Every finding on record at Palace Rehabilitation and Care Center, The

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to maintain kitchen and equipment areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA) During the kitchen tour the surveyor observed the following: 1.The surveyor took a white paper town to wipe down the white plastic ice guard in the ice machine which guided the ice into the large bin. When the surveyor looked at the paper towel it was left with red and brown substance. When the surveyor visualized the white plastic guard in the ice machine, the red and brown substance was noted on the white guard. The surveyor reviewed the ice machine cleaning log which showed the ice machine was cleaned weekly and the last cleaning was 2/9/26. The surveyor asked the RLNHA if weekly cleaning was sufficient based on what was seen and he stated, No. 2.A large bin of rice with the scoop laying inside of the rice (large clear scoop with attached handle). The surveyor asked the FSD if the scoop should be stored within the product and the FSD stated no. 3.The lid of a large flour bin had a large amount of black and brown substance smeared on the top. The surveyor asked the RLNHA if the container appeared clean and he stated no. 4.A seven pound can of cranberry sauce with a large dent in dry storage area. 5. A can opener blade, when lifted from the hold, had a large amount of black debris. 6.During tray line temperature checks, the surveyor observed, in the water of the steam table, a large amount of rectangular shaped pasta and yellow brown sediment on the bottom of the water holder and floating in the water. Pasta was not being served on the day of observation. The FSD immediately said We have to empty that. A policy regarding kitchen cleanliness was not provided by the FSD when requested. NJAC 8:39-17.2 (g)

Based on observation and interview it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of debris and failed to cover 2 of the 4 dumpsters. This was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA). During the kitchen tour, the surveyor, in the presence of the FSD and the RLNHA, observed four outside dumpsters located behind the kitchen. Two of the four dumpsters had open lids. Surrounding the front of the four dumpsters were multiple cardboard boxes on the ground. To the right of the dumpsters there was a fence with a grassy area extending down the back of the building. The surveyor observed multiple debris including papers and paper cups scattered on the ground. The surveyor interviewed both the RLNHA and the FSD who told the surveyor it was both the dietary staff and the housekeeping staff who were responsible for ensuring the area was kept clean. No policy regarding the outside dumpster area was provided to the surveyor. NJAC 8:39-19.7 (b), 31.5 (a)

Based on interview and review of facility documentation, it was determined that the facility failed to provide immediate access to records and requested information necessary to conduct the survey.The deficient practice was evidenced by the following: On 2/17/26 at 10:10 AM, during the entrance conference, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), the Regional LNHA, and the Regional DON, was informed that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification on 10/29/24. Also at that time, the Survey Team Coordinator requested the LNHA to complete the AAS-11 (Daily Nursing Staff Report used to track actual hours worked by shift) and AAS-12 (Facility Census and Care Evaluation used to track resident acuity and specialized clinical needs) for the facility staffing and return them via email by 2/18/26.1.) On 2/19/26 at 1:15 PM, the survey team started reviewing the personnel portion of the employee files but there was no evidence of the medical files. At that time, the Director of Social Services (DSS) stated that the Infection Preventionist (IP) kept the health files and confirmed the survey team only received the personnel portion of the employee files. On 2/20/26 the survey team reviewed the 55 employee personnel files and medical files. On 2/20/26 at 1:16 PM, the survey team reviewed the employee files with the LNHA and the DON which revealed that there were new hire records missing reference checks, background checks, license verification, and had incomplete health physicals. 2.) On 2/18/26 at 4:32 PM, the survey team received the AAS-11 and AAS-12 forms via email. A review of the AAS-11 and AAS-12 forms completed by the Staffing Coordinator (SC), and signed by the DON, revealed inconsistent numbers on the forms. The Survey Team Coordinator returned the forms to the LNHA for correction. On 2/19/26 at 2:23 PM, the LNHA returned the forms with corrections that still contained data-entry errors. On 2/19/26 at 4:11 PM, the SC emailed the forms with corrections that again contained inconsistent numbers on the forms. On 2/20/26 at 9:20 AM, the surveyor met with the LNHA, the DON, and the SC to identify continued findings of inconsistent data entry. The SC appeared to correct the data on her computer in the presence of the surveyor and emailed the final forms at 11:36 AM, which were determined to be inaccurate again. On 2/20/26 at 11:36 AM, the SC returned the forms, and the DON signed the forms, but the daily census was missing on the forms. On 2/20/26 at 1:20 PM, the LNHA sent the forms to the survey team for the last time for Department of Health review. On 2/24/26 at 10:20 AM, the surveyor interviewed the LNHA who stated she was responsible for everything and the overall function of the facility. A review of the Administrator's Job Description, included, the primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities.6. Represent the facility in dealings with outside agencies .9. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed.10. Delegate a responsible staff member to act in your behalf when absent from facility. Personnel Function 8. Assure that appropriate documentation is filed in the employee's personnel record in accordance with current regulations. N.J.A.C. 8:39-9.2(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI).This deficient practice was identified for 11 of 11 residents (Resident #1, #8, #55, #65, #73, #108, #110, #142, #156, #159 and #171) reviewed for PNA and was evidenced by: On 2/17/26 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of 2/17/26. A review of the facility's PNA Quarterly Statement from 10/1/25 to 12/31/25 revealed 11 residents had balances that ranged from $1877.71 to $2316.28. A review of the facility's Trial Balance as of 2/17/25 revealed the 11 residents still had pending balances that ranged from $1,800.25 to $1,800.71. On 2/18/26 at 10:44 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that the PNA statements were provided quarterly to the residents and/or resident's representatives who were also provided ways to spend down the balances. She further stated the PNA Quarterly Statements included the name of the resident or representative who received the statement. At that time, the surveyor requested all the documentation that the DSS stated she did for the 11 residents. On 2/18/26 at 11:16 AM, the DSS provided emails and other pertinent facility documents that included clothing purchases from October 2025 and prepaid funeral arrangements from 2022 and 2023. A further review of the email dated 1/27/26, for Resident #65, reflected the Office of Public Guardianship (OPG) reached out and requested the PNA balance to be spent down for Medicaid purposes. On 2/19/26 at 10:48 AM, during a follow up interview, the DSS explained ways the facility spent down PNA balances such as buying clothing or prepaying funeral arrangements. She further stated she discussed with the residents and/or the representative on ways to spend down their PNA balances. When asked if a written notification was provided when the PNA balances were approaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI, the DSS stated that she did not document it in the resident's chart, but she went over the statements quarterly and if the balance was approaching $2000.00, then she purchased items to spend down the balance. On 2/19/26 at 1:18 PM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (LNHA) who stated that the DSS would sit with the residents to spend down their PNA balance. He further stated he was unsure if there was a written notification but would look. There was no evidence of a written notification when approaching the limit that could jeopardize the 11 residents' eligibility for Medicaid or SSI prior to surveyor inquiry. On 2/20/26 at 9:38 AM, the DSS stated in the presence of the Regional LNHA and the survey team that they reviewed the regulations and that they ensured the residents were not going over the $2000.00 maximum for Medicaid. At that time, the Regional LNHA acknowledged that they should have provided a written notification of approaching the limit. When ask was there was a specific amount at which the resident should be notified, the Regional LNHA stated they did not have a specific amount but that if it was approaching $2000.00, there should be a written notification. The DSS stated after surveyor inquiry she reached out to each resident and the OPG of their PNA balance and the need for it to be spent down. On 2/20/26 at 9:48 AM, the surveyor interviewed the LNHA who stated the DSS notified the families on how to spend the PNA balance down when they were nearing $2,000.00. The LNHA stated it was important to inform the residents they were approaching $2000.00 because they could be cut from Medicaid. A review of the facility's Personal Needs Allowance policy, revised July 2025, did not include a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI. A review of the regulations the facility provided NJ Admin Code 10: 166-1.16 - Utilization of resident's income for cost of care in the Nursing Facility (NF) and for PNA, included: 1. If the NF is handling the PNA, the facility shall closely monitor the PNA account and inform the beneficiary and/or his or her representative when the amount comes within $200.00 of the resource eligibility cap. NJAC 8:39-9.5

Based on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 2/18/26 at 10:30 AM, five of five alert and oriented residents (#32, #40, #86, #89, and #104), said they were not aware of the location of the State Survey results, that the facility had not spoken to them about the results, and that they were interested in reading the reports. On 2/19/26 at 11:55 AM, the surveyor toured the A-Wing Unit to locate the State Survey results, but the State Survey Book was not readily accessible. When the surveyor asked Unit Manager/Registered Nurse (UM/RN #2 and other floor staff where the State Survey results could be found, they had difficulty locating the State Survey Book. When found, the surveyor reviewed the State Survey book, but the most recent survey results were not current and were dated 6/5/23. On 2/19/26 at 12:04 PM, the surveyor toured the B-Wing Unit, but the State Survey Book was not readily accessible. When located by UM/RN #1, the surveyor reviewed the survey book and found the most recent survey results were not current and were dated 6/5/23. On 2/19/26 at 12:12 PM, the surveyor toured the C-Wing Unit. The UM/LPN #1 and her staff were unable to locate the State Survey book. During the survey, there were no signs posted to direct the residents to the location of the State Survey results. In addition, the State Survey results book in the front lobby was not readily accessible to residents due to the locked door that required a four-digit code to enter between the lobby and residents' units. During an interview with the surveyor on 2/24/26 at 11:27 AM, the LNHA was informed that the State Survey results were behind the nurse's station and not readily accessible by the residents without having to ask staff. The surveyor also explained that only two (2) out of the three (3) units had Survey Result Books and that they were not current. The facility provided a policy, Resident Rights, with a revision date of July 2025, that included the statement, Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the residents' right to: F. Examine survey results. NJAC 8:39-9.4(b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe and homelike environment by providing adequate lighting. This deficient practice was identified on 1 of 3 nursing units (C-Wing) toured and was evidenced by the following: On 2/17/26 at 10:51 AM, on initial tour of the facility, the surveyor entered room [ROOM NUMBER], located on the C Wing. The surveyor observed Resident #87 sitting on the side of the bed and the resident told the surveyor that the bathroom light did not work. The surveyor entered the bathroom and there was no cover on a ceiling light. When the surveyor turned the light switch on, the light did not turn on. The resident was in a semiprivate room, and both residents used the bathroom independently. Resident #87 utilized a rolling walker to ambulate. The resident told the surveyor that maintenance was aware of the problem and had not fixed it yet. The surveyor asked how long the light did not work and the resident stated, Maybe two weeks. On 2/18/26 at 11:10 AM, the surveyor observed the Resident #87 in bed in his/her room. The resident told the surveyor that the light was not fixed, and It's pretty hard going to the bathroom at night. On 2/18/26 at 11:15 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 regarding the maintenance process. She told the surveyor there was a maintenance log that the staff write in and maintenance checked the log, I think every day, but don't quote me. The surveyor then interviewed Unit Manager/Licensed Practical Nurse (UM/LPN) #1 regarding the process for repairs from maintenance. She told the surveyor there was a logbook any staff could write in any issue, and maintenance checked the book daily and they also communicated through an app on the phone if they needed them right away. On 2/18/26 at 11:28 AM, the surveyor reviewed the maintenance book. On 2/9/26 there was an entry for room [ROOM NUMBER], Resident #87's room number. It was documented as bathroom light out. The column in the book where maintenance would sign when the issue was repaired was blank. On 2/18/2026 at 12:48 PM, the surveyor interviewed the Maintenance Technician (MT) regarding the process for repairs in residents' rooms. The MT stated every unit had a book they wrote in their issues, and he checked the book in the morning. When the repairs were done, he then signed the book. He told the surveyor he checked the book three (3) more times each day. The surveyor asked about the 2/9/26 request for the bathroom light to be fixed and he stated the facility was waiting on an order. The surveyor asked what the plan was until the order arrived as the resident was in the dark at night and he stated the plan was to get another light in the meantime. The surveyor explained it had been nine (9) days since the light stopped working, and the MT had no response. The surveyor requested to see the order for the new light, but the MT did not provide one to the surveyor. On 2/20/26 at 10:56 AM, the surveyor requested a policy for homelike environment from the Licensed Nursing Home Administrator (LNHA). The LNHA stated the facility did not have one. On 2/24/26 at 11:00 AM, the surveyor asked the Regional LNHA for a copy of the invoice for the light ordered on 2/9/26, but the facility was unable to provide one. NJAC 8:39-31.2 (e)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation and failed to implement policies and procedures related to pre-employment screening. Specifically, the facility did not complete required license verifications, reference checks, or criminal background checks prior to the start of employment. This deficient practice was identified in 10 of 55 employee files reviewed (Employees #1 through #10). The deficient practice was evidenced by the following:On 2/17/2026 10:10 AM, the surveyor requested that the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional DON and the Regional LNHA provide personnel files for all employees hired since the last annual recertification survey 10/29/24, regardless of current employment status. The requested documentation included the department of hire, date of hire, license verification, reference checks, criminal background checks, and pre-employment medical documentation, including physical examinations and two-step Mantoux test results.On 2/20/26 at 9:15 AM, the surveyors began reviewing the personnel files of 55 newly hired employees. Of the personnel files reviewed, there was no evidence that license verifications, reference checks, or criminal background checks were completed prior to the start of employment for 10 of the employee files. The review of the personnel files of all newly hired employees revealed the following: Employee # 1, a Certified Nursing Assistant (CNA) with date of hire (DOH) of 11/3/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 2, a CNA with DOH 9/8/25. There was no evidence that a reference check or a certification verification was completed prior to the start of employment.Employee # 3, a CNA with DOH 11/24/24. There was no evidence that a reference check was completed prior to the start of employment.Employee # 4, a Registered Nurse (RN) with DOH 8/11/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 5, a LNHA with DOH 6/1/25. There was no evidence that a license verification was completed prior to the start of employment.Employee # 6, a CNA with DOH 10/20/25. There was no evidence that a certification verification was completed prior to the start of employment.Employee # 7, an RN with DOH 10/6/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 8, a CNA with DOH 3/24/25. There was no evidence that a reference check was completed prior to the start of employment.Employee # 9, a Smoke Aide with DOH 1/25/25. There was no evidence that a background check was completed prior to the start of employment.Employee # 10, a Housekeeper with DOH 1/7/25. There was no evidence that a background check was completed prior to the start of employment. On 2/20/26 at 1:00 PM, the surveyor interviewed the Director of Human Resources (DHR) in the presence of the DON and LNHA, who stated she had been employed for one (1) week and was still in training. The LNHA stated that the onboarding process included a completion of an employment application and verification of references, vaccination records, applicable licenses, and a criminal background check prior to orientation. The LNHA further stated that it was important that all documentation must be completed prior to the employee working on the floor to ensure staff are physically fit and properly credentialed. A review of the facility's Residents/Patient rights-Abuse, Neglect, Mistreatment, or Misappropriation of Resident/Patient's Property policy, revised July 2025, revealed that the facility will be thorough in the investigation of past histories of individuals hired, This will be done through: a. inquiry of State Aide Registry, b. inquiry of licensing authorities, when appropriate and c. references will be checked. NJAC 8:39-9.3(b)

