Every finding on record at Oakland Rehabilitation and Healthcare Center

Refer F 835 Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to ensure that a.) a non-certified Nursing Aide (NA#1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 2 of 3 NAs reviewed (NA#1 and NA#2) who provided direct care to residents on 4 of 4 nursing units. NA#1 was hired on 9/16/24, to provide care to the residents. NA#1 began independent resident care assignments on 9/27/24, and was not enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) until 1/13/25. NA#1 worked 68 shifts with no evidence of completing the required modules/Skill Competency and NATCEP program prior to providing independent resident care and worked past 120 days (1/13/25) in the facility without being certified as a nursing aide. The facility's failure to ensure all NAs were trained with the appropriate competencies and skills required prior to receiving an independent resident care assignment posed a likelihood that serious injury, harm, impairment, or death could occur to residents since untrained staff were providing resident care. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/27/24, after NA #1 was assigned an independent resident care assignment. The facility Administration was notified of the IJ on 5/28/25 at 2:38 PM. The facility submitted an acceptable Removal Plan (RP) on 5/28/25 at 5:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. The evidence was as follows: Part A A review of the undated facility provided Position Title: Nursing Assistant (NA) In Training job description included; assist residents with daily dental and mouth care .assist residents with bath functions .assists residents with dressing .assist with bowel and bladder functions .assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc .Must posses a Nursing Assistant Student Certificate from a state-approved NATCEP Training Program. Specific Requirements: Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served A review of the undated facility provided Caring Partner Job Description included; the primary purpose of job position is to provide non-clinical assistance to the patients/residents at the direction of supervisors . Duties and responsibilities include bedmaking, tidying rooms and personal spaces, placement of call bells/bed controls in reach of patients, [NAME] pass, linen retrieval, meal tray pass, resident companionship and activities assistance/room visits/resident video conferencing . On 5/22/25 at 9:49 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services (RDoCS), Surveyor #1 (S#1) asked if the facility utilized non-certified Nurse Aides (NAs), and the LNHA responded yes. The surveyor also asked if the NAs were providing direct care to residents, and the LNHA stated that the NAs, which included NA#1, were providing direct care under the direction of the Certified Nursing Aide (CNA) and nurse, and that the NAs were in school preparing to take their written examinations. The surveyor requested the NAs' employee files for review. On 5/22/25 at 1:40 PM, the LNHA provided Surveyor #2 (S#2) with a list of NAs who worked at the facility. NA#1 was included on the list with a date of hire (doh) of 9/16/24. On 5/27/25 at 12:32 PM, S#2 reviewed NA#1's employee file which revealed the following: -Nursing Assistant in Training: doh 9/16/24. Position: Nursing Assistant in Training, shift assigned 3:00 PM to 11:00 PM (3-11), signed by NA#1 and the previous DON. -Job Description, Position Title: Caring Partner, doh 9/16/24, signed by NA#1 on 9/16/24, shift assigned was blank, and signature of the Hiring Manager was blank. Duties and responsibilities did not include direct care. -Payroll Related Information: effective date 9/16/24, full time, five shifts per week . -School letter dated 9/11/24: This letter is to certify [NA#1] has been enrolled in the CNA Program at [name of school redacted] start date September 16th, 2024 to October 17th, 2024, Monday through Friday from 9:00 AM to 3:00 PM. Signed by the Administrative Assistant. -Student CNA Status Change Form: date of completion of first 16 hours of CNA class dated 9/18/24. The form included, You must submit this form with supporting documentation from the CNA class instructor for proof of completion of the first 16 hours of the CNA class, signed by Human Resource (HR) Manager on 9/18/24. Further review of NA#1's employee file did not include documented evidence that NA#1 completed the 16 hours or 90 hours of required education, training, and competencies in order to provide direct care to residents. A review of NA#1's time sheets provided by the RDoCS revealed NA#1 worked the following: -From 9/27/24 to 5/26/25, NA#1 worked the 3-11 shift Monday through Friday. In addition, NA#1 worked 3-11 PM and 7:00 AM-3:00 PM (7-3) shift double shifts on 9/21/24, 9/22/24, 9/28/24, 10/5/25, 10/7/24, 10/12/24, 10/13/24, 10/14/24, 10/19/24, 10/20/24, 10/21/24, 10/27/24, 10/28/24, 11/1/24, 11/2/24, 11/3/24, 11/9/24, 11/10/24, 11/14/24, 11/16/24, 11/17/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/21/24, 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/12/25, 1/23/25, 1/24/25, 1/30/25, 1/31/25, 2/6/25, 2/7/25, 2/13/25, 2/14/25, 2/21/25, 2/22/25, 2/27/25, 3/2/25, 3/6/25, 3/8/25, 3/13/25, 3/14/25, 3/16/25, 3/20/25, 3/22/25, 3/23/25, 3/27/25, 3/29/25, 3/30/25, 4/1/25, 4/4/25, 4/5/25, 4/6/25, 4/8/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/16/25, 4/19/25, 4/20/25, 4/22/25, 4/26/25, 4/27/25, 4/30/25, 5/2/25, 5/3/25, 5/6/25, 5/7/25, 5/9/25, 5/10/25, 5/15/25, 5/17/25, 5/18/25, 5/20/25, 5/25/25, and 5/26/25. A review of the corresponding CNA assignments sheets provided revealed the following: On the 9/27/24's 3-11 shift, NA#1 was independently assigned to Assignment #2, which included 14 residents in total, showers for two residents (rooms: 117 W and 122 P), and one resident for feeding assistance and hoyer lift transfer (transfer using a mechanical lift) (room [ROOM NUMBER] P). Further review of the CNA assignment sheets provided revealed that NA#1 worked as an NA for total of 68 shifts and provided independent resident care that included bathing, feeding, transferring, toileting, and hygiene from 9/27/24 through 1/12/25, without any evidence of completing the modules/Skill Competency. A review of the additional CNA assignment sheets confirmed NA#1 worked on all four nursing units with independent resident care assignments that corresponded with their timesheets. According to NA#1's school letter, NA#1 was attending the CNA school Monday through Friday from 9:00 AM to 3:00 PM, beginning 9/16/24 through 10/17/24. According to the facility's CNA assignment sheets and NA#1's timecard, NA#1 was working at the facility providing resident care during the same dates and times NA#1 was supposed to be attending school. On 5/27/25 at 2:10 PM, Surveyor #3 (S#3) attempted to conduct a telephone interview with NA#1, there was no answer, and a message was left to call back. On 5/27/25 at 2:23 PM, S#2 interviewed the Regional Human Resources Director (RHRD), who stated that the previous HR staff of the facility left, and she was the covering HR of the facility for two weeks now. The RHRD further stated that the facility's protocol with hiring NAs was to; ensure that the NAs were enrolled in school, get the test done before 120 days before transferring their title to a CNA, provide direct care after training and competencies were done, and all required certificates, including the completion of 16 hours of training should be in the NAs files. At that time, the facility was unable to provide documentation that NA#1 completed their competency skills. The RHRD did not respond to the surveyor inquiry how the facility would know NA#1 completed their competency skills with no documentation. On 5/27/25 at 2:35 PM, S#3 called NA#1's school and spoke to the Receptionist, who stated that NA #1 started school on 1/13/25, and finished on 2/13/25. The Receptionist further stated that the school administrator was on vacation, and the Receptionist had no further information to provide. On 5/27/25 at 2:55 PM, NA#1 called back and was interviewed by S#3. NA#1 informed S#3 that his job title was NA, he went to CNA school in January 2025, and he was unable to provide the exact dates. NA#1 acknowledged he was in school back in 2024, and he could not say how many times he was enrolled in the NATCEP program prior to his January 2025 enrollment. NA#1 stated that he took care of residents in his assignments. When S#3 further asked NA#1 to explain what were the tasks and their assignments, NA#1 hung up the phone and did not answer his phone for a follow-up interview. On 5/28/25 at 9:39 AM, the LNHA, RDoCS, and [NAME] President of Operations (VPO) met with the survey team. The LNHA informed the surveyors that the facility management acknowledged the concerns of the surveyors that the NAs were hired at the facility, including NA#1, who the facility did not have documented evidence of completing the modules/Skill Competency prior to providing independent care to residents that included hygiene, toileting, bathing, transferring, and feeding. The LNHA further stated that she was aware of the 16 hours requirement as part of the regulation before their date of hire. (The regulation requires prior to the NA rendering independent resident care to complete the 16 hours.) On that same date and time, the LNHA confirmed that NA#1 had floor orientation that was done from 9/18/24 through 9/23/24, and that NA#1 did hand in hand direct care with residents, i.e. toileting, bathing, feeding, transferring, and hygiene. The LNHA further stated that NA#1 was off the schedule on 1/13/25, re-enrolled in school on 1/13/25, and completed the 16 hours on 1/16/25. The LNHA confirmed that the last day NA#1 worked was on 5/26/25, after surveyor's inquiry. The LNHA also stated that NA#1 was loved by residents and there were no reported incidents/accidents or grievance that involved NA#1. On 5/28/25 at 10:48 AM, S#2 interviewed a CNA, who stated that she remembered NA#1, and had worked with NA#1. The CNA informed S#2 that NA#1 was paired up in the beginning for two to three weeks, then NA#1 had their own assignments. The CNA further stated that NA#1 had to give showers, bathing, toileting, feeding if residents needed to be fed, dressed, and transferred. The CNA also stated that NA#1 worked on different shifts and different units. On 5/28/25 at 1:02 PM, S#2 interviewed the LNHA, who stated that she was aware who would be hired at the facility, and what positions were open. The LNHA informed the surveyor that it was the responsibility of the HR staff to follow the facility's policy and protocol for hiring a NA which included what documents were required prior to rendering direct resident care. The LNHA stated that she relied on the verbal confirmation of the HR staff that all requirements for NAs were completed. The LNHA also stated that she did not review the NAs files. At that same time, the LNHA stated that she was familiar the with requirement that the NA should be enrolled in school, but she had no knowledge of NATCEP. The LNHA confirmed that NA#1 provided direct care that included; toileting, bathing, feeding, transferring, and hygiene without evidence that the modules/Skill Competency was completed on 1/16/25, when the school had provided the certificate after surveyor's inquiry. Furthermore, the LNHA stated that the facility did not have a policy for NAs and Caring Partners; that the facility followed their job descriptions and titles. On 5/28/25 at 1:20 PM, S#2 interviewed the DON, who stated that she was responsible for interviewing the NAs. The DON further stated that she was not involved in checking the paperwork for the NAs, and that was the responsibility of the HR staff. The DON confirmed that she was unaware about the 16 hours and modules/Skill Competency certificates because she did not check them. An acceptable Removal Plan was received on 5/28/25 at 5:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; NA#1 was taken off the schedule on 5/26/25, and will not return to the resident care until obtaining CNA certification. No NAs are currently assigned to resident care. Any newly hired NAs will have completed: 16-hour introductory NATCEP training, required modules and competency checklist, enrollment in a state-approved NATCEP program, and no other staff were found to be noncompliant. Documentation of all NA competencies and NATCEP progress will be maintained in a centralized digital tracker and paper file in HR and will require the LNHA, DON, HRD, and Staff Educator's signatures prior to hiring. The LNHA, DON, HRD, and Staffing Coordinator (SC) were re-educated by the governing body (Vice President of HR) on the regulations, and clear accountability structure was implemented that included; HR will confirm NATCEP enrollment, the LNHA will confirm completion of Module one and Module two of the NATCEP course with written documentation, the DON will verify clinical competencies were completed prior to the NA providing direct resident care, and the SC will ensure no assignment without full clearance. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 5/29/25 at 11:46 AM. NJAC 8:39-43.1(a)(2,3); 43.2(a)(1,3)(b) PART B On 5/22/25 at 9:49 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services (RDoCS), Surveyor #1 (S#1) asked if the facility utilized non-certified Nurse Aides (NAs), and the LNHA responded yes. The surveyor also asked if the NAs were providing direct care to residents, and the LNHA stated that the NAs, which included NA#1, were providing direct care under the direction of the Certified Nursing Aide (CNA) and nurse, and that the NAs were in school preparing to take their written examinations. The surveyor requested the NAs' employee files for review. On 5/22/25 at 1:40 PM, the LNHA provided Surveyor #2 (S#2) with a list of NAs who worked at the facility. NA#2 was included on the list with a date of hire (doh) of 5/20/24. On 5/27/25 at 12:32 PM, S#2 reviewed NA#2's employee file which revealed the following: -Nursing Assistant in Training: doh 5/20/24. Position: Nursing Assistant in Training, shift assigned 3:00 PM to 11:00 PM (3-11), and signed by NA#2. -Payroll Related Information: effective date 5/20/24, full time, five shifts per week . -School Certification: Certified Nurses Aide Program Certification was completed on 12/19/22. The certification was signed by the school's Assistant Director. -NA#2 passed the skills test on 12/26/22. NA#2 was required to take and pass the written test to get the CNA license. A further review of NA#2's employee file did not include documentation that NA #2 passed the written test. There was no evidence that NA#2 received his CNA license. A review of NA#2's timesheets provided by the RDoCS revealed NA#2 worked from 6/1/24 through 5/25/25, as a NA. A review of the corresponding CNA assignments sheets provided revealed the following: On the 6/1/24's 7:00 AM to 3:00 PM (7-3) shift and 3:00 PM to 11:00 PM (3-11) shift, NA#2 was assigned as a NA on the nursing Unit 2D. On 5/27/25 at 2:09 PM, Surveyor #3 (S#3) attempted to conduct a telephone interview with NA#2, there was no answer, and a message was left to call back. On 5/27/25 at 2:23 PM, S#2 interviewed the Regional Human Resource Director (RHRD), who stated that the previous Human Resource (HR) staff of the facility left, and she was the covering HR of the facility for two weeks now. The RHRD further stated that the facility's protocol with hiring NAs was to; ensure that the NAs were enrolled in school, get the test done before 120 days before transferring their title to a CNA, provide direct care after training and competencies were done, and all required certificates, including the completion of 16 hours of training should be in the NA's files. On that same date and time, the RHRD confirmed that NA#2 was hired on 5/20/24, and did not receive his CNA license. NA#2's last day of work at the facility was on 5/25/25. On 5/28/25 at 9:39 AM, the LNHA, Regional Director of Clinical Services (RDoCS), Regional Director of Operations (RDO), and [NAME] President of Operations (VPO) met with the survey team. The LNHA stated that NA#2 previously completed the Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) program in December 2022, and failed the written test. The LNHA confirmed that NA#2 was not enrolled in school at the time he was hired on 5/20/24. The LNHA further stated that NA#2's 120 days should have been 10/10/24. The LNHA confirmed that NA#2's last day of work was on 5/25/25. NJAC 8:39-43.1(a)(2,3); 43.2(a)(1,3)(b)

