Every finding on record at Pine Acres Rehabilitation and Healthcare

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.On 1/11/26 at 9:28 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour:1. In the three-door standing freezer, the surveyor observed an open bag of French Fries, vegetable burgers, all-beef hamburger and shrimp; all missing open and use-by labels. The FSD stated all items that have been opened should have open and use-by dates.2. In the ice cream freezer, the surveyor did not observe a thermometer. The FSD stated they would put a new thermometer in the freezer immediately. 3. In the beverage preparation area, the surveyor observed the juice dispenser with 4 of 7 tubes noted with a sticky build up on the tubing. The FSD stated the tubing would be cleaned immediately.4. In the milk refrigerator, the surveyor did not observe a thermometer. The FSD stated they would put a new thermometer in the milk refrigerator immediately.5. On the food preparation table, the surveyor observed the can opener with a blackish debris. Also, observed the microwave with a yellowish grease-like substance. The FSD stated both items would be cleaned immediately. 6. In the cooking area, the surveyor observed the top of the standing two door oven and a shelf above the 6-range stove top with a sticky substance. The FSD stated all cooking equipment would be cleaned immediately. 7. On the spice rack, the surveyor observed an 80-ounce (oz) container of honey, 16oz paprika, 1-quart egg shade liquid color, 4 pounds (lb.) fine granulated sugar, 16oz ground cinnamon, 1 quart barbeque sauce, and 24 oz strawberry gelatin mix all open without open and use-by labels. The FSD stated all opened and unlabeled items would be disposed of immediately.8. In the dishwashing area, the surveyor observed two dietary aides (DA#1 and DA#2) both with facial hair that was not covered with a beard guard. The FSD had both DA#1 and DA#2 put on beard guards.9. In the dry storage area, the surveyor observed three bags of hamburger buns and one loaf of white bread, all were open without open and use by labels. The FSD disposed of the nonlabelled items.10. On 1/12/26 at 11:18 AM, during the follow up inspection of the kitchen, in the presence of the FSD, the surveyor observed the chef checking food temperatures for the lunch meal. While the chef was checking the temperature of the baked chicken, the plastic portion of food thermometer touched the chicken, contaminating the chicken. The chef stated they did not realize the plastic portion of the thermometer touched the chicken and that the chicken should be discarded due to contamination. On 1/14/26 at 9:47 AM, the Administrator in Training (AIT) provided the surveyor with multiple facility policies. The labelling and dating policy with a reviewed date of 7/2025 revealed under the process section, 1. All food products, upon receiving, must be dated with a receiving date. 2. All food items must be labeled with either a manufacturer label or handwritten label.a. Once a product has been prepared or portioned, a new use by date is established.c. Once prepared or portioned food items will be dated with compliance of 72-hour rule and labeled with use on or by. The sanitation policy with an updated date of 10/2025 revealed under the procedure section, 1. The dietary service director monitors the safety and sanitation of the dietary department on a daily basis. The hair and beard guard policy with a reviewed date of 9/2025, revealed under the procedure section, 2. [NAME] guards should be worn by any employee with facial hair. The record of food temperature policy with an updated date of 9/2025, revealed under the policy explanation, 14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.On 1/14/26 at 12:23 PM, the surveyor met with the Licensed nursing Home Administrator (LNHA), Infection Preventionist (IP), AIT, Regional Registered Nurse (RRN), Director of Operations (DOP) and Director of Nursing (DON) to review concerns found during the survey. The DOO stated the kitchen concerns would be corrected immediately.On 1/15/26 11:21 AM, the surveyor met with the LNHA, DON, DOO, AIT, RRN, and DON for the exit conference; no further pertinent information was provided. NJAC 8:39-17.2(g)

Complaint # 2707766 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 6 of 6 residents (Resident #1, #13, #16, #41, #68 and #83) observed for incontinence care on 1 of 3 units (First floor nursing unit). This deficient practice was evidenced by the following: 1. On 1/11/26 at10:39 AM, the surveyor was touring the 1st floor unit and smelled a strong odor of urine throughout the unit. On 1/11/26 at 11:15 AM, the surveyor interviewed Resident #1, who was sitting in their wheelchair next to their bed. The surveyor observed an adult brief laying on the top of the Resident #1's bed that was statured with urine. Resident #1 stated the brief had been there for 45 minutes and they had removed the adult brief themselves because a Certified Nursing Assistant (CNA) had not checked on them. A review of Resident #1's admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; pneumonia (an infection that inflames the air sacs in one or both lungs), generalized muscle weakness (weakness in multiple muscle groups) and type 2 diabetes mellitus (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to provide enough insulin). A review of Resident #1's Quarterly Minimum Data Set (MDS), an assessment tool dated 12/9/25 reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #1 was cognitively intact. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident #1's two Care Plans (CP): 1. Included a focus area that the resident had the potential for skin breakdown related to decreased mobility and episodes of bowel and bladder (B&B) incontinence with interventions that included but were not limited to; provide incontinence care throughout the shift. 2. Included a focus area that the resident has bladder incontinence related to activity intolerance with interventions that included but were not limited to; incontinent: check throughout shift for incontinence. Wash, rinse and dry eith perineum. Change clothing after incontinence episodes. 2. On 1/13/2026 at 7:25 AM, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) identified residents as being incontinent and dependent on staff for care. On 1/13/26 at 7:30 AM, the surveyor conducted an incontinence tour on the 1st floor East Nursing Unit and observed the following: a. On 1/13/26 at 7:30 AM, the surveyor accompanied by the LPN/UM observed Resident #13 in bed. The LPN/UM exposed Resident #13's incontinence brief and the surveyor observed that the incontinence brief was saturated with urine. The LPN/UM confirmed that the brief was saturated. A review of Resident #13's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia ( a general term for loss of memory, language, problem-solving and other thinking abilities) anxiety (a feeling of uneasiness and worry subjectively seen as menacing) and hypertension (high blood pressure). A review of Resident #13's Quarterly Minimum Data Set (MDS), an assessment tool dated 10/19/25 reflected Resident #13 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident #13's Care Plan (CP) included a focus area that the resident had the potential for impaired skin integrity related to bladder incontinence with interventions that included but were not limited to; provide incontinence care throughout the shift. b. On 1/13/26 at 7:40 AM, the surveyor accompanied by the LPN/UM observed Resident #16 in bed with a strong urine odor in the room. The LPN/UM exposed the resident's incontinence brief and the surveyor observed that the brief was wet and the under pad was saturated with urine. The LPN/UM confirmed the strong malodorous odor and the wet and saturated under pad. The surveyor reviewed the medical record for Resident #16 A review of the Resident #16's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; epilepsy (a brain disorder causing seizures due to abnormal electrical activity), aphasia ( a language disorder that impairs a persons ability to speak) and diabetes mellitus ( a chronic condition where the body's blood sugar (glucose) levels become too high). A review of Resident 16's Quarterly MDS dated [DATE] reflected the resident's cognitive skills for daily decision making were severely impaired. A further review of the MDS reflected Resident #16 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of the resident's CP included a focus area that the resident had a potential for skin breakdown related to impaired mobility and incontinence with interventions that included but were not limited to; provide incontinence care every 2 hours and when needed. c. On 1/13/26 at 7:45 AM, the surveyor accompanied by the LPN/UM observed Resident #68 in bed. The surveyor observed a strong smell of urine in the resident's room. The LPN/UM exposed the resident's incontinence brief and observed a second brief inserted within the first one. The surveyor observed that both briefs and the under pad were all saturated with urine. The LPN/UM confirmed the unpleasant odor and saturated briefs and under pad. A review of Resident #68's admission Record reflected Resident #68 was admitted to the facility with diagnoses that included but were not limited to; seizures, (abnormal electrical activity in the brain) hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) , hypertension and aphasia. A review of Resident #68's Quarterly MDS dated [DATE] reflected that the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for personal hygiene. A further review of the MDS indicated the resident was frequently incontinent of bladder, and always incontinent of bowel. A review of Resident #68's CP included a focus area that the resident was at risk for impaired skin integrity related to incontinence and impaired mobility due to cerebral vascular accident (CVA) with right-sided weakness and history of pressure-related wounds with interventions that included but were not limited to; provide incontinence care as needed. d. On 1/13/26 at 7:55 AM, the surveyor accompanied by the LPN/UM observed Resident #41 in bed. The LPN/UM exposed the resident's incontinence brief and observed the incontinence brief was saturated with urine. The LPN/UM confirmed the incontinence brief was saturated with urine. A review of Resident #41's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and hypertension. A review of Resident #41's Annual MDS dated [DATE] reflected the resident had a BIMS score of 3 out of 15 which indicated a severe cognitive impairment. A further review of the MDS reflected that the resident required the assistance of staff for personal care and was always incontinent of bowel and bladder. A review of Resident #41's CP included a focus area that the resident had a potential for skin breakdown related to incontinence with interventions that included but were not limited to; provide incontinence care every two hours and as needed. e. On 1/13/26 at 8:00 AM, the surveyor accompanied by the LPN/UM observed Resident #83 in bed with an oxygen concentrator ( a medical device that filters nitrogen from the air to provide a concentrated flow of up to 95% pure oxygen) in place with the oxygen flow rate at 3 LPM. The LPN/UM exposed the resident's incontinence brief and the surveyor observed that the brief was saturated with urine. The LPN/UM confirmed the incontinence brief was saturated with urine. A review of Resident #83's admission Record reflected Resident #83 was admitted to the facility with diagnoses that included but were not limited to; hypertension and Congestive Heart Failure. A review of Resident #83's Quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 7 out of 15 which indicated the resident had a severe cognitive impairment. A further review of the MDS revealed that Resident #83 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of Resident #83's CP included a Focus area that the resident had the potential for impaired skin integrity related to anticoagulant therapy, bladder incontinence and decreased mobility with interventions that included but were not limited to; keep skin clean and dry and provide incontinence care throughout the shift and as needed. On 1/13/26 at 8:05 AM, the LPN/UM confirmed that the residents were not provided with timely and appropriate incontinence care every 2 hours per the facility policy. On 1/13/26 at 8:10 AM, during an interview with the surveyor, the 7PM-7 AM LPN, stated that the CNA should have provided incontinence care every 2 hours, but that the CNA had too many residents and might not have been able to do that. On 1/13/26 at 8:20 AM, during a phone interview with the surveyor and in the presence of the LPN/UM, the 11-7 CNA, confirmed that she should have provided the residents with incontinence care every 2 hours, but that she was only able to make rounds twice during her shift because she had 21 residents on her assignment and it was just not possible to provide incontinence care every 2 hours with 21 residents. On 1/13/26 at 8:55 AM, during an interview with the surveyor, the staffing coordinator (employed for 3 years), stated that they were unsure of the state-mandated CNA-to-resident ratios but would check upstairs as they had all the ratios listed on their computer. On 1/13/26 at 2:20 PM, during an interview with the surveyor in the presence of the Director of Operations, the staffing coordinator confirmed that they were not aware of the state-mandated staffing ratios. The staffing coordinator further stated that they thought the nurses could be working and counted as CNAs even if they were the only nurse on the unit. The Director of Operations acknowledged that the night shift had a CNA-to-patient ratio of 1:21 and that it should have had 1:14 ratio. The Director of Operations confirmed that the 1st floor was not staffed in accordance with state regulations. On 1/14/26 at 12:25 PM, the survey team met with the LNHA, DON, AIT, Director of Operations, Infection Preventionist Nurse, and Regional Nurse, to discuss the above observations and concerns. A review of the facility's Incontinence Care policy, dated as reviewed 9/2025, reflected .It is the policy of this facility to promote resident comfort by keeping residents clean and dry to prevent skin breakdown . On 1/15/26 at 10:30 AM, the survey team met with the administrative staff. The DON confirmed that incontinence care should be provided by the CNAs every 2 hours and as needed. No further information was provided. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed in 1 of 3 units during the initial tour. The deficient practice was evidenced by the following:On 01/13 /2026 at 10:00 AM, the surveyor toured the 1st floor nursing unit and observed the following:1. In room [ROOM NUMBER], the heater cover in the bathroom was broken. The surveyor also observed that the wall behind the door bed had chipped paint, exposing the wallboard, and the wall by the window bed had chipped paint across the entire wall, exposing the wallboard.2. In the shower room, there were broken floor tiles and a broken toilet seat. The shower mat was heavily soiled, and the floor beneath it was covered in a thick brown substance. On 1/14/26 at 10:55 AM, during an interview with the surveyor, the Director of Housekeeping (DHK) stated that the housekeeping staff were responsible for cleaning and mopping the shower rooms daily. The surveyor showed the DHK the soiled shower mat and floor beneath it. The DHK confirmed that the floor had not been cleaned recently, and this did not provide the residents with a clean, homelike environment. On 1/14/26 at 11:02 AM, during an interview with the surveyor, the Housekeeper assigned to the 1st floor nursing unit stated that he was responsible for cleaning the shower room daily. He confirmed that he had not cleaned it today, nor had he cleaned it when he worked on the 1st-floor nursing unit on Monday. The HK stated, I just didn't get to it. On 1/14/26 at 11:10 AM, the surveyor showed the Director of Maintenance (DOM) the broken tiles in the shower room, the broken toilet seat, the broken heater cover in room [ROOM NUMBER], and the chipped paint in room [ROOM NUMBER]. The DOM stated that he was not aware of the above areas in disrepair and confirmed that they should have been repaired, as this does not provide residents with a homelike environment. On 1/15/26 at 10:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in training, Director of Operations, Infection Prevention Nurse and regional nurse to discuss the above observations and concerns. A review of the facility's policy, Clean/Homelike Environment dated as reviewed 9/2025, reflected that residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on observation, interview, record review, and review of facility policies it was determined that the facility failed to provide safety measures, nursing orders and follow interventions for a resident who has a history of falls. This deficient practice was identified for 3 of 3 residents (Resident #3, #5, and #66) reviewed for falls.The deficient practice was evidenced by the following: 1. On 1/11/26 at 10:55 AM, the surveyor observed Resident #3 in their room sitting in a medical reclining chair with a call bell in hand. Resident #3 was unable to participate in an interview related cognition. On 1/11/26 at 11:30 AM, the surveyor reviewed the hybrid medical record (combination of the electronic medical record (e-MAR) and the physical medical chart). The admission Record (AR) revealed that the resident had been admitted to the facility with diagnosis that included but were not limited to; hemiplegia and hemiparesis (one-sided paralysis), aphasia (disorder that results from damage usually from a stroke or traumatic brain injury to areas of the brain that are responsible for language), and muscle weakness (weakness in multiple muscle groups). A review of the annual Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 11/19/25, revealed that the resident had a BIMS score of 99, which indicated Resident #3 was unable to complete the interview. A review of the order summary report revealed a nursing order dated 7/16/24, Floor mat at bedside. Check for placement every shift for fall precautions. A review of Resident #3's care plan (CP) included a focus area that the resident has a potential for falls related to muscle weakness, use of mechanical lift for transfers, secondary to recent hospitalization; with interventions that included but not limited to; mattress on floor next to bed and place bed in the lowest position. On 1/13/26 at 9:24 AM, in the presence of the Regional Registered Nurse (RRN), the surveyor observed Resident #3 in bed without a floor mat present as well as the bed in a high position. The RRN acknowledged that Resident #3 did not have a floor mat at bedside despite a nursing order and the resident's bed was not in the lowest position per care plan interventions. On 1/13/26 at 12:26 PM, the RRN provided the surveyor with a facility policy titled, Care Plans - Comprehensive with a reviewed date of 6/2025. The policy interpretation and implementation revealed, 3. Each resident's comprehensive care plan to: a. incorporates identified problem areas .e. identify the professional services that are responsible for each element of care. 2. On 1/11/26 at 10:24 AM, the surveyor observed Resident #5 lying in bed with their eyes closed on an air mattress. The resident's fall mat was in a folded position leaning up against the nightstand. There was not a floor mat on the floor while the resident was in bed. A review of the AR revealed the resident had diagnoses which included but were not limited to; metabolic encephalopathy, (when the brain has trouble working because of a chemical, or metabolic, problem in the body), muscle weakness, and severe protein-calorie malnutrition. A review of the resident's most recent quarterly MDS, included a BIMS score of 4 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 12/9/25,.that the resident presents with decreased strength, transfers, balance and ambulation.has potential for falls related to deconditioning, recent hospitalization, and noncompliance with safety, dated 9/4/25.falls noted on the care plan for 8/26/25 and 9/6/25.interventions included: floor mat in place next to bed, dated 8/31/25 and to monitor on all rounds, dated 8/31/25. A review of the Order Summary Report (OSR) did not include an order for floor mats. 3. On 1/11/26 at 10:36 AM, the surveyor observed Resident #66 lying in bed with their eyes closed on an air mattress. The resident's fall mat was in a folded position between the end of the bed and was leaning against the nightstand. There was not a floor mat on the floor while the resident was in bed. A review of the AR revealed the resident had diagnoses which included but were not limited to; unspecified dementia (symptoms affecting memory, thinking and social abilities). A review of the resident's most recent quarterly MDS, included the BIMS score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS section J1800, indicated the resident had 3 falls. A review of the resident's individual comprehensive care plan (ICCP) included a focus area. had a history of falls, dated 9/4/23. Intervention included but not limited to floor mat in place next to bed, dated 9/17/25 and to monitor on all rounds, dated 9/22/25. A review of the OSR physician orders (PO): did not include an order for floor mats. On 1/14/26 11:37 AM, the surveyor interviewed the Licensed Practical Nurs/ Unit Manager (LPN/UM). She stated floor mats are used for safety. She further stated that when the residents are in bed floor mats should be in place. On 1/14/26 11:54 AM, the surveyor interviewed the Director of Nursing (DON) who stated, when we identify a patient, the facility puts the floor mats in the room to prevent injury, and the resident will be care planned for it. A review of the Fall Mat- Fall intervention policy, dated 10/2025, revealed.to implement the use floor mats as nonrestrictive, precautionary measure for residents identified as high risk from repeated falls. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer Oxygen Therapy according to the physician's order for 1 of 3 Residents (Resident # 83), reviewed for respiratory therapy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/13/26 at 8:00 AM, the surveyor, accompanied by the LPN/UM observed Resident #83 in bed with Oxygen (O2) delivered via a nasal cannula (NC) tubing (a light weight tube with two prongs that deliver supplemental oxygen from the oxygen concentrator directly into the nostrils) attached to the O2 Concentrator (a medical device that filters nitrogen from the air to provide a concentrated flow of up to 95% pure oxygen) in place with the O2 flow rate set at 3 liters per minute (lpm. The LPN/UM confirmed that the gauge was set at 3 lpm, but stated that she was not sure if that was what the physician had ordered.A review of Resident #83's admission Record reflected that Resident #83 was admitted to the facility with diagnoses that included but were not limited to; hypertension (high blood pressure) and Congestive Heart Failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). A review of Resident #83's Quarterly Minimum Data Set (MDS) dated [DATE] reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had a severe cognitive impairment. A further review of the MDS revealed that Resident #83 had not received intermittent or continuous oxygen therapy. A review of the current Order Summary Report had a current physician's order (PO) with a start date of 1/11/26, which included Oxygen at 2 lpm as needed for SPO2 (oxygen saturation, representing the percentage of oxygen-carrying hemoglobin in the blood) less than 92 every 6 hours as needed for shortness of breath. A review of the 7 PM-7 AM nurse's note dated 1/13/26 at 7:42 AM, reflected that the resident slept through in no distress.Spo2 97% on O2 at 3 lpm. A review of Resident #83's CP included a Focus area that the resident had Congestive Heart Failure with interventions that included but were not limited to; Oxygen therapy as ordered by MD. On 1/13/26 at 8:30 AM during an interview with the surveyor, 7 PM-7 AM, LPN confirmed that she had not checked the PO to ensure that the O2 was administered according to the physician's orders and confirmed that the PO was to administer the O2 at 2 lpm, not 3 lpm. The LPN stated that she should have checked the PO. On 1/15/26 at 10:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in training, Director of Operations, Regional Nurse, and Infection Control Nurse to discuss the above observations and concerns. The DON confirmed that nurses should follow the physician's orders for administering O2. A review of the facility's Oxygen Administration policy dated 10/2025 reflected It is the policy and procedure of this facility to provide oxygen to residents in compliance with their physician's order. On 1/15/26 at 11:25 AM, no further information was provided. NJAC 8:39-27.1 (a)