Based on observation, interview, and record review it was determined that the facility failed to ensure an accurate assessment of a resident with a history of falls in the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 5 residents (Resident #79) reviewed for accidents and was evidenced by the following:On 2/17/26 at 10:48 AM, the surveyor observed Resident #79 in bed with eyes closed. The surveyor observed a fall mat on the right side of the bed and the left side of the bed was against the wall. On 2/17/26 at 11:16 AM, the surveyor walked past Resident #79's room and observed a Certified Nursing Assistant (CNA) sitting in a chair in the doorway. The surveyor asked if the CNA was there to observe the resident because of a fall history and she stated yes. A review of the admission Record revealed the resident was admitted to the facility with medical diagnoses which included, but were not limited to, dementia, chronic kidney disease, abnormal gait and mobility, and falls. A review of the quarterly MDS, dated [DATE], indicated Resident #79 had a Brief Interview of Mental Status (BIMS) of 00 of 15, meaning the resident had severe cognitive impairment. Review of section J1800 of the MDS for any falls since admission to facility was documented as zero, meaning the resident had no falls since admission to facility. A review of Resident #79's incidents and accidents showed that Resident #79 had falls on 4/5/25, 4/18/25, 5/2/25, 11/12/25, 12/20/25, and 1/8/26. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus for falls initiated on 4/5/25. Review of the interventions revealed that the care plan was revised following each fall with new interventions related to fall prevention. On 2/20/26 at 10:25 AM, the surveyor interviewed the Minimum Data Set Coordinator (MDSC) regarding Resident #79's MDS. The surveyor asked how the MDSC was updated if residents had falls. The MDSC stated that falls would be a quarter look back, meaning the number of falls which happened in the previous three months would be added to the quarterly MDS being completed. The surveyor asked how she would be made aware if a resident were to have a fall and she stated, in the morning meeting, or I would look at the risk assessment. The surveyor had the MDSC review the Electronic Medical Record (EMR) for Resident #79 and the MDSC stated she did not know how she missed it. The surveyor asked if any falls should be on the 12/24/25 quarterly MDS and she stated, Yes. The facility did not have an MDS policy to provide to the surveyor. NJAC 8:39-11.1

Based on observation, interview, and review of pertinent facility documents it was determined the facility failed to revise an Individual Comprehensive Care Plan (ICCP) for a resident no longer receiving tube feedings. This deficient practice was identified in 1 of 1 resident (Resident #164) reviewed for tube feeding and was evidenced by the following: On 2/17/26 at 10:10 AM, Resident #164 was observed in bed in his/her room. The resident was not receiving any tube feeding at the time of the observation and there was no feeding pump in the room. A review of the admission Record revealed Resident #164 had diagnoses which included, but were not limited to, bipolar disorder, gastrostomy tube (feeding tube), dementia, anxiety, and failure to thrive. A review of the Physician Order Summary Report showed an order for regular diet, regular texture, thin consistency and super cereal at breakfast. The order was dated 12/1/25 and remained active. There was also an order for Ensure Plus (oral liquid supplement shake) three times a day given by mouth, ordered on 12/1/25 and remained an active order. Further order review showed an order to cleanse feeding tube site daily with soap and water and cover with a drain sponge, an active order dated 12/2/25. The surveyor did not locate any orders for tube feeding formula. A review of the ICCP showed a focus for the need for a feeding tube and resident refuses feedings at times. The care plan was initiated on 5/15/23 with a revision date of 10/22/24. Interventions included, but were not limited to, administer tube feeding formula, hydration, and flushes per orders, and encourage compliance with tube feedings, hydrations, and flushes as ordered. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/7/25, revealed the resident had a Brief Interview of Mental Status of 4 of 15, meaning the resident had severe cognitive impairment. Review of Section K for nutritional status was marked as yes for having a feeding tube, and yes for receiving a therapeutic diet. On 2/20/26 at 9:56 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN) #1 of C Wing regarding care plans. The UM/LPN#1 told the surveyor that when any type of care focus was resolved, such as a completed tube feeding, the care plan would be revised to include a resolved under that specific focus. UM/LPN#1 stated that the Nursing Supervisor, Minimum Data Set Coordinator (MDSC), and nursing staff were all responsible for care plans but the UM/LPN #1 and the MDSC were the most responsible to ensure they were completed. A review of the facility's Interdisciplinary Care Planning Protocol policy, undated, included, that nursing provides overview of medical and nursing care regimes and problems established by the team with resident/family input must be specific and individualized. The policy did not address care plan revisions. NJAC 8:30-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility did not ensure the daily nurse staffing report was updated and posted each day in a location accessible to the public. This deficient practice was evidenced by the following: On 2/17/26 at 8:56 AM, upon initial entrance to the facility, while the survey team was in the lobby awaiting facility administration, the surveyor observed the posted daily staffing sheet located in the lobby was dated 2/5/26. During an interview with the surveyor on 2/20/26 at 12:50 PM, the Staff Coordinator (SC) stated that staffing information was required to be updated to reflect any changes and posted daily in the facility lobby in a location accessible to the public. During an interview with the surveyor on 2/20/26 at 1:10 PM, the Licensed Nursing Home Administrator (LNHA) stated that the daily staffing sheet was required to be updated to reflect any changes and was to be posted each day in the facility lobby in a location accessible to the public. When asked by the surveyor to provide the facility's staffing policy, the LNHA stated that the facility followed the state staffing regulations and did not maintain a separate written staffing policy. The facility was unable to provide a written policy regarding daily staffing postings. NJAC 8:39-41.2 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate medication dispensing and administration for 1 of 6 residents (Resident #50) observed during the medication pass. This deficient practice was evidenced by the following:On 2/18/26 at 8:22 AM, the surveyor observed Licensed Practical Nurse (LPN #1) dispense five medications for Resident #50. As the LPN pulled the medications from the medication cart, she handed them to the surveyor. The LPN handed the surveyor an over-the-counter (OTC) pill bottle of calcium citrate 200 milligrams (mg) and then the LPN dispensed one pill from the bottle into the medication cup. When the LPN finished dispensing the medications, she locked the medication cart and turned on the privacy screen on the monitor. Before the LPN entered the resident's room, the surveyor asked the LPN to review the resident's medications. The LPN verified the resident had the following physician's order: calcium citrate-vitamin D 315-5 milligrams (mg)-micrograms (mcg) give one table by mouth one time a day. At that time, the LPN acknowledged that she dispensed the incorrect calcium citrate medication and used a drug buster to destroy the medication. She looked in the medication cart for the correct medication but was unable to locate it. The LPN then asked Licensed Practical Nurse/Unit Manager (LPN/UM) #2 to find the correct medication in the facility's OTC supply. On 2/18/26 at 8:37 AM, the surveyor interviewed LPN #1 who stated the process for medication administration included reading the physician's order and checking the medication against the order. The LPN explained this process was important to prevent medication errors. When asked about the calcium citrate-vitamin D order, the LPN stated she only read the part of the order that said, calcium citrate. The surveyor reviewed the medical record for Resident #50. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, dementia and disorders of bone density and structure. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 11/18/25, included the resident had a Brief Interview for Mental Status score of 5 out of 15 which indicated the resident's cognition was severely impaired. A review of the Order Summary Report, as of 2/18/26, included the following physician's order (PO):A PO, dated 5/31/23, for calcium citrate-vitamin D oral tablet 315-5 mg-mcg, give one tablet by mouth one time a day for supplement. On 2/18/26 at 8:48 AM, the surveyor interviewed LPN/UM #2 who stated that during medication pass, the nurses should check the physician's order against the medication to ensure the right medication is given. The LPN/UM further stated that if the nurse could not find the correct medication, she should notify the physician. When asked about the calcium citrate-vitamin D, the LPN/UM stated she was unable to locate the medication in the facility's OTC supply and would notify the physician. On 2/18/26 at 9:17 AM, the surveyor interviewed the Director of Nursing (DON) who stated that during medication pass, the nurses should read the physician's order and then check the medication against the order three times to make sure the medication was correct and to prevent a medication error. On 2/18/26 at 10:25 AM, during a follow-up interview, the surveyor informed the DON of the above medication error. The DON acknowledged that LPN #1 should have read the physician's order thoroughly before dispensing or administering the medication. A review of the facility's Administering Medications policy, dated 7/2025, included, Medications must be administered in accordance with the physician's orders, and, The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. NJAC 8:39-27.1(a)NJAC 8:39 - 29.2(d)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1of 1 resident (Resident #143).On 2/17/26 at 11:15 AM, the surveyor observed Resident #143 seated in his/her wheelchair in their bedroom, waiting to go to therapy. A nebulizer medication vial was noted on the bedside table. The resident stated that he/she administered their own breathing treatments after the nurses leave the medication for him/her. The surveyor reviewed the medical record for Resident #143. A review of the admission Record, indicated the resident was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) (long-term lung disease that makes it hard to breathe). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 1/15/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 1/8/26 indicating that Resident #143 was at risk for respiratory impairment. Interventions included, administering medications and treatments as ordered per physician orders. A review of the Order Summary Report (OSR), dated as of 2/19/26, included the following physician orders (PO): A PO, dated 9/22/25, for Albuterol Sulfate Nebulization Solution (2.5 milligrams (mg)/3 milliliters (mL) 0.083%, 3mL inhale orally via nebulizer every 6 hours as needed for COPD. A PO, dated 12/3/25, for Budesonide inhalation Suspension (0.5 mg/2mL), 2 mL inhale orally two times a day for COPD. A PO, dated 12/3/25, for Ipratropium-Albuterol Inhalation Solution 0.5 -2.5 (3) mg/3 mL inhale orally three times a day for COPD. During an interview with the surveyor on 2/18/26 at 12:25 PM, the Registered Nurse/Unit Manager #2 (RN/UM #2) stated that Resident #143's nebulizer medication vial should not have been left on the bedside table, the resident did not have a care plan to self-administer medications, and for safety reasons. During an interview with the surveyor on 2/18/26 at 12:30 PM, the Licensed Practical Nurse #1 (LPN #1) stated that she usually leaves Resident #143's nebulizer medication vials at the bedside, and the resident places the medication into his/her nebulizer mask and turns on the nebulizer machine. The LPN #1 stated that she returns in approximately 10 to 15 minutes to ensure the resident has completed the nebulizer treatment. She further stated that if the resident was not care planned to self-administer medications, the medication should not be left at the bedside, and she should administer the medication to ensure the breathing treatment was completed for the safety of the resident. A review of the facility's Storage of Medications policy dated July 2025, included, The nursing staff be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. A review of the facility's Medication Administration policy dated July 2025, included, Licensed nursing professionals will administer medications according to times of administration determined by the facility. NJAC 8:39-29.2(d)

Based on observations, interview, and review of pertinent facility documentation it was determined that the facility failed to follow the planned written menu for 2 of 2 meals observed. This deficient practice was evidenced by the following:On 2/19/26 at 11:10 AM, the surveyor entered the kitchen during lunch preparation. The menu for lunch was crispy baked chicken, macaroni and cheese, and roasted zucchini. The surveyor observed a vegetable mix cooking on the stove top which had cauliflower, carrots, and zucchini. It was simmering in a stainless-steel pan with water on the stove top. At that time, the surveyor interviewed a [NAME] who stated the lunch was chicken and the alternate lunch was glazed ham. During the observation the [NAME] was cleaning chicken thighs. The surveyor asked about the menu process for resident choices and the [NAME] stated that the Food Service Director (FSD) hanged the menus on the units an hour before lunch was served and residents could choose the main meal, the alternate, or the always available options. On 2/19/26 at 12:33 PM, the surveyor went into the kitchen with the FSD. The tray line temperatures were checked by FSD in the presence of the surveyor. During the observation, the surveyor observed the chicken being placed in a deep fryer. The surveyor asked the [NAME] if all the chicken was fried or if baked chicken was an option, and he stated that all the chicken was fried. On 2/20/26 at 10:41 AM, the surveyor reviewed the breakfast menu for the day. The menu provided to the surveyor and the menu posted on the A, B, and C wing indicated the residents would receive orange juice, farina, egg and spinach frittata, apple cinnamon muffin, whole milk and coffee. At that time, the surveyor interviewed a Certified Nursing Assistant (CNA) on C wing regarding what was served on the breakfast trays. She said scrambled eggs, bacon, English muffin, and coffee. The surveyor then interviewed an unsampled resident on C wing who stated they received scrambled eggs, bacon, English muffin and coffee and milk. The surveyor then interviewed a CNA on B wing who stated all the residents' received eggs, bacon, English muffin, and coffee. The surveyor then interviewed an unsampled resident on A Wing who stated breakfast included scrambled eggs, bacon, English muffin, and coffee. On 2/20/26 at 11:54 AM, the surveyor interviewed the Regional Dietician (RD) regarding menus. The surveyor asked why it was important for a facility to follow the menu for residents. The RD replied, Because when menus are developed a nutrient analysis is done, and if you are changing menu, it may not meet the nutritional needs of the residents. On 2/24/26 at 11:50 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA), who stated that the facility found a fault in the kitchen that caused incorrect meals/menus. The surveyor asked why following a planned menu was important for the facility and he stated that it was important due to meeting the residents' preferences and to ensure nutritional value was being met. The facility did not provide any documentation on meal substitutions or menu changes. NJAC 8:39-17.4 (a) 3

Based on observations and interviews it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) and the Medical Director's (MD) licenses were visibly displayed. This deficient practice was evidenced by the following:On 2/20/26 at 12:15 PM, two surveyors toured the facility and there was no evidence that the current MD (MD #1) or the LNHA's licenses were visibly displayed. During the tour, the two surveyors observed in the facility's copier room a copy of MD #2's license on the bulletin board. On 2/20/26 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that MD #2 was the previous Medical Director and MD #1 was the current Medical Director. At that time, the Regional DON, the Director of Social Services (DSS), and the DON, with the surveyor, looked in the main hallway and they stated that the license was previously visibly posted. They all confirmed it was not currently posted and would have to see where it went. The DSS stated that one of the bulletin boards fell and they put it somewhere. The DSS further stated, we just have to find it. On 2/20/26 at 12:38 PM, the surveyor interviewed the LNHA who stated the DON had a copy of the MD's license in her office and that she personally kept hers. The LNHA confirmed the MD and her license were not currently visibly posted and that it should be posted in the main hallway. She then stated the licenses were previously posted but she was not sure what happened. On 2/20/26 at 12:56 PM, the LNHA stated the MD's license was posted visibly in the main hallway after surveyor inquiry. On 2/24/26 at 10:20 AM, the LNHA showed the surveyor her license was now posted visibly in the main hallway. She stated that the bulletin with the licenses in the main hall was taken down to put up a new time clock that needed to be connected through the wall. She stated the time clock was completed about three weeks ago. The LNHA acknowledged the MD and the LNHA's licenses should have been visible to the public prior to surveyor inquiry. No additional documents were provided. NJAC 8:39 - 5.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility did not ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to a.) follow appropriate hand hygiene practices for 1 of 2 nurses who administered medications to 3 of 6 residents (Resident #42, Resident #50, and Resident #59) during the medication pass, and b.) properly store a nebulizer mask leaving the mask exposed to air on a bed table for 1 of 1 resident (Resident #143) reviewed for respiratory care. This deficient practice was evidenced by the following:1.) On 2/18/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 exit a resident's room and return to the medication cart. The surveyor explained to the LPN that the surveyor would be observing the medication pass and the LPN informed the surveyor that she was going to prepare Resident #59's medications. At that time, without performing hand hygiene, the LPN dispensed five medications into a medicine cup and then administered them to Resident #59. When the LPN returned to the medication cart, she did not perform hand hygiene. At 8:22 AM, LPN #1 moved her medication cart to Resident #50's room and without performing hand hygiene, the LPN dispensed five medications, removed an incorrect medication from the medicine cup and destroyed it, and then administered the remaining medications to Resident #50. When the LPN returned to the medication cart, she did not perform hand hygiene. At 8:30 AM, LPN #1 moved her medication cart to Resident #42's room and without performing hand hygiene, the LPN dispensed six medications into a medicine cup and then administered them to Resident #42. When the LPN returned to the medication cart, she did not perform hand hygiene. On 2/18/26 at 8:37 AM, the surveyor interviewed LPN #1 who stated hand hygiene should be performed before and after administering medications to prevent the spread of germs. When asked about her hand hygiene during the medication pass, LPN #1 acknowledged that she did not perform hand hygiene during the medication pass observation. On 2/18/26 at 8:48 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that during the medication pass, nurses should use hand sanitizer between each resident to prevent the spread of germs. On 2/18/26 at 9:17 AM the surveyor interviewed the Director of Nursing (DON) who stated the nurses should perform hand hygiene before dispensing medications and after administering medications by either washing their hands with soap and water or using hand sanitizer for infection control purposes. On 2/18/26 at 10:25 AM, the surveyor informed the DON of LPN #1's lack of hand hygiene during the medication pass observation and the DON stated LPN #1 should have used the hand sanitizer that was available on her medication cart. A review of the facility's Administering Medications policy, dated July 2025, included, Staff shall follow established facility infection control procedures (e.g., handwashing.) for the administration of medications, as applicable. A review of the facility's Handwashing/Hand Hygiene policy, dated July 2025, included, In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: a. Before and after direct contact with residents;. d. Before preparing or handling medications;. 2.) On 2/17/26 at 11:15 AM, Surveyor #2 observed Resident #143 seated in his/her wheelchair in his/her bedroom, waiting to go to therapy. A nebulizer mask was left on the bedside table, exposed to air. The surveyor reviewed the medical record for Resident #143. According to the admission Record, the resident had diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD) (long-term lung disease that makes it difficult to breathe). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 1/15/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 1/8/26 that the resident was at risk for respiratory impairment. Interventions included, but were not limited to: administering medications and treatments as ordered per physician orders. A review of the Order Summary Report (OSR), dated as of 2/19/26, included the following physician orders (PO): A PO, dated 9/22/25, for Albuterol Sulfate Nebulization Solution (2.5 milligrams (mg)/3 milliliters (mL) 0.083%, 3mL inhale orally via nebulizer every 6 hours as needed for COPD. A PO, dated 12/3/25, for Budesonide inhalation Suspension (0.5 mg/2mL), 2 mL inhale orally two times a day for COPD. A PO, dated 12/3/25, for Ipratropium-Albuterol Inhalation Solution 0.5 -2.5 (3) mg/3 mL inhale orally three times a day for COPD. During an interview with the surveyor on 2/18/26 at 12:25 PM, the Registered Nurse/Unit Manager #2 (RN/UM #2) stated that Resident #143's nebulizer mask should not have been left on a bedside table exposed to air and should have been placed in a plastic bag after use for infection control purposes. During an interview with the surveyor on 2/18/26 at 12:30 PM, the Licensed Practical Nurse #1 (LPN #1) stated that Resident #143's nebulizer mask should not have been left at bedside after use and should be placed in a plastic bag to prevent exposure to germs. A review of the facility's Oxygen Therapy policy, dated July 2025, revealed that When not in use, the nasal cannula or oxygen mask will be placed in a plastic bag. The plastic bag will be labeled with the resident's name and dated. The plastic bag will be changed when the cannula/mask and humidifier bottle are changed weekly. NJAC 8:39-19.4(a)(1)