Refer to F 728 Based on interview and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as herself, implemented the facility's policies and procedures including a.) the hiring and utilization of non-certified Nursing Assistants (NAs) to ensure NAs were trained with the appropriate competencies and completed modules prior to receiving their own independent resident care assignment and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 1 of 3 NAs (NA#1) reviewed, who worked on 4 of 4 nursing units. Interviews on 5/28/25, with staff and the LNHA, revealed that NA#1 was hired on 9/16/24, to provide care to the residents and worked past 120 days (1/13/25) without being certified as a nursing aide. NA#1 began performing independent resident care on 9/27/24, and worked 68 shifts rendering independent resident care with no evidence of being enrolled in a State approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP), or completed the required modules and skills competencies. The facility's failure to ensure all staff, including the LNHA, implemented the facility's policies and procedures to ensure all staff completed the appropriate modules and skills competencies prior to rendering independent resident care posed the likelihood that serious injury, harm, impairment, or death could occur to residents from untrained staff. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 9/27/24, after NA#1 was assigned an independent resident care assignment. The facility Administration was notified of the IJ on 5/28/25 at 2:38 PM. The facility submitted an acceptable Removal Plan (RP) on 5/28/25 at 5:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. The evidence was as follows: A review of the Administrator Job Description, signed on 4/24/23, by the LNHA revealed: The Administrator was responsible to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing centers to assure that the highest degree of quality of care can be provided to the residents at all times . Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs activities. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Personnel Functions: Assist in the recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etc. Ensure that appropriate employment identification and work documents are presented prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary . A review of the facility's undated Staffing, Sufficient and Competent Nursing Policy, reflected that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . On 5/22/25 at 9:49 AM, the surveyor met with the LNHA and the Director of Nursing (DON) during an entrance conference, and the LNHA stated that currently there were three NAs working at the facility. The LNHA further stated that the three NAs were currently in school, working under direction of a Certified Nursing Assistant (CNA) and nurse, and that they were in the process of taking the exams. The surveyor requested from the LNHA and DON for the NAs' employee files. A review of the three NAs' employee files revealed that NA#1 was hired on 9/16/24. NA#1 was enrolled in a NATCEP program from 1/13/25 through 2/13/25, and completed their modules and skills competencies on 1/16/25. NA#1 had an independent resident care assignment on 4 of 4 nursing units from 9/27/24 to 1/12/25, for a total of 68 shifts with no evidence of completing their required modules or skills. NA #1 also worked past 120 days (1/13/25) without being certified as a nursing aide. On 5/28/25 at 9:39 AM, the LNHA, in the presence of the Regional Director of Clinical Services (RDoCS), Regional Director of Operations (RDO), and [NAME] President of Operations (VPO), confirmed that NA#1 rendered resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming independently without evidence of completing modules/Skill Competency. On that same date and time, the RDoCS informed the surveyors that on July 2024, the team did a Quality Assurance and Performance Improvement (QAPI) and reviewed the process for the required NA documentation that included the 16 hours modules/Skill Competency completion prior to the NA receiving their own assignment and rendering resident care. On 5/28/25 at 1:02 PM, the surveyor interviewed the LNHA, who informed the surveyor that she was not used to hiring NAs. The LNHA stated that she does not always review employee files and relied on the Human Resource Director (HRD) that everything was done or completed accordingly. She stated that she was unsure what NATCEP was, and what modules were to be completed. The LNHA further stated that as part of the requirements of the NAs was that they should be in a program. On that same date and time, the LNHA informed the surveyor that it was the responsibility of the HRD to check if the NAs were in school and the continued communication of the NAs' progress. The LNHA further stated that it was her responsibility as the administrator to do a verbal follow-up with the HRD. The LNHA also stated that it was not until July 2024, that she became aware that the NAs were required 16 hours of modules prior to the NAs being able to provide direct resident care. The LNHA acknowledged that the facility's process and policies should have been followed and it was part of her responsibility to oversee the onboarding process. On 5/28/25 at 1:20 PM, the survey team interviewed the DON, who informed the surveyor that she was responsible for interviewing the NAs. The DON stated that it was the responsibility of the HRD and Staffing Coordinator (SC) to ensure that the requirements of the NAs were completed before they worked on the nursing units independently. The DON further stated that she was unaware of the modules/Skill Competency because she did not deal with the NAs' files. An acceptable Removal Plan (RP) was received on 5/28/25 at 5:40 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; the LNHA, DON, HRD, and SC were re-educated by the governing body (Vice President of HR) on the regulation requirements specifically regarding administration oversight and enforcement of facility policies and procedures related to hiring, training, and assignment of NAs. The facility's policies related to the training, onboarding, and assignment of NAs were reviewed and reissued to all leadership employees in the nursing department. Policies include; requirement of 16 hour NATCEP training prior to any resident care, confirmation of module completion and competency prior to independent assignment. The LNHA will sign-off confirming the completed documentation prior to scheduling. A clear oversight structure has been put into place. The LNHA holds final accountability and will confirm file completion prior to assignment. The survey team verified the implementation of the RP during the continuation of the on-site survey on 5/29/25 at 11:46 AM. NJAC 8:39-9.2(a); 9.3(a)(1,2,3,4); 13.1(a),(b); 14.2

Based on interviews and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment with regard to use of non-certified Nursing Aides (NAs) to address the need of those residents under NAs care and b.) revised the facility assessment to address the contingency plan that included staffing guidelines. This failure had the potential to affect all 199 residents who currently live in the facility. This deficient practice was evidenced by the following: On 5/22/25 at 9:49 AM, Surveyor#1 (S#1) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference, the LNHA informed S#1 that the current census was 199 (total number of residents). The LNHA stated that currently there were three NAs working at the facility. The LNHA further stated that the three NAs were currently in school, working under direction of a Certified Nursing Assistant (CNA) and nurse, and that they were in the process of taking the examinations. S#1 requested from the LNHA and DON for the NAs' employee files and the Facility Assessment. On that same date and time, S#1 asked the LNHA and DON if the facility had contracted agencies for the use of nurses and CNAs, and the LNHA responded no. The LNHA informed S#1 that the facility currently utilizing contracted agencies for their residents' rehabilitation (i.e. physical, occupational, and speech therapy), dietary staff, Dietician, and housekeeping services. A review of the provided NAs files revealed: -NA#1 was hired on 9/16/24. NA#1 had an independent resident care assignment on 4 of 4 nursing units from 9/27/24 to 1/12/25, for a total of 68 shifts and continued to work until 5/26/25. -NA#2 was hired on 5/20/24. NA#2 worked as NA from 6/1/24 through 5/25/25. -NA#3 was hired on 1/27/25. NA#3 worked as NA from 1/30/25 through 5/25/25. A review of the provided Facility Assessment (FA), with an update date of 4/1/25, that was provided by the LNHA, revealed, the facility must review and update the assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment .Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required . Staffing Guidelines .staffing process includes ensuring that resident needs are met in the face of the challenges related to call outs or emergent situations. In the event of staffing challenges, our facility may utilize contracted staff to ensure that the needs of the residents are met. Contracted staff would be provided with appropriate education to ensure knowledge of facility systems and processes . Department: Dietary Services-4/1/25 contracted-Staffing: Cook, Food Service Director, Dietary Supervisor, Dietary Aide, and Dietitian. Department: Housekeeping and Laundry Services-contracted service-Staffing: Floor Tech, Housekeeping Aide, and Laundry Aide. Department: Nursing-Direct Care-Staffing: Supervisor, Registered Nurse (RN), Licensed Practical Nurse (LPN), and CNA . Department: Rehabilitation Services-contracted service-Staffing: Physical Therapist (PT), PT Assistant, Occupational Therapist (OT), OT Assistant, and Speech Language Pathologist . Appendix C-Staffing Contingency Plan . 1. Staff members will be reassigned to assist in the provision of resident care should staffing levels be compromised . b. Staff members will not be assigned duties for which they are not deemed competent or by licensure, unable to complete . 6. The facility may utilize contracted resources to support facility staffing patterns. a. contracted staff must meet requirements for hire and would be provided with appropriate education to ensure knowledge of CMS (Centers for Medicare and Medicaid Services) requirements and facility systems and processes . A review of the above FA revealed that NA was not included in the updated FA on 4/1/25, as part of the staffing guidelines. On 5/29/25 at 11:06 AM, Surveyor#2 (S#2) in the presence of the Regional Human Resource Director (RHRD) interviewed the Staffing Coordinator (SC). The SC informed S#2 that he was responsible for ensuring staffing needs of the facility were met. The SC stated that the facility, as part of company's protocol, did not utilize agency (contracted) nurses and CNAs. Both the SC and RHRD were unaware that the FA included information that as part of facility contingency plan to utilize contracted staff. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), LNHA, and Regional Director of Clinical Services (RDoCS), S#1 notified the above concerns with FA that contingency plan for staffing to utilize the agency and that the IDT (interdisciplinary team) did not identify NAs as part of their staffing guidelines. The LNHA acknowledged that the FA was to address the need of the residents. On 5/30/25 at 12:15 PM, the survey team met with the DON, LNHA, RDoCS, and RDO. The LNHA stated that the IDT met last evening, and that the FA was revised and modified to address the staffing guidelines, annual competencies, and staff education. The LNHA also stated that the Medical Director was notified of changes and agreed. NJAC 8:39-33.1; 33.2(b)(c)(13)(d); 33.4; 34.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 1 of 4 units (2E Unit) and 1 of 1 dining room, and was evidenced by the following: 1. During an initial tour of the facility on 5/22/25 at 11:10 AM, in 2E Unit, the surveyor observed upon entry to Resident Room#215 (RR#215), the ceiling tile near the window had brownish discoloration. The surveyor observed the 1st bed with broken basin and wedge for positioning under the resident's bed, and the floor was dusty. The 1st bed overhead light with another wedge for positioning. The resident in the 1st bed stated that they were unaware that there was a basin under their bed and probably that was the one they (nursing aides) use for cleaning the resident. At that same time, inside the RR#215's toilet room, the surveyor observed one ceiling tile had dried brownish discoloration and two basins (not stored and not labeled properly) on top of a dusty commode. On 5/22/25 at 11:23 AM, both the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) observed RR#215 the ceiling tile near the window had brownish discoloration, wedge on the floor, wedge on top of overhead light, broken basin on the floor, and the toilet room vent and commode with two basins. The LPN/UM informed the surveyor that the wedge and the broken basin should not be on the floor, as well as the wedge on top of the overhead light. She also stated that the dust in the toilet room vent should have been cleaned. The LPN/UM further stated that the basins inside the toilet room should have been stored inside a bag and labeled. On 5/23/25 at 9:03 AM, both the surveyor and the Certified Nursing Aide (CNA) observed RR#215's ceiling tile near the window had a brownish discoloration. Both the surveyor and the CNA also observed the toilet room had a dusty commode and some brownish dried spots, the ceiling tile with dried brownish discoloration, and the vent with accumulation of grayish substances. Outside the resident's room, the surveyor interviewed the CNA, who informed the surveyor that both residents inside RR#215 did not use the commode nor the toilet room because both residents were incontinent, and the commode should have been removed from that room. The CNA further stated that the commode was being used by the aides as a table to put their stuff, because there was no place to put the aides stuff. He also stated that the brownish discoloration on the ceiling tiles was from the rain and that the grayish substances were accumulation of dust. 2. On 5/22/25 at 11:20 AM, in 2E Unit, both the surveyor and the LPN/UM observed Resident Room#217's (RR#217) toilet room vent with accumulation of grayish substances and the LPN/UM confirmed it was dust and should have been cleaned. On that same date and time, both the surveyor and the LPN/UM observed a meal tray on top of the resident's table inside RR#217, the LPN/UM confirmed that it was the breakfast tray of the resident and should have been picked up. 3. On 5/22/25 at 11:27 AM, in 2E unit, both the surveyor and the LPN/UM observed in the hallway between Resident Rooms#204 and #205 the vent with accumulation of grayish substances. The LPN/UM confirmed that was dust and should have been cleaned. 4. On 5/22/25 at 11:29 AM, both the surveyor and the LPN/UM went inside the dining room near 2E Unit and observed 26 Residents and three Activity Staff during activity session. Both surveyor and LPN/UM also observed the chipped wood in the sink and above was vent with accumulation of blackish substances which the LPN/UM confirmed that dust in the vent should have been cleaned and the sink should have been fixed. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above findings and concerns with environment with regard to RR#215 and RR#217, hallway vent in 2E Unit, and the dining room. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, Director of Nursing (DON), RDoCS, and the RDO. The LNHA stated, with regard to the concerns with environment, we did do vent tour, rounding house wide, and ongoing audits were done. The LNHA also stated that they did change the countertop in the dining area with chipped wood, and other concerns were addressed after surveyor's inquiry. A review of the facility's Homelike Environment Policy, with a revised date of February 2021, that was provided by the LNHA, revealed, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment . On 5/30/25 at 1:28 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-31.2(e), 31.4(a)(f)