Complaint # 2707766 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 5 of 6 residents (Resident #13, #16, #41, #68 and #83) on 1 of 3 units (1st -floor Nursing Unit). This deficient practice was evidenced by the following: Refer to F6771.On 1/13/2026 at 7:25 AM, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) identified residents as being incontinent and dependent on staff for care. On 1/13/26 at 7:30 AM, the surveyor conducted an incontinence tour on the 1st floor East Nursing Unit and observed the following: a. On 1/13/26 at 7:30 AM, the surveyor accompanied by the LPN/UM observed Resident #13 in bed. The LPN/UM exposed Resident #13's incontinence brief and the surveyor observed that the incontinence brief was saturated with urine. The LPN/UM confirmed that the brief was saturated. A review of Resident #13's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia ( a general term for loss of memory, language, problem-solving and other thinking abilities) anxiety (a feeling of uneasiness and worry subjectively seen as menacing) and hypertension (high blood pressure). A review of Resident #13's Quarterly Minimum Data Set (MDS), an assessment tool dated 10/19/25 reflected Resident #13 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was always incontinent of bowel and bladder.A review of Resident #13's Care Plan (CP) included a focus area that the resident had the potential for impaired skin integrity related to bladder incontinence with interventions that included but were not limited to; provide incontinence care throughout the shift. A Review of the 11-7:00 AM Certified Nursing Aide (CNA) assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11-7AM shift. b. On 1/13/26 at 7:40 AM, the surveyor accompanied by the LPN/UM observed Resident #16 in bed with a strong urine odor in the room. The LPN/UM exposed the resident's incontinence brief and the surveyor observed that the brief was wet and the underpad was saturated with urine. The LPN/UM confirmed the strong malodorous odor and the wet and saturated underpad. The surveyor reviewed the medical record for Resident #16A review of the Resident #16's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; epilepsy (a brain disorder causing seizures due to abnormal electrical activity), aphasia ( a language disorder that impairs a persons ability to speak) and diabetes mellitus ( a chronic condition where the body's blood sugar (glucose) levels become too high).A review of Resident 16's Quarterly MDS dated [DATE] reflected the resident's cognitive skills for daily decision making were severely impaired. A further review of the MDS reflected Resident #16 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder.A review of the resident's CP included a focus area that the resident had a potential for skin breakdown related to impaired mobility and incontinence with interventions that included but were not limited to; provide incontinence care every 2 hours and when needed. Review of the CNA assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11-7AM shift. c. On 1/13/26 at 7:45 AM, the surveyor accompanied by the LPN/UM observed Resident #68 in bed. The surveyor observed a strong smell of urine in the resident's room. The LPN/UM exposed the resident's incontinence brief and observed a second brief inserted within the first one. The surveyor observed that both briefs and the underpad were all saturated with urine. The LPN/UM confirmed the unpleasant odor and saturated briefs and underpad. A review of Resident #68's admission Record reflected Resident #68 was admitted to the facility with diagnoses that included but were not limited to; seizures, (abnormal electrical activity in the brain) hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) , hypertension and aphasia. A review of Resident #68's Quarterly MDS dated [DATE] reflected that the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for personal hygiene. A further review of the MDS indicated the resident was frequently incontinent of bladder, and always incontinent of bowel. A review of Resident #68's CP included a focus area that the resident was at risk for impaired skin integrity related to incontinence and impaired mobility due to cerebral vascular accident (CVA) with right-sided weakness and history of pressure-related wounds with interventions that included but were not limited to; provide incontinence care as needed. Review of the CNA assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11-7AM shift. d. On 1/13/26 at 7:55 AM, the surveyor accompanied by the LPN/UM observed Resident #41 in bed. The LPN/UM exposed the resident's incontinence brief and observed the incontinence brief was saturated with urine. The LPN/UM confirmed the incontinence brief was saturated with urine. A review of Resident #41's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and hypertension.A review of Resident #41's Annual MDS dated [DATE] reflected the resident had a BIMS score of 3 out of 15 which indicated a severe cognitive impairment. A further review of the MDS reflected that the resident required the assistance of staff for personal care and was always incontinent of bowel and bladder. A review of Resident #41's CP included a focus area that the resident had a potential for skin breakdown related to incontinence with interventions that included but were not limited to; provide incontinence care every two hours and as needed. Review of the CNA assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11-7AM shift. e. On 1/13/26 at 8:00 AM, the surveyor accompanied by the LPN/UM observed Resident #83 in bed with an oxygen concentrator ( a medical device that filters nitrogen from the air to provide a concentrated flow of up to 95% pure oxygen) in place with the oxygen flow rate at 3 LPM. The LPN/UM exposed the resident's incontinence brief and the surveyor observed that the brief was saturated with urine. The LPN/UM confirmed the incontinence brief was saturated with urine. A review of Resident #83's admission Record reflected Resident #83 was admitted to the facility with diagnoses that included but were not limited to; hypertension and Congestive Heart Failure. A review of Resident #83's Quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 7 out of 15 which indicated the resident had a severe cognitive impairment. A further review of the MDS revealed that Resident #83 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of Resident #83's CP included a Focus area that the resident had the potential for impaired skin integrity related to anticoagulant therapy, bladder incontinence and decreased mobility with interventions that included but were not limited to; keep skin clean and dry and provide incontinence care throughout the shift and as needed. Review of the CNA assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11:00PM-7:00AM shift. A Review of the 11-7:00 AM Certified Nursing Aide (CNA) assignment sheet revealed that the first-floor nursing unit had a census of 21 Residents with 1 assigned aide. The CNA had an assignment of 21 residents on that 11-7AM shift. On 1/13/26 at 8:05 AM, the LPN/UM confirmed that the residents were not provided with timely and appropriate incontinence care every 2 hours per the facility policy. On 1/13/26 at 8:10 AM, during an interview with the surveyor, the 7PM-7 AM LPN, stated that the CNA should have provided incontinence care every 2 hours, but that the CNA had too many residents and might not have been able to do that. On 1/13/26 at 8:20 AM, during a phone interview with the surveyor and in the presence of the LPN/UM, the 11-7 CNA, confirmed that she should have provided the residents with incontinence care every 2 hours, but that she was only able to make rounds twice during her shift because she had 21 residents on her assignment and it was just not possible to provide incontinence care every 2 hours. On 1/13/26 at 8:55 AM, during an interview with the surveyor, the staffing coordinator (employed for 3 years), stated that they were unsure of the state-mandated CNA-to-resident ratios but would check upstairs as they had all the ratios listed on their computer On 1/13/26 at 2:20 PM, during an interview with the surveyor, the Staffing Coordinator confirmed that on 1/12/26- 1/13/26 during 11:00 PM-7:00 AM, shift the census on the first-floor nursing unit was 21. The staffing coordinator stated that there was 1 CNA scheduled to the first-floor unit and that he thought the nurse could be counted as a CNA even though she was the only nurse assigned to the first-floor unit. The staffing coordinator was not aware that the ratio for the 11:00 PM-7:00 AM, shift was 1 CNA to 14 Residents for the night shift.A review of the facility's staffing policy dated as reviewed 10/2025 reflected.It is the policy and procedure of this facility to adequately staff the facility. On 1/15/26 at 10:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in training (AIT), Infection Prevention Nurse (IPN), Regional Nurse (RN) and Director of Operations to discuss the above observations and concerns. The LNHA stated that he was not aware that the staffing on the first-floor nursing unit was not sufficient. He further stated that he felt the nurse on the first-floor should help the CNA provide incontinent care for the residents. The LNHA's lack of awareness failed to ensure adequate staffing levels were maintained to meet the residents' needs. NJAC 8:39-5.1(a), 27.1 (a), 27.2 (h)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan (CP) to meet the resident's needs. This deficient practice was observed for 2 of 19 residents reviewed, Resident #30 and #15, as evidenced by the following: 1. On 08/26/24 at 08:22 AM, the surveyor observed Resident #30 in the dining room eating, using their left hand. The resident stated to the surveyor that their right hand was weak. The resident further stated that the facility provided something for their right hand, but they refused to wear it. On 08/27/24 at 10:05 AM, the surveyor interviewed the Certified Nurse Assistant #2 (CNA#2) who was assigned to Resident #30. CNA #2 stated the resident used the left arm most of the time due to the weakness of the right arm. On 08/27/24 at 12:01 PM, the surveyor interviewed the Licensed Practical Nurse #3 (LPN#3) assigned to Resident #30, who stated that the resident refused to wear the right-hand splint. The surveyor reviewed the electronic record medical record which revealed the following: According to the Admission Record (an admission summary) (AR), Resident #30 was admitted to the facility with diagnoses that included but were not limited to Hemiplegia (one-side paralysis) and Hemiparesis (one-sided muscle weakness) following Cerebral Infarction (disruptive blood flow to the brain) affecting the right dominant side. A review of the Quarterly Minimum Data Set (an assessment tool used to facilitate the management of care) (Q/MDS), dated [DATE], revealed in Section C. Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of Q/MDS revealed Section GG - Functional Limitation in Range of Motion, A. Upper extremity (shoulder, elbow, wrist, hand) 1. Impairment on one side. B. Lower extremity (hip, knee, ankle, foot) 1. 1. Impairment on one side. The surveyor reviewed Resident #30's comprehensive CP which did not reflect the resident's refusal to wear the right-hand splint. 2. On 08/26/24 at 08:40 AM, the surveyor observed Resident #15 in bed with eyes closed. On 08/28/24 at 11:11 AM, the surveyor interviewed CNA#1, who stated that the resident had a resting hand splint during the night and CNA #1 removed it at the start of her shift at 7AM. On 08/28/24 at 11:20 AM, the surveyor interviewed LPN#1, who confirmed to the surveyor that the resident had a physician's order for a resting hand splint at night. The surveyor reviewed the electronic record medical record that revealed the following: According to the AR, Resident #15 was admitted to the facility with diagnoses that included but were not limited to other Genetic-Related Intellectual Disability. A review of the Q/MDS, dated [DATE], revealed in Section C - Cognitive Patterns the resident had a BIMS score of 99, indicating severe cognition impairment. A review of the August 2024 Order Summary Report revealed a PO dated 8/12/24 to Apply left resting hand splint at night to wear up to 6+ hours as tolerated. Monitor skin daily and remove if pressure points or redness present. Every night shift for contraction prevention. A review of the Progress Notes dated 7/29/24, documented left-hand splint in place per orders. The surveyor reviewed the residents' comprehensive CP which did not reflect the resident's use of resting hand splint at night. A review of the facility's policy and procedure with a review date of 01/2024 titled Care Plans under Policy revealed that: A comprehensive care plan will be developed for each resident within seven (7) days of completion of resident assessment. The care plan must include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment. The Interdisciplinary Team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on comprehensive assessment. On 08/29/24 at 01:07 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Infection Preventionist and discussed the above concern. No further information was provided. NJAC 8:39-11.2 (e)

