Every finding on record at Optima Care Castle Hill

Based on interviews and review of pertinent facility documents on 01/12/26, it was determined that the facility failed to maintain a safe environment during supervision by staff of a severely cognitively impaired resident (Resident #1) who was a high risk for elopement, had poor safety awareness, and exit-seeking behaviors.On 12/30/25, Resident #1 was able to open the 6th floor [NAME] side alarmed exit door, went down ten flights of stairs and exited through the side door of the facility on to the street. At approximately 4:00 PM, Licensed Practical Nurse (LPN) #1 alerted the nurse management that the resident was nowhere to be found. The last sighting of the resident was approximately at 3:25 PM by LPN #1 when the resident was seen ambulating the hallway on the 6th floor towards the high side of the Unit near the exit door. It was probable that the resident exited the 6th floor door through the stairwell which alarmed. The resident was found by the local police at approximately 9:00 PM. According to the Licensed Nursing Home Administrator (LNHA), the resident's family called them and stated the police found the resident. The resident was brought to the emergency department (ED) for evaluation and stayed overnight. The facility's failure to ensure a safe environment during supervision of a severely cognitively impaired resident at risk of elopement, with poor safety awareness, and exit seeking behaviors placed Resident #1 at risk.This posed the likelihood of serious physical harm, injury, or death which resulted in an immediate jeopardy (IJ) situation. The IJ began on 12/30/25 at 3:25 PM when LPN #1 had last sighting of the resident walking the hallway on the 6th floor towards the high side of the unit near the exit door and sitting on a couch in the hallway. The facility's administration was notified of the IJ on 01/12/26 at 5:30 PM. The facility submitted an acceptable Removal Plan (RP) on 01/13/26 at 3:38 PM. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 01/15/26. The deficient practice was evidenced as follows: A facility policy, Elopement and Wandering Residents, revised on 03/2025 included: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their plan of care. Under Procedures, 1. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering .evaluation and analysis of hazards and risks .; 2. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for elopement and unsafe wandering upon admission .b. Interventions to increase staff awareness of the resident's risk .c. Adequate supervision will be provided to help prevent accidents or elopements. A review of the Reportable Event Record/Report (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 12/30/25, revealed the date and time of event as 12/30/25 at 4:00 PM. The FRE included under Narrative that at approximately 4:00 PM, Resident #1 was nowhere to be found. The building was searched room to room and the surrounding area within a mile was also searched by foot. The FRE revealed under Narrative, 3) Wander Guard was utilized, indicating that the resident had a wander guard.A review of the facility's Summary of Investigation (SI) with a date of event of 12/30/25, revealed that at approximately 4:00 PM on 12/30/25 LPN #1 alerted nurse management that Resident #1 was nowhere to be found. Immediately a room to room and in-house searches were initiated. The search continued outside. Local police were informed about the missing resident, as well as Resident #1's family and hospitals. It was probable that the resident exited through the 6th floor unit door, as an audible door alarm sound was heard. Staff responded to the audible alarm and looked at the stairwell, but no one was in sight. The SI indicated that the resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment and judgment, poor safety awareness and had an inability to recognize environmental hazards. The resident was able to ambulate independently. The SI further indicated that the resident was admitted to the facility from the hospital following a significant fall prior to admission which necessitated a craniotomy [brain surgical procedure] resulting from traumatic subdural hematoma [accumulation of blood in the brain]. The SI revealed that Resident #1 was found by local police at approximately 9:00 PM on 12/30/25. The resident was brought to the ED for evaluation and stayed there overnight. The resident returned to the facility the next morning and was re-assessed by the nurse practitioner (NP). The resident was requested to re-enact the process of their way off of the unit. The SI indicated that the resident led facility staff to the northside stairwell and admitted to opening the emergency door and proceeded down to the egress door towards the local street. A review of the staff statements obtained by the facility during investigation revealed: -LPN #1 statement: According to LPN #1 when they arrived on the 6th floor to work the 3-11 shift, the resident was sitting inside the nurse's station. LPN #1 further stated that after making rounds, counting narcotics, taking endorsement from the 7-3 shift nurse, LPN #1 noticed the resident was not in his wheelchair anymore. This was approximately 3:25 PM. LPN #1 stated they looked around and saw Resident #1 nearby, slowly ambulating and then sitting on the couch along the high side hallway. After reading the 24-hour report [endorsement report] LPN #1 went to look for Resident #1. Resident #1 was no longer on the couch. This was approximately 3:35 PM. LPN #1 began a room search of the 6th floor. LPN #1 saw the DON and reported that Resident #1 could not be found. All staff were alerted and LPN #1 continued to look for the resident on every floor and exit stairs multiple times. -Certified Nursing Assistant (CNA)#1, 3-11 shift: According to CNA#1 when they came to the floor at 3:30 PM, they were looking for the resident and did not see them.-Registered Nurse (RN) #1, 3-11 shift: RN #1 was sitting at the nurse's station getting report from nurse going off shift and Resident #1 was seated in wheelchair in the back of nurse station. It was around 3:15 PM and that was the last time RN #1 saw the resident. -Social Worker (SW): The SW's office was across from the [NAME] alarmed exit door on the 6th floor. The SW came back to the 6th floor from a meeting, as they came off the elevator they heard an alarm. The SW was going to their office and realized the alarm was coming from the exit door across from their office. The SW deactivated the door alarm and went to look down the stairs but did not see anyone. The SW went back to the floor and as they were going down the hallway to inform nursing staff, they saw LPN #1 and reported that the exit door was alarming and that they checked down the stairs and did not see anyone. The SW and LPN #1 then went down the stairs all the way down to bottom and noted that the exit door on the ground floor was partially opened. SW and LPN #1 checked outside the door that led to outside to local street and did not see any residents from the facility. A review of the Police Report (PR) titled Incident Report, a document submitted by the local and neighboring town police department, revealed that on December 30, 2025, at 4:17 PM the police were dispatched to [street redacted] on a missing person report. The police met with the Licensed Nursing Home Administrator (LNHA) who said that Resident #1 walked out of the facility using the exit door located leading to local streets. The resident was wearing a brown jacket, navy blue pants, black shoes, and a clear helmet. The PR further stated the resident was reportedly missing approximately 3:30 PM. The PR further revealed that Resident #1 was found in a [neighboring town] on [street redacted]. The local police brought the resident to the ED of local hospital after they notified the family member.The surveyor reviewed the medical record for Resident #1.A review of the admission Record (AR), an admission record summary, revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to: non traumatic intracranial hemorrhage [brain bleed], type 2 Diabetes Mellitus, dysphagia [difficulty swallowing], alcohol abuse, depression, and hypertension [high blood pressure]. A review of the Resident #1's Care Plan Report (CP) revealed the following Foci [Problem Areas]:-Focus: [Resident #1] has the potential for wandering r/t [related to] their behavior and history of wandering with a 12/11/25 dated intervention of: approach resident in a calm manner and attempt to redirect when wandering in an inappropriate area.-Focus: [Resident #1] was at risk for elopement due to exit seeking behavior with 12/11/25 dated interventions of: redirect residents as needed, wander guard to left ankle as approved by the family.-Focus: [Resident #1] has limited physical mobility r/t disease process (h/o [history of] multiple falls, s/p [status post] craniotomy [brain surgery], weakness with a 12/12/25 dated intervention of: resident will receive skilled physical therapy services for therapeutic exercises/activities, neuromuscular reeducation, gait skills training.-Focus: [Resident #1] had special needs for head helmet r/t presence of cranioplasty [brain surgery] wound upon admission with 12/17/25 dated interventions of: keep helmet on until instructed by surgeon, redirect resident as needed, and instruct resident not to bend head or have sudden head movement. On 01/12/26 at 12:16 PM, the surveyor, together with the LNHA, DON, and the Maintenance Director (MD), went to the 6th floor nursing unit, to the [NAME] side alarmed exit door. The surveyor heard an alarm sound after the door was pushed open. The surveyor, LNHA, DON, and MD went down the stairs. The surveyor noted that there were ten flights of stairs from the 6th floor to the ground floor. The stairwell led to a side door that opened to the local street. On 01/12/26 at 1:53 PM, the surveyor interviewed the Social Worker (SW). According to the SW, around 3:30 PM to 3:40 PM they went to their office on the 6th floor. As the SW came off the elevator they heard a door alarming. The SW said it was the high side door. The SW stated she only went down 2-3 flights of stairs and looked down the stairs, admitting they did not go all the way down the stairs. The SW told LPN #1. The SW and LPN #1 then went all the way down the stairs to the bottom. It was noted that the exit door on the ground floor was partially opened. The SW and LPN #1 checked outside the door and did not see any residents from the facility.On 01/12/26 at 2:14 PM, the surveyor requested to see facility video footage of the lobby on 12/30/25 from 2:00 to 4:00 PM in the lobby. According to the Licensed Nursing Home Administrator (LNHA), the facility had only three camera locations: lobby with 2 angle views, punch clock (no exit door), and the kitchen. The camera footages did not show images of Resident #1 in the vicinity. On 01/12/26 at 4:13 PM, the surveyor interviewed the LNHA and DON. The LNHA stated they called the police right away when the resident could not be found, notified the family and the medical doctor. LNHA further stated the facility will increase the sound or alarm audibility of the exit doors for fast and quick staff response and re-educate the staff on facility's elopement prevention policy which included the heightened vigilance or supervision of the residents at risk. An acceptable Removal Plan (RP) was submitted by the facility on 01/13/26 at 3:38 PM indicating the actions the facility will take to prevent serious harm from occurring or reoccuring. The facility implemented a corrective action plan to remediate the deficient practice including on 12/30/25, an immediate room to room and in-house thorough search were initiated and a foot and car search near the building perimeter was immediately initiated. Code Gray was paged to the entire building to alert all staff. Local police were informed about the missing person, Resident #1's profile and description were given to the local police. The resident's family and physician were notified. Hospitals were also alerted of the missing person. Resident #1 was brought to ED for evaluation and stayed overnight. On 12/30/25, immediately after the elopement, a full head count of all residents in the building was done. All residents were accounted. On 12/30/25, all residents at risk of elopement were reassessed and care plans (CP) were re-evaluated. All residents remain at risk and care plan interventions were deemed appropriate and in place. Resident #1 returned to the facility on [DATE] with no injury, impairment, or harm noted. Resident #1 was placed on 1:1 supervision for 24 hours. Upon return, Elopement Risk was re-assessed, and care plan was re-evaluated and all was deemed appropriate and in place for Resident #1. The Director of Nursing (DON)/Designee re-educated all staff on the facility's policy on Elopement and Wandering on 12/30/25 and is ongoing. On 01/12/26 the facility implemented 24/7 monitoring of the 6th Floor's East and [NAME] stairwell doors to ensure that residents at risk of wandering and elopement have the necessary supervision to prevent unsafe access to the stairwell doors. A STOP sign barrier was put on both the East and [NAME] doors as an additional deterrent. On 01/12/26, a work order was requested from door security vendor for the installation of additional magnetic lock.The surveyor verified the implementation of the RP on-site on 01/15/26 and determined the immediacy was removed as of 01/13/26. N.J.A.C. 8:39-27.1(a)