Complaint #: NJ 185087 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain hot water temperatures at a safe level to protect residents from third degree burns and serious injury on 1 of 3 nursing units (C-Wing). Hot water temperatures obtained on 3/29/25, in both residents' rooms and in the resident shower room on the C-Wing nursing unit, registered between 137.1 degrees Fahrenheit (F) and 138.4 degrees F. Interviews with the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD) revealed that hot water temperatures should be maintained between 95 and 110 degrees F to prevent residents from being burned. The RLNHA and the MD stated that the C-Wing nursing unit had a separate boiler that provided hot water to all those residents which included cognitively impaired residents. The facility's failure to ensure the residents were protected from excessive hot water temperatures posed the likelihood of serious harm and injury from third degree burns. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/29/25 at 1:30 PM, when the survey team identified water temperatures on the C-Wing nursing unit in excess of 130 degrees F. The facility's Administration was notified of the IJ on 3/29/25 at 3:16 PM. The facility submitted an acceptable Removal Plan (RP) on 3/29/25. The surveyor verified the implementation of the RP during the continuation of the on-site survey on 3/31/25. The evidence was as follows: Reference: State Operation Manual; Guidance to Surveyors for Long Term Care Facilities; 483.25 (d)(1); Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Time and Temperature Relationship to Serious Burns Water Temperature and Time Required for Third degree Burn (Penetrate the entire thickness of the skin and permanently destroy tissue). Water temperature and time required for a third degree burn to occur: 148 F - 2 Seconds 140 F - 5 Seconds 133 F - 15 Seconds 127 F - 1 Minutes 124 F - 3 Minutes 120 F - 5 Minutes On 3/29/25 at 10:20 AM, the surveyor interviewed the Social Worker (SW), who stated that the facility had a fire yesterday (3/28/25) that started at approximately 10:30 AM, that affected the laundry room, A-wing's dining room, and Resident room [ROOM NUMBER]. The SW stated that utilities were shut off including the facility's boilers, but all utilities had been restored and the facility was fully functioning. On 3/29/25 at 11:25 AM, the surveyor interviewed the RLNHA, who stated that the facility had a fire yesterday, and the Fire Marshal (FM) and Local Health Department (LHD) cleared the facility so the residents returned to their room and the utilities were restored. The RLNHA confirmed that there was hot water throughout the building. On 3/29/25 at 12:15 PM, the surveyor conducted a telephone interview with the FM, who stated that the facility had an accidental fire to their outside laundry dryer vents. The FM reported that before he left the facility last night, he had checked the boiler and the facility had hot water. On 3/29/25 at 1:18 PM, the surveyor (Surveyor #1) and the Director of Dietary (DD), in the presence of Surveyor #2 and the RLNHA, calibrated two thin probed thermometers using an ice bath. The surveyor and DD checked the hot water temperatures throughout the kitchen. Then the surveyor asked the DD if the RLNHA could use his calibrated thermometer to check water temperatures throughout the building. The DD confirmed and provided the RLNHA with his thermometer. At that time, the surveyor asked the RLNHA at what temperature should the hot water be at, and the RLNHA stated between 95 and 110 degrees F to prevent burns. On 3/29/25 at 1:20 PM, Surveyor #1 and the RLNHA were both obtaining a water temperature from Resident room [ROOM NUMBER]'s sink, and halfway through obtaining the temperature, the RLNHA stopped. The surveyor obtained a water temperature of 105 degrees F, and the RLNHA acknowledged it as the temperature. The surveyor then instructed the RLNHA that moving forward, they wanted them to both obtain the water temperature, and the RLNHA stated that he would go with the temperature that the surveyor obtained because the surveyor was better at obtaining the water temperature. On 3/29/25 from 1:30 PM through 1:41 PM, the surveyors and the RLNHA obtained hot water temperatures on the C-Wing nursing unit and the following occurred: At 1:30 PM, Surveyor #1 obtained a water temperature of 138.3 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, Surveyor #1 and the RLNHA felt the hot water and they both agreed the water was hot. The RLNHA stated it was scalding and confirmed a resident could get burned. At 1:31 PM, Resident #1 informed the surveyor that the hot water got really hot that they could make tea with it. Surveyor #1 asked if it would steep it, and Resident #1 confirmed yes. Surveyor #1 then asked how long this was occurring for, and Resident #1 stated they were not saying nothing. A review of Resident #1's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/30/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated a fully intact cognition. At 1:33 PM, the RLNHA informed the surveyors that he called the maintenance staff and instructed them to turn the boiler down. The RLNHA stated that the C-Wing nursing unit had a separate boiler from the other two nursing units. Surveyor #1 asked if any resident had ever been burned from the facility's hot water, and the RLNHA stated no. At 1:34 PM, Surveyor #1 obtained a water temperature of 137.1 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, the RLNHA acknowledged the temperature, and he confirmed that the unit had cognitively impaired residents residing on it. At 1:35 PM, Surveyor #2 obtained a water temperature of 138.4 degrees F from Resident room [ROOM NUMBER]'s sink. At that time, the RLNHA acknowledged the temperature. At 1:37 PM, Surveyor #1 obtained a water temperature of 137.7 degrees F in the C-Wing Shower Room. The RLNHA acknowledged the temperature, and he confirmed that was the only shower room on the nursing unit. At 1:39 PM, Resident #2 informed the surveyor that they were able to make instant noodle soup using their sink. The surveyor asked if the water softened the noodles, and the resident confirmed yes. A review of Resident #2's most recent quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. At 1:41 PM, Surveyor #2 obtained a water temperature of 138.4 degrees F from the sink at the Nurse's Station. The RLNHA acknowledged the temperature, and he stated that staff were instructed to turn the boiler down. On 3/29/25 at 1:42 PM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that the facility's water was usually not too hot, and she stated no residents had complained. On 3/29/25 at 1:44 PM, the surveyor interviewed the Maintenance Staff (MS #1), who stated that water temperatures were obtained daily throughout the facility by the MD. On 3/29/25 at 1:45 PM, the surveyors accompanied by MS #1 and the RLNHA observed C-Wing's boiler room. The surveyors observed the boiler system for C-Wing was a residential unit with no gauge to show the water temperature. The boiler had a dial that could be set to low, medium, or high. The dial was currently set to high. On 3/29/25 at 1:47 PM, the surveyor interviewed the Registered Nurse (RN #1), who stated that residents did not complain about the hot water. On 3/29/25 at 1:48 PM, the MD provided the surveyor with water temperature logs for February 2025 and March 2025. The logs had sustained water damage from the fire and the ink had bled in places. However, there were no markings in the boxes for the C-Wing water temperature from 3/18/25 through the present date, and there was no indication that any ink had bled through from water damage, the boxes were paper colored. The surveyor then showed the log to the RLNHA and asked if it looked like there was anything written in those boxes that might have bled, and the RLHNA responded, that is what my MD is saying. The log also did not specify where in C-Wing the water temperatures were obtained from. At that time, the RLNHA stated that the facility had been checking water temperatures in every resident room since last night on a separate log, and the surveyor requested a copy of it and the facility's water policy. On 3/29/25 at 1:55 PM, the surveyors observed the boiler room in A-Wing that contained all the facility's state inspection certificates. The MD stated one of those certificates was for C-Wing's boiler that was inspected on 10/10/24, but he was unsure which one. The MD stated that C-Wing's boiler was an eighty gallon tank that serviced only C-Wing. The MD stated that the maintenance staff checked water temperatures daily, and that none of his staff had adjusted the boiler to make the temperature hotter; the boiler maintained the same setting. The MD stated that the facility had never had high water temperatures. The surveyor informed the MD that both surveyors in the presence of the RLNHA obtained high water temperatures over 130 degrees F. The MD denied the findings. The surveyor asked what the temperature should be, and the MD stated between 95 and 110 degrees F. On 3/29/25 at 2:04 PM, the RLNHA stated that the facility did not have a water policy and the facility followed the regulations. At that time, the RLNHA provided the surveyor with a copy of the water temperature logs for all three nursing units from 3/28/25 at 8:00 PM, until 3/29/25 at 12:00 AM. The highest temperature recorded was 109 degrees F in Resident room [ROOM NUMBER]. On 3/29/25 at 2:15 PM, the SW provided the surveyor with a list of forty-eight residents who resided on C-Wing. Out of those residents, the SW indicated that twenty-two of the residents were cognitively impaired. At that time, the surveyor requested the RLNHA to ask the MD to meet the surveyors in C-Wing to obtain water temperatures. The RLNHA stated the MD was already there. On 3/29/25 at 2:17 PM, the surveyor, in the presence of the MD, obtained a water temperature of 122 degrees F from the C-Wing Shower Room. The MD did not want to use his thermometer in hand to obtain a temperature, and he stated that the surveyor's temperature was sufficient. The surveyor then obtained a water temperature of 121 degrees F from Resident room [ROOM NUMBER]'s sink. The MD stated that no one had touched the boiler yet to bring the temperature down, and he was waiting for us. The surveyor then questioned the RLNHA about informing the surveyors that the facility staff had lowered the boiler temperature when they first obtained high readings, and the RLNHA stated he thought they did. An Acceptable Removal plan was received on 3/29/25, which indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; on 3/29/25 at 3:30 PM, the MD lowered the hot water temperature on the boiler, water temperatures were obtained throughout every residents' room in the facility, the facility initiated water temperatures to be taken every two hours for three days, all residents on C-Wing were assessed for skin damage, the facility conducted a resident council meeting to discuss safe water temperatures with the residents, and the Director of Nursing/designee initiated a house-wide staff in-service on safe water temperatures, the process of taking water temperatures, and any staff not in-serviced would be prior to their next shift. During the verification of the Removal Plan on 3/31/25 at 11:10 AM, Resident #3 informed the surveyor that the water could be hotter now, and they understood why the temperature needed to be cooler. Resident #3 reported that they were able to (prior to the IJ) make hot chocolate or tea using the water from their sink, but now they could not since the temperature was lowered. The surveyor asked how long the resident had been able to make hot beverages using their sink water, and Resident #3 stated the whole time they resided in the facility. A review of Resident #3's most recent comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. The surveyor verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/31/25. NJAC 8:39-31.7(h)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) label all food items in the refrigerator. This deficient practice was identified in the facility kitchen and in 1 of 1 nursing unit pantry and was evidenced by the following: On [DATE] at 9:39 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1.) In the refrigerator identified as the walk-in cooler, a cluster of bok choy and lemongrass was noted on the shelf. Both items were dated [DATE]. At that time, the surveyor interviewed the FSD who stated that he was unsure of when the items needed to be discarded. 2.) In the food preparation area, a heavy duty commercial blender base was observed with hardened food stain and a moderate amount of discoloration. At that time, the surveyor interviewed the FSD who stated that the blender should be clean. He further stated that the facility planned on purchasing a new blender. 3.) When the surveyor opened the pellet heater (used to warm pellets - a plate-like device used to keep foods hot) door, the interior sides and multiple pellets were noted with small food particles and a moderate amount of thick brownish sticky-like residue. At that time, the surveyor interviewed the FSD who stated that the pellets were last used for breakfast ([DATE]). When asked if the pellets had been cleaned, the FSD stated, not yet, they are going to do that right now. When asked the process for when the pellets were returned to the kitchen, the FSD explained the pellets went to the dish room, were cleaned, allowed to be air dried, and then they were returned to the pellet heaters to get ready for the next meal. 4.) The surveyor requested to see the dish washer temperature and chlorine log. The FSD provided the surveyor with the log which revealed the Dish Machine Ware Washing- Low Temperature log for the month of October was incomplete; the lines to record the temperature and chlorine level for [DATE]th, 21st, and 22nd were blank for breakfast, lunch, and dinner. At that time, during an interview, Dietary Aide (DA) #1 stated the temperature and chlorine levels were tested before and after he started the wash. I make sure the machine is working right. When asked if the temperature and chlorine levels were checked today ([DATE]), DA#1 replied, Yes. He further stated that the results were not documented in the log. At that time, the FSD stated that the temperature and chlorine levels on ,d+[DATE], ,d+[DATE], and ,d+[DATE] should have been completed and documented in the log. On [DATE] at 10:29 AM, the surveyor, accompanied by the FSD, observed the following in the food storage supply area located in the basement: 5.) There were two (2) boxes containing multi packages of barley from two (2) different manufacturers. The packages in Box #1 had a best by date of [DATE]. The surveyor observed bugs crawling inside the packages. Box #2 did not have an expiration date on the individual packages or on the outside of the box. On the same shelf, there was also a box containing multiple packages of green split peas with the expiration date of [DATE]. At that time, the surveyor interviewed the FSD who confirmed the surveyor's findings and discarded the expired barley and green split peas. The FDS stated that he was responsible for ensuring that there were no expired foods on the shelf. The FSD further stated, everything should be labeled with a receive date and discarded after six (6) months. On [DATE] at 12:14 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that the pellets should be cleaned after every meal. When asked how often the dish machine solution should be tested , the LNHA stated, they do it every day. He further stated that the dish machine log should be completed and, I constantly audit the logs to make sure they fill them in. On [DATE] at 9:03 AM, the surveyor, accompanied by Certified Nursing Aide (CNA) #1, observed the following unlabeled food items in the refrigerator/freezer designated for resident food in the B Wing pantry: 6.) In the refrigerator: -Plastic container with soup -Two (2) cups of juice -A can of soda -Bottle of strawberry banana juice -Potato chips 7.) In the freezer: -An insulated travel cup -Ice cream At that time, CNA #1 stated that all of the items in the refrigerator belonged to the residents. She further stated that staff members brought items from other units and placed them in the refrigerator and CNA #1 does not know what food belongs to each resident. She also stated that each food item should be labeled accordingly. On [DATE] at 9:18 AM, Regional Director of Nursing (RDON) #2 confirmed the surveyor's findings. She stated that all items in the refrigerator should have been labeled with the resident's name and the use by date. Review of the facility's Subject: Labeling and Dating Procedure Implemented in the Dietary Department policy, undated, revealed the following: 1. Food items, as appropriate will be labeled and dated by dietary staff using the facility labeling system, and the food service director/designee will oversee labeling and dating. 2. All perishable products will be dated using the date of production. The dated product will be used up to and including the 3rd day from the date of production unless otherwise marked. All products after this date will be discarded. 3. Perishable foods are checked for spoilage by the FSD/designee. 4. Dated products are checked for expiration by the FSD/designee. Review of the facility's Dish Machine policy, reviewed/revised [DATE], revealed, The kitchen will wash, rinse and sanitize after each meal service. Procedure: Staff will scrape waste off dishes and trays into food waste container. Rinse dishes thoroughly into scrap sink. Remove all dishes and inspect for cleanliness and dryness . Dishwasher staff will monitor and record dish machine temperatures to assure compliance for wash and rinse cycles. Low Temp Machine (Wash 120 degrees F, rinse no higher than 150 degrees F) Must use chlorine test strip prior to and during use and must read ,d+[DATE] PPM. FSD or designee will monitor temp. log and PPM readings prior to each usage for compliance. NJAC 8:,d+[DATE].2(g)