Based on observations and interviews on 5/22/2025 in the presence of the Regional Director of Plant Operations (RDPO) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to initiate call bell notifications were properly functioning. This deficient practice had the potential to affect 60 residents and was evidenced by the following: An observation at 12:45 PM revealed that the shower room near room [ROOM NUMBER] contained 2 shower stalls and a toileting area. Three of 3 resident call bell pull stations did not function when tested by the MD. An observation at 1:31 PM revealed that the shower room near room [ROOM NUMBER] contained 2 shower stalls and a toileting area. One of 3 resident call bell pull stations did not function when tested by the MD. In interview at the time, the MD confirmed the observations. The facility's Administrator and the RDPO were informed of the deficient practice at the Life Safety Code exit conference on 5/23/2025 at 2:30 PM. NJAC 8:39-31.2(e)

Based on observation, interview, and record review, it was determined the facility failed to treat a resident in a dignified and respectful manner for 2 of 38 residents (Residents #22 and #28) reviewed. This deficient practice was evidenced by the following: 1. On 5/23/25 at 9:21 AM, during a tour on a unit, the surveyor observed the nurse's medication (med) cart in front of the door to Resident #22's room and the door was open. The surveyor observed from the hallway into the room, no privacy curtain drawn. The Registered Nurse (RN) wore a disposable gown and gloves, was seated in a chair at the resident's bedside facing away from the door. A private duty aide was seated across from the resident's bed with their back facing away from the door. The resident was lying in their bed, with the head of bed elevated and dressed in a long-sleeved shirt and long pants. The surveyor observed from the hallway the RN administering the resident's enteral feeding and medications (meds) through their gastrostomy tube (a feeding tube to deliver nutrition directly into the stomach through a hole in the abdomen). On 5/23/25 at 9:23 AM, the door to the resident's room remained open and the surveyor went to the RN/unit manager (RN/UM), who was nearby at the nurses' station. The surveyor asked the expectation for when nurses were administering meds or enteral feedings. The RN/UM replied it was expected that the door was closed to provide privacy. The RN/UM with the surveyor observed Resident #22's door open and the resident could be seen from the hallway while being administered their med. The RN/UM informed the RN that the door should be closed and then the RN/UM closed the door. The RN/UM stated that maybe the private duty aide opened the door after the RN had closed it. The RN/UM could not confirm that it was what had occurred. The RN/UM acknowledged that the door should have been closed. On 5/23/25 at 9:29 AM, the surveyor interviewed the RN, who stated that when a nurse was administering meds and enteral feedings privacy should be provided by closing the door and/or the privacy curtain. The surveyor notified RN#1 of their observation. The RN stated I thought I closed door .I did not? The RN acknowledged the door should have been closed. The surveyor reviewed the electronic medical record of Resident #22. A review of the admission Record (AR; an admission summary) reflected that the resident had diagnoses that included but were not limited to; Parkinson's disease, anxiety disorder, bipolar disorder, and gastrostomy. A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 3/26/25, indicated a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS further documented the resident required set up or clean-up assistance for meals. A review of the physician's order (PO) dated 11/20/24, indicated, enteral feed five times a day; Jevity 1.5 Cal (calorie) via gravity bolus, 237 ml (milliliters) at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 8:00 PM. 2. On 5/27/25 at 12:33 PM, during a tour on a unit, the surveyor visited Resident #28's room. The resident was assigned to the bed by the window and their privacy curtain was drawn between their bed and their roommate's side of the room. The resident was observed lying in bed, resting with their eyes closed. The surveyor observed Resident #28 was wearing a long sleeved top and an incontinent brief. The resident had a urinary catheter which was attached to a drainage bag at the side of the bed. There was no blanket or top sheet covering the resident and none observed nearby the bed. Upon the surveyor's greeting Resident #28 opened their eyes and did not verbally respond to the surveyor's greeting or questions. There was no staff in the room or in the hallway near the room. On 5/27/25 at 12:35 PM, the surveyor asked Licensed Practical Nurse (LPN), who was assigned to care for Resident #28, to accompany the surveyor to the resident's bedside. The LPN with the surveyor entered the room and observed Resident #28 in their bed as observed above. The surveyor and the LPN stepped out of the room. The LPN could not speak to resident's appearance and stated if the resident was not wearing pants, they should have a blanket covering them. The LPN went to get the resident a blanket and stated the resident's assigned certified nurse aide (CNA) was currently in the dining area to assist feeding residents for lunch. On 5/29/25 12:11 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Regional Director of Clinical Services (RDoCS), and the Regional Director of Operations (RDO) of the observed concerns for Resident #22 and #28. On 5/30/25 at 12:14 PM, the LNHA, the RDoCS, the RDO, and the Director of Nursing (DON) met with the survey team. The DON stated education was provided to staff. There was no additional information provided by facility management. A review of the facility's Dignity Policy, last revised in February 2021, under Policy Statement revealed: Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self- worth and self-esteem . Under Policy Interpretation and Implementation, revealed: 1. Residents are treated with dignity and respect at all times .11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . A review of the facility's undated policy titled Resident Rights Guidelines for All Nursing Procedures, under General Guidelines revealed: 1. For any procedure that involves direct resident care, follow these steps .f. Close the room entrance door and provide the resident's privacy . N.J.A.C. 8:39-4.1(a)12

Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Physician (RP) of a change in condition for 1 of 38 residents (Resident # 85) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the electronic medical record (eMR) for Resident #85. A review of Resident #85's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dysphagia (difficulty swallowing foods or liquids), essential hypertension (high blood pressure), and neuropathy (nerve damage that can cause pain or numbness). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) date of 4/16/25, which indicated a brief interview for mental status (BIMs) score of 11, which reflected that the resident has moderate cognitive impairment. A review of the resident's Comprehensive Care Plan (relevant information about a resident's diagnosis, interventions, and the goals of treatment) dated 3/27/25, revealed treatment for pain and interventions of monitoring for side effects, and reporting to the RP. A review of the resident's Order Summary Report (OSR) (a listing of the resident's current medications) revealed a physician order for gabapentin oral capsule 300 mg (milligram), (a medication frequently used to treat pain from neuropathy), give 300 mg by mouth three times a day for right upper extremity neuropathy. A review of Resident #85's electronic medication administration record (eMAR) for May 2025, revealed that the nursing staff had documented the resident refusing the gabapentin. Further review revealed that the resident refused 26 times between 5/1/25 and 5/29/25. A review of the resident's progress notes (PN) revealed nursing documentation that the resident had refused the gabapentin with reasons reflected that it made them drowsy and difficulty speaking. Further review of the PN did not reflect any nursing notes that the RP was notified of the resident's refusals, or the side effects being experienced. The PN also did not reflect any Physician notes addressing the refusal or side effects being of gabapentin. On 5/27/25 at 12:36 PM, the surveyor interviewed Resident #85. The resident stated that they felt ok today and the pain was ok. The surveyor asked about any medications (meds) that made them sleepy. The resident stated that they were better without it (gabapentin), it made them feel too sleepy and could not talk right. The surveyor asked if they did not want the medication (med), did the nurse not gave it, and the resident stated yes. The resident also stated that they did not notify the RP, but resident notified the nurse. On 5/29/25 at 10:22 AM, the surveyor interviewed the License Practical Nurse (LPN). The surveyor asked the LPN about the resident's med refusals, and the LPN stated that she would talk to the resident's Nurse Practitioner (NP) today about recent refusals. On the same date and time, the surveyor then interviewed the LPN/Unit Manager (LPN/UM), and the Director of Nursing (DON). The LPN/UM stated that the NP should be aware of the refusals. The DON stated that the resident had pain relief due to the gabapentin but there was resident's representative that may influence the resident not to take it, and that the RP and NP were aware. The surveyor asked if there were any notes that reflected that they were aware. The RN/UM and DON could not locate any at that time and stated that the RP was coming in today and they would let them know. On 5/29/25 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Services (RDoCS), and Regional Director of Operations (RDO), and the surveyor discussed the above concerns. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, DON, RDoCS and RDO. The DON stated that education was done for staff regarding refusal of meds and notifying the physician. The DON further stated that Resident #85's physician spoke with the resident about the gabapentin and decreased the med. A review of the facility's Administering Medications Policy, dated April 2019, reflected, under line 21, that if a med is refused the nurse should document it, but it did not reflect that the resident's physician should be notified. The facility did not provide any further pertinent information. N.J.A.C. 8:39-13.1 (d)