Based on observation, interview, and review of medical records, it was determined that the facility failed to a.) follow appropriate hand hygiene practices to prevent the potential spread of infection observed during care for Resident #15 and b.) provide urinary care in a sanitary manner for 1 of 2 for Resident #59. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site for the same patient, After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. 1. On 8/28/24 at 11:11 AM, the surveyor in the presence of the Certified Nursing Assistant #1 (CNA#1) went inside the resident's room to see Resident #15. CNA #1 donned a new pair of clean gloves and touched resident's blanket. After CNA #1 put the blanket in place, CNA#1 then removed her used gloves and discarded them in the garbage bin. The surveyor observed CNA #1 walked outside the resident's room without performing any hand hygiene or use of ABHR. The surveyor also observed CNA #1 placed her hand inside her pocket. CNA#1 went inside another resident's room to perform hand hygiene when the surveyor observed CNA #1 lathered her hands for a total of eight (8) seconds. During the interview, CNA #1 stated to the surveyor that handwashing must be at least 40-60 seconds. CNA #1 further stated that she should have performed hand hygiene after removing the gloves. On 08/29/24 at 09:25 AM, the surveyor interviewed the facility's Infection Preventionist/Registered Nurse (IP/RN), who stated that the staff were in serviced regarding hand washing. The IP confirmed that CNA #1 should have performed hand hygiene after removing the gloves. On 08/29/24 at 01:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), IP/RN and discussed the above concern. No further information was provided. A review of the facility's Policy titled, Handwashing/Hand Hygiene with a review date of 01/2024 provided by LNHA revealed under procedure: 1. d. After removing gloves and under Washing Hands stated 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for twenty (20) seconds under a moderate stream of running water, at a comfortable temperature. 37175 2. On 8/26/24 at 9:00 AM, the surveyor observed Resident #59 in their room seated in a wheelchair eating breakfast. The surveyor observed the bathroom and found a urinary catheter bag (UCB) (a container or collector for the urine as it leaves the body and passes through the catheter tube) with urine present in the tubing hanging on to the rail next to the toilet. The UCB was not in a plastic bag and the end of the catheter tubing was exposed and not capped. A review of the AR reflected Resident #59 was admitted to the facility on [DATE], with diagnoses that included Hypertension (elevated blood pressure), Neuromuscular dysfunction of the Bladder (lack of bladder control) and Benign Prostatic Hyperplasia (enlarged prostate). A review of the Annual Minimum Data Set, an assessment tool dated 7/11/24, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated intact cognition. Further review revealed in Section H. Bladder and Bowel the resident had an indwelling urinary catheter. A review of the August 2024 Physician Orders Summary Report revealed a physician's order dated 1/11/24, to change the urinary drainage bag to a leg bag (pouch that is worn on the leg to collect urine from catheter) while out of bed daily. A review of the individual person-centered care plan CP revealed that the resident was at risk for multidrug resistant organism (MDRO) infections and was placed on an enhanced barrier precautions (an infection control intervention designed to reduce transmission of MDRO in nursing homes) related to the use of indwelling catheter(hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), dated 4/10/24, reflected a goal which included, the resident would not contract MDRO infection. Some of the CP interventions included but not limited to implement the use of gown and gloves for high contact care activities such as device care for indwelling urinary catheter. On 8/26/24 at 9:20 AM, the surveyor interviewed Resident #59's CNA#1 who stated that she performed the resident's care. CNA #1 further stated that the resident had an indwelling urinary catheter, and she removed the urinary catheter bag, placed a leg bag on the resident and stored the urinary bag in the bathroom. The surveyor showed CNA #1 the urinary bag and she stated that she omitted the plastic bag and the urinary bag should not be hung in the bathroom that way. On 8/26/24 at 9:30, the surveyor interviewed Licensed Practical Nurse (LPN#2) who stated that the urinary bag should not be hung on the handrail in the bathroom and must be placed in a plastic bag when removed. On 8/28/24 at 12:50 PM, the surveyor interviewed the IP/RN who stated the urinary drainage bag was changed weekly, washed daily and stored in a plastic bag in the bathroom. The IP/RN further stated that the CNA must clean the tip of the catheter with an alcohol pad and then place a blue cap at the end of the catheter to prevent any contamination. On 08/29/24 at 01:07 PM, the survey team met with the LNHA, DON, and IP/RN and discussed the above concern. No further information was provided. The surveyor reviewed the facility's policy titled, Care and Maintenance of Foley Drainage System dated 11/23, which revealed when the drainage bag was not it use the facility will clean the bag by rinsing the bag out with water and capped and place in a plastic bag and be hung in the resident's bathroom for later use. NJAC 8:39-19.4(a) (n)

Based on the interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with the federal guidelines for 1 of 19 residents (Resident #75) reviewed for the accuracy of MDS completion. The deficient practice was evidenced by the following: On 08/26/24, at 09:05 AM, the surveyor observed Resident #75 seated in bed eating their meal. On 08/27/24 at 12:54 PM, the surveyor reviewed Resident #75's electronic medical record, which revealed the following information: According to the Admission Record (an admission summary), Resident #75 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory) and other behavioral disturbances. A review of the Admission MDS (A/MDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status score of 04 out of 15, indicating that the resident had severe cognitive impairment. Further review of the A/MDS Section N. Medications under Section N0415 High-Risk Drug Classes: Use and Indication 1. Is taking - Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days 1. Is taking A. Antipsychotic was checked indicating that the resident used an anti-psychotic medication. Further review of the A/MDS under Section N0450 Antipsychotic Medication Review A. Did the resident receive antipsychotic medications since admission or reentry or the prior OBRA assessment, whichever is more recent? indicated 0 (zero) No - antipsychotics were not received. A review of the August 2024 Order Summary Report revealed a physician's order (PO) dated 7/15/24 for Risperdal oral tablet 0.5 mg (Risperidone) Give 1 tablet by mouth at bedtime which was an anti-psychotic drug. A review of the July 2024 Medication Administration Record revealed a PO indicating a start date of 7/15/24 for, Risperdal oral tablet 0.5 mg (Risperidone) give 1 tablet by mouth at bedtime. The medication was signed as administered on July 15, 16, and July 17, 2024. On 08/28/24 at 11:30 AM, the surveyor interviewed the Registered Nurse who worked part-time as a MDS Coordinator (MDS/C). The part-time MDS/C stated that she missed to code the medication to reflect in the A/MDS. The MDS/C added that they follow the Resident Assessment Instrument (RAI) Manual for guidance. The surveyor reviewed the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, updated October 2023. The RAI manual revealed under Chapter 3, page N-14, Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used. On 08/29/24 at 01:07 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Infection Preventionist and discussed the above concern. No further information was provided. NJAC 8:39-33.2(c)2, (d)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. On 8/26/24 at 7:30 AM, upon arrival of the surveyors to the facility, the surveyor observed a signage outside the facility that stated, Pine Acres Rehab + Healthcare outside the building and had a name that did not correspond with the CMS licensed, approved name and provider registered name Pine Acres Convalescent Center. On 08/26/24 at 09:44 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist (IP), and Administrator in Training for Entrance Conference. On 8/26/24 at 11:30 AM, the surveyor reviewed various documents and facility policies that were provided by the LNHA that were titled, Pine Acres Rehab + Healthcare. A review of the facility Admission agreement revealed under the facility name section as Pine Acres Rehabilitation and Health Care Center. The Business cards provided to the surveyors upon entrance reflected the facility name as Pine Acres Rehab + Healthcare. On 08/29/24 1:06 PM, the surveyor met with the LNHA, DON, Operations and IP to discuss the above noted documents did not match the documentation according to what they were licensed for. On 8/30/24 at 9:10 AM, the surveyor met with the LNHA who explained that the facility is called Pine Acres Convalescent Center, and the facility didn't change their name. The surveyor asked if the facility had filed a 855B form to CMS and the LNHA explained that they have not done the 855B form. A review of the facility license that was issued by the New Jersey Department of Health Division of Certificate of Need and Licensing with an issue date of June 11, 2024, and an expiration date of August 31, 2025 revealed the name licensed to operate was Pine Acres Convalescent Center and not Pine Acres Rehab + Healthcare. NJAC 8:39-5.1 (a)

Based on observations, interviews, record review, and policy review, the facility failed to ensure staff followed sanitation procedures for the sanitizing of dishware through the dishwasher and failed to label and date residents' food and monitor the freezer temperatures for the residents' refrigerators located at the nursing stations. These failures had the potential for 86 out of 89 residents to be at risk for food-borne illness (three residents received nutrition via feeding tubes). Findings include: 1.The kitchen inspection was conducted on [DATE] from 10:42 AM to 11:23 AM. The following observations and interviews revealed the dish machine rinse temperature did not meet the minimum temperature specification of 180 F. Staff did not follow their policy to ensure adequate sanitizing of the dishware: At approximately 10:45 AM, the Dietary Aide (DA) was washing breakfast dishes and indicated the minimum required temperatures were 150 degrees F for wash and 180 degrees F for rinse as she pointed to the dish machine instructions that were posted on the wall next to the dish machine. The instructions verified minimum wash and rinse temperatures of 150 F and 180 F. The wash temperature exceeded the requirement at 165 F; however, the rinse temperature was too low at 169 F, verified by the DA. A second cycle was observed, and the rinse temperature reached 170 F. Although the rinse temperature was not hot enough, DA1 and a second dietary staff continued to wash dishes. At approximately 11:10 AM, the Dietary Director (DD) stated they had been having issues with the dish machine lately. DA and a second staff member had been washing dishes continuously since 10:45 AM. The DD and the surveyor watched a cycle of dish washing and the DD verified a maximum rinse temperature of 170 F. The DD showed the surveyor the dish machine log and temperatures of 170 were recorded for rinse the day before ([DATE]) for both breakfast and lunch. A temperature of 180 was recorded for dinner on [DATE]. The DD stated she should have been notified, but had not been, of the rinse temperatures of 170 on [DATE] for breakfast and lunch and the low temperature that morning. A fourth cycle of dishwashing was observed with the DD and the rinse temperature continued to be 170 F. The DD stated she thought 170 F for rinse was acceptable to sanitize the dishes and staff continued to use the machine. During an interview on [DATE] at 12:30 PM, the Administrator stated he had not been informed the dish machine rinse temperature was not reaching the minimum required temperature. The Administrator stated the machine could be run with chemical sanitizer if it was not meeting the minimum required temperatures. During an interview on [DATE] at 12:41 PM, the Administrator stated dietary staff would not use the machine and would serve lunch on disposable dishware for lunch until the machine was serviced. During observation of the second floor on [DATE] at 1:21 PM, two carts with used dishes from lunch were observed. Most residents had finished eating. There were regular ceramic plates and plastic bowls, coffee cups, and regular silverware observed on the trays. Disposable dishware was not observed on any of the trays on the second floor. During observations of the third floor on [DATE] at 01:31 PM, residents were served on both disposable and regular dishware, approximately half the residents on disposable and half with regular dishware. During an interview, the Infection Preventionist (IP) contacted the kitchen to find out why some residents were served on disposable and some on regular dishware and reported disposable dishware was being used because the dishwasher was broken. The IP verified residents on the third floor had been served on both disposable and regular dishware. During observations of the first floor on [DATE] at 1:43 PM, the cart with residents' used meal trays was in the dining/activity room outside the kitchen entrance. All trays contained regular dishware; no disposable dishware was observed. During an interview [DATE] at approximately 2:30 PM, the Corporate Food Service Director stated the booster on the dish machine (which heated the water) was now working following a repair being made on the dish machine after lunch. He stated the policy was if the machine was not working properly, staff were to call the service provider and they generally came quickly. He stated if the machine was not working properly, meals should be served on disposable dishware. Review of the dish machine service Invoice dated [DATE] and provided by the facility revealed, The booster is not hitting temp [temperature] even after we fixed it last month. Tech Notes: Worked on booster. I put thermostat on higher temp and checked all 3 legs. It was working fine . Review of the facility's policy titled, Dish Machine Operation dated [DATE] revealed, High Temperature Dish Machine: Use hot water to clean and sanitize . If water is not hot enough it will not sanitize Final rinse temperature must reach at least 180 [degrees Fahrenheit (F)] If the temperature drops the technician and chemical company are contacted If it is not repaired before the following meal the procedure is as follows: Turn off the booster and activate the chemical sanitizer making it a Low Temp If the above option is not available, meals will be served on disposable until repairs are completed . 2. Review of an undated typed document attached to the residents' refrigerators at the nursing stations on all resident floors (first, second, and third) titled 72 Hour Rotation read, All incoming food items once opened for freshly made must be dated and labeled with the resident's name and room number. These items must be discarded after 3 days. If take out is delivered on the 6th, it can only be consumed/used till the end of the 8th and then thrown away. An exception to this rule would be purchase dressings, sauces, and mayonnaise. These items have 30 days. Items with their own expiration date are only acceptable while they are sealed. Observation of the residents' second floor refrigerator/freezer at the nursing station on [DATE] at 3:46 PM, revealed the log for recording temperatures measured the refrigerator temperature only. The freezer temperature was not monitored. Observation of the residents' third floor refrigerator/freezer on [DATE] at 3:52 PM revealed the log for recording temperatures measured the refrigerator temperature only. The freezer temperature was not monitored. In addition, numerous food items were not labeled or not labeled properly as follows: One brown paper bag with a restaurant take out container was noted without a name, room number, or date. Two packages of opened cheese were labeled with a room number but no date. One of the bricks of cheese had green spots of mold. Licensed Practical Nurse (LPN)2 verified the presence of the mold on the cheese. One opened package of pepperoni with a room number but no date was noted. A partially used bottle of Italian salad dressing without a name and a date of ,d+[DATE]. One opened carton of Almond Breeze milk with a room number but no date was noted. An unlabeled and undated sandwich was noted. An opened package of cream cheese with a room number but no date was noted. During an interview with LPN2 on [DATE] at 3:54 PM', LPN2 stated, the nurses were supposed to go through the refrigerator once a day and check for expired dates on the food. LPN2 stated food could be held three days and stated the night shift nurse was responsible for taking and recording the refrigerator temperature on daily basis. LPN2 confirmed the log only indicated refrigerator temperatures and that the freezer was not being monitored. During an interview on [DATE] at 3:56 PM, Unit Manager (UM)2 of the third floor, stated food was not allowed to remain in the refrigerator past three days. UM2 verified the presence of unlabeled food items in the refrigerator and stated the labels should include the date the foods were placed in the refrigerator. Observation of the residents' first floor refrigerator/freezer on [DATE] at 4:05 PM revealed the log for recording temperatures measured the refrigerator temperature only. The freezer temperatures were not being monitored Inside the refrigerator was a cup of fruit in a disposable cup with lid with a room number but no date. There was also a sandwich wrapped in paper that that had no label. UM1 stated the sandwich and fruit should have labels with the date the items went into the refrigerator and the resident's name or room number. During an observation of the residents' refrigerators on [DATE] at 10:05 AM, the Corporate Food Service Director (CFSD) stated he conducted monthly audits of the refrigerators on the floor and had identified issues with labeling and dating the residents' foods. The CFSD stated staff should be monitoring and recording both refrigerator and freezer temperatures. During an interview on [DATE] at 1:37 PM, the Housekeeper stated he cleaned the residents' refrigerators on all three floors every Tuesday. He stated, he would notify the UM if food was expired based on the date. The Housekeeper stated nursing staff were responsible for disposing of expired food. During an interview on [DATE] at 9:48 AM, the Administrator stated cleaning the refrigerator was the responsibility of housekeeping and managing residents' food including disposing of expired food was the responsibility of nursing staff. The Administrator stated he had been notified of issues regarding labeling and dating food in residents' refrigerators by the Corporate Food Service Director. Review of the facility's policy titled, Storage and Use of Food and Beverage Brought in for Residents dated February 2022 revealed, Policy: To provide safe and sanitary storage of all foods provided to residents including those provided by family and other visitors. Procedure: 1. Any leftover personal food or food from local restaurants that enters the facility by family members or visitors will be brought to the nursing station for safe storage. 2. Food that requires refrigeration or freezing will be labeled by facility employees or family members in a sealed food container. The label will include the date it was brought into the facility and name/room number of the resident who is to receive the food item. 3. Leftover foods will be used within 3 days or discarded. 4 All refrigerator and freezer temperatures will be checked daily and recorded on temperature log to ensure within desirable range . Review of the facility's policy titled Refrigerators dated [DATE] revealed, This facility will ensure safe refrigerator maintenance temperatures, and sanitation, and will observe food expiration guidelines . Nursing employees will check and record refrigerator temperatures daily . All food shall be appropriately dated to ensure proper rotation by expiration dates . Supervisors will be responsible for ensuring food items in pantry refrigerators are not expired or past perish dates . NJAC 8:,d+[DATE].2(g)