Complaint #: NJ175570 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a safe and sanitary physical environment in the central supply room. This deficient practice has the potential to affect 3 of 3 nursing units and was evidenced by the following: On 10/23/24 at 12:25 PM, the surveyor conducted a tour of the facility's basement, in the presence of the facility's Regional Licensed Nursing Home Adminstrator (RLNHA) and the staff member in charge of Central Supply. At that time, the surveyor entered the Central Supply room and observed, adhered on the wall board ceiling to the right of the doorway near the pipes, a black substance approximately 24 inches in length. On 10/23/24 at 1:00 PM, the surveyor revisited the Central Supply room and observed the RLNHA and the Maintenance Assistant (MA) present in the room. The MA had a pitcher of white paint with a brush and was applying the white paint over the black substance on the ceiling. At that time, the surveyor interviewed the RLNHA who stated, it was dirt on the ceiling. On 10/23/24 at 1:10 PM, the surveyor interviewed the staff member in charge of Central Supply who stated she was unaware of the black substance that was observed on the ceiling. She further stated the prior staff had resigned and she was covering. On 10/23/24 at 1:15 PM, the surveyor interviewed the Maintenance Director who stated that he was unaware that there was a black substance on the ceiling in the Central supply room. On 10/28/24 at 1:34 PM, the RLNHA, in the presence of the LNHA, Director of Nursing (DON), Regional DON (RDON) #1, RDON#2 and the survey team, stated that it was scud and dirt on the ceiling and it came right off. He further stated that the ceiling was cleaned and then painted over after surveyor inquiry. The facility was unable to provide a policy related to maintaining a safe and sanitary physical environment. The RLNHA stated they followed their Infection Control policy. NJAC 8:39-31.2(e)

COMPLAINT #: NJ172102 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to report an alleged violation of misappropriation of resident property to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following: 1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the Admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/19/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the resident's electronic medical record (EMR) revealed the resident had the following physician's orders: -Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions. -Start Date: 12/12/23 -End Date: 6/16/24 -Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Start Date: 12/12/23 -End Date: 02/21/24 A review of the resident's Individual Patient's Controlled Drug Record for February 2024 revealed the following: A sheet with the date range of 1/23/224 - 2/5/24: 2/1/24: 2 Percocet tablets were signed out at 4 PM, 8 PM 2/2/24: 2 Percocet tablets were signed out at 3 PM 2/3/24: 2 Percocet tablets were signed out at 7 AM, 12 PM, 4 PM, 8 PM 2/4/24: 2 Percocet tablets were signed out at 8 PM 2/5/24: 2 Percocet tablets were signed out at 4 PM, 8 PM An additional sheet with the date range of 2/4/24 - 2/23/24: 2/4/24: 2 Percocet tablets were signed out at 8 PM 2/5/24: 2 Percocet tablets were signed out at 12 AM 2/6/24: 2 Percocet tablets were signed out at 4 PM, 8 PM 2/7/24: 2 Percocet tablets were signed out at 12:30 AM, 4 PM, 11 PM 2/13/24: 2 Percocet tablets were signed out at 12:30 PM 2/14/24: 2 Percocet tablets were signed out at 9 AM 2/15/24: 2 Percocet tablets were signed out at 8 PM 2/16/24: 2 Percocet tablets were signed out at 9 AM, 8 PM 2/17/24: 2 Percocet tablets were signed out at 5 PM 2/18/24: 2 Percocet tablets were signed out at 11 AM, 5 PM 2/19/24: 1 Percocet tablet was signed out at 8 AM 2/19/24: 2 Percocet tablets were signed out at 5 PM 2/20/24: 2 Percocet tablets were signed out at 4 PM A review of the Medication Administration Record (MAR) for February 2024 revealed the resident was prescribed: Percocet Oral Tablet 5-325 MG (Oxycodone w/Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain (4-6) For moderate pain 4-6 on pain scale/ MD aware of drug side effects/ drug interactions -Order Date- 12/12/2023 -D/C Date- 06/16/2024 Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Order Date- 12/12/2023 -D/C Date- 02/21/2024 A further review of the February 2024 MAR for the corresponding dates revealed the following: 2/1/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/2/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/3/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 7 AM, 12 PM, 4 PM, 8 PM. 2/4/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM 2/5/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/6/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/7/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/13/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/14/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/15/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM. 2/16/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 9 AM, 8 PM 2/17/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 5 PM. 2/18/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/19/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered. 2/20/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 4 PM A review of the progress notes for the above corresponding dates did not include any additional documentation regarding Percocet administration for the aforementioned dates and times. 2.) Resident #365 was not at the facility during the survey. A closed record review for Resident #365 was completed. A review of the Admission Record (an admission summary), revealed the resident had diagnoses which included, but were not limited to; opioid dependence, spinal stenosis (the narrowing of one or more spaces within your spinal canal), and fracture of the right tibia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/13/23, which revealed the resident had a Brief Interview for Menal Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's electronic medical record (EMR) revealed the resident had the following physician's orders: -Oxycodone HCl Oral Tablet 20 milligram (mg) (Oxycodone HCl) Give 20 mg by mouth every four (4) hours as needed for (severe pain 8-10) -Start Date: 11/13/23 -End Date: 12/26/23 A review of the resident's Individual Patient's Controlled Drug Record for December 2023 revealed the following: A sheet with the date range of 11/23/23 - 12/3/23: 12/1/23: 1 Oxycodone 20 mg signed out at 1:45 AM 12/2/23: 1 Oxycodone 20 mg signed out at 12 AM An additional sheet with the date range of 12/4/23 - 12/12/23: 12/11/23: 1 Oxycodone 20 mg signed out at 2:46 PM A review of the Medication Administration Record (MAR) for December 2023 revealed the resident was prescribed: Oxycodone HCl Oral Tablet 20 MG (Oxycodone HCl) Give 20 mg by mouth every 4 hours as needed for (severe pain 8-10) -Order Date- 11/13/2023 -D/C Date- 12/26/2023 A further review of the December 2023 MAR for the corresponding dates revealed the following: 12/1/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 1:45 AM 12/2/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 12 AM. 12/11/23: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 2:46 PM. A review of the Progress Notes for the above corresponding dates did not include any additional documentation regarding Oxycodone administration. The facility provided the surveyor with an Investigation Summary for three staff: Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. Under the Investigation Findings of each of the summaries, the following was noted: .Upon investigation, interviews and statements, alleged drug diversion was unsubstantiated . The investigation for LPN #1 also included an Employee Suspension Notice which revealed, [LPN #1] is being suspended pending investigation while facility investigates possible drug diversion. There was no evidence provided to the surveyor that the facility notified the NJDOH of the investigation related to a possible drug diversion. On 10/28/24 at 1:24 PM, during an interview with the surveyor that included Regional Director of Nursing (RDON) #1, RDON #2, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Administrator (RLNHA), the surveyor asked if the concerns of the alleged drug diversion as referenced in the three Investigation Summaries had been reported to the NJDOH. RDON #1 stated, No, because we immediately ruled out the drug diversion issue through interviews with residents who all expressed relief of pain. We were also under the impression that the ombudsman had already informed the state. The surveyor reviewed the facility's undated Incident/Occurence Investigation Procedure. Under the Policy Statement section the policy revealed, .3. All allegations of misappropriation of residents' property will be investigated . Further review of the policy did not reveal that the facility was to contact the NJDOH to report an alleged violation of misappropriation of resident property, per the regulation. NJAC 8:39-9.4 NJAC 8:39-27.1(a) NJAC 8:39-29.7(c)

COMPLAINT #: NJ172102 Based on observations, interviews, records review, and review of other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents (Resident #58) reviewed for personal property. This deficient practice was evidenced by the following: On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 7/19/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the electronic medical record (EMR) revealed the resident had the following physician's orders: -Percocet Oral Tablet 5-325 milligrams (mg) (Oxycodone w/ Acetaminophen) Give two (2) tablets by mouth every four (4) hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Start Date: 12/12/23 -End Date: 02/21/24 A review of the Individual Patient's Controlled Drug Record for February 2024 revealed the following: A sheet with the date range of 1/23/224 - 2/5/24: 2/4/24: 2 Percocet tablets were signed out at 8 PM The Destroyed/Wasted Medication Doses section of the form was blank. An additional sheet with the date range of 2/4/24 - 2/23/24: 2/4/24: 2 Percocet tablets were signed out at 8 PM The Destroyed/Wasted Medication Doses section of the form was blank. A review of the Medication Administration Record (MAR) for February 2024 revealed the resident was prescribed: Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain (7-10) For severe pain 7-10 on pain scale/ MD made aware of side effect and dosage -Order Date- 12/12/2023 -D/C Date- 02/21/2024 A further review of the February 2024 MAR for the corresponding dates revealed the following: 2/4/24: No pain level recorded, no pain evaluation, no signature noting that medication was administered at 8 PM A review of the Progress Notes for the above corresponding dates did not include any additional documentation regarding Percocet administration for the aforementioned date and time. The facility provided the surveyor with an Investigation Summary for three staff: Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3. Under the Investigation Findings of each of the summaries, the following was noted: .Upon investigation, interviews and statements alleged drug diversion was unsubstantiated . The investigation for LPN #1 also included an Employee Suspension Notice which revealed that, [LPN #1] is being suspended pending investigation while facility investigates possible drug diversion. On 10/28/24 at 2:54 P.M., the surveyor interviewed the [NAME] President of Clinical Services (VPCS) #1, in the presence of Regional Director of Nursing (RDON) #2. The VPCS stated, The 2/4/24 duplicate dose at 8 PM was not investigated because it was not brought to our attention. The surveyor reviewed the facility's undated Incident/Occurence Investigation Procedure. Under the Policy Statement section the policy revealed, .3. All allegations of misappropriation of residents' property will be investigated . The Procedure section further revealed, .Nursing or Social Services will conduct their initial investigation and review all pertinent documentation related to the event within 24 hours . NJAC 8:39-9.4 NJAC 8:39-27.1(a) NJAC 8:39-29.7(c)

