Every finding on record at Mount Holly Rehabilitation & Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a resident was free from chemical restraints for one of two resident (Resident (R) 108) and failed to ensure there was a stop date for an as-needed (PRN) psychotropic medication for one residents (R108 a) reviewed for psychotropic medications out of 37 sample residents. This failure had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation, and had the potential to affect all residents receiving psychotropic medications in the facility. Findings include: Review of R108's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and major depressive disorder. Review of R108's Care Plan, dated 02/29/24 and located in the EMR under the Care Plan tab, revealed, The resident uses antianxiety medication. Interventions in place were to administer the medication as ordered, observe for effectiveness and side effects, consult with the physician to consider dosage reduction when clinically indicated, educate the resident/family about the risks, benefits, and side effects. The interventions also included that the medication was associated with increased risk of confusion, loss of balance, and cognitive impairment. Review of R108's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. Review of R108's Physician Order Report, dated 01/24/26 and found in the EMR under the Orders tab, indicated that R108 was to receive Ativan (an anti-anxiety medication) 0.5 milligrams (mg), one tablet by mouth every four hours as needed (PRN) for anxiety. Further review revealed no stop date. Review of R108's Medication Administration Record (MAR), dated January through June 2026 and found in the EMR under the Orders tab, revealed the Ativan was administered on 01/26/26, 02/08/26, 02/10/26, 02/13/26, 02/15/26, 03/29/26, 04/22/26, 04/23/26, 05/03/26, 05/25/26, 05/28/26, 06/03/26 and 06/08/26. Further review revealed there was no documentation of a rationale for the administration of the PRN Ativan or of any non-pharmacological interventions attempted prior to the administrations except on 03/29/26 when it was indicated the medication was administered due to the resident's repeated walking on the unit. Review of R108's Nurse's Note, dated January 2026 through 06/10/26, located in the EMR under the Notes'' tab, revealed that there was no documentation of a rationale for the administration of the PRN Ativan or of any non-pharmacological interventions attempted prior to the administration for all dates except on 03/29/26 when it was documented as administered due to the resident's repeated walking on the unit. Observations throughout the survey on 06/10/26 at 12:25 PM, 4:40 PM and on 06/11/26 at 1:05 PM revealed R108 walking around the unit up and down the halls and around the nurses station. During an interview on 06/10/26 at 1:03 PM, Licensed Practical Nurse (LPN) 3 said that when a PRN medication was administered staff should document the behaviors that led to the medications being administered. LPN3 also stated that staff should be attempting non-pharmacological interventions prior to administering a PRN psychotropic medication and documenting whether the interventions were effective or not. LPN3 further stated that R108 was unable to tell staff if he/she needed or wanted a medication; therefore, staff needed to determine when a PRN medication was indicated. LPN3 reported that R108 paced around the unit and at times appeared tired, attempted to catch his/her breath, and increased his/her pace, which staff interpreted as an indication of anxiety and an appropriate time to administer a PRN psychotropic medication. LPN3 stated he/she was unsure why there was no documentation of a reason or nonpharmacological interventions on the days he/she administered the Ativan but confirmed the documentation should have been completed. LPN3 also reported that R108's medication was administered crushed in applesauce and that staff spoon-fed it to the resident. During an interview on 06/10/26 at 12:41 PM, Certified Nurse Aide (CNA) 4 said he/she was very familiar with R108 due to regularly working on the unit. CNA4 stated that R108 liked to walk and do things but as time has gone by his dementia has progressed. CNA4 reported that R108 walked the unit throughout the day and could become combative at times, but he/she said there was always a way redirect him/her. CNA4 further reported that R108 paced a lot on the unit but would sit down when tired. During an interview 06/10/26 at 2:54 PM, LPN8 said R108 was usually fine and just walked bath and forth on the unit, with staff monitoring for signs of fatigue. LPN8 reported that when R108 appeared tired, staff would offer to assist him/her back to his/her room or encourage him/her to sit down. LPN8 stated he/she was unaware of any need to administer PRN medications to R108; however, he/she noted that staff should attempt nonpharmacological interventions first and, if ineffective, a PRN could be considered, with all interventions and outcomes documented. LPN8 further stated that he/she was unsure how to get permission when a resident lacked the capacity to give it. He/she had never had to administer a PRN psychotropic medication to R108 because he/she had always been able to redirect R108. During an interview on 06/10/26 at 3:47 PM, LPN10 said R108 had dementia and frequently walked around the unit. LPN10 reported that R108 had a PRN order for Ativan, but that he/she never had to administer it because R108 did not show much aggression to warrant its use. LPN10 further stated that if staff considered administering a PRN medication, they should try non-pharmacological interventions first. R108 was receptive to redirection and loved cookies and water; however, he/she did not remain seated for long and would resume walking shortly thereafter. LPN10 stated that if a PRN medication were administered, staff would have to document the medication, the indication for its use, and the non-pharmacological interventions attempted beforehand. During an interview on 06/11/26 at 9:53 AM, LPN4 stated staff should be monitoring PRN medications for potential side effects. Staff should be trying non-pharmacological interventions first. LPN4 stated staff should attempt multiple interventions before giving a PRN medication, and the interventions should be documented in the progress notes. LPN4 stated if staff attempted non-pharmacological interventions and residents became more agitated, it would be appropriate to give the a PRN medication before residents became a danger to themselves or others. LPN4 stated Ativan was not a good option for residents with dementia because it could have the opposite effect. LPN4 stated he was unsure why there was nothing documented in the medical record when he/she administered R108 a PRN Ativan; He/She stated R108 became agitated and aggressive and staff were unable to redirect him/her or calm him/her down. LPN4 confirmed the rationale and attempted interventions were not documented and should have been. LPN4 further stated that staff crushed the PRN Ativan and fed it to R108 in applesauce. He/She stated there should be a physician's order to crush medications if staff were doing so but was unsure whether such an order existed for R108's Ativan. LPN4 said he/she crushed the medication because another nurse told him/her he/she could. During a call on06/11/26 at 11:15 AM Family Member (FM) 1 stated he/she was aware that there was a PRN order for Ativan for R108; he/she had been assured by staff that they would notify him/her if they ever had to administer it. FM1 stated he/she was never made aware that staff had administered PRN Ativan to R108. He/She said the only reason he/she agreed to the medication was because staff told him/her that was the only way they would be able to take care of R108. FM1 stated the medication offered no medical benefit and felt it was given simply for staff's convenience. He/She stated they gave it to him because he walks a lot on the unit. FM1 stated that R108 was very active in his/her life and walked every day; the walking was a routine and not a behavior and that the facility wanted to medicate R108 because of this angered him/her During an interview on 06/11/26 at 7:05 PM, the Director of Nursing stated staff should only administer a PRN psychotropic medication when there was a clinical indication and after they had attempted non-pharmacological interventions first and they have failed. The DON also stated all of this should be documented in the residents' medical records. NJAC 8:39-4.1(a)6

Based on record review and staff interviews, the facility failed to ensure the resident and/or resident representative were provided complete written notice at the time of an emergency transfer, including all required elements (reason for transfer, bed-hold policy, appeal rights, and ombudsman contact information), for five of six sampled residents (Resident (R) 157, R135, R109, R6, and R150) reviewed for transfers to the hospital. This deficient practice had the potential to affect the residents' ability to make informed decisions regarding the transfer, exercise the right to appeal the transfer/discharge, and retain access to bed-hold rights, which could result in loss of the resident's bed and/or return to the facility.Findings include: Findings include: 1. Review of R157's admission Record, located under the Profile tab of the electronic medical record (EMR) indicated she was admitted on [DATE] with diagnoses that included asthma, chronic pulmonary edema, malignant pleural effusion, and type 2 diabetes mellitus. Review of R157's Discharge – Return Anticipated Minimum Data Set (MDS), dated [DATE], indicated R157 was discharged to the hospital. Review of R157's Health Status Note dated 03/12/26 at 12:51 PM and located under the Progress Notes tab of the EMR indicated the resident was sent to the hospital for abnormal laboratory values and hypotension. The note indicated attempts were made to notify the resident's representative via phone. Review of R157's Health Status Note dated 03/12/26 at 1:51 PM and located under the Progress Notes tab of the EMR indicated R157's representative came to facility and was informed in person her mom was at the hospital. Review of R157's Notice of Emergency Transfer, dated 03/12/26 and provided on paper by the Director of Nursing (DON), indicated the location of transfer, reason for transfer, and Ombudsman contact information. The document did not include information regarding the resident's right to appeal the transfer/discharge. 2. Review of R135's ''admission Record, located in the ''Profile'' tab of the EMR, revealed R135 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease. Review of R135's quarterly MDS, with an assessment reference date (ARD) of 04/23/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated R135 was severely cognitively impaired. Review of R135's Progress Note, dated 08/07/26, 09/28/26 and 10/25/26 and located under the Progress Note tab of the EMR, revealed R135 had a change in condition and anew order was received to send R135 to the hospital for evaluation and treatment. Review of R135's Notice of Emergency Transfer, dated 08/07/25, 09/28/25 and 10/25/25, provided by the facility, revealed that the document did not include the appeal process and a copy was not provided to the resident or RR. 3. Review of R6's admission Record, located in the Profile tab of the EMR, revealed he/she was admitted to the facility on [DATE] with diagnoses including dysphagia, aphasia, heart failure, and schizophrenia. A review of the Progress Notes located in the Progress Notes tab of the EMR revealed R6 was sent to the emergency room (ER) on 01/27/26 related to abdominal pain and vomiting. A copy of the transfer notice was provided by the facility. The document tilted Notice of Emergency Transfer dated 01/27/26. The notice indicated the reason for transfer was for gastrointestinal intestinal (GI) bleeding. The notice indicated if the representative disagreed with the transfer they could contact the Long-term care Ombudsman. The notice did not contain the location to which the resident was transferred, the name of the state entity which receives appeals, how to obtain an appeals form and how to obtain assistance in completing and submitting an appeals request. 4. Review of R109's Face Sheet, located in the Profile tab of EMR, revealed he/she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of brain, heart disease, and severe protein calorie malnutrition. A review of the Progress Notes located in the Progress Notes tab of the EMR revealed R106 was sent to the ER on [DATE] related to GI bleed. A copy of the transfer notice was provided by the facility. The document tilted Notice of Emergency Transfer dated 06/02/26. The notice indicated the reason for transfer was for gastrointestinal intestinal (GI) bleeding. The notice indicated if the representative disagreed with the transfer they could contact the Long-term care Ombudsman. The notice did not contain the location to which the resident was transferred, the name of the state entity which receives appeals, how to obtain an appeals form and how to obtain assistance in completing and submitting an appeals request. 5. Review of R150's Face Sheet, located in the Profile tab of the EMR, revealed he/she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, Type II diabetes, dementia, chronic kidney disease and heart disease. A review of the Progress Notes dated 05/09/26 located in the Progress Notes tab of the EMR revealed R150 requested to be sent to the hospital related to a distended abdomen and shortness of breath (SOB). R150 was admitted to the hospital with SOB. A copy of the transfer notice was provided by the facility. The document tilted Notice of Emergency Transfer dated 05/09/26. The notice indicated the reason for transfer was for Shortness of breath. The notice indicated if the representative disagreed with the transfer they could contact the Long-term care Ombudsman. The notice did not contain the location to which the resident was transferred, the name of the state entity which receives appeals, how to obtain an appeals form and how to obtain assistance in completing and submitting an appeals request. During an interview on 06/11/26 at 2:32 PM Social Worker (SW) stated that he/she is responsible for filling out and giving the responsible party (RP) the copy of the transfer forms. The SW stated that the form was provided by the Ombudsman and was not aware they had to include any appeals information on the forms provided to RP. The SW stated they do not have any information on how to appeal transfers to provide to the resident or RP. During an interview on 06/11/26 at 2:36 PM, the Social Worker (SW) stated he/she utilized the Notice of Emergency Transfer, which was a form provided to him/her by the Ombudsman, for notification to the resident or representative as well as notice to the Ombudsman of any hospital transfer. The SW stated he/she did not know the notice did not contain necessary information regarding appeal rights and contact information for the appeals agency as well as resources for residents with mental illness or intellectual disability. During an interview on 06/11/26 at 4:58 PM, Registered Nurse (RN) 2 stated family notification should occur with each transfer, typically by phone if not present, and indicated the nursing staff did not provide information to the resident or representative in writing. During an interview on 06/11/26 at 7:11 PM, the Director of Nursing (DON) stated the facility used the Notice of Emergency Transfer form, which included contact information for the Ombudsman. The DON stated he/she was not aware the appeals agency was a different entity than the Ombudsman and confirmed the facility did not provide written information on the appeals process or contact information. Review of the facility's policy titled, Transfer or Discharge Notices dated March 2025 revealed, The resident and representative are notified in writing of the following information: a. The specific reason for transfer or discharge .;b. The effective date of the transfer or discharge;c. The specific location . to which the resident is being transferred or discharged ;d. An explanation of the resident's rights to appeal the transfer or discharge to the state including (1) the name, address, e-mail, and telephone number of the entity which received such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e. The name address and telephone number of the office of the state long term care Ombudsman; f. The notice of facility bed hold and policies;g. The name address e-mail and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies) and;h. The name address e-mail and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder are related disabilities (as applies). NJAC 8:39-4.1(a)31,32 NJAC 8:39-5.1(a)

Based on interviews, record review, and review of facility policy, the facility failed to ensure staff maintained professional standards of practice by ensuring one resident (Resident (R) 108) out of a sample of 37 residents was not administered crushed medications when there was not a clinical indication to do so. This failure had the potential to change the absorption rate of the medication and cause over-sedation and increased fall risk.Findings include: Review of R108's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and major depressive disorder. Review of R108's Care Plan, dated 02/29/24 and located in the EMR under the Care Plan tab, revealed, The resident uses antianxiety medication. Interventions in place were to administer the medication as ordered, observe for effectiveness and side effects, consult with the physician to consider dosage reduction when clinically indicated, and educate the resident/family about the risks, benefits, and side effects. The interventions also included that the medication was associated with increased risk of confusion, loss of balance, and cognitive impairment. Review of R108's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. Review of R108's Physician Order Report, dated 01/24/26 and found in the EMR under the Orders tab, indicated that R108 was to receive Ativan (an anti-anxiety medication) 0.5 milligrams (mg), one tablet by mouth every four hours as needed (PRN) for anxiety. Further review revealed no indication or instruction to crush medications. Review of R108's Medication Administration Record (MAR), dated January through June 2026 and found in the EMR under the Orders tab, revealed it was administered on 01/26/26, 02/08/26, 02/10/26, 02/13/26, 02/15/26, 03/29/26, 04/22/26, 04/23/26, 05/03/26, 05/25/26, 05/28/26, 06/03/26 and 06/08/26. During an interview on 06/10/26 at 1:03, Licensed Practical Nurse (LPN) 3 said R108's medication was administered crushed in applesauce and that staff spoon-fed it to him/her. LPN3 stated that R108 had no issues with swallowing and that there should be an order to crush medications if staff were crushing any medications. He/She was unsure if R108 had a current order to crush medications and confirmed that staff should not be crushing them if there was no order to do so. During an interview on 06/11/26 at 9:53 AM, LPN4 stated that staff crushed the Ativan and fed it to R108 in applesauce. He/She stated there should be an order to crush medications if staff were crushing them but was unsure if there was an order to crush R108's Ativan. LPN4 said he crushed them because another nurse told him/her that he/she could. During an interview on 06/11/26 at 7:05 PM the Director of Nursing said staff should not be crushing medications without an order to do so. She stated R108 should have a standing order to crush medications. She confirmed there was no current order for any of R108 medications to be crushed. Review of the facility's policy titled Crushing Medications revised April 2018 revealed, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure a medication error rate was below 5% with five errors out of 27 opportunities resulting in a medication error rate of 22%. This failure had the potential for residents not to receive medications following the five rights including right dose, right amount, and right time. This failure affected four out of seven sampled residents, (Resident (R) 99, R41, R98, and R63). The facility sample size was 30. Findings include1. Record review of R63's admission Record located under the Profile tab of the Electronic Medical Record (EMR) revealed an admission date of 02/03/23. with a diagnosis of diabetes mellitus. Record review of R63's Order Summary Report found under the Orders tab in the EMR revealed an order for Insulin Lispro Subcutaneous (under the skin) Solution Pen-injector 100 UNIT/ML (milliliter) inject as per sliding scale and an order for Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) inject 20 units subcutaneously with meals for Diabetes Mellitus (DM ). During an observation on 06/09/26 at 12:44 PM, revealed Licensed Practical Nurse LPN ()1 dialed four units on an insulin lispro Quikpen then injected the insulin into R63's left abdomen. LPN1 did not prime the insulin pen prior to administration of the insulin. During an observation on 06/09/26 at 12:46 PM, LPN1 dialed 20 units of insulin lispro on an insulin lispro Quikpen then injected the insulin into R63's right abdomen. LPN1 did not prime the insulin pen prior to administration of the insulin into R63's right abdomen. During an observation on 06/9/26 at 10:08 AM, LPN (Licensed Practical Nurse)-1 administered the Cinacalcet HCl Oral Tablet 30 MG with administration directions for Give one tablet by mouth one time a day for chronic kidney disease. Give with breakfast to R63.Breakfast was served to the resident at 8:00 AM 2. Record review of R98's admission Record located under the Profile tab of the EMR revealed an admission date of 04/07/23 with a diagnosis of diabetes mellitus. Record review of R98's Order Summary Report located under the Orders tab of the EMR revealed and order for Humalog KwikPen Subcutaneous Solution Pen-injector100 UNIT/ML (Insulin Lispro) Inject as per sliding scale before meals for DM. During an observation on 06/10/26 at 11:37 AM, LPN1 removed a Humalog Quikpen insulin pen from a case in the bottom drawer of the medication cart, removed the cap, placed a needle on the insulin pen and dialed two units. LPN1 did not prime the insulin pen then injected the insulin into R98's right arm. 3. Record review of R41's admission Record located under the Profile tab of the EMR revealed an admission date of 09/16/22. R41 had a diagnosis of diabetes mellitus. Record review of R41's Order Summary Report located under the Orders tab of the EMR revealed and order for NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale subcutaneously before meals forDM. During an observation on 06/10/26 at 11:48 AM LPN1 retrieved a Novolog Flexpen from a box in the bottom drawer of the medication cart, removed the cap and placed a needle onto the end, dialed three units without priming the pen, and took the pen into R41's room and injected the insulin into R41's left abdomen. 4. Record review of 99's admission Record located under the Profile tab of the EMR revealed an admission date of 09/04/23 with a diagnosis of diabetes mellitus. Record review of R99's Order Summary Report located under the Orders tab in the EMR revealed an order for Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject five unit subcutaneously before meals for DM and Insulin Lispro Injection Solution 100 UNIT/ML. Inject as per sliding scale subcutaneously before meals and at bedtime for DM. During an observation on 06/10/26 at 11:57 AM, LPN1 removed an insulin lispro insulin pen from the box in the bottom drawer of the medication cart, removed the cap, placed a needle on the pen, dialed 11 units on the pen and injected the insulin into R99's left abdomen. LPN1 did not prime the insulin pen prior to the injection. During an interview with the facility Director of Nursing (DON) on 06/10/26 at 4:56 PM, the DON revealed they had confirmed the insulin pens were to be primed before each use. The DON stated they had contacted the pharmacy and verified this and they will need to re-educate the nurses because they understood the insulin pens were already pre-primed and they were not. Record review of an undated and untitled document provided by the facility revealed there were 38 residents listed used an insulin pen. Review of the undated facility document Insulin Pen Administration received from the facility DON on 06/11/26 identified by the DON as the correct insulin pen administration procedure revealed the following: Prime the insulin pen prior to every single dose. Priming before each administration confirms the correct dose is being administered to the patient. NJAC 8:39-29.2(d)