Based on observation and interview, the facility failed to ensure the dumpster area was maintained in a sanitary manner on two of two days in which a significant amount of garbage was on the ground around the dumpster creating the potential for harborage of pests. Findings include: 1. During the initial dietary inspection on 08/22/22 from 10:42 AM - 11:23 AM, the dumpster area revealed two dumpsters on a concrete pad located next to a parking area. The dumpsters lids were closed; however, there were approximately 30 pieces of garbage on the concrete pad behind the dumpsters and in the grass adjacent to the dumpster extending approximately 25 feet in front of four parked cars. The garbage consisted of used latex gloves, disposable face masks, plastic cups, paper debris, plastic bottles and lids, cans, cardboard pieces, and a gallon jug of a cleaning product. 2. A second observation of the dumpster area was made on 8/24/22 at 10:01 AM with the Corporate Food Service Director (CFSD). The dumpster lids remained closed with masks, gloves, plastic debris, cups, bottles, paper, cardboard, and an empty gallon of a chemical located on the concrete behind the dumpster and in the grass in front of four parked cars. The CFSD indicated the area was not sanitary and stated it needed to be cleaned up. The Food Service Director stated he was not sure who was responsible for maintaining the area. 3. A third observation of the dumpster area was made on 8/24/22 at 1:37 PM with the Housekeeper. There was a piece of broken glass, a half and half container, a few plastic pieces, and a few pieces of paper/cardboard behind the dumpster on the concrete and in the grass in front of the parked cars. The Housekeeper stated, Normally we clean it up when we see it. It is not scheduled. 4. During an interview on 08/25/22 at 8:52 AM, the Administrator stated the housekeeping department was responsible for maintenance of the dumpster area including cleanliness. He stated there was no facility policy regarding the dumpster area. During a subsequent interview on 08/25/22 at 9:48 AM, the Administrator stated the dumpster area should be free of garbage on the ground. NJAC 8:39-19.3(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) provide disinfectant wipes and sanitize the equipment used by staff in the COVID-19 screening process; b) ensure proper use of personal protective equipment (PPE) for 1 of 2 staff; and, c.) properly dispose of used COVID-19 testing swab and kit in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: A review of the U.S. CDC's Cleaning and Disinfecting Your Facility, updated on 7/28/20, included, Practice routine cleaning of frequently touched surfaces. High touch surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc. Disinfect with a List N: disinfectants for use against [DIAGNOSES REDACTED]-CoV, [MEDICAL CONDITION] that causes COVID 19. For electronics, such as tablets, touch screens, keyboards, remote controls, and ATMs, consider putting a wipeable cover on electronics. Follow the manufacturer's instructions for cleaning and disinfecting. If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly and wear appropriate PPE when cleaning or disinfecting frequently touched surfaces and electronics. The U.S. CDC's Preparing for COVID-19 in Nursing Homes updated on 11/20/20, indicated, Environmental Cleaning and Disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Ensure HCP are appropriately trained on its use. According to the U.S. CDC guidelines Responding to Coronavirus (COVID-19) in Nursing Homes, Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/20 included, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes the use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. According to the U.S. CDC's Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20 included guidelines to Collection of Diagnostic Respiratory Specimens It specified that, Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. 1. On 11/20/20 at 8:55 AM, the surveyors, observed the Employee entrance with hand sanitizer noted upon entry, a table with a computer, telephone, thermo scan (a thermometer for scanning body temperature), and signage with instruction on, How to take your own temperature. The thermo scan was directly touching the top of the table with no barrier or a liner. The signage did not indicate cleaning or disinfecting the thermo scan in between use. There were no disinfectant wipes available to clean the thermo scan and the computer screen. There were no staff monitoring the Employee's entrance. Afterward, the receptionist instructed the surveyors to go around the front entrance lobby to be screened before entering the facility. At 9:00 AM, the surveyors entered the front lobby and performed hand hygiene using hand sanitizer, and were asked by the receptionist to answer the screening questions for COVID-19 on the computer. At that time, the receptionist used a thermo scan to check the surveyor's temperature. The receptionist had to check both the surveyor's temperatures twice. The receptionist did not clean or disinfect the computer screen in between surveyor's use. There were no disinfecting wipes available at that time. On that same date and time, the receptionist stated that the thermo scan sometimes doesn't work right. She further noted that the employee entrance where staff perform self-screening for Covid-19 was not monitored by staff because, staff was in-serviced about self-screening, If there was a problem, staff could use the phone to call for assistance. At 9:23 AM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The LNHA and the DON both informed the surveyors that one resident and two staff tested positive for COVID-19 in the facility. The DON stated that the positive resident and staff were from the 3rd-floor unit. On that same date and time, the DON described the facility staff's self-screening process upon entering the facility. The DON did not state that the staff should be disinfecting the thermo scan and the computer screen in between use. At that time, the LNHA stated that the 2nd floor low-side was the PUI (person under investigation) unit where the new admissions stay for SAR (subacute rehab). The DON further stated that staff were mandated to wear full PPE that includes a gown, N95 mask, face shield, and gloves when inside resident rooms. At 10:52 AM, during an interview, the Certified Nursing Aide (CNA) informed the surveyor that she routinely goes to the back of the building by the employee entrance to do the self-screen for COVID-19 where she sanitized her hands then self-checked her temperature with the thermo scan. The CNA further stated that she would enter her temperature into the computer and answer the screening COVID-19 questions, time-in and then proceed to her unit. The CNA said that no one monitors the employee entrance or the screening process, and said there were no wipes to clean the computer screen. She further stated, sometimes I put hand sanitizer in my hands and use my hands to wipe the computer screen to clean it. On that same date and time, the CNA mentioned that the thermo scan acts funny sometimes, so I put the temperature that I remembered from yesterday or a day before to complete the screening process. The surveyor asked the CNA why she did not call for help when there was a problem with the thermo scan. The CNA further stated that the thermo scan was put back on top of the table and that there was no clean barrier or liner in between the table and the thermo scan. At 12:45 PM, the surveyors discussed the above concerns with the LNHA, DON, and ADON. The DON stated that there was no need to clean the computer screen and the thermo scan because the staff sanitized their hands before and after the COVID-19 screening process. The DON and the ADON both acknowledged that the thermo scan should not be placed directly on top of the table, and there should be a barrier between the thermo scan and the table. The DON further stated that the receptionist should have sanitized the computer screen in between visitor's use. 2. On 11/20/20 at 9:23 AM, the LNHA stated that the 2nd floor low-side was the PUI (person under investigation) unit where the new admission resident's stay for SAR (subacute rehab). The DON further stated that staff was mandated to wear a full PPE that includes a gown, N95 mask, face shield, and gloves when inside resident rooms. At 10:18 AM, the surveyor observed the Occupational Therapist Assistant (COTA) inside a PUI room on the 2nd-floor low side unit, assisting the resident with upper extremity exercises. The COTA was wearing PPE (N95 mask, face shield and gloves) but was not wearing an isolation gown while performing direct care to a PUI resident. At 10:22 AM, during the interview, the COTA informed the surveyor that the PUI resident was a new admission and was on the PUI unit for a 14-day observation period and had not been exposed. The COTA stated that staff should wear an N95 mask, gloves, face shield, and a gown when inside the PUI rooms. She further said that she forgot to wear the isolation gown when she was inside the PUI room. 3. On 11/20/20 at 10:20 AM, the surveyor observed the Director of Nursing, who was also the Infection Preventionist Nurse (IPN) perform a nasopharyngeal (back of the nose and throat) swab collection in the day room of the subacute unit. The IPN did not disinfect the table used for specimen collection. After the IPN obtained the specimen, she opened the media vial, inserted the swabbed end, swirled the swab around into the media for 10 seconds, removed the swab, and then went into a resident's room and discarded the contaminated nasal swab into the resident's trash can. The surveyor asked the ICP if it was her routine practice to discard contaminated swabs in the residents' personal trash receptacles. The IPN stated that she usually swabbed in rooms that had trash cans, didn't want to throw it in the public trash in the day room and that the housekeeping department would be picking up the trash from the resident's room sometime that morning, so she didn't feel it was an issue. On that same day, at that same time, the ICP went back into the resident's room, removed the trash bag that contained the contaminated swab, and proceeded to discard it in the main garbage located in the housekeeping closet. The surveyor asked if it should have been discarded in a biohazard bag. The IPN replied, I'm not sure. The surveyor asked if the facility had a policy for the disposal of Covid-19 swabs. The IPN replied, let me find out. On that same day, at 11:00 AM, the surveyor again asked the IPN if the facility had a policy for the disposal of infectious materials. The DON did not respond. At 12:45 PM, the surveyors discussed the above concerns with the LNHA, DON, ADON. The ADON stated that the COTA should have worn full PPE when she provided treatment to the PUI resident and that included a gown. No further information was provided by the facility. NJAC 8:39-19.4 (a) NJAC 8:39-27.1

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 4 of 23 residents reviewed for resident assessment (Resident #1, #53, #289, #290) and was evidenced by the following: On 02/20/20 at 9:30 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. 1. Resident #1 was triggered under the survey facility task as MDS record over 120 days old. Review of Resident #1's Nurses Notes revealed that the resident was discharged on [DATE] to the community. The surveyor reviewed the MDS 3.0 assessment tool, including all the completed MDS assessments for the resident. The MDS assessment history revealed that the Discharge Assessment for Resident #1 was not submitted until 02/16/20. MDS discharge assessments must be submitted no later than 28 days after the discharge. 2. Resident #53 was admitted to the facility on [DATE]. The surveyor reviewed the MDS 3.0 assessment tool, including all the completed MDS assessments for the resident. The MDS assessment history revealed that there was no Entry tracking record for the resident's admission to the facility. An Entry MDS assessment is used to track residents and gather quality data at transition points, such as when they enter a facility. MDS entry assessments must be submitted no later than 7 days from admission. 3. Resident #289 was admitted to the facility on [DATE]. The surveyor reviewed the MDS 3.0 assessment tool, including all the completed MDS assessments for the resident. The MDS assessment history revealed that there was no Entry tracking record for the resident's admission to the facility. MDS entry assessments must be submitted no later than 7 days from admission. 4. Resident #290 was admitted to the facility on [DATE]. The surveyor reviewed the MDS 3.0 assessment tool, including all the completed MDS assessments for the resident. The MDS assessment history revealed that there was no Entry tracking record for the resident's admission to the facility. MDS entry assessments must be submitted no later than 7 days from admission. Further review of the record showed that there was no Admission/Comprehensive MDS assessment that was completed. MDS Admission Comprehensive assessments must be submitted no later than 28 days from admission. On 02/20/20 at 9:50 AM, the surveyor spoke to the Director of Nursing and the MDS Coordinator regarding the above concern. The MDS Coordinator acknowledged that the assessments were not submitted timely in accordance with the federal regulations. NJAC 8:39-11.2

Based on observation, interview and record review, it was determined that the facility failed to ensure that a.) the Registered Nurse (RN) assessed a resident after a the resident fell and sustained an injury, and b.) the resident received an evaluation and treatment, in accordance with nursing standards of clinical practice and the facility's fall policy. This deficient practice was identified for Resident #2, 1 of 2 residents reviewed for falls and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Administrative Code, Title 13, Law and Public Safety, Chapter 37, New Jersey Board of Nursing, under 13:37-6.5 Non-Delegable Nursing Tasks, includes: A registered professional nurse shall no delegate the physical, psychological, and social assessment of the patient, which requires professional nursing judgement, intervention, referral, or modification of care. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 02/18/2020 at 10:07 AM, the surveyor observed Resident #2 lying in a low bed with a bed alarm and floor mat next to the right side of the bed. On 02/20/20 at 8:41 AM, the surveyor observed the resident seated in the bed as a Certified Nursing Assistant (CNA #1) provided feeding assistance. At that time, CNA #1 informed the surveyor that the resident was cognitively impaired, required total assistance with activities of daily living (ADLs), incontinent, and needed to be fed. She stated that the resident was non-ambulatory and on fall precautions. CNA #1 stated the resident had a history of [REDACTED]. A review of the resident's Face Sheet (an admission summary), disclosed that the resident had [DIAGNOSES REDACTED]. A review of the 10/05/19 Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated the resident had severely impaired cognition. The MDS revealed that the resident had a fall with a major injury. A review of the Incident/Accident (I/A) Report, provided by the Director of Nursing (DON), showed that the resident had a witnessed fall on 10/04/19 at 7:25 PM, in another resident's room. A review of the Investigation of Incident/Accident Statement, signed by LPN #1 and attached to the 10/04/19 I/A Report, revealed that the resident was observed on the floor laying on the right side and holding his/her right leg. LPN #1's I/A Statement indicated that the x-ray of the right hip was ordered and PRN (as needed) Tylenol was given. The I/A Report documented that the primary physician ordered an x-ray of the right hip. A review of the Summary of Investigation form, signed by the RN/UM and attached to the 10/04/19 I/A Report, revealed she was notified by the primary nurse, on 10/04/19 at 7:25 PM, that the resident was noted lying on his/her right side on the floor in another resident's room. The statement included that a full assessment was rendered by the nurse. The resident was able to move all extremities but was noted guarding the right leg. The physician was notified, an x-ray was ordered and the resident was given PRN Tylenol. X-ray results received on 10/05/19 and the physician was made aware. The resident was transferred to the hospital. A review of the medical records, evidenced there was a lack of documentation that the resident was assessed by a Registered Nurse (RN) on 10/04/19, after the resident's fall. A review of the Progress Notes (PN) showed that on 10/04/19 at 21:22 (9:22 PM), the x-ray company called back to state that the x-ray might not be possible tonight but would be done early the following morning. There was no documentation in the medical record that the physician was made aware that the x-ray could not be done until the following day. A review of the PN showed that on 10/05/20 at 11:52 AM, LPN #2 administered PRN Tylenol to Resident #2 for a complaint of right hip pain and when the x-ray of the right hip was performed. In addition, the 10/05/19 PN revealed that the Medical Director ordered the transfer. Resident #2 was transferred to the hospital around 12:20 PM on 10/05/19. A review of a New Jersey Universal Transfer Form, dated 10/05/19, showed the resident was transferred to the hospital with the reason for transfer listed as fracture/dislocation of right hip. The surveyor reviewed the physician's orders [REDACTED].#2 had a physician's orders [REDACTED].#1). A review of the (MONTH) 2019 electronic Medication Administration Record [REDACTED]. During a phone conversation on 02/20/20 at 12:56 PM, LPN #1 informed the survey team that Resident #2 was cognitively impaired with an unsteady gait, had a fall incident on 10/04/19, which resulted in a right [MEDICAL CONDITION]. He stated that the resident was found lying on the right side in another resident's room holding his/her right leg and complaining of pain. He further stated, as far as I remember, it was me who assessed the resident post-fall. During the same phone conversation, LPN #1 informed the surveyor that he reported the fall incident to the facility manager, who was not in the building. He further stated that the primary physician ordered an x-ray to rule out injury. In addition, LPN #1 stated, I can't remember if the physician was notified that the x-ray could not be carried out immediately, but would be done the following morning. On 02/21/20 at 8:53 AM, the surveyor called and left a message for the primary physician to return the call for an interview. The primary physician did not return the surveyor's call. On 02/21/20 at 9:07 AM, the survey team interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that if a resident fell and was then observed guarding a body part, it indicated the resident was in pain and the area should be immobilized. She stated that the physician should be called to order an x-ray to determine the extent of the injury. She further stated that if the x-ray could not be done immediately or on that day, the physician should be called to get an order for [REDACTED]. On 02/21/20 at 9:43 AM, the survey team spoke to the Administrator, DON, and Regional Administrator regarding the above observations and concerns. The DON informed the surveyors that the RN/UM was not in the facility at the time of the fall. The DON stated that the RN/UM's I/A statement for the 10/04/19 fall, was created on 10/07/19 according to the information supplied to her by LPN #1's report by phone conversation. The DON stated that the RN/UM documented that the resident was guarding the left leg according to LPN #1's report. During the above team meeting with the DON, she could not give any further information as to why there was no RN assessment at the time of the fall and the facility did not transfer the resident to the hospital according to their Fall Investigation Report policy. On 02/24/20 at 9:01 AM, the surveyor called and left a message to interview LPN #3 and CNA #2, who were scheduled as working on 10/04/19 when the resident fell . LPN #3 and CNA #2 did not call back and could not be interviewed. On 02/24/20 at 9:03 AM, the surveyor called CNA #3 who was also scheduled to work on 10/04/19, when Resident #2 fell . CNA #3 stated, I can't remember anything that had happened on that day, I'm sorry. On 02/24/20 at 9:06 AM, the surveyor called the agency that employs CNA #4, who was scheduled to work in the facility on 10/04/19 when the resident fell . The agency representative stated that CNA #4 no longer worked with the agency, since 01/19/20. The agency representative could not provide any further follow-up information. A review of the Fall Investigation Report Policy, dated revised on 05/11/09, provided by the Administrator, reflected that if a fracture was suspected, an x-ray must be done. The policy also indicated that if there were any signs symptoms of a fracture observed, the resident must be transferred to the hospital for evaluation and treatment. NJAC 8:39-11.2 (b)

Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyor observed 3 nurses administer 30 doses of medication to 5 residents and there were 6 errors which resulted in a medication error rate of 20%. This deficient practice was evidenced by the following: 1. On 01/26/18 at 8:18 a.m. the surveyor observed the first medication nurse (MN1) administer medications to Resident #38. The resident had current physician orders [REDACTED]. MN1 made 4 errors during administration. The printed cautionaries on the eMAR and on the bubble pack that the [MEDICATION NAME] Sprinkle ER Capsules came in stated to swallow whole, do not crush or chew, drink plenty of water. MN1 opened (1) capsule and sprinkled it over applesauce and administered it with a milkshake. He administered a [MEDICATION NAME] tablet instead of a capsule. On 01/31/18 at 8:00 a.m. the surveyor spoke to MN1 regarding the errors. He did not have a response when asked why he only dispensed (1) [MEDICATION NAME] Sprinkle ER Capsule instead of 2. He stated that the resident could not swallow the medications whole so he opened the [MEDICATION NAME] Sprinkle ER Capsule. He gave a [MEDICATION NAME] tablet so he could crush it, mix with applesauce and dispense. MN1 nurse said it was necessary to have an order to do this but he did not. He stated that the resident did not like water. MN1 agreed that he did not follow the cautionaries. 2. On 01/26/18 at 9:42 a.m. the surveyor observed a second medication nurse (MN2) administer medications to Resident #67. The resident had a current physician's orders [REDACTED].½ tablet (12.5 mg). MN2 made 2 errors during administration. The medication was ordered to be given at 8 a.m. because it should be administered with or immediately after a meal. The medication was not given until 9:42 a.m. The resident did not have their own supply of this medication so the medication was obtained from the backup supply and there was no cautionary on the packaging. There was no cautionary printed on the eMAR. MN2 did not offer the resident any food. The surveyor asked the resident what time they ate last and the resident stated about 2 hours ago. On 01/26/18 at 11:00 a.m. the surveyor asked MN2 if she was aware that the medication needed to be administered with or immediately after a meal and she stated that she was not. On 02/01/18 at 8:43 a.m. the surveyor spoke with the Unit Manager regarding the cautionaries on the eMAR. She said the cautionaries should be entered on the eMAR by the facility staff at the time the medication was ordered and she did not know why it had not been done in this case. She said that a medication ordered at 8 a.m. should also alert the medication nurse to administer with food. On 01/29/18 at 9:40 a.m. the surveyor brought the medication pass results to the attention of the Director of Nursing and Administrator. They did not dispute these findings. A review of the facility Medication Administration times revealed that a medication that needed to be given with food should be administered at 8 a.m. A review of the undated Medication Pass Techniques policy revealed that nurses should be aware of cautionary warnings on the MAR and/or prescription label, e.g. don't crush, give with food, etc. Potassium supplements are recommended with a full glass of water or fruit juice. Medication ordered with food should be given within a half hour of a meal. If it is past this time, a sandwich and four ounces of milk, juice or a supplement should be ordered. NJAC 8:39-29.2 (d)

Based on observation, interview and review of documentation provided by the facility it was determined that the facility failed to maintain proper kitchen sanitation practices, properly store fresh and frozen food items and Dry Storage items in a safe and sanitary environment to prevent the development of foodborne illness. This deficient practice was evidenced by the following: On 1/24/18 at 11:10 a.m., during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The shelf stable food items in the Dry Storage room and refrigerated food products in the walk-in refrigerator were stocked too high. Food storage requirements include at least 6 inches above the floor and at least 18 inches below the ceiling. The FSD stated there was a black line on the cinder block walls for the 18 inch height requirement but the line was not visible due to the dry food items that were stored too high. 2. The storage rack located in the reach-in freezer area had 5 clean, covered coffee/tea carafes with 1/2 inch of standing water in each container. 3. The hood lights were off during food preparation. 4. The perimeter of the kitchen where the wall meets the floor was highly soiled with a build-up of black debris. 5. The Director of Nurses (DON) went into the kitchen and stood behind the active tray line in progress. The steam table was filled ready-to-serve food and the DON had no hair restraint on. Neither the FSD or the dietary aides (DA) were able to explain why the DON was in the kitchen. 6. The underneath section of the shelf above the filled tray line was soiled with dried, caked-on debris and was in direct contact with the ready-to-serve food. 7. On 1/31/18 at 10:00 a.m. during a revisit to the kitchen, the food order delivery was observed directly on the floor in the dry storage room, outside on the soiled cement floor across from the walk-in refrigerator with multiple cases of liquid eggs, bagels, English muffins, margarine and cheeses. 8. No garbage pail was located under or in the area of the hand wash sink. The FSD stated she never had a separate garbage pail for the hand wash sink. On 1/31/18 at 10:45 a.m. the surveyor reviewed the D-703 Food Ordering and Receiving Policy and Procedure (P&P) effective date 2/1/05 and D-409 Storage of Frozen and Refrigerated Foods P&P effective date 2/1/05 and neither P&P included storage guidelines/requirements that included items had to be stored at least 6 inches above the floor and at least 18 inches below the ceiling. A copy of the facility's Hair Restraint P&P was requested and not received. On 1/31/18 at 1:45 p.m. the Administrator and DON were notified of the surveyor's observations. N.J.A.C. 8:39-19.7d

Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by incorrectly transcribing physician's orders [REDACTED].#4 and #72. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. The surveyor reviewed the Admission Record of Resident #4 that reflected that Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A review of the electronic Medication Administration Record [REDACTED]. The time change had never been carried out. Further review of the record indicated that a twenty-four-hour chart check was performed on 01/13/18 to check for new orders and to see that they were carried out. The order discrepancy was not addressed at that time. On 01/26/18 at 1:05 p.m. the surveyor spoke to the nurse on duty assigned to the resident. She agreed that the order had never been carried out and would call the doctor for clarification. 2. The surveyor reviewed the Admission Record of Resident #72 that reflected that the resident was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed a Therapeutic Suggestions form initiated by the Consultant Pharmacist dated 11/07/17 which questioned if the medication Alendronate was still clinically warranted. On 12/07/17 the physician indicated on the form to discontinue the medication as of 01/01/18. The form stated to initiate orders if indicated and that it was not an order sheet. The surveyor reviewed all December 2017 POS and did not find the order to discontinue the medication. On 01/31/18 at 9:02 a.m. the surveyor spoke with the Assistant Director of Nursing (ADON) regarding this order. She agreed that there was no order to discontinue the medication on the POS. The medication had been discontinued from the eMAR on the computer as of 01/01/18. The ADON said that the facility policy was to write the order on the POS and then enter it on the computer. Further review of Resident #72's record revealed an order written [REDACTED]. A review of the eMAR revealed this order transcribed as: [MEDICATION NAME] Suspension 1%--instill (1) drop in both eyes two times a day and [MEDICATION NAME] Solution 0.5%--instill (1) drop in both eyes two times a day. On 01/30/18 at 11:51 a.m. the surveyor spoke with the ADON regarding this order. She agreed that the order was incorrectly written on the POS. She stated that the nurse who wrote the order on the POS entered it into the computer as it appeared on the eMAR but could not explain why it was written incorrectly on the POS. The nurse who wrote the order was not available to be interview at the time of the survey. The ADON stated she would call the doctor to clarify. Further review of the record indicated that a twenty-four-hour chart check was performed on 12/22/17 to check for new orders and to see that they were carried out. The order discrepancy was not addressed at that time. On 01/31/18 at 2:30 p.m. the surveyor brought these findings to the attention of the Director of Nursing and Administrator. They did not dispute these findings. A review of the 24-Hour Chart Check Policy dated 03/17 revealed that the night nurse should review the POS for new orders and for medication orders to make sure they are entered properly onto the eMAR. A review of the undated Medication Transcription Policy revealed that medication orders must have the following information: date of order, name of medication, dose, route and administration times. NJAC 8:39-11.2(b)

Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to provide supportive rationale for the continued use of an antipsychotic medication for 2 of 5 residents reviewed, Residents #4 and 72. This deficient practice was evidenced by the following: 1. On 01/24/18 at 11:37 a.m. the surveyor observed Resident #4 in bed watching television. The resident was soft spoken and confused and disoriented when spoken to. The resident was neatly groomed and dressed. The surveyor reviewed the Admission Record that reflected Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) an assessment tool dated 10/26/17, the resident was severely cognitively impaired. The MDS indicated that the resident had no indicators of [MEDICAL CONDITION], displayed no behavioral symptoms, did not reject care and wandered 4-6 days per week. Further review revealed that the resident had episodes of inattention and disorganized thinking. These behaviors were present but fluctuated and were not constant. A review of the Annual MDS dated [DATE] revealed no indicators of [MEDICAL CONDITION] and no behaviors. A review of the quarterly MDS dated [DATE] documented no indicators of [MEDICAL CONDITION] and rejection of care on 1-3 days. A review of the physician's orders [REDACTED]. The medication was being given for the [DIAGNOSES REDACTED].#4 was paranoia. The resident had a care plan in place for impaired cognitive function and thought process related to Alzheimer's and Dementia with interventions including: allow time to verbalize needs, re-approach later if resistant to care and keep routine and care givers as consistent as possible. There was no care plan in place related to the target behavior of paranoia. A review of the monthly Psychiatry Notes (PN) completed by the facility nurses for there period of March 2017 through January 2018 revealed no episodes of paranoia - which was the target behavior for the use of the antipsychotic medication. Other behaviors listed were: agitation, agitation only when provoked, refusing care and social isolation. The other behaviors indicated were not quantified or documented in detail as to how the behavior manifested itself and how it affected the resident. A review of the Psychiatry Progress Note (PPN) dated 04/27/17 written by the Advanced Practice Nurse (APN) indicated that the resident was calm on evaluation and was occasionally resistant to care but overall had no major behavioral issues. The APN also indicated that the reduction of [MEDICATION NAME] was contraindicated because the benefits of taking this medication outweighed the risks. She did not specify what the benefits or risks were. A review of the PPN dated 05/30/17 written by the Psychiatrist indicated that the resident was refusing to give a urine sample and blood work. Additionally, the resident got agitated during care. A review of the PPN dated 07/20/17 written by the APN indicated that the resident had periods of noncompliance with medication and treatments. A review of the PPN dated 09/26/17 written by the APN indicated that according to nursing, the resident was restless at times, paced and was difficult to redirect at times. A review of the PPN dated 12/20/17 written by the Psychiatrist indicated that the resident refused care at times and was accusatory. The resident made a statement to her so much of my stuff has been stolen. The Psychiatrist documented that the resident had ongoing paranoia and required the continued use of [MEDICATION NAME]. A review of the Psychology Visits dated 03/02/17 through 11/09/17 revealed that the resident displayed the target behavior of paranoia on 08/04/17. The Psychologist documented questionable paranoia when the resident claimed that something was stolen. The Psychologist indicated that she would notify the nursing staff to determine if this was a valid complaint or a delusional belief. A review of the July 2017 through January 2018 electronic Medication Administration Record [REDACTED]. On 01/30/18 at 7:40 a.m. the surveyor spoke with the Licensed Practical Nurse (LPN) on duty regarding Resident #4's behaviors. She stated the resident refused care, recently refused to allow blood to be drawn and could be verbally aggressive. 01/30/18 at 8:38 a.m. the surveyor spoke with the certified nursing assistant (CNA) on duty caring for the resident. The CNA stated that the resident verbally refused care at times and sometimes kicked. When asked how often this behavior occurred, the CNA just shrugged her shoulders. The surveyor asked what she did when the resident refused care the CNA stated she would leave the resident to calm down and then go back later. The surveyor asked the CNA if the resident would be more cooperative when she went back and she said yes. On 01/29/18 at 9:40 a.m. the surveyor spoke with the Director of Nursing (DON) and Administrator regarding the continued use of [MEDICATION NAME] in the absence of the facility identified target behavior of paranoia. The surveyor also expressed concern that no further dose reduction was done after 2/28/17 even though the behavior documentation did not indicate any episodes of the target behavior. The surveyor asked the DON if the resident's statements regarding theft had been investigated to determine if they were perhaps factual. She said they had been. The surveyor requested to see any documentation but the DON never provided any further information. 2. On 01/29/18 at 8:15 a.m. the surveyor observed Resident #72 seated out of bed in a wheelchair eating breakfast. The resident was confused and disoriented, smiled and maintained eye contact when spoken to. The surveyor reviewed the Admission Record that reflected that Resident #72 was admitted to the facility with [DIAGNOSES REDACTED]. According to the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE], the resident was severely cognitively impaired. The MDSs indicated that the resident had no indicators of [MEDICAL CONDITION], displayed no behavioral symptoms and did not reject care. Further review revealed that the resident had episodes of inattention and disorganized thinking. These behaviors were present but fluctuated and were not constant. A Review of the POS [REDACTED]. This medication had a black box warning which indicated that elderly patients treated with this medication were at increased risk of death and antipsychotics were not approved for the treatment of [REDACTED].#72 was paranoia. The resident had a care plan in place for impaired thought process related to Dementia with interventions including: engage in simple activities that avoid overly demanding tasks, keep routine and caregivers consistent as much as possible and involve in daily decision making. There was no care plan in place related to the target behavior of paranoia. A review of the PPN dated 07/20/17 written by the APN recommended to trial a gradual dose reduction (GDR) of the [MEDICATION NAME] from 25 mg at bedtime to 25 mg Monday to Saturday and 12.5 mg on Sunday. A review of the Nursing Progress Note dated 07/24/17 revealed that the Primary Medical Doctor (PMD) was notified of the APN's recommendation for the GDR but he did not agree. There was no reason documented as to why the recommendation was rejected. A review of the monthly PN completed by the facility nurses for the period of August 2017 through December 2017 revealed no episodes of paranoia or any other behaviors. A review of the PPN dated 10/12/17 written by the APN revealed that the resident continued to exhibit agitation, combative behaviors and engaged in self-dialogue. The APN also indicated that the reduction of [MEDICATION NAME] was contraindicated because the benefits of taking this medication outweighed the risks. She did not specify what the benefits or risks were. A review of the Psychology Visits dated 06/19/17 through 10/23/17 revealed that the resident did not display the target behavior of paranoia. On 01/30/18 at 8:18 a.m. the surveyor spoke with LPN who was assigned to the resident regarding if the resident displayed any behaviors. The LPN stated that sometimes it seemed that the resident saw things in the hallway but they did not cause upset. He also stated that the resident used foul language at times, was not aggressive and was funny. On 01/30/18 at 9:45 a.m. the surveyor spoke to the CNA who was assigned to the resident. She stated that the resident was very confused and resistant to care at times but not combative. On 01/31/18 at 2:30 p.m. the surveyor brought these findings to the attention of the DON and Administrator. The surveyor expressed concern regarding the lack of documentation regarding why the PMD rejected the APN's recommendation for a GDR. Additionally, there was no documentation regarding the target behavior of paranoia to support the use of the antipsychotic medication. No further information was provided. A review of the undated [MEDICAL CONDITION] Drug Usage policy and procedure indicated occurrences of specific behaviors per day/shift will be documented in the progress notes as episodic charting. This procedure is followed for antipsychotics and anxiolytics. A monthly summary will be documented in the Psychoactive Monitoring Form/Monthly Summary based on the targeted behavior being monitored. Behaviors will be totaled monthly (quantitative) and documented. Define and document specific behavioral problems in a descriptive way. A review of the Antipsychotic Drug Use policy revealed residents will receive antipsychotic medications only when justified by a specific condition and only in conjunction with gradual dose reductions unless clinically contraindicated. NJAC 8:39-27.1 (a)