Based on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a.) ensure the facility policy for Falls Management was followed to appropriately assess a resident and determine the causal factor of a fall and implement appropriate interventions to prevent recurrent falls for a cognitively impaired resident (Resident #23), who was identified as a high fall risk, required extensive assistance with bed mobility, and had a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency roiagnom on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). A subsequent unwitnessed fall occurred on 05/21/23 and required 911 transport to the emergency room , and resulted in a laceration to the forehead measuring 6 centimeters (cm) x 5 cm and a mild frontal scalp swelling per a computerized tomography (CT) scan, b.) ensure a complete Head to Toe Assessment was completed as required by a Registered Nurse prior to transferring Resident #23 to the bed, when reportedly Resident #23 was found on the floor on 05/21/23 at 6:00 AM, c.) provide adequate supervision to prevent recurrent falls, and d.) ensure that existing interventions to prevent falls were consistently implemented. This deficient practice occurred for 1 of 3 residents, Resident #23, reviewed for falls with injury and was evidenced by the following: On 05/22/23 at 10:40 AM, the surveyor observed Resident #23, positioned on the right side, in a bed that was against the wall and the resident was facing the wall. The surveyor observed a pad on the floor next to the bed. Resident #23 was unable to maintain a conversation with the surveyor and the resident also had a blanket covering the head. On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed, and was again positioned in the same manner as observed by the surveyor two days prior. At that time, the Certified Nursing Assistant (CNA) was inside the room and attempted to assist Resident #23 with the breakfast meal. The CNA stated to the surveyor that Resident #23 had a poor appetite and exited the room shortly after the surveyor entered. On 05/24/23 at 10:25 AM, (two hours later) Resident #23 was observed still in bed and was in the same position facing the wall. The B-Wing Activities of Daily Living (ADLs) worksheet (a document that direct care staff documented the resident care that was provided), could not be located by the staff to verify any documented care that had been provided to Resident #23 regarding position change or being repositioned. On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed, on his/her back with head elevated. At that time, the surveyor observed a large, black and blue in color hematoma (collection of blood) on Resident #23's right forehead. A Licensed Practical Nurse (LPN), who later identified herself as the Infection Preventionist (LPN IP) was in the room and assisted Resident #23 with the lunch meal. Upon surveyor inquiry regarding the observed injury on Resident #23's forehead, the LPN IP stated that the injury was from a fall the resident sustained and she would not elaborate further on the observed injury. On 05/24/23 at 1:25 PM, the surveyor reviewed Resident #23's electronic medical record and could not locate any documentation regarding the observed injury that the LPN IP confirmed Resident #23 sustained during a fall at the facility. According to the Admission Face Sheet, Resident #23 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, acute kidney failure, blindness left eye, and acquired absence of right leg above the knee. A review of the Significant Change Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 02/28/23, revealed that Resident #23 was severely cognitive impaired. Resident #23 scored 6/15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS, which referred to activities of daily living (ADLs), revealed that Resident #23 was totally dependent on staff for care and required an extensive assistance of two-person physical assist for transfer, and one-person physical assist for care. A review of the progress notes did not contain documentation regarding the fall that the LPN IP stated occurred on 05/21/23 for Resident #23, however a fall that occurred on 02/15/23 was documented. The following entry dated 02/15/2023 timed 19:42:31 [7:42 PM], Note Text: Notified by aide that resident was on the floor. I found resident laying on the floor on the right side. I observed no head injuries and resident said [his/her] head was fine. Resident expressed that [his/her] left arm was hurting, and [he/she] was in pain. Called MD to make aware. Called for X-ray of left arm. Neuro checks in progress. Made supervisor aware. Will continue to monitor resident throughout the shift. VS [vital signs] 95/51 [blood pressure] 74 [pulse] 97.3 [temperature] 95% [oxygen saturation] 17 [respirations]. Another entry dated 02/16/23 revealed the following: Resident had increased in pain, MD was notified and [Resident #23] was sent out to the hospital. CT scan cervical spine, CT head without contrast, X-ray left humerus and X-ray left shoulder done. Resident found to have acute fracture through the left humerus surgical neck extending into the greater tuberosity, without significant displacement. Small glenohumeral hemorrhagic effusion. The surveryor reviewed the current Comprehensive Care Plan (CP) initiated 09/22/20, last revised 05/25/23 (revised four days after the fall that occurred on 05/21/23) which included 17 pages and had a Focus for ADL and functional mobility deficit related to: decreased strength, balance, endurance and coordination. I require extensive assistance/Total Dependence with ADLs, transfers, functional mobility and safety awareness. The Goal for this Focus was for Resident #23 to improve ADL and functional mobility level by next review. Initiated 09/22/20, and Revised 05/25/23, with a Target Date of 08/14/23, The CP interventions included: Converse during care, Ensure that all assistive devices are in place, and Introduce yourself and explain all care. Date Initiated: 10/15/21, Date Revised: 05/25/23. Resident #23 also had a CP Focus for At Risk for falls due to Impaired balance/poor coordination, Date Initiated: 02/13/21. The Goal was Minimize risk for falls through next review, Date Initiated: 02/13/21. The following interventions were documented: Provide assistance to transfer and ambulate as needed. Initiated 02/13/23. Reinforce the need to call/ring for assistance. Initiated 02/13/23. Reinforce wheelchair safety as needed such as locking brakes. Initiated 02/13/23. Therapy evaluation and treatment as ordered. Initiated 02/13/23. On 02/15/23 Resident #23 was found lying on the floor in his/her room. The following interventions were added to the care plan: Assess for pain and medicate if needed. Initiated 02/15/23 Assessment Completed, Date Initiated 02/15/23. Continue at risk for fall intervention, Date Initiated 02/15/23. Monitor range of motion every shift x 72 hours, Date initiated 02/15/23. Neuro check x 72 hours, Date initiated 02/15/23 Notify MD [Medical Doctor] of the incident and for any significant change, Date initiated 02/15/23. Epic evaluation of meds[medications], Date initiated 02/16/23. Floor mat at bedside, Date initiated 02/16/23. Sent to Hospital for evaluation of pain. Initiated 02/16/23. Sling to shoulder. Initiated 02/17/23. Orthopedic appt [appointment] scheduled, Date Initiated 02/20/23. Pain management adjustment, Date Initiated 02/20/23. A review of the Fall Risk assessment dated [DATE], 13:30 [1:30 PM] revealed that Resident #23 was assessed as a High Fall Risk, Resident #23 received a score of 37 indicative of a high fall risk. On 05/24/23 at 11:00 AM, the surveyor requested all investigations for Resident #23. On 05/24/23 at 12:10 PM, the surveyor, again reviewed the electronic medical record. There was no documentation regarding the fall that occurred on 05/21/23. On 05/24/23 at 1:30 PM, the surveyor reviewed the CP for Resident #23. There was no revision made to the CP, including additional interventions added, after Resident #23 sustained a fall on 05/21/23. On 05/25/23 at 8:30 AM, the surveyor went to B-Wing and observed that Resident #23 was no longer in the room. The bed was stripped, and the mattress had been deflated. On 05/25/23 at 9:10 AM, the LPN assigned to the B-Wing, informed the surveyor that Resident #23 was transferred on 05/24/23 to another facility that was owned by the same company. The LPN could not offer any details as to why Resident #23 was transferred the prior evening. On 05/25/23 at 9:49 AM, the surveyor reviewed the electronic progress notes. There was no documentation in the medical record regarding Resident #23's transfer. When interviewed, the staff would not comment on who authorized or any reason for the transfer. There was no physician order for the transfer. At that time, the surveyor attempted to contact Resident #23's physician and the responsible party. Messages were left for both, and neither returned the surveyor's phone calls. The surveyor again, reviewed the electronic progress notes and noted the following entry dated 05/24/23 timed 21:37 [9:37 PM]: This note is a follow up to: 5/21/2023 7:39:00 Nursing Progress Note (Other) Focus: Effective Date: 5/24/2023, 21:10:00 [9:00 PM] Department: Nursing, Position: registered nurse, Created Date: 5/24/2023, 21:37:06 [9:37 PM], Note Text: On 5/21/23 at 7:39 AM, CNA advised me that res [resident] fell in [his/her] room. Upon arrival to res [resident] room, I observed res [resident] lying in bed. Res [resident] observed bleeding on head. Pressure dressing applied. Assessment and neuro (neurological assessment done to evaluate level of consciousness) check complete. Res [resident] was alert and oriented, responsive, PERRLA (Pupils Equal Round, Reactive to Light and Accommodation), hand grasp equal. Vital signs were taken (BP) blood pressure: 198/51 Pulse:86 Temp (temperature): 96.4 Respirations 18, Unable to obtain (SPO2) [Oxygen saturation]. 911 was called for immediate attention and MD was notified. No family listed. EMTs (Emergency Medical Transport) transferred res [resident] to [hospital name redacted] for further observation of the resident. Onboarding nurse made aware. On 05/25/23 at 10:15 AM, the surveyor again requested any investigations for Resident #23 from the Director of Nursing (DON), including any statements that were obtained from staff that worked on 05/21/23 for the 11:00 PM-07:00 AM shift [when fall occurred]. The investigation, nor any supporting documentation was provided. On 05/26/23 at 11:15 AM, the DON provided two Fall documents dated, 02/15/23 and 05/21/23 respectively. There were no statements attached to either document or that had been requested by the surveyor. There were no statements attached to the Fall documents to inform the reader who had witnessed the fall. The causal factor/s were not identified. A note entered on the Fall document dated 03/03/23 (18 days after the first fall), indicated the following: Resident was found on the floor. When asked as to what happened, he stated, I was trying to leave. On assessment c/o[complain] of left arm pain. MD [Medical Doctor] notified and ordered X-ray left arm. Resident was medicated for pain and assessed every shift while waiting for the X-ray to be done. Floor Mat was placed at bedside. To continue current at-risk care plan. Resident #23 was transferred to the Emergency Department on 02/16/23 at 10:50 AM due to complaint of pain in left arm. Resident #23 was diagnosed with a comminuted mildly displaced fracture of the left humeral head. The Fall document dated 02/15/23 timed 18:40 PM [6:40 PM], did not provide information regarding when Resident #23 was last observed and cared for and by whom. The Fall document did not include, and documentation in the Other section including if the bed was in low or high position, if the resident was in bed or in a wheelchair when found on the floor, if the call light was activated, if the resident was incontinent, the presence of absence of any devices that would alert the staff of the fall. The Predisposing Situation Factors section had History of Falls Bruising as the only checked area. Other. Alarm Sounded, Call Light on at Time, Reaching for Something, Wanderer, Attempted Self Toileting was left blank. The fall was unwitnessed. The revised care plan for falls dated 02/15/23 failed to address the line of supervision required by Resident #23 to prevent recurrence. Another Fall document dated 05/21/23 timed 07:21 AM, revealed the following notes entered by the LPN (Licensed Practical Nurse) on duty that night: CNA notified nurse that resident fell while attempting to change [him/her]. Resident [hit his/her] head on the floor just missing the floor mat and was bleeding profusely. The Registered Nurse (RN) who went to the room to assess the resident, documented the following on the Fall document: CNA notified nurse that resident fell when attempting to change [him/her]. Resident hit [his/her] head on the floor just missing the mat and was bleeding profusely. IDT Interdisciplinary Team discussed resident upon return from ER [emergency room ] and [resident] will be treated with antibiotic per MD order, family also requested hospice services. On 05/25/23 at 11:00 AM, the surveyor reviewed the assignment sheet dated 05/21/23 provided by the 07:00-3:00 PM shift which revealed that a Hospitality Aide (HA) was assigned to the B-Wing and cared for Resident #23 on the 11:00-PM-7:00 AM shift. The facility did not have a statement from the staff who cared for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23 according to the assignment sheet provided. On 05/30/23 at 10:30 AM, the DON provided a witness statement dated 05/22/23, which was not attached to the Fall document dated 05/21/23. According to the CNA's statement, she was assigned to Resident #23 during the 11:00 PM-7:00 AM shift, not the HA per the original assignment sheet as provided to the surveyor. On 05/30/23 at 11:00 AM, the facility provided a copy of a revised CP that included 26 pages, with additional interventions added that were not included on the CP that was revised on 05/25/23, and documented the following: Focus: [Resident #23] had a fall was found lying on the floor in [his/her] room. 05/21/23 Resident fell during care when [he/she] was turned to the side of the bed, it happened so fast, staff unable to prevent fall, Date Revised: 05/25/23. The Goal was to Risks for falls will be mitigated, Date Initiated: 02/15/23, Date Revised: 05/25/23 and Target Date: 08/14/23. The following interventions were documented: 2 persons assist during care, Date Initiated 05/21/23. 911 Was called and sent to hospital for evaluation, Date Initiated 05/21/23. Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23. Complete assessment with bleeding on left side of head, Date Initiated 05/21/23. Neuro check Initiated, Date Initiated 05/21/23; Neuro check x 72 hours, Date Initiated 05/21/23. Pressure dressing applied, Date Initiated 05/21/23. Primary physician made aware of the event, Date Initiated 05/21/23; Resident returned to the facility with antibiotic- Fosfomycin x 1 dose and doxycycline x 10 days, Date Initiated: 05/21/23. On 05/30/23 at 11:30 AM, an interview with an additional CNA who worked the 07:00-3:00 PM shift on 05/21/23 on the B-wing and who was listed on the assignment sheet for the same day, confirmed that the CNA who documented the statement did not provide care for Resident #23 on 05/21/23 on the 11:00 PM-07:00 AM shift. The CNA confirmed that the HA provided care to Resident #23 when the incident occurred. On 06/01/23 at 09:35 AM, the surveyor conducted a telephone interview with the Registered Nurse who worked on the 11:00 PM-07:00 AM shift on 05/21/23. The RN revealed that she was informed around 06:45 AM by the HA, that the resident sustained a fall. She went to the room and observed the resident was in bed and was bleeding profusely from the head, the resident reported feeling cold and was confused. The RN stated she then applied a pressure dressing, assessed the resident, implemented a neuro check, and called 911. Upon inquiry, the RN stated that the CNA who documented the statement was not assigned to Resident #23. In the presence of three other surveyors and the supervisor of the survey team, the RN stated that the HA was assigned to the resident. The RN further stated that when she questioned the HA regarding the mat that was to be in place to minimize injuries from falls, the HA changed his story several times. The RN also stated that she discussed the incident with the DON. The RN stated she did not know who transferred the resident back to bed after the resident was found on the floor. She further stated that she was made aware only two days ago that the staff who cared for Resident #23 on 05/21/23 during the 11:00 PM-07:00 AM shift, was a HA and was not a Certified Nurse Aide (staff trained to assist with certain non-resident care tasks). On 06/01/23 at 11:30 AM, the survey team informed the DON that the CNA who signed the witness statement, per interview and review of the timecard, was not assigned to the 11:00 PM shift on 05/21/23. The DON stated that she was told that the CNA reported that Resident #23 fell during care, she was not aware that Resident #23 was found on the floor by the Hospitality Aide. The DON was unable to explain why the HA was documented on the assignment sheets as having a resident assignment and was assigned to provide direct care to Resident #23. On 06/01/23 at 12:25 PM, the surveyor in the presence of the survey team, interviewed the CNA who signed the witness statement dated 05/22/23. The CNA stated that she was the CNA assigned to Resident #23 when the incident occurred, although her name was not listed on the schedule as being assigned to Resident #23 and contradicted the RN and LPN interviews. She stated during care Resident #23 fell , missed the mat and she yelled for help. The nurse then came into the room, assessed the resident on the floor and assisted her in transferring the resident to bed with a pulled sheet. On 06/01/23 at 12:30 PM, a review of the CNA's timecard provided by the Staffing Coordinator, revealed that the CNA who signed the witness statement worked 16 hours on 05/20/21 and reported to work on 05/21/23 at 07:02 AM. The CNA was not at the facility when Resident #23 sustained the fall. On 06/01/23 at 12:41 PM, the surveyor interviewed the Director of Nursing regarding the HA job description and inquired about who was responsible to monitor the HA. The facility had 8 Hospitality Aides assigned to the facility. The DON replied that the HAs had been working at the facility before she accepted the position as a DON, and she was not too sure of who was responsible to supervise or monitor the HAs. The DON then stated the nurses were responsible to monitor the HAs A review of the job description for the HA provided by the facility on 06/01/23 at 12:15 PM, revealed under Duties Report all pertinent information concerning resident care as directed to the appropriate supervisor/ personnel. Transport residents to activities, therapy, outside to smoke. Make beds, distributes linen as needed, and transports dirty linen to the linen room using established standards precautions. Distributes and sets up food trays for residents during meal times and collects empty trays from resident rooms and dining rooms. Monitor dining areas as assigned. Passes water pitchers Complete assignments timely, completely, and accurately. Conduct resident rounds as assigned. Answer call lights and obtain assigned staff members if direct patient care is needed. Cannot do any clinical care. On 06/02/23 at 09:53 AM, a telephone interview with the HA revealed that he worked the 11:00 PM -07:00 AM shift on 05/21/23. He stated that around 06:00 AM he went to the room to distribute linen and confirmed that he found Resident #23 on the floor bleeding (not the CNA as documented on the statement) and then he informed the nurse. The HA stated that he discussed the incident briefly with the DON on 05/21/23 and was not asked to document a statement. The surveyor then inquired regarding his name being on the schedule with a full assignment, he could not provide the rationale why he had a resident assignment. He stated that his job was to assist with task not related to direct care such as passing water, make beds, distribute linen. On 06/02/23 at 10:07 AM a telephone interview was conducted with the LPN who worked the 11:00 PM-07:00 AM shift. The LPN confirmed she worked on 05/21/23 and the HA was the person who reported the fall. The LPN continued and stated, that the RN went into Resident #23's room and assessed the resident after the fall. The LPN stated she did not go to the room, and she assisted with the paperwork for the emergent transfer. The LPN was unaware of who transferred the resident to bed. The LPN confirmed that the HA was the one assigned to and provided care for Resident #23 on the 11:00 PM-07:00 AM shift on 05/21/23. On 06/02/23 at 10:16 AM, during a second telephone interview with the RN, she stated that the HA had a resident assignment that day, and he cared for Resident #23 and confirmed that he was the one that reported the fall. The RN went on to state that when she entered the room, Resident #23 was already in bed and bleeding profusely. She did not ask who transferred the resident to bed. She was aware of the process to follow: Assessed while on the floor, ensure no head injury, implement neuro, alerted EMT (Emergency Medical Transport), notify the physician. She further stated that she discussed the fall with the DON. The surveyor reviewed Resident #23's ADLs worksheet for the month of May, left blank and there was no staff initials documented to identify who cared for Resident #23 on 05/21/23 during any of the shifts. On 06/02/23 at 11:15 AM, the DON was made aware of the discrepancy surrounding the fall dated 05/21/23. The DON was made aware of the telephone conversations with the nurses and the HA who worked the 11:00 PM-07:00 AM shift on 05/21/23. The DON stated that she was told that Resident #23 fell during care. The DON further stated since the resident was found on the floor, she considered the incident as a fall and did not investigate any further. The DON was asked to provide any additional information along with any Interdisciplinary Team Notes regarding the Fall document dated 05/21/23 for review on the exit day. On 06/05/23 at 11:34 AM, in the presence of the acting Administrator, the DON stated she went along with the information that was provided to her that Resident #23 fell during care, and that the fall was a witnessed fall, and she did not investigate. The facility did not present any further information. A review of a form titled, Accidents and Incidents-Investigation and Reporting dated 11/15/22, indicated the following: Policy Statement: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of accidents or incidents as appropriate. 2. The following data, as applicable shall be included on the Report of Incident/Accident form: The date and the time the accident or incident took place. The nature of the injury /illness. The circumstances surrounding the accident/incident if known. Where the accident/incident took place if known. The name (s) of witnesses if any and their accounts of the incident or accident if known. The injured person's account of the accident/incident if able to communicate. Other pertinent data as necessary or required . 3. The Nurse Supervisor/ Charge Nurse and /or the department director or supervisor shall complete a Report of Incident/Accident form and get witness statements if any at the time of the incident. This individual will submit completed documents to the Director of Nursing Services /designee and discuss the incident at the morning management meeting. Post Fall/ Injury Resident Management In the event a resident has fallen and/ or is found on the ground, a complete head to toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.) Remain with the resident while calling for assistance. If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). Upon arrival of the nurse, a quick head- to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. Fall Injury Prevention-Post Fall 1. Assess the resident/ patient and immediately implement appropriate measures to prevent injury. Initiate and complete the Incident including pertinent witness statements. Review Fall Risk Assessment for any changes in fall risk, reassess post fall. On 06/05/23 at 08:35 AM, the acting administrator provided a folder with in-services that were done regarding some of the concerns addressed with the facility on 06/02/23 during a pre-exit conference. Regarding the incident of 05/21/23 the acting administrator submitted a witness statement from a CNA that was not on the schedule. No statement from the nurses who worked that night were collected even when the facility was made aware of the discrepancy and the telephone interviews with staff that worked on 11:00 PM -07:00 AM shift. The Acting Administrator also submitted an undated form titled, Falls and Falls Risk Management. Under Policy Statement the following were entered: Based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under procedure #7 Falls are discussed at the clinical meeting in an attempt to determine the root cause(s). Review the fall, each morning and document in PCC (Point Click Care . However Resident 23 sustained a fall on 05/21/23. The facility did not submit the IDCP notes along with any root cause analysis that was done to identify the causal factor of the fall and rule out abuse. (Resident #23 was transferred from the floor to the bed prior to the nurse arrival to the room. There was no facility information provided regarding the transfer that occurred on 05/21/23 when the resident was found in bed, profusely bleeding, and required 2 persons physical assist for transfer.) NJAC 8:39-27.1 (a)