Based on observation, interview, record review, and policy review, the facility failed to clean the glucose testing meter in a manner approved by the manufacturer and failed to clean the insulin pen stoppers prior to insulin administration. This failure had the potential to place residents at risk for cross contamination. This failure affected six residents, (Resident (R)18, R41, R63, R98, R99, and R113). The facility identified 41 residents potentially affected by this failure.Findings include: 1. Record review of R63's admission Record located under the Profile tab of the Electronic Medical Record EMR revealed an admission date of 02/03/23 with a diagnosis of diabetes mellitus. Record review of R63's Order Summary Report located under the Orders tab in the EMR revealed an order for Insulin Lispro Subcutaneous (under the skin) Solution Pen-injector 100 unit/ milliliter (ML.0++) inject as per sliding scale and an order for Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) inject 20 units subcutaneously with meals for Diabetes Mellitus (DM ). During an observation on 06/09/26 at 10:10 AM, Licensed Practical Nurse (LPN)1 performed a blood sugar check for R63 by taking the EvenCare G3 meter 1 into R63's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN1 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. LPN1 used a Microkill One wipe wiping the meter for 10 seconds and laid it on a towel on the medication cart. The meter was dry within 10 seconds. During an observation on 06/09/26 at 12:36 PM, LPN1 performed a blood sugar check for R63 by taking the EvenCare G3 meter 2 into R63's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN1 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. LPN1 used a Microkill One wipe wiping the meter for 10 seconds and laid it on a towel on the medication cart. The meter was dry within 10 seconds. During an observation on 06/09/26 at 12:44 PM, LPN1removed the cap from an insulin pen, inserted a needle into the rubber stopper on the insulin pen, dialed four units on an insulin lispro Quikpen then injected the insulin into R63's left abdomen. LPN1 did not clean the rubber stopper on the insulin pen prior to applying the needle and injecting the insulin. During an observation on 06/09/26 at 12:46 PM, LPN1 removed the cap from an insulin pen, inserted a needle into the rubber stopper on the insulin pen, dialed 20 units of insulin lispro on an insulin lispro Quikpen then injected the insulin into R63's right abdomen. LPN1 did not clean the rubber stopper on the insulin pen prior to applying the needle and injecting the insulin. 2. Record review of R98's admission Record located under the Profile tab of the EMR revealed an admission date of 04/07/23 with a diagnosis of diabetes mellitus. Record review of R98's Order Summary Report located under the Orders tab of the EMR revealed and order for Humalog KwikPen Subcutaneous Solution Pen-injector100 UNIT/ML Inject as per sliding scale before meals for DM. During an observation on 06/10/26 at 11:32 AM, LPN1 performed a blood sugar check for R98 by taking the EvenCare G3 meter 1 into R98's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN1 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. LPN1 used a Microkill Bleach wipe wiping the meter for 10 seconds and laid it on a towel on the medication cart. The meter was dry within 20 seconds. During an observation on 06/10/26 at 11:37 AM, LPN1 removed a Humalog Quikpen insulin pen from a case in the bottom drawer of the medication cart, removed the cap from an insulin pen, inserted a needle into the rubber stopper on the insulin pen, and dialed two units. LPN1 did not clean the rubber stopper on the insulin pen prior to applying the needle and injecting the insulin. 3. Record review of R41's admission Record located under the Profile tab of the EMR revealed an admission date of 09/16/22 with a diagnosis of diabetes mellitus. Record review of R41's Order Summary Report located under the Orders tab of the EMR revealed and order for NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject as per sliding scale subcutaneously before meals for DM. During an observation on 06/10/26 at 11:45 AM, LPN1 performed a blood sugar check for R41 by taking the EvenCare G3 meter 2 into R41's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN1 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. LPN1 used a Microkill Bleach wipe wiping the meter for 15 seconds and laid it on a towel on the medication cart. The meter was dry within 20 seconds. Further observation revealed LPN1 then retrieved a Novolog Flexpen from a box in the bottom drawer of the medication cart, removed the cap and placed a needle onto the end, dialed three units, and took the pen into R41's room and injected the insulin into R41's left abdomen. LPN1 did not clean the rubber stopper on the insulin pen prior to applying the needle and injecting the insulin. 4. Record review of 99's admission Record located under the Profile tab of the EMR revealed an admission date of 09/04/23 with a diagnosis of diabetes mellitus. Record review of R99's Order Summary Report located under the Orders tab in the EMR revealed an order for Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML Inject five unit subcutaneously before meals for DM and Insulin Lispro Injection Solution 100 UNIT/ML. Inject as per sliding scale subcutaneously before meals and at bedtime for DM. During an observation on 06/09/26 at 11:56 AM, LPN1 performed a blood sugar check for R99 by taking the EvenCare G3 meter 1 into R99's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN1 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. During an observation on 06/10/26 at 11:57 AM, LPN1 removed an insulin lispro insulin pen from the box in the bottom drawer of the medication cart, removed the cap, placed a needle on the pen, dialed 11 units on the pen and injected the insulin into R99's left abdomen. LPN1 did not clean the rubber stopper on the insulin pen prior to applying the needle and injecting the insulin. LPN1 then went out of R99's room to the medication cart and LPN1 used a Microkill Bleach wipe wiping the glucose meter for 14 seconds and laid it on a towel on the medication cart. The meter was dry within 20 seconds. 5. During an observation on 06/09/26 at 4:44 PM LPN5 performed a blood sugar check for R113 by taking the EvenCare G3 meter 1 into R113's room, lancing the finger, obtaining a drop of blood, handling the resident's hand to place the drop of blood on the strip in the meter, then removing the strip with the blood on it. LPN5 then gathered the testing items including the lancet, strip with the blood on it, and the meter and took the items out to the cart handling all of the items together with the same gloved hands. LPN5 used a Microkill Bleach wipe scrubbing the meter for 30 seconds and laid it on a towel on the medication cart. It was dry within 20 seconds. 6. During an interview on 06/09/26 at 4:54 PM, LPN1 revealed they had completed blood glucose checks using the EvenCare G3 glucose meter 1 for R63, R18, and EvenCare G3 glucose meter 2 for R98. LPN1 revealed they had used the MicroKill Two wipes to clean the meter between tR63 and R18 and after R98 used the meter. LPN1 opened the medication cart and observation at that time revealed there were no bleach wipes on the medication cart. The only wipes observed on the medication cart were the MicroKill Two wipes. LPN-1 revealed the EvenCare G3 glucose testing meters were utilized by multiple residents and that the residents did not have their own glucose testing meters. LPN-1 reported there were 2 meters on the medication cart, 1 and 2 that they used and alternated back and forth between residents and the meters were utilized for all of the residents and were not specifically designated for certain residents. During an interview on 06/10/2026 at 1:50 PM the DON confirmed the nurses were expected to clean the stopper on the insulin pen with alcohol before putting the needle onto the pen. During an interview on 06/11/26 at 9:17 AM the DON revealed the nurses were to follow the label directions on the disinfectant for contact time of the cleanser. Record review of the Order Listing Report dated 06/10/26 received from the DON and identified by the DON as a list of residents who receive insulin via insulin pen revealed there were 38 residents listed. Record review of the facility document Active Accu-Check Orders dated 06/09/26 received from the DON and identified by the DON as a list of residents who have blood glucose checks using the EvenCare G3 meters revealed there were 41 residents in the facility who utilized the EvenCare G3 glucose meters. Record review of the undated procedure Insulin Pen Administration provided by the facility DON (Director of Nursing) revealed the following: Wipe the rubber seal and the area of injection with an alcohol swab (use a different alcohol swab for each of these actions). Review of the facility policy EVENCARE G3 Meter - Cleaning and Disinfecting updated May 2024 revealed the following: The EVENCARE G3 Meter must be cleaned and disinfected between each patient. Step 1. Wash hands with soap and water and don gloves. Step 2. lnspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 3. Wipe all external areas of the meter including both the front and back surfaces until visibly clean using an approved disinfectant wipe. Avoid wetting the meter test strip port. Note - No actual drying time is necessary before starting the disinfecting procedure. Step 4. To disinfect the meter, wipe all external areas of the meter including both front and back surfaces until visibly wet using an approved disinfecting wipe. Avoid wetting the meter test strip port. Step 5. Allow exteriors to remain wet for the appropriate contact time and then wipe the meter dry with a clean cloth or place the meter on a barrier such as a paper towel and allow it to air dry. Step 6. Remove gloves. Disposal of infectious material: Blood, body fluids and cleaning materials should be disposed of according to federal, state, and local regulations for infectious waste disposal. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: Medline Micro-Kill Bleach Germicidal Bleach Wipes Contact Time 30 seconds Dispatcho Hospital Cleaner Disinfectant Towels with Bleach Contact Time l minute Clorox Healthcare Bleach Germicidal and Disinfectant Wipes Contact time l minute Other EPA registered wipes may be used for disinfecting the EVENCARE G3 system, however, these wipes have not been validated and could affect the performance of your meter. Review of the undated EvenCare G3 User's Guide revealed the following: Cleaning and Disinfecting Procedures for the Meter The EVENCARE G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) Medline Micro-Kill+™ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) Medline Micro-Kill™ Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1) Note: These disinfectants were validated separately; therefore, only one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeable has not been evaluated. Materials needed: EVENCARE G3 Meter Gloves A validated disinfecting wipe Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the EVENCARE G3 system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Record Review of the undated Micro-Kill Bleach manufacturer's specifications provided by the facility DON revealed the following: Micro-Kill Bleach Germicidal Bleach Wipes: kills Clostridium difficile spores in 3 minutes and Candida auris in 2 minutes. Common uses: For disinfection of glucose meters, patient care equipment, point-of-care equipment, and hard, non-porous healthcare surfaces. See label for specific instructions for use. Micro-Kill Bleach Wipes contact times. Contact time for a disinfectant is the amount of time a surface must remain wet with the product to achieve disinfection. Review of the manufacturer's website revealed the following specifications for the following products: Micro-Kill Bleach wipes: Premoistened with solution equivalent to 1:10 dilution of 6.5% bleach is effective against 62 microorganisms including Acinetobacter baumannii-MDR, Klebsiella pneumoniae, E. coli, MRSA, VRE, VRSA, and VISA EPA-registered product that kills Clostridium difficile spores in 3 minutes and Candida auris in 2 minutes. See product label for directions for use and more kill claims. Kills 99.999% of SARS-CoV-2 virus on hard, nonporous surfaces in 30 seconds. Micro-Kill One Germicidal Alcohol Wipes: Durable, low-line polypropylene cloth that features quaternary ammonium and alcohol solution that kills TB, Norovirus, Rotavirus and Rhinovirus in one minute. Micro-Kill Two Wipes: One-step clean and disinfection for hard, nonporous surfaces. Bactericidal, tuberculocidal, fungicidal and virucidal. Effective against SARS-CoV-2, Candida auris, and TB in 2 minutes or less. NJAC 8:39-19.4

Based on observations, record review, interviews and policy review, the facility failed to provide treatment and care in accordance with professional standards of practice, the resident's comprehensive care plan, and the resident choice when an Licensed Practical Nurse (LPN) administered narcotic pain medication without a physician order for one of one resident (Resident (R)46). This had the potential to affect the resident's physical, mental, and psychosocial well-being. The total sample was 37.Findings include: Review of R46's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses which included Von Willebrand disease, urinary tract infection, kidney failure, uterovaginal prolapse, rectocele, and repeated falls. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/26 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of R46's Care Plan, dated 05/05/26, located in the Care Plan tab of the EMR revealed a Focus area of Chronic Pain. Interventions included administering analgesia as per orders, anticipate my need for pain relief and respond to reports and sign/symptoms of pain. Review of the current Physician Orders located in the Orders tab of the EMR indicated on 05/05/26 R46 included Morphine Sulfate Extended Release (ER) 30 Milligram (MG) one capsule orally every eight hours (6:00 AM, 2:00 PM and 10:00 PM) for chronic pain for 14 days until finished. The order started on 05/05/26 and ended on 05/19/26. A review of the May 2026 Medication Administration Record (MAR) located under the Order tab of EMR indicated R46 administered the final doses of Morphine 30 mg. on 05/21/26 at 2:00 PM. There were no active orders for Morphine 30 mg. documented until 05/24/26 at 10:00 PM. A review of the May 2026 Narcotic Sign-Out sheet provided by the facility revealed a dose of 30 mg. Morphine had been signed out on 05/22/26 at 9:30 PM and on 05/23/26 at 6:00 AM by LPN 13 for R46. There was no documentation in the EMR the medication had been administrated to R46. There was no documentation the physician had been notified of the need for Morphine for consistent pain control for R46 until 05/24/26 at 10:00 PM. During an interview on 06/08/26 at 12:16 PM, R46 stated he/she had been on pain medication since 1990. R46 stated he/she has a pain control plan that includes schedule Morphine and during the Memorial holiday he/she had an interruption in that medication which caused his/her some anxiety. During an interview on 06/10/26 at 2:26 PM the Consulting Pharmacist (CP) stated that Morphine was a medication that should not be stopped abruptly. The CP stated that it would have needed another physician review to be re-ordered. During an interview on 06/11/26 at 10:01 AM Licensed Practical Nurse (LPN) 14 stated the medication should not have been stopped. LPN 14 stated he/she did give the last dose but did not think to alert the physician. During an interview on 06/11/26 at 2:12 PM the Medical Director stated that someone who has used Morphine for close to 40 years would be considered dependent on the medication. The Medical Director stated that Morphine is not a medication that should be stopped abruptly and that a physician is always available to the facility who could have prescribed the medication. During an interview on 06/11/26 at 4:20 PM R46 stated he/she has been on a pain control plan using Morphine since 1990. R46 stated he/she can maintain a bearable pain level on this dose. R46 stated he/she realized on 05/24/26 that his/her pain medication was not in his/her medication and alerted LPN6. R46 stated he/she always looks at his/her medication and knows what he/she is getting. During an interview on 06/11/26 at 5:22 PM the Director of Nursing (DON) stated that she received a call late night on 05/24/26 from Licensed Practical Nurse (LPN)6 to inform her that R46 was requesting pain medication for which there was no order. The DON stated he/she looked at R46's EMR to confirm the orders and then placed a call to the Medical [NAME] (MD) to obtain an order for Morphine 30 mg. During an interview on 06/11/26 at 6:55 PM the DON confirmed there was no active order in place for Morphine 30mg on 05/21 and 05/22 and the medication should not have been given until an active order was in place. The DON stated the error should have been reported to him/her and the MD should have been notified. During an interview on 06/13/26 at 8:35 AM LPN13 stated he/she always looks at the MAR at the start of his/her shift to see scheduled medications. LPN13 stated she was sure she had seen this medication on R46 Mar and that is why she would have administered it. LPN13 stated she would have initialed the medication as given on the MAR and confirmed her initials were not on the MAR for the medication administered on 05/21/26 and 05/22/26. LPN13 stated if a medication error occurs, they are to notify the DON and the MD immediately. LPN13 stated he/she did not notify the DON or the MD because he/she was not aware of the error. A review of the facility's policy titled, Administering Pain Medication, dated April 2025 indicated that the pain management program is based on appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident choices related to pain management. NJAC 8:39-27.1(a)