Based on observation, interview and review of medical records and other facility documentation it was determined that the facility failed to maintain adequate infection control practices during food service in the kitchen and dining room. This deficient practice was evidenced by the following: On 1/24/18 at 11:10 a.m., during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. A Dietary Aid (DA) was observed as she washed her hands at the hand wash sink. The DA obtained soap from the soap dispenser and began to rub her hands together. The DA turned on the faucet and rinsed her hands under the water, obtained paper towels, dried her hands and discarded the soiled paper towels in an open garbage pail on the other side of the kitchen. 2. The Director of Nurses (DON) went into the kitchen and stood behind the active tray line in progress. The steam table was filled ready-to-serve food and the DON had no hair restraint on. 3. At 11:55 a.m. a DA was observed in the West Lounge as he dropped a napkin on the floor, picked it up, threw it in the garbage pail and put on gloves to continue to serve lunch to the residents. Before the DA continued the surveyor stopped him and asked him to remove his gloves and wash his hands. The DA requested to use the wall mounted hand sanitizer and was told by the surveyor that the best practice was to wash his hands. On 1/31/18 at 11:25 a.m. the surveyor reviewed the nursing department's Handwashing Policy and Procedure (P&P). The P&P was not dated and the objective involved the nursing department and stated promote good antiseptic technique and to prevent cross-contamination, cross-infection, and colonization by potentially pathogenic organisms to susceptible individuals, including resident belongings. The P&P did not include any recommendations for the dietary staff as to when gloves should be changed and hands should be washed. N.J.A.C. 8:39-19.4 m,n

