Every finding on record at Raritan Post Acute and Healthcare Center

Complaint #: 3054992 Based on interview and record review on 7/23/26 and 7/24/26, it was determined that the facility failed to follow acceptable standards of clinical practice when a nurse obtained Resident #3's blood sugar without a physician order. This deficient practice was identified for one of two residents reviewed (Resident #3) for medication administration and was evidenced by the following:Resident #3 was not at the facility at the time of the survey. A closed record review was completed. A review of the admission Record face sheet (an admission summary) revealed Resident #3 was admitted to the facility with diagnoses which included but were not limited to: spinal stenosis (the narrowing of one or more spaces within your spinal canal), scoliosis (a side-to-side curve of the spine), and hypertension. A review of Resident #3's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/23/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident's cognition was intact. A review of a Grievance Report filed on behalf of Resident #3, dated 5/26/26, revealed that the family expressed concern over a possible medication error that occurred on 5/25/26, during the 7-3 shift. It further indicated that Licensed Practical Nurse (LPN #1) acknowledged to the resident that she had made a mistake and that Resident #3 did not need to have a blood sugar check nor insulin administered. Further review of the report revealed under the Summary of Investigation section that LPN #1 stated that she had inadvertently taken a blood sugar from Resident #3 and when she returned to the med cart to check for insulin, she realized that Resident #3 did not need their blood sugar taken. A review of Resident #3's May 2026 Order Summary Report revealed no order for blood sugars to be taken. During an interview on 7/23/26 at 6 PM, LPN #1 stated that prior to administering any medication she was to ensure that a physician's order was in place, because their role was to prescribe. She stated that she recalled an incident involving Resident #3 where she introduced herself as the nurse and then proceeded to obtain the resident's vital signs, including the resident's blood sugar. LPN #1 stated that she then proceeded to enter the resident's vital signs into the resident's electronic medical record and realized that the blood sugar was not needed. She stated that there was no physician order to obtain the blood sugar, so she should not have taken it and that she should have double checked before taking it. During a joint interview on 7/23/26 at 7:30 PM, with the Director of Nursing (DON), Regional Nurse, Regional Director of Operations, and the Licensed Nursing Home Administrator (LNHA), the LNHA who participated via telephone stated that he recalled the grievance that was filed on behalf of Resident #3. He stated that he was onsite at the time and that staff informed him that there was a concern on the unit. He stated that the family expressed to him that they had concerns related to medications that were administered that morning. He stated that he spoke with LPN #1 who stated that a blood sugar was obtained for Resident #3 that morning and that when she went to enter the value into the system, she realized that a blood sugar was not needed for the resident. During an interview on 7/24/26 at 3:29 PM, the Nursing Supervisor (NS) stated that she was supervising on the day of the incident involving Resident #3 but could not recall the date or time. She stated she recalled overhearing yelling on the unit and when she approached, she was told by the family that LPN #1 had made a mistake. She stated that when she asked LPN #1 what happened LPN #1 told her that she had obtained a blood sugar for Resident #3 but that when she went to enter it into the system, she realized that it was not needed. The NS stated that she called the LNHA to inform him of the incident. During an interview on 7/24/26 at 4:25 PM, with the DON and the LNHA, the DON stated that resident #3's blood sugar was checked and there was no physician order for it. He stated that it should not have been checked without an order. Review of the facility's undated Obtaining a Fingerstick Glucose Level policy revealed that the first step in their preparation process was to verify that there was a physician order in place for the procedure. Review of the facility's Physician Orders policy, updated January 2025, revealed that nurses were to obtain, document and provide care and services in accordance with orders received from a physician. NJAC 8:39-11.2(b); 27.1(a); 29.2(d)

COMPLAINT #2976477 Based on interviews, review of medical records and other pertinent facility documentation on 7/23/26 and 7/24/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to document details related to the transfer of Resident #1 including: a) contacting the treating provider and the family, and b) entering an order obtained to start intravenous fluids. This deficient practice was identified for 1 of 2 residents reviewed for discharges (Resident #1) and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed medical record review was conducted. A review of the admission Record face sheet (an admission summary) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and atrophy, neuromuscular dysfunction, anorexia, and cognitive communication deficit. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/14/26, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #1's care plan revealed that Resident #1 had a focus related to the resident being at risk for respiratory complications. Interventions for this focus included monitoring vital signs and documenting findings and interventions. A review of Resident #1's electronic medical record revealed a New Jersey Universal Transfer Form (NJUTF), dated 3/24/26 at 12:49 PM, which revealed that the resident was transferred to a hospital due to, Refusing feeding, Diarrhea, Hypotension. The form was noted as being completed by the Registered Nurse/Unit Manager (RN/UM). A review of Resident #1's progress notes (PN) revealed a nursing note dated 3/24/26 at 8:58 PM, which revealed that the resident had been admitted to a hospital for hyponatremia (a medical condition where the sodium level in the body is too low). A further review revealed no other PNs concerning Resident #1's transfer. No additional documentation was provided to the surveyor regarding Resident #1's transfer. During an interview on 7/24/26 at 2:56 PM with RN/UM, he stated that all information should be documented in a resident's medical record so that everyone is aware of what happened during a resident's stay. The RN/UM recalled completing the NJUTF and stated the resident's blood pressure was low (91/53) and that he immediately contacted the Nurse Practitioner, who gave an order to start intravenous fluids. He stated that at the same time the family was contacted and provided an update, to which they requested that the resident be sent to the hospital. The RN/UM reviewed Resident #1's PN and stated that he should have documented all this information in the PN. During a joint interview on 7/24/26 at 4:25 PM with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the DON stated that any details related to the transfer of a resident, including contacting the treating provider, entering any orders obtained and any communication with the family should have been documented by the RN/UM. A review of the facility's Transfer or Discharge policy, revised March 2025, revealed that transfers must be documented in the medical record. The policy further revealed a list of documentation that was required, including the basis for transfer, notice provided to the resident and/or their representative, and summary of the resident's overall medical condition. A review of the facility's Charting and Documentation policy, revised July 2017, revealed that all services provided to the resident and any changes in the resident's condition shall be documented. N.J.A.C. 8:39-27.1(a); 35.2(d)16

Based on record review, interview, review of facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. The facility further failed to ensure staff wore the proper personal protective equipment (PPE) when providing care to one (Resident (R)3) out of one reviewed for proper PPE being donned (put on) out of a total sample of 35 residents. This had the potential for an increase in infections for all the residents of the facility. Findings include: Review of a document titled, Centers for Disease Control (CDC) . National Healthcare Safety Network (NHSN) . Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities ., dated 01/25, indicated . Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance. The NHSN LTCF modules provide standard surveillance definitions, allowing participating facilities to consistently apply well defined data elements to ensure accurate, reproducible, and comparable data. Review of a facility policy titled Infection Prevention and Control Policy and Procedure Manual dated 04/25 indicated . The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of the data. Surveillance includes a review of any or all of the following information to help identify possible indicators of infections.Laboratory records.Skin care sheets.Infection control rounds or interviews.Verbal reports from staff.Infection documentation records.Temperature logs.Pharmacy records.Antibiotic review.and Transfer log/summaries. 1.During an interview on 09/11/25 at 9:01 AM, the Infection Preventionist (IP) 1 and IP2 (who was an IP from a sister facility) provided tracking from 04/25 through 07/25. A request was made for a full year of surveillance data during this interview. During an interview on 09/11/2025 at 9:18 AM the Administrator stated they did not have access to any other surveillance data since the previous company took the tracking and trending data. 2. Review of R7's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] and had a diagnosis of acute osteomyelitis given on 08/13/25. Review of R7's EMR under the Orders tab revealed a physician's order, dated 09/09/25, for contact isolation related to ESBL [extended-spectrum beta-lactamase, refers to enzymes produced by bacteria that make them resistant to many commonly used antibiotics] of wound. Review of R7's Care Plan, dated 08/14/25, revealed, I am on [intravenous] therapy (cefiderocol) [an antibiotic] for osteomyelitis until 9/9/25. I.V. (micafungin) [antifungal medication] for candida until 9/10/25. An addition to the Care Plan, dated 09/09/25, revealed, I have an active/colonized multidrug resistant organism r/t [related to] ESBL in wound. The approaches included, Isolation precautions per policy. During an observation on 09/10/25 at 9:39 AM outside of R7's room, a sign that documented, Contact Precautions was in place at the doorway and directed staff to sanitize hands, don (put on) a gown and gloves prior to entering the room, remove the gown and gloves prior to room exit, and to sanitize hands at room exit. There was a bin with available personal protective equipment (PPE) at the door. R7's room door and privacy curtain were open, and LPN7 was observed inside the room administering medications, taking the resident's vitals including blood pressure, and touching the resident's overbed table. LPN7 was not wearing a gown or gloves. Upon exiting the room, LPN7 did not sanitize her hands. At this time, LPN7 stated R7 had an open wound, so she required a gown and gloves for high-contact care only. She stated she did not have to don any PPE when administering medications or providing care that was not considered a high contact activity. When asked about the Contact Precautions sign on the door, LPN7 stated she was not sure why that was there, as she thought PPE was only required during high-contact activities and added she would need to check with the LPN/Unit Manager (LPN/UM). LPN7 confirmed she did not wear a gown or gloves while in R7's room administering medications and monitoring vitals. During an interview on 09/10/25 at 9:51 AM, the LPN/UM stated R7 was on contact precautions due to osteomyelitis and a fungal infection in her wound. He stated staff were to wear a gown and gloves any time they entered the room. Review of the policy titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022, revealed, Contact Precautions . Staff and visitors wear gloves. when entering the room . Gloves are removed and hand hygiene performed before leaving the room . Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room. NJAC 8:39-19.4

Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure five of five residents (Resident (R) 116, R21, R114, R121, and R26) out of 35 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents.Findings include: Review of the RAI manual, dated 10/2024 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 1.Review of R116 electronic medical record (EMR) titled admission Record located under the Profile tab indicated that the resident was admitted to the facility on [DATE]. Review of R116's EMR titled quarterly MDS located under the MDS tab with an Assessment Reference Date (ARD) of 06/19/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident was at risk for the development of pressure ulcers, had no current pressure ulcers, and identified that the resident had a pressure reducing device for her wheelchair. During an observation conducted on 09/09/25 11:09 AM R116 was sitting in a transportation wheelchair, and the wheelchair seat was covered with a towel. There was no preventative pressure reducing cushion on the resident's wheelchair. During an observation conducted on 09/09/25 at 2:40 PM the Occupational Therapist (OT) verified R116 sat on a towel, and this was not appropriate for a resident who was at risk for the development of pressure ulcers. During an interview with the Regional Director of Case Management (RDCM) and MDS Coordinator (MDSC) on 09/10/25 at 2:26 PM confirmed R116 did not have pressure ulcer prevention measures on the resident's wheelchair. Both stated the MDS was incorrect. 2.Review of R21's EMR titled admission Record located under the Profile tab indicated that the resident was admitted to the facility on [DATE]. Review of R21's EMR titled annual MDS located under the MDS tab with an ARD of 08/21/25 indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. The assessment indicated that the resident was offered a pneumococcal vaccine, but he declined. Review of R21's EMR titled Immun (Immunization) tab failed to contain evidence that the resident received a pneumococcal vaccine. During an interview on 09/10/25 at 2:26 PM with the RDCM and the MDSC, both confirmed the resident did not have evidence of being offered the pneumococcal vaccine. Both stated the MDS was incorrect. 3.Review of R114's EMR titled admission Record located under the Profile tab indicated that the resident was admitted to the facility on [DATE]. Review of R114's EMR titled Immunization located under the Immun tab dated 04/06/22 indicated the resident was administered Pneumovax Dose 2 [PPSV23]. Review of R114's EMR titled annual MDS located under the MDS tab with an ARD of 07/04/25 indicated the resident had a BIMS score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident was up to date with the pneumococcal vaccine. During an interview on 09/10/25 at 2:26 PM, the RDCM and the MDSC confirmed there was no evidence that R114 was offered the pneumococcal vaccine. Both stated the MDS was incorrect. 4.Review of R121's EMR titled admission Record located under the Profile tab indicatedthe resident was admitted to the facility on [DATE]. Review of R121's EMR titled annual MDS located under the MDS tab with an ARD of 01/16/25 indicated the resident had a BIMS score of four out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident was offered and declined the pneumococcal vaccine. Review of R121's EMR titled Immunization located under the Immun tab failed to contain evidence that the resident and/or his representative was provided the opportunity to be vaccinated with the pneumococcal vaccine. During an on 09/10/25 at 2:26 PM interview with the RDCM and MDSC both confirmed there was no evidence that R121 was offered and declined the pneumococcal vaccine. Both stated the MDS was incorrect. 5.Review of R26's EMR titled admission Record located under the Profile tab indicatedthe resident was admitted to the facility on [DATE]. Review of R26's EMR titled annual MDS located under the MDS tab with an ARD of 05/07/25 indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident was offered and declined the pneumococcal vaccine. Review of R121's titled Immunization located under the Immun tab indicated the facility did not offer the resident a pneumococcal vaccination. During an interview 09/10/25 at 2:26 PM, with the RDCM and MDSC confirmed that R121 did not have evidence of being offered the pneumococcal vaccine. Both stated the MDS was incorrect. NJAC 8:39- 33.2(d)