Based on record review and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for two of four residents (Resident (R)108 and R67) reviewed for abuse out of 37 sampled residents. This had the potential for continued abuse to the residents.Findings include: 1. Review of R108's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified dementia and major depressive disorder. Review of R108's Care Plan, initiated on 08/30/23 and located under the Care Plan tab of the EMR, revealed, . The resident is at potential risk for elopement related to dementia and poor impulse control . Further review revealed interventions in place were to engage R108 in group activities and redirect during wandering episodes. Review of R108's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. Review of R108's Nurses Note, written on 04/23/26 by Licensed Practical Nurse (LPN) 3 and located under the Notes tab of the EMR, revealed, . around 7 PM while standing in front of back hall med [medication] cart overheard loud voices coming from the end of the hallway in [room number removed]. This nurse immediately responded to a commotion in [room number removed]. [R67] observed, sitting on the floor upright position back resting on the wall, facing his bed. Another resident observed in the room [R108] being followed by [Certified Nurse Assistant (CNA) 10]. Both residents appeared to be involved in an altercation. This writer asks [R67] what happened? No direct response received, instead [he/she] stated, get off my stuff or I will punch you in the face! Response directed to [R108]. Both [R108] and [R67] were evaluated for injury no injuries noted. Denies pain or discomfort. Full ROM [range of motion] to all extremities. Both residents immediately separated and closely monitored. Supervisor immediately notified to assist with incident. 2. Review of R67's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia. Review of R67's Care Plan, initiated on 03/28/24 and located under the Care Plan tab of the EMR, revealed . The resident has potential to demonstrate physical behaviors related to dementia and poor impulse control . Further review revealed interventions in place were to analyze key times, places, circumstances, and triggers, to de-escalate the behavior and document, to encourage the resident to call staff when other residents entered his room, and to monitor and document the observed behavior and attempted interventions in the behavior log. Review of R67's annual MDS, with an ARD of 03/30/26 and located under the MDS tab of the EMR, revealed a BIMS score of 08 out of 15, which indicated severely impaired cognition. Review of R67's Nurses Note, written on 04/23/26 by LPN8 and located under the Notes tab of the EMR, revealed, . this nurse was notified by staff that [R67] punched another resident in the back . Skin intact, no new concerns. This nurse placed call to provider and spoke with NP [nurse practitioner]. Facility protocol was initiated and police were notified. DON [Director of Nursing] and Administrator were notified. This nurse spoke with family, and [he/she] stated that [he/she] would like [his/her family member] to be seen by psych because he had recent adjustments to his medications and been having increased anxiety. Currently [R67] is resting in his room and care is ongoing. Review of R67's Nurses Note, written on 04/24/26 by Social Services Director (SSD) and located under the Notes tab of the EMR, revealed, . SS [social services] went to see [R67] to discuss the incident last night. He/She stated the other resident went into his/her room and was trying to get in his/her bed, so he/she hit him. [R67] feels safe here and is not afraid of anyone. SS informed him/her that next time he/she should call the staff to redirect him/her. Review of facility's LTC [long-term care] Reportable Event Summary dated 04/24/26 at 12:30 PM and written by the Administrator revealed, . At approximately 7pm, [R108] wandered into [R67's] room. [R67] followed [R108] into [his/her] room and stated, [he/she] was touching my stuff. [R67] told [R108] to leave [his/her] room. As [R108] was exiting the room and [R67] was witness [sic] by staff hitting [R108] in the back. The CNA stepped in between the two residents to intervene. R67 lost [his/her] balance and fell to the floor with no injury. Further review revealed the conclusion was [R108] wandered down the hallway and entered [R67's] room. [R67] became upset and hit [R108] as [he/she] was leaving room with staff present. During an interview on 06/10/26 at 1:03 PM, LPN3 said that on 04/23/26 he/she was getting ready for the end of the shift when he/she heard staff screaming for help. Upon arriving at the scene, LPN3 observed R108 exiting R67's room and observed R67 sitting on the floor in his/her room. LPN3 further reported that CNA10 stated that R108 had touched R67's personal belongings, causing R67 to become upset and hit R108. During an interview on 06/10/26 at 2:54 PM, LPN8 said that LPN3 informed her on 04/23/26 that R67 punched R108 in the back. It was reported to the supervisor and they got staff statements and made notifications to the family and physician. During an interview on 06/10/26 at 4:58 PM, CNA10 said he/she was in another resident's room providing care when he/she heard R67 yell, get out. CNA10 reported going into the hallway, looking into R67's room, and observing R67 punching R108 in the back. CNA10 stated he/she intervened and removed R108 from the room and was then assigned to monitor R108 for the remainder of the shift. CNA10 further reported that R108 had both good days and bad days. During an interview on 06/11/26 at 7:05 PM, the DON stated that all residents have the right to be free from abuse and that the facility tries hard to ensure resident safety in interactions with other residents. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f)

Based on record review and interviews, the facility failed to ensure a resident's safety after a staff member entered through a door striking the resident in the head causing a laceration for one (Resident (R) 108) of one resident reviewed for accident hazards out of a sample of 37 residents. This had the potential to affect all residents in the facility. Findings include: Review of R108's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and major depressive disorder. Review of R108's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severely impaired cognition. Review of R108's Care Plan, dated 02/29/24 and located in the EMR under the Care Plan tab, revealed, The resident uses antianxiety medication. Interventions in place were to administer the medication as ordered, observe for effectiveness and side effects, consult with the physician to consider dosage reduction when clinically indicated, and educate the resident/family about the risks, benefits, and side effects. An intervention also included that the medication was associated with increased risk of confusion, loss of balance, and cognitive impairment. Review of R108's Incident Report dated 06/05/26 revealed it was written by Licensed Practical Nurse (LPN) 3 and signed by LPN3 but was unsigned by a supervisor or manager. Further review revealed, Received report from staff about an incident that happened approximately around 2:00 PM when a dietary staff coming in to the unit opened the door and hit resident's [R108's] forehead while resident was approaching the door at the same time. Observed with minimal bleeding to the forehead. Bleeding controlled with gentle pressure. Cleanse [sic] with NSS [normal saline], applied bacitracin and covered with dry dressing. No report of losing consciousness. The physician was made aware. Family notified. Small linear laceration with minimal bleeding observed. Surrounding skin intact with mild redness no swelling noted. Review of R108's skin assessment dated [DATE], located in the EMR under the Assessments tab, revealed a laceration to the center of his/her forehead No measurements were noted. During an interview on 06/10/26 at 1:03, LPN3 said that Certified Nurse Aide (CNA) 4 came and told her that R108 was hit by the door of the unit by one of the dietary staff. LPN3 stated she did not ask the CNA who the dietary staff was, but she reported it to the Director of Nursing (DON). He/She stated there are windows on the door to the unit, but that staff should still pay attention when opening the doors to ensure there were no residents close by. LPN3 further stated R108 was a wanderer and staff should be monitoring him and redirecting him/her away from the doors to make sure he was not close to the door when someone came onto the unit. She said it was all staffs' responsibility to make sure residents were safe on the units. During an interview on 06/11/26 at 9:04 AM, CNA7 stated R108 paced up and down the hall all day and staff were supposed to monitor him/her on the unit when he/she wandered and ensure his/her safety. CNA7 reported that on 6/05/26 he/she was returning to the unit after coming off break when one of the kitchen aides came to collect the big bins. CNA7 observed the kitchen aide open the door to the unit, which struck R108 in the head. CNA7 said there were windows, but he/she thought that R108 was in the blind spot. R108 frequently remained near the doors and staff were supposed to monitor him and open the doors carefully. CNA7 stated she did not remember the staff looking through the door windows before opening it to ensure no residents were close. He/She further indicated the staff would have had to swing the door with enough force to hit R108 hard enough to cut his/her head. He/She notified the nurse of the incident and stated he/she was never interviewed or asked to provide a written statement. During an interview on 06/11/26 at 7:05 PM, the DON stated that staff should be careful when opening the doors to go onto the Maple Unit. He/She stated there were windows and staff could see in to see if there were any residents near. The DON reported he/she had not reviewed the incident yet and that he/she had not identified who the staff member was to provide re-education. The DON further reported that he/she was unaware that a staff member had hit R108 with the door because the nurse only told him/her that R108 was hit by a door. NJAC 8:39-27.1(a)

Based on interview, record review, and policy review, the facility failed to ensure that a resident who required extensive to total assistance with bathing received bathing services in accordance with physician orders, facility policy, and the resident's assessed needs for one of seven residents (Resident (R) 16) reviewed for activities of daily living. This failure placed R16 at risk for poor hygiene, compromised skin integrity (including increased risk for skin breakdown and infection), decreased dignity, and reduced quality of life.Findings include:Review of R16's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including heart attack, stroke, hemiplegia and hemiparesis, peripheral vascular disease, weakness, dependence on renal dialysis, and need for assistance with personal care. Review of R16's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date of 06/04/26 indicated she was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The assessment revealed R16 was totally dependent on staff for showering; R16 also required assistance with bed mobility and had impaired range of motion on one side. Review of R16's Care Plan, dated 01/15/26 and located under the Care Plan tab of the EMR revealed a self-care performance deficit related to generalized weakness and directed staff to provide assistance by two staff members for all care. The Care Plan documented, Personal hygiene: I require staff assistance with grooming/personal hygiene; however, it did not address R16's shower preferences, shower schedule, or level of assistance needed for showers. Review of R16's EMR under the Orders tab revealed a physician order, dated 06/01/26, directing he/she receive showers twice weekly on Mondays and Thursdays during the evening shift. Review of R16's EMR under the Tasks tab revealed no recorded shower documentation. Review of R16's May 2025 and June 2025 Medication Administration Record (MAR) located under the Orders tab of the EMR revealed showers were recorded on 05/04/26, 05/11/26, 05/18/26, 05/25/26, 06/04/26, and 06/08/26, which did not reflect the ordered frequency of twice weekly bathing. During an interview on 06/09/26 at 9:02 AM, R16 stated he/she did not get two showers per week but would like to stick to that schedule. R16 reported he/she did not know what his/her shower schedule was because it was not done routinely. R16 stated he/she did not get showered often enough. During an interview on 06/11/`26 at 3:20 PM, Certified Nurse Aide (CNA) 1 indicated R16 went to dialysis on Mondays and often did not return until later in the evening, and by the time R16 ate dinner it was too late for a shower. CNA1 stated R16's EMR under the Tasks tab should have had entries to document whether or not a shower was given on the scheduled days; however, these entries were not in the chart. CNA1 stated there was no other place where a CNA would document whether a shower was given or information such as a refusal of a shower or whether a bed bath was given instead. During an interview on 06/11/26 at 3:43 PM, Registered Nurse (RN) 2, who served as the Unit Manager, stated R16 was expected to receive bathing services twice weekly, either shower or bed bath, and that refusals should be communicated by aides. RN2 acknowledged R16's MAR did not indicate showers were provided per his/her physician's order. RN2 stated there was no other place where a nurse would document whether a shower was given or information such as a refusal of a shower or whether a bed bath was given instead. Review of the facility's policy titled, Bathing and Showering, dated 02/19/24, revealed, The facility will offer showers and tub baths to residents in accordance with their preferences . The interdisciplinary team will develop bathing/showering schedules with resident and/or resident representative input . Provision and refusals of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse. NJAC 8:39-4.1(a)22

Based on observations, record review, interviews and policy review, the facility failed to notify the physician when opioid pain medication was administered to one of one resident (Resident (R) 46) without an order. The total survey sample was 37Findings include:Review of R46's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses which included Von Willebrand disease, urinary tract infection, kidney failure, uterovaginal prolapse, rectocele, and repeated falls. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/26 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of the current Physician Orders located in the Orders tab of the EMR indicated on 05/05/26 R46 had an order for Morphine Sulfate Extended Release (ER) 30 Milligram (MG) one capsule orally every eight hours (6:00 AM, 2:00 PM and 10:00 PM) for chronic pain for 14 days until finished. A review of the R46's Care Plan, dated 05/05/26, located in the Care Plan tab revealed a Focus area of Chronic Pain. Interventions included administered analgesia as per orders. A review of the May 2026 Medication Administration Record (MAR) indicated R46 was administered the final doses of Morphine 30 mg. on 05/21/26 at 2:00 PM. There were no active orders for Morphine 30 mg. documented until 05/24/26 at 10:00 PM. A review of the May 2026 Narcotic Sign-Out sheet provided by the facility revealed a dose of 30 mg. Morphine had been signed out on 05/22/26 at 9:30 PM and on 05/23/26 at 6:00 AM by LPN 13 for R46There was no documentation the physician had been notified of the need for Morphine for consistent pain control for R46 until 05/24/26 at 10:00 PM. There was no documentation that the physician had been notified of Morphine 30 mg. being administered to R46 without an active order in place. During an interview on 06/11/26 at 6:55 PM the DON confirmed there was no active order in place for Morphine 30mg on 05/21 and 05/22 and the medication should not have been given until an active order was in place. The DON stated the error should have been reported to him/her and the MD should have been notified. During an interview on 06/13/26 at 8:35 AM LPN 13 stated he/she always looks at the MAR at the start of his/her shift to see scheduled medications. LPN13 stated he/she was sure he/she had seen this medication on R46 Mar and that is why he/she would have administered it. LPN 13 stated she would have initialed the medication as given on the MAR and confirmed her initials were not on the MAR for the medication administered on 05/21/26 and 05/22/26. LPN 13 stated if a medication error occurs, they are to notify the DON and the MD immediately. LPN 13 stated she did not notify the DON or the MD because she was not aware of the error. A review of the facility's policy titled, Change in a Resident's Condition or Status, dated February 2021, indicated that the facility will promptly notify the physician when there is an accident or incident involving the resident. NJAC 8:39-4.1(a) NJAC 8:39-5.1(a) NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for one of three residents (Resident (R) 134) reviewed for side rails out of 37 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include: Review of R134's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar disorder, and depression. Review of R134's Physician Orders located under the Orders tab in the EMR, dated 08/15/25, revealed half side rail use as a patient enabler. Review of R134's Care Plan located under the Care Plan tab of the EMR, dated 08/25/25, revealed R134 used bed rails for mobility. Review of R134's MQS-Quarterly Packet-Bedrails located under Assessments tab in the EMR, dated 11/07/25, revealed no evidence that alternates were attempted prior to bed rail installation. Observations on 06/08/26 at 1:35 PM revealed R134 in bed with side rails on both sides. During an interview on 06/10/26 at 1:03 PM, Licensed Practical Nurse (LPN) 3 said that all beds have bed rails preinstalled. He/She stated for residents that do not want bed rails, they can leave the side rails in the down position. Alternatives were not explored prior to bed rail use/installation. On admission all residents or families were asked if they wanted bed rails or not. During an interview on 06/11/26 at 7:05 PM, the Director of Nursing stated all beds have bed rails preinstalled. They either have bedrails in the up or down position. Review of the facility's policy titled Bed safety and Bedrails revised August 2022 revealed, Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Before using bed rails for any reason, the staff shall inform the resident or representative about thebenefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:a. The assessed medical needs that will be addressed with the use of bed rails;b. The resident's risks from the use of bed rails and how these will be mitigated;c. The alternatives that were attempted but failed to meet the resident's needs; andd. The alternatives that were considered but not attempted and the reasons. NJAC 8:39-27.1(a)

