for Resident #222 who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2018 POS revealed a diet order dated 11/30/07 for puree with honey thickened liquids. Review of Resident #222's care plan for nutrition/hydration initiated on 12/12/14 and revised on 2/14/18 revealed the following interventions: provide with pureed diet as ordered, thicken all liquids to honey consistency as ordered. Monitor for signs and symptoms of swallowing difficulty. SLP evaluation as needed. No water pitcher at bedside. A review of the Quarterly MDS dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment. Review of the functional status for eating indicated the resident was totally dependent on one person assistance for eating. Review of the swallowing/Nutritional status revealed the resident was assessed for mechanically altered diet which required a change in texture of food or liquids. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5/10/16 Feeding Program Guide and Caregiver Training dated 3/31/16 provided by the ST revealed the following: must be alert, seated at 90 degrees during meal (HOB) [head of bed] fully upright, remain at 60 degrees for half an hour after meals, liquids thickened to consistency of nectar, needs to be fed, and ASPIRATION RISK. The following feeding strategies checked indicated to Alternate solids and liquids, small sips/bites, allow time between mouthfuls and reminders to swallow. 3. On 3/2/18 at 12:10 p.m., the surveyor heard the unit manager (UM) a LPN on unit 1B tell another staff member yes she can feed the resident. The surveyor then observed a HA#6 feed Resident #56 who was seated in a specialized wheelchair near the nurses station. The surveyor observed the HA seated on the right side of the resident, the HA was observed removing the cervical collar and place it back on the residents neck and began feeding the resident. A short time later the HA stood up and went to the residents left side to continue to feed the resident. The HA was observed holding the residents forehead back during feeding. The resident's lunch meal ticket indicated a regular puree diet with honey thick liquids. The surveyor reviewed the medical record for Resident #56 who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2018 POS revealed a diet order dated 12/30/17 for puree with honey thickened liquids. Review of Resident # 56's care plan for falls/safety initiated on 11/11/15 and revised on 12/22/17 revealed interventions to apply soft cervical collar during all meals; check his/her skin integrity before application and after removal; hold (Resident #56's) head gently and upright at 90 degrees with his/her head/face midline for ease of swallowing while feeding the resident; continue to feed (Resident #56) near the nurse's station; and feed him/her slowly with a spoon, wait until his/her mouth is clear and he/she had done a double swallow before his/her next spoon of food. Review of the resident's nutrition/hydration care plan initiated on 10/8/14 and revised 12/14/17 revealed interventions to feed pureed diet as ordered-refer to feeding guide for direction; thicken all liquids to honey consistency as ordered. Monitor for signs and symptoms of swallowing difficulty. SLP evaluation as needed. A review of the Quarterly MDS dated [DATE] indicated that Resident #56 cognitive skills for daily decision making was severely impaired. Review of the functional status for eating indicated the resident was totally dependent on one person assistance for eating. Review of the swallowing/nutritional status section K0100 for swallowing disorder indicated the following checks loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. In addition, the resident was assessed for mechanically altered diet which required a change in texture of food or liquids. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor interviewed HA#6 later that same day at 1:50 p.m., in the presence of the survey team. The HA said [Resident #56's] head must be held back if not you can put food down the wrong way. The HA said you have to hold his/her head up and give sips in between bites and listen to him/her swallow. The unit manager trained me. Today was my first day with (Resident #56). I got special instructions for (Resident #56) from the unit manager. The HA further said she mixes the thickener powder into the liquid. No, I was not trained. I put one packet for a cup. She said she doesn't know the difference between thickener consistencies. I'm confused between consistencies. When I set up the tray I give puree and I mix the thickener with coffee or tea and stir it well. It will settle after awhile. The thickener packet comes on the meal tray. The HA said she knows that honey thickener comes in a yellow packet and nectar comes in a green packet. But without the packet she doesn't know the difference between thickener consistencies. The HA told the surveyor the training she received on Resident #56 was just verbal. I was watching what