This is a repeat deficiency from the Standard Survey Date: 03/31/22 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to identify and consistently comprehensively assess, implement, and modify interventions, consistent with professional standards of practice a.) in response to an unplanned significant weight loss of 16.38% in less than 6 months for (Resident #128), and b.) in response to a significant weight loss of 8.6 pounds (lbs) in four days for (Resident #51). This deficient practice occurred for 2 of 5 residents reviewed for nutrition. The deficient practice was evidenced by the following: Reference: The Academy of Nutrition and Deititians, Position of the Academy of Nutrition and Dietitianss: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated April 2018. Position Statement It is the position of the Academy of Nutrition and Dietitians that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered Dietitian nutritionist assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered Dietitian nutritionists in the implementation of individualized nutrition care. a.) On 05/24/23 at 10:30 AM, Surveyor #1 observed Resident #128 as he/she attended the Resident Council Meeting (RCM). During the RCM, Resident #128 stated the food was inedible and that he/she had lost weight. Resident #128 stated that everything is mushy because it was steamed like the vegetables. I've eaten very few veggies (vegetables), too overdone. Resident #128 stated that he/she had spoken to the Dietitian twice and provided food preferences and that the Dietitian informed him/her that the vegetables were frozen and steamed. Resident #128 stated he/she would be happy with one piece of celery and a carrot, just fresh and that also the fruit was all canned and served at room temperature, not cold. Resident #128 stated that he/she was also informed by the Dietitian that whole grains never going to happen. Resident #128 further stated that the protein is inedible. All six residents who attended RCM acknowledged that they were not offered an alternative menu such as the Asian menu provided to the Asian population of residents. A review of Resident #128's Admission Record (an admission summary), revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to; alcohol use, other psychoactive substance abuse, depression, atherosclerotic heart disease (arteries become narrowed and hardened from a buildup of plaque), hypertension (elevated blood pressure), Type 2 diabetes, hyperlipidemia (elevated lipids in the blood), folate (vitamin B) deficiency, anemia, and hyperkalemia (elevated potassium) in the blood. A review of the facility provided, Weights and Vitals Summary, dated 05/31/23, revealed the following dates / weights: 01/31/23 weight 210 lbs (pounds) 02/01/23 weight 204.5 lbs 02/08/23 weight 202 lbs 02/13/23 weight 198.5 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -5.5%, -11.5 lbs] 02/20/23 weight 197.4 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -6%, -12.6 lbs] 02/22/23 weight 195 lbs -5.0% change [comparison weight 01/31/23, 210 lbs, -7.1%, -15 lbs] 03/06/23 weight 192.6 lbs -5.0% change [comparison weight 02/01/23, 204.5 lbs, -5.8%, -11.9 lbs]; -7.5% change [comparison weight 01/31/23, 210 lbs, -8.3%, -17.4 lbs] 04/08/23 weight 183 lbs 04/17/23 weight 177 lbs 04/24/23 weight 175.2 lbs 05/01/23 weight 176.2 lbs 05/08/23 weight 175.6 lbs. There were no further documented follow up weights or re-weights in the electronic medical record (eMR). A review of the Assessment section in the eMR did not reveal any nutritional assessments. A review of the Progress Notes (PN) in the eMR ranging from 02/01/23 through 06/01/23, revealed the following: 01/31/23, Admission notes revealed weight 210 lbs. 02/01/23, the Physician's history and physical revealed a weight of 204.5 lbs. 02/15/23, a Physician's note indicated a weight of 202 lbs. 03/02/23, 31 days after admission, the first dietary note, indicated review of weights upon admission. The note included 'does not consume all vegetables in facility limiting intake of vitamins and minerals' 'resident educated .possibility of MVI (multivitamin) with mineral supplement' 'resident request [name redacted - supplement drink]' The note indicated a different supplement drink was requested by Dietitian. Food preferences reviewed and noted. There was no calculation of estimated protein or calorie needs, and determination of causal factor for the unplanned weight loss. 03/9/23, a nursing note indicated the resident was seen by the dentist and recommendations were made for periodontal scaling. 03/12/23, a Physician's note indicated a weight of 195 lbs. 04/03/23, a Physician's note indicated a weight of 192.6 lbs. 05/15/23, a Physician's note indicated a weight of 175.6 lbs 5/8 (on 5/8/23), admission weight 210 lbs. progressive wt (weight) loss from 210 lbs to 175 lbs-will sch (schedule) f/u (follow up) CBC (complete blood count), CMP (comprehensive metabolic profile), Hba1c (hemoglobin a 1 c - blood work to indicate blood sugar levels over a three-month period), TSH (thyroid-stimulating hormone), monitor po (intake by mouth) intake, dietary eval (evaluation), consider dietary supplement and Remeron (medication used for appetite stimulation). The Progress Notes did not contain any additional notes from the Dietitian, any assessment to determine the causal factor of the weight loss and interventions to prevent weight loss. The PN dated 05/15/23, by the Physician did not indicate that a weight loss plan was ordered. A review of the facility provided, Order Summary Report (OSR), dated active orders as of 05/31/23, included but was not limited to; an order dated 2/10/23 for renal/CCD (carbohydrate-controlled diet regular texture, thin consistency, for low potassium diet), and an order dated 03/02/23 for [name redacted] liquid supplement two times a day for supplement. An order dated 4/4/23, with no end date for a BMP (basic metabolic profile blood work). There were no active orders for the Remeron, the follow up blood work, po intake monitoring, or dietary evaluation requested by the physician on 5/15/23. There were no active orders for a planned weight loss. A review of the person-centered comprehensive Care Plan last review completed 05/10/23, with a print date of 05/31/23, revealed no focus area regarding Resident #128's significant weight loss, no Goals regarding the weight loss, and no interventions regarding the weight loss. A review of the most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 05/02/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 14 out of 15; which indicated the resident was cognitively intact. Section K indicated a height of 71 inches and a weight of 176. K0300 loss of 5% or more in the last month or loss of 10% or more in last 6 months was inaccurately documented as 0 NO. On 05/30/23 at 12:17 PM, during an interview with the surveyors, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the Dietitian was on vacation and unavailable for interview. The LNHA further stated she would have to see who is covering and that she was unable to locate the Dietitians credentials. On 05/30/23 at 12:22 PM, the LNHA stated that the Dietitian was only gone for one week, so the facility did not need coverage. She also stated that the practice is the Dietitian would document in the eMR and that the Director of Nursing (DON) would confer with the Dietitian. On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated she worked with the Dietitian and that every Monday weights and reweighs would be completed. On Thursday they would have a weekly weight meeting and discuss significant weight changes and interventions. She stated the Dietitian would make recommendations for the nurses to carry over. The DON stated, we discuss what could have caused the weight change, any supplements that may be needed, review what might be appropriate, speak to dietary to see that orders were carried out, monitor weights, we assign a specific Certified Nursing Aide (CNA) to do the weights. We have to investigate what's wrong with the weights like maybe a different wheelchair was used, and we notify the doctor for orders. The DON stated that the Dietitian would ask about food preferences and that some residents ask for organic food, but we can't accommodate organic for just one and we would have to tell resident. The DON stated that the weekly weights were documented in a log and the Dietitian would document them in the eMR as well. The surveyor inquired what would happen if a CNA obtains a resident weight and there was a 10 lbs difference, what would be the process. The DON stated that the CNA assigned should know to re-weigh the resident. The DON stated the Dietitian went on vacation 5/25/23 and was expected to return 6/8/23 (15 days later) and that the DON had only been with the facility for 3 months but the Dietitian was at the facility much longer. The DON stated she would provide the weight meeting information regarding Resident #128. On 05/31/23 at 12:11 PM, Surveyor #1 observed Resident #128 in his/her room with their lunch tray on top of the over bed table. Resident #128 showed the surveyor that he/she only ate a chicken thigh and not the mashed potatoes or carrots. Resident #128 stated he/she had talked to Dietitian about fresh versus canned vegetables. Resident #128 stated he/she usually only drinks the supplement drink once a day not twice. He/she further stated the Dietitian knew about the weight loss and that he/she wanted to lose some weight but not because of (facility) food choices. Resident #128 stated I just want better food choices. On 05/31/23 at 1:00 PM, the Regional Administrator #2, the DON, and the Regional [NAME] President of clinical services (RVPCS) were made aware of the above concerns. On 06/02/23 at 9:00 AM, the DON provided four photocopied untitiled pages. The DON indicated the pages were the Weight Meeting notes. The pages included, but were not limited to Resident #128's name and the following information 1/31/2023 weight 204.5 # (pounds); 2/6/2023 weight 202 #; DO: (doctor order) 2/3/23 WW (weekly weights) x 4; and 2/10/23 WW x 3. Page 2 added 2/13/2023 weight 198.5 #; 2/20/23 weight 197.4 #; and 2/17/23 WW x 2. Page 3 added 2/27/23 weight 192.6 #, 3/6/23 weight 192.6 #, 3/13/23 weight 191.8 #; and 3/3/23 WW x 1, 3/10/23 WW x 4 due to monthly weight loss, and 3/17/23 WW x 1 since weight stable. Page 4 added 4/17/23 weight 177 #; 4/24/23 weigh 175.2 #; 5/1/23 weight 176.2 #; 5/8/23 weight 175.6 #; and 4/13/23 WW x 4; 4/20/23 WW x 3; 4/27/23 WW x 2; 5/4/23 WW x 1; and 5/11/23 monitor weights monthly. There was no documentation by the physician regarding a planned weight loss, any discussion of a weight loss plan with the resident or interventions ordered. On 06/02/23 at 10:40 AM, the RVPCS stated that the weight sheets were worksheets, and they can't go by those weights. She stated that on Sunday the Dietitian would review Thursday's weights, and Tuesday she would review Thursday weights. The RVPCS further stated the weights would be in the weight meeting book and if a resident were being monitored for weight loss, that would also be in the eMR. She stated any interventions or orders would be implemented immediately. A review of the weights revealed that on 01/31/2023, the resident weighed 210.0 lbs. On 05/08/2023, the resident weighed 175.6 pounds which was a -16.38 % loss in less than 6 months. The facility was unable to explain the discrepancies in the weights documented in the eMR versus the weight meeting logs; to provide documented evidence that interventions were revised in response to the significant weight loss; to provide any additional documentation of the weight loss by the Dietitian; to provide a Dietitian assessments, food preference list; or any person-centered comprehensive care plan of focus area, goals, or interventions for Resident #128's significant weight loss. b.) On 05/22/23 at 10:25 AM, Surveyor #1 observed Resident #51 lying in bed with just a sheet on. Resident #51 appeared very thin, and the surveyor was able to observe bones under areas of his/her skin. On 05/23/23 at 12:36 PM, Surveyor #1 observed Resident #51 in a high back wheelchair in the B-unit day room. The resident had a lunch tray with beef macaroni casserole and carrots. The resident was drinking his/her juice but not eating the casserole. On 05/23/23 at 12:45 PM, the Licensed Practical Nurse (LPN) was encouraging Resident #51 to eat but the resident refused. The LPN asked if the resident wanted a peanut butter and jelly sandwich, and the resident nodded his/her head yes. During an interview at that time, the LPN stated the resident likes peanut butter and jelly and would usually eat all of the breakfast meal. The LPN stated that the facility Dietitian would be the one in charge of the resident's weight loss if any. A review of the facility provided, Weights and Vitals, dated 05/31/23, revealed the following: 03/09/23 a weight of 110 lbs. 03/14/23 a weight of 101.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -7.8 %, -8.6 lbs.] 04/17/23 a weight of 100.4 lbs. (recorded by the Dietitian); -5.0% change [comparison weight 03/09/23, 110 lbs., -8.7%, -9.6 lbs.] and -7.5% change [comparison weight 03/04/23, 110 lbs., -8.7%, -9.6 lbs.] A review of Resident #51's Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, hemiplegia (paralysis of one side of the body), and hypertension. A review of the most recent Annual MDS dated [DATE], included but was not limited to a BIMS of 01 out of 15, which indicated the resident was severley cognitively impaired. Section G, Functional Status, revealed Resident #51 required limited assistance with a one-person physical assist for eating. Section K, Swallowing/Nutritional Status, revealed the resident weight as 110 lbs. and a score of 0 NO for weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A review of the PN for Resident #51 date range 03/01/23 to 03/20/23, revealed a nursing entry on 03/08/23, that the resident's weight was 110 lbs. The next entry was dated 03/09/23, by Social Services and did not address the resident's weight. The next entry was dated 03/18/23, by nursing and did not address the resident's weight. There were no progress notes to indicate the Dietitian evaluated the resident or that the physician was notified of the resident's weight loss. A review of Resident #51's person-centered comprehensive care plan printed 05/30/23, included but was not limited to a focus area of nutritional problem related to low body mass index (BMI) date initiated 03/21/23. Interventions date initiated 03/21/23, included monitor/record/report to MD (physician) PRN (as needed) signs / symptoms of malnutrition: significant weight loss: 3 lbs. in 1 week, > (over) 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no evidence in the eMR that the physician was notified of the weight loss of 8.6 lbs. in March 2023. On 05/30/23 at 12:17 PM, during an interview with surveyors, the LNHA stated she would have to see who was covering for the Dietitian who was on vacation from 05/27/23 and to return on 06/03/23. The facility Dietitian was unavailable for interview. On 05/30/23 at 1:29 PM, during an interview with the surveyors, the DON stated the weekly weight documented in a log and the Dietitian would document the weights in the eMR. Surveyor #1 requested the weight meeting notes. On 05/31/23 at 10:07 AM, the DON stated that she was still looking for the weight meeting information. The DON acknowledged she could not locate any documentation to immediately address the 8.6 lbs. weight loss in 4 days and stated she did not know why Resident #51 was not reweighed. On 05/31/23 at 11:10 AM, the DON provided an untitled paper and stated it was the weight meeting notes with resident names. Resident #51's name was included. The paper included monthly weight difference -3.6#/30 days -4.4#/6 months; monthly weight 3/2023 weight 98.6#, 2/2023 weight 102.2#, 9/2022 weight 103#; Date weekly weight 2/20/23 weight 102.2# w/c (wheelchair), 3/6/23 weight 98.6#, 3/13/23 weight101.2#. Interventions included 2/14/23 [name redacted] supplement drink four times a day, 2/17/23 WW x 4, 2/24/23 WW x 3, 3/3/23 WW x 2, 3/10/23 WW x 1, 3/17/23 monitor weights monthly. The interventions did not address the 8.6 lbs. weight loss in 4 days and the weights listed were either different or not documented in the eMR. There were no documented weights for 02/17/23, 02/24/23, 03/03/13, or 03/10/23. On 05/31/23 at 11:10 AM, the facility provided, Nutritional Assessment-Quarterly, dated 03/22/23, which was reviewed and included but was not limited to; current weight 108#. The assessment was signed by the Dietitian on 04/08/23. The eMR did not include a documented weight of 108 lbs. The facility provided hand written, paper weight meeting notes which reflected a weight for 03/13/23 of 101.2 lbs. Surveyor #1 reviewed the weight logs on Resident #51's unit. An entry dated weekly weights March 14, 2023 indicated Resident #51's weight was 101.2 lbs. An entry dated April Monthly Weights indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights May 1, 2023 indicated Resident #51's weight as 98.2 lbs. An entry dated Weekly weights 05/08/23 indicated Resident #51's weight as 97.4 lbs. An entry dated Weekly weights 05/15/23 indicated Resident #51's weight as 98.2 lbs. All of the entries were left blank in the area for staff to initial as having weighed the resident. The 03/14/23 weight was not documented in the eMR. The April weight in the eMR was 04/17/23, 100.4 lbs. and 04/24/23, 100.6 lbs. The 05/01/23 weight was not documented in the eMR. The 05/09/23 weight was not documented in the eMR. The 05/15/23 weight in the logbook was 98.2 lbs. and the eMR had a documented weight of 103.0 lbs. indicating a 4.8 lb. discrepency. On 06/01/23 at 10:05 AM, Surveyor #1 informed the facility of the weights which did not coincide with the eMR and Resident #51's 8.6 lbs. weight loss, and no documented reweigh or immediate interventions, as stated by the DON, upon discovery of a significant weight loss. At that time, the facility was unable to provide additional information. On 06/02/23 at 9:39 AM, during an interview with Surveyor #1, the LPN working on B-Wing stated that if there was a large discrepancy in a resident's weight, the staff would first re-weigh the resident and then inform the DON and physician. Upon reviewing the weight on 03/13/23, the LPN stated that weight was entered by the Dietitian, and she would be the one responsible for comparing and reviewing the weights. The LPN further stated that if there was a re-weigh completed on 03/13/23, it would be located in the eMR. The LPN accessed the eMR in the presence of the surveyor and was unable to find a documented re-weigh for Resident #51. On 06/02/23 at 10:40 PM, during an interview with the surveyor team, the RVPCS stated that the weight sheets were worksheets and you can't go by those weights. A review of the facility provided, Dietitian job description, reviewed 06/10/22, included but was not limited to; communicates with medical staff, nursing and other department personnel; must be able to relate information concerning a resident's condition; conduct nutrition assessments of patients referred by healthcare providers; maintains nutritional care plans, reviews medical records, documents findings; collects patient information and records patient information; effectively and efficiently completes all paperwork requirements for billing and medical records compliance; evaluates how patients respond to their diets; and works to ensure patient satisfaction. A review of the facility provided, Weight Assessment, Management and Intervention Procedure, undated, included but was not limited to Weight Assessment 1. The nursing staff will measure resident weight, weight will be placed in unit weight book for Dietitian review; 2. Any weight change of 3% or more since the last weight will be retaken for confirmation; 3. The Dietitian will respond within 24-72 hours of receipt of notification; 4. the threshold for significant unplanned and undesired weight loss will be based on: a. 1 month - 3% weight loss is significant; greater than 5% is severe; 6 months- 10% weight loss is significant; greater than 10% is severe; 5. If the weight change is desirable, this will be documented. Analysis 1. The interdisciplinary team will identify conditions and medications that may be causing weight loss or increasing the risk of weight loss. 2. The Dietitian will discuss undesired weight gain with the resident and/or family; 3. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. NJAC 8:39-17.1 (c); 17.2(d)