Based on observations, record review, and interviews, the facility failed to provide a copy of the baseline care plan for one of 36 residents (Resident (R) 46). This failure had the potential to interfere with the continuity of care and safeguard against adverse events that are more likely to occur right after admission.Findings include: A review of the facility's policy titled Care Plans-Baseline dated March 2022 indicated a Baseline Care plan is developed within 48 hours and a copy is provided to the resident and/or the representative. Review of R46's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses which included Von Willebrand disease, urinary tract infection, kidney failure, uterovaginal prolapse, rectocele, and repeated falls. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/26 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was moderately impaired.During an interview on 06/08/26 at 12:16 PM, R46 stated she did not receive a copy of the baseline care plan when she was admitted . A review of R46's Progress Notes, dated 05/06/26, located in the Progress Notes tab revealed an initial guide navigation meeting note. Review of the note revealed the Baseline Care Plan Review with copies provided to Resident/Caregiver was blank with no indication a copy was provided to the resident. During an interview on 06/11/26 at 10:59 AM the Social Worker Director (SWD) stated she always gives a copy of the Baseline Care Plan with a list of medication to the resident during the initial guide navigation meeting. The SWD stated that if she had given a copy to the resident, it would have been documented in the chart. The SWD stated if she didn't document it, she should have. NJAC 8:39-11.1 NJAC 8:39-11.2

Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed for one of one resident (Resident (R) 134) reviewed for PASARR out of 37 sampled residents. This failure had the potential to affect resident ability to receive needed services. Findings include: Review of R134's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar disorder, and depression. Review of R134's Preadmission Screening and Resident Review, dated 08/12/25 and located in the resident's EMR under the Miscellaneous tab, revealed no diagnosis or indication of mental illness (MI) identified. Review of R134's Medical Diagnosis list in the EMR revealed schizophrenia, bipolar disorder, and depression were present on admission. During an interview on 06/11/26 at 3:30 PM, the Social Services Director (SSD) stated he/she was responsible for reviewing the PASARR that was completed and sent by the hospital for accuracy. He/She stated it was an oversight and she missed that R134's PASARR was not done correctly, as all of his/her mental illness diagnoses were not listed. During an interview on 06/11/26 at 7:05 PM, the Director of Nursing stated she expected a residents PASARR to be completed accurately. NJAC 8:39-5.1(a)

Based on record review, interview, and policy review, the facility failed to ensure the discharge tracking Minimum Data Set assessments were completed for one of 37 sampled residents (Resident (R) 152. The failure created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care.Findings include:Review of R152's admission Record located under the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic respiratory failure, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, and vertigo. Review of R152's Care Plan dated 01/20/26 and located under the Care Plan tab of the EMR revealed, I am at risk for falls r/t [related to] deconditioning/ weakness, unsteady gait, [and] dizziness. Review of R152's quarterly MDS with an Assessment Reference Date (ARD) of 01/26/26 and located under the MDS tab of the EMR revealed R152 experienced one fall with no injury over the previous three months or since the prior assessment (10/29/25). Review of R152's Health Status Note located under the Progress Notes tab and dated 12/4/25 revealed R152 experienced a fall with knee pain. R152 had an x-ray, which was negative for fracture. Review of R152's Health Status Note located under the Progress Notes tab and dated 01/17/26 she was observed sitting on the floor beside her wheelchair in the bathroom. There were no injuries noted. Review of R152's Health Status Note located under the Progress Notes tab and dated 1/20/26 revealed she was observed on the floor in a sitting position next to the wheelchair and the toilet. There were no injuries noted. During an interview on 06/11/26 at 1:50 PM, the MDS Coordinator (MDSC) stated R152 should have had three falls coded on her 01/20/26 MDS; two with no injury and one with minor injury. The MDSC stated the falls were missed and the assessment would be corrected retroactively. Review of the policy titled, MDS 3.0 Resident assessment dated [DATE] revealed, A comprehensive, accurate, standardized assessment of each resident's functional capacity will becompleted and documented. NJAC 8:39-33.2(d)

Based on record review, interview, and policy review, the facility failed to ensure the discharge tracking Minimum Data Set assessments were completed for two of nine residents (Resident (R) 48 and R114) reviewed for transfer or discharge. These failures created a potential to result in gaps in the resident's clinical record, impaired care coordination during transitions of care, and failure to ensure accurate data reporting for resident outcomes.Findings include:1. Review of R48's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] and discharged on 03/23/26. Review of R48's Health Status Note dated 03/23/26 and located under the Progress Notes tab of the EMR revealed, Patient discharged to [name of] nursing and rehabilitation center. Transport provided by [receiving facility]. discharged [sic] instructions and scripts provider [sic] to transport driver. All belongings taken by driver, 5 large bags taken. Report called in to nursing supervisor. Review of R48's EMR under the MDS tab revealed the most recent assessment was dated 02/07/26. There was no discharge assessment completed. 2. Review of R114's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] and discharged on 02/19/26. Review of R114's Health Status Note dated 02/19/26 and located under the Progress Notes tab of the EMR revealed, Resident discharged to home, all meds [medications] reviewed. Meds given and assisted to car. Review of R114's EMR under the MDS tab revealed the most recent assessment was dated 01/28/26. There was no discharge assessment completed. During an interview on 06/11/26 at 2:46 PM, the Corporate MDS Consultant (CMDSC) stated the two residents had been discharged and should have had discharge tracking assessments completed. The CMDSC stated the two discharge assessments were missed and would be completed retroactively. Review of the policy titled, MDS 3.0 Resident assessment dated [DATE] revealed, OBRA Discharge Assessment . Must be completed when the resident is discharged from the facility. NJAC 8:39-11.2

Based on observation, interview and document review, it was determined that the facility failed to immediately address the smell of natural gas in the kitchen. Observations conducted on 1/29/25 at 8:30 AM and 8:40 AM, with two surveyors, and interviews conducted that same day confirmed the smell of natural gas was present on 1/29/25, and the facility used a lighter to regularly light the gas stove. The facility's failure to address the natural gas smell, while utilizing a lighter to light the stove top burners, placed all residents at risk from an explosion or fire and resulted in an Immediate Jeopardy (IJ) Situation. The IJ began on 1/29/25 at 8:30 AM, and the Licensed Nursing Home Administrator (LNHA) was provided the IJ template on 1/29/25 at 11:20 AM. The facility provided an acceptable Removal Plan (RP) which was verified on-site by the survey team on 1/29/25 at 2:36 PM. The evidence was as follows: On 1/29/25 8:17 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Regional Director of Dining (RDD). At 8:30 AM, the surveyor approached the cooking area and observed the strong smell of natural gas was present and then observed a large lighter was directly opposite of the stove on top of a metal table. At that time, the surveyor asked the RDD what the smell was, and the RDD stated it was gas, and stated, the pilot light was out, and the staff needed to use the lighter to light the stove. The surveyor asked the RDD how long the staff have been using the lighter to light the stove, and he stated, not today. The surveyor then asked the RDD if you needed to light the stove with the lighter all the time, and the RDD stated, most of the time. On 1/29/25 at 8:40 AM, the surveyor asked the RDD if he had informed the LNHA of the stove not working properly and he stated he did not recall if he informed the LNHA. The surveyor then exited the kitchen and returned with a second surveyor and the LNHA. On 1/29/25 at 8:44 AM, in the kitchen, in the presence of the RDD, the LNHA and another surveyor (Surveyor #2) confirmed the smell of natural gas was present and the LNHA confirmed he was not made aware of the issue of the gas and using a lighter to light the stove. On 1/29/25 at 10:09 AM, the surveyor conducted an additional interview with the RDD regarding what could happen if gas leaked and a lighter was used, and he stated, not good, disaster. The surveyor then asked if it could explode, and he confirmed, yes. The RDD stated it was the pilot light, and the surveyor asked the RDD how he would know if it was the pilot light, and the RDD stated, he did not know for sure. The surveyor asked the RDD how long it had been an issue, and he confirmed that he did not know for sure. On 1/29/25 at 10:38 AM, the surveyor interviewed the [NAME] who confirmed she used the stove on 1/29/25, to cook eggs for the breakfast meal. The [NAME] stated she had been working at the facility for the past two months and has always had to use the lighter to light the stove. When asked if she smelled the natural gas smell that was still present, she confirmed that she smelled the gas. On 1/29/25 at 11:42 AM, the surveyor interviewed the facility Maintenance Director (MD) regarding the stove. The MD stated he was unaware that the stove was not functioning but he had been aware that the lighter was used to light the pilot lights. The MD confirmed that the stove was now turned off, and if he had known it was not working properly it would have been addressed, right away. The MD also stated that a repair person was coming to fix the stove. On 1/29/25 at 1:11 PM, the surveyor entered the kitchen and observed a repairman was working on the stove and was in the presence of the Regional Director of Operations (RDO) for the facility. The surveyor asked the repairman what was wrong with the stove and the repairman stated, right now it was going to need parts, some of the pilots [pilot lights on the range] have failed, and he stated he did not have the parts to fix the pilot lights. The surveyor asked the repairman if the pilot lights failed would gas leak from the stove? The repairman stated, yes and confirmed that gas would leak from the failed pilot lights. The repairman stated it would be a small leak, but it will leak gas. On 01/30/25 at 10:07 AM, the LNHA provided the manufacturer's Owner Manual for the stove which indicated the following: Page 1. [Manufacturer's name redacted] Ranges: WARNING: Improper installation, adjustment, alteration, service or maintenance can cause property damage, injury or death . Page 2. SAFETY PRECAUTIONS: Before installing and operating this equipment, be sure everyone involved in its operation is fully trained and aware of precautions. Accidents and problems can be caused by failure to follow fundamental rules and precautions . WARNING: In the event a gas odor is detected, shut down equipment at the main gas shut- off valve and immediately call the emergency phone number of your gas supplier. Improper ventilation can result in headaches, drowsiness, nausea, and could result in death . Page 8. OPERATION: DANGER, EXPOLSION and ASPHYXIATION HAZARD; In the event a gas odor is detected, shut down equipment at the main gas shut- off valve and immediately call the emergency phone number of your gas supplier. Improper ventilation can result in headaches, drowsiness, nausea, and could result in death . CAUTION: If top burner pilots go out, the flow of gas to the burners is NOT interrupted .Consequently, it is the responsibility of the operator to check the ignition of the burners, immediately after burner valve has been turned ON . On 2/5/25 at 10:51 AM, the RDO provided the service report from the repairman. The report indicated the following: Describe the Nature of the Problem? Pilot Light Issues; What is the fuel type of the equipment? Gas; What type of commercial appliance is being repaired? Range. The report Timeline documented the following dated communication entries that were completed by the repairman to the facility: -1/29/25, Tech [Technician] Arrived: 12:31 PM and Tech Departed 2:55 PM; The work for this job is not yet complete for the following reason: Temporarily fixed, Quote needed. Comments: As reported unit had pilots not lighting. I found the front right pilot not working and the other 5 pilots degraded. Unit needs new pilots. I shut the gas off to the right front pilot to prevent any gas leaking out . -1/30/25, . Extension Approval Timelines: failed pilots. front right pilot does not light, other 5 also are degraded. shut off the gas to the failed right front pilot so no gas will leak. [documented by repairman] -1/30/25 at 11:06 AM, We ordered a new stove. [facility's response] An acceptable Removal Plan (RP) was received on 01/29/25 at 1:09 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: the staff were immediately instructed to stop manually lighting the pilot light, the gas line was disabled at 10:30 AM, to prevent further manual lighting until repairs were made, the stove was replaced on 01/29/25. The survey team verified the RP was implemented on-site on 1/29/25 at 2:36 PM. NJAC 8:39-31.7 (d)