Based on interviews and review of pertinent facility documents on [DATE] and [DATE], it was determined that the facility failed to thoroughly investigate by obtaining complete statements from involved staff on an incident of injury of unknown origin of a cognitively impaired resident, Resident #2, who was noted to have a fading discoloration on her left hand near thumb area and a fading [discolored] area on her left forehead. On [DATE], Resident #2 was noticed to have a fading discoloration on her left hand near thumb area, measuring 4.0x4.0 cm [centimeters] and a small fading area on her left forehead measuring less than 2.0x2.0 cm. There was no sign of swelling and the resident denied pain to the sites. Resident #2 who was cognitively impaired was unable to recall any fall, trauma or unusual event that led to discoloration. MD [doctor] was informed and ordered x-ray on the resident's left hand. This deficient practice was evidenced as follows:A review of the form AAS-45, a Facility Reportable Event (FRE), a document submitted by the facility to the New Jersey Department of Health (NJDOH) on [DATE], included the date of event: [DATE], no time indicated. The FRE reflected under Narrative that Resident #2 was noticed to have a fading discoloration on their left hand near thumb area, measuring 4.0x4.0cm. Also a very small nearly fading area on their left forehead measuring less than 2.0x2.0. There was no sign of swelling, denies pain to the sites. Resident was alert, but confused, forgetful, verbally responsive but unable to recall any fall, trauma, or unusual event that led to discoloration. Daughter noticed the discoloration during her visit. MD was informed and ordered x-ray on left hand. The surveyor reviewed the medical record of Resident #2. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #2 was admitted to the facility with diagnoses which included but were not limited to: history of falling, dementia, psychotic disorder, anemia, sarcopenia [a condition wherein there is progressive loss of skeletal muscle, strength, and function associated with aging], depressive disorder, and anxiety. A review of the Minimum Data Set (MDS), an assessment tool, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's Care Plan Report (CPR) included a focus: [Resident #2] has potential/actual impairment to their skin integrity r/t her history of fragile skin (bruises easily) that was initiated on [DATE] and revision on [DATE]. The CPR further revealed interventions which included but not limited to: encourage good nutrition, follow facility protocols for treatment of injury, keep skin clean and dry, bilateral arm sleeve in placed (initiated [DATE]), and side rail noodle applied for protection (initiated [DATE]). The resident's CPR also included a focus of: [Resident #2] has bilateral padded half siderails as an enabler with date initiated on [DATE]. A review of the facility's Summary of Investigation (IS) revealed that on [DATE], the nurse supervisor was informed about the fading discoloration noticed on their [Resident #2] left hand near their thumb measuring 4.0x4.0 cm. The IS further indicated there was also a very small almost faint discoloration on their left forehead measuring less than 2.0x2.0 cm. Resident #2 was alert with confusion and forgetfulness. They were unable to recall the cause of discoloration. The resident had no incident of fall, nor did the resident have any physical altercation with anyone. The resident did not have any recent blood drawn to cause skin discoloration. The resident was unable to self-propel their wheelchair. They had very thin sensitive skin, prone to bruising. The IS further included under Conclusion: Statements were obtained from direct care-givers past 48 hours after the discovery date. There no unusual occurrences reported. There was no evidence of neglect or abuse that occurred. The facility IS further concluded the probable cause could be secondary to the resident's diagnosis of Sarcopenia and also side effect of medication Duloxetine HCL [anti-depressant medication and can be used for pain] .the siderails will be padded; Geri sleeves will be given for the resident to wear. A review of the facility's document: Incident Report (IR #3696) with date and time of [DATE] 16:00 (4:00 PM) and documented by Registered Nurse (RN) #1 and appeared as the Person Preparing Report in the IR. RN #1 was the RN Supervisor on [DATE] 3-11 shift. The IR indicated under Nursing Description: Resident was out of bed to wheelchair in the dayroom. Observed fading skin discoloration to left forehead measuring 2.0cm x 2.0cm and fading skin discoloration to left thumb area measuring 4.0cm x 4.0cm. Complete assessment done. No noted swelling to both areas of discoloration. Denies pain to site. Alert, oriented to self, verbally responsive. BIMS was 3. Unable to explain what happened. A review of the statements obtained by the facility from staff during the investigation revealed the following:-[DATE], 7-3 shift [morning] 5th Floor Unit - According to RN #2,who was assigned as one of the nurses in Unit 5, the resident was noted with a bruise to left hand. When asked if they hit their hand, Resident #2 said they do not remember. The RN further indicated in their statement the resident's family was contacted, MD [doctor] was contacted and supervisor was made aware. RN #2 statement did not disclosed time of incident. -[DATE], 11-7 shift [night] 5th Floor Unit - According to Licensed Practical Nurse (LPN) #1, the resident was received at 11 PM in bed. No report given of any incident with this resident. During 7 AM rounds, resident was seen still resting comfortably. No complaints noted from resident during the shift. -[DATE], 11-7 shift 5th Floor Unit - According to certified nursing assistant (CNA) #1, they provided care to the resident and did not notice any discoloration on the forehead. -[DATE], 3-11 shift 5th Floor Unit - According to RN #3, they took care of resident in their 3-11 shift, they gave medications and nothing was observed on resident. The CNA assigned did not report anything.-[DATE], 7-3 shift 5th Floor Unit - According to CNA #2, they worked 7-3 shift and did AM [morning] care on the resident [room # redacted] and found everything was okay on their skin. -[DATE], 11-7 shift 5th Floor Unit - According to LPN #2, they were the nurse assigned to work on the floor. Nobody reported anything to me. -[DATE], 11-7 shift 5th Floor Unit - CNA #1 was assigned to the resident. The CNA stated they provided care to the patient and did not notice any bruise on their forehead. -[DATE], 3-11 shift 5th Floor Unit - According to RN #4, they worked 3-11 shift and gave medications to the resident and did not observe anything on the resident. The resident was calm throughout the shift. The assigned CNA did not report anything about the resident to me. -[DATE], 7-3 shift 5th Floor Unit - According to CNA #3, they took care of the resident [name redacted] gave morning care. Their skin was intact. There were no further statements obtained from other staff (nurses and CNA) on [DATE] 7-3 shift particularly a statement from the CNA [#4] assigned to Resident #2 and from staff on 3-11 shift when the incident was made known on [DATE] at 4:00 PM. On [DATE] at 12:37 PM, the surveyor interviewed RN #2 regarding the incident on Resident #2. RN #2 was the assigned nurse to Resident #2 on [DATE] 7-3 shift. RN #2 stated at around 3:15 PM, CNA #4 (according to RN #2, the CNA was from the agency), as they were leaving told RN #2 downstairs by the front desk that Resident #2 had a discoloration that the CNA cannot remember where. RN #2 immediately went back upstairs and checked on the resident . The resident was in their wheelchair in the dayroom. The RN further stated they then checked on the resident and noted discoloration on their inner thumb and forehead. RN asked the resident regarding the discoloration but the resident said they cannot remember. The RN stated the resident was confused. RN then told the 3-11 shift Supervisor. RN #2 stated that they were the Unit Manager in the other Unit but today they were assigned in the 5th Floor Unit. RN #2 further said that when they went back to the dayroom (DR), Resident #2 had their visitors with them. The RN said they contacted the resident's other family member (daughter-in-law)[name redacted]. The RN Supervisor assessed the resident and notified the doctor. According to RN #2, the nursing supervisor attempted to notify the agency to get statement from the agency CNA #4 but was not able to contact the CNA agency. On [DATE] at 1:11 PM, the surveyor interviewed the Director of Nursing (DON) with the Licensed Nursing Home Administrator (LNHA). The DON stated they could not remember if the CNA #4 agency was contacted. DON remembered the nursing supervisor was trying to contact the agency. After confirming with the nursing supervisor, the DON stated the CNA #4 agency was not contacted but the DON affirmed CNA #4 never return to work in the facility. The DON stated CNA #4 statement was important in the investigation but they were not able to follow up. The LNHA stated they did the investigation and collected statements from previous shifts. LNHA further said the statements from the nurses and CNAs who assigned specifically to the resident. The surveyor reiterated to LNHA and DON that there were no statements from the CNA #4 who was specifically assigned to the resident. A review of the facility's policy on Abuse, Neglect and Exploitation, under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; under Procedure: .IV. Identification of Abuse, Neglect and Exploitation: .Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body.3. Physical injury of a resident, of unknown source .; V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion or allegation of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include; 1.Identifying staff responsible for the investigation; .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; .6. Providing complete and thorough documentation of the investigation. N.J.A.C. 8:39-9.4(f); Appx. B

Based on observation, interview and document review it was determined that the facility failed to ensure the proper rinse temperature was consistently maintained for the dish machine and dishware was appropriately dried to limit potential bacterial growth and the potential for food borne illness. The deficient practice was evidenced by the following: On 03/04/25 at 9:28 AM, the surveyor observed the dish machine in use cleaning the breakfast dishes. The surveyor observed, with staff, the final rinse temperature was 172 degrees Fahrenheit (F). Dietary Staff (DS #1) was also observed removing the plates from the dish machine with his bare hands and he proceeded to wipe the plates with a rag, and then placed them on a rack. The Food Service Director (FSD) was present and informed DS #1 to not wipe the dishes. The surveyor again observed DS #2 loading the dish machine with soiled items and then asked DS #2 what the temperatures for the wash and rinse should be. DS #2 stated, wash should be 160 F and rinse should be 180 F. The surveyor observed the rinse temperature which only reached 170 F as the items when through, when the surveyor asked the DS #2 why the temperature did not reach 180 F, DS #2 stated, sometimes it varies. DS #2 then placed a rack that contained soiled insulated tray lids into the machine and the rinse temperature reached 165 F. The surveyor asked the FSD what the temperature should be for the rinse and the FSD stated 180 F, and he then observed as items were placed in the dish machine that the temperature was 165 F for the rinse. The FSD stated he was going to check the hot water booster and shut the machine down. The FSD stated he checked it in the morning and it was working. The surveyor requested the dish machine policy and reviewed a temperature log affixed to the wall that indicated the rinse temperature was 186 F on 03/04/25. On 03/04/25 at 1:18 PM, the Liscened Nursing Home Administrator confirmed that the dish machine was not being used until the machine was fixed. On 03/05/25 at 9:41 AM, the surveyor interviewed the repairman for the dish machine via telephone. The repairman stated, the water pressure was too high and he adjusted it because when the pressure was too high the waster went through the machine too quickly and did not have enough time to heat up to the appropriate temperature. The surveyor asked if the facility should have been using the machine if the rinse temperature was not 180 F. The repairman stated, the rinse temperature should have been 180 F and the temperature was and obvious indication regarding the dish machine function. The Dishwashing Policy, undated, revealed #4: .Check temperature gauges before and during dishwashing to determine is wash and rinse temperatures being maintained. Wash temperatures should be 160- 175 degrees and final rinse temperature greater than 180 . Any deviations in temperatures will be reported to maintenance. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to ensure all residents were treated in a dignified manner by failing to ensure a) residents who were dependent on staff for care were provided with incontinence care prior to being served meals, and b) residents eating meals in the same dining room were served meals at the same time. This deficient practice occurred for 3 of 3 residents reviewed for dignity (Resident #31 and #42 and #129) and was evidenced by the following: On 2/27/25 at 10:16 AM, the surveyor observed Resident #129 in bed and the resident was partly covered and the incontinence brief could be observed bulging from the back. The resident informed the surveyor they were last provided with incontinence care at 5:00 AM. The resident informed the surveyor that they were unable to get out of the bed to use the bathroom, they could not walk, and staff would not answer the call light in a timely manner. On 2/27/25 at 10:59 AM, an incontinence observation performed with a random Certified Nursing Aide (CNA) revealed that Resident #129 was wearing an incontinence brief that was soaked with urine and soiled with feces. On 2/27/25 at 11:46 AM, the surveyor returned to Resident #129's room and the resident stated that they still had not been changed. The surveyor then observed that the resident had been served the lunch meal while not having been first provided with incontinence care. On 2/27/25 at 11:50 AM, the surveyor accompanied the Licensed Practical Nurse (LPN) to Resident #129's room and the resident informed the nurse that they had not been provided with incontinence care prior to the meal delivery. The LPN stated that the protocol was to check and change the residents prior to serving meals to the residents. On 2/27/25 at 12:00 PM, a review of the medical record revealed that Resident #129 was admitted to the facility with diagnoses that included, but were not limited to; Hemiplegia (paralysis that affects only one side of the body) and Hemiparesis (one sided muscle weakness) and ischemic cardiomyopathy. The Admission Minimum Data Set (MDS), an assessment tool used to manage care dated 12/11/24, reflected that Resident #129 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental status (BIMS). The MDS also revealed Resident #129 was dependent on staff for most activity of daily living including mobility, transfer and toileting. The undated Care Plan provided by the facility on 3/5/25 at 10:30 AM, reflected a Focus for Self Care /Mobility Performance Deficit related to Cerebrovascular Accident (damage to the brain from interruption of its blood supply). The goal was for Resident #129 to improve current level of function in mobility, transfer and personal hygiene. The interventions were to document, report any changes, any potential for improvement reasons for self care deficit, expected course, declines in function . On 2/27/25 at 12:08 PM, during an interview at with the LPN, she stated, the CNA would document their care in the Point of Care (POC) system. The surveyor reviewed the POC with the LPN and there was no documentation regarding any care provided on 2/27/25 for Resident #129. On 2/27/29 at 12:15 PM, the surveyor interviewed the CNA who cared for Resident #129. The CNA stated that she served breakfast that morning to the resident and confirmed that she did not provide any care to the resident. She stated she was Agency Staff and was not informed of what was to be done for the resident. 2. On 2/28/29 at 11:40 AM, the surveyor observed the lunch meal pass on the 4th floor. The surveyor observed three residents seated in the right corner of the room that was adjacent to the nursing station. The surveyor observed a CNA set up the lunch tray for Resident #77. Resident #77 began eating their lunch meal while Resident #31 and #42 watched television and waited for their trays. The surveyor observed that both residents waited 25 minutes before they received their lunch meals. Resident #31 and #42 received their lunch meal at 12:05 PM. On 3/04/25 at 11:20 AM, the surveyor again observed the lunch meal on the 4th floor. The first lunch cart arrived on the floor at 11:24 AM. The surveyor observed 3 residents seated in the right corner of the room same as on 2/28/25. On 3/04/25 at 11:34 AM, the surveyor observed Resident #77 received their lunch meal. The CNA set-up the lunch meal for the resident and left the room. Resident #77 was eating their lunch and Resident #31 and #42 were actively watching Resident #77 eating while waiting for their trays. Resident #77 completed their meal at 11:45 AM. Resident #31 and #42 received their trays at 12:01 PM. On 3/4/25 at 12:50 AM, the surveyor interviewed the LPN assigned to the unit regarding the above observation. The LPN stated, The trays arrived at different times, and Residents should be fed at the same time while seated at the same table. The surveyor then asked the LPN if it was normal practice for residents to sit and observe other residents eating their meals. The LPN stated, I agreed with you, they should be served at the same time, it is what it is. The surveyor then reviewed Resident #31's medical record which revealed the resident was admitted to the facility with diagnoses that included, but was not limited to; unspecified Dementia with behavioral disturbances. According to the most recent MDS, dated [DATE], Resident #31 had severe cognitive impairment and required staff assistance with set-up for eating. Resident #31 scored 02 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a severe cognitive impairment. The surveyor reviewed Resident #42's medical record which revealed diagnoses which included, but were not limited to; hemiplegia, hemiparesis and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #42 was severely cognitively impaired. Resident #42 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS). On 3/05/25 at 10:16 AM, during an interview with the nurse educator regarding the above concern, she stated that the staff had since been in-serviced. On 3/6/25 at 1:30 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator (LNHA) who stated that the facility had been educated and the facility did not have a related policy for dining. NJAC 8:39 - 17.4(d)