Based on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 38 residents (Resident #135) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: A review of the Centers for Medicare & Medicaid Services (CMS's) Resident Assessment Instrument (RAI; helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Version 3.0 Manual, October 2024, reflected, definitions for injury except major, includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. Major injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. On 5/22/25 at 10:56 AM, the surveyor observed Resident #135 lying on bed. The surveyor reviewed the medical records of Resident #135 and revealed: A review of the face sheet or admission Record (an admission summary) documented that Resident #135, was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, other Alzheimer's disease, and history of falling. A review of Resident #135's most recent quarterly MDS (qMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 2/12/25, reflected that Resident #135 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Section J - Health Conditions, reflected that the resident had fall incident with no injury. A review of the active personalized care plan (CP) revealed that the resident had an actual fall related to poor safety awareness, 1/7/25 actual fall. A review of the provided incident date/time 1/6/25 at 11:00 AM, revealed, Resident #135 was found on the floor in resident's bathroom lying on their right side, and sustained laceration on the left side of the forehead and left eyebrow. A review of the Progress Notes, that was electronically signed by the Licensed Practical Nurse (LPN) on 1/6/25 at 12:30 PM, reflected that the resident was found lying on the floor in the bathroom on their right side and was noted with hematoma a small amount of bleeding on left eyebrow. On 5/28/25 at 10:17 AM, the surveyor notified the MDS Director (MDSD) of the concern about that the 1/6/25 fall incident was not reflected in the 2/12/25 ARD of the MDS, that the resident sustained an injury. The MDSD stated that she would get back to the surveyor. On 5/28/25 at 11:05 AM, the MDSD informed the surveyor, in the presence of the Regional Case Management, that after checking the resident's 2/12/25 MDS, Section J was not coded accurately, and it should have been coded with minor injury. The MDSD further stated that it was not considered major injury because the hematoma was not subdural. She also stated that the MDS was modified to correct Section J. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above concerns with the accuracy of MDS. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, Director of Nursing (DON), RDoCS, and the RDO. The LNHA and the DON did not provide response with regard to MDS accuracy. On 5/30/25 at 1:28 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for an exit conference, there was no additional information provided by the LNHA. NJAC 8:39-33.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with bladder patterning was completed and monitored in accordance with resident's comprehensive assessment and facility's policy and procedure. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for bladder and bowel (B & B) incontinence. This deficient practice was evidenced by the following: On 5/22/25 at 11:10 AM, the surveyor observed Resident #111 lying on bed, awake, able to respond to surveyor's inquiries appropriately. At that same time, the surveyor observed the toilet room, inside resident's room with a commode. On 5/23/25 at 9:03 AM, the surveyor observed the Certified Nursing Aide (CNA) inside the resident's room while the resident was lying on bed with call bell within reach. Outside the resident's room the surveyor interviewed the CNA, who informed the surveyor that nobody uses the commode in the room because both residents in the room were incontinent, including Resident #111, and the commode should have been removed. The CNA also stated that the resident was incontinent of B & B, and not something new to the resident, since the resident was moved to the unit. The surveyor reviewed the medical records of Resident #111 and revealed: A review of the face sheet or admission Record (an admission summary) documented that Resident #111 was admitted to the facility with diagnoses that included but were not limited to rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly, often due to high intensity exercise over a short period) and low back pain. A review of the clinical reports from the transferring facility (other facility), revealed that the resident did not care plan for B & B incontinence. There was no documented evidence from the clinical reports that the resident was incontinent of B & B. A review of the Bladder Patterning paper dated 7/28/23, 7/29/23, and 7/30/23, with Resident #111's name and room number, revealed that the form was filled out for three days for hours of 12 midnight through 7:00 AM (every hour interval). The hours from 8:00 AM through 11:00 PM (every hour interval) were blank. A review of the Documentation Survey Report of the Certified Nursing Aides accountability task for bladder continence for the following dates and times were blank: 7/27/23 and 7/29/23, at day shift (7:00 AM to 3:00 PM). A review of Resident #135's most recent quarterly MDS (qMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 4/29/25, reflected that Resident #111 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. On 5/23/25 at 9:30 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in the nursing station regarding the Bladder Patterning, which the LPN/UM claimed that was the bladder training program of the facility. The LPN/UM stated that the Bladder Patterning paper (also known as the facility's tool) should have been filled out for all shifts for three days in order to determine bladder pattern, and to formulate care plan and interventions. The surveyor notified of the concerns that it was not filled out accordingly and there were blanks in the form. The LPN/UM stated that the resident was not in her unit at the time it was supposed to be filled out. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above concerns with Residents#111's Bladder Patterning and that according to provided clinical records from another facility that the resident had no documented evidence of incontinence. The surveyor also discussed the concerns that if a resident was admitted with incontinence of bladder, the resident should receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, Director of Nursing (DON), RDoCS, and the RDO. The DON stated that for Resident # 111's concerns, upon admission the resident was incontinent upon evaluation on admission. The surveyor asked the DON, should the form be completed accordingly with no blanks as part of facility's practice and protocol, and the DON responded and said yes. A review of the facility's Urinary Incontinence-Clinical Protocol Policy, with a revision date of September 2012, that was provided by the LNHA, revealed: Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with impaired urinary continence, i.e. reduced ability to maintain urine in a socially appropriate manner. a. For example, review of a hospital discharge summary may reveal an individual was incontinent with or without catheter placement during a recent hospitalization, or a previous urology evaluation may have identified bladder outlet obstruction . Treatment/Management: 4. As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions try to improve the individual's continence status . Monitoring: 1. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. a. This should include documentation of a resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence . On 5/30/25 at 1:28 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for an exit conference, there was no additional information provided by the LNHA. NJAC 8:39-27.1(f)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) recommendation to upgrade the resident's diet was followed for resident identified as at risk for nutritional problem and b.) monitored weight according to the physician's order, and care plan interventions, for 1 of 3 residents, Resident#113, reviewed for nutrition. This deficient practice was evidenced by the following: On 5/22/25 at 11:00 AM, the surveyor observed Resident#113 inside their room with a Certified Nursing Aide (CNA) providing morning care to the resident. The surveyor reviewed the medical records of Resident #113 and revealed: A review of the resident's face sheet or admission Record (an admission summary), reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; vascular dementia, hemiplegia (condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (also called unilateral paresis, is the weakness of one entire side of the body (hemi- means half), and unspecified protein-calorie malnutrition. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 4/4/25, revealed in Section C Cognitive Patterns, a brief interview for mental status (BIMS) score of 7 of 15, which reflected that the resident's cognitive status was severely impaired. The qMDS also included that the resident had a weight loss and was coded #2 (yes, not on physician-prescribed weight loss regimen). A review of the personalized care plan (CP) revealed that Resident#113's potential for nutritional problem related to low body mass index (BMI; calculated measure of body weight relative to height and categories are underweight, healthy weight, overweight, and obesity), cognitive loss, swallowing problems, and requires extensive assistance with meals that was initiated on 10/1/24, and quarterly review completed on 4/5/25; significant weight loss was noted. The CP interventions that was initiated on 10/1/24, included but were not limited to adjust diet per Speech Language Pathologist (SLP; also known as a speech therapist, is a health professional who assesses and treats swallowing disorders in children and adults) and obtain weights at ordered intervals. A review of the Speech Therapy, SLP Discharge Summary that was electronically signed by the SLP on 3/20/25, revealed a discharge recommendations of mechanical soft textures diet. A review of the Nutrition Note dated 4/5/25, reflected that the resident's diet was upgraded by the SLP on 2/3/25 to mechanical soft texture with thin liquids. A review of Resident#113's Physician's Orders (PO) revealed: -Order date 9/28/24, bedtime snack offered, pureed texture. -Order date 4/5/25, weights weekly every day shift every Tuesday. A review of April 2025 and May 2025 electronic Medication Administration Record (eMAR) revealed: -4/8/25 and 4/22/25 weight records were blank -5/20/25 weight record was blank On 5/23/25 at 1:36 PM, the surveyor reviewed and copied the Weights and Vitals Summary (W&VS) for April 2025 and May 2025. The W&VS for April 2025 and May 2025 revealed there were no documented evidence that weights on dates 4/8/25, 4/22/25, and 5/20/25 were obtained according to the PO and CP. On 5/27/25 at 9:07 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who informed the surveyor that Resident#113 with some confusion, able to make needs known to staff if they have pain or need to be change. The LPN stated that the resident required total assistance with activities of daily living (ADLs), at times needs assistance with feeding, and with excellent appetite. The LPN also stated that the resident had history of weight loss when the resident first came into the facility. The surveyor asked if the resident was on weight monitoring, and the LPN responded that she was unsure. The LPN further stated, if the resident was on weekly weights, it should be in the eMAR. She further stated that there was a paper log where the monthly weights were documented, and then the Dietician entered them to the electronic medical records under W&VS. At that same time, the surveyor asked the LPN, why the eMAR was blank for 5/20/25 weight, and the LPN responded that she probably forgot. The LPN acknowledged that she was the nurse who worked on 5/20/25, and should have documented the weight as per PO. Afterward, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that she had the weight files in her office. The LPN/UM provided the weight files copies from January 2025 through May 2025. A review of the provided weight copies revealed that there was no weight specific to dates 4/8/25, 4/22/25, and 5/20/25. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above concerns with Resident #113's diet upgrade and missing weights. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, Director of Nursing (DON), RDoCS, RDO. The DON stated that one on one in-service was provided to the nurse on the late entry weight documentation. The DON also stated that the order for snacks was corrected to reflect the upgraded diet order. On that same date and time, the LNHA provided a copy of the late entry note and electronically signed by the LPN, for effective date of 5/27/25, with a note text: Late entry weight 91 pounds on 5/20/25. The LNHA also provided a copy of the W&VS that included weights for dates 4/8/25 and 4/22/25. In the presence of the LNHA RDO, DON, and survey team, the surveyor showed to the RDoCS the copy of the W&VS (that did not reflect 4/8/25, 4/22/25, and 5/20/25 weights), the April 2025 and May 2025 blanks in the eMAR (that reflected blanks on weekly weights for dates 4/8/25, 4/22/25, and 5/20/25) of Resident#113. The surveyor then asked the LNHA, DON, RDO, and RDoCS, how was the facility able to document in an electronic medical records the weights in the W&VS and in the 5/20/25 eMAR past the actual dates without showing an indication of a late entry, and the facility management did not respond. A review of the facility's Bowel & Bladder Training & Weight Documentation that was provided by the LNHA, revealed, proper recording: weigh the resident at the same time each morning, ideally before breakfast and after voiding .enter the weight into the eMAR or designated weight log the same day . A review of the facility's Weighing and Measuring the Resident Policy that was provided by the RDoCS, with a revision date of March 2011, reflected, purpose: this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Documentation: the following information should be recorded in the resident's medical record; the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure . On 5/30/25 at 1:28 PM, the survey team met with the LNHA, Director of Nursing, RDoCS, and RDO for an exit conference, and no additional information provided by the LNHA. NJAC 8:39-17.1(c); 27.1(a); 27.2(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents received timely and appropriate incontinence care to achieve their highest practical wellbeing. This deficient practice was identified for 1 of 2 residents, Resident#113, reviewed, and was evidenced by the following: On 5/22/25 at 11:00 AM, the surveyor observed Resident#113's door was closed with a linen cart outside the door. Inside the resident's room, there was a strong smell of urine. The surveyor observed a Certified Nursing Aide (CNA) providing incontinence care to Resident#113. The CNA showed the resident's soaked incontinence brief. On that same date and time, the CNA informed the surveyor that when she arrived at 7:00 AM, for her 7:00 AM to 3:00 PM (7-3) shift, she did not have a chance to provide incontinence care to the resident until now, at 11:00 AM, because she had a lot of residents on her assignment. The CNA was unable to say how many total residents she had on her assignment. The CNA further stated that Resident#113 was the second to last resident that she had to provide incontinence care. On 5/22/25 at 11:05 AM, the surveyor went outside the resident's room and interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the CNA's resident care assignment for that shift. The LPN/UM reviewed the CNA assignment sheet and informed the surveyor that the CNA had a total of 11 residents assigned to her. The LPN/UM stated that today, the census on the 2E unit was 55 total residents, and there should have been six CNAs, but they had to split assignment #3 due to short staff, and that was why the CNA was assigned 11 residents. At that same time, the surveyor notified the LPN/UM of the above findings and concerns that Resident#113 was observed with a soaked incontinence brief, and that the CNA confirmed the strong smell of urine inside the resident's room. The LPN/UM confirmed that Resident#113 was incontinent of both bladder and bowel elimination and required total assistance with incontinence care. The surveyor asked the LPN/UM if it was appropriate that incontinence care was provided to the resident for the first time during the 7-3 shift at 11:00 AM, and the LPN/UM responded, not really. The LPN/UM stated that the CNAs were short staffed and had to divide a CNA care assignment among the CNAs, so the CNAs had a lot of residents to provide care to. The surveyor reviewed the medical record for Resident#113. A review of the resident's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to; vascular dementia, hemiplegia (condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (also called unilateral paresis, is the weakness of one entire side of the body (hemi- means half), and unspecified protein-calorie malnutrition. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool with an assessment reference date (ARD) of 4/4/25, revealed in Section C Cognitive Patterns, the resident had a brief interview for mental status (BIMS) score of 7 of 15, which reflected that the resident's cognitive status was severely impaired. The qMDS also included that the resident was coded #2 for bladder continence, which reflected that the resident was frequently incontinent. A review of the personalized care plan (CP) revealed that Resident#113, was incontinent of bladder and bowel elimination related to decrease cognition that was initiated on 1/19/25. The CP interventions included but were not limited to; check resident approximately every two hours and provide incontinence care as needed and was initiated on 1/19/25. A review of the provided Documentation Survey Report of CNA (CNA interventions and tasks accountability) for May 2025, revealed for bladder continence on 5/15/25 and 5/17/25, during the 3:00 PM to 11:00 PM (3-11) shift, the log was blank. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above concerns with Resident #113 with regards to their incontinence care not provided in a timely manner according to resident's CP due to short staff per the CNA and LPN/UM. On 5/30/25 at 1:28 PM, the survey team met with the LNHA, Director of Nursing, RDoCS, and RDO for an exit conference, and no additional information provided by the LNHA. A review of the facility's Bowel & Bladder Training & Weight Documentation that was provided by the LNHA, revealed, key points: every two hours checks are essential, resident on toileting schedule must be checked every two hours and toileted or cleaned promptly . A review of the undated facility's Staffing, Sufficient and Competent Nursing Policy that was provided by the LNHA, revealed, facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident CP and the facility assessment. Policy Interpretation and Implementation, sufficient staff: licensed nurses and certified nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including; attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; assessing, evaluating, planning and implementing resident CP; and responding to resident needs . NJAC 8:39-25.2(b); 27.2(h)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate documentation of the receipt of a controlled substance for 13 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on 3 Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) out of 15 reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 5/27/25, the surveyor reviewed a binder provided by the Director of Nursing (DON), containing, but not limited to; facility DEA 222 Forms, copies of medical director state and federal controlled substance registration certificates, and packing slips associated with the DEA 222 Forms for controlled substance deliveries. A review of the facility DEA 222 Forms that were filled out and used to order controlled substances (CDS) revealed the following: DEA 222 Form with order form #23052853, dated 10/18/24, with the section Part 5: to be filled in by purchaser, date received, not filled in for lines 1, 2, and 3. Lines 4 and 5 not filled in for number received and date received. DEA 222 Form with order form #230528054, dated 8/31/24, with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. DEA 222 Form with order form #230628052, dated 6/21/24, with the section Part 5: to be filled in by purchaser, date received, not filled in. Part 5 was blank. On 5/29/25 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Director of Clinical Services (RDoCS), and Regional Director of Operations (RDO), and the surveyor discussed the above concerns with the DEA 222 forms. On 5/30/25 at 10:17 AM, the surveyor interviewed the DON. The surveyor asked the DON who handles the ordering of the back up medications (meds) including the CDS. The DON stated that they do along with the nursing supervisors. The DON stated they began as the DON in January of 2025, and that the previous DON and nursing supervisors were responsible for the DEA 222 forms prior to her starting. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, DON, RDoCS, and RDO, and the DON provided packing slips that were associated with two of the DEA 222 forms in question and stated that the facility received the meds for two of the forms and the third form was canceled. A review of the instructions for completing the DEA 222 Forms located in the Code of Federal Regulations at 21 CFR1305.13, revealed the following: Section (e) The purchaser must record on its copy of the DEA Form 222 the number of commercial or bulk containers furnished on each item and the dates on which the containers are received by the purchaser. A review of the facility's Controlled Substances Policy, dated November 2022, did not reflect any mention of the use or correct filling out of DEA 222 forms. The facility did not provide any further pertinent information. NJAC 8:39-29.3(a)6, 29.4(g), 29.7(c) 21 CFR 1305.13(e)