Complaint # NJ 173844 Based on observation, interview, record review, and document review it was determined that the facility failed to provide adequate monitoring and supervision to prevent falls with injury for a resident who was assessed as a high risk for falls. On 12/23/24, Resident #92 who had a fall and the nurse documented that the resident was on one staff-to-one resident (1:1) monitoring, had a second fall within one hour that required emergency services to transfer the resident to the hospital. The resident sustained from the fall: an acute comminuted fracture (breaks in three or more pieces) of the left inferior orbital rim (eye socket); an acute comminuted and mildly displaced fracture of the left lateral orbital rim; an acute comminuted and mildly displaced and depressed fracture of the left anterior maxillary sinus wall; left periorbital and facial soft tissue contusion with soft tissue swelling; and a laceration to left cheek that required five sutures. This deficient practice occurred for 1 of 5 residents (Resident #92) reviewed for accidents. This deficient practice was evidenced by the following: On 01/29/25 at 9:15 AM, the surveyor toured the Maple Unit of the facility and observed Resident #92 seated in a recliner chair in the dayroom with a Certified Nursing Aide (CNA) at their side. Resident #92 was observed with purplish bruises to the facial area, both eyes were closed, and the resident did not engage in a conversation with the surveyor. On 01/30/25 at 10:15 AM, the surveyor observed Resident #92 in the dayroom. The CNA was observed seated next to the resident and informed the surveyor that the resident was on 1:1 observation. On 02/04/25 at 10:30 AM, the surveyor reviewed Resident #92's electronic medical record. A review of the Admission Record face sheet (an admission summary) reflected that Resident #92 was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, major depressive disorder, restlessness and agitation, and other abnormalities of gait. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/30/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that the resident had severe cognitive impairment. Further review of the MDS indicated that Resident #92 required supervision or touching assistance for bed mobility, required moderate assistance for transfers from the bed to the chair and utilized a wheelchair. Resident #92 was coded as Yes as having falls since admission, and coded 2 for J 1900 B. Fall with injury (except major)- including skin tears, abrasions, lacerations, superficial bruises, hematoma's and sprains; or any fall related to injury that causes the resident to complain of pain, and coded 1 for J 1900 C. Fall with Major Injury- bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. On 02/05/24 at 9:46 AM, the Director of Nursing (DON) provided the following Fall Risk Evaluations which revealed: -On 01/01/24, Resident #92 received a score of 24, which indicated a high risk for falls. -On 02/04/24, Resident #92 scored 20, which indicated a high risk for falls. -On 04/20/24, Resident #92 received a score of 23, which indicated a high risk for falls. -On 11/01/24, Resident #92 received a score of 26, which indicated a high risk for falls. A review of the Progress Notes and Care Plan (CP) revealed the following fifteen falls and the interventions implemented: 1. On 01/01/24 at 10:40 AM, the resident had a fall in the resident's bathroom. Upon assessment, the resident had moderate blood on the back of their head with a small gash. Resident #92 was sent to the hospital and the resident returned with four staples to their head from the fall. A review of the CP indicated that on 01/01/24, the intervention for staff to remain within easy reach of the resident while washing in the bathroom was added. 2. On 01/14/24 at 9:06 PM, the resident was found lying on their back with the wheelchair on side. The resident stated I hit my head. Neurological checks (neuro checks; assessment to ensure neurological functions were working correctly) were started and the resident went to the hospital. The resident returned with no injuries. A review of the CP indicated that no new interventions were added post fall on 01/14/24. 3. On 01/20/24 on 12:45 AM, the resident was found lying on top of the fall mat in their room, and the resident stated that their head was hurting. The resident reported that they fell while trying to go to the bathroom. The resident was sent to the hospital and returned to the facility with no new orders. A review of the CP indicated that no new interventions were added post fall on 01/20/24. 4. On 02/08/24 at 11:30 PM, the resident was found in their room on their knees on top of the fall mat that was next to their bed. There were no injuries noted at that time. When asked what happened, the resident stated they did not know why they were getting up since they were already in the room. A review of the CP indicated that no new interventions were added post fall on 02/08/24. 5. On 02/21/24 at 4:20 AM, the resident was found on the floor in their room, and the resident stated they were trying to get some water. The resident was noted with a skin tear to the top upper mid back and a dime sized abrasion that was reddened to their right elbow. A review of the CP indicated that no new interventions were added post fall on 02/21/24. 6. On 03/01/24 at 4:58 AM, the resident was found lying on top of the fall mat noted with redness to the inside of their bottom lip along with some blood and an abrasion to the right side of their forehead. The resident stated they had fallen and did not remember where they were going. A review of the CP indicated that on 03/01/24, the interventions to keep mobility devices close at hand and check on the resident frequently to offer assistance were added. 7. On 03/21/24 at 2:16 AM, Resident #92 was noted lying on the floor near the closet door and upon assessment, the resident was noted bleeding from their left temple and a large skin tear was seen on their lower left arm. The resident was sent to the hospital and returned with an order for Dermabond (sterile liquid, topical skin adhesive) on left eyebrow to close the laceration. A review of the CP indicated that no new interventions were added post fall on 03/21/24. 8. On 04/21/24 at 6:25 AM, the CNA went into the resident's room and notified the writer that she had observed the resident fall and hit their head on the nightstand. The resident was noted with a bump to top of scalp 1 inch by 0.5 inch, and the resident was brought to the nurse's station for monitoring and safety. A review of the CP indicated that no new interventions were added post fall on 04/21/24. 9. On 05/13/24 at 1:48 AM, the CNA and the writer (nurse) went into Resident #92's room and assisted the resident into the wheelchair to be assisted to the bathroom per the resident's request. When putting the resident back to bed, the CNA called and informed the nurse that Resident #92 complained of chest pain and upon assessment, an irregular in size bruise, red and purple in color, was observed on the resident's sternum (breastbone) area. An x-ray was ordered with no evidence of a fracture but soft tissue swelling presternal region (upper segment of breastbone). A review of the CP indicated that no new interventions were added post fall on 05/13/24. 10. On 06/16/24 at 5:40 PM, the resident attempted to get out of the geriatric (geri) chair and slid to the floor. The resident denied hitting their head, and the resident stated they only hit bottom. The resident was assessed; vital signs were stable; and denied pain. A review of the CP indicated that no new interventions were added post fall on 06/16/24. 11. On 08/15/24 at 1:05 PM, the resident was found sitting on floor in the dayroom in front of a chair and upon assessment, the resident had bleeding from a small laceration to the left side of head. Treatment services were rendered to control bleeding. A review of the CP indicated that no new interventions were added post fall on 08/15/24. 12. On 08/16/24 at 9:00 PM, the resident had fallen in the dayroom and upon assessment, the resident had bleeding from small laceration to the left side of head. Treatment services were rendered to control the bleeding. The resident was transferred to the hospital and returned with an order for cefdinir (antibiotic used to treat bacterial infection) 300 mg; give one capsule by mouth every 12 hours for a urinary tract infection. A review of the CP indicated that on 08/16/24, the intervention to provide the resident a snack was added. 13. On 08/22/24 at 7:34 PM, the resident and their primary aide were walking in the hallway when Resident #92 fell . The primary aide who witnessed the incident stated, [Resident] didn't hit [their] head. The primary aide was asked how the resident ended up falling, and the primary aide stated [Resident] turned around, I literally just saw [them] going down slowly. The resident complained of pain in the sacrum (lower back) and a noted abrasion to their right elbow area. When the nurse asked the aide how the resident fell , the CNA replied, I'm not going to be here trying to chase [resident]. A review of the CP indicated on 08/23/24, the intervention to sit and rest when noted to be fatigued was added. 14. On 09/07/24 at 5:00 PM, the resident was noted to be on the floor in the dayroom sitting on their buttocks with the chair alarm still attached to the resident and the chair. The resident was assessed and no new injuries were noted. A review of the CP indicated on 09/09/24, the intervention of hospice ordered another [specialized chair] allowing resident's feet to touch the floor was added. 15. On 12/11/24 at 6:33 PM, the resident was noted to be on the floor and upon assessment, Resident #92 was noted to have a laceration with bright red blood drainage noted to the right side of eye. The resident was sent to the hospital and returned to the facility with Dermabond to top of right eye to close the laceration. A review of the CP indicated that on 12/12/24, the intervention to keep close observation when sitting in the chair was added. The following progress notes detailed two falls that occurred within one hour on 12/23/24, and revealed the following: On 12/23/24 at 5:55 AM, this nurse was notified by staff that resident had fallen. When asked what happened staff stated, I was walking resident to the bathroom and above resident lost balance and fell . The resident was unable to give an account of what happened. The supervisor was notified; Primary Care Physician (PCP) made aware; and the Resident Representative was made aware. An assessment was conducted and the resident was at baseline, no injury noted. The resident was able to move all extremities and did not hit their head per staff. The resident had no discomfort noted on assessment and personal care needs were met. The resident was made comfortable and 1:1 was in place with safety maintained. - A subsequent note, documented by the same nurse revealed: On 12/23/24 at 7:30 AM; around 6:30 AM, this nurse was notified by staff that the resident was bleeding from their face. Upon entering the resident's room, the resident was noted with blood on their face, a cut to their left cheek area, and the resident was unable to tell what happened. The supervisor and PCP were notified. An order was obtained to send the resident to the hospital. The resident's face was cleaned, bleeding was controlled, and no further cut or open area noted. An assessment was conducted, neuro checks started, and emergency services were called. The resident was sent to the hospital at 7:05 AM, for evaluation, and the family was notified. The progress note did not include the 1:1 supervision that was documented as in place for safety being maintained in the previous note on 12/23/24 at 5:55 AM, after the resident fell . On 12/24/24 at 3:31 AM, it was documented that Resident #92 returned from the hospital around 1:33 AM, with a fracture to their left orbit [eye socket] and left maxillary sinus. They had a laceration to their left cheek with five sutures and bruising and swelling was noted to their left orbit, left cheek, left side of the neck, above left eyebrow, and upper chest. Redness was also noted to their mid-back. Care was given to the resident when they returned from the hospital. New orders for Augmentin 875-125 mg (an antibiotic) for seven days to prevent infection, Mucinex 600 mg for congestion, nasal sprays for congestion, and bacitracin to sutures. As needed Morphine (narcotic pain medication) and Ativan (sedative) were given and noted to be effective. The supervisor was made aware of the resident's return and new orders. A review of the CP provided by the Director of Nursing (DON), in effect during the time of the fall, dated last revised 01/04/25, revealed the resident was at risk for falls related to confusion, reconditioning/weakness, history of falls, poor safety awareness. The goal, dated initiated 05/24/23, with a target date of 04/07/25, included risk for serious injury from falls will be mitigated with proper interventions through review date. A second goal, dated initiated 06/07/23, with a target date of 04/07/25, included the resident will be free of falls related to injury through the next review date. The interventions included: to monitor resident at nurses station when awake overnight initiated 10/17/23, to provide staff interaction during episodes of restlessness initiated 12/17/23; and the resident receives sedatives/hypnotics at night for sleep; monitor for safety throughout the night initiated 09/04/23. A review of the Emergency Department Encounter with a Date of Service of 12/23/24 at 9:58 AM, revealed: Assessment and Plan: resident on Eliquis, presented after fall. The resident was at increased fall risk and had a history of dementia and was not a reliable historian. There was a skin tear to the left cheek, ecchymosis peri-orbitally on the left, having active epistaxis from the left nare [bleeding from left nostril]. Radiology Final Results: CT scan to head or brain without Contrast: acute left facial fractures including involving the left inferior orbital rim and the left maxillary sinus walls, with adjacent fascial contusions and hemorrhage within the sinus and nasal cavity/nasopharynx; CT Facial Bones without Contrast Final Result: Acute comminuted fracture of the left inferior orbital rim . Acute comminuted and mildly displaced fracture of the left lateral orbital rim . Mild left orbital proptosis [protrusion of eye from socket]. Acute comminuted and mildly displaced and depressed fracture of the left anterior maxillary sinus wall. Acute comminuted mildly displaced fracture of the left lateral maxillary sinus wall. Left periorbital and facial soft tissue contusion with soft tissue swelling and gas related to sinus injury. Hemorrhage near completely filling the left maxillary sinus as well within the left nasal cavity and nasopharynx . On 02/05/25 at 11:01 AM, the surveyor interviewed the DON regarding Resident #92's multiple falls. The DON stated that Resident #92 needed constant redirection and was very impulsive. The DON added that all falls were discussed in the morning meeting. When inquired about the two falls that occurred on 12/23/24, which resulted in an injury requiring hospitalization , the DON was unable to explain why after the resident fell the first time, the resident sustained the second fall within one hour. A review of the facility provided Falls- Clinical Protocol dated revised 3/2018, and updated 1/2023, which indicated the following: Under Cause and Identification: For an individual who has fallen, the staff and the practitioner will begin to try to identify possible causes within 24 hours of the fall. After a fall, Clinical staff should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. The staff will continue to collect and evaluate information until the cause of the falling is identified, or it is determined that the cause cannot be found or it is not correctable. Under Treatment /Management: Based on the preceding assessment, the clinical staff will identify pertinent interventions to try to prevent subsequent falls and address the risks of clinical consequences of falling. NJAC 8:39-27.1 (a)

Complaint # NJ 165805 Based on interview, record review, and other facility documentation, it was determined that the facility failed to ensure that Resident #29 was free from neglect and received adequate supervision when a Certified Nurse Aide (CNA #1) neglected to supervise the resident. Resident #29 was found lying on the floor complaining of severe pain and CNA #1 who refused to supervise Resident #29 was found sleeping at the nurses' desk on 5/17/23 at 3:35 AM. The resident required emergent transfer to the hospital and was diagnosed with a closed fracture of the left hip that required surgical repair (open reduction external fixation). This deficient practice was identified for 1 of 1 resident (Resident #29) reviewed for neglect. The evidence was as follows: On 2/5/25 at 10:30 AM, the surveyor reviewed Resident #29's electronic medical record. The Admission Face Sheet reflected that Resident #29 was admitted to the facility with diagnoses which included but was not limited to; other lack of coordination, unspecified dementia with other behavioral disturbances, muscle wasting and atrophy. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated Resident #29 was severely cognitively impaired. The MDS further revealed that the resident needed extensive assistance with all activities of daily living (ADL; toileting, bathing, washing, etc.). A review of the Care Plan (CP), initiated on 5/4/23, included a focus area for falls related to deconditioning, weakness, and other lack of coordination. The interventions included but were not limited to; call light within reach and to provide reminders to use call bell for assistance as needed. There was also a focus area for ADL self-care performance deficit related to deconditioning and status post hospitalization , initiated on 5/4/23. One of the interventions documented was Resident #29 required a one-person physical assist with toileting. A focus area for incontinence initiated on 5/4/23, indicated I have urinary incontinence; I will not have skin breakdown due to incontinence through the review date. Interventions included to: provide incontinence care and apply moisture barrier as needed; offer/encourage toileting prior to bedtime; check resident approximately every two hours and provide incontinence care as needed. A review of a Progress Note (PN) documented by the Licensed Practical Nurse (LPN #1), dated 5/17/23 at 4:18 AM, revealed that around 3:35 AM, a thud was heard. Staff went to check where the noise came from and found Resident #29 lying on their left side by their room door. [Resident #29] stated they had to go to the bathroom. Upon assessment, the resident could be seen with their hand over their left leg complaining of pain. [Resident #29] would not let staff turn them to assess the site where they reported the pain. The on-call Medical Doctor (MD) assessed the resident via video chat and ordered to send the resident to ER [emergency room ]. The supervisor and Director of Nursing (DON) and unit manager were notified. A review of the nurse's note from the Registered Nurse/Supervisor of Nursing (RN/SON) dated 5/17/23 at 4:44 AM, included the writer was called to assess the resident who had an unwitnessed fall. Upon arrival, the resident was lying on the floor on their left side complaining of severe pain to left thigh. A complete body assessment was not completed as the resident complained of severe pain when we tried to move them. The resident denied hitting their head; no bleeding noted at this time. The MD was made aware, and paramedics were called per MD order. The resident was transferred to the ER at 4:20 AM. The Resident Representative, Licensed Nursing Home Administrator (LNHA), and DON were notified. A review of Resident #29's hospital medical record (HMR) dated 5/17/23 at 4:22 AM, included the reason for visit: fall; comments: . coming from [facility name redacted]- staff found [resident] on floor- unwitnessed fall. Hip pain: resident complaining of left hip pain . Primary diagnoses: closed fracture of left hip . On 2/5/25 at 9:40 AM, the surveyor requested the facility's investigation for review, and the DON submitted the Facility's Reportable Event record (FRE) that was forwarded to the New Jersey Department of Health (NJDOH) on 5/17/23. The FRE included no statements, and the summary provided dated 5/2023, included under investigation revealed the following: Per the Certified Nurse Aide [CNA #1], resident was last seen at 2:37 AM, and was in bed. At 3:30 AM, CNA (#2) heard a loud bang, and [Resident #29] was observed on the floor. The resident was noted in pain; new order received to be sent to hospital . Conclusion: Per hospital records, [Resident #29] sustained a fracture of the left hip. [Resident #29] will be evaluated by therapy upon return and will follow their recommendations. No abuse or neglect could be substantiated. The document was not signed. The incident occurred on 5/17/23. The surveyor reviewed the document with the DON and requested any statements from staff who were involved with Resident #29's care during the 11:00 PM-7:00 AM shift (during the time the unwitnessed fall occurred). A review of the Fall Witness Statement signed by CNA #1 revealed that the last time they saw the resident was at 2:37 AM. The resident was last toileted at 1:00 AM. CNA #1 heard a loud bang and rushed to resident room. A review of LPN #1's statement included that around 3:35 AM, she heard a thud, and staff went to check where the noise came from. Staff found [Resident #29] on the floor lying on their left side by their door, and [Resident #29] stated that they had to go to the bathroom. Upon assessment, the resident was seen with their hands over the left leg, complaining of pain. [Resident #29] would not allow staff to turn and assess the site where they were complaining of pain. The on-call MD assessed the resident via video chat and said to send resident to the ER. A review of LPN #2's statement dated 5/24/23, indicated that [Resident #29] was sleeping in bed when [CNA #1] was assigned to sit by the room side. (CNA was assigned to sit outside the resident's door and supervise them.) LPN #2 documented that both her and LPN #1 informed CNA #1 of their assignment to sit by Resident #29's door and supervise. LPN #2 documented that CNA #1 refused the assignment. LPN #1 and LPN #2 were making rounds on the unit when they heard a loud sound coming towards Resident #29's room, and they observed Resident #29 on the floor. They asked [Resident #29] if they had pain and the resident stated, yes. LPN #2 documented that CNA #1, who was assigned to supervise Resident #29, was sleeping at the nurse's desk until the nurse screamed. CNA #1 then got up and came to the scene. The paramedics were called, and the resident was taken to the hospital. On 2/5/25 at 11:15 AM, the surveyor reviewed LPN #2's statement with the DON. The DON stated that she did not review the statements, and she had not been aware that the CNA assigned to provide supervision for Resident #29 was found sleeping instead of watching the resident she was assigned to supervise. The surveyor then asked the DON what the facility protocol was if a CNA refused an assignment, and the DON stated that the nurse covered the assignment with someone else and notified the nursing supervisor immediately. The surveyor reviewed the facility provided Quality Assessment Report (incident type report) provided by the DON. The Quality Assessment Report revealed the following: Problem Statement: The resident had to go the bathroom and fell . Why 1: The resident had been toileted four hours prior. Why 2: The resident did not have to go and was asleep during next round. Root Cause: The resident was dry and asleep during last round. Awoken, self-transferred from bed and fell attempting to go the bathroom. The surveyor requested CNA #1, CNA #2, LPN #1, and LPN #2's phone numbers for interviews. The DON informed the surveyor that all four staff involved in the incident were no longer employed by the facility, and no contact information was provided. The surveyor reviewed all four staff's files (CNA #1, CNA #2, LPN #1, and LPN #2) and the incident was not documented in their employee files. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated last revised 9/2022, included: Policy Statement: All reports of resident abuse (including injuries of unknown origin) neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings off all investigations are documented and reported. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator . NJAC 8:39-4.1(a)5