the other girls were doing. The nurse showed me how to set up (Resident #56) a real quick refresher from last week. The HA said she took it upon herself to learn how to feed Resident #56. I watched the other girls being trained by the nurse put a packet of thickener in one cup of liquid. The coffee has to be thickened. Sometimes the juice is prethickened. The HA said I would show the nurse if the wrong packet of thickener was on the tray. The HA further said that Resident #56 was difficult to feed because the resident was moving [his/her] head and [he/she] was fighting me. I had to keep moving to be comfortable feeding the resident. On 3/2/18 at 2:37 p.m., the ST provided the surveyor the Feeding Program Guide & Caregiver Training dated 9/8/17 for Resident #56 which indicated the residents diet was puree with honey thick liquids. The following general checks indicated the following: Must be alert, seated at 90 degrees during meal (HOB) [head of bed] fully upright, remain at 60 degrees for half an hour after meal. Review of the specific checks indicated the following: Liquids thickened to honey, liquids given by cup regular, needs to be fed, and ASPIRATION RISK. Review of the feeding strategies checked indicated alternate solids & liquids, small bites, allow time between mouthfuls. Review of the other revealed: hold head lightly at midline. On that same day and time, the ST stated [Resident #56] had specific feeding strategies. I have not been asked to train the HA's. It is a new program and they haven't reached out to me. The ST also provided the ST progress notes dated 9/28/17 for Resident #56 which indicated staff education regarding use of safe swallowing strategies-cervical collar at meal times, alternate solids/liquids and pacing and the note section indicated Pt [patient] requires compensatory swallow strategy cervical collar with head held at midline, alternating solids/liquids and pacing in order to safely swallow current diet. On 3/2/18 at 9:30 a.m., during an interview with the Director of Recreation (DR), she said the HA program started in November of 2017, and she prepares their schedules. The DR said the HA's work two shifts from 8 am to 4 pm and from 11 am to 7 pm which covers breakfast, lunch, and dinner. She said the HA's go through training at the facility with the facility staff educator for feeding training. Our main goal is to send them to CNA school to become certified. The DR said the HA's cannot feed any resident in their rooms unless a CNA or nurse is present. They can only feed residents near nurses station or the day room. The DR said the HA's are allowed to feed residents on a special diet such as puree and thickened liquids. They were trained and they are under the supervision of unit manager and recreation aide also watches over them. So they are well supervised. The DR further said that each unit has a binder with each residents diet which is updated every Monday. On 3/2/18 at 10:12 a.m., during an interview with HA#4 on unit 2B, the HA said she feeds residents in the day room and she can feed residents who are on a puree diet and thickened liquids. The HA said she was trained but cannot remember who trained her. On 3/2/18 at 11:21 a.m., during an interview with a HA#5 on unit 1B said she feeds residents in the day room or any common area where there is nursing supervision. She said I mostly feed residents on puree because these are usually the residents who need to be fed. On 3/2/18 at 12:45 p.m., during an interview with a HA#7 on unit 2A. The HA said the CNA's tell me who to feed. I don't feed any resident in their rooms. I can feed any resident. The HA said no restrictions only cannot feed residents in their room. On 3/2/18 at 1:04 p.m, in the presence of the survey team, the facility Registered Nurse (RN) educator said that the HA's are not paid feeding assistance. They are recreation and hospitality aides, they are not paid feeding employees. They cannot feed anywhere except the day room or at the nurses station. There must always be a nurse present and they cannot feed residents on a special diet such as puree or thickened liquids, or any resident with dysphasia (difficulty swallowing). The RN further stated if a resident had difficulty chewing or swallowing, they need to alert the nurse. They cannot feed anyone with pureed, ground, or thickened liquids; only whole food, regular diet. They are not supposed to feed pureed or thickened liquids. This program is new and I started working with the activity aides to be sure they were feeding correctly. I also called the state and we started this program. I am doing the competencies with making beds and feeding competencies. The nursing unit managers were instructed that HA's cannot feed puree, thickened liquids. I watch them, but I have not seen them feed any resident on a puree diet or thickened liquids. No, there is no schedule for observations of the HA's. They are not paid feeding assistants. It's geared