Complaint # NJ 167926 Based on interview, record review and document review it was determined that the facility failed to report an allegations of abuse, and injury of unknown origin to the Department of Health (NJDOH) as required within two hours of the allegation being made. The deficient practice was evidenced for 2 of 4 resident reviewed for investigations (Resident #343 and #290) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343, sitting in the room in a wheelchair. The surveyor observed the right side of the resident's face with large area of discoloration and a bump around their right eyebrow. On 3/4/25 at 12:29 PM, Surveyor #1 reviewed the medical record for Resident #343. A review of the Admission Record face sheet (an admission summary) reflected that Resident #343 was admitted to the facility with diagnoses which included but were not limited to; Heart Failure, Chronic kidney disease and history of falling. A review of an Annual Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 2/27/25, reflected that Resident #343 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognition. A review of the electronic Progress Notes (PN) dated 2/25/25 at 10:30 AM, reflected that the resident was noted with a bump on head. The PN reflected that the resident was assessed, vital signs were stable. Resident #343 was scheduled for dialysis treatment that day, left the facility for dialysis and returned at 4:57 PM. Upon return from the dialysis center, the Licensed Practical Nurse (LPN) who assessed the resident, indicated that the hematoma had increased in size (no measurement provided), the Registered Nurse/Unit Manager (RN/UM) was made aware. The Physician was notified and ordered to transfer the resident to the Emergency Department for evaluation and treatment. The Resident Representative was made aware of the transfer. A CT (computed tomography) scan (noninvasive imaging procedure that uses X-rays to create cross-sectional images of the body) performed at the hospital was negative for intracranial bleeding according to the facility. Resident #343 returned to the facility on [DATE] at 11:55 PM. On 3/5/25 the surveyor requested the investigation for review. On 3/5/25, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of the Reportable Event Record/Report dated 2/25/25. The incident was reported to the New Jersey Department of Health (NJDOH) on 2/28/25 at 4:30 PM (3 days later). On 3/7/25 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged to the survey team that she was made aware of the incident late in the evening, although the incident occurred at 10:00 AM that day. She informed the surveyor that the LNHA was in charge of the investigation and reported the incident to the NJDOH. She could not provide the rationale for reporting the incident 3 days later while the survey team was on site. 2. On 2/28/25 at 12:55 PM, upon an inquiry from Surveyor #2, the LNHA stated there were no investigations for Resident #290 related to care concerns, however, then provided Surveyor #1 with copies of progress notes beginning 9/15/23. On 3/04/25 at 9:06 AM, the LNHA stated she had an investigation regarding Resident #290, and then confirmed that nothing was reported the NJDOH. The surveyor reviewed the following: A Grievance/Concern Form revealed: Description of Concern: Resident reported to Registered Nurse Supervisor (RNS) on 11:00 AM on 9/16/23, that while in therapy the resident had a bowel movement in diaper and asked the therapist to bring them to their room to be changed. Resident #290 stated, three Certified Nurse Aides (CNAs) assisted them and I was aggressively and forcefully wheeled to the bathroom, as I was pleading to put back to bed to be changed because I am dizzy. Another Grievance/Concern Form revealed: Concern Reported To: IDC [Interdisciplinary Care Team] LNHA, Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), Description of Concern: Resident #290 requested a meeting with the IDC team and was extremely infuriated due to many issues but the in particular the treatment they received from two CNAs last Friday 9/15/23. The resident claimed they defecated in diaper and needed to be changed. Resident #290 stated both CNAs were aggressive in the process and one CNA was taunting them, and the CNAs nails dug into them. On 3/07/25 at 8:50 AM, Surveyor #1 interviewed the LNHA in the presence of the survey team. The LNHA confirmed that Resident #290's documented allegations were allegations of abuse and confirmed they were not reported to the NJDOH. Surveyor #1 asked the LNHA if there was any reason the allegations were not reported to the NJDOH and the LNHA had no comment. The Abuse, Neglect and Exploitation policy, signed by the LNHA on 5/25/24 revealed: VII: Reporting/Response: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes: a. immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39- 9.4(f) 48423

Complaint # NJ 167926 Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to complete a thorough investigation to rule out abuse or neglect for a resident who sustained an injury of unknown origin, for an allegation of abuse, and ensure a resident was protected from potential abuse while an investigation was completed. This deficient practice occurred for 2 of 4 residents reviewed for abuse (Resident #290 and Resident #343) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343 sitting in the wheelchair in their room. Surveyor #1 observed the right side of the resident's face with large area of discoloration, and a bump around their right eyebrow. On 03/04/25 at 12:29 PM, Surveyor #1 reviewed the Medical Record (MR) for Resident #343 which revealed the following: The Admission Record revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; sepsis (a serious condition in which the body responds improperly to an infection), pneumonia (an infection that affects one or both lungs), Type 2 diabetes, and dependence on renal (kidney) dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/27/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score 14 out of 15 that indicated the resident had intact cognition. The Care Plan (CP) revealed a focus area initiated 2/25/25 that revealed Resident #343 had sustained an actual fall with skin discoloration to right forehead related to gait/balance problems. Interventions included neurological checks (assessment for head injury) for 24 hours. A review of the Nursing Progress Notes (PN) dated 2/25/25 at 10:30 AM revealed the following: RN #1 was called into resident's room by RN #2 and the Certified Nurse Aide (CNA) to show the bump on Resident #343's head. RN #1 asked the resident how it happened, and the resident stated that while in the chair, they were sliding from the chair. The CNA called for help and RN #2 and the CNA both assisted the resident back into the chair. The PN revealed that when RN #1 assessed the resident, the resident seemed okay and was alert. RN #1 checked resident's vital signs (VS/ blood pressure, pulse, respirations, temperature and pain). The Unit Manager (UM) was made aware of the incident after it occurred. On 3/5/25 at 8:31 AM, the surveyor requested any facility's incidents, investigations, reportable events that were sent to the New Jersey Department of Health (NJDOH) and any grievances for February 2025. On 3/5/25 at 10:07 AM, Surveyor #1 interviewed the RN/UM regarding the fall that occurred for Resident #343. The RN/UM stated she was made aware of the fall on 2/25/25 around 12:00 PM, which was after the morning meeting. At that time, the RN/UM stated she was unable to complete an assessment of the resident, as the resident had already left the building for dialysis treatment. The resident then returned from dialysis at 4:57 PM and the RN/UM was made aware by the Licensed Practical Nurse (LPN) on duty that the hematoma (an abnormal collection of blood outside of a blood vessel) was observed on the right forehead and had increased in size. On 3/5/25 at 11:32 AM, Surveyor #1 interviewed RN #1 regarding the fall. RN #1 stated she had asked the CNA to assist the resident to get the resident ready for dialysis on 2/25/25. RN #1 stated the resident was already sitting in the wheelchair and RN #1 had been passing medications on the opposite hallway. The CNA then exited out of Resident #343's room and called for help, and then RN #2 went to help and assisted the CNA to pull Resident #343 back into the wheelchair as the resident was sliding off. RN #1 then stated RN #2 informed her that he had observed the resident sitting on the edge of the wheelchair. RN #1 stated that RN #2 told her that they assisted the CNA to pull the resident back into the wheelchair and at that time had observed a small bump on the right side of Resident #343's forehead. RN #1 stated that RN #2 then asked them to check on the resident because of the observed forehead injury. RN #1 stated that she assessed Resident #343's vital signs and neurological status (assess an individual's neurological functions, motor and sensory response, and level of consciousness) and then the resident was sent out for dialysis at their scheduled time. RN #1 stated she contacted the RN/UM via text message. On 3/5/25 at 11:55 AM, Surveyor #1 reviewed the facility provided Investigation for the incident that occurred on 2/25/25 included the following statements: A statement signed by RN #1, dated 2/25/25 revealed . that called by other nurse on high side and the CNA who showed the bump on head . seemed fine . the unit manager was made aware after the incident . A statement completed by RN #2 dated 2/25/25 revealed . I was called by the CNA to assist with repositioning patient who was at the edge of the wheelchair after securing the patient back into the chair I observed a bump on the right side of the forehead when I asked if the patient had fallen she said no and notified the nurse the changes of the patient and to follow up. The patient left the unit at 11:00 AM for dialysis and returned at 4:00 PM with a more noticeable bump on forehead, the supervisor was informed . and [primary medical doctor] was informed .the patient will be transferred to the hospital for further evaluation and treatment. A statement from the CNA dated 2/25/25 revealed . at 9:45 AM the nurse informed me that the resident was going out at 10:00 AM to dialysis and wanted me to get the resident dressed . When got to the room the resident was already dressed and sitting in the wheelchair with back to the door. I asked if the resident was wet and needed to be changed and the resident responded, I am not sure if I am wet or not. I then made my way to the bathroom with the resident in wheelchair and as I approached the bathroom I noticed the resident started sliding down the chair and slid down to floor and was on [their] knees. I then went to get help from the nurse for a minute or so so the nurse can help me get the resident up to the chair. When the resident was back in the wheelchair I noticed [they] had a hematoma on [their] forehead, the nurse took a photo. I am not sure if the resident attempted to get up front her wheelchair on [their] own while I went to get help and hit [themselves] on the side or corner of [their] wheelchair because at that time there was nothing around her that [they] could use to harm [themselves] The RN/UM completed a statement dated 2/26/25 that revealed on 2/25/25, received a text from RN #1 that resident #343 had a bump on head on right side. I was in morning report at that time and I did not check my text messages. I got out of morning report at 12:05 PM and upon arrival RN #2 informed me of incident and resident was not at facility as left for dialysis. At 4:18 PM, I received a call from RN #2 that Resident #343 had returned and assessed patient. Called to notify [Medical Doctor] who gave order to send out resident for [Computer Aided Tomogrophy] of the head (multiple x-ray test to determine head injury) . A statement dated 2/26/25, signed by two social workers revealed they met with Resident #343 and documented: resident stated that fell from the chair in the bathroom on Tuesday around 8:00 AM. CNA was with the resident when fell and CNA called another person to help pick up . A Reportable Event Record submitted to the NJDOH on 2/28/25 at 4:30 PM, revealed an undated Summary of Investigation for the Date of Event: 2/25/25 revealed: On February 25, 2025 [no time indicated] the CNA brought Resident #343 to get ready for dialysis. While Resident #343 was being wheeled to the bathroom door, the resident began to slip from the wheelchair and fell on knees forward leaning more on right side, at this time the CNA decided to leave in that position to summon assistance in getting back to wheelchair. There investigation failed to identify a causal factor for the head injury, what initially led to the resident allegedly sliding out of the chair, how long the resident was left unattended on knees in the bathroom, and why the physician was not immediately notified of the identified injury prior to being transported to dialysis. On 3/6/25 at 8:36 AM, Surveyor #1 attempted to call RN #2 for an interview regarding the fall and RN #2 was not available for the interview. On 3/6/25 at 10:39 AM, Surveyor #1 completed a telephone interview with the CNA regarding the fall. The CNA stated she did not observe the fall, but the resident told her that they fell . On 3/6/25 at 11:00 AM, in the presence of the survey team, Surveyor #1 asked the the Director of Nursing (DON) if the investigation that was provided complete and the DON confirmed that the investigation that was provided to Surveyor #1 was complete. Surveyor #1 asked the DON about the facility's investigative process. The DON stated the supervisor would start the investigation and obtain statements from anyone involved with the resident care and also including the roommate, the resident and the supervisor would completed a summary. The DON stated usually they would go back 48 hours if the injury was identified as an injury of unknown origin. The DON then stated, not even close with the amount of statements that should have been received from staff regarding the investigation. The DON further stated she had interviewed the night supervisor from previous shift to inquire if there were any incident that happened during the night; however, the DON could not provide any statements collected from the night shift staff. The DON stated that the responsible party (RP) were present when the social workers interviewed the Resident and the RP stated the resident was not comprehending anything. When the DON was asked if she had been notified of the injury, she stated that she was made aware late in the afternoon after the resident had returned from dialysis and she did not know when the physician and RP's were notified. The surveyor asked why the staff did not follow-up after not receiving a response to the text, the DON stated, exactly, I don't know why. The surveyor asked the DON if the resident had fallen on the floor and the DON stated, don't know. On 3/6/25 at 12:23 PM, in the presence of the survey team, Surveyor #1 interviewed the Licensed Nursing Home Administrator (LNHA) who was in charge of the investigation. The LNHA stated the staff observed the resident in the morning prior to the dialysis treatment with a bruise and a bump on the forehead and stated the DON did not know when it happened. Upon return from the dialysis, RN #2 assessed the resident and reported that the hematoma had increased in size. The physician was then made aware and gave order to transfer the resident to the Emergency Department for evaluation and treatment. 2. On 2/28/25 12:41 PM, Surveyor #2 asked the Licensed Nursing Home Administrator (LNHA) about recalling Resident #290 during September 2023 and asked about any investigations completed while the resident was at the facility. The LNHA stated she recalled Resident #290, but there were no investigations at all, there were no grievances from the resident and there was nothing reported to the DOH regarding Resident #290. On 2/8/25 at 12:55 PM, the LNHA stated there were no investigations for Resident #290, however, then provided Surveyor #1 with copies of progress notes beginning 9/15/23. On 3/4/25 at 8:30 AM the surveyor reviewed the Electronic Medical Record for Resident #290 which revealed: the Admission Record indicated the resident had diagnoses including, but were not limited to; Fracture of one Rib, Type 2 Diabetes, and Congestive Heart Failure, a Psychiatry Follow Up Note, dated 09/06/23 revealed the resident was admitted for Sub-Acute rehabilitation and presents calm and cooperative, pleasant reports, I feel a little bit better and I'm going to therapy but I still feel depressed and anxious, no signs and symptoms of mania or psychosis noted at that time. On 3/04/25 at 9:06 AM, the LNHA stated she had an investigation regarding Resident #290, and then confirmed that nothing had been reported the NJDOH. The surveyor reviewed the following: Grievance/Concern Form revealed: Description of Concern: Resident reported to Registered Nurse Supervisor (RNS) on 11:00 AM on 09/16/23, that while in therapy the resident had a bowel movement in diaper and asked the therapist to bring them to their room to be changed. Resident #290 stated, three Certified Nurse Aides (CNA #1, #2 and #3) assisted them and I was aggressively and forcefully wheeled to the bathroom, as I was pleading to be put back to bed to be changed because I am dizzy. The Actions taken to resolve the concern and the Results of the action taken part of the form were both left blank and the form was signed by the RNS and dated 9/16/23. The following attached employee statements revealed: Employee Name: CNA #1, Dated 9/18/23, Date incident occurred/found: 9/15/23. Description of the Incident/Accident: On Friday [9/15/23] I went to help CNA #2 with Resident #290 to put the resident on the toilet and after standing up, the resident said to change them in the bed and put them back to bed, and CNA #2 and #3 changed them; CNA #2, Dated 9/18/23, Date incident occurred/found: [left blank]. Description of the Incident/Accident: went with CNA #1 and #3 to put resident on toilet but couldn't do it and put in bed and changed diaper; CNA #3, Dated 9/18/23, Date/ shift assigned as caregiver: 9/15/23, Date incident occurred/found:9/15/23, 7:00 AM to 3:00 PM, Description of the Incident/Accident: Friday around 2:25 PM, Resident #290 called for help. I went to room, told me needed to have diaper changed. I called my coworkers to help to put on the toilet but resident could not do it and changed diaper. There was no statement from the resident included in the documents provided by the LNHA. Another document provided by the LNHA, dated October 5, 2023, was a grievance from Resident #290's Health Insurance Company (HIC). The document revealed Resident #290 alleges that was physically assaulted in the bathroom in room by the CNA. The resident alleged that they had an accident while at physical therapy and needed to be changed due to defecating in clothes, stated they were sitting when 3 aides [ Names redacted of CNA #1, #2 and #3] came to clean the resident and when they tried to pick the resident up from the chair, and when they realized that, [Resident #290] had an accident they slammed down in their chair then forcibly took them to the restroom in the resident's room. They were being extremely rough with the resident and forcing the resident to stand up on their own, also the resident stated that they were unable to stand on their own. Resident #290 alleged that the CNAs did not clean him/her well and the CNAs told him/her to stop faking it, and another CNA told him/her to stop crying once they got him/her on their bed. On 3/5/25 at 12:00 PM the LNHA provided Surveyor #2 with the requested CNA assignment sheets for 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/18/23, 9/19/23 and 9/20/23 which revealed: CNA #3 was assigned to Resident #290 on 9/14/23 [CNA #2 also worked on the same unit], 9/15/23 [CNA #1 and #2 also worked on the same unit]. On 9/18/23, two days after Resident #290 reported CNA #1, CNA #2 and CNA #3 forcibly and aggressively wheeled then back to bed to be changed because the resident was dizzy, CNA #3 was again assigned to Resident #290. On 3/07/25 at 8:50 AM, Surveyor #2 interviewed the LNHA in the presence of the survey team and the reviewed the allegations that Resident #290 made to the RNS on 9/16/23 and asked the LNHA if the allegations constituted abuse, and the LNHA confirmed that Resident #290's documented allegations were allegations of abuse. Surveyor #2 asked the LNHA what should immediately happen, per facility policy, after an allegation of abuse is made. The LNHA stated remove the CNA involved and the surveyor asked if that had occurred and the LNHA stated, I don't think so. Surveyor #2 asked again if it was an allegation of abuse and the LNHA responded, yes. There was no evidence that the CNAs were removed and did not have access to Resident #290. On 3/07/25 at 11:00, during the exit conference held with the LNHA, Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director, there was no additional information provided. The Abuse, Neglect and Exploitation policy, signed by the LNHA on 5/25/24 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident's property. V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI: Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, D. Room or staffing changes . A review of the facility's Unexplained injuries policy revised date 11/22, included that all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. NJAC 8:39- 4.1(a)12 48423