3. On 5/28/25 at 8:54 AM, Surveyor#2 (S#2) observed Licensed Practical Nurse#2 (LPN#2) assigned to the med cart (med-cart) located on the 2nd Floor, prepare and administer due meds to Resident #162. S#2 observed LPN#2 prepare and administer ferrous sulfate 325 mg (iron, a med that is a mineral used to treat anemia or low iron in the blood) and calcium carbonate 500 mg with vitamin D 200 u (unit) (calcium, a med that is a mineral used to treat low blood calcium and strengthen the bones along with the resident's other meds). Both the iron and calcium were scheduled to be given at 9:00 AM per the PO. S#2 asked LPN#2 if there were any drug interaction warning in the eMAR for the calcium or iron. LPN#2 could not locate any interaction warnings. S#2 asked LPN#2 if there were any drug interaction warnings on the containers for iron or calcium. LPN#2 and S#2 could not locate any warnings about the interaction on the med container labels. S#2 asked LPN#2 if they were aware that iron and calcium can interact if given at the same time. LPN#2 stated they were not aware of the interaction but would contact the physician to get the order time changed so they would not be given together. S#2 reviewed the electronic medical record for Resident #162. A review of Resident #162's AR reflected that the resident was admitted to the facility with diagnoses of, but not limited to, essential hypertension (high blood pressure) and type 2 diabetes (a chronic condition when the body cannot use insulin effectively). A review of Resident #162's qMDS with an ARD of 5/8/25, reflected, in Section C, that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #162 had severe cognitive impairment. A review of the resident's OSR, revealed the following: A PO for ferrous sulfate tab 325 mg, give 1 tab by mouth one time a day for supplement, with a start date of 8/1/24. A PO for oyster shell calcium/vitamin D tab 500-200 mg-unit, give 1 tab once a day for supplement. A review of the resident's eMAR revealed that the orders iron and calcium were both scheduled for administration at the 9:00 AM. A review of the CP report revealed that the CP did document that the resident's chart was reviewed for the period of August 2024 through present, and did not reflect any irregularities with the iron and calcium orders or the time the iron and calcium was scheduled. On 5/29/25 at 11:45 AM, S#2 interviewed the CP by telephone and S#2 asked the CP if there was an interaction between calcium and iron and if the meds should be administered together. The CP stated that iron and calcium should not be administered together. S#2 asked the CP if they would consider that an irregularity and comment to the facility about it. The CP stated that they would comment if something was on the med labels. On 5/29/25 at 12:20 PM, the survey met with the LNHA, RDoCS, and RDO, and S#2 discussed the above concerns with the med pass. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for responses to concerns. The DON stated that the orders for calcium and iron for Resident #162 were clarified and had the administration times separated on the eMAR. A review of the facility's Pharmacy Services- Role of the Consultant Pharmacist Policy, dated April 2019, reflected under Policy Interpretation and Implementation: 3.g. provide feedback about performance and practices related to med administration. 5.b. appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of meds ., including med irregularities . The facility did not provide any further pertinent information. NJAC 8:39-29.3(a)(1) Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 3 of 38 residents (Residents#3, #135, and #162), identified during Medication Regimen Review (MRR). This deficient practice was evidenced by the following: 1. On 5/22/25 at 10:50 AM, Surveyor#1 (S#1) interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident#3 had facility acquired wound to their midback and on hospice care. On 5/22/25 at 11:20 AM, both S#1 and the LPN/UM observed Resident#3 lying on their gerichair. S#1 reviewed the medical record for Resident#3, and revealed: A review of Resident#3's admission Record or facesheet (AR; an admission summary) reflected that the resident was re-admitted to the facility with diagnoses of, but not limited to; primary generalized osteoarthritis (the most common form of arthritis, can damage any joint, the condition most commonly affects joints in the hands, knees, hips and spine), dementia in other diseases classified, major depressive disorder, and anxiety disorder unspecified. A review of Resident#3's most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD; the last day of the observation period) of 1/11/25, reflected, in Section C Cognitive Patterns, cognitive skills for daily decision making was coded #3, which indicated resident's cognition was severely impaired. A review of the resident's Order Summary Report (OSR, a listing of the resident's active meds and other orders) revealed the following: -a Physician's Order (PO), date ordered 4/19/22, acetaminophen tablet (tab) 325 milligram (mg), give 2 tablets (tabs) by mouth every 6 hours (hrs) as needed (PRN) for general discomfort total dose 650 mg, do not exceed 3 grams per 24 hrs. -a PO, date ordered 1/21/25, lorazepam oral concentrate 2mg/ml (milliliters), give 0.25 ml sublingually (SL) every 2 hrs PRN for anxiety. -a PO, date ordered 1/21/25, morphine sulfate oral solution 20mg/ml, give 0.25 ml SL every 2 hrs PRN for severe pain. The above orders for PRN acetaminophen, lorazepam, and morphine sulfate were transcribed in the resident's electronic Medication Administration Record (eMAR) from January 2025 through May 2025. A review of the Consultant Pharmacist (CP) Medication Regimen Review (MRR) Recommendations to Prescriber revealed that the CP did document that the resident's chart was reviewed for the period of January 2025 through April 30, 2025. There was no document evidence that the CP identified any irregularities with the PRN acetaminophen, lorazepam, and morphine sulfate orders. On 5/27/25 at 9:04 AM, S#1 interviewed Licensed Practical Nurse#1 (LPN#1) in the 2E nursing station, who informed S#1 that for resident with multiple orders of PRN pain medications (meds), the PRN pain meds should be sequenced for mild, moderate, and severe pain to determine which PRN pain medication (med) to administer first. S#1 then notified the concern with Resident #3, that the PRN acetaminophen (also known as Tylenol) was for generalized pain and PRN morphine was for severe pain. LPN#1 stated that the PRN Tylenol should have been clarified as mild pain. On 5/29/25 at 11:33 AM, S#1 interviewed the CP by telephone. The CP informed S#1 that she did MRR monthly of all residents, submitted reports the Director of Nursing (DON) and Unit Managers via email. The CP stated that if a resident with multiple PRN pain meds, it should be sequenced as to mild, moderate, and severe pain. The CP also stated that she usually recommended to have 14 days stop date and re-evaluate by physician the PRN psychoactive meds that included lorazepam as antianxiety med even if the resident was on hospice care as a requirement in the regulations. At that time, S#1 notified the CP of the above findings and concerns that Resident#3's PRN pain meds were not sequenced, the PRN lorazepam had no stop date when it was ordered on 1/21/25, and the CP's MRR recommendations did not identify those irregularities. The CP informed the S#1 that she recommended on her 3/26/25 visit notes in MRR to review and re-evaluate the resident's multiple PRN orders for meds. The CP further stated that she was unsure why it was not in the facility's provided reports, and that she would send it via email to the Licensed Nursing Home Administrator (LNHA) to provide it to S#1. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), LNHA, and Regional Director of Clinical Services (RDoCS). S#1 notified the facility management the above concerns with Resident#3's irregularities that were not identified by the CP. A review of the facility's Medication Orders Policy that was provided by the RDoCS, with a revision date of November 2014, revealed, the purpose of this procedure is to establish uniform guidelines in the receiving and recording of med orders .Recording Orders: PRN med orders, when recording PRN med orders, specify the type, route, dosage, frequency, strength, and the reason for administration. Example: Tylenol 500 mg by mouth every 4 hrs PRN for mild pain . On 5/30/25 at 12:14 PM, the survey team met with the LNHA, DON, RDoCS, and RDO. The surveyor asked the DON should there be a stop date for PRN lorazepam, and DON stated yes. The DON stated, for Resident#3, the staff were provided an in-service about PRN pain sequencing and the order for lorazepam was changed to reflect a stop date for 30 days. At that same time, the surveyor followed up with the LNHA about the email copy of the 3/26/25 recommendations of the CP, the LNHA confirmed that there was no documentation received from the CP for Resident#3. 2. On 5/22/25 at 10:56 AM, S#1 observed Resident#135 lying on bed. S#1 reviewed the medical records of Resident#135 and revealed: A review of the AR reflected that Resident#135 was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, other Alzheimer's disease, and history of falling. A review of Resident #135's most recent qMDS, with an ARD of 2/12/25, reflected that Resident #135 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. A review of the resident's OSR revealed the following: -a PO, date ordered 5/9/24, risperidone 0.25 mg, give 1 tab by mouth at bedtime related to unspecified dementia, unspecified severity, with other behavioral disturbance. A review of the Psychiatric follow up consult's notes, dated 11/26/24, 1/18/25, 3/4/25, and 5/6/25, revealed, diagnosis and plan to continue Risperdal (also known as risperidone) for mood disorder (d/o) not otherwise specified (NOS), home regime, and no history (h/o) of psychosis. A review of the CP MRR Recommendations to Prescriber revealed that the CP did document that the resident's chart was reviewed on 5/30/2024 at 12:59, with a CP Note Text: Medication regimen reviewed. No recommendations at this time. On 5/29/25 at 12:11 PM, the survey team met with the RDO, LNHA, and RDoCS, and the surveyor notified them of the above concerns with risperidone appropriate use and diagnosis, that was ordered on 5/9/24, the diagnosis was unspecified dementia, unspecified severity, with other behavioral disturbance, while the Psychiatrist documented diagnosis of mood d/o NOS. S#1 also discussed the concern that the 5/30/24, CP documented during her MRR she did not identify any irregularities, and no recommendations at that time. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, DON, RDoCS, and the RDO. The DON stated that the appropriate diagnosis for Resident#135's use of risperidone was clarified and changed to mood disorder. A review of the facility's Medication Regimen Reviews Policy that was provided by the RDoCS, with a revision date of February 2025, revealed, a licensed pharmacist reviews the med regimen of each resident at least monthly .The MRR includes a review of the medical record to prevent, identify, report, and resolve med related problems, med errors, or other irregularities, for example, the use med: inconsistent with accepted pharmaceutical services standards of practice .Irregularities may also include: other med errors, including those related to documentation .Timeframe for reporting: within 24 hrs of the MRR, the CP provides a written report to the attending physicians for each resident identified as having a med irregularity that is deemed not life-threatening .The CP provides the DON and Medical Director with a written, signed, and dated copy of all MRR. Copies of MRR, including physician responses, are maintained as part of the permanent medical record . On 5/30/25 at 1:28 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for an exit conference, and no additional information provided by the LNHA.

Based on observation, interview, and record review, it was determined the facility failed to follow a physician's order for medications with a parameter and acceptable professional standards of practice for 1 of 28 residents, Resident#54, reviewed. The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 5/27/25 at 8:59 AM, the surveyor reviewed the electronic medical records (EMR) of Resident #54. A review of the admission Record (admission summary) revealed that Resident #54 had diagnoses that included but were not limited to; end stage renal disease, heart failure, hypertension (high blood pressure), and dementia. A review of the comprehensive Minimum Data Set (MDS), assessment tool used to facilitate management of care, with an assessment reference date of 4/22/25, had a Brief Interview Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. A review of the physician's order dated 4/22/24, included an order for metoprolol tartrate, 25 milligram (mg) tablet (tab), give 1 tab by mouth two times a day for HTN [hypertension]; hold for sbp [systolic blood pressure] below 110 and HR [heart rate] below 60, give with meals. The medication (med) was scheduled to be given to the resident at 8:00 AM and 5:00 PM. A review of the May 2025 electronic Medication Administration Record (eMAR) revealed the metoprolol tartrate order entry had the blood pressure (BP) at the time of the med administration by the nurse. The entry had no documentation of the HR at the time of the med administration. A review of the Weights/Vitals section of the EMR which documented the recorded BP and HR of the resident revealed that there was no documentation to account for the resident's HR at the time of the 8:00 AM doses for the med. On 5/29/25 at 11:15 AM, the surveyor interviewed a Registered Nurse (RN) #1 assigned to care for Resident #54 about medications (meds) with parameters. RN #1 stated BP and HR were checked prior to medication administration and the parameters were indicated in the physician's order. The RN explained the BP and HR results were documented in the MAR and then would be show up in the weights/vitals section of the EMR. RN #1 stated if the results were outside the parameters of the medication order, the medication should be held, not administered to the resident, and a note written as to why the medication was not given. The surveyor with RN #1 reviewed the metoprolol tartrate entry for Resident #54's MAR. RN #1 confirmed that there was no documentation of the HR and that it should be documented in the entry at the time of administration. On 5/29/25 at 11:41 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) about meds with parameters. The ADON stated the nurses would document BP and HR results in the eMAR upon administering med and the results were carried over to vital signs section. The surveyor with the ADON reviewed Resident #54's metoprolol tartrate order in the eMAR. The ADON stated there should be an entry for the HR along with the BP entry. The surveyor with the ADON reviewed the vital signs section. The ADON confirmed the HR was not documented for every dose of metoprolol administered. The ADON acknowledged it would be expected for the nurses to clarify the order. The ADON stated she would clarify the order and would review to provide any additional information for HR documentation. On 5/29/25 at 12:11 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), and the Regional Director of Clinical Services (RDoCS) of the above concerns. On 5/30/25 at 12:14 PM, the LNHA, the Director of Nursing (DON), the RDO, and the RDoCS met with survey team. The DON stated Resident #54's metoprolol order was clarified, and an audit was completed to ensure no other resident was affected. There was no additional information provided by facility management. A review of the facility's Administering Medications Policy, with a last revised date of April 2019. Under Policy revealed: meds are administered in a safe and timely manner, and as prescribed . Under Procedure of the policy revealed: .4. Meds are administered in accordance with prescriber orders, including any required time frame .11. The following information is checked/verified for each resident prior to administering meds .b.Vital signs, if necessary . NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 5 medication carts observed on 1 of 4 nursing units of the facility. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 5/27/25 at 12:34 PM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence of Registered Nurse (RN) inspected the med cart identified as middle cart located on 1A. The surveyor observed a total of eight unidentified tablets (tabs) and/or capsules (caps) located in the bottom of the 2nd and 3rd drawers. The surveyor asked the RN if they could identify the loose tabs or caps and if they should be stored that way. The RN stated that they could not identify what the med was or who it was for and that it should not be stored that way since it was not clean. The surveyor observed the RN dispose of the unidentified medications (meds) in a self-contained drug disposal system. On 5/29/25 at 12:20 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Services (RDoCS), and the Regional Director of Operations (RDO), and the surveyor discussed the above concerns with med storage. On 5/30/25 at 12:14 PM the survey team met with the facility LNHA, Director of Nursing (DON), RDoCS, and RDO, and the DON stated that the facility conducted audits of the med carts and education of the staff regarding med storage and loose pills. The LNHA did not provide any further pertinent information for med storage. A review of the facility's Medication Labeling and Storage Policy, dated February 2023, reflected, med storage: 1. Meds and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 2. The nursing staff is responsible for maintaining med storage and preparation area in a clean, safe, and sanitary manner .5. Med is stored in an orderly manner in cabinets, drawers, carts . NJAC 8:39-29.4(d)(g)

Complaint # 172385 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate and easily accessible. This deficient practice was evidenced by the following: On 5/22/25 at 1:32 PM, the surveyor requested from the Director of Nursing (DON) the Certified Nurse Assistant (CNA) unit assignment sheets for the facility's 4 units for the day shift for 3/19/24, 3/20/24, and 3/21/24. On 5/23/25 at 12:13 PM, the facility provided a computer printout of the staff in the facility for 3/19/25, 3/20/25, and 3/21/25. The surveyor requested from the Licensed Nursing Home Administrator (LNHA), the CNA assignment sheets for the facility's 4 units for the day shift for the three dates. On 5/29/25 at 12:50 PM, the surveyor notified the LNHA that the CNA assignment sheets that were provided to the surveyor were for the year 2025, and not the requested 2024. On 5/30/25 at 10:00 AM, the surveyor requested from the LNHA the CNA assignment sheets. On 5/30/25 at 10:18 AM, the LNHA provided the surveyor the CNA assignment sheets for unit 1AB for the correct three dates requested. The LNHA stated that she was still looking for the other unit's assignment sheets, 1C, 2D, and 2E. On 5/30/25 at 12:14 PM, in the presence of the Regional Director of Operations (RDO) and the Regional Director of Clinical Services (RDoCS), the LNHA provided the surveyor the following CNA assignment sheets: Unit 1C, 11-7 (11:00 PM-7:00 AM) shifts. The 7-3 (7:00 AM-3:00 PM) shift for the three dates were not provided. Unit 2D, all shifts for 3/19/24 and 3/21/24. The 3-11 (3:00 PM-11:00 PM) and 11-7 shifts for 3/20/24. The 7-3 shift for 3/20/24 was not provided. Unit 2E, no assignment sheets were provided for the three dates. At that same time, the LNHA stated that they were still looking for Unit 2E. On 5/30/25 at 12:33 PM, in the presence of the RDO and the RDoCS, the LNHA confirmed that she did not provide the surveyor all of the requested 7-3 shift CNA assignment sheets for the three dates for all units. The surveyor notified the LNHA the concern that the records were not accessible. The LNHA did not provide any additional information. NJAC 8:39-23.2 (a)(b); 35.2 (d)(6)