Complaint #s NJ: 165805, 166524, 166709, 169246, 170726, 173844, 175487, 178803 Based on observation, interview and document review it was determined that the facility failed to have sufficient and competent nursing staff to consistently provide all related nursing services to ensure residents received care to ensure resident safety, and maintain the highest practical physical and mental well-being by failing to ensure staff provided a) appropriate and timely incontinence and nail care for residents dependent on staff for Activities of Daily Living (ADLs) care, b) resident supervision for safety, c) appropriate wound care per physician orders, d) a communication tool for a resident who who was known to speak a foreign language (Resident #122), and e) consistent access to the call bell (Resident #20 & #29). The deficient affected, or had the potential to affect all residents who resided on 3 of 3 units, and was evidenced by the following: Refer to F558E, F600G, 676E, 677E, 684G, 686E, 689G a) 1. On 2/4/25 AM at 7:20 AM, the surveyor observed Resident #100 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry, the resident informed the surveyor that they were wet and needed incontinence care. The surveyor asked the resident to activate the call light. The resident's call device was observed lying on the floor. The surveyor informed staff that Resident needed assistance. On 2/4/25 at 10:00 AM (over 2.5 hours later), the surveyor observed Resident #100 in bed. The call device was observed on the floor. The resident informed the surveyor that they had not been changed. The surveyor left the room and asked a random Certified Nursing Aide (CNA) to assist with a care tour. The resident's incontinent brief was observed saturated with urine, and the resident stated that they were last assisted with incontinence care last night. 2. 01/29/25 at 9:27 AM, the surveyor observed Resident #89 in bed, with long facial hair, and the nails were long and jagged. On 1/30/25 at 10:45 AM, the surveyor observed Resident #89 in bed, after morning care had been provided with nails long and jagged, black substance under [NAME] the finger nails, and Resident #89 was unshaven. On 1/31/25 at 8:00 AM, the surveyor returned to the room and observed that Resident #89 had just completed breakfast. The resident's nails were still long, jagged and not trimmed. Resident #89 had not been shaved. On 2/4/25 at 9:19 AM, the surveyor interviewed the resident who stated that they would like their nails to be trimmed and cleaned. On 2/5/25 at 8:35 AM, the surveyor observed the resident in bed, the resident stated again they would like to be shaved. On 2/5/25 at 10:30 AM, the surveyor interviewed the Assistant Director of Nursing regarding the expectations for resident care. She stated that the manager and the nurses were to make rounds and ensure the residents were being cared for properly. On 2/4/24 at 11:30 AM, the surveyor interviewed the CNA regarding Resident #89's nail care. The CNA stated that nail care could be offered daily with the morning care or on shower days. The CNA stated that Resident #89 had a shower scheduled on Tuesday and they had not been shaved, and the nails were not trimmed. On 2/5/25 at 8:30 AM, the surveyor interviewed the CNA assigned to Resident #89. The CNA revealed that Resident #89 was able to feed themselves after set-up, able to assist with turning and able to make their needs known. The CNA stated that she would ask the resident if they wanted to be shaved. When asked regarding the resident nail care, the CNA did not offer any comments. 3. On 1/30/25 at 10:00 AM, the surveyor observed Resident #132 in bed, and was observed with thick facial hair. On 1/31/25 at 6:45 AM, the surveyor observed Resident #132 and had not received care yet. Resident #132 was observed saturated with urine upon during the care observation provided by a random CNA. The resident had not been shaved, and the surveyor asked the resident if they would like to be shaved, they stated, oh yes I would like to. On 1/31/25 at 11:15 AM, the surveyor observed Resident #132 in bed and observed that the resident had not been shaved. The surveyor then escorted the Assistant Director of Nursing to the room where we both observed that the resident had not been shaved. 4. 1/30/25 at 9:50 AM, the surveyor observed Resident #150 in bed, their nails were long, discolored with dark substances underneath the finger nails. Resident #150 was unshaven. On 1/31/25 at 11:30 AM, the surveyor returned to the room, the resident was sitting in a wheelchair at the bedside, The nails were long, discolored and jagged. The Surveyor asked Resident if they would like their nails to be trimmed and cleaned, the Resident stated, yes. On 1/31/25 at 11:45 AM, the surveyor escorted the Unit Manager (UM) to the room where we both observed Resident #150's nails and facial hair. The UM confirmed that Resident #150's nails needed to be trimmed and cleaned. 5. On 1/29/25 at 9:20 AM, during initial tour, the surveyor observed Resident #370 in bed and observed a strong urine odor in the room. The resident was not able to tell the surveyor when the last time was, when they were changed. The surveyor observed Resident #370's both hands with square shape long fingernails with jagged edges. The nails on the right index finger was half broken and both thumb nails had dried brown colored substance around the cuticles. On 1/29/25 at 9:34 AM, the surveyor returned with the assigned Certified Nurse Aide (CNA #1) for Resident #370 to observe the resident for incontinence rounds. The CNA #1 checked Resident # 370's brief and the resident brief was saturated with urine. The CNA #1 stated that she reported to work at 7:00 AM this morning, delivered the breakfast tray, and she stated she had not yet provided any care to Resident #370 (2.5 hours after beginning her assignment). CNA #1 then closed the brief without changing the resident, and informed the resident that she would come back to clean the resident after she provided a shower to resident's roommate. CNA #1 exited and left the resident soiled. On 1/30/25 at 9:03 AM, the surveyor observed Resident #370 in bed. The surveyor observed Resident #370's both arms were shaking, and resident's hands were noted with square shaped long nails with jagged edges. The right index fingernail was half broken. The resident stated they would like their nails to be trimmed. On 1/31/25 at 8:18 AM, the surveyor observed Resident #370 eating breakfast in their bed. Resident #370's both arms were shaking. The surveyor observed resident #370's long nails with jagged edges in the same condition as observed on 1/29/25 and 1/30/25. On 1/31/25 at 9:07 AM, during a follow-up interview with the surveyor regarding the 1/29/25 observation, the CNA #1 stated that she had not made incontinence rounds on Resident #370 until the incontinence rounds that the surveyor observed on 1/29/25. The CNA #1 stated she was familiar with Resident #370. The CNA #1 stated, I am assuming we could provide nail care and cut resident's nails. The CNA #1 further stated it was important to provide nail care and clean nails with wash rags every day during morning care because the residents got stuff like feces and germs under their nails, and they [the residents] put their nails in their mouth, and for infection control. The CNA #1 stated that Resident #370 might be able to trim their own nails if you provided assistance or sat by the resident and told them what to do. At 9:45 AM, the surveyor accompanied the CNA #1 to Resident #370's room and both observed the resident with shaky arms. The CNA #1 acknowledged that the resident was not able to cut their own nails. The CNA #1 looked at resident's nails and stated the nails got a lot of food under them, and they needed to be cleaned and cut down. 6. On 1/29/25 at 9:31 AM, during initial tour, the surveyor observed Resident #123 in bed and observed a urine odor in the room. Resident stated, I am wet, I am wet. On 1/29/25 at 9:34 AM, the surveyor returned with the assigned CNA #1 for Resident #123 to check on the resident for incontinence rounds. The CNA #1 checked Resident #123's brief and the resident brief was saturated with urine. The CNA #1 looked at the brief and stated it is kind of wet, and informed the resident that she would take the resident to shower since it was their shower day. On 1/30/25 at 12:16 PM, the surveyor reviewed the electronic medical record for Resident #123 which revealed: 7. On 1/29/25 at 9:43 AM, during an initial tour, the surveyor observed Resident #71 walking on the unit and was holding a cup in their right hand. The surveyor observed resident's long half broken nails with jagged edges on their right hand. On 1/31/25 at 8:59 AM, the surveyor observed resident walking on the unit. Resident #71 was pleasant, and the surveyor observed resident's both hands with long jagged nails, same as observed on 1/29/25. 8. On 1/30/25 at 8:29 AM, the surveyor observed Resident #122 in their bed, eating breakfast. The surveyor observed Resident #122's both hands with long square shaped and pointy nails with food like debris under their nails. 9. On 1/30/25 at 8:38 AM, the surveyor observed Resident #82 sitting up in their bed. The surveyor observed the resident's left hand placed on the left side rail with long brown colored discoloration with substance under their thumb nail. The surveyor was not able to observe resident's right hand. 10. On 1/29/25 at 12:11 PM, the Surveyor #2 (S #2) observed Resident #77 eating lunch in the room. The surveyor observed Resident #77's long and jagged nails with dark substance underneath the fingernails. On 1/30/25 at 8:14 AM, Surveyor #1 and S #2 observed the resident eating breakfast in their bed. Both surveyors observed Resident #77's long and jagged nails with dark substance underneath the fingernails. On 1/31/25 at 12:58 AM, Surveyor #1 and S #2 observed Resident #77 sitting in bed. Both surveyors accompanied the Assistant Director of Nursing (ADON) to the resident's room and observed Resident #77's nails. The ADON acknowledged that the nails were long. 11. On 1/30/25 at 8:35 AM, the surveyor observed Resident #35 eating breakfast in their room. The surveyor observed resident had long dark colored nails and right thumb nail was half broken horizontally. The surveyor asked the resident about their nails and the resident stated, I want my nails cut. The resident was having difficulty opening butter. The resident asked for assistance with opening up butter. The surveyor notified the staff of resident's requests. On 1/31/25 at 8:44 AM, the surveyor observed the resident eating breakfast in their bed. Resident's nails were same as observation on 1/30/25. On 2/5/25 at 10:15 AM, the surveyor interviewed the UM regarding her responsibilities. The UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignment, and make rounds. The surveyor then asked the UM who supervise the care, the UM replied all the nurses and during medication. On 2/5/25 at 11:30 AM, the DON informed the surveyor that she was not aware of the above concerns with nails and incontinence care, and would in-serviced the staff. On 2/5/24 at 11:45 AM, the surveyor escorted the UM to Resident #150's room we both observed the condition of the resident's hands and nails. The nails were jagged and a black coated substance was noted underneath all the finger nails. On 2/5/25 at 1:53 PM, the survey team met with DON and the Regional Director of Clinical Services (RDCS). The surveyor informed them of the above-mentioned concerns for all the residents regarding their nail care and incontinence care. The DON stated if two residents were incontinent, and one resident was scheduled to have a shower then incontinence care should be provided to a resident who wouldn't be getting a shower first and the other resident would be next. The DON did not offer the survey team how long a resident should have to wait to receive incontinence care. b) On 2/5/25 at 10:30 AM, the surveyor reviewed Resident #29's electronic medical record. On 2/5/25 at 9:40 AM, the surveyor requested the facility investigation for review, and the DON submitted the Reportable Event Record (RER) that was forwarded to the Department of Health on 5/17/23. There were no statements attached to the RER and the summary provided, dated 5/2023, under Investigation the following was documented: Per the Certified Nurse Aide (CNA #1), patient was last seen at 2:37 AM and was in bed. At 3:30 AM, CNA heard a loud bang and Resident was noted on the floor. Resident was noted in pain, new order received to be sent to hospital . Conclusion: Per hospital records, Resident #29 sustained a fracture of the left hip. Resident #29 will be evaluated by therapy upon return. Will follow their recommendations. No abuse or neglect could be substantiated. The document was not signed. The incident occurred on 5/17/23. The surveyor reviewed the document with the DON and requested any statements from all staff involved with Resident #29's care during the 11:00 PM-7:00 AM shift (during the time the unwitnessed fall occurred). The Fall Witness Statement signed by CNA #1 revealed: Last seen resident at 2:37 AM. Resident was last toileted at 1:00 AM. Heard a loud bang and rushed to resident room. On 2/5/25 at 11:15 AM, the surveyor reviewed LPN #2's statement with the DON. The DON informed the surveyor that she had not reviewed the statements she had not been aware that the CNA assigned to provide supervision for Resident #29 was found sleeping instead of watching the resident as she was assigned. The surveyor then asked the DON what the facility protocol was if a CNA refused an assignment, and the DON stated that the nurse should cover the assignment with someone else then notify the nursing supervisor immediately. The surveyor reviewed the facility provided Quality Assessment Report (incident type report) provided by the DON. The following was documented: Problem Statement: Patient had to go the bathroom and fell . Why 1: Patient had been toileted four hours prior. Why 2: Patient did not have to go and was asleep during next round. Root Cause: Patient was dry and asleep during last round. Awoken, self-transferred from bed and fell attempting to go the bathroom. The surveyor requested the CNA and the nurses phone number for interviews. The DON informed the surveyor that the CNA and the nurses were no longer employed by the facility. No contact information was provided. The surveyor reviewed both the CNA and both nurses' files and the incident was not documented. On 2/07/25 at 9:00 AM, the surveyor interviewed the DON regarding the incident dated 5/17/23 when the CNA refused the assignment and the resident had fallen and sustained an injury, and the DON stated that the protocol was for the nurse to carry the assignment, then reported the incident immediately to the Nursing Supervisor. c) On 1/29/25 at 9:15 AM, the surveyor toured the Maple Unit of the facility and observed Resident #92 seated in a recliner chair in the dayroom with a Certified Nursing Aide (CNA) at their side. Resident #92 was observed with purplish bruises to the facial area, both eyes were closed, and the resident did not engage in a conversation with the surveyor. On 1/30/25 at 10:15 AM, the surveyor, again, observed Resident #92 in the dayroom. The CNA seated next to the resident informed the surveyor that the resident was on a 1:1 observation. On 2/04/25 at 10:30 AM, the surveyor completed an initial review of Resident #92's electronic medical record. The Admission Record (an admission summary) reflected that Resident #92 was admitted to the facility with diagnoses which included, but were not limited to; unspecified dementia, major depressive disorder, restlessness and agitation and other abnormalities of gait. The Significant Change Minimum Data Set (MDS) dated [DATE], (an assessment tool used by the facility to prioritize care) reflected that Resident #92 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. Resident #92 also required supervision or touching assistance for bed mobility, required moderate assistance for transfers from the bed to the chair and utilized a wheelchair. Resident #92 was coded Yes as having falls since admission, and coded 2 for J1900B. Fall with injury (except major)- including skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall related to injury that causes the resident to complain of pain, and coded 1 for f J1900C. Fall with Major Injury- bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. The Progress Notes revealed the following: -Type: Health Status Note: Effective: 12/23/24 at 5:55 AM; This nurse was notified by staff that resident had fallen, when asked what happened staff stated, I was walking resident to the bathroom and above resident lost balance and fell . Resident unable to give account of what happened. Supervisor was notified, PCP [primary care physician] made aware, Resident Representative made aware. Assessment obtained, Resident at baseline, no injury noted, resident able to move all extremities, no head hitting noted per staff. No discomfort noted on assessment. Personal care needs met; resident was made comfortable. 1:1 in place safety maintained. - A subsequent note, documented by the same nurse revealed: Type: Health Status Note: Effective: 12/23/24 at 7:30 AM; Around 6:30 AM, this nurse was notified by staff that resident was bleeding on their face. Upon entering resident's room, noted resident with blood on their face, noted cut to left cheek area, resident unable to tell what happened. supervisor was notified. Primary Care Physician notified. Obtained an order to send resident to hospital. Face cleaned, bleeding was controlled, no further cut or open area noted. Assessment was obtained. Family made aware of the fall, Neuro check started, 911 was called and resident was sent to the hospital for evaluation at 7:05 AM. d)On 1/29/25 at 12:58 PM, the surveyor observed Resident #122 in bed. The surveyor was unable to communicate with the resident. On 1/30/25 at 8:29 AM, the surveyor observed Resident #122 eating breakfast in the bed. Resident #122 spoke in Spanish when the surveyor was in the resident's room. The surveyor was not able to understand or communicate with the resident. A review of Resident #122's individual comprehensive care plan (ICCP) included a focus area dated 5/14/24, that the resident required the services of an interpreter because their primary language was not English. Primary language: Spanish. Interventions included: Provide resident with a communication board with common words in English and resident's preferred language to aide in communication for simple daily needs. On 2/5/25 at 9:06 AM, during an interview with the surveyor, the Certified Nursing Assistance (CNA #1) stated Resident #122 was Spanish speaking. The CNA #1 stated when she had taken care of the resident, she would not understand the resident because the resident did not speak English. CNA #1 stated when she did not understand the resident then she would use hand gestures during care. CNA #1 further stated she would tap on Resident #122's side to turn to the other side when she provided toileting hygiene. CNA #1 acknowledged that when the resident spoke in their language, CNA #1 did not understand the resident and the only way she would communicate with Resident #122 was with hang gestures. On 2/5/25 at 9:55 AM, during an interview with the surveyor, CNA #2 who was assigned to the resident, stated Resident #122 was mainly Spanish speaking. The surveyor inquired about how was the resident able to make their needs knows and CNA #2 stated that the resident used hand gestures a lot. CNA #2 stated that the resident had a communication board in their room. The surveyor accompanied the CNA #2 to Resident #122's room. Both observed the resident sitting in bed and resident spoke only Spanish and tried to have conversation with CNA #2. The surveyor and the CNA both were not able to understand and/or communicate with the resident. The CNA #2 searched, and she did not find a communication board in resident's room. On 2/5/25 at 10:12 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated Resident #122 was mainly Spanish speaking. The LPN stated she was able to understand the resident because some of her language vocabulary matched with resident's language, so she did not utilize any devices to communicate with the resident. The LPN further stated if she was not able to understand the resident, she would take the Spanish speaking CNA with her to resident's room. The LPN stated the communication board wouldn't be effective for Resident #122 because it was used for people who have hard time speaking or if they were hard of hearing. On 2/5/25 at 1:53 PM, the survey team met with Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS). The surveyor informed them of the above-mentioned concerns for the Resident #122. The DON acknowledged that Resident #122 should have had a communication board in the room so that the resident would be able to express their needs. e) On 1/30/25 at 10:00 AM, the surveyor observed Resident #29 lying in bed, with the call bell on the the bedside table. Resident #29 was unable to reach the call bell. On 1/31/28 9:10 AM, the surveyor observed Resident # 29 in bed. The call bell was in the same position as observed on 1/30/25 at 9:25 AM, when Resident #29 was in bed and the call bell on the bedside table. On 2/5/25 at 9:00 AM, the surveyor observed Resident #29 lying in bed with the call bell hanging over the side rail, and was tucked underneath the mattress, away from the resident. The resident stated they knew how to use the call bell, but that they could not locate it to demonstrate the process to the surveyor. On 2/5/25 at 9:20 AM, the surveyor escorted the Unit Manager (UM) to the resident's room and the UM confirmed that the call bell was not accessible. During an interview with the surveyor on 02/05/25 at 9:00 AM, the Certified Nursing Assistant (CNA) stated that the resident uses the call bell sometimes when they need assistance. The CNA further stated that she placed the call bell on the side of the resident's bed prior to leaving the room. During an interview with the surveyor on 2/5/25 at 9:20 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that the resident could use the call bell to ask for assistance. The surveyor then escorted the LPN/UM to the room where we both observed the call bell was tucked underneath the mattress and not accessible to the resident. The UM stated that she expected staff to secure the call bell to prevent the call bell from falling out of reach. f) The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the State of New Jersey as follows: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified as N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. 1. For the 2 weeks of staffing from 8/06/2023 to 8/19/2023, the facility was deficient in CNA staffing for residents on 8 of 14 day shifts; deficient in total staff for residents on 1 of 14 evening shifts; and deficient in CNAs in total staff on 1 of 14 evening shifts as follows: -8/06/23 had 16 CNAs for 142 residents on the day shift, required at least 18 CNAs. -8/07/23 had 15 CNAs for 141 residents on the day shift, required at least 18 CNAs. -8/12/23 had 12 CNAs for 137 residents on the day shift, required at least 17 CNAs. -8/13/23 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -8/14/23 had 15 CNAs for 137 residents on the day shift, required at least 17 CNAs. -8/15/23 had 15 CNAs for 135 residents on the day shift, required at least 17 CNAs. -8/18/23 had 16.5 CNAs for 135 residents on the day shift, required at least 17 CNAs. -8/19/23 had 14 CNAs for 135 residents on the day shift, required at least 17 CNAs. -8/19/23 had 12 total staff for 135 residents on the evening shift, required at least 13 total staff. -8/19/23 had 5 CNAs to 12 total staff on the evening shift, required at least 6 CNAs. 2. For the 2 weeks of staffing from 8/27/2023 to 9/09/2023, the facility was deficient in CNA staffing for residents on 7 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -8/27/23 had 14 CNAs for 137 residents on the day shift, required at least 17 CNAs. -8/29/23 had 16 CNAs for 137 residents on the day shift, required at least 17 CNAs. -8/31/23 had 16.5 CNAs for 140 residents on the day shift, required at least 17 CNAs. -9/01/23 had 14 CNAs for 139 residents on the day shift, required at least 17 CNAs. -9/03/23 had 15.5 CNAs for 135 residents on the day shift, required at least 17 CNAs. -9/05/23 had 16 CNAs for 135 residents on the day shift, required at least 17 CNAs. -9/07/23 had 8.5 total staff for 135 residents on the overnight shift, required at least 10 total staff. -9/09/23 had 16.5 CNAs for 138 residents on the day shift, required at least 17 CNAs. 3. For the 2 weeks of staffing from 10/06/24 to 10/19/2024, the facility was deficient in CNA staffing for residents on 13 of 14 day shifts and deficient in total staff for residents on 1 of 14 evening shifts as follows: -10/06/24 had 12.5 CNAs for 157 residents on the day shift, required at least 20 CNAs. -10/07/24 had 18.5 CNAs for 156 residents on the day shift, required at least 19 CNAs. -10/08/24 had 14 CNAs for 156 residents on the day shift, required at least 19 CNAs. -10/09/24 had 18 CNAs for 156 residents on the day shift, required at least 19 CNAs. -10/10/24 had 16 CNAs for 156 residents on the day shift, required at least 19 CNAs. -10/11/24 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/12/24 had 15 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/12/24 had 15 total staff for 163 residents on the evening shift, required at least 16 total staff. -10/14/24 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/15/24 had 16.5 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/16/24 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/17/24 had 18 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/18/24 had 18 CNAs for 163 residents on the day shift, required at least 20 CNAs. -10/19/24 had 12 CNAs for 161 residents on the day shift, required at least 20 CNAs. 4. For the 2 weeks of staffing prior to survey from 1/05/2025 to 1/18/2025, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts and deficient in total staff for residents on 1 of 14 evening shifts as follows: -1/05/25 had 16 CNAs for 161 residents on the day shift, required at least 20 CNAs. -1/06/25 had 12 CNAs for 161 residents on the day shift, required at least 20 CNAs. -1/09/25 had 20 CNAs for 168 residents on the day shift, required at least 21 CNAs. -1/10/25 had 19 CNAs for 168 residents on the day shift, required at least 21 CNAs. -1/11/25 had 19 CNAs for 168 residents on the day shift, required at least 21 CNAs. -1/12/25 had 15 CNAs for 171 residents on the day shift, required at least 21 CNAs. -1/13/25 had 13.5 CNAs for 171 residents on the day shift, required at least 21 CNAs. -1/14/25 had 16.5 CNAs for 171 residents on the day shift, required at least 21 CNAs. -1/15/25 had 19 CNAs for 170 residents on the day shift, required at least 21 CNAs. -1/16/25 had 15.5 CNAs for 170 residents on the day shift, required at least 21 CNAs. -1/17/25 had 18.5 CNAs for 169 residents on the day shift, required at least 21 CNAs. -1/17/25 had 16 total staff for 169 residents on the evening shift, required at least 17 total staff. -1/18/25 had 15 CNAs for 169 residents on the day shift, required at least 21 CNAs. -For the 2 weeks of AAS-12 staffing from 1/05/2025 to 1/18/2025, the facility was deficient in RN staffing hours as follows: For the week of 1/12/25 Required Staffing Hours: 462.50 -1/18/25 had 460 actual staffing hours, for a difference of -2.50 hours. On 2/7/25 at 9:18 AM, the Staffing Coordinator stated she was aware of the mandated staffing ratios and that the facility met those standards most of the time unless there was a call out. She further stated that the staff would be determined by the resident census and would be reassessed daily. A review of the facility provided policy, Staffing Levels dated 8/2021, was for a assisted living facility and not long-term care. The Certified Nursing Assistant Job Position document provided by the facility on 2/5/25 at 1:05 PM revealed: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care, and services in accordance with the resident's assessment and care plan and as may be directed by your supervisors. The Personal Nursing Care Functions: Assist residents with nail care (i.e. clipping, trimming, and cleaning the finger/toenails); Shave male residents; Keep hair on female residents clean shaven (i.e. facial hair, under arms, on legs, etc.) as instructed; Keep residents dry (i.e. change gown, clothing, linen etc. when it becomes wet or soiled). The Licensed Practical Nurse Job Description revealed: The primary purpose of your position is to provide direct nursing care to the residents, and to supervise the day to day nursing activities performed by the Certified Nurse Assistants or other nursing personnel. To monitor the performance of the Certified Nurse Assistants, nursing and non-licensed personnel, provide education and counseling . Nursing Care Functions: Ensure that personnel providing direct care to resident are providing such care in accordance with the resident's care plan and wishes. NJAC 8:39-27.1(a)