Repeat Deficiency Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement a baseline individual comprehensive care plan (ICCP) to meet resident preferences and goals to address all medical and psychosocial needs within 48 hours of admission. This deficient practice was identified for 1 of 27 residents (Resident #131) reviewed for ICCP and was evidenced by the following: On 2/28/25 at 9:38 AM, the surveyor observed Resident #131 being escorted off the unit. When asked, the Licensed Practical Nurse Unit Manager (LPN UM) stated that the resident was anxious, and they wanted to provide the resident with activities. On 2/28/25 at 11:00 AM, the surveyor reviewed the Admission Record (an admission summary) which reflected Resident #131 had diagnoses which included but were not limited to; altered mental status, unspecified psychosis, anxiety disorder, and Alzheimer's disease. A review of the most recent annual Minimum Data Set (MDS), an assessment tool, dated 12/25/24, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 06 out of 15 which indicated a severely impaired cognition. The MDS further documented that Resident #131 was administered high-risk antipsychotic medications. The MDS revealed Resident #131 had care areas which included cognitive loss and psychotic drug use. A review of the most recent psychiatric evaluation dated 2/12/25, included but was not limited to; the use of Aricept (used to treat dementia with Alzheimer's) 5 milligram (mg) at bedtime, Namenda (used to treat dementia) 5 mg twice a day, and Seroquel (used for psychosis) 25 mg at bedtime. The evaluation revealed a gradual dose reduction was not recommended, included potential side effects, and recommended bloodwork for monitoring. A review of the ICCP failed to document a focus area for the use of an antipsychotic medication, and medication for dementia; goals associated with the medications; or any interventions. On 3/06/25 at 9:04 AM, the direct care Certified Nurse Aide (CNA) #1 stated she was familiar with Resident #131. CNA #1 stated in the resident's mind, the resident wanted to go to work, take out the garbage, and perform normal daily tasks. CNA #1 stated the staff can sometimes provide clothes for the resident to fold to take their mind off of wanting to leave. On 3/06/25 at 10:33 AM, the Director of Nursing (DON) stated the process for developing a care plan would include when a resident was admitted , the supervisor on duty would be responsible to document a baseline care plan within 48 hours. The DON further stated that she expected antipsychotic medications to be included in the baseline care plan. The DON was then made aware of the missing information in the baseline care plan. On 3/7/25 at 11:00 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director. The facility acknowledged that Resident #131's use of antipsychotic medication use was not included in the baseline care plan. A review of the facility provided policy, Use of Psychotropic Drugs revised 9/2022, included but was not limited to; the use of psychotropic medication needed to be documented, monitored, and documented response to the medication. The indications for use will be documented . Residents who use psychotropic medications shall receive non-pharmacological interventions . A review of the facility provided policy, Baseline Care Plan revised 7/2023, included but was not limited to; . develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care . that meet standards of quality care. The baseline care plan will be developed within 48 hours of the resident's admission and include the minimum information necessary to care for the resident including but not limited to . initial goals . physician orders. The facility must provide . a summary of the baseline care plan that includes but not limited to; initial goals, summary of the medication instructions, services and treatments to be administered, and updated information as necessary. NJAC 8:39-11.2(d)(g)

Complaint NJ # 169842 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care and bathing for 2 of 2 residents (Resident #73 and #104) reviewed for activities of daily living. This deficient practice was evidenced by the following: On 02/27/25 at 9:57 AM, the surveyor observed Resident #73 in bed. A Certified Nursing Aide (CNA) was at the bedside providing care and an interview conducted with the CNA revealed that the resident skin was intact. Per the surveyor request the CNA checked the resident for incontinence care. The surveyor observed that Resident #73 was wearing two incontinent briefs. One of the brief was folded and placed inside the first brief and secured in place with the liner of the first brief. The CNA informed the surveyor that the second brief was to catch the urine while the resident was in bed. On 2/27/25 at 10:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #73. The Admission Record revealed with diagnoses that included, but were not limited to; Morbid (Severe) Obesity, unspecified Dementia and obstructive Pulmonary disease. The Minimum Data Set (MDS), an assessment tool, dated 02/04/25, reflected that Resident #73 was severely cognitively impaired and required extensive assistance with Activities of Daily Living (ADL). Resident #73 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a severe cognitive impairment. A review of Resident # 73's Care Plan (CP), with no revision date indicated that Resident #73 had impaired movement, weakness, and was totally dependent on staff for bathing, toilet use and personal hygiene. Resident #73 was frequently incontinent of bladder and bowel (B/B) functions and at risk for skin impairment. The CP interventions included but were not limited to: Provide frequent incontinence care every shift, turn and reposition every 2 hours. On 03/05/25 at 10:50 AM, the surveyor interviewed Resident #73 with an activity staff that was able to translate for the resident. Upon inquiry, Resident #73 stated they received a bed bath daily, and had not had a shower for 4 months. Resident #73 stated that they would like to get out of the bed for shower. The activity staff informed the Infection Preventionist (IP) of the interview with the resident. On 03/05/25 at 10:30 AM, the IP informed the surveyor that the facility had a large Gurney (wheeled bed or stretcher that is used to move patients who are sick or injured) on the 6th floor that could be used to transfer Resident #73 to the shower room. The surveyor went to the 6th floor with the IP and observed a Gurney that did not appear to accommodate a safe transfer out of the bed. The facility IP confirmed they had not used the Gurney before for a shower. The facility then confirmed that Resident #73 only received a bed bath daily, and could not verify when the resident last had a shower. The resident's CP did not indicate that staff would get the Gurney on the 6th floor to shower the resident on the day assigned for shower. A review of the shower log with the Unit Manager (UM) revealed 30 of the log dates for February 2025 for the 4th floor, were left blank and the UM could not indicate if the resident was bathed. On 3/6/25 at 9:30 AM, during an interview with the CNA who cared for Resident #73, she stated that she washed the resident in bed every day, and was not informed to get the Gurney from the 6th floor to transfer the resident for a shower. 2. On 2/27/25 at 10:01 AM during the initial tour, the surveyor observed Resident #104 was in bed. The Resident informed the surveyor that they were last provided with incontinence care at 6:00 AM that morning and would next get changed after lunch around 12:00 PM. The surveyor then asked the resident if they were soiled and the resident stated, yes. The surveyor left the room and observed a CNA in the hallway. The surveyor asked the CNA to assist with an observation. At 10:35 AM the CNA entered Resident's #104's room with the surveyor to perform an incontinence observation. The resident was observed wearing an incontinence brief that was soiled with large amount of feces and was soaked with urine. On 2/27/25 at 11:30 AM the surveyor reviewed the EMR for Resident #104. The Admission Record revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; Parkinson's Disease, Anxiety disorder, need for assistance with personal care. The Quarterly MDS dated [DATE] revealed that Resident #104 had intact cognition. The MDS also revealed that Resident #104 was always incontinent. On 02/28/25 at 11:12 AM, the surveyor interviewed the nurse regarding incontinence care. The nurse stated that she was not aware of a policy that would dictate when incontinence care was to to be provided. The nurse went on to state that the residents were provided with incontinence care before breakfast and again after lunch. On 03/04/25 at 10:59 AM, the surveyor observed a CNA about to exit Resident #104's room. The surveyor asked the CNA to assist with an incontinence observation. The resident was observed soiled with urine and feces. An interview with the CNA at 11:05 AM, revealed that she provided care to the resident this morning, and would again change the resident after lunch. The above concerns were discussed with the LNHA and the Director of Nursing on 3/6/25 at 1:30 PM. On 3/7/25 at 11:17 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Clinical Director and the above concerns were mentioned. The DON stated, that was unacceptable regarding the rolled up incontinence brief inside of the incontinence brief, and stated that there should be no residents wearing double incontinence briefs. Upon reviewing the concerns regarding residents not receiving showers, the LNHA stated, I know there were holes you found regarding the bathing documentation. A review of the facility's policy titled, Activities of Daily Living, revised on 7/2023, indicated under Policy: The facility must provide necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such deterioration was unavoidable. The same policy under Procedure: 3 A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming personal and oral hygiene. NJAC 8:39-27.1(a)2(h)