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer four of five residents (Resident (R) 21, R26, R114, and R121) reviewed for flu/pneumonia vaccinations out of 35 sample residents and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for this resident to contract pneumonia.Findings include: Review from the CDC website titled PCV20 or PCV21 Vaccination for Adults 65 Years or Older dated 09/11/24 indicated .Adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 and meet the following criteria.Previously received one dose of PCV13 (but not PCV15, PCV20, or PCV21) at any age, and .Previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age). The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider. SCDM recommendations are optional and informed by the characteristics, values, and preferences of the patient, and the clinical discretion of the health care provider. Review of the facility policy titled Pneumococcal Vaccine dated 10/23 indicated All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series within 30-days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 1. Review of R21's electronic medical records (EMR) titled admission Record located underthe Profile tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission. Review of R21's EMR titled Immun (Immunization) tab failed to contain evidence that the resident received a pneumococcal vaccine. During an interview on 09/10/2025 at 2:26 PM the Regional Director of Case Management (RDCM) and the MDS Coordinator (MDSC) both confirmed that R21 did not have evidence of being offered a pneumococcal vaccine per CDC recommendations. 2. Review of R26's EMR titled admission Record located under the Profile tab indicatedthe resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission. Review of R26's EMR titled Immunizations located under the Immun tab failed to indicate the resident was offered a pneumococcal vaccine. Review of a document for R26 provided by the facility titled Patient Immunizations Administered Report dated 11/09/21 indicated the resident received Pneumo Poly [PPSV23]. During an interview conducted on 09/10/2025 at 2:26 PM the RDCM and the MDSC both confirmed the resident should have been offered a second pneumococcal vaccine per CDC recommendations a year later and this was not done. 3. Review of R114's EMR titled admission Record located under the Profile tab indicatedthe resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission. Review of R114's EMR titled Immunization located under the Immun tab dated 04/06/22 indicated the resident was administered Pneumovax Dose 2 [PPSV23]. During an interview conducted on 09/10/25 at 2:26 PM the RDCM and the MSDC both confirmed R114 did not have evidence of being offered a second pneumococcal vaccination per CDC recommendations. 4. Review of R121's EMR titled admission Record located under the Profile tab indicatedthe resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission. Review of R121's titled Immunization located under the Immun tab indicated the facility did not offer the resident a pneumococcal vaccination. Review of a document for R121 provided by the facility titled Patient Immunizations Administered Report failed to address if the resident was offered a pneumococcal vaccine. During an interview conducted on 09/10/25 at 2:26 PM the RDCM and MDSC both confirmed R121 did not receive a pneumococcal vaccine per CDC recommendations. During an interview on 09/10/25 at 8:27 AM, Infection Preventionist (IP) 2, who was the IP for a sister facility stated if a resident had the PCV13 and the PPSV23, the resident would be technically up to date and then five years later to be offered the PCV20 or PCV21. IP2 stated the physician can order whatever their preference was, and the facility would then supply the vaccination to the resident. IP2 stated the goal was to provide the resident with the opportunity to be vaccinated. NJAC 8:39-19.4

Based on observation, interview, and facility policy review, the facility failed to ensure one resident (R 116) out of one reviewed for accommodations of needs, out of a survey sample of 35, was provided and assessed for an appropriate wheelchair. This had the potential for R116 not to be able to propel herself and have to wait for staff assistance.Findings include: Review of a facility policy titled Resident Mobility and Range of Motion dated 04/20 indicated .Interventions may include therapies, the provision of necessary equipment.based on professional standards of practice consistent with state laws and practice acts. Review of R116's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R116's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 06/19/25 indicated the resident had a Brief Interview of Mental Status (BIMS) score of five out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no impairments of her upper or lower extremities. The assessment indicated the resident required partial to moderate assistance with activities of daily living. Review of R116's EMR titled Care Plan located under the Care Plan tab dated 07/30/25 revealed the resident had decreased safety awareness, endurance, and dynamic balance. One of the interventions included Occupational Therapy (OT) to evaluate and treat. The OT treatment included therapeutic activities and wheelchair management. Review of a document for R116 provided by the facility titled Occupational TherapyOT Evaluation & Plan of Treatment dated 07/30/25 indicated the therapeutic goal included that the resident would complete all functional transfers from the wheelchair, toilet, and bed. There was no further assessment which addressed the use of a transportation wheelchair (for individuals who have no upper body strength) or for a standard wheelchair (an individual can self-propel). During an observation on 09/09/25 at 11:09 AM, R116 was sitting in a transportation wheelchair. The resident's bi-lateral legs were placed on legs rests attached to the transportation wheelchair. The resident was participating in activities. During an interview on 09/09/25 at 11:52 AM, Certified Nurse Aide (CNA) 1 stated that the transportation wheelchair must have been brought in by R116's family. During an interview on 09/09/25 at 12:17 PM the Director of Rehabilitation (DOR) stated that residents were assessed for the use of a standard wheelchair. The DOR stated normally residents were assessed for the use of a standard wheelchair and then measurements would be taken for the height, depth, width, and leg rests. The DOR stated he was unsure if R116 was able to propel herself due to her poor cognition. The DOR stated he would have tested R116 in a standard wheelchair prior to the use of a transportation wheelchair. A request was made for any wheelchair assessments for R116. During an interview on 09/09/25 at 2:07 PM, the DOR confirmed that the OT completed an evaluation for R116 but there was no evaluation for the use of which type of wheelchair the resident required. During an observation on 09/09/25 at 2:11 PM, R116 was observed sitting in her transportation wheelchair playing activities with the other residents. During an interview on 09/09/25 at 2:40 PM, the OT stated the therapy department typically did not place a resident into a transportation wheelchair since the resident could not be positioned properly in them. The OT and surveyor went to observe R116. The OT stated she was not aware of the resident being in a transportation wheelchair and confirmed that the resident would be dependent on staff for mobility. During an interview on 09/10/25 at 8:25 AM, CNA2 stated R116 always had a transportation wheelchair. During an interview on 09/11/25 at 11:34 AM, the Administrator stated that she believed that the family brought the transportation wheelchair for R116 and stated she believed that staff provided the family with risks verses benefits on the use of the transportation wheelchair. The Administrator stated she would verify if this information was in the medical records for the resident. No additional information was provided at the conclusion of this survey. NJAC 8:39-4.1(a)

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure an open window was covered with a screen for one of 33 Initial Pool residents (Resident (R) 73) whose rooms were observed. This failure had potential to increase pest activity and risk of infection for R73.Findings include: Review of R73's admission Record, located under the Profile tab of the electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia, and chronic kidney disease. Review of R73's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/25 and located under the MDS tab of the EMR, revealed he scored an eight out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. During an observation in R73's room on 09/08/25 at 10:07 AM, R73 was unable to answer most questions and was speaking nonsensically. His room had a heavy urine odor, feces smeared on the wall, the floor, and the mattress; dirty laundry and used incontinence briefs in bags on the floor of the room, and crumbs and debris on the floor. The window was open, and the screen of the window was resting against the wall of the resident's room. There were several flies and other flying insects in the room. During an observation from the hallway outside of R73's room on 09/10/25 at 2:17 PM and on 09/11/25 at 9:00 AM, the window was again observed open with the screen missing, resting against the wall in the room. There were several flying insects in the room. During an interview on 09/11/25 at 9:30 AM, the Maintenance Director (MD) stated the missing window screen had not been reported to him to address. The MD stated there was a system in place for the staff to create work orders for items that needed fixing, and the staff were expected to report any concerns. The MD stated if he was aware of the missing screen in R73's window, he would have addressed it right away. The MD stated R73 had habit of keeping his room dirty and a window screen was important for keeping flies out of his room. Review of the policy titled, Work Orders, Maintenance, dated August 2025, revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. NJAC 8:39-4.1(a)NJAC 8:39-5.1(a)

Based on record review, interview, and facility policy review, the facility failed to ensure adequate monitoring for the use of psychotropic medications for two of five residents (Resident (R) 8 and R10) reviewed for unnecessary medications out of a total sample of 35 residents. For R8, behaviors were not identified for monitoring of medication effectiveness and failed to ensure ongoing assessment for adverse side effects of medication for R10. These failures had the potential to contribute to unnecessary psychotropic medication use and risk for adverse side effects of the medications.Findings include: 1.Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including intellectual disabilities, depression, and psychosis. Review of R8's EMR under the Orders tab revealed a physician's order, dated 05/14/24, for aripiprazole [an antipsychotic medication] 7.5 milligrams (mg) at bedtime for psychosis. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/25 and located under the MDS tab of the EMR, revealed she scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R8 did not exhibit mood or behavioral symptoms. She received routine antipsychotic medication and gradual dose reduction (GDR) had not been attempted. Review of R8's Care Plan, dated 08/18/25 and located under the Care Plan tab of the EMR, revealed, The resident uses psychotropic medications [aripiprazole, an antipsychotic medication] r/t [related to] behavior management and the goal was, [R8] will reduce the use of psychoactive medication through the review date. The approaches included, Administer medications as ordered. Monitor/document for side effects and effectiveness. R8's Care Plan did not describe her target behaviors to monitor to determine effectiveness of the medication. Review of R8's MAR, dated August 2025 and located under the Orders tab of the EMR, revealed she received antipsychotic medication daily. The MAR documented behaviors were exhibited on 08/09/25, 08/10/25, 08/13/25, 08/15/25, 08/20/25, 08/21/25, 08/22/25, 08/23/25, 08/24/25, 08/27/25, 08/29/25, and 08/30/25. Review of R8's EMR under the Progress Notes tab revealed no corresponding notes to indicate the nature of the behavior, the severity, the non-pharmacological intervention, and the intervention's effectiveness. Review of R8's Medication Administration Record (MAR), dated September 2025 and located under the Orders tab of the EMR, revealed she received antipsychotic medication daily. The MAR documented behaviors were exhibited on 09/03/25, 09/06/25, 09/07/25, and 09/08/25. Review of R8's EMR under the Progress Notes tab revealed no corresponding notes to indicate the nature of the behavior, the severity, the non-pharmacological intervention, and the intervention's effectiveness. During an interview on 09/10/25 at 2:57 PM, Licensed Practical Nurse (LPN) 7 stated R8 did not exhibit any behavioral symptoms and was pretty quiet. During an interview on 09/10/25 at 3:12 PM, Recreation Aide (RecA) 1 stated R8 did not exhibit behavioral symptoms and was pleasant and cooperative. During an interview on 09/11/25 at 9:50 AM, the Long-Term Care Social Worker (LTCSW) stated R8's most recent psychiatrist report documented a dose reduction of the aripiprazole was not indicated as the resident was experiencing auditory hallucinations. The LTCSW stated it was important to monitor not only if a behavior occurred, but the specific behavior exhibited and any contributing factors to ensure adequate monitoring for effectiveness of the medication. The LTCSW also stated the specific behaviors, and individualized interventions should be included in the Care Plan. During an interview on 09/11/25 at 11:37 AM, the Director of Nursing (DON) stated a behavior tracking sheet should be completed to quantify the specific behaviors exhibited and interventions used; however, these sheets were not yet in place. The DON stated at minimum, a corresponding Progress Note describing the behavior should be entered. The DON stated it was important to track specific behaviors to determine if the medication could be trialed for a dose reduction. The DON also stated these specific behaviors should be outlined in the Care Plan.Review of the facility's policy titled, Psychotropic Medication Use, dated February 2025, revealed, Residents receiving psychotropic medication are monitored and the response to treatment is documented. 2.Review of the admission Record located in the Profile tab of the EMR revealed R10 was admitted to the facility on [DATE] with diagnoses of intellectual disabilities, anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Review of the Evaluations tab in the EMR revealed an AIMS (abnormal involuntary movement scale assessment used to determine if there are any adverse side effects that develop when someone is taking an anti-psychotic medication) was completed on 08/15/24 with a score of zero. There was no evidence of any other AIMS being completed. There was no other evidence in the medical record that any monitoring for side effects was being completed. Review of the significant change MDS located in the MDS tab of the EMR with an ARD of 06/24/25 revealed R10 had a BIMS score of three out of 15 which indicated R10 was severely impaired in cognition and was administered an anti-psychotic medication during the seven-day observation period. Review of the Order Summary dated 07/25/25 revealed R10 had an Order for Risperdal [an anti-psychotic medication] 1 mg [milligram] every 12 hours for psychosis [a mental health condition characterized by a loss of contact with reality.] During an interview on 09/11/25 at 10:11 AM, the DON confirmed there was no other documentation to show there was any monitoring for any adverse side effects for the Risperdal for R10 and there had been a lack of monitoring overall for the use of an antipsychotic. NJAC 8:39-4.1(a)6NJAC 8:39-27.1(a)