Based on observation, interview and review of pertinent documents it was determined that the facility failed to maintain the kitchen environment and equipment in a clean and sanitary manner to limit the potential for bacterial growth and potential food borne illness. The deficient practice was evidenced by the following: On 1/29/25 at 8:17 AM, an initial tour of the kitchen was conducted with the Regional Dining Director (RDD) and the surveyor observed the following: - The 1st walk in refrigeration unit had a soiled gasket, debris throughout the ceiling and on the fan. The RDD confirmed the observation and stated it needed attention right away. -There was various debris throughout the floor and on a shelf liner in the dry food storeroom. The RDD stated there was a new Food Service Director and he was helping to develop a cleaning schedule. -The meat slicer was covered and the RDD confirmed that it was clean. The cover was lifted and the surveyor observed debris on the base and by the blade. The surveyor asked the RDD if it was clean, and the RDD stated, not as clean as it should be. The Sanitization Policy, Revised November 2022 revealed a Policy Statement: The food service area is maintained in a clean and sanitary manner. 1. Al kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris . NJAC 8:39-17.2(g)

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #56) of 7 sampled residents reviewed for nutrition received thickened liquids per the physician's orders. During the survey, Resident #56, a resident assessed to be at risk for aspiration was ordered nectar thickened liquids. On [DATE] at 1:13 PM, Resident #56 was provided a glass of regular consistency ice water. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death of residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.60 (Food and Nutrition Services) at a scope and severity of J. The IJ began on [DATE] at 1:13 PM, when Resident #56 was not provided thickened liquids. The Administrator and the Regional Director of Clinical Services were notified of the IJ and provided the IJ Template on [DATE] at 2:54 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 5:23 PM. The IJ was removed on [DATE] at 8:25 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F808 remained at the lower scope and severity of isolated potential for harm that was not immediate jeopardy related to the potential for aspiration by Resident #56. Findings included: Review of a facility policy titled, Thickened Liquids, dated February 2023, revealed, Thickened liquids are prepared and served as prescribed by the physician. General Guidelines 1. A physician's order is required for therapeutic diets, including thickened liquids. The policy further indicated, Levels of Liquid Thickness 1. Nectar -like: Approximately as thick as a milkshake. Should pour in a continuous stream without breaking into drops, such as fruit nectars, eggnog, maple syrup, tomato juice, V-8 juice, cream-based soup and commercially prepared nectar-like thick products. Review of an Admission Record indicated the facility admitted Resident #56 on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, pneumonia, acute respiratory failure with hypoxia, dysphagia (difficulty or discomfort with swallowing), and history of traumatic brain injury. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated Resident #56 had severely impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status. The MDS indicated the resident required limited, one-person physical assistance with eating and had functional limitation in range-of-motion on one side for both upper and lower extremities. The MDS revealed, the resident coughed or had choking during meals or when swallowing medications, had complaints of difficulty or pain with swallowing, and received a therapeutic and mechanically altered diet. Review of Resident #56's comprehensive care plans revealed a care plan, initiated on [DATE], that indicated the resident had a cerebral vascular accident (stroke) related to heart disease. This care plan included an intervention that specified, If resident is able to eat, make sure diet is the correct consistency to facilitate safe swallowing. Review of Resident #56's Order Summary Report revealed an order, dated [DATE], for aspiration precaution. Per the report, on [DATE], the resident received an order for a consistent carbohydrate diet of pureed texture, with nectar thickened liquids. Review of Resident #56's Endoscopic Swallowing Test, dated [DATE], revealed a swallowing test was ordered for Resident #56 to rule out aspiration and to judge the resident's current swallowing skills to provide recommendations for proper swallowing care. The report indicated the resident had previously been on a pureed diet with honey thickened liquids, and the reason for the referral was to determine if the resident was ready for an upgrade. The report indicated Resident #56 experienced silent aspiration with thin liquids (normal consistency). The report further indicated the contributing factors to this resident's dysphagia consisted of the following: resident exhibited penetration, silent aspiration, and coughing at times, as well as a history of aspiration pneumonia, coughing, and silent aspiration. The report included a recommendation for a pureed diet with nectar thickened liquids. The report also listed, the staff should assist and observe the resident with feeding. On [DATE] at 1:13 PM, Resident #56 was observed in their bed in their room with the head of the bed raised, eating their lunch meal. Next to the resident's meal tray was a plastic cup that contained ice water, with a lid and straw. At 1:24 PM, Licensed Practical Nurse (LPN) #16 entered the resident's room and removed the lunch tray from the resident's over-bed table. The nurse informed the resident the cup of ice water would have to be removed, because the resident was supposed to have thickened liquids. As the nurse left the room, LPN #16 and the surveyor observed the straw in the cup of ice water had food debris on the outside of the straw. LPN #16 reported it appeared the resident drank some of the ice water that was not thickened. and the resident was supposed to have thickened liquids. LPN #16 stated she did not know who provided Resident #16 with the ice water. LPN #16 indicated the certified nursing assistants should check the assignment sheet that reflected which residents required thickened liquids. On [DATE] at 1:35 PM, LPN #16 reported to the surveyor that Certified Nursing Assistant (CNA) #15 was the staff member that distributed the regular consistency ice water to Resident #56. During an interview on [DATE] at 1:42 PM, CNA #15 said the CNAs knew which residents were to receive thickened liquids by looking at the assignment sheet that was provided at the beginning of the shift. CNA #15 referred to her assignment sheet and said it only listed Resident #56's name and room number and did not have any information about the resident's thickened liquids status. However, CNA #15 acknowledged she was aware Resident #56 required thickened liquids, because the nurse told her at the beginning of the shift. CNA #15 said she provided the ice water to the resident by mistake and said Resident #56 should not have received it. On [DATE] at 11:34 AM, Registered Nurse (RN) #37, a unit manager, reported the assignment sheet, which informed the staff of the residents who required thickened liquids, had not been updated with Resident #56's thickened liquids due to the unit secretary being off with a death in the family. RN #37 said she did not have access to the software needed to add Resident #56's thickened liquids to the assignment sheet. On [DATE] at 11:42 AM, the Director of Nursing (DON) indicated the staff were informed at the beginning of their shift who was on thickened liquids by the assignment sheet. The DON reported all nurses could update the assignment sheets when there were new admissions or diet changes. On [DATE] at 1:59 PM, the Director of Rehabilitation reported Resident #56 had been discharged from rehabilitation services with an order for a pureed diet with nectar thick liquids. The Director of Rehabilitation stated she had discussed Resident #56 with the Speech Language Pathologist (SLP), who confirmed the resident should only be provided thickened water, without ice. In a follow-up interview on [DATE] at 2:47 PM, RN #37 reported the night shift nurse, LPN #17, had reported Resident #56 could have un-thickened liquids, but had to be watched closely. During an interview on [DATE] at 4:34 AM, LPN #17 said the first time she was assigned to care for Resident #56, the resident refused their thickened liquids, so she provided the resident with some sips of un-thickened water that was located on the resident's bedside table. During a follow-up interview on [DATE] at 10:20 AM, LPN #17 said RN #37 had informed her Resident #56 was to receive thickened liquids as ordered, until re-evaluated by speech therapy. During an interview with Resident #56's primary physician, Medical Doctor (MD) #19, on [DATE] at 11:53 AM, MD #19 reported the resident required nectar thickened liquids due to a frequent, moist cough, likely due to aspiration. MD #19 said Resident #56 was at high risk for aspiration and likely aspirated during their last meal. MD #19 indicated his expectation was that staff would provide Resident #56 with nectar thickened liquids as currently ordered. In an interview on [DATE] at 4:45 PM, the Administrator reported the expectation was that staff would pay attention and follow the physician's orders to ensure thickened liquids were distributed correctly. Removal Plan l. Resident #56 was affected by this deficient practice. A nursing assessment was completed on [DATE] and no negative outcomes were found. The assessment included vital signs and respiratory assessment. On [DATE], results of the nursing assessment were reviewed with Resident #56's physician. No new orders at that time. As a follow up, with Resident #56's physician, he ordered a chest X-ray on [DATE] with results the same day. The X-ray results were, There is no infiltrate or pleural effusion. Heart and mediastinum are within normal limits. There are degenerative changes. Follow up monitoring consists of respiratory assessments, and vital signs, every shift for 72 hours. Any changes will be immediately communicated with the physician. 2. Eleven residents have the potential to be affected. Vital signs and respiratory assessments were completed on [DATE], by the Director of Nursing and Unit Managers, on each of the 11 residents. 3. On [DATE], the Director of Nursing and the clinical team completed an audit of all 11 current residents that have thickened liquids. The audit consisted of comparing physician orders against the residents' kardex, as well as the residents' care plans. 4. For residents identified as having thickened liquids, nursing updated their individual care plans to meet the residents' individual needs. We updated the care plans to identify no thin liquids, thicken liquids only. The care plans were completed on [DATE]. 5. Residents with thickened liquids were assessed on [DATE] to assure that the correct consistency has been provided. No other residents were found to have incorrect thickened liquids. No additional assessments were needed. If any negative findings were found, they would have been immediately reported to the physician. 6. The center clinical leadership, which consists of the Director of Nursing and Assistant Director of Nursing were notified of the incident and initiated an investigation. Center leadership, Nursing Home Administrator, and Director of Nursing conducted an Ad Hoc Quality Assessment and Performance Improvement plan meeting on [DATE], to develop a quality assurance process improvement action plan. The committee consisted of the Administrator, Director of Nursing, Regional Director of Clinical Services, Regional Director of Operations, and the Medical Director. 7. On [DATE], the Director of Nursing re-educated Certified Nursing Assistant #15. The education included, why residents may be on different liquid consistencies, reviewing the kardex for resident specific liquid consistency and speak to the nurse when unsure of liquid consistency, how to identify altered liquids, and how to prepare each level of thickness and what to do if they identify incorrect liquid consistency. There was also a demonstration of each liquid consistency to ensure the certified nursing assistant knows how to prepare each liquid. The certified nursing assistant should review the kardex at the beginning of each shift. All clinical staff will receive an updated report generated from Point Click Care [ electronic health record system] diet type report to update the daily liquid consistency report as it relates to liquid consistency. This report will include resident name, room number, and liquid consistency. Staff will use this report to review prior to providing liquids to residents. This report will also be used as part of shift-to-shift reporting to assure that all licensed nurses and certified nursing assistants have the most up to date information. 8. On [DATE], the Director of Nursing and Assistant Director of Nursing provided one-on-one education with all nurses and all certified nursing assistants who were working the ,d+[DATE] shift. Inservice educational content included: how to identify altered liquids and how to prepare each level of thickness and what to do if they identify incorrect liquid consistency. They were also inserviced on reviewing the kardex for the order liquid consistency prior to the start of their shift. Nurses were given one-on-one education regarding their role in assuring the accuracy of liquid consistencies is in accordance with physician orders prior to fluid hydration pass. Nurses were educated regarding their role and must supervise and oversee certified nursing assistants. All clinical staff will receive an updated report generated from Point Click Care diet type report to update the daily liquid consistency report as it relates to liquid consistency. This diet type report is given to staff by the Director of Nursing or Assistant Director of Nursing. All licensed nurses and certified nursing assistants were given education and in-service on the diet type report. This report will be given by the Director of Nursing, the unit manager, or the supervisor. This report will include resident name, room number, and liquid consistency. Staff will use this report to review prior to providing liquids to residents. This report will also be used as part of shift-to-shift reporting to assure that all licensed nurses and certified nursing assistants have the most up to date information. The Director of Nursing also in-serviced all nursing staff that nurses are responsible for the oversight of certified nursing assistants. Also, on [DATE], the Director of Nursing and Assistant Director of Nursing started education of all licensed nurses and certified nursing assistant on residents on thicken liquids. Educational content included: how to identify altered liquids, how to prepare each level of thickness, and what to do if they identify incorrect liquid consistency. They were also in-service on reviewing the kardex for the order liquid consistency prior to the start of their shift. Nurses were given one-on-one education regarding their role in assuring the accuracy of liquid consistencies is in accordance with physician orders prior to fluid hydration pass. Nurses were educated regarding their role and must supervise and oversee certified nursing assistants. The Director of Nursing also in-serviced all nursing staff that nurses are responsible for the oversight of certified nursing assistants. Education included full-time, part-time, per diem, and agency licensed nurses and certified nursing assistant staff. Before the start of each shift, education will be given to all clinical staff, including agency staff. All clinical staff will be educated prior to the start of their next shift by the Director of Nursing, Assistant Director of Nursing, or unit managers and supervisors. No licensed nurse or certified nursing assistant will work until education is completed. 9. The Director of Nursing and clinical leadership will review all new admissions, readmits, and residents who may experience a change of condition as part of the morning clinical meeting, to determine liquid consistency. All clinical staff will receive an updated report generated from Point Click Care diet type report to update the daily liquid consistency report as it relates to liquid consistency. This report will include resident name, room number, and liquid consistency. Staff will use this report to review prior to providing liquids to residents. This report will also be used as part of the shift-to-shift reporting to assure that all licensed nurses and certified nursing assistants have the most up to date information. Auditing of this process will occur Monday through Friday, until three (3) months of 100% compliance is achieved, weekly until three (3) months of 100% compliance is achieved, and monthly until three (3) months of 100% compliance is achieved. The Director of Nursing is responsible for the oversight of this process. 10. The Administrator or the Director of Nursing will audit fluid hydration pass and medication pass to ensure the correct liquids are given, three times weekly until 100% compliance is achieved for 3 consecutive months. The Director of Nursing will bring findings from audits to the Quality Assurance and Process Improvement Committee meetings monthly for review until 100% compliance is achieved for 3 consecutive months. 11. The Administrator is responsible for the implementation and oversight of this plan. 12. The Medical Director was notified of the IJ on [DATE] and was also involved in the development of the removal plan and also approved the removal plan. 13. All corrections were completed on [DATE]. 14. The immediacy of the IJ was removed on [DATE]. Onsite Validation: The survey team verified the implementation of the facility's Removal Plan as follows. Onsite verification began on [DATE] at 5:29 PM . 1. Review of Resident #56's progress notes dated [DATE] revealed the resident's vital signs were checked and respiratory assessments were completed. A review of the chest x-ray for Resident #56, dated [DATE], revealed findings of no infiltrates or pleural effusion. 2. During the IJ process, one of the eleven residents on thickened liquids had died and one was in the hospital. The facility, at the time of the validation, had nine residents on thickened liquids. The electronic medical records were reviewed for the nine residents, including vital signs and respiratory assessments. 3. Reviews of the Diet Type Report dated [DATE], the resident's Kardex, care plans, and physician orders were compared and found to be consistent with the ordered thickened liquids. 4. The care plans for the nine residents on thickened liquids were reviewed and found to reflect the resident's thickened liquids status. 5. Observations were made of thickened liquids, in resident rooms, for the nine residents with orders for thickened liquids. 6. Review of the Ad Hoc (created or done for a particular purpose as necessary) quality assurance and performance improvement (QAPI) minutes dated [DATE] and interviews with the Director of Nursing and Administrator revealed the AD Hoc QAPI meeting had been conducted and the IJ concerns had been discussed on [DATE]. 7. Review of the in-service attendance record were reviewed, which included CNA #15. The in-services had been initiated on [DATE] and continued until [DATE]. 8. Review of the in-service attendance logs indicated the staff had been re-educated on Knowing Diet Orders for Residents, Diet Consistencies, Liquid Consistency Report. During the validation process, current staff and oncoming staff were interviewed regarding the process for thickened liquid determination. 9. The Director of Nursing was interviewed on [DATE] regarding the process for new admission, readmits, and diet changes. 10. The Director of Nursing and Administrator were interviewed on [DATE] related to hydration passes and ensuring thickened liquids were correct. 11. The Administrator was interviewed regarding the plan for the oversight and process. 12. A signed document was reviewed that revealed the Medical Director (MD) #18 had been informed of the IJ on [DATE]. The Director of Nursing reported the MD had been involved in the development of the plan of removal and ordered resident follow-up as needed. 13. The survey team verified all corrections were completed on [DATE]. The IJ was removed on [DATE] at 8:25 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. New Jersey Administrative Code S 8:,d+[DATE].1(a)