Complaint #: NJ , NJ Based on interview and review of medical records and facility policy, it was determined that the facility failed to ensure that 3 of 4 sampled residents, (Resident #2, #3, and #4) were protected from verbal, physical intimidation, as well as actual physical abuse/mistreatment, from a resident who exhibited a lack of impulse control and aggressive behavior (Resident #1). In addition a Certified Nursing Assistant, (CNA #1) was also the recipient of a physical assault by Resident #1 on 6/11/14. Facility licensed nursing staff and direct care staff witnessed and/or had knowledge of physical abuse incidents, and failed to adequately address Resident #1's increasing behaviors. These incidents were documented in the resident's medical record from 4/30/14 to 6/12/14 and interventions were not revised to protect the identified residents as well as other residents who resided on the unit. The incidents documented in the medical record included but were not limited to; two physical assaults from Resident #1 towards Resident #4 which occurred on 4/30/14 and 5/12/14. These incidents were documented in nurses notes in Resident #4's medical record. On 4/30/2014 at 6:10 p.m., Resident #1 was reported to have slapped Resident #4 on the face. Resident #1 and Resident #4 were separated at that time. On 5/12/2014 at 12:30 p.m., Resident #4 was struck on the right shoulder by Resident #1. The facility transferred Resident #1 to a hospital for psychiatric evaluation after the 5/12/14 incident. Resident #1 was transferred back to the facility later the same day and moved to another room on another unit, as an intervention to protect Resident #4. Verbal and a reported physical assault from Resident #1 towards Resident #3, occurred on 6/5/14. This incident was documented in a nurse's note, dated 6/6/2014, as a late entry, in Resident #3's medical record as a verbal altercation. In a social service note, dated 6/6/2014, the following was documented: "On the evening of 6/5/2014, Resident #3 had an altercation with (Resident #1.) It was primarily verbal with minimal physical contact, and no serious resulting injury." An intervention was offered to Resident #3 for a temporary room change for the weekend, by the Social Worker (SW) on 6/6/14. Resident #3 declined. On 6/9/14 the SW offered a room change to Resident #3 from a room that was adjacent to Resident #1's to another room down the hall from his/her present room. Resident #3 declined and requested to stay in current room. No further interventions were offered or made. On June 11, 2014 at 11:00 p.m., a nurse's notes reflected that CNA (#1) reported to Licensed Practical Nurse (LPN) #1 that Resident #1 grabbed her by the shoulder and she started yelling for help. On June 12, 2014, at 12:30 a.m., LPN #1 placed Resident #1 on "Every 15 minute monitoring" and gave report to LPN #2. The CNA assigned to provide every 15 minute checks had no knowledge of the aforementioned incident. On 6/24/14 at 11:40 a.m., the surveyor conducted an interview with CNA #2, who was assigned by LPN #2 to perform "Every 15 minute monitoring" for Resident #1. CNA #2 stated, "I was with Resident #1 all night, except for about 7 minutes. I was worried that Resident #1 would fall. I wasn't watching Resident #1 because I was afraid the he/she would hurt someone. I did not know that Resident #1 had a problem with another CNA earlier in the night/evening." The deficient practice resulted in an immediate jeopardy situation, for Resident #2 who was later that same night, hit in the head with a wheelchair leg rest by Resident #1 on 6/12/14 at 3:30 a.m. This resulted in Resident #2 requiring emergency nursing intervention and hospitalization . Resident #1 was transferred to the hospital for an evaluation and was later admitted for inpatient care on 6/12/14 at approximately 4:00 a.m. The immediate jeopardy for Resident #2, began on 6/11/14 at 10:45 p.m. and was corrected on the day of survey 6/24/2014, based on an acceptable Plan of Correction (POC) which was implemented by the facility. This deficient practice is evidenced by the following: The medical record was reviewed by the surveyor on 6/24/14. 1. According to a medical record Face Sheet, Resident #1 was admitted to the facility in April of 2014. According to an undated "Resident Summaries" sheet, the Director of Nursing (DON) documented that Resident #1 had the following diagnoses, which included but were not limited to; Urinary Tract Infection, Influenza, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and Depression. In addition, Resident #1 had a [DIAGNOSES REDACTED]." A review of Resident #1's Care Plan (CP) initiated on 4/24/14 reflected the resident had episodes of yelling and screaming. Interventions included but were not limited to; attempt to re-direct and ease during periods with behavior symptoms such as provide snack, one to one interaction, minimal light/noise distraction, psychiatry/psychology visits as needed, encourage to verbalize thoughts and feelings openly, Social worker to provide with one to one room visits, social worker as well as nursing staff will monitor for any possible signs of mood and/or behavior changes, and psychiatry/psychology visits as needed, administer [MEDICATION NAME] (an anti-depressant) and Klonopin (an anti-anxiety medication) as ordered and monitor for any side effects. Resident #1's CP was updated on 5/12/14 to reflect the resident had a physical alteration on 5/12/14 with another resident. Interventions included; 5/12/14 sent out to hospital for evaluation and room changed from Second floor unit to Third floor unit. In addition, on 6/12/14 Resident #1's CP was updated and reflected Resident #1 struck roommate with leg of wheelchair. The intervention was to send Resident #1 out via 911 to the hospital for evaluation of aggressive behavior. A Minimum Data Set (MDS), an assessment tool, dated 4/11/14, documented Resident #1 had a BIMS (Basic Interview for Mental Status) score of nine, which indicated that Resident #1 had moderate cognitive impairment. On a subsequent MDS dated [DATE], the BIMS score was 13 that indicated the resident had intact cognition. The MDS further reflected that Resident #1 required assistance with all aspects of activities of daily living. According to a Facility Reportable Event Record (FRE) dated 6/12/14 and faxed to the New Jersey Department of Health (DOH) on 6/12/14, Resident #1 struck roommate Resident #2 in the head and face with the leg of a wheelchair on 6/12/14 at approximately 3:45 a.m. The FRE further reflected Resident #1 had "relative [DIAGNOSES REDACTED]." A review of a Licensed Practical Nurse (LPN) #1 nurse's note, dated 6/11/14 timed "3-11" reflected CNA #1 reported to LPN#1 that Resident #1 was shouting and she went to check on the resident. CNA #1 noted that the resident's gown was off and she tried to put it back on the resident. The resident was "resistive to care." The nurse's note further reflected "that the resident grabbed her by the shoulder and she started yelling for help." In the same note the LPN#1 documented at 11:15 p.m. "I called the Social Worker to inform about the incident and left a message to call us back." Further documentation indicated at 11:30 p.m. Resident #1 was observed lying in bed in a calm manner. At 12:30 a.m. (June 12, 2014), the LPN documented he "put one CNA" to watch Resident #1 and report was given to the oncoming nurse. A statement from CNA # 1 dated 6/12/14 obtained during the course of the facility's investigation revealed that at 10:45 p.m. (on 6/11/14) she heard Resident #1 yelling. She found the resident with the gown off and when she "went to put it on the resident he/she held her "from my neck" and she screamed for someone to help her. CNA #1 further documented that Resident #1 had never done that before. During a post-survey telephone interview with CNA #1 on 7/1/14 at 9:50 a.m., CNA #1 revealed that on 6/11/14 during the 3:00 p.m. to 11:00 p.m. shift she heard a voice saying "help me, help me." She entered Resident #1's room and found the resident standing up next the bed with the gown off and blankets on the floor. CNA #1 stated that when she bent over to pick up the gown and blankets, Resident #1 "grabbed me from behind by the neck and threw me onto the bed face down. I shouted help, help, but no one came for 5 minutes. I couldn't yell loud because my face was in the bed." Furthermore, she revealed that Resident #1 had his/her elbow "holding my neck down." The resident was "big and heavy and I couldn't move." CNA #1 stated that the CNA who helped her told Resident #1 to release her and the resident did. CNA#1 stated she was not injured. In addition, she revealed that she informed the 3:00 p.m. to 11:00 p.m. LPN of what happened and the next day she provided a statement. The CNA stated "I went home at 11:30 p.m. I don't know what they did after I left." On 6/24/14 at 6:30 p.m., the surveyor conducted an interview with LPN #1 and asked about his documentation in a nurses note dated 6/12/14 at 11:00 p.m. LPN #1 stated at 11:00 p.m., the CNAs came to him and reported that Resident #1 had put his/her hands on CNA #1's neck/shoulder area. He then went to talk with Resident #1 and CNA #1. Resident #1 was confused, and was repeating the same thing, I hate this place, I need to get out of here. Resident #1 did not remember doing anything to CNA #1. LPN #1 stated Resident #1 had never put hands on any staff before. He revealed that he called the Social Worker (SW) and left a message. In addition LPN #1 stated that there was no 3-11 supervisor and there wasn't a Registered Nurse (RN) in the building that he knew of. LPN #1 confirmed he didn't notify the DON or the doctor of the aforementioned incident. On June 24, 2014 at 10:15 a.m., the surveyor conducted an interview with the DON and asked why LPN #1 had called the SW and not the DON after Resident #1's physical altercation with CNA #1 on 6/11/14 at 10:45 p.m. The DON replied, "(LPN #1) told me he thought it was a social work issue. I have since counseled him and others on notifying me of incidents." The DON further stated, the facility did not have a 3-11 or 11-7 RN supervisor, and there was not a RN in the building on 6/11/14 from 11:00 p.m. to 7:00 a.m. A review of a nurses note written by LPN #2, dated 6/12/14 at 3:30 a.m., LPN #2 documented that Resident #1 was found over roommate (Resident #2), with a wheelchair footrest in his/her hand. Resident #2 was bleeding from his/her head and around the right side of the nose. It appeared that Resident #1 had hit Resident #2 on the head with the wheelchair footrest he/she was holding. The footrest was taken from Resident #1 and Resident #1 was removed from the room to the hallway. In addition, 911 was called and they arrived with an ambulance. Both residents were taken to the hospital. Both resident's family and doctor were made aware of the incident. On June 24, 2014 at 5:20 p.m., the surveyor conducted an interview with LPN #2 and asked about her documentation in a nurses note dated 6/12/14 at 3:30 a.m. LPN #2 stated that LPN #1 during report told her to monitor Resident #1's behavior. He did not tell us about "hitting or grabbing a CNA." LPN #2 also stated that "just for that night we had a CNA sitting outside" of Resident #1's room. LPN #2 revealed that CNA #2 was in another resident's room when CNA #2 heard Resident #1's bed alarm sounding. CNA #2 returned to the room and observed Resident #1 hitting Resident #2 with the foot-pedal of a wheelchair, and she called for help. LPN #2 arrived and observed Resident #2 "bleeding seriously," and CNA #2 "struggling" to get Resident #1 away from Resident #2. LPN #2 revealed she had to "free" the footrest from Resident #1's hand as Resident #1 was now attempting to hit CNA#2 and LPN #2 with it. Resident #1 was placed in a wheelchair and removed from the room. LPN #2 further stated a CNA stayed with Resident #2 while 911 was called and was tended to. LPN #2 stated Resident #1 was removed from the room. Both Resident #1 and Resident #2 were transferred to a hospital, for evaluation. Resident #1 was sent for psychiatric evaluation and Resident #2 was sent for medical evaluation. LPN #2 called both families (for Resident #1 and Resident #2), then called the resident's physicians and DON. A review of a facility "Daily Behavior Monitoring Log" with a start date of 6/11/14 at 11:15 a.m. to 6/12/14 at 3:30 a.m., reflected 15 minute checks were being made during that time period and the form was signed as being completed by the 11:00 p.m. to 7:00 a.m. CNA #2. CNA #2 documented for each 15 minute entry that Resident #1 was either in the bed or chair. On 6/24/14 at 11:40 a.m., the surveyor conducted a interview with CNA #2 and asked about the purpose of the Daily Behavior Monitoring Log used for Resident #1 during the night of 6/11/14 into the day of 6/12/14. CNA #2 stated that she was with Resident #1 "all night" because "I was worried that the resident was going to fall." CNA #2 revealed that she was not aware that Resident #1 had a physical altercation with another CNA earlier that night. She stated she wasn't "watching" Resident #1 because she was afraid the resident "would hurt somebody." CNA #2 revealed she had been seated in the hall by Resident #1's room, when she heard another resident scream, and a bed alarm was sounding. She stated she was away from Resident #1's room for 7 minutes. During that time while she was helping the other resident, she heard Resident #1's bed alarm "going off." She finished with the other resident and went back to Resident #1's room. CNA #2 revealed Resident #1 was at Resident #2's bed "hitting" Resident #2 "with the leg rest of a wheelchair." During an interview on 6/24/14 at 3:40 p.m., the surveyor asked the DON what she would have done if she had known about Resident #1's physical altercation with CNA #1. The DON replied, "I would have monitored (Resident #1), made an incident report out, called the doctor about it and probably would have transferred (Resident #1) to the hospital for evaluation." 2. According to a medical record Face Sheet, Resident #2 was admitted to the facility in April of 2005. A Monthly Physician order [REDACTED].#2 had the following diagnoses, which included but were not limited to; Hypertension, [MEDICAL CONDITIONS] Joint Disease, [MEDICAL CONDITION] and Dementia. A review of an MDS dated [DATE] reflected Resident #2 had a BIMS score of 3, which indicated that Resident #2 had severe cognitive impairment. The MDS further indicated that Resident #2 required assistance with all aspects of activities of daily living. A review of nurses notes dated 6/12/14 at 3:30 a.m. reflected that the CNA was yelling for help and LPN #2 ran to the residents room and Resident #2 was observed "pinning resident down" with a wheelchair "foot rest" and the resident was bleeding from the head. A review of an Incident/Accident Report, dated 6/12/14 at 3:30 a.m., reflected Resident #2 was stuck on the head and "around the nose" by Resident #1 with a wheelchair footrest. Resident #2 was transferred to the hospital, via 911 ambulance at 4:00 a.m. on 6/12/14. In the area of pain level/location, the LPN documented "resident unable to say a word." A hospital CT scan report dated 6/12/14 indicated Resident #2 had sustained a right front scalp hematoma extending inferiorly with right peri-orbital soft tissue swelling extends over right nasal bone with a mildly displaced [MEDICAL CONDITION] right nasal bone. Additionally there was a mild depression of the left mid nasal bone was noted. A review of nurses notes, dated 6/12/14 at 11:40 a.m., indicated Resident #2 returned from the hospital via ambulance with sutures on head and nose, swelling of the face. The resident's right eye was fully swollen and Resident #2 cannot open it. Resident #2 was assessed for pain, which was documented on a pain scale of 4 of 10 (four indicated moderate pain according to June 2014 physician order [REDACTED]. A post-incident Psychiatry Evaluation dated 6/16/14, indicated Resident #2 discussed the "assault" that occurred "days ago." The resident spoke of feeling "comfortable/satisfied prior to incident." Resident #2 discussed the wish for Resident #1 "not to return" and expressed relief if this was the case. On June 24, 2014 at 12:30 p.m., the surveyor conducted an interview with Resident #2 and asked the resident if he/she was afraid of the person who used to live in the room with him/her. Resident #2 replied, "No, but (Resident #1) just started to hit me. I don't know why." 3. According to a medical record Face Sheet, Resident #4 was admitted to the facility in April of 2014, with [DIAGNOSES REDACTED]. A review of an MDS dated [DATE] documented Resident #4 had memory problems and was moderately impaired cognitively; decisions poor; cues/supervision required. Resident #2 required assistance with all aspects of activities of daily living. Resident #4's CP indicated the resident had impaired cognition secondary to disease process and was at risk for episodes of anxiety and restlessness; unsafe standing from wheelchair and ambulating unassisted. A review of a nurses note, dated 4/30/14 at 6:10 p.m. reflected "Resident (#4) was calling for help in lounge room. Upon arrival, Resident #4 stated (Resident #1) hit (Resident #4) on face...Doctor and family notified." During an interview with LPN #3, on 6/24/14 at 5:42 p.m., the surveyor asked about the 4/30/14, 6:10 p.m. incident. LPN #3 stated she made out an incident report and called the Director of Nursing (DON) as the DON was in the conference room. She told the DON about the incident and put the incident report on her desk where she had other incident reports. She revealed she took Resident #4 out of the dining room and kept Resident #4 with her. Resident #1 stayed in the dining room/lounge with another CNA. There was no documentation in Resident #4's and/or Resident #1's care plan that reflected new interventions were put in place to address the resident to resident abuse incident. A nurse's note, dated 5/12/14 at 12:30 p.m., reflected the LPN documented she heard Resident #4 "yelling help" coming from hallway dining room. Resident #4 was getting hit by Resident #1 and was visibly upset. In addition, the LPN documented a videotape from the dining room camera revealed an altercation which resulted in Resident #4 being struck in the right shoulder by Resident #1. The residents were separated and the resident's physician was made aware. On 6/26/14 at 4:00 p.m., the surveyor conducted a telephone interview with LPN #4 and asked about the 5/12/14 incident that occurred between Resident #1 and Resident #4. LPN #4 stated that she and the DON watched the video of the incident and had observed Resident #1 was seated at a different table from Resident #4. Resident #1 "rolled over" to Resident #4's table, it looked like they had words and then Resident #1 flipped Resident #4's lunch tray over and "hit" Resident #4 on the shoulder. LPN #4 then reported that Resident #1's physician was called and Resident #1 was transferred to the hospital for a psychiatric evaluation. Resident #1 returned to the facility at 8:00 p.m. on 5/12/14, and was transferred to a room on a different floor, as an intervention. A review of Resident #1's "[MEDICAL CONDITION] Monitoring Form" for the April and May 2014, reflected the resident was on the [MEDICAL CONDITION] medication [MEDICATION NAME] mg by mouth daily. There was no documentation of what the targeted behavior was and no documentation of the aforementioned incident. 4. According to a medical record Face Sheet, Resident #3 was admitted to the facility in November of 2013. A Careplan summary sheet listed [DIAGNOSES REDACTED]. A review of Resident #3's MDS, dated [DATE] reflected Resident #3 had a BIMS score of 15, which indicated that Resident #3 was cognitively intact. The MDS further indicated that Resident #3 required assistance with all aspects of activities of daily living and was non-ambulatory. A review of Resident #3's CP initiated on 12/6/13, indicted the resident presented with mood symptoms such as; little pleasure in doing things, trouble sleeping, feeling tired and having little energy. Interventions included but not limited to; encourage to participate in activities, SW to provide one to one visits, SW as well as nursing staff will observe for any possible signs of mood and/or behavioral changes and will attempt to re-direct during any episodes of anxiety and other mood symptoms. A review of a nurses note, dated 6/6/14, "late entry" reflected "on the evening of 6/5" resident had an altercation with another resident verbally, "resident at this time is being monitored for behaviors." There was no documentation that reflected which resident was being monitored for behaviors. There was no documentation that reflected Resident #3 was assessed for injury by the nursing staff. A Social Service Progress Note (SSPN) dated 6/6/14 (not timed) also confirmed that on the evening of 6/5/14 Resident #3 had an altercation with another resident. It was primarily verbal with minimal physical contact and no serious injury. The SSPN further reflected that Resident #3 was offered a temporary room change for the weekend period. In addition, indicated the careplan will be reviewed/updated and staff will continue to observe Resident #3's mood and behavior. A subsequent SSPN dated 6/9/14 (not timed) indicated Resident #3 was offered a room change and declined. A review of a statement obtained during the course of the facility's investigation dated 6/6/14 from Resident #3 and written by the SW, reflected that Resident #3 came out of their room and Resident #1 was in the day room. Resident #1 left the day room and came right up to Resident #3. Resident #1 then "locked" the little wheel of his/her wheelchair into Resident #3's big wheel of the wheelchair, so Resident #3 could not move. Resident #3 told Resident #1 to "get away from me" and Resident #1 said I don't have to move if I don't want to. Resident #3 then attempted to push Resident #1's wheelchair away. LPN #1 then moved Resident #1 near the nurse's station and told the Resident to stay there. Resident #3 then went to use the microwave and upon return, Resident #1 blocked Resident #3. Resident #3 then pointed at Resident #1 and stated LPN #1 told you to stay over there. Resident #1 then grabbed Resident #3's fingers and twisted them. Another nurse (unidentified) told them to stop fighting. Both residents accused each other of hitting. On 6/24/14 at 12:10 p.m., the surveyor conducted an interview with Resident #3 and asked about Resident #1. Resident #3 stated that Resident #1 "would say to me 'I hate you' and sit outside my door and say 'I hate this place, I hate this place.' It even happened in front of the social worker, everyone knew about this. (Resident #1) would say to me, "I hope you die a slow and painful death." The resident revealed that Resident #1 "would bang on my wall at night. Nobody was doing a damn thing, none of the nurses, nobody." The surveyor then observed that Resident #3 started to cry. Resident #3 continued and stated that a couple of nights before Resident #1 did what he/she did to Resident #2, Resident #1 came by me and "grabbed my two fingers and bent them back." Resident #3 identified to the surveyor the right index and 3rd finger. Resident #3 further stated "I pulled my hand away. They thought I was going to hit (Resident #1)." A review of a statement obtained during the course of the facility's investigation from Resident #1 documented by the SW, reflected Resident #1 felt Resident #3 was purposely picking on him/her and that they both went their own way. The SW asked if Resident #1 remembered "getting physical" or hitting each other. The resident replied no. The SW asked Resident #1 if they said anything to Resident #3. Resident #1 replied "I might have said-I hope you die [MEDICAL CONDITION]." The SW further documented that Resident #1 stated I think Resident #3 "hit me on the arm once." On 6/24/14 at 12:30 p.m., the surveyor conducted an interview with a non-sampled resident who wrote a statement on the 6/5/14 regarding the incident between Resident #1 and Resident #3. The resident stated that he/she was waiting to get their medications from the nurse and saw that Resident #1 was blocking Resident #3 from passing by with his/her wheelchair. Resident #3 asked Resident #1 to move so that Resident #3 could get by. After asking three times, Resident #1 said, 'No.' The non-sampled resident further stated that LPN #1 then moved Resident #1 out of the way and informed Resident #1 that he/she could not block Resident #3's way. LPN #1 walked away and Resident #1 started yelling, swinging and grabbing Resident #3's arm. A review of a statement dated 6/5/14 from the non-sampled resident confirmed the aforementioned interview with the surveyor. A statement (not dated) written by the Director of Nursing (DON), reflected that on 6/5/14 there was an altercation between Resident #1 and Resident #3. The DON reviewed the statements obtained during the investigation as well as a video tape taken of the incident. The DON documented as Resident #3 approached Resident #1, when he/she attempted to pass Resident #1, Resident #1 rolled forward in the wheelchair blocking Resident #3 from turning left toward the low side of the hallway. Resident #3 put hands up to wave Resident #1 back and Resident #1 reached for Resident #3's hand. The DON documented that Resident #3 immediately pulled his/her hand away. In addition, as Resident #3 continued to try to pass, Resident #1 grabbed the back handle of Resident #3's wheelchair. Resident #3 then pushed Resident #1's arm away and continued on their way. The DON documented that the residents were not observed hitting each other. The videotape was not available the day of survey for the surveyor to view. The Director of Nursing (DON) reported that the recordings from 6/5/14 had been recorded over. A review of Resident #1's physician order [REDACTED]." A review of Resident #1's "[MEDICAL CONDITION] Monitoring Form" for the June 2014, reflected the resident was on the "[MEDICAL CONDITION] medication" [MEDICATION NAME] 10 mg, by mouth, daily. There was no documentation of what the targeted behavior was and/or no documentation of the aforementioned incident that occurred on 6/5/14. In addition, there was no documentation that reflected the facility was monitoring for the effectiveness of the [MEDICATION NAME] that was prescribed by Resident #1's physician on 6/5/14 and/or that the facility identified what the targeted behavior was. A facility policy titled "Resident Abuse/Neglect Misappropriation of Property" policy, dated February 15, 2011 contained the following documentation: "Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants or volunteer staff or other agencies serving the individual, the family members, legal guardians, friends, or other individuals. All alleged violations involving mistreatment, neglect or abuse including injuries of an unknown source, are reported immediately to the Administration or the designee. The alleged victim will be promptly examined, if applicable, and the findings documented on both the investigation report and clinical record. Immediate steps will be taken to protect the alleged from further abuse...Incidents of Resident to Resident abuse should not be routinely reported to State agencies, (the decisions are made on a case by case basis.)" The immediate jeopardy to the resident's health and safety was brought to the attention of the facility Administration on 6/24/14 at 3:40 p.m. The immediate jeopardy for Resident #2, #3 and #4 began on 4/30/14 at 6:10 p.m. and was corrected on the day of survey 6/24/2014, based on an acceptable Plan of Correction (POC) which was implemented by the facility. The POC is as follows: 1. Resident #1 was immediately removed from the building and will not be returning. Resident #2 was sent to the hospital via 911 for medical attention. 2. All residents with identified aggressive behavior problems will be reassessed to make sure all appropriate interventions are in place. 3. All staff will be re-educated on an updated policy with regards to abuse with special focus on resident to resident abuse starting today and continuing until all staff have been educated; will be included in new hire orientation moving forward. 4. All allegations of abuse will be investigated and reported per regulatory guidelines. 5. All residents will be reviewed in our daily clinical reporting/meeting with review of nursing 24 hour reports. All allegations of abuse are to be included in the nursing 24 hour report. 6. Clinical reports will be reviewed through our Quality Assurance Committee. 7. Outcome of our daily clinical meetings will be reviewed by DON/Administrator and our Quality Assurance Committee. 8. Quality Assurance Committee minutes will be reviewed quarterly at our CQI meetings. NJAC 8:39 - 27.1 (a)