Based on interview and record review, the facility failed to ensure one resident (Resident (R)7) reviewed for a hospital transfer out of a total sample of 35 was provided with a written transfer notice. This failure has the potential to affect all residents by not having knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.Findings include: Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R7 was admitted to the facility 07/28/24. Review of the Progress Notes located in the Progress Notes tab of the EMR revealed on 07/15/24, .Seen by MD [Medical Doctor]. Order rec'd [received] and carried out to send to [hospital name] for surgical wound debridement eval and treat. Review of the Progress Notes located in the Progress Notes tab of the EMR, revealed on 07/16/25, .Called ER [emergency room] Department for a status update. Patient was admitted . Admitting diagnosis Acute Osteomyelitis [bone infection] .Review of the EMR did not show documentation that R7 and/or her representative was provided with a written transfer notice regarding her transfer to the hospital, as required. During an interview on 09/10/25 at 11:36 AM, the Long-Term Care Social Worker (LTCSW) was asked if the transfer notice had been provided to R7, as it was not documented in the EMR. The LTCSW stated, We stopped doing them in May. I was not aware that we needed to keep doing them. NJAC 8:39-4.1(a)

Based on record review, interview, and facility policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR), Level II Determination recommendations were developed and implemented for one of four residents (Resident (R) 73) reviewed for PASARR out of a total sample of 35 residents. This failure had the potential to lead to continued or worsening behavioral symptoms without intervention.Findings include: Review of R73's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia, and chronic kidney disease. Review of R73's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/25 and located under the MDS tab of the EMR, revealed he scored eight out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R73 experienced delusions and exhibited behaviors of rejection of care daily. Review of R73's PASRR Level II Determination Notification, dated 05/09/25 and located in the Miscellaneous tab of the EMR, revealed the following recommendations were included: Formulate and implement a behavioral modification plan to address any behavioral disturbances and Develop a Crisis Intervention/Safety Plan with the client. Review of R73's Care Plan, located under the Care Plan tab of the EMR and dated 08/12/25, revealed, I meet the PASRR 2 Level of determination secondary to diagnosis of mental health disability . Recommendations as follows: Med [medication] monitoring, routine f/u [follow up] visits with psychiatrist and PCP [primary care physician], routine lab testing, develop crisis intervention plan for client. The approaches included: Case consultation . [and] Structured social activities, medication monitoring. Further review of R73's Care Plan revealed the focus, dated 05/23/25, [R73] has a diagnosis of schizophrenia. [R73] has a history of hallucinations and delusions . [R73] becomes agitated during care, shower, and hands on care and will yell at staff. The approaches included: Medications as ordered . Track behaviors . Validate resident's emotions . Approach in a calm, slow friendly manner . [and] Inform [R73] of care provided. Review of R73's EMR revealed there was no evidence of a behavior modification plan or a crisis intervention/safety plan. During an interview on 09/11/25 at 9:57 AM, the Long-Term Care Social Worker (LTCSW) stated she was in the process of making referrals to behavioral health facilities for R73, as his care could not be managed in the facility. She stated R73's behavior included all care including labs, weights, and medications as well as washing his linens in the toilet, washing his walls with toilet water, leaving soiled briefs and clothing on the floor, urinating on the floor, and refusing staff to enter his room. The LTCSW stated a behavior modification program and crisis intervention/safety plan were not created for R73 because he refused care. The LTCSW stated the PASARR Level II recommendations were typically sent to the unit manager for follow up and she was unsure why these recommendations were not followed through. During an interview on 09/11/25 at 11:29 AM, the Director of Nursing (DON) stated R73 had extreme behaviors related to schizophrenia, and the best way to manage his behavior was to leave him alone and re-approach at a later time when he can be reasoned with. The DON stated there was a certain way for staff to approach R73 to not set off his behaviors. The DON stated these approaches should be included in the Care Plan or in a behavior modification plan. The DON stated R73's behaviors were not appropriate for the nursing home and referrals were being made for mental health care. The DON was unaware the PASARR Level II recommendations were not implemented. Review of the policy titled, admission Criteria, dated March 2019, revealed, Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate . The state PASARR representative provides a copy of the report to the facility . The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. NJAC 8:39-40.3(d)

Based on observation, record review, review of facility policy, and interview, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for two of 35 sampled residents (Resident (R)116 and R56) reviewed for care plans. The failure had the potential for the residents to have unmet care needs.Findings include: Review of a facility policy titled Care Plans, Comprehensive Person-Centered dated 03/22 indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1.Review of R116's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R116's EMR titled admission Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 03/19/25 indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS). The assessment indicated the resident had no pressure ulcers, and was assessed and considered to be at risk for the development of pressure ulcers. Under the Care Area Assessment (CAA) revealed the resident triggered for the development of pressure ulcers and directed the staff to develop a care plan. Review of R116's EMR titled Care Plan located under the Care Plan tab failed to contain evidence that the clinical staff developed a pressure ulcer care plan. During an interview on 09/10/25 at 2:26 PM, the Director of Case Management and the MDS Coordinator (MDSC) stated if a resident triggers under the CAA the care plan should reflect this. During an interview on 09/10/25 at 3:25 PM the Regional Director of Case Management (RDCM) and the MDSC confirmed that a pressure ulcer care plan should have been developed for R116, and it was not. During an interview on 09/11/25 at 10:28 AM the Director of Nursing (DON) confirmed if R116 triggered under the CAA the care plan should have been developed. 2. Review of R56's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility 05/02/22 and had diagnoses including dementia, contracture, muscle weakness, and osteoarthritis. Review of R56's quarterly MDS, with an ARD of 07/20/25 and located under the MDS tab of the EMR, revealed she was rarely/never able to make herself understood and severely impaired cognition. R56 was always incontinent of bladder and frequently incontinent of bowel. She required substantial/maximum assistance with toileting hygiene and did not use the toilet. Review of R56's Care Plan, dated 06/27/25 and located under the Care Plan tab of the EMR, revealed she was dependent on staff for assistance with activities of daily living. The Care Plan did not address R56's incontinence or toileting hygiene needs. During an interview on 09/11/25 at 11:37 AM, the Director of Nursing (DON) stated a toileting/changing schedule was based on each individual; the facility did not have a protocol to apply to every resident. The DON stated the information on how often to check and change R56 should be included in her Care Plan. During an interview on 09/11/25 at 12:27 PM, the MDS Coordinator (MDSC) stated R56's incontinence and toileting hygiene needs should have been addressed in the Care Plan. NJAC 8:39-11.2(e) thru(i)

Based on record review, staff interview, and facility policy review, the facility failed to ensure one of five residents reviewed for unnecessary medications (Resident (R) 12) received antibiotic eye medication as ordered and failed to notify the physician of missed doses of the medication out of a total sample of 35 residents. This failure had the potential to delay healing or contribute to worsening infection and pain.Findings include: Review of R12's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and had diagnoses including encephalopathy, sepsis, and dementia. Review of R12's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/25 and located in the MDS tab of the EMR, revealed she was rarely/never able to make herself understood and had severely impaired cognition. Review of R12's Electronic Medication Administration Record (eMAR), dated September 2025 and located under the Orders tab of the EMR, revealed a physician's order, dated 09/04/25, for tobramycin [antibiotic] ointment 0.3%, one application in the left eye three times a day for infection for seven days. The eMAR documented the eye ointment was applied twice on 09/04/25 and three times on 09/05/25, then was not administered at all on 09/06/25 or 09/07/25, then was administered three times daily on 09/08/25. On 09/06/25 and 09/07/25, Licensed Practical Nurse (LPN) 7 documented three times daily, drug/treatment not administered. Review of R12's EMR under the Progress Notes tab revealed the following corresponding notes:-An eMar Medication Administration Note dated 09/06/25 at 2:56 PM documented, Awaiting delivery. -An eMar Medication Administration Note dated 09/06/25 at 2:57 PM documented, Awaiting delivery. -An eMar Medication Administration Note dated 09/06/25 at 4:33 PM documented, Awaiting delivery. -An eMar Medication Administration Note dated 09/07/25 at 10:57 AM documented, Not available. -An eMar Medication Administration Note dated 09/07/25 at 3:30 PM documented, Not available. An eMar Medication Administration Note dated 09/07/25 at 6:15 PM documented, Not available. During an interview on 09/09/25 at 12:34 PM, LPN7 stated that over the weekend on 09/06/25 and 09/07/25, she was unable to find the tobramycin ointment for R12. She stated she looked for the medication but did not see it anywhere. LPN7 stated she did not alert the physician to the missed doses of medication nor contact the pharmacy to determine whether the medication had been delivered. She stated she should have called the physician as the medication was only ordered for seven days but she had already missed two days of application. During an interview on 09/11/25 at 11:35 AM, the Director of Nursing (DON) stated LPN7 should have contacted the pharmacy to check on the status of the medication and notified the physician of the missed doses. Review of the policy titled, Unavailable Medication, dated June 2021, revealed, In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication, explain the circumstances, report the date of expected availability, and provide the alternative medication(s) recommended by pharmacy.i. Obtain a new order and discontinue prior order, orii. Obtain a hold order for the unavailable medication. NJAC 8:39-27.1(a)