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate use of personal protective equipment (PPE) and the physician's order for Enhanced Barrier Precautions (EBP). This deficient practice was identified on 1 of 1 contracted staff (Hospice Aide), failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, revealed, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBP are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . On 5/22/25 at 10:50 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident#3 have facility acquired wound to their midback and on hospice care. On 5/22/25 at 11:20 AM, both surveyor and the LPN/UM observed upon entering the resident's room, there was no posted sign for EBP. Both surveyor and the LPN/UM observed Resident#3 lying on the gerichair. The surveyor reviewed the medical record for Resident#3, and revealed: A review of Resident#3's admission Record or face sheet (an admission summary) reflected that the resident was re-admitted to the facility with diagnoses of, but not limited to; primary generalized osteoarthritis (the most common form of arthritis, can damage any joint, the condition most commonly affects joints in the hands, knees, hips and spine), dementia in other diseases classified, major depressive disorder, and anxiety disorder unspecified. A review of Resident#3's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD; the last day of the observation period) of 1/11/25, reflected, in Section C Cognitive Patterns, cognitive skills for daily decision making was coded #3, which indicated resident's cognition was severely impaired. A review of the resident's Order Summary Report (a listing of the resident's active medications and other orders) revealed the following: -a Physician's Order (PO), date ordered 4/17/25, cleanse mid thoracic spine wound with normal saline (NS), pat dry, apply medi-honey (wound paste recommended for hard-to-dress wounds) to wound bed cover with saline moistened woven gauze (kerlix) and foam boarder dressing daily/PRN (as needed) if soiled for stage 3 pressure (full thickness tissue loss, ubcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) wound. -a PO, date ordered 5/25/25, EBP: wound every shift for wound. A review of the Wound Care Progress Note, electronically signed by the Nurse Practitioner (NP) on 5/22/25, revealed, Resident#3 was seen by the NP for a follow up wound evaluation .Wound assessment: mid thoracic spine, stage 3 pressure injury, improving .exudate: small serosanguinous drainage (is a combination of serous and sanguineous drainage, typically appears as light pink, thin, and watery fluid.). On 5/27/25 at 8:54 AM, the surveyor observed a posted sign outside the resident's door for EBP and with PPE. The EBP posted sign included the following information: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must also: wear gloves and a gown for the following: High-contact resident care activities. Dressing. Bathing/showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting . Wound care: any skin opening requiring a dressing. Inside the resident's room, the surveyor observed a Certified Nursing Aide (CNA), who claimed she was from a hospice company, and was performing morning (AM) care that included incontinence care to Resident#3. The surveyor observed also that the hospice CNA was at that time putting on the pants and then the sock of the resident with gloves in use, and no gown. The surveyor asked the hospice CNA if she should be wearing gown while performing AM care, and the hospice CNA responded that she did not need a gown and the gloves were enough. The CNA confirmed that the resident had a dressing to mid thoracic (back) due to a wound. On 5/27/25 at 9:25 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in the 2E nursing station regarding resident's EBP posted sign and asked why the resident was on EBP. The LPN/UM informed the surveyor that during the wound rounds of the NP last week, the resident was put back on EBP due to mid back pressure ulcer had a drainage and confirmed that the resident's mid back wound still had a light drainage up to this time. At that time, the surveyor notified the LPN/UM of the above concern about the hospice CNA, and the LPN/UM stated that she would talk to hospice aide because she should have worn a gown and mask as well. The LPN/UM further stated that on 5/22/25, the resident had no order for EBP, not until the NP assessed the resident during wound rounds and noted drainage to the wound area, and recommended to put back the order for EBP. On 5/29/25 at 12:11 PM, the survey team met with the Regional Director of Operations (RDO), LNHA, and Regional Director of Clinical Services (RDoCS). The surveyor notified the facility management the above concerns with hospice CNA not following the posted sign and order for EBP of Resident#3. On 5/30/25 at 12:14 PM, the survey team met with the LNHA, Director of Nursing (DON), RDoCS, and RDO. The DON stated that they had in service the hospice aide for EBP. A review of the facility's Enhanced Barrier Precautions Policy with a revision date of December 2024, that was provided by the RDoCS, revealed, Policy Interpretation and Implementation: 6. Examples of secretions or excretions include wound drainage .8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, providing hygiene, or grooming, changing briefs or assisting with toileting .wound care .12. EBP are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that a higher risk . On 5/30/25 at 1:28 PM, the survey team met with the LNHA, DON, RDoCS, and RDO for an exit conference, and no additional information provided by the LNHA. NJAC 8:39-19.4(a)(2)

Based on interviews, record review, and policy review, the facility failed to ensure five residents reviewed for abuse (Resident (R) 1, R5, R13, R14, and R32) out of 32 sampled were free from physical abuse. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 2001, provided by the facility, revealed Residents have the right to be free from abuse . The resident abuse . consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect . by anyone including but not limited to: a. facility staff; . f. family members . 1. Review of R1's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted on [DATE]. Review of R1's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/14/23, located in the EMR under the MDS tab, revealed R1's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. Review of R1's Skin Assessment dated 07/10/23 located in the EMR under the Assessment tab, revealed a bruise to the left upper arm measuring 17 x 15 centimeters (cm). Review of R1's Health Status Note dated 07/10/23 located in the EMR under the Prog Note tab, revealed, R1 observed with bruise to left upper arm. He/She had full range of motion to his/her left arm. No s/s [signs or symptoms] of pain and discomfort, denies pain and discomfort . Review of R1's Onsite Note dated 07/13/23 located in the EMR under the Prog Note tab, revealed, .Chief complaint: asked to see resident with bruise to left forearm .resident who was recently noted to have ecchymosis to left upper arm. Change nurse reports he/she had some injury over the weekend and sustained some ecchymosis. X-ray of the LUE [left upper extremity] was ordered and results showed no fracture . Review of the facility's Incident Report dated 07/10/23 provided by the facility, revealed a skin issue was investigated and the conclusion was R1's granddaughter did not follow the plan of care for transfers and did not wait for staff to transfer the resident back into bed from the Geri chair via Hoyer lift on 07/09/23. In an interview on 01/28/25 at 1:12 PM, Licensed Practical Nurse (LPN)7 stated Certified Nurse Aide (CNA)9 notified him that she observed a bruise on R1's left arm on 07/10/23 at 10:30 AM and then he reported it to the Assistant Director of Nursing (ADON) and Director of Nursing (DON) immediately. LPN7 also stated he performed on R1 a skin and pain assessment. In an interview on 01/28/25 at 1:45 PM, the ADON stated CNA9 notified LPN7 that she observed a bruise to the underside of R1's left arm and he reported it to her. The ADON also stated LPN9 conducted a skin assessment, and pain assessment. They did not consider it an injury of an unknown injury. In an interview on 01/28/25 at 2:34 PM, the Administrator stated she did not identify the bruise as an injury of an unknown source. In an interview on 01/28/25 at 3:09 PM, CNA9 stated she was providing care to R1 on 07/10/23 at 10:25 AM and noted and reported a dark bruise on his/her left upper arm. CNA9 indicated she reported the bruise to LPN7 at 10:30 AM. CNA9 also stated R1's granddaughter told her that she transferred R1 from the chair to the bed without assistance on 07/09/23 so she informed the ADON when interviewed about the identified bruise. CNA9 confirmed she was assigned to R1 on the evening shift of 07/09/23 and had provided incontinent care to him/her. 2. Review of R12's EMR admission Record located under the Profile tab indicated that the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R12's EMR admission MDS with an ARD of 07/19/24 indicated the resident had a BIMS score of 11 out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident had verbal behaviors directed at others such as screaming or threatening. The assessment indicated R13 was able to ambulate on his/her own. Under the Care Area Assessment (CAA) the resident triggered behavioral symptoms and directed the staff to develop a care plan. Review of R12's EMR Care Plan located under the Care Plan tab dated 08/06/24 indicated the resident had poor impulse control and as a result R12 hit R13 since they argued over a towel. Review of R12's EMR Health Status Note located under the Prog (Progress) notes dated 08/06/24 revealed CNA6 walked into the room of R12 and observed R12 hitting R13's head and attempting to take a towel away from R13. R12 reported that R13 poured water on his/her bed and stated he/she needed the towel to clean up his/her bed. According to the progress notes, both residents were separated. The Administrator, family members, and physicians were notified of the incident. 3. Review of R13's EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R13's EMR titled Care Plan located under the Care Plan tab dated 10/03/23 indicated the resident had an anxiety disorder. Review of R13's EMR quarterly MDS with an ARD of 07/11/24 indicated the resident had a BIMS score of 99 which meant the resident was unable to complete the cognitive assessment. The assessment indicated the resident had no behaviors directed towards others, either verbally or physically. The assessment indicated the resident was able to ambulate with assistance from staff. Review of R13's EMR Health Status Note located under the Prog note tab dated 08/06/24 indicated CNA6 entered the resident's room and R13 was attempting to take a towel from R13 and R12 was observed to hit R13's head. According to the progress notes, both residents were separated. Review of a Facility Reported Incident (FRI) dated 08/06/24 in which the Administrator was notified of the incident with R12 to R13. The Administrator detailed the residents were separated, assessed, and no injuries identified. 4. Review of R32's EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R32's EMR quarterly MDS with an ARD of 07/24/24 indicated the resident had a BIMS score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors directed towards others. Review of R32's EMR Health Status Note located under the Prog note dated 08/16/24 indicated a physical altercation between R32 and R12. Both residents were separated and assessed. R32 had some swelling on the left side of his/her face and an ice pack was applied. Review of R32's EMR Care Plan located under the Care Plan tab dated 08/16/24 indicated the resident was slapped in the face. Review of a FRI dated 08/16/24 indicated the Administrator was notified of R12 and R32 altercation. The FRI revealed R12 hit R32's face. CNA17 observed the incident and before CNA17 could intervene, R12 slapped R32's face. 5. Review of R14's EMR Admissions Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R14's EMR quarterly MDS with an ARD of 08/09/24 indicated the resident had a BIMS score of 99 which revealed the resident was unable to complete an interview for cognitive status. The assessment indicated the resident had no behaviors directed towards others. Review of R14's EMR Health Status Note dated 10/21/24 indicated LPN 9 went to get something from the pantry. LPN9 documented that she heard a slap and when she went up to the nurse station, R12 was observed to slap R14. R14 confirmed he/she was slapped by R12 and said the slap did not hurt him/her. LPN9 notified the Administrator, family, and the physician. Review of a FRI dated 08/16/24 which indicated the Administrator was notified of R12 and R14 altercation. The FRI revealed R12 rolled impulsively to R14 and slapped him/her across the face. The FRI indicated R12 was placed back in his/her room and provided one-on-one supervision until he/she was sent to a local hospital for evaluation and treatment. R12 returned after his/her hospitalization and was immediately placed under one-to-one supervision. During an interview on 01/28/25 at 10:47 AM, LPN9 stated she did not believe the other residents were afraid of R12. LPN9 stated R12 was transferred to an in-patient psychiatric hospital. LPN9 stated R12's behavior was unpredictable and mostly directed at the caregiving staff. LPN9 confirmed she observed R12's slapping R14 and R14 appeared to be stunned. LPN9 went through R12's EMR and addressed that the care plan was updated after each incident of resident-to-resident altercations. LPN9 stated after the 08/06/24 the resident was to be in his/her room without a roommate. LPN9 stated after the 08/16/24 incident that the care plan was updated to keep all residents away from R12's room. LPN9 stated a stop sign was placed on R12's door as a deterrent for other residents to enter. Finally, the care plan was updated from the 10/21/24 incident and R12 had one-on-one supervision. During an interview on 01/28/25 at 11:03 AM, CNA13 confirmed she observed R12 slap R13 across the face. CNA13 stated she reported the resident-to-resident incident since residents were not permitted to hit each other since this was considered abuse. 6. Review of R5's EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R5's EMR Care Plan located under the Care Plan tab dated 07/12/22 indicated the resident was combative and resistive during care. The care plan direction was the resident may need to have two staff members to assist in care for the resident. Review of R5's EMR Health Status Note located under the Profile tab dated 10/08/23 at 10:15 PM, indicated the resident became combative while the staff attempted to check his/her blood glucose level and administer his/her insulin. The progress note indicated no bruising or skin tears noted after the encounter. Review of R5's EMR Health Status Note located under the Profile tab dated 10/09/23 at 9:45 AM, indicated LPN6 overheard the resident yelling out and CNA10 was in the room with the resident. LPN6 noted she asked CNA10 what was going on and it was documented in the clinical records that CNA10 stated she was about to provide the resident with care when LPN6 noticed the resident had a bruise on his/her right upper lip which measured 2 by 2 centimeters (cm), and the resident's lower lip was swollen. In addition, the resident had two dry skin tears on his/her left arm. During an interview on 01/28/25 at 1:04 PM, CNA10 stated she entered R5's room and the resident just began to yell. CNA10. CNA10 stated she observed the resident with busted lip and skin tears on his/her arm. CNA10 denied that she abused R5. During an interview on 01/28/25 at 1:14 PM, LPN6 confirmed she was the nurse on duty on 10/09/23 and stated she heard R5 yell out. LPN6 stated this was typical behavior for the resident. LPN6 stated she did not know how the injuries to the resident happened and may have happened the previous night. The LPN6 confirmed CNA10 was in the resident's room by himself/herself. During an interview on 01/28/25 at 1:34 PM, the ADON confirmed she was the previous DON at the time of the 10/09/23 incident. ADON confirmed CNA10 worked the day shift and was in the room with R5 by herself. ADON stated she did not consider the incident a potential staff to resident abuse. ADON stated she has been through additional training since the incident and now was aware of the potential of staff to resident abuse when injuries have been identified on a resident and taken the incident a step further. During an interview on 01/28/25 at 2:28 PM, the Administrator stated she began a Quality Assurance Performance Improvement (QAPI) plan in 11/23 and stated she was hired prior to the 10/09/23 incident and was not aware of the allegation. The Administrator stated her goal was to tighten up the reporting of potential abuse allegations. The Administrator stated the company who owns the facility required quarterly abuse prevention training for all staff. The ADON was present during this interview. N.J.A.C. 8:39-4.1(a)(5)