toward recreation. An adjunct to recreation. The ones who want to become CNA's are still here, the ones who did not are no longer here. We give them an incentive to become a CNA. On 3/2/18 at 1:33 p.m., in the presence of the survey team the ST said she was aware the HA's were feeding residents. They were educated by the facility nurse educator. I don't know what the education entailed. The ST said they do not train nor are they involved in training the HA's any feeding techniques or feeding strategies. The ST stated that a HA feeding a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ST further said once a resident is discharged from ST services and required specific feeding techniques or strategies we would train the CNA's and nurses. On 3/2/18 at 2:26 p.m., in the presence of the survey team, the DON said HA's are educated not to feed residents with dysphasia. The CNA's are probably asking the HA's to feed. The activities director is responsible for the oversight of the HA's and the facility nurse educator is responsible for their training. On 3/2/18 at 2:45 p.m., the UM/LPN from unit 1B said HA's are to lend an extra hand. They can pass trays in rooms, spend social time with the residents and help feed in the day room. They are in-serviced on how to feed and will feed all residents without any restrictions. I have a diet book on the floor. I keep an eye on them. They've been good. Resident #56 wears a neck collar, he/she needs to sit upright, and is fed slowly with liquid in between. I do not train, that is not my role. The UM/LPN said yes, I give tips and verbal instructions to the HA's regarding (Resident #56) head position. I've never done a formal group instruction. My understanding is that they have been trained on what they can and cannot do. There is verbal communication between the trainer and the unit manager. We were told they could feed the residents because they were trained. On 3/2/18 at 3:05 p.m., the administration was made aware of the Immediate Jeopardy. On 3/5/18 at 9:55 a.m., the Licensed Nursing Home Administrator (LNHA) said we stopped the HA's from feeding on Friday 3/2/18. When I read the regulations we were under the impression that with adequate training they could feed residents. It helped lessen the burden on the CNA's. The HA's were never allowed to feed residents in their rooms only in day room or near nurses station. We put together a comprehensive training program for them. The LNHA acknowledged that there was no state-approved training program in New Jersey (NJ) for paid feeding assistance and said that they weren't considered paid feeding assistance but they under were under activities and he thought because activities staff can help feed residents the HA's would to. He did not consider residents with complicated swallowing problems. On 3/6/18 at 10:40 a.m., in the presence of the survey team, the LNHA said the facility nurse educator had a training module and she called someone at the state. I'll take the blame because I was under the impression it was okay as long as the HA's were under the Recreation department. I thought we could substitute her training module for the state approved training. On 3/6/18 at 3 p.m., the facility nurse educator said she spoke to the Department of Health in NJ but didn't remember who she spoke with. She said she asked if NJ had a certification feeding program. The person I spoke with said no. I took it that we need assistance with feeding and that is how the program started. In my mind NJ didn't have anything so I looked at other feeding programs and brought a book so that is what I used. I tried to do something good. I didn't think in those terms that if NJ didn't have a certification training I couldn't do it. The program was meant and intended to feed but not any resident. It somehow involved into something else. I don't really know how. I heard the HA's really wanted to help out. No there was no specific oversight of the feeding program to ensure that HA's weren't feeding residents on special diets or with feeding difficulties. The program was under the recreation director. I'm the one who taught the class to the HA's. I put together a comprehensive training module as you can see I spent a lot of time on it. I did go over thickening liquids and types of diet but not in specific detail because I knew they were only HA's they were just regular people with no other training. They were told in class that they cannot feed any resident on special diets or anyone with thickened liquids. They knew that, so, yes they knew what was allowed and what wasn't. The surveyor asked if other staff such as the CNA's and nurses knew. The facility nurse educator said It should have been disseminated from the charge nurse to the CNA. It was discussed in morning meeting. During morning meeting nurse managers knew what they can and cannot do. On 3/9/18 at 10:10 a.m., the unit manager/Registered Nurse (UM/RN) from unit 2D said They told us