Based on interview, record review, facility document review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure pressure ulcer prevention measures were in place for two residents out of four reviewed (Resident (R) 116 and R3) for pressure ulcers out of a total sample of 35 residents. This had the potential for the residents to develop pressure ulcers and/or worsen current pressure ulcers.Findings include: Review of the RAI manual, dated 10/2024 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. Review of a facility policy titled Prevention of Pressure Injuries dated 04/20 indicated .The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.For prevention measures associated with specific devices, consult current clinical practice guidelines. 1.Review of R116's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R116's EMR titled quarterly MDS located under the MDS tab with an assessment Reference Date (ARD) of 06/19/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident used a wheelchair for mobility, required partial to moderate assistance from staff for activities of daily living, and was considered to be at risk for the development of pressure ulcers and the facility had applied pressure reducing devices to her wheelchair. During an observation on 09/09/25 at 11:09 AM, R116 sat in a transportation wheelchair and under her was a white towel. At 2:11 AM, R116 sat in a transportation wheelchair and under her was a white towel. During an interview on 09/10/25 at 8:03 AM, the Assistant Director of Nursing (ADON) stated if a resident was at risk for the development of pressure ulcers, the physician would order baseline bloodwork, and Registered Dietician (RD) would assess the resident to ensure the resident ate adequately. The ADON stated R116's goal was to continue to assist her with walking and involved in activities. ADON stated all the transportation wheelchairs should have a gel cushion. During an interview on 09/09/2025 at 2:40 PM, the Occupational Therapist (OT) stated that therapy did not like the use of a transportation wheelchairs since the wheelchair was difficult to reposition a resident in. During this interview, the OT observed the resident and confirmed the resident was not on a gel cushion and would recommend a Roho cushion due to the resident being at risk for the development of pressure ulcers. The OT also confirmed that the resident sat on a white towel during this interview. During an interview on 09/10/2025 at 8:25 AM, Certified Nurse Aide (CNA) 2 stated that R116 never had a Roho cushion to be placed on the resident's wheelchair. CNA2 stated she was unsure who placed the resident on a towel. During an interview on 09/11/25 at 10:09 AM, the MDSC stated R116's the resident had a Roho cushion but R116's family member would place the cushion behind the resident's back instead of underneath her. 2. Review of R3's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, protein-calorie malnutrition, peripheral vascular disease, and dementia. Review of R3's significant change of condition MDS, with an ARD of 07/23/25 and located under the MDS tab of the EMR, revealed she was rarely/never able to make herself understood and had severely impaired cognition. R3 was at risk for development of pressure ulcers and had one stage III pressure ulcer. Review of R3's Care Plan, located under the Care Plan tab of the EMR and dated 07/28/25, revealed, The resident has pressure ulcer to her right heel r/t [related to] history of pressure ulcers. The approaches included: Follow facility policies/ protocols for the prevention and treatment of skin breakdown. The Care Plan did not include the specific interventions to use for prevention. Review of R3's Progress Note by the wound care physician, dated 07/21/25 and located under the Miscellaneous tab of the EMR, revealed, Patient has a new right heel pressure injury. Possibly from immobility. She has hx [history] of DM-uncontrolled, PVD, impaired mobility, and incontinence all which increases [sic] wound incidence and further inhibit optimal wound healing. Reviewed with staff the importance of offloading, dressing changes, nutrition optimization, and strict glycemic control . Offload heels per Facility Protocol - Heel booties. Review of R3's EMR under the Orders tab revealed no order for use of heel booties to offload pressure. During observations on 09/10/25 at 8:45 AM, 10:07 AM, 11:38 AM, 1:16 PM, 2:11 PM, and 2:24 PM, and 2:42 R3 was seated in her reclining wheelchair in the day room. She had her heels directly on a pillow and was not wearing heel booties. During an interview on 09/10/25 at 2:11 PM, CNA5 confirmed R3 was not wearing heel booties. She stated she thought she only wore booties while in bed. During an interview on 09/10/25 at 2:42 PM, LPN7 stated R3 should be wearing heel booties every day, in and out of bed as she spent her time out of bed in a reclining wheelchair. LPN7 stated she had a pressure ulcer on her heel, and the booties were important to offload pressure for wound healing and prevention of further breakdown. LPN7 confirmed R3 did not have heel booties on. LPN7 stated she was unable to find a physician's order for use of the heel booties. During an interview on 09/11/25 at 11:44 AM, the DON stated R3 should have the heel booties on at all times while in bed and while out of bed in her reclining wheelchair. The DON stated the booties should be included in the physician orders and Care Plan.Review of the policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated March 2014, revealed, The physician will help identify medical interventions related to wound management. Review of the policy titled, Prevention of Pressure Injuries, dated April 2020, revealed, Review the resident's Care Plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure interventions were in place for one of one resident (Resident (R) 56) out of two residents reviewed for range of motion (ROM) out of a total sample of 35 residents. This had the potential for the residents contracture to worsen. Findings include: Review of R56's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility 05/02/22 and had diagnoses including dementia, contracture, muscle weakness, and osteoarthritis. Review of R56's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/25 and located under the MDS tab of the EMR, revealed she was rarely/never able to make herself understood and severely impaired cognition. R56 did not have limited ROM. Review of R56's Care Plan, dated 06/27/25 and located under the Care Plan tab of the EMR, revealed she was dependent on staff for assistance with activities of daily living. The Care Plan did not address R56'shand contracture or interventions to manage it. Review of R56's EMR under the Orders tab revealed a physician's order, dated 09/18/24, for Gauze roll to be applied to [left] hand daily. Skin checks and hand hygiene at AM/PM.Review of R56's Care Plan, located under the Care Plan tab of the EMR and dated 08/18/25, revealed, Continue to do range of motion exercises and Keep skin clean and dry. The Care Plan did not address the use of a gauze roll in the left hand. Review of R56's Treatment Administration Record (TAR), dated September 2025 and located under the Orders tab of the EMR, revealed the order to apply a gauze roll to the left hand was signed as completed daily. During an observation on 09/08/25 at 10:31 AM, R56 was seated in her reclining wheelchair in the sensory group without a gauze roll in her left hand. Her left hand was in her lap and was balled into a fist. R56 was not seen to use her left arm/hand. During an observation on 09/09/25 at 8:51 AM, R56 was seated in her reclining wheelchair at the breakfast table. Her left hand was in her lap and there was no gauze roll in the hand. Her left hand remained in a fist. During observations on 09/10/25 at 10:56 AM and 2:48 PM, R56 was seated in her reclining wheelchair in the sensory group. She did not have a gauze roll in her left hand, which was in a fist on her lap. w/c to sensory group after changing in room. During an observation and concurrent interview on 09/10/25 at 3:08 PM, Licensed Practical Nurse (LPN) 7 confirmed R56 did not have a gauze roll in her left hand, and she needed to have it to protect her skin due to contracture. LPN7 did not know why the gauze roll was not applied but was documented on the TAR as completed. LPN7 placed a gauze roll in R56's left hand and stated it was a challenge to get it in the hand. During an interview on 09/11/25 at 11:37 AM, the Director of Nursing (DON) stated he had no explanation for the gauze roll not being applied as ordered and signed as completed on the TAR. The DON stated the gauze roll should be applied to R56's left hand daily. Review of the policy titled, Resident Mobility and Range of Motion, dated July 2017, revealed Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility . As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including . skin integrity issues . The care plan will be developed by the interdisciplinary team based on comprehensive assessment. NJAC 8:39-27.1(a)

Based on record review, observation, interview, and facility policy review, the facility failed to provide respiratory care per standards of practice for one of two sampled residents (Resident (R)142) reviewed for respiratory care out of a total sample of 35 residents. Specifically, the facility failed to ensure respiratory equipment (Ambu-bag) was accessible. The failure had the potential for the resident to have respiratory issues and unmet care needs.Findings include: Review of a facility policy titled Tracheostomy Care dated 06/25/25 failed to address the importance of an Ambu-bag to be stored by a resident, who has a trach, at bedside. Review of R142's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R142's EMR titled Care Plan located under the Care Plan tab dated 09/06/25 indicated the resident had a tracheostomy related to respiratory failure and that the resident required emergency equipment at the bedside which included an Ambu-bag. Review of R142's EMR titled admission Minimum Data Set (MDS) located under the MDS tab dated 09/12/25 was in progress and data could not be collected. During an observation and interview on 09/09/25 at 6:05 AM, Registered Nurse Supervisor (RNS) entered R142's room and proceeded to show the emergency medical equipment which was at the bedside of the resident. RNS confirmed there was no Ambu-bag at the resident's bedside. RNS stated it was important for an Ambu-bag to be at the bedside if the resident was unable to breathe on his own and required manual assistance with the Ambu-bag. During an interview on 09/11/25 at 10:09 AM, the Director of Nursing (DON) stated he was unsure why the Ambu-bag was not at the bedside of R142 but it was critical for the clinical staff to have access to the Ambu-bag if the resident was unable to breathe on his own. NJAC 8:39-5.1(a)NJAC 8:39-27.1(a)

Based on interview, record review, and facility policy review, the facility failed to ensure the physician responded to the consultant pharmacist medication reviews for one resident (Resident (R7) out of five reviewed for unnecessary medications in a total sample of 35 residents. This failure placed the resident at risk of receiving unnecessary medications.Findings include: Review of the facility policy titled, Medication Regimen Reviews (MRR), dated July 2025, revealed, .A licensed pharmacist reviews the medication regiment of each resident at least monthly.The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.Upon receiving the MRR, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them.If the physician does not provide a timely or adequate response, or the consultant pharmacist identified that no action has been taken, he/she contacts the medical director or the administrator. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R7 was originally admitted to the facility on [DATE] and was readmitted after a hospital stay on 08/13/25 with diagnoses that included hypotension (low blood pressure), atrial fibrillation (an irregular heart rhythm), and a bone infection of the left ankle and foot. Review of an 05/12/25 Pharmacist Consultant Report provided by the Administrator revealed, This resident has an order for Midodrine [Midodrine is a medication used to treat a sudden drop in blood pressure when standing up.] q [every] 8 hours. Midodrine should not be dosed after 5 PM in order to minimize the potential for supine [laying on your back] hypertension [high blood pressure]. Please update MD [Medical Doctor] orders and MAR [Medication Administration Record] to indicate doses separated by at least 3 hours and the last dose of the day no later than 5 PM. There was no provided documentation or indication on the Pharmacy Consultant Report that R7's physician had responded to the request by the Pharmacist. Review of the June and July 2025 MARs located in the Orders tab of the EMR revealed R7 was restarted on Midodrine HCL [hydrocholoride] on 06/20/25. The medication was ordered at 2.5 mgs [milligrams] every eight hours. Hold for systolic [upper number on a blood pressure reading] greater than 130. The dosing times of the Midodrine were listed as 6:00 AM, 2:00 PM, and 10:00 PM. Review of the August 2025 MAR revealed R7 had an order for Midodrine HCL 2.5mgs q 8 hours. Hold for systolic greater than 120. Dated 08/13/25. Review of the 08/14/25 Pharmacy Consultant Report provided by the Administrator revealed, This resident has an order for Midodrine q 8 hours. Midodrine should not be dosed after 5 PM in order to minimize the potential for supine hypertension. Please update MD orders and MAR to indicate doses separated by at least 3 hours and the last dose of the day no later than 5 PM. There was no documentation on the Pharmacy Consultant Report indicating that the physician was notified of the pharmacist's recommendation or that the order had been changed on the MAR. Review of the September 2025 MAR revealed R7 was being administered Midodrine q 8 hours. The dosing times were listed as 6:00 AM, 2:00 PM, and 10:00 PM. During an interview on 09/11/25 at 10:14 AM, the Director of Nursing (DON) stated, The physician came in and ordered the Midodrine for two times daily, yesterday. The DON was asked how the physician knows about the pharmacy recommendations and when does he answers them. The DON stated, We send them to him electronically. He is not very good at electronics and did not return them to us timely. During an interview on 09/11/25 at 11:06 AM, the Pharmacist Consultant was asked if the physician had responded to her recommendations. The pharmacist stated, No. During a follow-up interview on 09/11/25 at 12:23 PM, the DON stated, We will usually put the pharmacy recommendation reports in the physician folder. Sometimes they don't check them. My expectation is they are reviewed in a timely manner. NJAC 8:39-29.3

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure the medical record was complete and accurate for three residents (Residents (R)7, R64, and R70) out of total sample of 35 residents reviewed. This failure had the potential for the resident's health status not be accurate, complete, and possibly create unmet care needs.Findings include: Review of the facility policy titled, Charting and Documentation, dated July 2017 revealed, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R7 was admitted to the facility with a diagnosis that included major depressive disorder. Review of the 04/22/25 Comprehensive Care Plan located in the Care Plan tab of the EMR revealed, I use anti-psychotic medication [a class of medications used to treat psychotic disorders, such as schizophrenia and bipolar disorder] r/t [related to] Psychosis [a mental health condition characterized by a loss of contact with reality]. Review of the EMR did not show documentation that R7 had a diagnosis of Psychosis or was being administered an anti-psychotic medication. During an interview on 09/10/25 at 10:28 AM, Unit Manager (UM) was asked if R7 was taking an anti-psychotic medication for psychosis, per the Care Plan. The UM stated, No, that was an error and should have been anti-anxiety instead of anti-psychotic and she did not have a diagnosis of Psychosis. 2. Review of the admission Record located in the Profile tab of the EMR revealed R64 was admitted to the facility on [DATE] with a diagnosis that included anoxic [without oxygen] brain injury. Review of the Order Summary located in the Orders tab of the EMR revealed, 10/24/25 Aspiration precautions.No water from the sink or foam cup at bedside. May drink bottled water. Review of the Order Summary located in the Orders tab of the EMR revealed, 06/26/25 NPO [nothing by mouth] diet, NPO texture, NPO consistency. Review of the 07/25/25 Nutrition Care Plan located in the Care Plan tab of the EMR revealed, R64 is at risk of malnutrition 2/2 [secondary to] anoxic brain injury.dependence on TF [tube feeding] regimen for total nutrition. Interventions included, but not limited to: Provide fluids as ordered: Currently on fluid restriction of 1600 ml [milliliters] Daily.Q8H [every eight hours]. Date initiated on 07/28/25. During an interview on 09/09/25 at 2:15 PM, the UM was shown the Order for bottled water and stated, This is an error. The dietician wrote that order and it is inaccurate as he is NPO. 3. Review of R70's EMR titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R70's EMR titled physician Orders located under the Orders tab dated 08/19/25 indicated the resident was to receive insulin Lispro subcutaneous before meals and at bedtime by sliding scale as follows: if 150 - 200 = 0 units and to call the physician if the resident's blood sugar was less than 75; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units and to call the resident's physician if the resident's blood sugar was greater than 400; 401+ = 10 units.Review of R70's EMR titled admission Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident took insulin.Review of R70's EMR titled Medication Administration Record (MAR) located under the Orders tab for the month of 08/25 revealed the resident had a blood sugar result of 11111 on 08/24/25 and on 08/28/25 at 11:00 AM. Review of R70's EMR titled MAR located under the Orders tab for the month of 09/25 revealed the resident had blood sugar result of 11111 on 09/06/25.Review of R70's EMR titled nursing Progress Notes located under the Prog Note tab failed to contain corresponding documentation of the abnormal blood sugar results. During an interview on 09/10/25 at 8:16 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the blood sugar entry for R70 was incorrect. During an interview on 09/10/25 at 8:17 PM Registered Nurse (RN) 1 confirmed the data entry error and stated she was unaware that there was a code for unapplicable since R70 did not require insulin. NJAC 8:39-4.1(a)NJAC 8:39-5.1(a)