Based on interview, record review, and policy review, the facility failed to ensure a potential allegation of abuse for two of seven residents reviewed for abuse in the sample of 32 was reported timely to the State Survey Agency (SSA). Specifically, the facility failed to report R1's suspicious bruising of the upper arm and an allegation of physical abuse which involved Certified Nurse Aide (CNA)10 and Resident (R) 5 to the SSA timely. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 2021 indicated, . All reports of resident abuse (including injuries of unknown origin).are reported to local, state, and federal agencies. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies. The state Licensing/certification agency responsible for surveying/licensing the facility.within two hours of an allegation involving abuse or result in serious bodily injury. Review of the facility's policy titled Investigating Resident Injuries dated 2001 indicated . Injury of unknown source is defined as an injury that meets both of the following conditions. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.The injury is suspicious because of.the extent of the injury.the location of the injury (e.g., the injury is in an area not generally vulnerable to trauma) .the number of injuries observed at one particular point in time.or the incidence of injuries over time. 1. Review of R5's electronic medical record (EMR) titled admission Record indicated the resident was admitted to the facility on [DATE]. Review of R5's EMR quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/28/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99 which revealed the resident revealed the resident was unable to complete an interview for cognitive status. Review of R5's EMR Health Status Note located under the Profile tab dated 10/09/23 at 9:45 AM, indicated Licensed Practical Nurse (LPN)6 overheard the resident yelling out and CNA10 was in the room with the resident. LPN6 noted the resident with a bruise on his/her right upper lip which measured 2 by 2 centimeters (cm), the resident's lower lip was swollen. In addition, the resident had two dry skin tears on his/her left arm. CNA 6 was in the resident's room alone and LPN6 asked him/her what happened. CNA6 stated she had not begun cares when the resident began to yell out. During an interview on 01/28/25 at 1:14 PM, LPN6 stated she did not report the bruise and skin tears to the abuse coordinator. During an interview on 01/28/25 at 1:34 PM, the Assistant Director of Nursing (ADON) stated she was the previous Director of Nursing (DON) at the time of the 10/09/23 incident in which R5's had bruising to the upper arm, a swollen lip and skin tears to the arms. She confirmed she did not report the potential abuse which involved R5 to the SSA since she believed she knew what happened and more than likely the bruising occurred during the provision of care. During an interview on 01/28/25 at 2:28 PM, the Administrator stated all suspicious bruising and potential abuse allegations were to be reported to the SSA within two hours. The ADON was present during this interview. 2. Review of R1's undated admission Record, located in the EMR under the Profile tab, revealed R1 was admitted on [DATE]. Review of R1's annual MDS with an ARD of 07/14/23, located in the EMR under the MDS tab, revealed R1's BIMS score was three out of 15 which indicated he/she was severely cognitively impaired. Review of R1's Skin Assessment, dated 07/10/23, located in the EMR under the Assessment tab, revealed a bruise to the left upper arm measuring 17 x 15 centimeters (cm). Review of R1's Health Status Note, dated 07/10/23, located in the EMR under the Prog Note tab, revealed R1 observed with bruise to left upper arm. He/She had full range of motion to his/her left arm. No s/s [signs or symptoms] of pain and discomfort, denies pain and discomfort. [FM2] and MD [Physician] made aware. Review of R1's Onsite Note, dated 07/13/23, located in the EMR under the Prog Note tab, revealed . resident who was recently noted to have ecchymosis to left upper arm. Change nurse reports he/she had some injury over the weekend and sustained some ecchymosis. X-ray of the LUE [left upper extremity] was ordered and results showed no fracture. Review of the facility's Incident Report, dated 07/10/23, provided by the facility, revealed the alleged abuse was not reported to the State Survey Agency (SSA). Interview on 01/28/25 at 1:45 PM, the ADON stated CNA9 notified LPN7 that she observed a bruise to the underside of R1's left arm, LPN7 reported it to the Administrator at 10:56 AM on 07/10/23 and then the Administrator reported it to her at 11:04 AM in person. The ADON indicated abuse was not suspected by CNA9 or the granddaughter, so it was not reported to the SSA. The ADON the skin injury met the definition of injury of unknown source and should have been reported to the SSA. Interview on 01/28/25 at 2:34 PM, the Administrator stated she is the Abuse Coordinator and was notified of the bruise to R1's arm on 07/10/23 at 10:56 AM in person by LPN7. The Administrator indicated she did not identify the bruise as an injury of an unknown source, and did not report it to the SSA within two hours. N.J.A.C. 8:39-5.1(a) .

Based on interviews, record review, and policy review, the facility failed to ensure a thorough investigation into allegations of abuse for two of seven residents reviewed for abuse (Resident (R) 1 and R5) out of 32 sampled residents. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, provided by the facility, revealed Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled, and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident e. interviews any witnesses to the incident f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly . Review of the facility's policy titled Protection of Residents during Abuse Investigations, revised April 2021, revealed . 1. If the alleged perpetrator is an employee or staff member, the individual is immediately reassigned to duties that do not involve resident contact or are suspended until the findings of the investigation are reviewed by the Administrator. 2. If the alleged perpetrator is a resident's family member or visitor, this person(s) is not allowed unsupervised visits with the resident . 1. Review of R1's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R1 was admitted on [DATE]. Review of R1's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/14/23, located in the EMR under the MDS tab revealed R1's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. Review of R1's Skin Assessment, dated 07/10/23, located in the EMR under the Assessment tab revealed a bruise to the left upper arm measuring 17 x 15 centimeters (cm). Review of R1's Health Status Note, dated 07/10/23, located in the EMR under the Prog Note tab, revealed R1 observed with bruise to left upper arm. He/She had full range of motion to his/her left arm. No s/s [signs or symptoms] of pain and discomfort, denies pain and discomfort. Review of R1's Onsite Note, dated 07/13/23, located in the EMR under the Prog Note tab, revealed . resident who was recently noted to have ecchymosis to left upper arm. Change nurse reports he/she had some injury over the weekend and sustained some ecchymosis. X-ray of the LUE [left upper extremity] was ordered and results showed no fracture. Review of the facility's Incident Report, dated 07/10/23, provided by the facility, revealed a skin issue was investigated, and the conclusion was R1's granddaughter (name not identified on document) did not follow the plan of care for transfers and did not wait for staff to transfer the resident back into bed from the Geri chair via Hoyer lift on 07/09/23. Based on the way the granddaughter described transferring the resident caused the bruise on the left arm. The incident report revealed R1's roommate was not interviewed during the investigation. Review of the witness statements revealed Certified Nurse Aide (CNA9), Licensed Practical Nurse (LPN)7, CNA14 were interviewed about the skin issue identified on 07/10/24. However, no other residents were interviewed about abuse in the same unit, skin assessments were not conducted on residents on the same unit. CNA9 was not suspended per the abuse policy. Also, the alleged abuse was not reported to the State Survey Agency (SSA). During an interview on 01/27/25 at 6:25 PM, FM2 stated she observed a huge bruise on R1's arm that looked like a torn muscle and her granddaughter did not cause the bruise when she transferred R1 from the chair to bed on 07/09/24. FM2 also stated the facility should have investigated the bruise as abuse and suspended the nurse aide because R1's roommate stated he/she heard R1 scream during the night when the nurse aide changed him/her on 07/09/24. Additionally, FM2 indicated his/her granddaughter was a physical therapist (PT) and had transferred him/her plenty of times and had not caused R1 any injuries. Interview on 01/28/25 at 1:12 PM, LPN7 stated CNA9 notified him that she observed a bruise on R1's left arm on 07/10/23 at 10:30 AM and then he reported it to the Assistant Director of Nursing (ADON) and Director of Nursing (DON) immediately. LPN7 also stated he performed on R1 a skin and pain assessment. LPN7 indicated he collected statements from CNA9 because she was assigned to R1 on 07/09/23 and 07/10/23 but she was not suspended or removed from care pending the investigation. In an interview on 01/28/25 at 1:45 PM, the ADON stated CNA9 notified LPN7 that she observed a bruise to the underside of R1's left arm and he reported it to her. The ADON also stated LPN9 conducted a skin assessment, and pain assessment. However, skin assessments were not performed on other residents and abuse interviews were not conducted with interviewable residents because they did not consider it an injury of an unknown injury. In an interview on 01/28/25 at 2:34 PM, the Administrator indicated she did not identify the bruise as an injury of an unknown source, she completed an incident report based on an interview with R1's granddaughter. The Administrator stated that she concluded the granddaughter did not follow the plan of care for transfers and caused the bruise to R1's arm. The Administrator also indicated nursing staff that cared for R1 on 07/09/23 and 07/10/23 were interviewed and provided statements but neither R1's roommate nor other interviewable residents were interviewed about abuse. The Administrator stated CNA9 was not suspended during the investigation and R1's granddaughter was allowed in the facility to visit R1 with FM2. In an interview on 01/28/25 at 3:09 PM, CNA9 stated she was providing care to R1 on 07/10/23 at 10:25 AM and noted and reported a dark bruise on his/her left upper arm. CNA9 indicated she reported the bruise to LPN7 at 10:30 AM. CNA9 also stated R1's granddaughter told her that she transferred R1 from the chair to the bed without assistance on 07/09/23 so she informed the ADON when interviewed about the identified bruise. CNA9 confirmed she was assigned to R1 on the evening shift of 07/09/23 and had provided incontinent care to him/her. CNA9 indicated that she was not suspended pending the investigation of the bruise on R1's left arm. 2. Review of R5's EMR admission Record indicated the resident was admitted to the facility on [DATE]. Review of R5's EMR Health Status Note located under the Profile tab dated 10/09/23, revealed R5 was identified with bruising on his/her lip with swelling and two dry skin tears on his/her left arm. CNA10 was in the room alone with the resident. During an interview on 01/28/25 at 10:45 AM, the Regional Clinical Nurse stated there was no Facility Reported Incident (FRI) for R5 regarding the 10/09/23 incident. The Regional Clinical Nurse stated that there was an incident report only. During an interview on 01/28/25 at 1:34 PM, the ADON stated she did not complete an investigation of R5's alleged potential abuse. During an interview on 01/28/25 at 3:41 PM, the Administrator stated the FRI was an investigation and reportable to the state agency and the incident report was an internal document. The Administrator stated her expectation was to investigate all allegations of abuse. N.J.A.C. 8:39-4.1(a)(5)

