Every finding on record at Riverside Health and Rehabilitation Center LLC

Based on observation, interview, and policy review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 04/15/2026 from 9:27AM to 10:41AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD):In the Stand Up/Cold Prep refrigerator, a partially empty jar of applesauce observed with no opened date or use by date. The FSD acknowledged it should be dated. On the floor beside the ice machine, debris was observed on the floor. In the dry storage room, the surveyor observed two boxes containing single-serve cereal bowls stacked directly on the floor. The FSD acknowledged the boxes should not be on the floor and relocated the boxes to the shelf unit. In the dry storage room, three boxes containing single-serve cereal bowls were not labeled with a received by date. The FSD acknowledged the received by date was missing from the boxes.In the dry storage room, an opened box of enriched macaroni product was observed with no opened date or use by date. In the walk-in refrigerator in an uncovered cardboard box of green and red bell peppers, four green peppers at the top of the box were observed to be discolored and mottled. The FSD stated they would dispose of them. In the walk-in freezer doorway, a used disposable glove was observed on the floor.In the walk-in freezer a box containing plastic bag of burger patties was observed opened to air with no opened date or use by date. Below the countertops a meat patty was observed on the floor against the wall.Components of the meat slicer including the blade cover and the tray on which the meat rests when slicing were observed on the table open to air on top of oven mitts. The FSD stated she was unsure if they needed to be covered with the slicer and then placed them under the cover with the meat slicer. On 04/17/2026 at 10:33 AM in the fourth-floor pantry refrigerator, the surveyor observed 2 cartons of milk that were frozen to the back of the refrigerator. The fourth-floor Unit Manager (UM) #1 stated that these items should not be frozen to the refrigerator. Licensed Practical Nurse (LPN) # 1 used a utensil to remove the milk cartons from the back of the refrigerator. The surveyor observed the cartons to have expiration dates of April 1 and April 7. LPN #1 confirmed the cartons of milk were expired and disposed of them. On 04/17/2026 at 11:04 AM, in the third-floor pantry freezer an unknown brown substance was observed on the bottom and on the door of the freezer. In the cabinet one white colored bin was observed with light brown colored particles at the bottom. On the shelf an unlabeled and undated take-out container was observed. On the same day at 11:11 AM, in an interview, LPN #2 stated that the take out containers were another staff member's food. LPN #2 further stated that the take out container should have been labeled and in the refrigerator. LPN #2 stated that the refrigerator is emptied once a week and unsure of how often it is cleaned. On 4/17/2026 at 11:13 with the permission of the resident and in the presence of LPN #2 the surveyor observed a resident's personal refrigerator. The surveyor observed that there was no thermometer in the refrigerator. When asked by LPN #2, the resident indicated that they had taken the thermometer out of the refrigerator and placed it in a drawer. At the same time, a temperature log with the month November written on it, was observed attached to the side of the resident's refrigerator. LPN #2 acknowledged that the temperature logs were not being completed. On the same date at 11:19 AM during an interview, UM #2 confirmed that only one resident in the facility had a personal refrigerator. UM #2 stated that nursing staff are responsible for maintaining and recording the temperature log of the refrigerator. On 04/17/2026 at 11:37 AM the surveyor observed a dark brown substance inside the ice machine, along top of the machine. On 04/21/2026 at 9:41 AM during an interview the Director of Nursing (DON) stated that housekeeping should be cleaning the pantry monthly and all staff should monitor daily for old or expired food items. On the same date and time during an interview the Licensed Nursing Home Administrator (LNHA) stated that staff should not store their personal food items in the pantry. A review the policy titled, Receiving revision date 2/2023, revealed under number 5, All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility was unable to provide a policy specific to labeling and dating but did provide a Labeling and dating in-service provided to new hires with no date. The in-service titled Labeling and Dating Inservice, under the section Guidelines for Labeling and Dating revealed, All foods should be dated upon receipt before being stored. A review of the policy titled Food Storage: Dry Goods revision date 2/2023, revealed under the section Procedures number 1, All items will be stored on shelves at least 6 inches above the floor. The policy further revealed under number 6, Storage areas will be neat, arranged for easy identification and date marked as appropriate.A review of the policy titled Food Storage: Cold Foods revision date 2/2026, revealed under the section Procedures number 5, All food will be stored wrapped or in covered containers, labeled and dated.A review of the policy titled Resident Refrigerators revised 08/27/2024 revealed in the section, Policy explanation and Compliance Guidelines under number 2, Maintenance or Designee shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. The policy further states A thermometer shall remain in the refrigerator.A pantry policy was requested but not provided by the facility. NJAC 8:39-17.2(g)