HA's cannot feed any resident who had dysphasia, special diet or thicken liquids. We did question them but we were told they were trained. You know some of the HA's are stubborn and think they are CNA's and feed residents who shouldn't have been fed. On 3/9/18 at 10:34 a.m., the UM/LPN on unit 2B said he was not formally informed of the scope of the HA's. He was under the impression that they were to assist the CNA's with dining, among other tasks, such as setting up trays for the residents. He said he was not aware they were feeding residents and they are definitely not feeding since last week. On 3/9/18 at 10:45 a.m., in the presence of the survey team, the DR said she is the person responsible to oversee the HA's. I didn't know the HA's couldn't feed residents on special diets or thicken liquids. It wasn't communicated to me from the nurse educator. Activities helps feed so I didn't think nothing of it. I didn't know that they were trained not to feed residents on special diets because I thought they were trained to feed residents in the training course. It would have been a waste of time because we have so few residents on regular diets. I do over see the HA's daily. I'm on the units. I saw them feeding residents on puree and thicken liquids but I didn't say anything because I thought they were trained to feed residents on special diets and thicken liquids. There was no communication between the nursing and activities department. The surveyor reviewed both the February and March 2018 HA schedules provided by the DR which indicated that HA's were assigned to 5 of 6 units. On that same day and time, the DR provided the surveyor with two Hospitality Aide Training topics dated 1/31/18 and 2/6/18 titled Working with Dietary. Review of both training topics did not indicate training HA's residents on specialized diets. On 3/14/18 at 12:25 p.m., the Registered Dietician (RD) #1 said she had no input into the planning or execution of the training program for the HA program. On 3/14/18 at 12:56 p.m., RD #2 said she had no input into the training of the HA's or their role in feeding the residents. The surveyor reviewed a list of HA's provided by the DON. The DON said the HA's are not certified nursing assistants (CNA's) just regular lay persons. The DON further said that the facility staff educator provides training for the HA's. The DON provided the training material titled Assisting with Feeding and Hydration in Long Term Care. The DON said that the schedules and performance evaluations for the HA's are done by the activities director. The DON said that each nursing unit has a binder with a list of residents and their current diets that the hospitality aides utilize. The DON said the HA's are not permitted to feed any resident in their rooms only in common areas and they cannot feed any resident with swallowing difficulties or any resident on a special diet and they are under the supervision of the RN. The surveyor reviewed an undated Hospitality Aides policy provided by the DON. The policy indicated it is the policy of the facility to employ hospitality aides as a sub group of the recreation/activities department. The purpose of the hospitality aides were to enhance the efforts of nursing, housekeeping, and activities in keeping the resident comfortable and safe, the residents possessions and environment orderly and comfortable, and to assist the resident to attend community meals and activities of choice. Review of the procedure indicated Candidates are screened and interviewed to ensure they are appropriate for the job. Upon hire in addition to standard orientation the hires are trained by the facility educator. The training consists of a comprehensive feeding module, in addition, to the job description. Hospitality aides are monitored and constantly educated on customer service by the activities director. Hospitality aides are not to be providing direct care to any resident. The policy did not address or specify which type of activities were prohibited such as feeding residents on a specialized diet and/or residents with swallowing difficulties requiring specific strategies during feeding. Locations for feeding and supervision during feeding were not addressed. The surveyor reviewed the job description for hospitality aides provided by the DON which indicated the following: -The hospitality aide reports to the Director of Recreation. The purpose of the position indicated This temporary position exists to enhance the efforts of nursing, housekeeping and activities in keeping the resident comfortable and safe, the resident's possessions and environment orderly and comfortable, and to assist the resident to attend community meals and activities of choice. -Under the section Duties and Responsibilities indicated the following: Delivers trays to residents who eat independently, opens containers if indicated, observes residents for intake, requests CNA/nurse to offer substitutes if not eating. Notifies