Based on observation, interview, record review and review of facility provided documents, it was determined that the facility failed to care for, and remove an intravenous (IV) line for 1 of 1 resident (Resident #38) reviewed for IV therapy. This deficient practice was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 in their room with an IV connection line inserted in the right hand between the thumb and first finger. Resident #38 stated that the IV had been inserted weeks ago for medication and had never been removed. On 2/28/25 at 9:56 AM, the surveyor observed Resident #38 in their room with the IV connection line still in place. On 3/04/25 at 9:00 AM, the Licensed Practical Nurse Unit Manager (LPN UM) stated the IV line was inserted because the resident had been receiving an IV antibiotic which had been stopped on 2/10/25. The LPN UM and surveyor reviewed the electronic medical record (emr) and the LPN UM was unable to locate any orders for the IV line. The surveyor inquired about the orders for the care of the line and the insertion site. The LPN UM reviewed the emr and was unable to locate any orders to maintain the patency of the IV line or to care for the dressing over the insertion site or any documentation that the IV line was being flushed to maintain patency or the dressing was being changed by the nursing staff. The LPN UM stated there should be a physician's order for both. The LPN UM further stated she took the verbal orders from the Nurse Practioner (NP) but was unable to locate the orders. She stated she was waiting for the orders to remove the IV line, but the IV had been removed. The LPN UM and surveyor went to the resident's room. Resident #38 did not have the IV line and informed the surveyor and LPN UM that it was just removed. On 3/4/25 at 10:00 AM, the surveyor reviewed the emr. A review of the Admission Record (an admission summary) included a diagnosis of pneumonia. A review of the admission Minimum Data Set (MDS) an assessment tool dated 2/7/25, included a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated intact cognition. A review of the Order Summary Report (OSR) revealed the following physician orders: dated 2/6/25, Sodium Chloride 0.9% 500 milliliters (ml) per hour (hr) intravenously one time only for hydration; dated 2/6/25, Sodium Chloride 0.9% 80 ml/hr intravenously every shift for 3 days; and dated 2/10/25 with an end date of 2/13/25, Sodium Chloride 0.9% 80 ml/hr intravenously every shift for 3 days. A review of a nursing note (nn) dated 2/13/25, documented the resident was on IV hydration until 2/13/25. The next nn dated 2/19/25, documented IV medications, but failed to document any care or orders for the IV line. A review of the Individual Comprehensive Care Plan (ICCP) including resolved and canceled focus areas date initiated 2/1/25, failed to include any focus area, goals, or interventions for the care and use of IV therapy. On 3/04/25 at 9:16 AM, the Director of Nursing (DON) stated if a resident completed IV therapy the IV should be removed. She further stated that if the IV was not being removed, it needed to be flushed (injecting ordered solution to keep the line patent) and that the orders and documentation that this was done should be documented in the treatment administration record (TAR). At 9:52 AM, the DON informed the surveyor that she had looked into this concern. She stated Resident #38 had 3 days of IV hydration that had been a verbal order. The DON added that the staff should have entered the orders in the emr to include a start date and end date and should be documented in the TAR. On 3/04/25 at 10:33 AM, during a telephone interview the NP stated she gave a verbal order to the LPN UM to administer the IV hydration for 3 days and to discontinue the IV after the order was completed. She was not sure the exact date the IV was to be removed. On 3/05/25 at 9:24 AM, the RN Infection Preventionist stated a resident with an IV would need to have monitoring every shift, change the IV site dressing once a week, and to flush the IV. She further stated she was familiar with Resident #38 who had a peripheral line but no IV line upon admission. The RN Infection Preventionist stated that she would focus on IV lines for antibiotic use and not for hydration. She stated that when a resident was finished with the IV use, the IV should be discontinued because it was a source of potential infection. A review of the facility policy, Intravenous Therapy revised 7/2023, included but was not limited to; IV tubing is changed every 96 hours or soon if the integrity of the system is compromised; all IV tubing is to be labeled with the date, time and initials; IV sites are checked ever 4 hours for signs and symptoms of infection and inflammation; IV documentation is recorded in the nurses' notes and/or medication administration record (MAR); and if the catheter is not being used for IV fluids or medications . will discontinue per the Practioner orders. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility provided position title, Certified Nurse Aide undated, included but was not limited to; performs duties in accordance with recognized standards; provides maximum resident care services; positions residents in correct body alignment . ; ensures that residents receive the highest quality of services; and assists with treatments. A review of the facility provided position title, Licensed Practical Nurse undated, included but was not limited to; takes an active role in resident assessment and care; administers medication and/or treatment and documentation of the same for the residents; responsible for clinical documentation; assists in developing and implementing care plans; communicates pertinent data to the charge nurse and/or physician; provides for the physical comfort and safety of the residents; supervises nursing personnel in providing direct resident care; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Registered Nurse undated, included but was not limited to; under the supervision of the DON, utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of care plans to ensure resident needs are met; formulates individualized nursing care plans; assesses residents daily and implements a change in action as needed; communicates resident information; maintains accurate resident care record and documents pertinent data; dispenses medication and performs treatments in accordance with policies and procedures; and ensures residents receive the highest quality of services. A review of the facility provided position title, Unit Manager undated, included but was not limited to; twenty-four hour responsibility for the continuity of nursing care and the management of the resident welfare; assesses the performance of nursing personnel as it relates to the standards of care and goals of the individual; encourages nursing staff to perform their jobs to the fullest of their potential; demonstrates, teaches and evaluates nursing skills utilized; concerns themselves with the safety of all facility residents; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Director of Nursing undated, included but was not limited to; evaluates work performance of all nursing personnel; performs rounds to observe residents and ensure needs are being met; and conducts observations of nursing care to ensure nursing staff is current in their knowledge and skills. On 3/6/25 at 12:53 PM, the above concern was presented to the facility administration team. The facility had no additional information to provide. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to consistently perform and document functional maintenance for 1 of 2 residents (Resident #51) reviewed for restorative care. This deficient practice was evidenced by the following: On 2/27/25 at 10:17 AM, the surveyor observed Resident #51 in bed and their left wrist and hand were bent backwards. On 2/27/25 at 1:23 PM, the surveyor reviewed the electronic medical record. The Admission Record revealed diagnoses which included need for assistance with personal care. A review of the quarterly MDS dated [DATE], documented a BIMS of 02 out of 15 indicating severely impaired cognition, and that Resident #51 had ended both Occupational and Physical Therapy on 9/3/24. A review of the Order Summary Report revealed an order dated 10/17/24, Functional Maintenance Program (FMP) for daily Active Assist Range of Motion (AAROM) on Right Upper Extremities/Lower Extremities (UE/LE) and Passive Range of Motion Exercise (PROME) on Left UE/LE x 10 repetitions x 2 sets to all tolerable planes. A review of the ICCP included a focus area dated 1/3/25 at risk for joint stiffness, tightness and decline in functional mobility FMP to be implemented; a goal to participate in FMP to preserve current functional status and joint integrity; and interventions which included FMP for daily AAROM on Right UE/LE and PROME on Left UE/LE x 10 repetitions x 2 sets to all tolerable planes. On 2/28/25 at 10:02 AM, a Registered Nurse (RN) #5 stated Resident #51 would wear a splint provided by the rehabilitation department on the left wrist and hand from 2 PM to 4 PM. On 2/28/25 at 11:23 AM, the Occupational Therapist (OT) reviewed Resident #51's emr and stated the resident was not on therapy, but had been given orders for the nursing staff to perform the [NAME] and PROME and stated the documentation should be in the emr. On 2/28/25 at 11:29 AM, during a second interview, RN #5 reviewed the emr. She stated that the restorative care order would be administered by the Certified Nurse Aide (CNA). However, she was unable to access the documentation of the FMP being completed. On 2/28/25 at 11:35 AM, the Licensed Practial Nurse Unit Manager (LPN/UM) was unable to find any consistent documentation for the FMP being administered to Resident #51. She stated she was responsible to ensure the FMP was being completed and that it was important for the FMP to be completed so the resident would not be so stiff. The LPN/UM stated she would usually check for documentation at the end of the shift but has not been checking. On 2/28/25 at 11:51 AM, the DON stated that when therapy ordered restorative care it would be completed by the CNAs and the nurses should know about the order. She stated it would either be documented in a binder located on the Unit or in the emr. The DON stated the facility policy would allow for documentation in either area. On 2/28/25 at 12:25 PM, the DON returned and provided the October 2024 and November 2024 documentation with multiple missing dates of documentation. The DON provided the January and February 2025 documentation which revealed no documentation on the weekends. The DON acknowledged the missing documentation and stated that there should be no missing documentation as the order was for daily [NAME] and PROME. The missing documentation was as follows: February 2025, 9 of 28 days missing and no documented amount of repetitions or sets. January 2025, 8 of 21 days missing and no documented amount of repetitions or sets. December 2024, 8 of 31 days missing and no documented amount of repetitions or sets. November 2024, 4 of 30 days missing and no documented amount of repetitions or sets. October 2024, 3 of 31 days missing and no documented amount of repetitions or sets. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility policy, Physician Orders Policy revised 5/2023, included but was not limited to; . ensure that each resident receives necessary care and services while in the facility. The physician orders should be transcribed and/or entered in the electronic medical record of the resident. A licensed nurse or professional shall provide the care and services based on a physician order when indicated. A review of the facility policy, Documentation, Resident Record revised 7/2023, included but was not limited to; all services . shall be documented in the resident's medical record. All . medications administered; services performed must be documented in the resident's clinical record. CNAs make entries in a point of care on the care hey provided on their shift, including any refusals or unusual occurrences which must be reported to the nurse assigned. A review of the facility provided position title, Certified Nurse Aide undated, included but was not limited to; performs duties in accordance with recognized standards; provides maximum resident care services; positions residents in correct body alignment . ; ensures that residents receive the highest quality of services; and assists with treatments. A review of the facility provided position title, Unit Manager undated, included but was not limited to; twenty-four hour responsibility for the continuity of nursing care and the management of the resident welfare; assesses the performance of nursing personnel as it relates to the standards of care and goals of the individual; encourages nursing staff to perform their jobs to the fullest of their potential; demonstrates, teaches and evaluates nursing skills utilized; concerns themselves with the safety of all facility residents; and ensures that residents receive the highest quality of service. A review of the facility provided position title, Director of Nursing undated, included but was not limited to; evaluates work performance of all nursing personnel; performs rounds to observe residents and ensure needs are being met; and conducts observations of nursing care to ensure nursing staff is current in their knowledge and skills. On 3/6/25 at 12:53 PM, the above concern was presented to the facility administration team. The facility had no additional information to provide. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure controlled substances were properly disposed of and ensure adequate supervision was provided to a resident who had a history of falls. This deficient practice was identified for 1 of 1 resident (Resident #1) observed during the medication pass and 1 of 1 resident reviewed for accidents (Resident #110). The evidence is as follows: a) On 3/4/25 at 8:39 AM, the surveyor conducted a medication pass observation and observed the Licensed Practical Nurse (LPN) prepared medication for Resident #1. The LPN prepared the following medications: Klonopin (a Benzodiazepine scheduled IV controlled substance that has the potential for abuse) 0.5 milligram (mg)1 tablet (a medication used to treat anxiety); Eliquis (anticoagulant ) 2.5 mg 1 tab; Losartan Potassium 50 mg (milligram) medication used to treat high blood pressure; Propafenone 150 mg 1 tab medication (to treat heart rhythm); Senna 8.6 mg 1 tab medication used to treat constipation; Verapamil 240 mg 1 tab medication to treat high blood pressure; and Vitamin D3 50 mcg. (micrograms) Supplement. On 3/4/25 at 9:03 AM, the resident refused all of the medications and also threw one pill on the floor. The LPM retrieved the pill from the floor and then discarded all the medications, which included the Klonopin into the trash can attached to the medication cart. The nurse left the medication cart in the hallway next to the resident's room, and went to the nurse's station to call the physician. The surveyor remained in the hallway next to the medication cart. On 3/4/25 at 9:08 AM, a housekeeping staff approached the medication cart and removed the plastic bag which contained the discarded medications and placed the garbage bag in their trash basket. The surveyor approached the housekeeper and informed her not to dispose of the bag, and the staff could not understand and insisted on holding the bag. The surveyor then summoned the Assistant Director of Nursing (ADON) who was in the hallway. The surveyor explained the above concern to the ADON, and the ADON then removed the bag that contained the discarded medications from the housekeeping trash basket. The ADON opened the bag and was able to visualize the medications in the plastic bag. The ADON then gave the plastic bag to the Registered Nurse (RN) the Infection Preventionist (IP). The ADON informed the surveyor that all medications should be discarded in the drug buster (container to safely dispose of medication) located inside of each medication cart, and stated, controlled substances should be witnessed and discarded with two licensed staff. The ADON then opened the medication cart and there was no drug buster inside of the medication cart. On 3/4/25 at 9:15 AM, the surveyor interviewed the LPN who disposed of the medication into the trash can. The LPN informed the surveyor that she failed to dispose of the medications properly. On 3/4/25 at 9:50 AM, the IP approached the surveyor and showed the medications that she retrieved from the plastic bag, and the IP informed the surveyor that the nurse was educated on proper drug disposal. b. On 3/4/25 at 10:51 AM, the surveyor observed Resident #110 in the dayroom in a recliner chair. The resident was sleeping in the chair and there were ten other residents observed in the room. On 3/5/25 at 8:55 AM, the surveyor observed Resident #110 in the dayroom on the 2nd floor. The resident had their right leg over the chair and was sleeping. The activity staff in attendance was not in direct observation of the resident as she had her back turned and was preparing a drink for another resident. The surveyor asked the staff if she was alone. The Staff stated that the other activity staff went to the floor to transfer other residents. At that time, the surveyor requested any incident reports for Resident #110 from the facility. On 03/05/25 at 10:30 AM, the surveyor reviewed the facility provided Incident Reports which revealed: An Incident Report dated 07/06/23 timed 6:30 AM, the Report reflected that staff informed the Registered Nurse (RN) that Resident #110 was found on the floor in the dayroom at 6:30 AM. The staff indicated that she had to briefly leave the dayroom to attend to another resident. Resident #110 stood up, lost their balance and fell . The Certified Nurse Aide (CNA) did not inform the RN that the resident was left unsupervised in the room. Intervention added, reeducate staff not to leave the resident unattended. Provide Resident #110 with a wheelchair saddle to promote safety. Another fall occurred on 07/14/23 at 1:55 PM, in the activity room. According to the Incident Report, the activity staff turned their back to attend to another resident, Resident #110 stood up and fell on the floor. The intervention was to place Resident #110 in an area near the staff who are conducting the activities. On 8/8/23 at 5:35 AM the resident fell in the dayroom. The statement provided revealed that the Resident was trying to get out of the bed at 5:25 AM. The CNA brought the resident to the dayroom and left the resident unattended. The resident fell and was found on the floor at 5:35 AM. The resident sustained a laceration to the right eye which measured 1.5 centimeters x 0.1 cm. On 3/5/25 at 12:00 PM, the surveyor reviewed the residents medical record which revealed: The Admission Face Sheet reflected that Resident #110 was admitted to the facility with diagnoses which included, but were not limited to; Altered mental status, unspecified sequelae of cerebral infarction. The Minimum Data Set (MDS) dated [DATE], reflected that Resident #110 had severe cognitive impairment. The resident undated comprehensive care plan provided by the facility on 3/6/25 at 11:30 AM, reflected that Resident #110 was at high risk for falls related to history of multiple falls, spontaneous and uncontrolled movement of both upper and lower extremities, communication deficit. The interventions on the care plan were to keep needed items within reach, place in supervised areas (dayroom/near nurses station) keep the bed against the wall and floor mat on the side. On 3/6/25 the surveyor discussed the above concerns with the Director of Nursing and the Licensed Nursing Home Administrator and asked to provide any additional information regarding the falls. On 3/7/25 at 11:30 AM the Regional Clinical Director informed the survey team that Resident #110 should not be left unsupervised in the dayroom and the staff had been educated. No additional information was provided. The policy for discarding and destroying medications last revised 03/2018, indicated the following: Medications that cannot be returned to the dispensing pharmacy ( e.g., non-unit dose medications, medications refused by the resident, and /or medications left by residents upon discharge) will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The policy for incidents/accidents revealed the following: A review of the facility's policy titled, Fall Prevention Program last revised 4/2023 revealed the following: Policy Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Procedure 1. The facility utilizes a standardized risk evaluation tool for determining a resident's fall risk. 3. Interventions will address resident's risk factors as identified by the risk assessment tool. Falls interventions will be documented on the resident's medical records e.g., baseline care plan. NJAC 8:39-294(i); 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to record and document the urinary output for residents with an indwelling urinary catheter per the Physician Order. This deficient practice was identified for 1 of 2 resident's reviewed for urinary catheter (Resident #122) and was evidenced by the following: On 3/4/25 at 9:48 AM, the surveyor observed Resident #122 resting in their bed. The resident's urinary drainage bag was in a blue colored bag (privacy bag) and secured to the bed frame on the right-hand side. On 3/4/25 at 10:38 AM, the surveyor reviewed the electronic medical record for Resident #122 which revealed the following: The resident was admitted to the facility with diagnoses that included but were not limited to, urinary tract infection (an infection in any part of the urinary system), malignant neoplasm of prostate (cancerous growth in prostate gland), and retention of urine (a condition where the bladder does not fully empty). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/29/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicative of moderately impaired cognition. Further review of the MDS reflected that Resident #122 had an indwelling catheter (thin hollow tube that is inserted into the bladder to drain urine ). Resident #122 was dependent on staff for toileting and hygiene. A review of the Comprehensive Care plan CP) included a focus area dated 1/22/25 which indicated that Resident #122 had an indwelling catheter related to: Obstructive uropathy (a condition when urine cannot flow), BPH (Benign Prostate Hypertrophy) a condition that causes prostate to grow larger than usual) with retention status post procedure. A review of the Physician Order Summary, (POS) revealed an order dated 1/22/25, to measure and record urine output every shift. The corresponding PO was transcribed into the electronic Treatment Administration Record (eTAR). Further review of the January 2025 - March 2025 eTARs for Resident #122 revealed the following date and time where the urine output was not recorded: Date: Shifts with no urine output documented: 1/24/25 Day shift (7 AM - 3 PM) 1/29/25 Evening shift (3 PM -11 PM) 2/4/25 Day shift (7 AM -3 PM) 2/5/25 Day shift (7 AM -3 PM) 2/9/25 Day shift (7 AM -3 PM) 2/12/25 Day shift (7 AM -3 PM) 2/16/25 Day shift (7 AM - 3 PM) 2/17/25 Evening shift (3 PM - 11 PM) 2/18/25 Day shift (7 AM - 3 PM) 2/28/25 Evening shift (3 PM - 11 PM) 3/1/25 Night shift (11 PM - 7 AM) 3/2/25 Evening shift (3 PM-11 PM) On 3/5/25 at 9:11 AM, during an interview with the surveyor, the Certified Nurse Aide (CNA #1) stated if she emptied the urinary drainage bag, she would measure the urine output and reported the amount to the nurse. She would also inform the nurse of any change in the urinary output. On 3/5/25 at 9:17 AM, during an interview with the surveyor, the Registered Nurse (RN) stated she would check the resident's urinary drainage bag at the beginning and at the end of her shift and measure the total output. The RN stated the CNA's were to empty the Foley catheter drainage and reported the amount to the nurses. The RN stated the nurses were responsible to record the urine output in the eTAR. The RN further stated if there was no urine output in the drainage bag then she would report it to the resident's Physician and the Unit Manager (UM) and document the changes in the progress notes. On 3/5/25 at 9:37 AM, during an interview with the surveyor, CNA #2 who worked the day shift stated she would report the urine output to the nurse at 2:00 PM before her shift ended. On 3/5/25 at 10:00 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager stated the urine output was recorded in the eTAR. The RN/UM explained the process. The CNA would empty the drainage bag, reported the output to the nurse, the nurse would document the amount in the eTAR. The RN/UM reviewed the eTAR with the surveyor and verified also the missing documentation. The RN/UM stated it was important to measure and record the urine output in the eTAR to ensure that the urinary catheter was patent and there was no infection. The RN/UM stated there were too many gaps in the eTAR, the staff needed to be educate to complete all their documentation in a timely manner. On 3/6/25 at 12:52 PM, the survey team met with the facility administrative staff, informed them of the above concerns and asked to provide any additional information on the next day. On 3/7/25 at 12:49 PM, during the exit conference, no additional information was provided. A review of the facility's Indwelling Catheter Justification and Removal undated policy included: It is the policy of the facility to ensure that the residents receive care and services to prevent the use of an indwelling catheter, unless clinically necessary and promotes urinary continence of its residents, in accordance with State and Federal Regulations. NJAC 8:39-19.4(a)5, 27.1(a)(b)

Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order and ensure oxygen equipment was stored properly. This deficient practice was identified for 1 of 1 resident (Resident #341) reviewed for respiratory care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/27/25 at 10:46 AM, the surveyor observed Resident #341 in their bed. The resident was receiving oxygen (O2) via nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower O2 levels). The oxygen concentrator was observed to be set at 4 liter per minutes (L/min). The surveyor observed a resident's wheelchair next to their bed with an O2 tank behind the wheelchair, connected to an undated NC which was wrapped around the handle of the O2 tank. The NC was not in any protective covering and was exposed to the environment. On 2/28/25 at 11:55 AM, the surveyor observed Resident #341 eating lunch in their room. The resident was receiving O2 at 3 L/min via NC, which was connected to the concentrator. The surveyor observed the wheelchair next to resident's bed with O2 tank behind the wheelchair and NC was connected. The NC was wrapped around the handle of the O2 tank and was not in any protective covering as on 2/27/25. On 2/28/25 at 12:28 PM, the surveyor reviewed the medical records of Resident #341 which revealed: A review of Resident #341's Admission Record (an admission summary) reflected that Resident #341 was admitted to the facility with diagnosis that included but were not limited to; Asthma (a condition in which your airways narrow and swell and may produce extra mucus), hypotension (low blood pressure) and muscle weakness. A review of the Annual Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, dated 2/13/25, revealed the resident had a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Further review of the MDS indicated that Resident #341 received O2 therapy continuously. The February 2025 Order Summary Report (OSR) revealed a Physician Order with an initial date of 2/7/25 for Oxygen inhalation (via NC at 2 L/min) every shift for Asthma. On 2/28/25 at 12:38 PM, during an interview with the surveyor, the Registered Nurse (RN) stated that she would make rounds in the beginning of her shift to make sure the resident was receiving O2 as per the physician' order. The RN further stated that she would date and store the NC in a plastic bag when the O2 was not being used to prevent infection. The RN informed the surveyor that Resident #341 was receiving O2 at 3 L/min. In the presence of the surveyor, the RN reviewed the physician order and verified that the resident was to have the Oxygen titrated at 2 liter per minute. The surveyor accompanied the RN to the resident's room and observed resident's O2 was titrated at 3 L/min. The RN changed the O2 to 2 L/min. The RN discarded the NC attached to the portable Oxygen Cylinder and stated, the nasal cannula should be dated and stored in a plastic bag. On 2/28/25 at 1:27 PM, during an interview with the surveyor, the RN/unit manager (UM) stated that her expectation was that the nurses would make rounds in the beginning of their shift, and ensure that the physician orders for oxygen delivery was being followed. On 3/6/25 at 12:52 PM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing and informed them of the above concerns. The Director of Nursing (DON) acknowledged that the NC should be placed in a bag to prevent infections. A review of the facility policy Oxygen Administration with a revised date of 6/23 included: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Under Procedure: 5.e Keep delivery devices covered in plastic bag when not in use. A review of the facility policy Physician Orders Policy with a revised date of 5/23 included under procedure: 4. A licensed nurse or professional shall provide the care and services for a resident based on a physician order, when indicated. On 3/7/25 at 12:49 PM, during the exit conference, no additional information was provided. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, record review and document review, it was determined that the facility failed to ensure that staff monitored, assessed and documented the care of a hemodialysis access site. This deficient practice was identified for 2 of 2 residents reviewed (Resident #2 and Unsampled Resident #1), and for 2 of 2 staff observed for dialysis access site care, and was evidenced by the following: On 2/27/25 at 1:26 PM, the surveyor observed Resident #2 in bed, and observed that Resident #2 had an Arterioventricular (AV) Fistula to the left arm (a procedure that connects an artery to a vein in preparation for dialysis). The resident's dominant language was Spanish and the resident was unable to communicate with the surveyor. At that time, a review of Resident #2's medical record revealed the following: The Admission Record revealed diagnoses which included, but were not limited to; End Stage Renal Disease (ESRD) and Hemodialysis (a treatment that requires a machine to cleans the blood of impurities when the kidneys do not work). The Annual Minimum Data Set (MDS ) assessment dated [DATE], revealed that the resident received a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS) and was moderately cognitively impaired. The March 2025, Physician Order (PO) Sheet revealed a PO with an original date of 03/21/24, to check for Bruit and Thrill every shift. The surveyor reviewed the resident's current care plan, last revised 2/06/24. The Care Plan had a Focus for Hemodialysis related to ESRD with an intervention to monitor the left forearm AV Fistula for signs and symptoms of bleeding, infections and drainage. The surveyor reviewed the Treatment Administration Record (TAR) and observed that staff initialed the TAR for all 3 shifts (7 AM-3PM, 3 PM-11PM and 11 PM-7AM) indicating that the left forearm AV-Fistula (dialysis access site) was checked by the nurse for Bruit (an audible sound) and Thrill (a vibration that indicated a good blood flow). On 2/28/25 at 11:16 AM, the surveyor reviewed the dialysis communication book for Resident #2 with the Licensed Practical Nurse (LPN #1). LPN #1 verified the dialysis schedule, and confirmed that Resident #2 had a dialysis access site on the left forearm. The communication form was signed by the nurse and reflected that the nurse checked for Bruit and Thrill, documented the vital signs and checked the patency of the AV Fistula site prior to dialysis. That same day at 11:30 AM, the surveyor escorted the nurse to the room, the nurse showed the dialysis access site to the surveyor and informed the surveyor that the dialysis center provided care for the AV Fistula, and she was not responsible for anything else besides documenting the vital signs, and to assess the resident for pain. On 3/05/25 at 9:30 AM, the surveyor interviewed LPN #1 regarding care of the dialysis access site. LPN #1 confirmed that she did not have to do anything prior to the resident leaving for dialysis. The nurse accompanied the surveyor to the resident's room and showed the AV Fistula to the surveyor, she again stated clearly that she does not have to check for anything. She informed the resident of the dialysis treatment, monitored and documented the vital signs on the communication form and stated that the dialysis center cared for the dialysis access site. On 3/05/25 at 10:05 AM, the surveyor interviewed LPN #2 on the high side of the Unit regarding the care of the dialysis access site. LPN #2 accompanied the surveyor to another resident's (Unsampled Resident #1) room who also had an AV Fistula site on the left forearm. LPN #2 stated that the dressing should have been removed four hours after the dialysis treatment. LPN #2, then stated, in the presence of the Facility Nurse Educator confirmed that she checked the vital signs, informed the resident of the dialysis treatment, and would also assess the resident for pain. LPN #2 was not aware that she had to check the dialysis access site for patency prior to dialysis. The surveyor reviewed the dialysis policy with LPN #2, who stated, that she had not been aware of the policy to monitor the dialysis access site for patency. The surveyor reviewed the facility provided orientation packet and the yearly competency evaluation provided by the nurse educator on 3/5/25 at 11:25 AM. There was no competencies or education related to the care of the dialysis access site. During an interview on 03/06/25 at 01:30 PM, the surveyor brought the above concerns to the attention of the Licensed Nursing Home Administrator and Director of Nursing. Both confirmed that since the surveyor brought the concern to the attention of the facility, nursing staff had been provided with in-service education on the care of the dialysis access site. On 03/07/25 at 11:00, during the exit conference held with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing, Regional Material Data Set Coordinator, and Regional Clinical Director. The LNHA confirmed that both nurses were not aware to check the dialysis access site. The policy titled, Dialysis Policy revised 07/23, reflected the following: It is the policy of this facility to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy indicated to monitor for patency of dialysis access site. NJAC 8:39- 27.1(a)

Based on observation, interview and record review it was determined that the facility failed to ensure a resident who required assistance with Activities of Daily Living (ADLs) had all necessary items maintained within reach of the resident. This deficient practice was identified for 1 of 1 resident (Resident #129) reviewed for accommodation of needs and was evidenced by the following: On 3/5/25 at 9:15 AM the resident was not available in their room, and at that time the surveyor reviewed the electronic medical record which revealed: a Progress Notes dated 3/4/25 timed 11:50 PM: Interdisciplinary Team Note. Note Text: Resident found on the floor at around 10:15 PM. According to the resident, the staff failed to place the bedside table within the resident's reach. While attempted to reach for the phone the resident fell on the floor, complaining of pain in their back. The resident was transferred to the Emergency Department for evaluation and returned to the facility on [DATE]. X- Ray (digital image ) and CT-Scan (Computer Aided Tomography) performed at the hospital were negative for fracture and intracranial bleeding (brain bleed). The Admission Record revealed Resident #129 was admitted to the facility with diagnoses which included, but were not limited to; Hemiplegia (paralysis that affects only one side of the body) and Hemiparesis (one sided muscle weakness) and ischemic cardiomyopathy. The Admission Minimum Data Set (MDS), an assessment tool used to manage care dated 12/11/24, reflected that Resident #129 had intact cognition as evidenced by a 15 out of 15 score on the Brief Interview for Mental status (BIMS). Resident #129 was dependent on staff for most activity of daily living which included mobility, transfer and toileting. The Comprehensive undated care plan provided by the facility on 3/7/25 at 12:30 PM, reflected a Focus for falls related to weakness and Cerebro-Vascular Accident (damage to the brain from interruption of its blood supply). The goal was for Resident #129 not to sustain serious injury through the review date. The interventions were to anticipate and meet needs, Be sure call light is within reach, and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance. On 03/06/25 at 8:51 AM, the surveyor observed the resident was in bed and the resident informed the surveyor that they fell , and had reported pain on the back area. When asked to elaborate regarding the fall, Resident #129 stated in the presence of the Assistant Director of Nursing, that prior to providing care the Certified Nurse Aide (CNA) moved the bedside table away, and that was where the resident's phone was, and the CNA did not move the bedside table back where it was originally located, next to the bed. Resident #129 stated then the nurse came to administer medications, and walked away before they could asked to move the bedside table close to the bed. The resident's phone was ringing and ringing, they attempted to reach for the phone, and could not reach it and they fell out of the bed. Resident #129 added that was not the first time that the phone had been placed of their reach and they could not answer the phone. The resident further stated, I cannot walk, I felt helpless because the bedside table was placed near the door with the phone, and I could not reach the phone. On 03/07/25 at 11:00, during the exit conference held with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Assistant Director of Nursing (ADON), Regional Material Data Set Coordinator, and Regional Clinical Director. The ADON confirmed that staff who provided care should move items back within reach of the residents and the ADON confirmed that was not the first time that items have been left out of reach of Resdient #129. NJAC 8:39-27.1(a)