Based on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 4 units (Second and Fourth Floor). The deficient practice was evidenced by the following: During the initial tour on 04/15/2026 at 9:30 AM, surveyor #1 observed the following: room [ROOM NUMBER]: A chair in the bathroom had a brown stain on the seat. room [ROOM NUMBER]: The bathroom wall had large scuff marks that penetrated through the drywall. room [ROOM NUMBER]: A foul odor was present, and the unmade bed had stained sheets and pillowcases. 3rd Floor Shower Room: A patch in the tiled wall had not been retiled. Additionally, the floor molding was peeling off and was held in place with tattered blue tape, which was also peeling. During follow-up rounds on 04/20/2026 at 10:50 AM, surveyor # 1 observed: room [ROOM NUMBER]: A foul odor remained, and the bed was made with visible stains on the top blanket. room [ROOM NUMBER]: The same chair remained in the bathroom with the same brown stain; an open, half-used roll of toilet paper was sitting on the chair. During an interview on 04/17/2026 at 11:35 AM with Surveyor #1, a Certified Nurse Aide (CNA) stated that residents' bedding is changed every other day unless it requires more frequent changing. During an interview on 04/20/2026 at 11:00 AM with Surveyor #1, a housekeeper (HK) stated they enter rooms several times a day to clean, specifically to sterilize the room, clean the bathroom, and empty the trash. When asked about the stained chair in room [ROOM NUMBER], the HK stated, It would be my responsibility to clean the chair if I saw it. During an interview on 04/20/2026 at 11:04 AM with Surveyor #1, the Director of Environmental Services (DES) stated that resident rooms are cleaned daily, including wiping high-touch areas, cleaning bathrooms, and sweeping/mopping floors. The DES noted that if furniture or surfaces are dirty, they should be cleaned. During an interview on 04/20/2026 with Surveyor #1, the Maintenance Assistant Director (MAD) stated that resident rooms and common areas are rounded on at least monthly. The MAD stated that concerns are typically fixed immediately and that holes should be patched with sheetrock and repainted. The MAD also confirmed the shower room patch should have been retiled and the floor molding should have been repaired rather than taped. On 04/15/2026 at 10:00 AM during tour of the low side of the second floor, Surveyor #1 observed the following: a dresser in room [ROOM NUMBER] with the wood veneer peeling exposing particle board, paint was peeling off of the wall under the window exposing the drywall in room [ROOM NUMBER], the sink in the low side shower room had multiple black and gray strands of hair in it. During an interview on 04/21/2026 at 9:46 AM, the Licensed Nursing Home Administrator stated that the bedside dresser in room [ROOM NUMBER] and the paint in room [ROOM NUMBER] were resolved yesterday. He furthered that the issues required quicker attendance. A review of the facility policy titled Safe and Homelike Environment revealed: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. N.J.A.C. 8:39-31.4(f)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately account for the administration, disposition, and reconciliation of 3 controlled medications for 3 sampled resident (Resident #47, Resident #58 and Resident #69) identified upon inspection of 2 of 3 medication carts (second floor low-side cart and high-side cart). The evidence was as follows: On 4/15/2026 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the second-floor high end medication cart. A review of the narcotics located in the secured and locked narcotic box revealed Resident 58's Chain-of-Custody Record (a declining inventory record) for methadone 100 mg (milligram) oral solution, a medication used to treat opioid use disorder, did not match. The bag contained 7 bottles, six contained medication and one was empty. The Chain-of-custody Record had not been completed to indicate any doses had been administered. A further review of the narcotic box revealed Resident #69's buprenorphine/naloxone 8/2 mg (milligram) film, a medication used to treat opioid use disorder, did not match the Individual Patient's Controlled Drug Record. The medication box contained two films and the declining inventory sheet indicated there should be three films remaining. The LPN stated she had administered the medications earlier and she had forgotten to sign the declining inventory sheets. The LPN further stated the declining inventory sheet should be signed after the medication had been administered. On 4/15/2026 at 11:03 AM, the surveyor in the presence of the Registered Nurse (RN) inspected the second-floor low-end medication cart. A review of the narcotics located in the secured and locked narcotic box and the declining inventory sheet, revealed Resident #47's tramadol 50mg tablets count was incorrect. Resident #47's medication order was for two tablets of tramadol 50mg to make a total dose of tramadol 100mg. The number of tablets remaining in the blister pack was nine. The declining inventory sheet also revealed there should be nine tablets remaining, this would not be possible if the dose required two tablets for accurate medication administration. At that time the RN acknowledged that the count could not be correct that if two tablets were administered at each dose, then the balance could not be an odd number of tablets such as nine, unless one tablet had been wasted. A review of the reverse side of