nurse if poor intake observed. -Under the section Prohibited Activities on page two indicated Employee may not feed residents unless employee is a certified feeding assistant. There is no state approved certified program in New Jersey. According to the facility's CASPER Report 1702S staffing summary report from 10/1/17 through 12/31/17 and last updated on 2/15/18, revealed feeding assistant staffing hours were 1,415.00. The facility was notified of the Immediate Jeopardy situation on 3/2/18 at 3:05 pm. An acceptable plan of correction (POC) was submitted to the team to address the immediacy on 3/2/18 at 3:35 PM. The remainder of the elements of the POC was verified by the team each remaining day of the survey. The submitted POC is as follows: 1.) On 3/2/18 the hospitality aide feeding program was discontinued immediately and all staffed involved with the feeding program were notified via phone calls and emails prior to the next meal being served. Resident's #56, #124, and #222 were assessed and showed no signs of aspiration or distress. 2.) All residents on a special diet, swallowing disorders or dysphasia have the potential to be affected by this deficient practice. 3.) Facility wide in-services to nursing staff and hospitality aides regarding the discontinuation of the feeding program. The hospitality aide job description and policy were revised to reflect that feeding residents or thickening liquids is not permitted and is not part of the hospitality aides job responsibility. Nurses and CNA's will be present in dayrooms to assist with setting up and feeding residents. Hospitality aide's will be inserviced weekly for one month by the director of recreation. All future nursing department employees will be educated on the HA policy during orientation. Nurses will continue to notify SLP of any changes in a resident's swallowing ability and ensure the resident is promptly evaluated. 4.) During week days the unit managers will monitor dayrooms and resident rooms during meal times; during evening and weekend hours, the nursing supervisor will monitor the dayrooms and resident rooms during meal times. The DON will meet with unit managers and nursing supervisors during clinical meetings held Monday through Friday for one month. Feeding of residents will be monitored daily by the unit managers and continued by the nursing supervisors during the off shifts for a period of six months or until the HA program is dissolved. Findings will be reported to the QA (Quality Assurance) for review. NJAC 8:39-27.1(a),(e)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision to prevent falls from reoccurring; re-evaluate the effectiveness of existing fall prevention interventions; and establish causal factors to prevent future falls. This deficient practice was evident for 2 of 16 residents, Resident #3 and 4. Resident #3 required hospitalization for a laceration which required sutures. The facility also failed to ensure that residents were prevented from accessing unoccupied areas in the facility. This deficient practice was evidenced by the following: 1. On 2/26/14 at 10:40 a.m. during the initial tour, with the charge nurse (CN), the surveyor observed Resident #3 in a geri-chair with tray table in place. The CN stated the resident was alert to self and had a history of [REDACTED]. On 2/27/14, at 9:05 a.m., the surveyor reviewed Resident #3's medical record, which indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 5/31/13 indicated that the resident's short and long term memory were severely impaired. The resident required total assistance with activities of daily living and 2 person assistance with ambulation. The surveyor reviewed the medical record and fall investigations that revealed Resident #3 had 4 falls from 3/26/13 through 5/3/13 and 5 falls from 5/18/13 - 1/28/14; 3 of the 5 falls occurred in the day room between 2:35 p.m. and 7:20 p.m. The most recent incidents were as follows: a.) On Saturday, 5/18/13 at 3:30 p.m., the resident was walking through the dayroom toward the door to leave, lost his/her balance and fell backward to a sitting position.The investigative report indicated that the certified nursing assistant (CNA) assigned to the day room observed the resident lose their balance upon standing and fall. The resident was unable to explain what happened. On 5/19/13 the nursing staff noted a blue discoloration on the resident's foot. The X-Ray revealed a fracture of the base of the 5th metatarsal (long bone) of the right foot. The physician ordered that the resident be placed in a geri-chair with a tray table to immobilize the right foot for 8 weeks.The care plan for falls was updated to include 1:1 observation b.) On 8/27/13 at 2:35 p.m., the resident slid to the floor while attempting to get up and landed on his/her buttocks. The CNA statement included that she and another CNA were assigned to the dayroom. The other CNA had to leave for an inservice and the nurse in charge was