Complaint #: NJ , NJ Based on interview and review of medical records and facility policy, it was determined that the facility failed to notify a resident's physician of a change in behavior, for 1 of 4 sampled residents (Resident #1.) The facility professional and direct care staff witnessed and/or had knowledge of an alleged physical abuse (grabbing the neck and shoulder area) of Certified Nursing Assistant (CNA) #1 by Resident #1, on 6/11/14 at 10:45 p.m. Resident #1's physician was not made aware of this incident. The deficient practice resulted in an immediate jeopardy situation, for Resident #2 who was later that same night, hit in the head with a wheelchair leg rest by Resident #1 on 6/12/14 at 3:30 a.m. This resulted in Resident #2 requiring emergency nursing intervention and hospitalization . Resident #1 was transferred to the hospital for an evaluation and was later admitted for inpatient care on 6/12/14 at approximately 4:00 a.m. The immediate jeopardy for Resident #2 began on 6/11/14 at 10:45 p.m., and was corrected on the day of survey 6/24/2014, based on an acceptable POC which was implemented by the facility. This deficient practice is evidenced by the following: The surveyor reviewed Resident #1's medical record on 6/24/14. 1. According to a medical record Face Sheet, Resident #1 was admitted to the facility in April of 2014. According to an undated "Resident Summaries" sheet, the Director of Nursing (DON) documented that Resident #1 had the following diagnoses, which included but were not limited to; Urinary Tract Infection, Influenza, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and Depression. A review of Resident #1's care plan (CP) initiated on 4/24/14 and last revised on 6/12/414 reflected the resident had episodes of yelling and screaming. Interventions included but not limited to; attempt to re-direct and ease during periods with behavior symptoms such as provide snack, one to one interaction, minimal light/noise distraction, psychiatry/psychology visits as needed. A Minimum Data Set (MDS), an assessment tool, dated 4/11/14, documented Resident #1 had a BIMS (Basic Interview for Mental Status) score of nine, which indicated that Resident #1 had moderate cognitive impairment. On a subsequent MDS dated [DATE], the BIMS score was 13 that indicated the resident had intact cognition. The MDS further reflected that Resident #1 required assistance with all aspects of activities of daily living. According to a Facility Reportable Event Record (FRE) dated 6/12/14 and faxed to the New Jersey Department of Health (DOH) on 6/12/14, Resident #1 struck roommate Resident #2 in the head and face with the leg of a wheelchair on 6/12/14 at approximately 3:45 a.m. The FRE further reflected Resident #1 had "relative [DIAGNOSES REDACTED]." A review of a Licensed Practical Nurse (LPN) #1 nurse's note, dated 6/11/14 timed "3-11" reflected CNA #1 reported to LPN#1 that Resident #1 was shouting and she went to check on the resident. CNA #1 noted that the resident's gown was off and she tried to put it back on the resident. The resident was "resistive to care." The nurse's note further reflected "that the resident grabbed her by the shoulder and she started yelling for help." In the same note the LPN#1 documented at 11:15 p.m. "I called the Social Worker to inform about the incident and left a message to call us back." Further documentation indicated at 11:30 p.m. Resident #1 was observed lying in bed in a calm manner. At 12:30 a.m. (June 12, 2014), LPN #1 documented he "put one CNA" to watch Resident #1 and report was given to the oncoming nurse. There was no documentation that indicated Resident #1's physician was made aware of the change in behavior/abuse incident by Resident #1 toward CNA #1. A statement from CNA # 1 dated 6/12/14 obtained during the course of the facility's investigation revealed that at 10:45 p.m. (on 6/11/14) she heard Resident #1 yelling. She found the resident with the gown off and when she "went to put it on the resident he/she held her "from my neck" and she screamed for someone to help her. CNA #1 further documented that Resident #1 had never done that before. During a post-survey telephone interview with CNA #1 on 7/1/14 at 9:50 a.m., she revealed that on 6/11/14 during the 3:00 p.m. to 11:00 p.m. shift she heard a voice saying "help me, help me." She entered Resident #1's room and found the resident standing up next the bed with the gown off and blankets on the floor. CNA #1 stated that when she bent over to pick up the gown and blankets, Resident #1 "grabbed me from behind by the neck and threw me onto the bed face down. I shouted help, help, but no one came for 5 minutes. I couldn't yell loud because my face was in the bed." Furthermore, she revealed that Resident #1 had his/her elbow "holding my neck down." The resident was "big and heavy and I couldn't move." CNA #1 stated that the CNA who helped her told Resident #1 to release her and the resident did. CNA#1 stated she was not injured. In addition, she revealed that she informed the 3:00 p.m. to 11:00 p.m. LPN of what happened and the next day she provided a statement. The CNA stated "I went home at 11:30 p.m. I don't know what they did after I left." On 6/24/14 at 6:30 p.m., the surveyor conducted a interview with LPN #1 and asked about his documentation in a nurses note dated 6/12/14 at 11:00 p.m. LPN #1 stated at 11:00 p.m., the CNAs came to him and reported that Resident #1 had put his/her hands on CNA #1's neck/shoulder area. He then went to talk with Resident #1 and CNA #1. Resident #1 was confused, and was repeating the same thing, I hate this place, I need to get out of here. Resident #1 did not remember doing anything to CNA #1. LPN #1 stated Resident #1 had never put hands on any staff before. He revealed that he called the Social Worker (SW) and left a message. In addition LPN #1 stated that there was no 3-11 supervisor and there wasn't a Registered Nurse (RN) in the building that he knew of. LPN #1 confirmed he didn't notify the DON or the doctor of the aforementioned incident. A review of a nurses note written by LPN #2, dated 6/12/14 at 3:30 a.m., LPN #2 documented that Resident #1 was found over roommate (Resident #2), with a wheelchair foot rest in his/her hand. Resident #2 was bleeding from his/her head and around the right side of the nose. It appeared that (Resident #1) had hit (Resident #2) on the head with the wheelchair foot rest he/she was holding. The foot rest was taken from (Resident #1) and (Resident #1) was removed from the room to the hallway. Emergency services (911) was called and they arrived with an ambulance. Both residents were taken to the hospital. "Both resident's family and doctor were made aware." On June 24, 2014 at 5:20 p.m., the surveyor conducted an interview with LPN #2 and asked about her documentation in a nurses note dated 6/12/14 at 3:30 a.m. LPN #2 revealed that CNA #2 was in another resident's room when she heard Resident #1's bed alarm sounding. CNA #2 returned to the room and observed Resident #1 hitting Resident #2 with the foot-pedal of a wheelchair, and she called for help. LPN #2 arrived and observed Resident #2 "bleeding seriously," and CNA #2 "struggling" to get Resident #1 away from Resident #2. LPN #2 revealed she forced the footrest from Resident #1's hand as Resident #1 was now attempting to hit CNA#2 and LPN #2 with it. Resident #1 was placed in a wheelchair and removed from the room. LPN #2 further stated a CNA stayed with Resident #1 while 911 was called and Resident #2 was tended to. Both Resident #1 and Resident #2 were transferred to a hospital, for evaluation. Resident #1 was sent for psychiatric evaluation and Resident #2 was sent for medical evaluation. LPN #2 called both families (for Resident #1 and Resident #2), then called the resident's physicians and DON. On June 24, 2014 at 10:15 a.m., the surveyor conducted a interview with the DON and asked why LPN #1 had called the SW and not the DON after Resident #1's physical altercation with CNA #1 on 6/11/14 at 10:45 p.m. had occurred. The DON replied, "(LPN #1) told me he thought it was a social work issue. I have since counseled him and others on notifying me of incidents." The DON further stated, The facility did not have a 3-11 or 11-7 RN supervisor, and there was not an RN in the building on 6/11/14 from 11:00 p.m. to 7:00 a.m. During a subsequent interview on June 24, 2014 at 3:40 p.m., the surveyor asked the DON what she would have done if she had known about (Resident #1's) physical altercation with (CNA #1). The DON replied, "I would have monitored (Resident #1), made an incident report out, called the doctor about it and probably would have transferred (Resident #1) to the hospital for evaluation." The facility policy titled "Change of Resident Condition", dated 2/2014 noted the following: "It is the policy of this facility to promote resident safety by observing, recording and reporting any condition change to the attending physician so proper treatment will be implemented. Any changes in condition, mental and or physical, possible injuries from any source, known or unknown, newly noted wounds, falls, etc. occur. Assess the resident's need for immediate care. Do not leave the resident alone. Assess the resident and notify the attending physician of the resident's condition. Compare the resident's current condition to his or her prior level of function. Assessment and monitoring include, but are not limited to, the following: ...Personality changes... Complete an incident and or accident report per facility procedure. Notify resident's responsible party. Monitor resident's condition frequently until stable." The facility policy titled "Notification of Changes", dated 2/2014 noted the following: "It is the policy of this facility to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member of the following changes...A significant change in the resident's physical, mental or psychosocial status (i.e. a deterioration in health, mental and or psychosocial status in either life threatening conditions or clinical complications." The immediate jeopardy to Resident #2's safety was brought to the attention of the facility Administration on June 24, 2014 at 3:40 p.m. The immediate jeopardy for Resident #2 began on 6/11/14 at 10:45 p.m., and was corrected on the day of survey 6/24/2014, based on an acceptable POC which was implemented by the facility. 1. Resident #1 was immediately removed from the building and did not return. 2. Resident #2 was sent to the hospital via 911 for medical attention. 3. All residents with identified aggressive behavior problems will be reassessed to make sure all appropriate interventions are in place. 4. All education will be initiated immediately and continue until entire nursing staff is completed. All staff will be in-serviced on notification on change of condition with physician notification. 5. All residents will be reviewed in our daily clinical reporting/meeting with review of nursing 24 hour reports. All allegations of abuse are to be included in the nursing 24 hour report. 6. Clinical reports will be reviewed through our Quality Assurance Committee. 7. Outcome of our daily clinical meetings will be reviewed by DON/Administrator and our Quality Assurance Committee. 8. Quality Assurance Committee minutes will be reviewed quarterly at our CQI meetings. NJAC 8:39 - 13.1 (c), (d)

C #: NJ Based on interview and a review of medical records, it was determined that the facility failed to notify a physician and the family, in a timely manner, of a significant change in a resident's medical status, for 1 of 4 sampled residents, (Resident #2). Resident #2 had a documented change in condition over a period of time between 6:00 PM on 10/1/2013 and when the physician was notified at 12:30 AM, on 10/2/2013. It was at that time, that the physician gave an order for [REDACTED].#2's decline until after the resident was transferred to the hospital, at 1:20 AM, on 10/2/2013. This deficient practice is evidenced by the following: 1. According to a Facility Face Sheet, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 subsequently had an Amputation of Left Leg above the knee and was again hospitalized and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 9/24/2013, documented that Resident #2's memory was severely impaired. Resident #2 also required extensive assistance with all activities of daily living. The surveyor observed the following documentation in the closed medical record: In a nurse's note, dated and timed 10/1/2013 at 6:00 PM, "(Resident #2) was noted being lethargic. Assessed resident, v/s (vital signs) taken BP (blood pressure) 125/56, (pulse) 123, O2 sat (oxygen saturation in blood) 88, Temp (temperature) 99.6 F (Fahrenheit). RN (Registered Nurse) in the facility was notified and assessed (Resident #2). MD (physician) was called and ordered to give resident a dose of BP (blood pressure) med (medicine) due to elevated pulse. Dose could not be given due to the fact (Resident #2) was unable to swallow. O2 sat given to resident." Reference: January 2013, Mayo Clinic Foundation for Medical Education and Research (MFMER). Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. The surveyor also observed the following documentation in subsequent nurse's notes: On 10/1/2013 at 8:00 PM: "(Resident #2) was being monitored very closely q (every) 15 minutes." At 10:00 PM: "Resident in bed sleeping. O2 (oxygen) sat (saturation) 95-98% with Non-rebreather on. Resident kept clean. Dressing on sacral done. Resident would open eye on verbal command." At 10:05 PM: "DON (Director of Nursing) made aware on the situation and advise nurse to keep monitoring (Resident #2)". At 11:00 PM: "Endorse to 11-7 shift to f/u (follow-up)". On further surveyor review of the medical record, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Due at 4:30 PM: Accucheck (Fingerstick blood sugar) before meal with Humalog (short acting insulin) sliding scale coverage. Due at 5:00 PM: (Oral medications): [MEDICATION NAME] 25 mg 1 tablet; Multivitamin 1 tablet; Vitamin C 500 mg 1 tablet; Prostat Sugar Free 30 ml (milliliters); [MEDICATION NAME] 0.25 mg (milligrams) 1 tablet. Due at 9:00 PM: Accucheck at bedtime with Humalog (short acting insulin) sliding scale coverage, and [MEDICATION NAME] (long acting insulin) 12 units subcutaneously at bedtime. (Oral Medications): [MEDICATION NAME] 125 mg 1 cap (capsule); [MEDICATION NAME] 100 mg 1 capsule; [MEDICATION NAME] 20 mg 1 tablet; [MEDICATION NAME] 0.25 mg 1 tablet; [MEDICATION NAME] 20 mg 1 tablet. Due at 10:00 PM: [MEDICATION NAME] 300 mg 1 capsule. The facility failed to provide documentation to support why the accucheck for blood sugar levels and medications were not administered or that the physician was notified that they were not administered. In a nurse's note, dated and timed 10/2/2013 at 12:20 AM, the following is documented: "(Resident #2) in bed, O2 inhalation via nasal cannula @ (at) 2 l/min (liters per minute), breathing regular, lethargic, skin is cold and clammy, verbally unresponsive and to tactile stimuli. v/s (vital signs) taken BP 100/65, HR (heart rate) 130, R (respirations) 22, T 103.9, O2 sat 87%. Non-rebreather mask applied at 15 liters with O@ sat 94%." At 12:25 AM: "DON (Director of Nursing) made aware of (Resident #2's) medical condition." At 12:30 AM: "(doctor) notified of (Resident #2's) status and ordered to transfer to hospital ER (emergency room ) for evaluation." At 1:10 AM: "(Resident #2) picked up by paramedics." At 1:20 AM: "(Resident #2's) family notified of (Resident #2's) status and transfer to hospital." On surveyor review of the hospital emergency room records, dated 10/2/2014, the Paramedic Report on transfer from the facility to the hospital, Resident #2 was receiving Basic Life Support (BLS) when the paramedics arrived at the facility at 1:09 a.m. At 1:18 a.m., Resident #2 was intubated en-route to the hospital emergency room . The emergency room record, documented that Resident #2 was given 3 liters 0.9% Sodium Chloride intravenously in bolus fashion, was started on a Phenylephine drip at 25 mcg/min (micrograms per minute) (a vasoconstictor used in cases of [MEDICAL CONDITION]), [MEDICATION NAME] (antibiotic) 1 gram intravenously, [MEDICATION NAME] (antibiotic) 4.5 grams intravenously, and [MEDICATION NAME] suppository for temperature of 103 degrees F. White Blood Cell Count on blood drawn on arrival to the emergency room was documented at 19.48. (The normal is 4.5-11.0) Resident #2 was admitted to the Medical Intensive Care Unit [MEDICAL CONDITION] at 1:58 a.m. on 10/2/2013. Resident #2 was transferred to the hospital and admitted with "Sepsis" per a 10/2/2013 nurse's note at 6:45 AM. On 1/16/2014 at 4:52 PM the surveyor conducted an interview with Director of Nursing (DON #1) and asked about physician notifications in change of status and obtaining orders for oxygen therapy. The DON #1 replied: "A nurse would put on oxygen in an emergency and get a doctor's order later." Nothing was stated about why there was no documentation why the physician was not notified for 6 1/2 hours about (Resident #2's) lethargy, inability to swallow and take medications, oxygenation levels and the application of and changing strengths of oxygen, nor the notification of the family regarding Resident #2's change in status. The surveyor observed the following documented in a undated facility policy titled "Change of Resident Condition, Observing, Recording and Reporting": "It is the policy of this facility to promote resident safety by observing, recording and reporting any condition change to the attending physician so proper treatment will be implemented... Notify resident's responsible party". NJAC 8:39-13.1 (c) (d)