Based on interview and document review it was determined that the facility failed to complete and transmit the required Material Data Set (MDS) assessment for 1 of 1 system selected MDS assessments reviewed and was evidenced by the following: On 3/4/25 at 10:05 AM, the surveyor reviewed the medical record for Resident #83. The MDS record revealed that the Resident was discharged on [DATE] and the MDS record was identified as 132 days overdue. On 03/04/25 at 10:51 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RN/MDS) regarding the MDS process when a resident was discharged . The RN/MDS stated the facility must complete a discharge MDS, and she stated it is usually completed immediately. The surveyor asked the RN/MDS to review Resident #83's MDS in the presence of the surveyor. The RN/MDS reviewed the MDS and stated, I must have missed this one and the surveyor requested a Validation report for Resident #83's MDS. On 03/05/25 at 8:31 AM , the Licensed Nursing Home Administrator provided a copy of the Final Validation Report, dated 3/4/25, which revealed. Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). NJAC 8:39- 11.1

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individual comprehensive care plan (ICCP) for a resident who received intravenous (IV) therapy and had an IV catheter. The deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for IV therapy and was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 sitting in a wheelchair in their room. The surveyor observed the resident's right hand with a short IV line (a tube that administers fluid or medication into veins) between the thumb and first finger. Resident #38 stated that they had received medication through an IV weeks ago. On 2/28/25 at 9:56 AM, the surveyor again observed the short IV line inserted in Resident #38's right hand. On 2/28/25 at 12:00 PM, the surveyor reviewed the electronic medical record (EMR). A review of the Admission Record (an admission summary) revealed Resident #38 had diagnoses which included, but were not limited to; pneumonia. A review of the admission Minimum Data Set (MDS) an assessment tool dated 2/7/25, included a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated intact cognition. A review of the Order Summary Report documented a physician order dated 2/10/25 for Sodium Chloride Solution 0.9% 80 milliliter (ml) per hour intravenously every shift for electrolyte imbalance for 3 days with an end date of 2/13/25. A review of the ICCP dated 2/1/25, including all resolved and canceled focus areas, failed to document the insertion and use of IV therapy including a focus area, goals, or interventions. On 3/4/25 at 9:00 AM, the Licensed Practical Nurse Unit Manager (LPN UM) reviewed the EMR and acknowledged there was no ICCP for the use of IV therapy. On 3/04/25 at 9:52 AM, the Director of Nursing (DON) stated that IV therapy should be in the care plan and when no longer in use, it would be marked as resolved. The DON further stated, I am educating the staff. A review of the facility provided policy, Comprehensive Care Plans revised 6/2023, included but was not limited to; to develop and implement a comprehensive person-centered care plan consistent with resident rights, includes measurable objectives and time frames to meet medical, nursing, and mental and psychosocial needs. The process will include an assessment of the resident's strengths and needs . The care plan will describe at a minimum . services to be furnished to attain or maintain the highest practicable physical well-being; any specialized services; specific interventions that reflect the needs and preferences of the resident; will include measurable objectives and timeframes . and interventions; and the staff responsible for carrying out interventions and the staff will be made aware when changes are made. NJAC 8:39-11.2(e)(i)

Based on observation, record review, interview, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while transferring one of six residents (Resident) 6 reviewed on EBP. Specifically, facility staff failed to don personal protective equipment (PPE) (gown and gloves) when transferring R6 from his/her bed to his wheelchair. Additionally, two Certified Nurse Aides (CNAs) and one Licensed Practical Nurse (LPN) did not follow hand washing protocol during the lunch meal services. Findings include: Review of R6's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R6 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease. Review of R6's Physicians Order, located in the EMR under the Orders tab, dated 03/29/24 revealed, .on Enhanced Barrier Precautions [EBP] . During an observation on 02/10/25 at 11:55 PM on the COVID unit, EBP signage was posted at the entrance of R6's room. During this time, CNA2 entered R6's room carrying a meal tray, placed the tray on his bedside table, and preceded to transfer R6 from his bed to his wheelchair. CNA2 was not wearing PPE during the transfer. During an observation on 02/10/25 at 12:22 PM on the COVID unit, CNA3 removed a dirty meal tray from the dining room, placed the dirty tray in a food cart, and proceeded to another resident room to provide care. CNA3 did not use alcohol-based hand rub (ABHR) in between rooms/residents. During this same observation, CNA1 removed a dirty meal tray from the dining room, placed the dirty tray on the food cart, returned to the dining room, and assisted residents in the dining room. CNA1 did not use ABHR or wash her hands between tasks. During an interview on 02/10/25 at 12:19 PM, CNA2 confirmed she did not follow proper donning (process of putting on protective gear to protect you from infection) while transferring R6. CNA 2 confirmed she should have worn a gown and gloves. During an interview on 02/10/25 at 12:41 PM, CNA1 confirmed she did not follow the proper hand hygiene protocol while handling dirty meal trays and should have used ABHR between residents/tasks. During an interview on 02/10/25 at 12:47 PM, Licensed Practical Nurse (LPN)1 revealed that she, along with CNA1 and CNA3, did not follow the proper hand hygiene protocol. LPN1 continued to share that staff should have sanitized their hands by using ABHR before returning to the dining room area and in between residents to prevent the spread of infections. During an interview on 02/10/25 at 12:56 PM, the facility Infection Preventionist (IP) revealed staff should wash or sanitize their hands with ABHR between each resident when providing care or removing dirty meal trays. The IP continued to share this is her expectation of her staff to follow proper PPE and hand hygiene protocols. During an interview on 02/10/25 at 1:03 PM, the Director of Nursing (DON) revealed all staff were expected and should know to don a gown and gloves before entering an EBP room to provide care. The DON continued to share staff should wash or sanitize their hands between each resident. Review of the facility's policy titled, Enhanced Barrier Precautions, revised date August 2024 revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention used to reduce transmission of multidrug-resistant organisms . EBP is an extension of standard precautions utilized for residents . all staff must wear gloves and gown during high contact activities for residents . transferring . Review of the facility policy titled, Hand Hygiene dated July 2023, revealed, . It is the policy of this facility to ensure that facility staff performs proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . N.J.A.C. 8:39-19.4(a)

Based on observations, interviews and review of documentation, the facility failed to consistently maintain a functional Heating, Ventilation and Air Condition Unit (HVAC) in good repair on 1 of 3 nursing units ( 3rd floor) in order to maintain a comfortable environment for its residents, staff, and visitors . This deficient practice was evident by the following: On 08/29/24, at 10:30 am., the surveyor conducted a tour of an empty 3rd floor unit with the Administrator (ADM) and Maintenance Director (MD). According to the ADM, a decision was made to utilize the 3rd floor unit to accommodate isolation for 11 Coronavirus (COVID-19) positive residents and 9 residents presumed exposed. The 11 COVID positive residents and 9 presumed exposed were housed on this unit from 8/27/2024 to 8/28/2024. During the tour, the ADM stated that 3rd floor unit had been closed for over one year and the air conditioning units were not working. The decision was made to transfer the COVID positive residents to this floor on 8/27/2024. The MD stated that the 3rd floor was not on his daily maintenance rounds inspections. The surveyor observed there were no residents on the floor during the tour. The thermostat on the wall indicated 74 degrees Fahrenheit (F). The air conditioners in residents' rooms were still not functioning. According to the MD, prior to the transfer of residents from the other floors on 8/27/2024, he took a temperature on the 3rd floor unit at 2 PM ,which indicated 76 degrees Fahrenheit (F). (Normal temperature ranges is from 71 F-81 F degree). According to the Environmental Temperature Log (ETL) for the 3rd floor on 8/28/2024, the temperatures at 11 AM was documented at 76 degrees F and at 2 PM the temperature was documented at 78 degrees F. There were no specific locations correlated to each temperature taken on the ETL. The surveyor was also provided a copy of the Administrator's ETL for the 3rd floor. The ETL for the 3rd floor on 8/27/2024 at 2 PM and 5 PM temperatures were both documented at 76 degrees. On 8/28/2024, the following temperatures were documented : 11 AM 76 degrees F; 2 PM 78 degrees F and at 5 PM 79 degrees F. There were no specific locations correlated to each temperature taken on the ETL. Also, the Surveyor confirmed with the Administrator that there were no more temperatures taken after 5 PM on 8/27/24 and 8/28/2024 on the 3rd floor. On 8/28/2024, the MD was told by the Administrator that residents were complaining of being warm, so he deployed an additional 3 portable air conditioners and electric fans to residents' rooms and placed a Commercial electric fan in the hallway. On 08/29/24 at 12:15 PM, the Surveyor interviewed Resident #2 who stated, that he/she was placed on the 3rd floor and confirmed that the room air conditioner was not working and was proved a fan, but the room was still hot. The resident couldn't provide the surveyor with a time or date regarding the temperature. On 08/29/24 at 3:19 PM, the surveyor interviewed Resident #3's daughter who stated, air conditioner was not working in Resident #3 room, but an electric fan was provided. NJAC 8:39-31.2(e)

Based on observation, interview, review of the medical records and other facility documentation, it was determined that the attending physician failed to document a discharge summary which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for 3 of 3 closed record's reviewed for discharge to community, expiration, and discharge to the hospital (Resident #128, #129, and #130). This deficient practice was evidenced by the following: 1. On [DATE] at 11:40 AM, the surveyor reviewed the closed medical record for Resident #130. The closed record revealed that the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the Minimum Data Set (MDS) Coordinator. 2. On [DATE] at 11:48 AM, the surveyor reviewed the closed medical record for Resident #129. The closed record revealed that the resident was admitted to the facility on [DATE] and had expired in the facility on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the MDS Coordinator. 3. On [DATE] at 12:01 PM, the surveyor reviewed the closed medical record for Resident #128. The closed record revealed that the resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the MDS Coordinator. On [DATE] at 1:24 PM, the surveyor conducted an interview with the Licensed Nursing Home Administrator (LNHA), who stated that the medical section of the discharge summary should be filled out by the doctor but could not explain why that section had been completed by the MDS Coordinator. On [DATE] at 1:32 PM, the surveyor interviewed the MDS Coordinator who has been working in this facility role for three years. The MDS Coordinator stated, they were told to fill out the medical section of the discharge summary by the Director of Nursing (DON). The MDS Coordinator added that they have not been in communication with the physician but only reading the physician's notes when filling out the medical section of the discharge summary. The MDS Coordinator stated that they were not aware that the physician was supposed to complete the medical section of the discharge summary. On [DATE] at 1:54 PM, the surveyor interviewed the DON, who stated that the previous Assistant Director of Nursing (ADON) filled out the Medical section of the discharge summary, but had recently asked the MDS Coordinator to complete the medical section of the discharge summary. The DON stated that she was not aware that the physician was responsible for filling out the medical section of the discharge summary. On [DATE] at 1:00 PM, the LNHA provided the surveyor with a policy titled, Policy/Procedure - Discharge Summary, dated, reviewed and signed by the LNHA on [DATE]. Under the Intent section, the policy states, It is the policy of the facility to assure that a discharge summary is completed in accordance to the State and Federal requirements. The Procedure section, states: 2. When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status to include items in paragraph (b) (1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). N.J.A.C. 8:,d+[DATE].2(d)(16)