the declining inventory revealed two tablets had been wasted and the RN again confirmed the count was not correct. The RN further stated she had not administered tramadol to Resident #47 that day. On 4/16/2026 at 12:30 PM, the surveyor interviewed the second-floor Licensed Practical Nurse Unit Manager (LPN/UM) who confirmed the nurses should have signed the declining inventory sheets when they removed the medications from the packaging and once administered, they should sign in the electronic medical record (EMR). When asked about the tramadol for Resident #47 he stated he was aware and had brought the information to the Director of Nursing (DON). On 4/20/2026 at 12:41 PM, the surveyor interviewed the DON and the Assistant Director of Nursing (ADON) who stated the nurses should sign out the controlled medications when they are removed from the packaging and once administered then sign off in the EMR. The DON and ADON confirmed the nurses had not followed the facility policy. The DON further stated they were currently investigating Resident #47's tramadol administration and discrepancy in documentation. A review of the facility's undated Controlled Substance Administration and Accountability policy included All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. scheduled II controlled substances dispensed from the pharmacy for a patient-specific are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. NJAC 8:39- 29.2(d), 29.7(c)

Based on interview and record review, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to 1 of 3 residents (Resident # 56) reviewed under Beneficiaries Task. The deficient practice was evidenced by the following: A review of Resident # 56's Electronic Medical Record revealed the resident was admitted with Medicare A as the primary payer source. A review of the Beneficiary Notification Review completed by the facility revealed that Resident # 56's Medicare Part A skilled services episode start date was 09/04/2025. The last covered day of Part A service was 12/1/2025. A review of the Beneficiary Notification Review revealed that the SNF ABN, Form CMS 10055 was not provided to the resident. No explanation was provided on the SNF Beneficiary Notification Review form. On 04/20/2026 at 10:43 AM during an interview with the surveyor, the facility's Business Manager said that the Social Worker at the time, did not know they had to issue a SNF ABN form. She said that originally yes was checked on the SNF Beneficiary Notification Review form but it was changed to no when it was discovered the Social Worker never sent the the SNF ABN form. A review of the facility policy titled, Advance Beneficiary Notices dated 05/07/2025 revealed under, Explanation and Compliance Guidelines that The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055.N.J.A.C. S 8:39-4.1 (a) 8

Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to implement care consistent with the resident's care plan by failing to order and implement Enhanced Barrier Precautions (EBP). This deficient practice was observed for 1 of 1 resident (Resident #3) reviewed for Tube Feeding. The deficient practice was evidenced by the following:On 04/15/2026 at 12:12 PM during initial tour, Resident #3 was observed lying in their bed attached to an enteral feed pump (a device used to deliver liquid nutrition directly into a person's stomach or small intestine through a tube). At that time, the surveyor observed no EBP signage outside the resident's doorway. At the same time the surveyor observed Resident #3s identification sign at the top of the doorway with no colored mark next to his/her name. On 4/16/2026 at 1:27 PM the surveyor observed no EBP signage outside of the room of Resident #3. No evidence was observed to indicate Resident #3 was on EBP. On 4/17/2026 at 10:51 AM, the surveyor observed and EBP sign to the right of Resident #3's doorway and a red dot visible on the identification sign at the top of the doorway. A review of Resident #3's Electronic Medical Record (EMR) revealed Resident #3's diagnoses that included but not limited to, Gastrostomy Status (Tube placed in stomach for feeding) and Dysphagia (Difficulty swallowing food or liquids). A review of Resident #3's EMR revealed no orders for Enhanced Barrier Precautions. A review of Resident #3's care plan revealed a Focus for Enhanced Barrier Precaution initiated on 02/17/2026. The focus revealed a goal of infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities r/t peg tube.On 04/16/2026 at 1:30 PM during an interview with the Unit Manager (UM) stated, staff know that residents are on EBP by the EBP signage outside of the resident's doorway and by a small colored mark next to the resident's identification signage at the top of the doorway. The UM indicated that she was unaware what the policy was for a resident care planned for EBP with no EBP order. On 4/17/2026 at 10:51 AM during a follow up interview with the UM, stated that if a resident is care planned for EBP they should have an order and a sign outside of the resident's doorway with the colored marking next to the resident identification sign.On 4/17/2026 at 1:03PM during an interview, the Infection Preventionist (IP) stated that residents with gastrostomy tubes should be on EBP. The IP further stated that once a resident is care planned for EBP, they should have an order placed. The IP stated that she was responsible for ensuring EBP orders are entered into the computer system. On 04/21/2026 at 9:41AM during an interview the Assistant Director of Nursing (ADON) stated that both the DON and IP will review resident