notified. The CNA stated that she "was in the dayroom all by myself with 45 residents. I was attending to another resident and I heard the alarm, I turned around to see the resident on the floor." The care plan was revised to discontinue the geri-chair with tray table and place in a regular chair with chair sensor alarm. A close monitoring log was initiated on 9/11/13. c.) According to the investigative report, on 9/20/13 at 7:20 p.m. in the dayroom, the resident stood up from the chair to walk and was re-directed by the nurse. At 7:25 p.m., the resident stood up again, the alarm sounded, "CNA said no, Nurse turned around and saw resident lying on (his/her) left side on floor. Laceration to the left eyebrow 4 cm x .4cm x.4cm with bleeding noted ... 4cm x 3cm purple area to left cheek." The physician was called and ordered the resident be sent to the hospital. At 2:20 a.m., the resident returned with 6 sutures to the left eyebrow area. The care plan was updated to continue to monitor every hour on the close monitoring sheet. On 9/20/13 the physician ordered a Tray table to wheelchair for rest periods. d.) On 1/28/14 at 9:45 p.m., the resident fell out of the bed onto the mat. The pull cord alarm system was still attached to her clothing and the alarm did not sound. The resident sustained [REDACTED]. On 2/27/14 at 10:05 a.m., the surveyor observed the resident in the activity room seated in a wheelchair with a tray table attached. The surveyor observed that the dayroom was very large and that the CNAs were standing at the doorways. At 10:10 a.m. the tray table was removed. The surveyor asked the CN what the tray table was used for. She stated that the resident was still unsteady on his/her feet. 2. On 2/26/14 at 10:43 a.m., during the initial tour, the CN stated that Resident #4 was confused, had anxious behaviors, and a history of falls with a hip fracture. The surveyor observed Resident #4 was self propelling in a wheelchair in the hallway. On 2/28/14, at 11:45 a.m., the surveyor reviewed the record which indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] status [REDACTED].#4 had [DIAGNOSES REDACTED]. Resident #4 had multiple falls prior to admission, one of which resulted in a scalp laceration. On 9/4/2013 at 2 a.m., the 11-7 nurse documented that Resident #4' s alarm was sounding and the nurse heard the resident yelling, " help, help." The resident was lying on his/ her back at the foot of his/her bed. Resident #4 stated that he/she was going to the bathroom. The resident had an x-ray done and the x-ray reported the resident had an acute left intertrochanteric fracture. The Significant Change Minimum Data Set (MDS), an assessment tool, of 9/20/13 indicated that the resident's BIMS (Brief Interview for Mental Status) was "6", which indicated that the resident had severe cognitive impairment. The resident needed extensive assistance with dressing, toileting, ambulation, and bathing. The nursing staff completed a Fall Risk Evaluation on 9/8/2013 with a score of 13, with a score of 10 or above indicating that a resident was at a high risk for falls. The facility staff developed a fall care plan for the resident on 9/24/13. The interventions included: offering assistance to the toilet every 2-3 hours and as needed and sensor alarms to wheelchair and bed. Additionally the resident's care plan indicated that the resident was "Anxious, difficult to re-direct, combative, argumetative and verbally abusive to staff." On 10/7/13 at 5:45 a.m., the CNA heard the alarming bed sensor and found the resident lying on the left side of the bed. The resident had a contusion 3 cm x 4 cm to the back of the head and cold compresses were applied. Care plan interventions were to obtain a scoop mattress. On 10/16/13 at 10:15 a.m. the resident fell in front of the nurses station. The investigative report indicated that the alarm was off/ delayed sounding. The nurse's statement indicated that she heard the resident screaming as the resident gripped the wheelchair and slid to the floor. There was no apparent injury. Interventions were to continue hourly monitoring and a rehab screen. On 12/30/13 at 6:20 p.m., the CNA responded to the alarm and found the resident in another resident's room in a sitting position on the bathroom floor. The CNA's statement was that she was in the dayroom till after supper and took the resident to the bathroom at 5:20 p.m. The CNA was then assigned to the dayroom from 5:30 -6:30 p.m. At 6:10 p.m., the resident left the dayroom and the CNA tried to re-direct the resident without success. At 6:20 p.m., the nurse told the CNA that the resident had fallen. The resident sustained [REDACTED]. Ice was applied. Interventions added were to "offer to toilet resident after dinner." However, the CNA stated that the resident was toileted after dinner. The CNA was unable to leave the dayroom because she was watching other residents. There was no evidence that interventions were put into place to