Complaint#: NJ 4 Based on interviews, medical records review, and review of other pertinent facility documentation on 8/9/2022, 8/15/2022, and 8/18/2022, it was determined that the facility failed to ensure a resident (Resident #2) with a known diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/1/2022, Resident #2 exhibited behaviors and was non-compliant with keeping his/her safety helmet on and sitting in the wheelchair on the 3:00 p.m. to 11:00 p.m. shift. Since Resident #2 was non-compliant, the Certified Nursing Assistant (CNA #1), who was assigned to Resident #2 until 9:00 p.m., requested CNA #2 to assist her in moving the long table in the dining/recreation room towards the wall. CNA #1 then placed Resident #2 in the Resident's wheelchair behind the table and against the wall for safety and to prevent the Resident from falling. CNA #1 left Resident #2 alone and restrained in the wheelchair from approximately 8:00 p.m to 10:00 p.m. Resident #2 was able to retrieve his/her cell phone from the pocket and called 911. The Police Officers responded to the 911 call at approximately 9:55 p.m. They found Resident #2 sitting in the Resident's wheelchair in a dark room and restrained against the wall with a long table to the front of the Resident, three small tables to the front of the long table, and three chairs to the left side, and three chairs to the right side of Resident #2. The Police Officers called the Emergency Medical Services (EMS), and Resident #2 was transferred to the hospital for further evaluation and did not return to the facility. In addition, the facility failed to follow its policies titled Restraints/Siderail-Bed Systems and Resident's Rights. The facility's failure to prevent a physical restraint placed Resident #2 and all other residents experiencing behavioral changes, at risk for falls or required 1:1 Supervision as needed at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant, Director of Nursing (ADON) on 8/15/2022 at 3:45 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 8/1/2022 and continued through 8/15/2022 when CNA #1 was taken off duty pending the completion of the investigation. On 8/18/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included removing CNA #1 from the schedule, and educating all facility staff on not using furniture as a restraint to prevent residents who are at risk for falls and require Supervision. This deficient practice was identified for 1 of 5 residents (Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents dated 8/2/2022, with an event date of 8/1/2022 and a time of event of 10:00 p.m., revealed the following: On 8/1/2022, at approximately 9:55 p.m., the Police Department (PD) entered the facility following a 911 call from someone on the 2nd floor. All staff was unaware of the 911 call made, the PD went to the 2nd floor, but no resident was there, so they proceeded to the 6th floor, where they encountered Resident #2 in the dining/day room. The PD questioned the nursing staff about the tables and chairs surrounding the Resident. The charge nurse began moving a table and was ordered to stop. The PD videotaped the Resident with a cell phone and body cameras. The PD transported Resident #2 to the hospital and arrested CNA #2. Further review of the FRE indicated CNA #2 was suspended pending the outcome of the investigation. Further review of the FRE included a written statement by CNA #1, dated 8/2/2022. According to the statement, Resident #2 was more aggressive and wanted to leave the facility. He/she threw his/her helmet on the big table and said he/she was done with his/her job, and he/she needed to call his/her boss because it was time for him/her to leave. The CNA also wrote that Resident #2 called Uber 4 times because he/she wanted to go to the Pharmacy to pick up medications. CNA #1 explained, I had to sit with Resident #2; the Resident was strong and could push and move the long table away from him/her. There were two chairs on both sides of the Resident. CNA #1 wrote before she sat with Resident #2, other residents were in the room, and they occupied the chairs next to the Resident, and she used one of the chairs to sit next to the Resident when the other residents were brought to bed. She further wrote, When I left work at 9:45 p.m., there was only one long table in front of (Resident #2), and (the Resident) was able to stand from his/her position and freely move his/her upper extremities. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 07/25/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs). A review of the Resident's Care Plan (CP) initiated on 7/20/2022 revealed under Focus: that Resident #2 is at risk for falls r/t (related to) unsteady gait. The CP also included under Goal: Resident will not sustain (a) serious injury through the review date. Also, under Interventions: included, Anticipate and meet needs .Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . Further review of Resident #2's CP initiated 08/01/2022, included under Focus: Resident #2 has (a) high risk for injury r/t noncompliance to wear helmet and disregard to safety. The CP showed under Goal: Resident #2 will show decreased episodes of noncompliance and disregard to safety precautions. The CP also showed under Interventions: . 1:1 intervention as needed, encourage to participate in activities for diversion and maintain close supervision. A review of Resident #2's Progress Notes (PNs) revealed the following: On 7/31/2022 at 6:10 a.m., the PN written by the Registered Nurse (RN #1) revealed Resident #2 on and off standing up without regard of safety, without wearing his/her helmet. The PN also revealed that redirections were provided, but Resident #2 could not follow the directions due to cognitive issues. Further review of the PN showed that the Patient [Resident] is alert x 2 (to self and place) with confusion. VS (vital signs), WNR (within normal range), SPo2 (blood oxygen level), 99% (percent) in room air. Closely supervised. Safety is maintained with the bed in the lowest position. Not in distress. With call bell at reach. On 7/31/2022 at 2:25 p.m., the PN written by the Unit Manager/Licensed Practice Nurse (UM/LPN) revealed Resident #2 was alert with period of confusion, maintained good PO (by mouth) intake. Assisted as needed. Non-compliant with helmet, keep removing the helmet, redirected, safety maintained, endorse to next shift. The PN further showed Resident #2 was educated on safety measures, diet regimen, helmet on when OOB (out of bed), wearing a mask, social distancing, and using the call bell for assistance. Further review of the PN showed the Resident had right, parietal, and temporal region craniotomy with staples, and no s/sx (signs/symptoms) of infection noted. The helmet was to be worn when out of bed . On 7/31/2022 at 3:34 p.m., the PN written by the UM/LPN showed that Resident #2 noted confused today, calling multiple times to let him/her out of the building. Redirected him/her with no positive effect. According to the PN, Resident #2 used his/her cell phone and called the police to inform them that he/she was in the hospital, was being held hostage, and did not receive breakfast. Further review of the PN showed Resident #2 was kept safe at all times, with one-on-one Supervision maintained due to the Resident continuously removing his/her protective helmet and attempting to stand up without regard to safety. On 7/31/2022 at 10:26 p.m., the PN written by RN #1 showed Resident #2 wasin bed awake, alert x 2 with confusion and no discomfort noted. Breathing pattern easy and unlabored in room air. Patient [Resident] kept standing up without wearing his/her helmet; health education provided . advantages/ disadvantages of wearing helmet, [Resident] verbalized understanding, but he/she is non-compliant. Closely monitored and frequently redirected . Closely monitored for safety. With call bell in reach. On 8/1/2022 at 6:16 a.m., the PN written by the RN showed Resident #2 was in bed awake, alert x 2 with confusion, no discomfort noted. Breathing pattern easy and unlabored on room air. Closely monitored and frequently redirected re (regards to ) wearing of helmet. All needs attended. Safety was maintained with the bed in the lowest position, with the call bell in reach. On 8/1/2022 at 2:53 p.m., the PN written by the Licensed Practice Nurse (LPN) revealed Resident #2 back from neurosurgeon appt (appointment), order CAT (computed tomography) scan of head w/o (without) contrast to be done . non-compliant w/(with) helmet, kept removing his/her helmet, redirected. Educated on safety measures, diet regiment, helmet on when OOB (out of bed), wearing a mask, social distancing, using the call bell for assistance, .Right parietal, temporal region craniotomy, staples removed today by the neurosurgeon. A review of the facility's Assignment Sheet for 8/1/2022, on the 3:00 p.m. - 11:00 p.m. shift revealed that two CNAs were assigned on the 6th floor, CNA #1 and CNA #2, and Resident #2 was assigned to CNA #1. During an interview on 8/9/2022 at 12:04 p.m., the UM/LPN stated when Resident #2 arrived, .he/she had a craniotomy, was alert and oriented x 3 and always carried his/her cell phone. She continued to say, I think on 7/31/2022, he/she was becoming more confused, the resident called the police, he/she didn't want to wear his/her helmet, he/she wanted to go and sell a company, a lady had to give him/her the money. Since he/she was confused, I had the CNA stay with him/her at all times in the activity room. I think the aide was CNA #1. In the same interview, the UM/LPN stated CNA #1 sat in a chair to watch Resident #2 in the activity room while the Resident sat in the wheelchair. The Resident called the police and said he/she was in the hospital; the Resident would not let me touch the phone. I gave the police the room number, and the police came. She stated, residents are never left alone in the day room. Usually, an aide or recreation is in there. During a telephone interview on 8/9/2022 at 12:35 p.m., in the Administrator's presence, CNA #2 stated that Resident #2 was not on her assignment. She said that she was not familiar with the Resident and was unaware of when CNA #1 left the floor as she was giving patient care at the time. CNA #2 continued to say the police arrived on the floor and questioned her as to why Resident #2 was in the dining room, and she replied that the Resident was a fall risk, and then the police arrested her. In the same interview, CNA #2 stated Resident #2 had a table in front and chairs on both sides of him/her and nothing else around the resident. During a telephone interview on 8/9/2022 at 1:50 p.m., CNA #1 stated that on 8/1/2022, Resident #2 was on her assignment, and she agreed to work until 9:00 p.m. because the facility was short-staffed. CNA #1 stated, in the evening, around 6:00 p.m.-7:00 p.m., Resident #2 became verbally and physically aggressive and wanted to go to a Pharmacy to get a package. She explained Resident #2 tried to go to the elevator, tried to hit me, and kept saying I'm at work and wanted to leave the job site, go home and get a package . Resident #2 kept getting out of the chair, throwing his/her helmet off, kept standing up, (and) trying to walk . to get a taxi to go home to get the package. CNA #1 stated that she would walk with Resident #2 and redirect the Resident to the wheelchair. She said, I got help from the Nurse and the aide to put him/her back in the wheelchair, then he/she would jump up out of the wheelchair after a half a minute, he/she was very combative. In the same telephone interview, CNA #1 stated, it was time for me to go home around 9:40 p.m.-9:45 p.m., so the other aide helped me place him/her behind the long table in the dining room, and there was a chair to the left and a chair to the right of the Resident, where I sat until I left. There was nothing in front of the table. She further stated I told CNA #2 I was going and left Resident #2 in the dining room with the chair next to him/her for safety. Resident #2 was placed there for safety with his/her cell phone in his/her pocket and he/she was able to stand up with the table in front of him/her. CNA #1 also stated, I was not aware that putting a resident behind a table was [considered] a restraint or abuse. However, the Surveyor reviewed the Time Card Report for CNA #1 dated 8/1/2022 and revealed CNA #1 clocked out of work on 8/1/2022 at 8:00 p.m., indicating she did not work until 10:00 p.m. but until 8:00 p.m. During a telephone interview on 8/9/2022 at 2:51 p.m., Police Officer (PO #1), who responded to Resident #2's 911 call on 8/1/2022, stated the following: We received a call around 10:00 p.m. from someone saying he/she was being held captive in the dining room; we opened the door to the dining room, located a person in a wheelchair against the wall with a large conference room table in front of the person over his/her knees, with 3 other tables in front of the large table with 3 chairs to the left and 3 chairs to the right of him/her. During a second telephone interview on 8/9/2022 at 3:20 p.m., CNA #2 stated CNA #1 asked me to help her move the table from against the wall because she wanted to leave to go home. CNA #2 continued to say that she did not see CNA #1 put Resident #2 behind the table, and the next time she saw the Resident was when the police came to the dining room. During an interview on 8/9/2022 at 4:07 p.m., RN #2 stated, after dinner, Resident #2 was agitated and called an Uber from his/her cell phone. The Resident was ambulating on the unit without the helmet and trying to get on the elevator while CNA #1 was watching him/her. She continued to say the last time she saw Resident #2 was when she administered the Resident his/her 9:00 p.m. medications. The RN said Resident #2 was in his/her wheelchair in the hallway by the Nurse's station when she administered the Resident the medications. She continued to say, I knew the Resident was there for awhile. Honestly, I don't know how long, The RN stated the next time she saw Resident #2 was when the police approached her to ask her about the Resident. According to the RN, Resident #2 was in the day room in his/her wheelchair, and the wheelchair was against the wall with his/her back against the wall, a long table in front of him/her, 3 chairs on each side of the resident, and 3 small tables, 2 circulars and 1 table in front of the long table. In the same interview, when the Surveyor asked the RN if Resident #2 was able to move the long table, she stated, it would take a lot of strength to move it, and the problem was the 3 tables in front of the long table. RN #2 continued saying, I think that it was a restraint. During an interview on 8/9/2022 at 4:42 p.m., in the presence of the Administrator, the Surveyor asked when the tables were in front of Resident #2, and the chairs were placed to the left and right side of the Resident were restraints. The ADON stated, of course, it was considered a restraint with tables and chairs around the resident because he/she could not walk. During a second interview on 8/15/2022 at 9:45 a.m., CNA #1 stated she was getting ready to leave to go home on 8/1/2022, so at 9:30 p.m., she and CNA #2 placed Resident #2, who was in his/her wheelchair behind the long table in the day room to prevent the Resident from falling. During an interview on 8/15/2022 at 10:35 a.m. in the presence of the Director of Nursing (DON), the ADON stated when CNA #1 left at 9:45 p.m., Resident #2 should not have been left alone in the day room, and it is not common practice for residents to be placed behind a table. During the same interview at 10:35 a.m., the DON stated, until the whole investigation was done, staff should not be in the building .a restraint is considered an allegation of abuse. During an interview on 8/15/2022 at 12:47 p.m., the Staffing Coordinator (SC), when the Surveyor showed her the Time Card Report (TCR) for CNA #1, she stated the clocking out process is done when the person is leaving the building for their shift; staff are paid for the shift they worked, no extras. The SC continued to say that the time clock is correct. According to the SC, she asked CNA #1 to work until 9:00 p.m. on 8/1/2022, and she did not know what happened after that time; the CNA did not say she couldn't work. I believe she left at 8:00 p.m. During a second interview on 8/15/2022 at 1:02 p.m., when the Surveyor asked CNA #1 about her TCR showing a clock out time of 8:00 p.m. on 8/1/2022, CNA #1 stated, I didn't clock out, and I left the floor at 9:30 p.m. However, no documentation was provided at the time of the survey indicating CNA #1 left at 9:30 p.m. During an interview on 8/18/2022 at 10:35 a.m., the DON stated, a one to one Supervision was done for his/her behavior episode, I don't know the patient [Resident #2], the CNA should notify the Nurse or aide if Resident is on one on one, closely monitoring means putting a resident in the dining room and an aide is with the Resident. During a telephone interview on 8/18/2022 at 4:40 p.m., PO #2 stated on 8/1/2022, he responded to a call about a male/female being held against his/her will. The PO explained they located the person on the 6th floor. He observed the lights were off in the cafeteria and the Resident was sitting in the wheelchair pushed up against the wall. PO #2 further stated a large table was pushed into Resident #2's stomach holding the Resident in place. He said there were round and square tables around the Resident to secure him/her and 3 chairs to the left and 3 chairs to the right. On 8/18/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included removing CNA #1 from the schedule, and educating all facility staff on not using furniture as a restraint to prevent residents who are at risk for falls and require Supervision. So, the noncompliance remained on 08/15/2022 as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: Resident #2 was taken to the hospital for evaluation and is no longer at the facility. A review of the facility policy titled Restraints/Siderail-Bed Systems dated 4/29/2022 revealed the following: Under Philosophy: included This Facility will promote and encourage a restraint free environment for all residents. Our goal is to achieve and maintain the optimum independence and dignity of our residents while providing a safe and secure environment, but also to deliver the highest quality care that promotes quality of life and independence. Policy: To reach this goal, this facility believes that an interdisciplinary approach provides the best assessment of resident needs. Physical restraints will only be utilized after less restrictive alternatives have been attempted and considered a last resort .At no time will a restraint be utilized for staff convenience or Resident discipline. Definitions: .Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's body .Convenience is defined as any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interests. A review of the updated facility policy titled Resident's Rights, revealed the following: I. Each Resident shall be entitled to the following rights: .6. To be free from chemical and physical restraints, unless they are authorized by a physician or an advanced practice nurse for a limited period of time to protect the Resident or others from injury. Under no circumstances shall the Resident be confined in a locked room or restrained for punishment, for the convenience of the nursing home staff . N.J.A.C.: 8.39- 4.1 (6)