Based on interviews, record review, and policy review, the facility failed to ensure a potential allegation of physical abuse by staff was reported timely to the Director of Nursing (DON) and to the State Survey Agency (SSA) when a resident sustained an injury during a transfer from the wheelchair to the bed for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE].Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated she was severely cognitively impaired. The MDS revealed she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of the facility's Reportable Event Record/Report, dated 06/20/25 and provided by the facility, revealed the event occurred on 06/09/25 at 8:44 PM. The reportable and follow-up report were submitted to the SSA on 06/20/25 and the type of incident was marked as Injury. The description of the event in the report revealed during routine overnight care on 06/09/25, staff observed a bruise on [R2's] left inner thigh and immediately informed nursing.'' Review of the resident's care notes shows she had been placed back in bed earlier on 06/08/25 after appearing lethargic. A two-person transfer was performed, and it is believed her thigh came into contact with the wheelchair armrest during positioning.Review of the facility's Timeline of the Event, provided by the facility, revealed on 06/08/25 Licensed Practical Nurse (LPN) 1 came into work and asked Certified Nursing Assistant (CNA) 1 and CNA2 to put R2 to bed because she was ill and falling asleep in her wheelchair. CNA1 and CNA2 put R2 to bed holding her legs and arms and then swinging her over the wheelchair's armrest. On 06/09/25, before the 7:00 AM shift, CNA3 observed a linear bruise to R2's left lateral and posterior thigh and reported it to LPN4. LPN4 reported the thigh contusion to LPN3, the oncoming nurse, during shift change at 7:00 AM. CNA3, LPN4, and LPN3 failed to report the concern to the DON or Administrator. CNA4 observed the bruise during incontinence care during the 3:00 to 11:00 PM shift and reported it to Registered Nurse (RN) 1. RN1 reported the injury to LPN5 and then reported it to the Director of Nursing (DON). The DON did not report it the Administrator, also the Abuse Coordinator, until the next morning on 06/10/25.During an interview on 08/18/25 at 5:59 PM, the Administrator confirmed she was not notified of the injury of unknown origin to R2 when it was observed by CNA3 and reported to LPN4 around 6:30 AM on 06/09/25 and that she did not submit the initial and 5-day follow-up report to the SSA within the required timeframes. The Administrator stated LPN4 should have reported the injury to the DON immediately and then the DON should have reported it to her immediately. The Administrator stated she thought she submitted the initial and 5-day follow-up report with the required timeframes but did not submit either until 06/20/25.During an interview on 08/18/25 at 6:29 PM, the DON stated he reported the allegation of abuse to the Administrator at 9:35 AM on 06/10/25 and did not recall when the injury to R2 was reported to him for he had just begun employment at the facility.During an interview on 08/18/25 at 7:11 PM, RN1 confirmed that CNA4 reported she observed a bruise on R2's thigh during incontinence care on 06/09/25 at 8:44 PM and then RN1 reported it to LPN5 and the DON via phone immediately.An interview was attempted with LPN4 on 08/19/25 at 10:00 AM, 10:15 AM, and 10:35 AM, but was unsuccessful due to not returning the phone call.An interview was attempted with LPN3 on 08/19/25 at 9:00 AM, 9:05 AM, and 9:10 AM, but the phone call was not returned.Review of the facility's policy titled Abuse Prevention Program, dated 2016, revealed, . Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The results of the investigation are reported within 5 working days of the incident .

Based on interviews, record review, and policy review, the facility failed to protect a resident during an investigation of a potential allegation of physical abuse by staff when a resident sustained an injury during a transfer from the wheelchair to the bed by two nursing aides for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of the facility's Reportable Event Record/Report, dated 06/20/25, provided by the facility, revealed the event occurred on 06/09/25 at 8:44 PM. The reportable and follow-up report were submitted to the State Agency on 06/20/25 and the type of incident was marked as Injury. The description of the event in the report revealed during routine overnight care on 06/09/25, staff observed a bruise on [R2's] left inner thigh and immediately informed nursing. The interventions that were implemented after the incident listed in the report included the finding was relayed to on-coming staff, escalated through clinical leadership, and the physician subsequently evaluated the resident on site. Full skin and pain assessments revealed no additional concerns . Review of the resident's care notes shows he/she had been placed back in bed earlier on 06/08/25 after appearing lethargic. A two-person transfer was performed, and it is believed his/her thigh came into contact with the wheelchair armrest during positioning.Review of the facility's Timeline of the Event, provided by the facility, revealed on 06/08/25 revealed Licensed Practical Nurse (LPN) 1 came into work and asked Certified Nursing Assistant (CNA) 1 and CNA2 to put R2 to bed because he/she was ill and falling asleep in his/her wheelchair. CNA1 and CNA2 put R2 to bed holding his/her legs and arms and then swinging him/her over the wheelchair's armrest. On 06/09/25, before 7:00 AM shift, CNA3 observed a linear bruise to R2's left lateral and posterior thigh and reported it to LPN4. LPN4 reported the thigh contusion to LPN3, the oncoming nurse, during shift change at 7:00 AM. CNA4 observed the bruise during incontinence care during the 3:00 to 11:00 PM shift and reported it to RN1. RN1 reported the injury to LPN5 and then reported it to the Director of Nursing (DON). The DON did not report it the Administrator, also the Abuse Coordinator, until the next morning on 06/10/25.Review of CNA1's Personnel File revealed he was not suspended during the investigation conducted on 06/10/25. Review of CNA1's Timecard, provided by the facility, revealed he worked on 06/10/25.Review of CNA2's Personnel File revealed he was not suspended during the investigation conducted on 06/10/25. Review of CNA2's Timecard, provided by the facility, revealed he worked on 06/10/25.An interview was attempted with CNA1 on 08/18/25 at 5:42 PM, 6:00 PM, and 6:15 PM and a message could not be left due to the voicemail not set up yet.An interview was attempted with CNA2 on 08/18/25 at 5:43 PM, 5:45 PM, and 5:55 PM and a return call was not received.During an interview on 08/18/25 at 5:59 PM, the Administrator confirmed she did not suspend either CNA1 or CNA2 when she was notified of the injury of unknown origin to R2 on 06/10/25 because she investigated while the CNAs were working on 06/10/25. The Administrator stated CNA1 and CNA2 were not assigned to R2 on 06/10/25 and she determined the CNAs did not abuse R2, but the injury was acquired during a transfer from the wheelchair to the bed on 06/08/25.During an interview on 08/18/25 at 6:29 PM, the DON stated he reported the allegation of abuse to the Administrator at 9:35 AM on 06/10/25 and then he interviewed CNA1 and CNA2 about transferring R2 on 06/08/25. The DON confirmed the CNAs were not suspended during the investigation on 06/10/25.Review of the facility's policy titled Abuse Prevention Program, dated 2016, provided by the facility, revealed . Investigation Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on interviews and record review, the facility failed to prevent an injury during an improper transfer for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of residents experiencing injuries during transfers.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of R2's Care Plan, dated 07/22/15 and located in the EMR under the Care Plan tab, revealed a focus of R2 wanting to assist with surface to surface transfers and requiring extensive assistance with surface transfers with interventions to use verbal cues to prompt his/her with transfers so he/she can assist the care partner and if not able to assist the care partner please refer R2 to rehab for a screening. Review of R2's Progress Notes, dated 06/09/25 and located in the EMR under the Prog Note tab, revealed called by the Primary Nurse due to purplish discoloration noted on the left inner thigh. Assessed with purplish discoloration extending from the right inner thigh to the right posterior thigh . MD [physician] was notified and made aware of the findings.Review of R2's Summary of Investigation for Injury of Unknown Origin, dated 06/09/25 and provided by the facility, documented issue/concern: during routine overnight care on 06/09/25, staff observed a bruise on the resident's left inner thigh and immediately informed nursing . Review of the resident's care notes showed he/she had been placed back in bed earlier on 06/08/25 after appearing lethargic. A two-person transfer was performed, and it is believed that his/her thigh came into contact with the wheelchair armrest during positioning. Plan of Action: Reinforce safe two-person transfer techniques for dependent residents.Review of the facility's Investigation of Incident Employee Care Partner Statement, dated 06/10/25 and provided by the facility, revealed Certified Nursing Assistant (CNA) 1 and CNA2 saw R2 sleeping in the chair so CNA1 and CNA2 transferred her to the bed. CNA1 held R2 by his/her pants on the right side and CNA2 held R2 by his/her pants on the left side.An interview was attempted with CNA1 on 08/18/25 at 5:42 PM, 6:00 PM, and 6:15 PM and a message could not be left due to the voicemail not set up yet.An interview was attempted with CNA2 on 08/18/25 at 5:43 PM, 5:45 PM, and 5:55 PM and a return call was not received.During an interview on 08/18/25 at 6:29 PM, the Director of Nursing (DON) stated he interviewed CNA1 and CNA2 on 06/10/25 and they stated they stood on the opposite sides of R2 then lifted his/her by putting their arms under his/her armpits and the other hand on his/her pants and then swung his/her over the wheelchair armrest into the bed. The DON stated the transfer was not performed properly because the nursing assistants should not have held onto his/her pants to transfer into the bed and should have removed the armrest from the wheelchair which caused the bruise to R2's thigh.During an interview on 08/19/25 at 3:13 PM, the Director of Rehabilitation (DOR) stated the nursing assistants, CNA1 and CNA2, stated they lifted R2 by holding onto his/her pants during the transfer from the wheelchair to the bed on 06/08/25. The DOR confirmed the transfer was not performed properly. The DOR stated the armrest should have been removed from the wheelchair prior to the transfer and they should have used a gait belt to assist them in the transfer and not pulled on her pants.The transfer policy was requested from the Administrator and was not received prior to exit of the survey.

Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to identify and prevent worsening of a contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) for one of four residents (Resident #13) reviewed for position and mobility. This deficient practice was evidenced by: On 03/25/24 at 10:28 AM, during the initial tour of the 3rd floor, the surveyor observed Resident #13 in bed. The resident's right hand was closed from the middle finger to the pinky finger and the index finger was pointing out. When asked by the surveyor, Resident #13 stated that they were not able to turn or open his/her right (R) hand/fist or extend his/her R arm. The surveyor observed that there was no a brace on the R arm or that there was nothing placed in the R hand. On 03/26/24 at 1:26 PM, the surveyor interviewed Certified Nursing Aide (CNA #1) who stated that if she saw a resident with a contracture then she would perform range of motion exercises and inform the nurse to schedule the resident for therapy. She also stated that she would place a gauze or a wash rag in resident's hand. On 03/27/24 at 12:00 PM, the surveyor observed Resident #13 in bed. The surveyor observed that there was no brace on the R arm and there was nothing placed in the R hand. Resident #13 stated that he/she was right-handed but was able to feed him/herself with their left hand. Resident #13 further stated, I learned how to eat with my left hand. On 04/01/24 at 12:07 PM, the surveyor observed Resident #13 in bed and that there was no brace on the R arm and there was nothing placed in the R hand. The surveyor interviewed the resident about his/her hand. Resident #13 stated My hand is contracted now but before that I was able to use my right hand. Resident #13 stated; the staff does not give me anything in my right hand. On 04/02/24 at 10:41 AM, the surveyor observed Resident #13 in a reclining chair in his/her room. The surveyor observed that there was not a brace on the R arm or that there was nothing placed in the R hand. The surveyor reviewed the electronic medical records (EMR) for Resident #13. A review of the Admission Record face sheet revealed Resident #13 was admitted to the facility with diagnoses which included but were not limited to; Cerebrovascular Disease (CVA) (conditions that affect blood flow to your brain), Right leg above knee amputation (removal of a limb), and Atherosclerotic heart disease (buildup of plaque in arteries causing reduced blood flow). A review of the resident's diagnoses did not include a diagnosis for an upper extremity impairment. A review of the Quarterly Minimum Data Set (MDS), used to facilitate the management of care, dated 12/15/23, revealed that Resident #13 had a Brief Interview of Mental Status (BIMS), score of 14 out of 15, indicating the resident was cognitively intact. The MDS also identified that the resident had an impairment on one side, the upper extremity. A review of the most recent Quarterly MDS dated [DATE], revealed that Resident #13 had a BIMS score of 14 out of 15, indicating the resident was cognitively intact. The MDS also identified that the resident had an impairment on one side, the upper extremity. A review of Resident #13's ongoing Care Plan (CP) did not reveal a Focus or intervention for the resident's upper extremity impairment or the R hand contracture. A review of the readmission Physician's History & Physical dated 11/28/23 at 20:12 (08:12 PM) did not reveal documentation of the resident's upper extremity impairment or a contracture. Additional review of the Physician's Progress notes dated 09/1/2023, 09/21/23, 10/17/23, 12/28/23, 01/02/24, 01/16/24, 02/20/24, and 03/12/24 did not reveal documentation of the resident's upper extremity impairment or a contracture. A review of nursing Progress notes from 09/01/23 to 04/03/24 did not reveal any documentation of the resident's upper extremity impairment or a contracture. A review of the Order Summary Report (OSR) from 11/24/23, did not reveal physician's orders (PO) for a splint or brace to the right arm or hand. Further review of OSR did not reveal an order for restorative care for Range of Motion (ROM) to right arm/hand. A review of September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, and April 2024 Treatment Administration Record (TAR) did not reveal documentation of treatment to address any interventions for the resident's upper extremity impairment or contracture. On 04/02/24 at 11:47 AM, the surveyor interviewed CNA #2, who stated that she was familiar with Resident #13. When asked how long the resident had a contracture and what was being done, she stated, It's been a long time. Nothing new, I just wash it (the hand) and make sure it's clean and dry. CNA #2 further stated that Resident #13 does not get therapy and I don't know if there is a range of motion plan of care for the hand. On 04/02/24 at 12:47 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that Resident #13 had a history of a CVA, and he thinks that the resident has had the contracture for long time but doesn't know when the traumatic event occurred. The UM/LPN further stated that if the CNA was providing care to the resident and noticed a new/acute (sudden onset) contracture then the CNA should come and notify the nurses. He then stated that his/her hand contracture seems to be chronic (persisting for a long time). The UM/LPN stated that the resident was not on a restorative program (A program of passive movement exercises to maintain flexibility and useful motion in the joints of the body). He further stated that if there was a decline in functional abilities, we discuss it during weekly meetings and if Physical Therapy (PT) can pick up the resident versus Restorative care. The UM/LPN was not sure if the resident was supposed to be wearing a splint to his/her right hand and could not speak to why he did not refer the resident to therapy for evaluation. On 04/03/24 at 12:54 PM, the surveyor interviewed the Occupational Therapist (OT) who stated that they have a restorative program for residents on Long Term Care (LTC) after the residents have completed their course of physical therapy or occupational therapy. The OT educates the nursing staff and aides about Range of Motion (ROM) exercises to prevent contractures. The OT stated the residents are screened quarterly, annually, on re-admission, after a fall or if the staff notices any acute changes. The OT stated the screening process included observation of the resident and interview of the resident if possible. She stated that she would also interview the CNAs and the licensed nursing staff. She stated that Resident #13 was screened within the last three months after he/she came back from the hospital and further stated, No contractures were reported to me when he/she was screened. The surveyor asked the OT if she knew about Resident #13's contractures, she stated she was Not aware of the resident having any contractures. The OT also stated I wasn't made aware that the resident had limited or a decrease in ROM. 04/03/24 02:10 PM, the surveyor requested a timeline of the upper extremity impairment for Resident #13 from the Licensed Nursing Home Administrator (LNHA). On 04/04/24 at 09:00 AM, the LNHA provided the survey team with a handwritten timeline and other documentation of Resident #13's upper extremity impairment. A review of the timeline revealed Resident #13 had an upper extremity impairment on the Annual MDS dated [DATE]. At this time, the surveyor interviewed the LNHA in the presence of the survey team. She acknowledged that there was no documentation or care planning for the resident's upper extremity impairment/contracture. She further acknowledged that the MDS identification of the upper extremity impairment did not include the location of the impairment. On 04/04/24 at 10:35 AM, the LNHA stated the resident was admitted to the hospital on 11/12/23, and was readmitted to the facility on [DATE]. The LNHA provided a copy of the hospital Progress Notes printed on 11/14/2023 17:11 (5:00PM). A review of the progress note revealed Physical Exam .Right arm contracted. A review of the Clinical Admission note dated 11/24/2023 at 22:50 (10:50 PM), revealed the resident was readmitted from the hospital. Further review revealed under Functional .Able to move all extremities. Upper extremity ROM: No impairment. A review of the Rehab (rehabilition) Screen dated 11/28/23, revealed: D. Primary Reason for Screen: check mark for b. Re-Admit; 3. PLOF (Prior Level of Function)/Specific Observations/Concerns: PT (patient) is a readmission to facility for hospitalization ,d+[DATE] (secondary) wound infection. PT was referred for concerns about feeding. Discussed with nurses as PT was listed in chart as needing assist with feeding. Staff reports PT can feed self if positioned properly .4. Therapy Evaluation Indicated: a. Physical Therapy, b. Occupational Therapy, c. Speech Therapy- All these were marked No. d. If no, please give reason: No evaluation indicated at this time. PT with no acute change in feeding status. Further review did not reveal documentation or evidence of an impairment/contracture to the RUE (right upper extremity). On 04/04/24 at 11:37 AM, the surveyors interviewed the Director of Rehabilitation, (DOR) who stated, I personally never worked with (the resident) and I don't think the resident received services. The DOR stated if the staff identified any decline in function or limitations with Activities of Daily Living (ADLs) then the staff makes referral to therapy. After surveyor inquiry, A review of OT (Occupation Therapy) Evaluation dated 4/4/24 reflected diagnosis: Contracture, unspecified joint. Prior Therapy . Pt refused last therapy attempts. Musculoskeletal-ROM: UE (upper extremity): RUE (right upper extremity) ROM=Impaired. Tone =abnormal; UE Muscle Tone=Rigid. RUE ROM: Shoulder=Impaired; Elbow/forearm=Impaired; Wrist=Impaired; Hand=Impaired (flexion contracture noted at digits (fingers) III (three)-V (five) with digits in 90 degrees of flexion at MCP [Manual Muslce Test for Metacarpophalangeal (knuckle) Flexion] and 65 degrees of flexion at PIP (proximal interphalangeal) joints (a hinge joint that connects the first two bones of the find, allowing it to benand extend). PT with swan neck deformity (an abnormal positioning of the joints in your fingers, with a curved appearance similar to the neck of a swan) at digit II (two). On 04/04/24 at 3:17 PM the survey team met with LNHA, DON and Regional Clinical Operations Registered Nurse to present the above concerns. On 04/08/24 at 11:31 AM, the LNHA stated she did not have anything additional from physical therapy or OT other than what she already provided due to the computer system change. A review of the undated facility provided Position Title: Certified Nurse Aide document revealed under responsibilities/Accountabilities included: Report any/all changes in resident's condition, any family concerns and resident's complaints to charge nurse and/or supervisor. A review of the undated facility provided Position Title: Licensed Practical Nurse document revealed under Responsibilities/ Accountabilities: Takes an active role in direct resident assessment and care; Formulates individualized nursing care plans utilizing the nursing process; Assesses each resident daily and implements a change in the course of action as needed. A review of the undated facility provided Position Title: Registered Nurse document revealed under Responsibilities/ Accountabilities: Takes an active role in direct resident assessment and care; Formulates individualized nursing care plans utilizing the nursing process; Assesses each resident daily and implements a change in the course of action as needed. A review of the facility policy Restorative Nursing- Active Range of Motion policy, revised on 09/2023, revealed: Unit Manager/Designee will: 7. Follow up with rehab when there are changes in resident condition including either an improvement or decline or unwilling to participate in the restorative program. A review of the facility provided Comprehensive Care Plans policy, revised on 09/2023 included: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. A review of the facility provided ADL Care policy, revised on 09/2023, revealed Each resident's physical functioning will be assessed in accordance with the facility's assessment procedures. NJAC 8:39-27.1(a); 27.2(m)