alert other staff members when a resident who is at high risk for falls wanders out of the dayroom with no staff supervision. On 2/12/14 at 2 p.m., a CNA heard Resident #4 yelling and found the resident lying on the floor in another resident's room. The nurse assessed the resident and noted a raised area to the occipital bone of the head, 2.8 x 2.5 cm, purple discolorations to her left hand and right leg. The interventions initiated were neuro-check as per policy and 1:1 supervision. The investigative report indicated that the resident was last toileted at 1:45 p.m. The Integrated Progress note indicated that the resident was on the falling star program and was being monitored hourly all shifts. The resident was noted to be continent at the time of the fall. There were no new interventions added to address how the facility would monitor the resident's whereabouts when the resident left a supervised area. Although the facility was monitoring the resident hourly, the resident fell within 15 minutes of the last observation check. On 3/6/14 at approximately 2 p.m., the surveyor interviewed the Administrator and Director of Nursing regarding the supervision in the dayroom for Resident #3 and causal factors that were investigated to prevent further falls. The Administrator acknowledged that the dayroom was large and stated that they (the facility) would be looking into measures to address resident supervision in that room. 3. On 2/27/14 at 9:58 a.m. during medication pass with a Licensed Practical Nurse (LPN) on Unit 2D (Dementia Unit) of the facility, the surveyor observed Resident #32 walking down the corridor pushing a wheeled cart. The ambulatory, confused resident slowly walked with the cart towards the nursing station from 9:58 a.m. to 10:02 a.m. when a CNA and Nurse approached the resident and suggested that the resident leave the cart and "come into the day room." On 2/27/14 at 10:15 a.m. the surveyor approached the unattended cart that Resident #32 had previously pushed and documented the items in a caddy on a shelf in the cart. The items stored in the caddy were: 2 tubes of A and D Ointment (1 capped and 1 open to the air), 2 cans of Ultra Sure Antiperspirant / Deodorant Spray, 1 bottle of Alpha Bath Body Oil, 1 bottle of Perianal Wash, 4 bottles of Moisturizing Body Lotion, 3 tubes of Nutrashield with Silicone, 1 bottle of Freshscent Hand and Body Lotion, 1 tube of Fresh Mint Toothpaste, 2 tubes of Hydraguard Skin Cream with 24% Silicone Blend, 7 towelettes of Soothe and Cool Fresh and 2 Combs (with hair lodged in the teeth of the comb). On 2/27/2014 at 10:28 a.m. the surveyor examined the other 4 carts in the hall that contained similar items within the caddys. On 2/27/14 at 2:30 p.m., the surveyor spoke to the Administrator regarding the residents in the Dementia unit having access to toiletry items. On 2/28/2014 at 11 a.m. the CN escorted the surveyor to the shower room where the CN explained that all CNA carts were to be stored there when not in use. 4. The building's 3rd floor was not occupied or used by the facility. During the building tour, On 2/27/14 at 10:55 a.m., the surveyor and the facility's Safety Director accessed the 3rd floor via elevator from the 1st floor. The Safety Director indicated in an interview at 11:00 a.m. that all 5 elevator cars were not restricted. The surveyor noted that residents on the 1st and 2nd floors could readily use the elevators to access the 3rd floor. The surveyor did not observe any conditions which could cause harm to residents on this floor. NJAC 8:39-31.2(e), 27.1(a)

Complaint # NJ Based on interview and review of medical records and facility documentation, it was determined that the nursing staff failed to follow facility policy regarding medication administration. By not following facility policy and pre-pouring medications before the taking of vital signs (VS), when necessary, the nurse failed to provide a safe resident environment. On 11/10/2013, the Registered Professional Nurse (RN) pre-poured Resident #1's medication prior to taking the resident's VS. The pre-poured medication was placed on the table out of the sight of RN #1. A resident, with a [DIAGNOSES REDACTED].#1 before the RN turned around, observed the situation, and removed the medication cup from Resident #3. The RN failed to prevent an avoidable accident, for 1 of 3 sampled residents, Resident #3. The nursing staff also failed to assess the resident in a timely manner and to notify the physician for almost 3 hours after the resident ingested the medications in error. The medications taken in error caused Resident #3's blood pressure to drop and required transfer to the hospital. The emergency room Medical Record, for Resident #3,documented an admitting [DIAGNOSES REDACTED]. The deficient practice is evidenced by the following: Medical Records were reviewed and interviews were conducted on the day of survey. Hospital records were requested and reviewed after survey date. Reference to the New Jersey Statutes Annotated, Title 45, Chapter 11-45: 11-23 Board of Nursing Statutes. "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 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." The facility policy on "Medication Rounds", dated December 2009, documented the following: "Take apical rate/blood pressure according to MV Policy and before pouring medication." The policy goes on to state that "Medications are not to be pre-opened, pre-poured, or signed for before administered." 