Complaint Intake # NJ 0 Based on observations, interviews, and record reviews, it was determined that the facility failed to provide pressure ulcer treatment for 1 (Resident #1) of 3 residents reviewed with pressure ulcers. This deficient practice resulted in Resident #1 developing a stage 4 pressure ulcer which then got infected and resulted in the resident getting [CONDITION(S)] (bone infection). Findings included: 1. The facility admitted Resident #1 on 01/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital for a wound infection on 06/20/2021 and returned to the facility on [DATE]. The resident was no longer in the facility. A review of a 01/29/2021 Nursing Admission Evaluation indicated Resident #1 had a left heel deep tissue injury (DTI) and a pink sacrum. There were no measurements for the DTI or the pink sacrum. A review of a history and physical, completed on 01/30/2021 by the nurse practitioner (NP), indicated Resident #1 had a left heel DTI with black eschar (necrotic/dead tissue) surrounding the area. The NP also indicated the DTI had serous drainage (serum, clear/thin liquid). The NP ordered a wound culture and sensitivity and wound care for the left heel. The redness that had been previously noted on the 01/29/2021 nursing admission assessment was not addressed by the NP. A review of the treatment administration record (TAR) revealed no treatment was started for Resident #1's pink sacrum when identified on admission. No interventions were noted on the TAR to help decrease the risk of the sacral pinkness becoming worse. The 02/04/2021 admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. The resident's hearing was adequate, the resident had clear speech, was understood and was able to understand, and vision was adequate. The resident had no behaviors identified including rejection of care. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident had the one pressure ulcer (unstageable, DTI) on the left heel. A review of the nurses' notes dated 02/26/2021 indicated the previously pink sacral area had opened. The nurse described the sacral pressure ulcer as silver-dollar sized with no drainage and no measurable depth. The nurse's note revealed a new order had been received to cleanse the sacral pressure ulcer with normal saline, apply [MEDICATION(S)] ointment and cover with a dressing daily. The nurse added Resident #1 was non-compliant with off-loading their heels, despite encouragement. A review of the February 2021 TAR for Resident #1 revealed no treatment was started for the sacral pressure ulcer until the area opened on 02/26/2021 at which time a treatment to cleanse the sacral wound with normal saline and apply [MEDICATION(S)] daily was added to the TAR. There was no indication the sacral redness had been assessed or treated prior to 02/26/2021. No interventions were added to the TAR to help the sacral pressure ulcer heal. A review of weekly cumulative measurements provided by the Director of Nursing (DON) indicated the first weekly wound measurement for the sacral pressure ulcer occurred on 03/08/2021, with the wound measuring 4 centimeters (cm) by 4 cm by 0.1 cm. This was 10 days after the sacral pressure ulcer was identified as open. There was no indication of what stage the ulcer was. A review of the physician's progress notes revealed the first mention of a sacral pressure ulcer for Resident #1 occurred on 03/10/2021. The physician listed the pressure ulcer as Problem #6, with no other information given about the sacral pressure ulcer. A review of the March 2021 TAR indicated on 03/16/2021 the previous treatment was discontinued. A new treatment was started on Resident #1's sacral pressure ulcer that consisted of cleansing with NS (normal saline) and applying [MEDICATION(S)] ointment twice a day. The physician's progress note, dated 03/29/2021, indicated the facility should continue in-house treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The gauze packing would be covered with border gauze and changed daily. A review of the March 2021 TAR for Resident #1 indicated treatments were ordered twice daily. All treatments were completed except for 03/31/2021. There was no indication the resident had refused the two treatments on that day. On 04/05/2021, the measurements listed for the sacral pressure ulcer were 5 cm x 4 cm x 1.5 cm and was described as a Stage 4 pressure ulcer. A review of physician's progress notes dated 04/12/2021 indicated the physician ordered a low air loss mattress for Resident #1. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the April 2021 TAR for Resident #1 indicated weekly skin assessments had been added for the nurse to complete on the 7:00 AM to 3:00 PM shift. All entries for skin assessments were initialed to indicate the assessment had been completed. Weekly skin assessments had not been completed from admission on 01/29/2021 until April 2021. On 05/24/2021, a review of orders revealed the 04/12/2021 order for a low air loss mattress had been transcribed and added to the TAR, indicating the resident had just received the air mattress on 05/24/2021. This was 42 days after the air mattress was ordered. The TAR also revealed weekly skin assessments had been signed as completed by the nurses. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered the sacral pressure ulcer to be cleansed with Dakin's solution and then packed with a calcium alginate (a soft, highly absorbent dressing made from seaweed/[NAME]) and covered. The treatment was ordered to be completed daily. A review of the physician's progress note, dated 06/07/2021, indicated Resident #1 had a chronic sacral wound. On 06/28/2021, the physician revealed the measurements for the stage 4 sacral pressure ulcer as 4 cm x 3.2 cm x 2 cm. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of nursing progress notes, dated 06/20/2021, indicated Resident #1 was transferred to the hospital and was admitted for an infection of the sacral pressure ulcer. The resident was readmitted to the facility on [DATE]. The Nursing Admission Evaluation indicated on readmission the Stage 4 sacral pressure ulcer measured 4 cm x 3.2 cm x 2 cm with dark pink/red tissue and moderate serosanguinous (combination of blood and serum) drainage. A review of a nurse's note dated 06/26/2021, indicated wound care had been provided secondary to bowel incontinence. The nurse documented, To this nurse the area is markedly larger c (with) copious, slime-like slough & (and) scattered exudate. There was no indication the physician or the responsible party was notified of the change in Resident #1's sacral wound. A review of physician's progress notes dated 06/28/2021, indicated Resident #1's sacral pressure ulcer was considered a Stage 4 by the physician. A review of the June 2021 TAR for Resident #1 indicated missed treatments on 06/07/2021, 06/08/2021, and 06/26/2021 through 06/30/2021. These dates were not signed off as completed. There was no evidence the resident had refused treatments on these seven days. The TAR also indicated the 06/25/2021 skin assessment had not been signed as completed. A review of the physician's progress notes dated 07/12/2021, indicated Resident #1's physician ordered magic cup (an ice cream like nutritional snack) and Vitamin C 500 milligrams twice daily to aid in sacral pressure ulcer healing. A review of the physician's progress notes dated 07/12/2021, indicated Resident #1's sacral pressure ulcer was considered a Stage 4. The physician documented the resident's current wound care would continue. On 07/13/2021 a review of nurse's notes indicated Resident #1 was seen by the wound nurse practitioner and a treatment change was ordered. The nurse documented the Dakin's solution was discontinued and a treatment using [MEDICATION(S)] would be used. [MEDICATION(S)] would be applied around the wound and then covered with a bordered gauze. A review of the cumulative measurements for Resident #1's sacral pressure ulcer, provided by the DON, indicated on 07/26/2021 the wound measurements were 9 cm x 7 cm x 2.8 cm. A review of the July 2021 TAR for Resident #1 indicated the resident received treatments 07/01/2021 through 07/05/2021 consisting of applying Santyl ointment daily. The entry for Santyl was marked as discontinued on 07/05/2021. On 07/14/2021 an entry had been added that indicated the sacral wound for Resident #1 would be cleansed with [MEDICATION(S)] and acetic moistened gauze packed into the wound twice daily. The entry start date was listed as 07/05/2021. There was no indication Resident #1 had refused treatments between 07/05/2021 and 07/14/2021. There was no evidence the resident refused treatment on these nine days. A review of the August 2021 TAR indicated [MEDICATION(S)] treatment continued twice a day. There was no indication any skin assessments were completed in August. On 08/13/2021 an entry was made on the TAR to reposition Resident #1 side to side every two hours while in bed and to document any refusals. There were also entries to use a wedge cushion for positioning and to use a cushion to the chair when the resident was out of bed with the instructions to limit Resident #1's time out of bed to two hours. The entries were identified as a FYI (for your information). There was no documentation that indicated Resident #1 had refused treatments or turning and positioning. Another entry on the TAR with a start date of 07/09/2021 indicated the resident was on an every two hours turn schedule. The entry was divided between the three shifts. Ten shifts had been omitted. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The sacral wound would be cleansed with Dakin's solution and packed with calcium alginate and [MEDICATION(S)] (a protective barrier) would be applied around the wound. The wound would be covered with ABD pads (Abdominal Dressing - a highly absorbent dressing) and secured with paper tape daily. A review of the September 2021 TAR indicated the entry for every two hours turn schedule had been changed to a FYI entry. The [MEDICATION(S)] treatment continued from 09/01/2021 through 09/07/2021. On 09/09/2021 the treatment was entered as cleanse Resident #1's sacral wound with Dakin's solution and pack the wound with silver alginate daily. On 10/01/2021 an MRI (magnetic resonance imagery) of Resident #1's sacral area was scheduled to rule out [CONDITION(S)] (bone infection). Transportation did not show up, so the MRI was rescheduled for 10/05/2021. A review of nurse's notes indicated on 10/11/2021 and 10/12/2021 the nurse placed a call to the hospital's radiology department to get the results of the MRI. The nurse documented she was notified the MRI results were not ready. The results of the MRI when received, identified Resident #1 with a decubitus ulcer with [CONDITION(S)] of the sacrococcygeal junction. On 10/13/2021 Resident #1 was scheduled to have a peripherally inserted central catheter (PICC) for long term intravenous (IV) medication administration. On 10/18/2021 Resident #1 was started on [MEDICATION(S)] (an IV antibiotic) for six weeks to treat [CONDITION(S)] in the sacral pressure ulcer. A review of the September 2021 TAR for Resident #1 indicated the resident had not received the ordered treatments of cleansing the wound with Dakin's solution and packing with silver alginate on 09/26/2021 and 09/27/2021. These dates were not signed off as completed. There was no evidence the resident had refused treatment on these two days. A review of the quarterly MDS, dated [DATE], revealed the resident had no behavior or rejection of care during the assessment period. The MDS indicated the resident required extensive to total assistance for bed mobility, toileting, personal hygiene, and bathing. The MDS indicated Resident #1 had one Stage 4 pressure ulcer that was not present on admission. The resident now had a BIMS score of six out of 15 indicating severe cognitive impairment. A review of the October 2021 TAR for Resident #1 revealed missing documentation that confirmed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the resident had refused treatments on these four days. The weekly skin assessment was not signed as completed on 10/29/2021. A review of Resident #1's care plan, last reviewed on 11/04/2021, indicated the resident had a stage 4 sacral pressure ulcer and was at risk for skin breakdown. The goal of wound improvement was to be attained using an anti-pressure mattress, encouraging, and assisting the resident to reposition, wound consult, pressure-reducing devices on bed and chair, diet and supplements per orders, preventative skin care, pillows and positioning devices as needed, medications as ordered, dietary evaluation, incontinent care, and repositioning on rounds. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered the dressing to be changed daily. A review of Resident #1's November 2021 TAR indicated an order to clean the sacral pressure ulcer with Dakin's solution and pack with Silver Alginate (a highly absorbent dressing made from seaweed and silver) daily. The treatment was signed as completed from 11/02/2021 through 11/09/2021. On the treatment entry was handwritten, D/C [discontinue] 11/15/21. There was no treatment signed as completed from 11/09/2021 until 11/15/2021 (seven days) when the new treatment started. The entry turn and position was written as a FYI (for your information) with no expectation staff would sign when completed. A review of Resident #1's December 2021 monthly orders indicated dietary interventions used to help Resident #1's wound included super cereal (a high calorie cereal) at breakfast, Magic Cup (a nutritional snack high in calories and vitamins) at dinner and, Prostat (provides extra protein needed for wound healing) 30 milliliters (ml) three times a day. Other interventions listed on the monthly orders included every-two-hour turning schedule, cushion for the geriatric chair (geri-chair) when out of bed, limit being out of bed to two-hour intervals, reposition and turn every two hours and document resident refusal, and off load heels in bed as tolerated. Review of the TAR failed to reveal Resident #1 had refused any pressure ulcer reducing interventions or refusal of pressure ulcer care. A review of the December 2021 TAR for Resident #1 revealed an entry for treatments to be completed daily on the sacral pressure ulcer. The TAR had been signed designating completed treatments on 12/12/2021 and 12/13/2021 and on 12/21/2021 and 12/22/2021. The rest of the dates for December were blank. There was no evidence the resident refused treatment to the sacral pressure ulcer for 24 days in December. A review of measurements, presented by the DON indicated on 12/27/2021 Resident #1's sacral pressure ulcer measured 5.8 cm x 3 cm x 1 cm. A review of progress notes from admission on 01/29/2021 through December 2021 revealed no evidence that Resident #1 had refused or was non-complaint with any pressure ulcer reducing interventions or refusal of pressure ulcer care. LPN #2 was interviewed on 01/25/2022 at 2:59 PM. LPN #2 stated she remembered Resident #1 was admitted with a red sacrum and added protective cream was applied after incontinence as a preventative measure. The LPN stated the protective cream should have been added to the TAR. LPN #2 stated the last time she cared for Resident #1 she sent the resident to the emergency department with a low blood pressure, high heart rate, and a temperature. She stated she had not liked the way the resident's sacral wound looked. She stated this was in June 2021. The LPN stated that without documentation there was no way to know for sure the cream had been applied to the resident's reddened sacrum. LPN #2 added if blanks were found on the TAR that was indicative the treatment had not been completed. Resident #1's primary care physician (PCP) was interviewed by phone on 01/26/2022 at 11:44 AM. The PCP stated she remembered Resident #1 and added the resident had [CONDITION(S)] of the sacral wound for which Resident #1 had received IV antibiotics. The PCP stated she felt Resident #1's sacral pressure ulcer was unavoidable due to the resident's overall medical condition was just not that good. The PCP stated if a treatment was not signed as done, it was concluded the treatment was not done as she had ordered but added in this case, she thought the nurses probably just forgot to sign. She stated even missing a treatment or two would not affect the outcome for this resident. The Director of Nursing (DON) and Administrator were interviewed on 01/26/2022 at 1:05 PM. The DON stated if a resident refused treatment, the nurse was expected to ask the resident more than once. If the resident continued to refuse, the nurse was expected to notify the PCP, initial the square and circle indicating a refusal, and then document on the back of the TAR that the resident had refused the treatment. The DON stated areas not signed for treatments meant the treatment was not completed as ordered and may result in a decline of the wound. The DON reviewed the TAR for Resident #1 and stated by the number of empty spaces and lack of signing that those treatments had been completed, there was a lot of education that needed to be done. She stated based on the TAR, Resident #1 had not received treatments to the sacral wound as ordered by the PCP. The DON stated she was unsure if the resident got sacral treatments since there was no entry for a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an undated facility policy titled, Skin Alteration Reporting and Documentation, indicated under Procedure, Paragraph 2 that a Licensed nurse/Nurse Supervisor will indicate location and description of the skin alteration on the skin occurrence report. Paragraph 3 continues, Licensed nurse/supervisor reports the occurrence to the Physician, Responsible Party/Family, and DON/Designee and indicate that on the skin incident report. Paragraph 6 of the policy indicated the licensed nurse/supervisor documents the occurrence in the progress notes to include, date, time, location of skin alteration, measurements of skin alteration, treatment initiated, names of persons notified, response of the family/significant other at the time of notification and document that 2 licensed nurses did a full head to toe skin assessment. New Jersey Administrative Code § 8:39-27.1(e)