Based on interviews, record review and facility policy review, the facility failed to ensure 1 (Resident #17) of 4 sampled residents reviewed for accidents was provided assistance with transfers. Specifically, on 05/01/2023, Resident #17 was found on the floor after they attempted to transfer themself due to a lack of staff available to assist the resident back to bed. Resident #17 sustained a laceration to their forehead that required two staples to close. Findings included: Review of an undated facility policy titled, Falls and Fall Risk, Managing, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of an Admission Record indicated the facility admitted Resident #17 on 07/08/2022 with diagnoses that included anemia, hyperlipidemia, overactive bladder, hypertension, and gout. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #17 had severe cognitive impairment. The MDS indicated Resident #17 required extensive assistance with bed mobility and transfers. The MDS indicated Resident #17 was not steady and only able to stabilize with staff assistance when moving from seated to standing position and during surface-to-surface transfers. Review of Resident #17's care plan, with an initiation date of 09/19/2022, revealed Resident #17 was at risk for falls due to confusion, gait and balance problems, incontinence, and poor safety awareness. Interventions directed staff to anticipate and meet the resident's needs, provide hands on assistance when the resident moved from place to place, and encourage the resident to use the call lights to request assistance. A review of Resident #17's Health Status Note, dated 05/01/2023 at 11:15 PM, revealed Resident #17 was in a reclining chair and attempted to ambulate back to bed. Per the note, the resident was found face down on the floor, bleeding from their forehead. The note indicated the resident was sent to the hospital emergency department. A review of Resident #17's Health Status Note, dated 05/01/2023 at 11:48 PM, written by Registered Nurse (RN) #40, revealed Resident #17 was found on the floor at 11:05 PM between the foot end of their bed and their Geri chair. Per the note, Resident #17 had a laceration on their forehead. A review of Resident #17's Full QA [Quality Assurance] Report, dated 05/01/2023, revealed Resident #17 had fallen and was found on the ground with their face and right shoulder on the floor around 11:00 PM. The report indicated the resident sustained a head laceration that required two staples to close. The report indicated Resident #17 attempted to transfer self and fell . The report indicated a causal and contributing factors to the fall was that the resident wanted to get into bed and cna [certified nursing assistant] was with another patient. The report indicated the root cause of the fall was [Resident #17] was out of [the resident's] routine and became agitation [sic] and attempted to transfer self and fell . During an interview with RN #40 on 05/19/2023 at 4:07 PM, she stated Resident #17 was found on the floor between their bed and Geri chair. Per RN #40, Resident #17 wanted to go back to bed, but the CNA that worked did not have help to get the resident back into their bed. During an interview with the Director of Nursing (DON) on 05/20/2023 at 12:19 PM, she stated that on 05/01/2023, during the time that Resident #17 would normally go to bed, there was plenty of staff to assist the resident. Per the DON, the resident did not want to go to bed at their usual time and when Resident #17 was ready to go to bed, later that night, there was not enough staff to assist Resident #17. New Jersey Administrative Code S 8:39-5.1(a)

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide adequate staffing to prevent falls for 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, on 05/01/2023, Resident #17 was found on the floor after they attempted to transfer themself due to a lack of staff available to assist the resident back to bed. Resident #17 sustained a laceration to their forehead that required two staples to close. Findings included: Review of a facility policy titled, Staffing, Sufficient, and Competent Nursing, with a revision date of August 2022, revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care for all residents in accordance with resident care plans and the facility assessment. 46258 Review of an Admission Record indicated the facility admitted Resident #17 on 07/08/2022 with diagnoses that included anemia, hyperlipidemia, overactive bladder, hypertension, and gout. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2023, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #17 had severe cognitive impairment. The MDS indicated Resident #17 required extensive assistance with bed mobility and transfers. The MDS indicated Resident #17 was not steady and only able to stabilize with staff assistance when moving from seated to standing position and during surface-to-surface transfers. Review of Resident #17's care plan, with an initiation date of 09/19/2022, revealed Resident #17 was at risk for falls due to confusion, gait and balance problems, incontinence, and poor safety awareness. Interventions directed staff to anticipate and meet the resident's needs, provide hands on assistance when the resident moved from place to place, and encourage the resident to use the call lights to request assistance. A review of Resident #17's Health Status Note, dated 05/01/2023 at 11:15 PM, revealed Resident #17 was in a reclining chair and attempted to ambulate back to bed. Per the note, the resident was found face down on the floor, bleeding from their forehead. The note indicated the resident was sent to the hospital emergency department. A review of Resident #17's Health Status Note, dated 05/01/2023 at 11:48 PM, written by Registered Nurse (RN) #40, revealed Resident #17 was found on the floor at 11:05 PM between the foot end of their bed and their Geri chair. Per the note, Resident #17 had a laceration on their forehead. A review of Resident #17's Full QA [Quality Assurance] Report, dated 05/01/2023, revealed Resident #17 had fallen and was found on the ground with their face and right shoulder on the floor around 11:00 PM. The report indicated the resident sustained a head laceration that required two staples to close. The report indicated Resident #17 attempted to transfer self and fell . The report indicated a causal and contributing factors to the fall was that the resident wanted to get into bed and cna [certified nursing assistant] was with another patient. The report indicated the root cause of the fall was [Resident #17] was out of [the resident's] routine and became agitation [sic] and attempted to transfer self and fell . During an interview with RN #40 on 05/19/2023 at 4:07 PM, she stated Resident #17 was still in their wheelchair around 11:00 PM on 05/01/2023 because there was not enough staff to assist the resident into their bed at that time. During an interview with the Director of Nursing (DON) on 05/20/2023 at 12:19 PM, she stated that on 05/01/2023, during the time that Resident #17 would normally go to bed, there was plenty of staff to assist the resident. Per the DON, the resident did not want to go to bed at their usual time and when Resident #17 was ready to go to bed, later that night, there was not enough staff to assist Resident #17. New Jersey Administrative Code S 8:39-5.1(a)

Based on observation, interview and review of facility documentation it was determined that the facility failed to monitor/maintain potentially hazardous food (PHF) items which included milk, yogurt and nutritional beverages at a safe temperature. The dairy products were stored in a refrigerator at temperatures above 40 degrees Fahrenheit (F). The immediacy was identified on 2/18/2016 at 10:50 a.m., when the surveyor, in the presence of the unit manager and the Food Service Director (FSD), observed dairy products that were available to the residents residing on 1 of 3 nursing units (Ridge). The PHFs were being stored in a refrigerator inside a pantry on the unit. The refrigerator was warm to touch and the temperature of the dairy products (individual milk, yogurt and nutritional beverages) ranged between 45.0 and 55.0 degrees (F). The PHF items should be maintained at 41.0 degrees (F) or below. The FSD was notified at the time of discovery at 10:55 a.m. that the PHFs items were at a dangerous temperature. At this time the PHFs were discarded. The immediate jeopardy was identified on 2/18/16 at 12:30 p.m., and the immediacy was corrected on 2/18/16 at 2:00 p.m. An acceptable plan of correction was accepted at this time. The deficient practice for the Immediate Jeopardy situation was evidenced by the following: On 2/18/16 at 10:50 a.m., the surveyor in the presence of the Unit Manager (UM), entered a pantry on the Ridge Unit. A review of a Food Refrigerator Log posted on the outside of the refrigerator revealed that temperatures were documented as being 46.0 F degrees. When interviewed at this time, the UM stated that the dietary staff were responsible for monitoring the refrigerators temperatures on all the units. The Surveyor, in the presence of the UM and later the FSD, tested the milk containers in which the temperatures registered at 55.0 degrees (F). The FSD disgarded the containers of milk, yogurt, nutritional drinks and other PHF items. When interviewed at this time, the FSD stated that the food service workers (FSW) were responsible for monitoring the refrigerator temperatures daily on the nursing units. The FSD stated that the FSWs were to document the temperatures on the Food Refrigerator Log. The FSD stated, that if the temperatures reached above 40.0 (F) degrees, the FSWs were instructed and trained to report unsafe temperatures to any supervisor on duty. A review of the Food Refrigerator Log dated 2/2016 revealed that on 2/16 and 2/17/2016, the FSW's documented unsafe temperatures on the log at 46.0 degrees (F). On 2/18/16, the FSD checked the temperature of the refrigerator and found that the internal thermometer reading was 55.0 degrees (F). When interviewed further by the surveyor, the FSD stated that the FSWs deliver PHF items to all the units daily around 2:00 p.m. According to the PAR level used by the facility to determine the number of PHF items to be distributed on each unit daily, revealed that 25 containers of milk and 4 containers of [MEDICATION NAME] were the standard number of beverages kept inside the refrigerator. There was no documentation available for review to determine the number of nutritional supplements, yogurts, cottage cheese or sandwiches that were delivered to the unit daily. When interviewed on 2/18/16, the FSD stated that they do not keep a record of the nutritional supplement or sandwiches. The FSD added that the yogurt and cottage cheese were probably a resident's personal items. At this time, in the presence of the FSD the following PHFs were found inside the refrigerator: 14- containers of milk 5- nutritional supplements 2- containers of [MEDICATION NAME] (a milk substitute) 1- container of yogurt 1- container of cottage cheese 1- meat sandwich The surveyor interviewed a FSW on 2/18/16 at noon. The FSW identified herself as being one of the FSW's who documented 46.0 degree (F) on the log on 2/16/16. The FSW stated that she knew that the refrigerator temperature was in the hazardous zone but did not tell anyone about the unsafe temperatures readings. The FSW also stated that she knew who she was suppose to report this information too. The other FSW was not available for an interview during the survey. According to the facility's policy for food storage. All potentially hazardous food shall be maintained at safe temperatures of 40.0 degrees (F) or below, and above 140.0 degrees (F), except during the necessary periods of preparation and service. Potentially hazardous foods include milk, milk products, eggs, meat, poultry, fish or combinations of these products. 1. Temperatures lower than 40.0 degrees (F) are recommended to preserve the fresh quality of perishable foods during storage. 2. Temperature log are taken daily on ALL refrigerators and freezers. 3. Food are stored in area designated for them, and all area are rotated. The plan of correction included the following: 1. Immediately, food items were removed from the refrigerator/freezer located on the Ridge Unit. 2. All residents on the Ridge Unit were initially assessed for any Gastro-Intestinal complaints or abnormalities (nausea/vomiting/diarrhea). Ongoing monitoring was initiated for the 72 hours. 3. All staff were reeducated on safe temperatures for foods requiring refrigeration and GI signs and symptoms that patients may experience if exposed to temperatures abnormalities. Staff Education was initiated immediately. The refrigerator was removed on 2/18/16, and replaced with a new refrigerator. 4. Only food items refrigerated at safe temperatures will be available to residents. 5. The FSD/Supervisory staff will monitor and ensure that no foods requiring refrigeration are available/served to resident if they have been stored within unsafe temperatures. The daily logs will be signed off by the Food Service Director/Supervisory staff to indicate this monitor has occurred. NJAC 8:39-17.2(g)