COMPLAINT # NJ , NJ , NJ Based on observation, interview, review of the Medical Records, and other pertinent facility documentation on 4/18/16, 5/4/16, and 5/17/16, it was determined that the facility failed to protect their Residents from physical abuse, and/or potential further abuse, as well as failed to follow their own policy titled Abuse, Neglect and Mistreatment of [REDACTED].#1). The facility failed to completely review the 4 video surveillance recordings from 4/6/16 through 5/10/16, resulting in a third identified incident of physical abuse (slapping) by a Certified Nursing Assistant (CNA) that occurred on 3/29/16, involving Resident #1. The failure to completely view the video discs resulted in the identified CNA (CNA#3) continuing to provide direct Resident care for 29 shifts from 4/6/16 through 5/5/16. This deficient practice placed Resident #1 and all other Residents at risk for physical abuse Immediate Jeopardy (IJ) situation. The IJ was past non compliance from 4/6/16 through 5/10/16, when the facility completed viewing all 4 video surveillance recordings and implemented acceptable interventions for a Plan Of Correction. This deficient practice was evidenced by the following: 1. According to the Move in Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/5/16, Resident #1 had severe cognitive impairment. The MDS documentation included that Resident #1 required staff assistance for all Activities of Daily Living (ADLs). During a care tour on 4/18/16 at 9:30 A.M., accompanied by the Assistant Director of Nursing (ADON), Resident #1's skin was observed to be intact with no bruises. During an interview with the Director of Nursing (DON) on 4/18/16 at 8:02 A.M., the DON stated that the local PD came to the facility on [DATE], asking the DON to identify a facility staff member. The DON went on to say that the PD returned to the facility the evening of 4/6/16, gave the facility copies of 4 video surveillance recordings (discs), and left the facility with the identified Certified Nursing Assistant (CNA #1). CNA #1 was arrested by the police and subsequently terminated by the facility on 4/8/16 . The DON stated that both the Administrator and DON had viewed the 4 video discs on 4/7/16. The DON went on to say that the facility identified a second incident of abuse by CNA #2 and notified the PD. CNA #2 was also arrested and terminated by the facility on 4/8/16. According to the DON, as stated in the above interview, Resident #1 was fully assessed on 4/6/16, by the DON and Assistant Director of Nursing (ADON). However, per the DON, no body assessments were performed on any other residents at that time. An interview with the DON on 4/18/16 at 8:40 A.M., revealed that Weekly Skin Checks had not been documented by 3 Licensed Practical Nurses (LPN), as having been performed for Resident #1, from 3/1/16 through 4/5/16. The DON stated that no Registered Nurses (RN) or Licensed Practical Nurses (LPNs) or CNAs had reported bruises on Resident #1, however, staff was disciplined for not completing the Weekly Skin Checks. During an interview with the DON and Administrator on 5/4/16 at 9:20 A.M., the DON and Administrator verified that they received 4 video discs from the local PD on 4/6/16. The DON and Administrator stated they only watched the video clips marked by the PD. The DON stated I have not gotten through all of the video discs, there is so many. I just haven't had the time. The DON and Administrator stated at that time, that no one at the facility had watched all 4 video discs from beginning to end. During an interview with the DON and Administrator on 5/4/16 at 2:53 P.M., it was revealed that the facility was made aware of 4 additional infractions from the video discs by another State Agency (SA). The Administrator stated I thought we viewed all the videos. I did not see the 4 additional infractions reported to us from another State Agency and after being notified by the SA, I did go back and look at the clips and saw the infractions. The DON stated I have written down the video clips that I have reviewed and have not identified any other issues thus far. The DON went on to say that I am watching as much as I can everyday. However, there was no evidence by the facility that the 4 video discs had been completely viewed at that time. The interview continued with the DON stating that the infractions were Poor work quality, not abuse. The Administrator and the DON also stated that Since 4/7/16, the DON, ADON, and the Administrator are coming in unannounced on the off shifts, to monitor the staff. The DON went on to say that the Supervisors and the Unit Managers are monitoring the staff as well. The DON stated The Supervisors as well as the DON and ADON are doing spot checks of the CNAs providing Resident care, but I did not ask the Supervisors or ADON to document the spot checks. On 5/6/16, the New Jersey Department of Health (NJDOH) received a Reportable Event Record/Report (FRE) from the facility documenting that the facility had identified from the video discs, a third CNA (CNA #3) slapping away Resident #1's hands. The FRE documented the date of the event as 3/29/16. The FRE went on to document that CNA #3 was suspended pending investigation. Although the facility identified this incident, there was no evidence provided by the facility that the video discs had been viewed entirely at that time. A review of a computer generated schedule form titled 28 Day, dated Sunday April 03, 2016 to Saturday April 30, 2016, as well as May 01, 2016 to Saturday May 28, 2016, documented that CNA #3 provided direct Resident care for 29 shifts from 4/6/16, when the facility had received the video discs, until 5/5/16, when CNA #3 was identified as slapping away Resident #1's hands on the video disc and was suspended. CNA #3 was subsequently sent a termination letter by the facility on 5/9/16. During an interview with the Administrator and DON on 5/17/16 at 10:10 A.M., the Administrator and DON confirmed they received 4 video discs from the PD on 4/6/16. The Administrator and DON went on to say that on 4/7/16, the Administrator along with 3 Corporate employees reviewed the discs. The DON stated she had joined them later in the day along with another Corporate employee. The Administrator stated We started watching the discs on 4/7/16 at approximately 2:00 P.M., and finished late between 6:00-7:00 P.M. The Administrator stated No. We did not fast forward the videos. The Administrator and DON stated While watching the discs on 4/7/16, other than CNA #2 they did not observe any further abuse. However, there was no evidence by the facility that the 4 video discs had been completely viewed at that time. The Administrator and DON again stated There was no further abuse identified after viewing the tapes on 4/7/16. The Administrator and DON stated I don't know how we missed the other 4 CNA's infractions. The Administrator went on to say that We watched the video clips that the other SA told us about. The DON also stated I relooked at all 4 discs starting 4/28/16, and finished on 5/10/16. I watched the videos around my other work. I should have done nothing but watched the videos. The Administrator and DON stated that It is our responsibility to make sure that our Residents are free from Abuse, Neglect and Mistreatment. The DON stated that the Supervisors as well as the ADON and DON are now documenting the spot checks of CNAs providing care to the Residents. The facility policy titled Abuse, Neglect and Mistreatment of [REDACTED]. Under Policy included: Observances, complaints or evidence of alleged abuse, neglect and/ or mistreatment are thoroughly investigated and reported to the appropriate parties The Past Non-Compliance IJ was corrected on 5/10/16, when the facility put the following corrective actions into place: 1. Full body assessment was completed on Resident #1 on 4/6/16, as well as 2 person care givers assigned. 2. Skin assessments on all residents on the 3rd floor were completed within the week starting 4/6/16. Social Services interviewed residents on the 3rd floor on 4/8/16. 3. On 4/7/16, the facility started inservicing on abuse and neglect to all Department Heads and Nursing Managers. 4. On 4/8/16, Life Enrichment Department (Activities) was inserviced on abuse and neglect. 5. On 4/12/16, Around the clock inservices were conducted for all Nursing staff. 6. On 4/13/16, Inservices were continued for Nursing staff on briefs, pads, abuse, linens and reporting abuse. 7. On 4/14/16, the Dietary Department was inserviced on abuse and neglect. 8. Behavioral health-Contracted Psychology Services Company was inserviced on abuse and neglect. 9. On 4/18/16, video cameras were installed in all common areas of the Home (facility). 10. On 4/28/16, the 4 CNAs (CNA # 3, 4, 5, and 6) were disciplined with a final written warning next step termination and inserviced for other identified infractions. 11. On 5/4/16, the facility met with the Resident Council to discuss the abuse incidents and reinforced the need to report any type of abuse or neglect that may occur. 12. On 5/5/16, CNA #3 was suspended pending investigation. 13. On 5/6/16, the DON reviewed the video with Corporate Human Resources (HR) and decided to terminate CNA #3 (5/9/16 the termination letter was mailed out for CNA #3). 14. On 5/6/16, the facility reported the third incident of physical abuse to: The New Jersey Department of Health (NJDOH), Office of the Institutionalized Elderly (OOIE), Office of Program Compliance, and the local PD were notified. 15. On 5/10/16, the DON completed viewing of all video surveillance recordings. NJAC 8:39-4.1(a) 5

Complaint # NJ , NJ , NJ Based on observation, interview, and review of the Medical Records and other pertinent facility documentation on 4/18/16, 5/4/16, and 5/17/16, it was determined that the facility failed to conduct a timely and thorough investigation as well as failed to follow their own policies titled Incident/Accident Reporting and Abuse, Neglect and Mistreatment of [REDACTED].#1), after having received 4 video surveillance recordings (discs) from the local Police Department (PD) on 4/6/16, that identified 2 Certified Nursing Assistants (CNA #1 and CNA #2) physically abusing (slapping) Resident #1. The facility failed to completely review/investigate the 4 video surveillance recordings from 4/6/16 through 5/10/16, resulting in a third identified incident of physical abuse (slapping) by CNA#3 that occurred on 3/29/16, involving Resident #1. The failure to completely view/investigate the video discs resulted in the identified CNA (CNA#3) continuing to provide direct Resident care for 29 shifts from 4/6/16 through 5/5/16. This deficient practice placed Resident #1, as well as all other Residents at risk for an Immediate Jeopardy (IJ) situation. The IJ was past non compliance from 4/6/16 through 5/10/16, when the facility completed viewing all 4 video surveillance recordings and implemented acceptable interventions for a Plan Of Correction. This deficient practice was evidenced by the following: 1. According to the Move in Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/5/16, Resident #1 had severe cognitive impairment. The MDS documentation included that Resident #1 required staff assistance for all Activities of Daily Living (ADLs). During a care tour on 4/18/16 at 9:30 A.M., accompanied by the Assistant Director of Nursing (ADON), Resident #1's skin was observed to be intact with no bruises. During an interview with the Director of Nursing (DON) on 4/18/16 at 8:02 A.M., the DON stated that the local PD came to the facility on [DATE], asking the DON to identify a facility staff member. The DON went on to say that the PD returned to the facility the evening of 4/6/16, and left the facility with the identified Certified Nursing Assistant (CNA #1). The CNA was arrested by the police and subsequently terminated by the facility on 4/8/16. The DON stated that both the Administrator and DON had viewed the 4 video surveillance recordings on 4/7/16. The DON went on to say that the facility identified another incident of abuse by CNA #2 and notified the PD. CNA #2 was also arrested and terminated by the facility on 4/8/16. During an interview with the Director of Nursing (DON) on 4/18/16 at 8:02 A.M., The DON stated that Resident #1 was observed to have a large bruise on the right arm and right hand. The DON went on to say that the right hand bruise was from a blood draw and that after viewing the video, the Nurses on all shifts were asked by the DON if they had observed any bruises on Resident #1, and that no one had reported bruising. The surveyor viewed video surveillance recording clips accompanied by the DON on 4/18/16 at 8:23 A.M. A video clip dated 3/23/16 at 4:10 A.M., revealed a large red/purple bruise located on Resident #1's left posterior hand as well as a large purple bruise located at the resident's right posterior arm above the elbow. During an interview with the DON on 4/18/16 at 8:40 A.M., the DON stated that the staff never reported any bruises on Resident #1 and I was not aware of the bruises until I saw the video. The DON went on to say that an investigation of the bruise was not done because on 4/6/16, a skin assessment was performed by her, and the bruise was not there. No evidence was provided at this time that any investigation had been initiated by the facility. During an interview with the DON and Administrator on 5/4/16 at 9:20 A.M., the DON and Administrator verified that they received 4 video surveillance recordings from the local PD on 4/6/16. The DON and Administrator stated they only watched the video clips marked by the PD. The DON stated I have not gotten through all of the video discs, there is so many. I just haven't had the time. The DON and Administrator stated that no one at the facility has watched all 4 video surveillance recordings from beginning to end. The DON went on to state that The Assistant Director of Nursing (ADON) and I performed a skin assessment on Resident #1 on 4/6/16, and the (right posterior arm) bruise was not there. The DON went on to say that I documented the skin assessment on the skin sheet and I started the investigation but it is not completed. I did not report the (right posterior arm) bruise (to the New Jersey Department of Health) as it was not there on 4/6/16. A review of a Weekly Skin Evaluation form dated 4/6/16, documentation indicated that Resident #1 had a 1 centimeter (cm) x 1 cm bruise, on the posterior right upper arm, and a 1 cm x 1 cm bruise above the right posterior elbow, and dime egg bruise below the right elbow. The form documentation included a 1 cm x 1 cm bruise, dime, to the right outer knee, a 1 cm x 1 cm bruise, dime, to the left knee, and 1 cm x 1 cm bruise to the left outer shin. A review of an untitled, undated type written form, given to the surveyor by the facility on 4/18/16, included documentation under Incident that on Resident #1's right arm, posterior side were three (3) old brownish colored bruises 1 cm x 1 cm, 1 cm x 1 cm, and 2 cm x 3 cm respectively. In addition the form revealed documentation that Resident #1 also had a 1 cm x 1 cm brown colored bruise on the right lateral knee, and on the left lateral knee was a 1 cm x 1 cm, and inferior to that was another brownish bruise that was 1 cm x 1 cm. During an interview with the DON and Administrator on 5/4/16 at 2:53 P.M., the Administrator stated I thought we viewed all the videos. and the DON stated I have written down the 'video clips' that I have viewed and have not identified any other issues thus far. The DON further stated that I am watching as much as I can everyday. However, there was no evidence provided by the facility at that time, that they had completed viewing the video discs or completed any investigations. On 5/6/16, the New Jersey Department of Health (NJDOH) received a Reportable Event Record/Report (FRE) from the facility documenting that the facility had identified from the video discs, another CNA (CNA #3) slapping away Resident #1's hands. The FRE documented the date of the event as 3/29/16. The FRE went on to document that CNA #3 was suspended pending investigation. Although the facility identified this incident, there was no evidence provided by the facility that the video discs had been viewed entirely at that time. A review of a computer generated schedule form titled: 28 Day and dated Sunday April 03, 2016 to Saturday April 30, 2016, as well as May 01, 2016 to Saturday May 28, 2016, documented that CNA #3 worked 29 shifts from 4/6/16, when the facility had received the video discs, until 5/5/16, when CNA #3 was identified and was suspended. CNA #3 was subsequently sent a termination letter by the facility on 5/9/16. During an interview with the DON on 5/17/16 at 10:10 A.M., the DON stated I asked the Nurses on all shifts if they saw the bruises because they give the Resident medication and they (Nurses) all denied knowing about the bruise. The DON further stated No, I did not ask the Certified Nursing Assistants (CNAs) about the bruise. The facility was unable to provide an investigation of the right posterior arm bruise for Resident #1. During an interview with the Administrator and DON on 5/17/16 at 10:10 A.M., the Administrator and DON confirmed they received 4 video surveillance recordings from the PD on 4/6/16. The Administrator and DON further stated that on 4/7/16 the Administrator along with 3 Corporate employees viewed the video surveillance recordings. The DON stated she had joined them later in the day along with another Corporate employee. The Administrator stated We started watching the discs at approximately 2:00 P.M. on 4/7/16, and finished late between 6:00-7:00 P.M. The Administrator stated No. We did not fast forward the videos. The Administrator and DON stated There was no further abuse identified after viewing the tapes on 4/7/16. The Administrator went on to say that We watched the 'video clips' that the other State Agency (SA) told us about, and the DON stated I relooked at all 4 discs starting 4/28/16 and finished on 5/10/16. I watched the videos around my other work. I should have done nothing but watched the videos. The Administrator and DON stated that It is our responsibility to make sure that our Residents are free from Abuse, Neglect and Mistreatment. The DON stated The Supervisors as well as the ADON and DON are now documenting the spot checks of CNAs providing care to the Residents. A review of the facility policy titled Incident/Accident Reporting dated 1/2012, documented under the Policy section that It is the policy of the facility to provide a system whereby resident's incidents/accidents are reported, their causes identified when possible and timely interventions are established to reduce the probability of repeated incident. The policy went on to document under the Procedure section #4, In cases of incidents or injuries of unknown etiology, an investigative Report of Injury of Unknown Origin and Investigative Report for Skin Tear/Bruise of Unknown Etiology are completed. The facility policy titled Abuse, Neglect and Mistreatment of [REDACTED]. Under Policy included: Observances, complaints or evidence of alleged abuse, neglect and/ or mistreatment are thoroughly investigated and reported to the appropriate parties Under Investigation: 1. The DON/designee is designated as the individual who conducts the investigation. The Past Non-Compliance IJ was corrected on 5/10/16, when the facility put the following corrective actions into place: 1. Full body assessment was completed on Resident #1 on 4/6/16, as well as 2 person care givers assigned. 2. Skin assessments on all residents on the 3rd floor were completed within the week starting 4/6/16. Social Services interviewed residents on the 3rd floor on 4/8/16. 3. On 4/7/16, the facility started inservicing on abuse and neglect to all Department Heads and Nursing Managers. 4. On 4/8/16, Life Enrichment Department (Activities) was inserviced on abuse and neglect. 5. On 4/12/16, Around the clock inservices were conducted for all Nursing staff. 6. On 4/13/16, Inservices were continued for Nursing staff on briefs, pads, abuse, linens and reporting abuse. 7. On 4/14/16, the Dietary Department was inserviced on abuse and neglect. 8. Behavioral health- Contracted Psychology Services Company was inserviced on abuse and neglect. 9. On 4/18/16, video cameras were installed in all common areas of the Home (facility). 10. On 4/28/16, the 4 CNAs (CNA # 3, 4, 5, and 6) were disciplined with a final written warning next step termination and inserviced for other identified infractions. 11. On 5/4/16, the facility met with the Resident Council to discuss the abuse incidents and reinforced the need to report any type of Abuse or Neglect that may occur. 12. On 5/5/16, CNA #3 was suspended pending investigation. 13. On 5/6/16, the DON reviewed the video with Corporate Human Resources (HR) and decided to terminate CNA #3 (5/9/16 the termination letter was mailed out for CNA #3). 14. On 5/6/16, the facility reported the third incident of physical abuse to: The New Jersey Department of Health (NJDOH), Office of the Institutionalized Elderly (OOIE), Office of Program Compliance, and the local PD were notified. 15. On 5/10/16, the DON completed viewing of all video surveillance recordings. NJAC 8:39-27.1 (a)