1. According to an Admission Record, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set, an assessment tool, the BIMS (Basic Interview Mental Status) score was documented as a 3. This denoted severe cognitive impairment. Resident #3 required the assistance of 1 for all activities of daily living. Resident #3 was able to feed self under supervision after set-up was provided. A review of Resident #3's Interdisciplinary Plan of Care for Cognition/Communication, initiated on 9/10/2013, identified the resident as pleasant but forgetful. An update on 10/6/2013 documented a problem of: "chewing pokeno soft chips during activities." Interventions were documented as follows: "Take away any object that may look like food to pt (patient) and monitor pt closely from what pt puts in (resident's) mouth." A facility Reportable Event Record/Report, faxed to the Department of Health on 11/12/2013, indicated that on 11/10/2013 at 11:00 a.m. Resident #3 reached for a medication cup containing crushed and whole medications in applesauce, that were meant for another resident, (Resident #1) who was sitting at the same table in the day room. The cup was removed from (Resident #3), with some of the meds (noted) in (resident's) mouth. The charge nurse was notified at 11:20 a.m. The nursing supervisor was notified at 1:55 p.m. The MD (physician) was called at 2:00 p.m. The family was aware at 2:40 p.m. Resident #3 was sent out to the hospital, at 4:45 p.m., via 911 and was admitted to the hospital with [REDACTED]. On surveyor review of the facility investigation and medical record for Resident #3, the following documentation was observed: The Medication Nurse, RN #1, wrote in a statement that on 11/10/2013 at 11:00 a.m., that she (RN #1) placed a medicine cup on the table, in front of where she was standing, containing (Resident #1's) medications crushed in applesauce. RN #1 turned away to check the vital signs of (Resident #1). When she turned back, the medicine cup was observed to be in (Resident #3's) hands, with some of the medicine in (Resident #3's) mouth. RN #1 removed the medicine cup from (Resident #3's) hands and called her Charge Nurse, RN #2. Both RN #1 and RN #2 failed to evaluate Resident #3 for two and a half hours. In a statement by RN #2, the following was documented: "At 1:50 p.m., when the Certified Nursing assistant (CNA) had difficulty standing Resident #3, (CNA notified RN #2), who at that time asked another nurse to take Resident #3's vital signs. (RN #2) asked RN #1, at this time, to write down exactly what medications were taken in error (by Resident #3). That is when I (RN #2) found out that Resident #3 got (sic) BP (blood pressure) meds (medications). (RN #2) called the doctor at 2:00 p.m. While waiting for the return call, (Resident #3) was returned to bed and was put in Trendelenberg position (head lower than legs). At 2:20 p.m., the doctor returned the call and gave orders to give (Resident #3) salty food (chicken broth with extra salt in it was given to him), give him lots of fluids and send him to the hospital if (Resident #3's) BP was less than 90. At 3:00 p.m., 117/70. She also gave order to take BP q (every) one hour." The surveyor also observed documented in a statement by the nursing supervisor, RN #3, that she was notified of this at 1:55 p.m. Also documented in RN #3's statement was the following: "(Resident #3's) BP was assessed again (by a nurse) at 4:10 p.m....(Resident #3's) BP was dropping again and transfer to hospital should be done...I called 911. Resident was transferred at 4:45 p.m." The surveyor reviewed the facility policy on "Medication Rounds", dated December 2009. The policy documented the following: "Take apical rate/blood pressure according to MV Policy and before pouring medication." The policy goes on to state that "Medications are not to be pre-opened, pre-poured, or signed for before administered." At 3:00 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and asked about the nurses' actions. The DON stated, "It happened on a Sunday, I investigated it on Monday and spoke with (RN #2). I educated her a few times about what happened and what would be done if it were to occur...(RN #1) was taken off the schedule until she can sit down for education on med pass. She will work with the educator and cannot work until she gets a zero percent wrong on med pass. Then the consultant pharmacist will work with her and do another med-pass." NJAC 8:39-27.1 (a)