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed care planned interventions to prevent falls for one of two residents (Resident (R) 10) reviewed for falls out of a total sample of 37 residents. This failure resulted in harm to R10 who was admitted to the hospital with a right femur fracture after sustaining a fall from being turned in bed by staff without assistance. Findings include: Review of R10's undated Admission Record, under the Profile tab in the electronic medical record (EMR), revealed R10 was admitted to the facility on [DATE] with multiple diagnoses to include chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), history of falling, acute respiratory failure with hypoxia, morbid obesity due to excess calories, presence of cardiac pacemaker, and paroxysmal atrial fibrillation. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/22 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating R10 was moderately impaired. The MDS indicated R10 weighed 211 pounds. The MDS revealed R10 was totally dependent on staff with two-person physical assistance for bed mobility, and transfers. The MDS indicated R10 was totally dependent on staff with one-person physical assistance for bathing and was extensive assistance with one-person physical assistance for dressing. Bed mobility is defined as how a resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Bathing is defined as how the resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Review of R10's Care Plan, dated 03/07/22, located in the EMR under the Care Plan tab, revealed the Problem I am at risk for falls r/t [related to] Gait/balance problems, History of falls, Unaware of safety needs. The care planned interventions for falls, initiated on 03/07/22, indicated I am a 2 person assist for bed mobility and 2 person assist for bathing I am able to pull myself over on my side and assist. Review of R10's CNA [Certified Nursing Assistant] Kardex, dated 06/30/22, located in the EMR under the Tasks tab, revealed R10 required 2 person assist for bed mobility and 2 person physical assist via lift for transfers. The CNA Kardex did not indicate the assistance required by staff for bathing. Review of R10's Fall Risk Assessment, dated 05/25/22, located in the EMR under the Evaluations tab, revealed the facility assessed the resident with a score of 15 indicating she was at moderate risk for a fall. Review of R10's Progress Notes, under the Progress Notes tab located in the EMR revealed the following: 07/03/22 . @ [at] 11:40 Am, CNA called me that the patient fell in the floor. Patient was in sitting position in the floor. CNA said while turning the patient on her side during Am [morning] care the patient's Lt. [left] leg slide out of bed. CNA put the patient's bed down and she tried to grab the patient to prevent her from falling but she was unable to. Patient slid down slowly in [to] the floor w/ [with] the low bed. Denies hitting her head but complained of mild pain on Rt. [right] hip, able to move toes and a little bit of Rt. [right] leg. Patient said she slid down on her butt. No other visible injury noted. Put patient back to bed w/ 6 person left using Hoyer pad, unable to use Hoyer lift, patient was too low in the floor. Nursing supervisor notified (daughter) and [the Medical Director] PRN [as needed] Tylenol given @ [at] 12 noon for mild pain on Rt. [right] hip. T [temperature] =98; PR [pulse] =88; RR [respirations] = 20; BP [blood pressure] = 118/82; SPO2 [oxygen] = 98% [percent] @ [at] RA [room air], Blood sugar = 152. Patient is on Lovenox (blood thinner that helps prevent the formation of blood clots). Patient sent to ER [emergency room ] in . for eval. [evaluation] as ordered @ [at] 12:30 pm via . ambulance. signed by the Nurse. 07/03/22 .admitted to [hospital] DX [diagnosis]: Fracture Right Femur . signed by the Nurse. 07/25/22 . 8:30 PM; admitted [R10] via stretcher from . w/ Dx of R [right] femur fracture . verbally responsive w/] forgetfulness . R anterior upper thigh w/ 5 intact staples; site red and dry. R lateral thigh w/ 3 surgical incisions; open w/ small amt. [amount] of serosanguineous drainage. R lat. [lateral] upper thigh w/] 9 intact staples; site red. R lower thigh sx [surgical] incision w/ 9 intact staples; site red. R mid knee w/ 5 intact staples; site red. R inner lateral knee w/ 6 intact staples; site red. R mid lower knee w/ 9 intact staples; site red. R [lateral knee, 3 sites, total of 13 intact staples. R lateral knee also w/ 3 open sx [surgical] incisions. Surgical sites on R knee w/ small amt. of serosanguineous drainage. W/ R] knee immobilizer in placed [sic] . signed by the Nurse. 7/29/22 . [R10] who presented to the ER [emergency room ] status post fall, was noted to have right hip fracture, status post surgery, she had ORIF [open reduction and internal fixation surgery used to stabilize and heal a broken bone] done as well as intramedullary nail placement [metal rod inserted into the bone and across the fracture to provide solid support for the femur] on 7/13/2022, was noted to have large hematoma . received blood transfusion . signed by the Nurse Practitioner. Review of the facility-provided Incident Report, dated 07/03/22, revealed at 11:40 AM CNA1 turned R10 towards her after washing her, then R10's legs came off the bed and R10 slid off the mattress onto the floor. CNA1 stated she attempted to hold onto R10 while lowering the bed. CNA1 also stated she eased R10 to the floor. Observations on 02/27/23 at 5:27 PM, 02/28/23 at 4:51 PM, and 03/01/23 at 4:51 PM revealed R10 was laying in a bariatric bed in a low position with oxygen on via nasal cannula. Attempts to interview with resident was not possible due to the resident's cognition. During an interview on 02/27/23 at 5:27 PM, Family Member (FM) 1 stated that she was notified on 07/03/22 by facility staff that R10 fell from the bed when CNA1 turned her on her right side without assistance from another CNA. FM1 also stated that R10 had surgery for the right femur fracture. During an interview on 03/01/23 at 4:48 PM, Registered Nurse (RN) 2, Unit Manager on the first floor where the resident resided, stated that the CNAs were expected to follow the care plan which was two-person assistance with bed mobility prior to R10's fall. During an interview on 03/01/23 at 7:51 PM, CNA1 confirmed that she turned R10 on her right side so that she could clean her without assistance of another CNA then R10 fell off the bed onto the floor. CNA1 stated that the R10 would not have fallen off the bed with the assistance of another CNA. CNA1 indicated that she was normally assigned to R10. CNA1 also stated that R10's required two-person assistance with bed mobility and transferring but only one person assistance with bathing per the CNA care plan. During an interview on 03/02/23 at 8:41 AM, the Director of Nursing (DON) confirmed R10 fell off the bed after CNA1 turned her without assistance of another CNA while dressing R10 after providing a bed bath on 07/03/22. The DON also confirmed that R10's CNA Kardex prior to the fall stated R10 required two-person assistance for bed mobility and that bathing was not addressed on the Kardex. The DON stated that she expected staff to follow the care plan. The DON indicated the meaning of bed mobility was turning and pulling up a resident in bed. During an interview on 03/02/23 at 9:08 AM, Licensed Practical Nurse (LPN) 4 revealed she was the Unit Manager on the first floor when R10 sustained a fall from the bed on 07/03/22. LPN4 stated CNA1 turned R10 towards during morning care then R10 rolled off the bed onto the floor and complained of right hip pain. LPN4 also stated that R10 was very weak at the time due to a recent hospitalization therefore she could not assist with turning. LPN4 indicated R10 was two-person assistance for bed mobility which included turning the resident and the CNAs were expected to follow the care plan. During an interview on 03/02/23 at 10:26 AM, the Medical Director revealed he was notified on 07/03/22 that R10 fell and was complaining of pain in the right hip so she was sent to the emergency room . The Medical Director stated he admitted her from the hospital on 07/27/22 with a distal fracture to the femur. During an interview on 03/02/23 at 10:55 AM, the MDS Coordinator (MDSC) confirmed that R10 required two-person assistance with bed mobility which included turning the resident in bed. The MDSC stated the Unit Managers developed the CNA care plans which were a short version of the care plan. Review of the facility-provided policy titled, Care Plans, Comprehensive Person-Centered, dated October 2022, revealed .a comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility-provided policy titled, Falls and Fall Risk, Managing, version 1.2, revealed .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.Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. NJAC 27.1(a)

Complaint # NJ 793 Based on observation, interview and review of the medical record it was determined that the facility failed to revise and initate interventions for a resident following a fall/injury in order to prevent repeat occurences. This deficient practice was noted for 1 of 9 residents sampled for falls with injuries, Resident #2, as evidenced by the following: During tour of the 1st floor unit 1A on 1/2/13 at 10:50 a.m. the Unit Manager told the surveyor that Resident #2 was alert and confused, was a fall risk, sustained a [MEDICAL CONDITION] while in the facility, and was visited by a supportive family. On 1/7/13 at 10:20 a.m. Resident #2 was observed in bed with eyes closed. The resident was completely dressed including shoes and glasses. The resident was lying in a low bed, a mat was noted on the floor next to the low bed and one side of the bed was against the outer wall in the room. Half side rails were noted up at this time. During record review for Resident #2 at 10:30 a.m., the surveyor noted that Resident #2 was admitted to the facility on [DATE] and had a recent re-admission on 12/26/12. The resident had [DIAGNOSES REDACTED]. Review of the medical record revealed that Resident #2 had a care plan in place from 5/23/12 for the potential for falls related to decreased mobility and use of [MEDICATION NAME]. The resident was ambulatory until a fall on 11/2/12 at 11:00 a.m. at which time the resident was admitted to the hospital for a fractured right hip. The care plan did note that the resident had a fall and fracture on 11/2/12 but there was no documented evidence that on readmission the facility updated the care plan to include any new interventions intended to prevent future falls. Resident #2 had a second fall on 11/24/12. The resident complained of left hip pain and was found to have a Left [MEDICAL CONDITION]. The resident was hospitalized and re-admitted to the facility on [DATE]. There was no documented evidence that upon this second readmission the facility updated the care plan or instituted any new interventions in place in an attempt to prevent further falls. Resident #2 had a 3rd fall on 12/22/12 at 1:10 p.m. The resident was admitted to the hospital and returned to the facility on [DATE]. The care plan written on 12/26/12 included no new interventions to prevent further episodes of falling. The surveyor discussed these concerns with the Administrator , DON, and Assistant Administrator on 1/8/13 at 2:20 p.m. The surveyor asked the administrative team if Resident #2 had any prior falls before November 2012 and the DON replied "no". On 1/10/13 at 9:40 a.m. the Administrator provided the surveyor with a timeline of events leading to the falls of Resident #2. The Assistant Administrator met with the surveyor at 10:30 a.m. and reviewed the timeline with the surveyor. The Assistant Administrator agreed that the care plan was not documented and updated after each resident fall to include new interventions. The Assistant Administrator also agreed that a timeline to show trending of falls for Resident #2 was not done at the times of occurrence. Refer to: F 323 NJAC 8:39-11.2(e)2

Complaint # NJ 739 Based on observation, interview and review of the medical record it was determined the facility failed to provide adequate supervision and respond with updated interventions for residents with repeated falls. Resident #2 sustained a left hip fracture when found on the floor 8 days after being hospitalized for [REDACTED].#1 and #2, 2 of 9 residents reviewed for falls with injury, and was evidenced by the following: 1. During tour of the 1st floor unit 1A on 1/2/13 at 10:50 a.m. the Unit Manager told the surveyor that Resident #2 was alert and confused, was a fall risk, sustained a hip fracture while in the facility and was visited by a supportive family. On 1/7/13 at 10:20 a.m. Resident #2 was observed in bed with eyes closed. The resident was completely dressed including shoes and glasses. The resident was lying in a low bed, a mat was observed resting on the floor next to the low bed and one side of the bed was against the outer wall in the room. Half side rails were noted up at this time. During record review for Resident #2 at 10:30 a.m., the surveyor noted that the resident was admitted to the facility on [DATE] and had a recent re-admission on 12/26/12. The resident had [DIAGNOSES REDACTED]. Review of the medical record revealed that Resident #2 had a care plan in place from 5/23/12 due to the potential for falls related to the resident's decreased mobility and use of the antidepressant Zoloft. Documentation in the medical record, as well as the Incident Accident report, revealed the resident had a fall on 11/2/12 at 11:00 a.m. which occurred when the resident walked out of the room carrying shoes and fell . The resident was sent to the hospital and was admitted for a fractured right hip. There was documentation on the care plan to note that the resident had a fall on 11/2/12 and that the resident sustained [REDACTED]. Based on review of a Team Note given to the surveyor by the Director of Nursing (DON) on 1/8/13, the resident was re-admitted to the facility on [DATE]. There was no documented evidence that the facility updated the care plan upon readmission to put any new interventions into place to prevent future falls. The medical record and the Incident Accident Report revealed that Resident #2 fell again 8 days after readmission, 11/24/12. On that date the resident was found sitting upright on the floor. The resident complained of left hip pain and was noted to have a Left Hip Fracture at this time. The resident was hospitalized at this time and re-admitted to the facility on [DATE]. There was no documented evidence that upon this second readmission the facility updated the care plan or put any new interventions in place in an attempt to prevent another fall. The surveyor noted in the Interdisciplinary Progress Notes, as well as the Incident Accident Report, that Resident #2 had a third fall on 12/22/12 at 1:10 p.m. The resident had to be transferred to the hospital due to slow response to verbal stimuli. The resident also sustained redness to the thoracic spine, left hip and left elbow. The resident returned to the facility on [DATE] and the care plan written on 12/26/12 included no new interventions to prevent further episodes of falling. The surveyor discussed these concerns with the Administrator, DON, and Assistant Administrator on 1/8/13 at 2:20 p.m. The surveyor asked the administrative team if Resident #2 had any prior falls before November 2012 and the DON replied "no". On 1/10/13 at 9:40 a.m. the Administrator provided the surveyor with a timeline of events leading to the falls of Resident #2. The Assistant Administrator met with the surveyor at 10:30 a.m. and reviewed the timeline with the surveyor. The Assistant Administrator agreed that the care plan was not documented and updated after each resident fall to include new interventions. The Assistant Administrator also agreed that a timeline to show trending of falls for Resident #2 was not done at the times of occurrence. 2. On the initial tour of the unit on 1/2/13 at 11:00 a.m. the Charge Nurse (CN) told the surveyor that Resident #1 had a history of [REDACTED]. The CN stated "the resident got out of bed, walked and fell , which resulted in a fracture of the left (L) hip." The resident was observed on the initial tour in the unit dinning room eating lunch. The resident was seated in a wheelchair with a chair alarm attached. The surveyor reviewed the medical record for Resident #1 on 1/3/13 at 11:15 a.m. which indicated the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 fell on [DATE] and was hospitalized from 11/3 to 11/6/12 with a fractured left hip. The resident was re-admitted to the facility on [DATE]. The surveyor reviewed the resident's Care Plan which identified the resident as being at risk for falls, a history of falls and a recent left hip fracture. The surveyor reviewed the Quarterly Minimum Data Set (MDS) an assessment tool, dated 10/15/12 which indicated the resident had short and long term memory impairment, and impaired decision making. The resident was also assessed to require extensive assist of one person for transfers and toilet use. The Significant Change MDS dated [DATE] (post readmission) indicated the resident had short and long term memory impairment and impaired decision making. The resident was assessed at this review to require extensive assist of one person for transfers and toilet use. The surveyor reviewed the Interdisciplinary Progress Notes on the medical record. The Nurse's Note (N.N.) dated 11/13/12 at 7:35 a.m. indicated "Resident found on floor of bathroom, full assessment revealed small scratch to (R) back, no further injuries apparent, surgical incisions to (L) hip and thigh with staples intact, called MD awaiting call back, neuro checks started." The surveyor reviewed the Incident/Accident Report dated 11/13/12 provided by the facility on 1/7/13 at 11:00 a.m. The narrative description on the report indicated, " Resident was being toileted, (resident) was found on floor of bathroom. Pt. complained low back pain." The report also indicated: Transfer Status: 1 person Alarm Use: Tabs alarm RN/LPN Statement related to Incident/Accident: who found resident immediately after incident? CNA (Certified Nursing Assistant) Does resident use alarm? yes Type: Tab alarm Was alarm sounding? No If alarm not sounding, why not? Not in place Did anyone witness fall? No On 1/8/13 at 2:00 p.m. the surveyor discussed with the facility Administrator, Director of Nursing (DON) the resident's fall, and conflicting information on the "Incident/Accident" Report. On 1/10/13 at 10:30 a.m. the DON confirmed that the resident was left alone in the bathroom by the CNA and sustained a fall. NJAC 8:39-11.2 (e) (2) & 27.1(a)