COMPLAINT # NJ , NJ , NJ A. Based on interview, and review of other pertinent facility documentation on 4/18/16, 5/4/16, and 5/17/16, it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility policy titled Abuse, Neglect and Mistreatment of [REDACTED]. The Administrator also failed to ensure that policies titled Incident/Accident Reporting and Abuse, Neglect and Mistreatment of [REDACTED].#1. The facility administration failed to completely review the 4 video surveillance recordings from 4/6/16 through 5/10/16. The failure to completely view the video discs resulted in the identified CNA (CNA#3) continuing to provide direct Resident care for 29 shifts from 4/6/16 through 5/5/16. This deficient practice placed Resident #1 and all other Residents at risk for an potential Immediate Jeopardy (IJ) situation.The IJ was past non compliance from 4/6/16 through 5/10/16, when the facility completed viewing all 4 video surveillance recordings and implemented acceptable interventions for a Plan of Correction. This deficient practice was evidenced by the following: CROSS REFERENCE: F223, F226 REFER to F223 Example #1. REFER to F226 EXAMPLE #1. The Past Non-Compliance IJ was corrected on 5/10/16, when the facility put the following corrective actions into place: 1. Full body assessment was completed on Resident #1 on 4/6/16, as well as 2 person care givers assigned. 2. Skin assessments on all residents on the 3rd floor were completed within the week starting 4/6/16. Social Services interviewed residents on the 3rd floor on 4/8/16. 3. On 4/7/16, the facility started inservicing on abuse and neglect to all Department Heads and Nursing Managers. 4. On 4/8/16, Life Enrichment Department (Activities) was inserviced on abuse and neglect. 5. On 4/12/16, Around the clock inservices were conducted for all Nursing staff. 6. On 4/13/16, Inservices were continued for Nursing staff on briefs, pads, abuse, linens and reporting abuse. 7. On 4/14/16, the Dietary Department was inserviced on abuse and neglect. 8. Behavioral health- Contracted Psychology Services Company was inserviced on abuse and neglect. 9. On 4/18/16, video cameras were installed in all common areas of the Home (facility). 10. On 4/28/16, the 4 CNAs (CNA # 3, 4, 5, and 6) were disciplined with a final written warning next step termination and inserviced for other identified infractions. 11. On 5/4/16, the facility met with the Resident Council to discuss the abuse incidents and reinforced the need to report any type of Abuse or Neglect that may occur. 12. On 5/5/16, CNA #3 was suspended pending investigation. 13. On 5/6/16, the DON reviewed the video with Corporate Human Resources (HR) and decided to terminate CNA #3 (5/9/16 the termination letter was mailed out for CNA #3). 14. On 5/6/16, the facility reported the third incident of physical abuse to: The New Jersey Department of Health (NJDOH), Office of the Institutionalized Elderly (OOIE), Office of Program Compliance, and the local PD were notified. 15. On 5/10/16, the DON completed viewing of all video surveillance recordings. The deficiemcy continues at a lower scope and severity level of E based on evidence in Part B. B. Based on observation, interview, review of medical record and other facility documentation it was determined that facility Administration failed to consistently implement and ensure that their own facility policies for Abuse, Neglect and Mistreatment of [REDACTED]. This deficient practice was evidenced by: CROSS REFERENCE: F225 and F281 REFER to F225 Example #1. REFER to F281 Example #1-6. NJAC 8:39-9.3 (a) 8:39-9.4 (f)

Based on observations and interviews, it was determined that the facility failed to protect residents residing on 4 of 5 units from accident hazards. Coffee brewers with red levers used to dispense hot water from spigots were operable and accessible. Hot water, dispensed from the spigots, was at temperatures ranging from 165 degrees Fahrenheit (deg. F.) to 191 deg. F. The screen display on each of the coffee brewers showed the statement Ready to Brew 200 degrees. This deficient practice posed a serious and immediate threat to the residents who were residing on these units. Residents were at risk for burns from the hot water. The Immediate Jeopardy was identified on 6/4/15 and reported to the Administrator at 12 p.m. (noon) and corrected at 2 p.m. based on an acceptable Plan of Correction submitted by the facility. The deficient practice was evidenced by the following: 1. On 6/4/15 at 10:50 a.m. during the inspection of the open kitchenette on the 4th Floor West unit, the surveyor observed the hot water spigot on the coffee brewer which was operable and dispensing hot water. The surveyor dispensed hot water from the unit into a plastic juice cup at 10:50 a.m. The temperature of the first hot water sample was 178.5 deg. F. The juice cup used to hold the hot water was hot to the surveyor's touch. A Certified Nurse Aide (CNA) verified that that the temperature of the second sample was 185.1 deg. F. The screen on the unit read Ready to Brew 200 deg. 2. On 6/4/15 at 11:10 a.m. during the inspection of the open kitchenette on the 4th Floor East unit, the surveyor observed the hot water spigot on the coffee brewer which was operable and dispensing hot water. The surveyor dispensed hot water into a cup at 11:10 a.m. The temperatures of the first hot water sample was 180 deg. F. and a second sample was 191 deg. F. The surveyor dispensed the third sample in the presence of a second surveyor. The second surveyor verified that the temperature of the second sample was 190.1 deg. F. The screen on the unit read Ready to Brew 200 deg. 3. On 6/4/15 at 11:25 a.m. during the inspection of the open kitchenette on the 3rd Floor West unit, the surveyor observed that the hot water spigot on the coffee brewer was operable and dispensing hot water. The surveyor dispensed hot water into a cup at 11:25 a.m. in the presence of the facility's Registered Dietitian (RD) and the survey Team Leader (TL). The RD confirmed that the temperature of the first hot water sample was 165 deg. F., and the temperature of the second sample of hot water was 176 deg. F. When the RD was interviewed during the water sampling, the RD indicated that the kitchenette was available to families and some residents. The RD also indicated that the stoves in all the kitchenettes were disabled, and the hot water dispenser was purposely deactivated in the water cooler. The RD explained that the water cooler was found in the same kitchenette, was deactivated because of the location of it and we really didn't need it because we have this. (pointing to the coffee brewer with a hot water spigot.) 4. On 6/4/15 at 11:40 a.m. during the inspection of the open kitchenette on the 2nd Floor unit, the surveyor observed that the hot water spigot on the coffee brewer was operable and dispensing hot water. This brewer was in an area that was accessible to all residents. A third surveyor dispensed hot water from the unit at 11:40 a.m. The temperature of the hot water sample was 185 deg. F. The screen on the unit read, Ready to Brew 200 deg. The surveyor interviewed one CNA on this unit. The CNA stated that some of the more alert residents used the hot coffee/water unit. 5. On 6/4/15 at 11:17 a.m., during the inspection of the open kitchenette on 3rd Floor East, the surveyor observed that the hot water spigot on the coffee brewer unit was not working. When asked about the hot water spigot on the coffee brewer, the CNA explained residents could get hot water out of the spigot until the past few days. During an interview on 6/4/15 at 1:30 p.m. with the Corporate Maintenance Director (CMD) in the presence of the Administrator, Director of Nursing (DON) and the facility's Maintenance Director, the CMD confirmed that the hot water dispenser on the water coolers, located in the vicinity of the coffee brewers, were disabled, i.e., never connected, secondary to the same issue. When the TL asked if it was due to resident safety, the CMD answered, yes. The Administrator confirmed that the coffee brewers with hot water spigots were not there in the kitchenettes at the time of the initial federal survey of 12/23/14. During the interview on 6/4/15 at 1:30 P.M., the Administrator stated that the policy regarding the use of the kitchenettes and the hot water spigots on the coffee brewers was not found. The facility's Administrator submitted an acceptable plan of correction (POC) on 6/4/15 at 2 p.m. which read as follows: On June 4, 2015 at approximately 12 noon Administration was notified by the Department of Health that there is an IJ situation in the kitchenettes of the resident floors at Venetian. 1. What corrective action will be accomplished for those individuals found to have been affected by these deficient practices? The coffee machines were removed immediately from each kitchenette. 06/04/15 2. How will the facility identify other individuals having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents, staff and guests have the potential to be affected by this practice. The corrective action immediately taken was that the coffee machines were immediately removed. 06/04/15 3. What measures will be put in place or what systemic change the facility will make to ensure that the deficient practice does not recur? All staff will be in-serviced with the changes in the beverage system in the kitchenettes. In-servicing immediately started with the 7 to 3 shift staff and will continue to include all shift members as well as families and residents. Focus will be put on the importance of the hot water temperature for residents, staff and visitor's safety. The coffee and hot water will be brewed in the main kitchen and will be available on the units in thermal carafes daily with all meals and as needed with a call to dietary. 06/04/15 4. How the corrective action will be monitored to ensure the deficient practice will not recur. Maintenance or Designee will conduct daily environmental rounds in all kitchenettes to ensure that equipment is properly functioning and safe. This information will be added to the daily round form that is currently in use. The findings of the daily rounds will be submitted to the DON and Administrator daily. Findings will be discussed during morning meetings for four weeks. Random audits will be conducted by the Maintenance Director/Designee until 100% compliance is attained. These findings will be discussed and recorded in the monthly Safety Committee meeting. The results of these audits will be reviewed in the QA meetings 07/20/15 The Administrator confirmed at 2 p.m. on 6/4/15 that the units were being removed from the kitchenettes at that time. NJAC 8:39-27.1(a), 31.2(e)