C#: NJ 0 Based on interviews, record reviews and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe environment for a severely cognitively impaired resident (Resident #3) with a roommate (Resident #2), who had a [DIAGNOSES REDACTED]. On 1/17/2021 at 7:45 a.m., Resident #2 physically assaulted Resident #3, sending that resident to the hospital. Resident #2 ,was refusing his medications that controlled his behaviors prior to this incident. The Pre-Admission Screening and Resident Review (PASRR) Level II was not followed, it indicated that Resident #2 needed to be seen for a psychiatric visit that was due upon re-admission on 12/23/2020 at the facility, however this visit was done on 1/12/2021, 15 days later. On this day, Resident #2 was seen by the Advanced Practice Nurse- Certified Psychiatrist, who documented that the resident needed inpatient psychiatric treatment to stabilized aggressive behaviors towards others and this was not possible due to refusal of medications. The facility also failed to follow its policy titled Safety and Supervision of Residents. This deficient practice was evident for 1 of 9 sampled residents (Resident #2) for behaviors by the following: According to the facility Admission Record (AR), Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 10/1/2020, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the resident was cognitively impaired. 2. According to the facility AR, Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], Resident #3 had short-term and long-term memory problems and was severely cognitively impaired. The MDS also indicated that Resident #3 needed extensive assistance with ADLs. Review of the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 1/19/2021 with an event date of 1/17/2021 and a time of event of 7:45 a.m., revealed the following: According to the FRE, Resident #2 had a physical altercation with Resident #3. The document revealed that on 1/17/2021, at approximately 7:45 a.m., the call light was on in Resident #2's and Resident #3's room, and the Licensed Practical Nurse (LPN #1) asked the Certified Nurse's Assistant (CNA #1) to respond to the residents' room. The FRE indicated when CNA #1 entered the room; the CNA observed blood on Resident #3's face, gown, pillow, and wall. The FRE revealed CNA #1 asked Resident #2 what happened, and Resident #2 stated, I did it! CNA #1 called for LPN #1, who responded and observed Resident #3 lying on his/her side; the resident's face was swollen and bloody, and there was blood on Resident #3's pillow and gown. The LPN called for the Registered Nurse (RN #1), who saw blood on Resident #3's sheets and nose. The FRE also indicated the right side of Resident #3's face was swollen and bruised, and the resident was unable to open his/her right eye. Further review of the FRE indicated RN #1 assessed Resident #3, the resident's SpO2 (oxygen saturation level in the blood) was 77% (percent). The FRE indicated Resident #3 was administered oxygen by a non-rebreather mask at 15 L (liters) and the resident's Sp02 then increased to 90% (percent). The FRE revealed 911 was immediately called, Resident #2 was placed on one-to-one observation until the police arrived, and both residents were sent to different hospitals to be evaluated. The FRE indicated the facility concluded that Resident to Resident Abuse was substantiated. A review of the Individual Statement Form (ISF) dated 1/17/2021, written by CNA #1, showed at Approximately 7:45 a.m., (LPN #1) asked me to go into room (number) because the call light was on. When I went into the room, I pulled the curtain, and I noticed dark stuff on (Resident #3's) pillow. I turned the light on, and I saw blood on (his/her) face and the wall. The ISF also indicated, CNA #1 asked Resident #2 what happened, and Resident #2 responded, (I did it). I immediately yelled for the nurse to come, and she came and asked me to get the nurse from B-Wing. A review of the ISF dated 1/17/2021, written by LPN #1, revealed that on 1/17/2021 at 7:45 a.m., the nurse noticed the call light was on and asked CNA #1 to go to the room then the CNA yelled that (Resident #3) was hurt and to please come to the room to assess. LPN #1 explained, Upon entering the room, I noticed (Resident #3) was lying on (his/her) side, (the resident's) face was swollen and bloody, and there was blood also on his/her pillow and gown. A review of the ISF dated 1/17/2021, written by RN #1, revealed that on 1/17/2021 at 7:45 a.m., the RN was called by LPN #1 to Resident #2's and Resident #3's room. When RN #1 arrived in the room, there was blood on Resident #3's sheets, gown, and blood coming out of the resident's nose. The ISF also revealed Resident #3' s right side face was swollen and bruised, and the resident could not open the right eye. Further review of the ISF showed 911 was called, and blood was noted to be on both of (Resident #2's) hands. The RN also wrote she asked Resident #2 what happened, and the resident did not answer. Review of Resident #2's Care Plan (CP) dated 01/11/2021 showed the following: Under: Focus: Resident #2 has episodes of verbal/physical agitation/aggression AEB (as evidenced by) pacing halls, physically intimidating staff, charging at staff, verbal aggression R/T (related to) Cognitive impairment, Sensory overload. Under: Goal showed Will not harm self or others, Will not strike others . through the target date. Under: Interventions included: Administer medication per physician orders .If behavioral intervention strategies are not working, leave (if safe to do so) and reapproach later . A review of the Physician's Orders revealed the following: [MEDICATION NAME] ([MEDICATION NAME]) 100 mg (milligram) Tablet. Give 3 tablets (300 mg) orally at bedtime for [MEDICAL CONDITION]. [MEDICATION NAME] ([MEDICATION NAME] ER) 500 mg ER (extended release). Give 2 tablets (1000 mg) orally daily for [MEDICAL CONDITION]. [MEDICATION NAME] ([MEDICATION NAME]) Tab 10 [MEDICATION NAME](orally disintegrating tablet). Give 1 tablet orally daily for [MEDICAL CONDITION]. A review of the December 2020 Medication Administration Record [REDACTED] [MEDICATION NAME] ([MEDICATION NAME]) 100 mg on 12/31/2020. [MEDICATION NAME] ([MEDICATION NAME] ER) 500 mgER on [DATE], 12/30/2020 & 12/31/2020. [MEDICATION NAME] ([MEDICATION NAME]) Tab 10 mg on 12/24/2020, 12/25/2020, 12/26/2020, 12/28/2020, 12/30/2020 and 12/31/2020. A review of the January 2021 MAR indicated [REDACTED] [MEDICATION NAME] ([MEDICATION NAME]) 100 mg on 1/1/2021, 1/2/2021, 1/3/2021, 1/4/2021, 1/5/2021. [MEDICATION NAME] ([MEDICATION NAME] ER) 500 mgER on [DATE], 1/2/2021, 1/3/2021, 1/4/2021, 1/5/2021, 1/6/2021, 1/12/2021, 1/13/2021, 1/14/2021. [MEDICATION NAME] ([MEDICATION NAME]) Tab 10 mg on 1/6/2021, 1/7/2021, 1/12/2021, 1/13/2021, 1/14/2021, 1/15/2021 and 1/16/2021. During an interview on 1/27/2021 at 11:47 a.m., the Unit Manager (UM) stated if a resident refused medications for more than 3 consecutive days. The medical doctor (MD) is notified, and a nurse's note is completed. The UM explained she would encourage the resident to take the medications and explain why he/she needed to take the medications. The UM indicated when Resident #2 refused the medications, there was nothing else done or no extra supervision provided. A review of the Interdisciplinary Progress Note (IPN) revealed on 12/4/2020 at 1:30 p.m., Resident #2 became combative with staff, hitting the CNA multiple times by following the staff out of the room and had to be sent out to Crisis for evaluation. During an interview on 1/27/2021 at 12:20 p.m., the Administrator stated Resident #2 was sent out to Crisis on 12/4/2020, I couldn't control (him/her.) The Administrator explained Resident #2 was .disrobed on the unit, pacing and knocked down the medication cart . The Administrator indicated that Resident #2 was admitted to the hospital and returned on 12/23/2020 to the facility. Review of the MR revealed Resident #2 was readmitted to the facility on [DATE] with the following recommendations: According to the Pre-Admission Screening and Resident Review (PASRR) Level II, dated 12/21/2020, upon admission/readmission to the facility, Resident #2 was to have a psychiatric consultant immediately. Further review of the MR showed no evidence that Resident #2 was seen by the Psychiatry group immediately upon returning to the facility on [DATE] per the PASSR II recommendations. However, the MR revealed that Resident #2 was not seen by the psychiatry group for evaluation until 1/12/2021, fifteen days after readmission to the facility despite displaying medication refusals upon return to the facility and aggressive verbal behaviors on 1/2/2021 and 1/10/2021. During an interview on 1/27/2021 at 1:10 p.m., the Social Worker (SW) indicated, the PASRR was correct that a psych (psychiatric) evaluation should have been completed immediately when Resident #2 was readmitted . The SW also stated, I do not know why it was not done. A review of IPN dated 1/17/2021 at 9:30 a.m., written by LPN #1, showed nurse went into the room to assess Resident #3, noticed blood on Resident #2 hands, and immediately ran to Resident #3 and noticed he/she was bloody and his/her face was swollen and blood on his/her gown. The IPN also revealed that 911 and Crisis were called, and both residents were sent out to the hospital for evaluation. During an interview on 1/27/2021 at 11:47 a.m., the Surveyor asked the UM how was Resident #2 being monitored; the UM stated Resident #2 had behavioral monitoring done every shift, every day noted on a Target Behavioral Symptom Sheet. The UM explained Resident #2 had no additional supervision. A review of January 2021 Psychoactive Medication Monthly Flow Records (PMMFR), Section I: Target Behavioral Symptoms, revealed monitoring of symptoms 3. Hitting, 4. Kicking, 5. Paranoia, 12. Disrobing and 13. Yelling Out for (Resident #2) every shift: Day, Evening, and Night every day. According to the PMMFR, Resident #2 had no identified behaviors on 1/2/2021 Day Shift, however, the IPN showed that the resident was verbally aggressive on 1/2/2021 at 7:00 a.m., screaming and calling staff Stupid Idiots. According to the PMMFR, Resident #2 had no identified behaviors on 1/10/2021 Night Shift, however, the IPN showed that the resident was verbally aggressive on 1/10/2021 at 2:30 a.m. yelling in the hallway. During an interview on 1/20/2021 at 2:00 p.m., the SW indicated she tries to protect and keep other residents safe by telling staff to avoid confrontation with Resident #2. The SW also stated, I inform staff to keep a safe distance. A review of Medication Management Assessment, (MMA) dated 1/12/2021 completed by the APN-C (Advanced Practice Nurse-Certified) Psychiatrist revealed the following recommendation for (Resident #2) . requires (inpt.) inpatient psychiatric treatment due to his/her increasingly aggressive behavior as he/she is a harm to others. Also, stabilization at the facility is not possible due to refusal of medications. During a telephone interview on 1/20/2021 at 12:10 p.m., the APN-C stated Resident #2 was aggressive and unable to be treated at the facility since the resident refused his/her medications. The APN-C explained she met with Resident #2, and the Resident was difficult to have a conversation with and was delusional and paranoid. The APN-C also stated, I felt (Resident #2) was unsafe to be around others. The APN-C also said she spoke to the Administrator, Social Worker, and the UM about the recommendations for Resident #2. However, the MR showed no documentation that the APN-C concerns were addressed. During a second telephone interview on 1/20/2021 at 1:15 p.m., the APN-C stated that in the long term, one-on-one monitoring would not be appropriate for Resident #2. She also stated the resident needed an inpatient psychiatric facility, and the (facility) was not appropriate for this resident (Resident #2). During an interview on 1/20/2021 at 1:40 p.m., the UM stated she was responsible for following up on the Psychiatry recommendations. A review of the facility policy titled Safety and Supervision of Residents dated 2001, with a revised date of December 2007, revealed the following: Under Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Under Policy Interpretation and Implementation .2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; . Under Resident-Oriented Approach to Safety .5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently; b. evaluating the effectiveness of interventions; c. modifying or replacing interventions as needed; and d. evaluating the effectiveness of new or revised interventions. N.J.A.C.: 8.39-4.1 (a) (5) N.J.A.C.: 8.39-27.1 (a)