orders and care plans to ensure accuracy. The ADON further stated the importance of ensuring that residents under EBP have the appropriate orders to maintain patient safety and for infection prevention purposes.A review of the policy titled Enhanced Barrier Precautions revised on 09/09/2025, revealed under number 2 Initiation of Enhanced Barrier Precautions under section b. An order for enhanced barrier precautions will be obtained for residents with any of the following: . indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes.) NJAC 8:39-27.1 (a)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide pain management that met professional standards of practice related to pain management. Specifically, by giving pain medication outside of the window of administration. This deficient practice was identified for 1 of 1 resident (Resident # 106) investigated for pain. The deficient practice was evidenced by the following: On 04/15/2026 9:43 AM the surveyor spoke to Resident #106 who stated that they received pain medication late. A review of Resident #106's admission Minimum Data Set (MDS) an assessment tool dated 03/20/26 reflected that they received routine pain medication. A review of Resident #106's electronic medical record (EMR) revealed a diagnosis of but not limited to muscle weakness and a lack of coordination. A review of Resident #106's physician's orders located in the EMR revealed an order for Acetaminophen Extra Strength Tablet 500 MG (milligrams) 2 tablets to be given by mouth twice a day for arthritis pain, and tramadol 50 MG (milligrams) 2 tablets to be given by mouth four times a day. A review of the Medication Administration Audit for March and April 2026 revealed the Acetaminophen Extra Strength Tablet tablets were administered on the following dates and times: 03/19/2026 scheduled for 06:00 PM and given at 07:14 PM03/21/2026 scheduled for 06:00 PM and given at 07:05 PM04/06/2026 scheduled for 06:00 PM and given at 07:11 PM04/08/2026 scheduled for 06:00 PM and given at 08:51 PM A review of the Medication Administration Audit for March and April 2026 revealed the tramadol tablets were administered on the following dates and times: 04/04/2026 scheduled for 12:00 PM and given at 01:35 PM04/05/2026 scheduled for 12:00 PM and given at 01:46 PM04/06/2026 scheduled for 06:00 PM and given at 07:11 PM04/07/2026 scheduled for 12:00 AM and given at 05:48 AM 04/08/2026 scheduled for 06:00 PM and given at 08:52 PM04/12/2026 scheduled for 12:00 AM and given at 06:55 AM04/13/2026 scheduled for 12:00 PM and given at 02:20PM During an interview with the surveyor on 04/16/2026 at 10:26 AM, the Unit Manager stated that medications can be administered one hour before and one hour after the scheduled time. The nurse should then document that the medication was administered at the time of administration. During an interview with the surveyor on 04/21/2026 at 10:29 AM, the Director of Nursing and the Assistant Director of Nursing acknowledged that Resident #106 received his/her pain medication late. A review of the facility policy titled, Pain Management, with an implemented date of 10/01/2023, reflected that the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards of practice to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage areas (first floor nursing office) inspected and was evidenced by the following: On 4/20/2026 at 12:29 PM, the surveyor in the presence of the Director of Nursing (DON), inspected the first-floor medication storage room. There was no medication refrigerator located in that room, the DON stated there was a refrigerator used to store medications located in the first-floor nursing office. On 4/20/2026 at 12:35 PM, the surveyor in the presence of the DON, Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) inspected the refrigerator in the first-floor nursing office. During inspection of the medication room refrigerator the surveyor observed an open, undated multi-use vial of Tuberculin Purified protein derivative (PPD) 5 TU/0.1ml (5 tuberculin units/0.1 milliliter), labeled house stock. At that time the IP stated the vial of PPD should have been dated when it was opened and that once it was opened it was only good for 30 days, then it should be discarded. Both the DON and the ADON confirmed the vial should have been dated when opened. A review of the facility's Labeling of Medications and Biologicals policy dated reviewed/revised 11/12/2024 included All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle punctured) b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. NJAC 8:39-29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure standardized recipes were utilized to ensure food was prepared to conserve nutritive value and flavor. This deficient practice was identified for 2 of 2 observed lunch meals prepared and the evidence was as follows:On 04/16/2026 at 11:50 AM, Resident #9 stated that they were unsatisfied with the food they were served. Resident #9 stated that they did not receive the food listed on their ticket and the portions were small.On 04/17/2026 at 11:10 AM during the resident council meeting, 5 out of 5 members in attendance stated that the food was not appealing and was not palatable. On 4/16/2026 at 12:02 PM during an interview, the Food Service Director (FSD) stated the menu is a set daily menu with a main entree and alternate entree. The FSD further stated that the computer system generates the resident's meal ticket based on their diet order. The FSD stated that any changes or any alternate are requested by the resident's nurse. The surveyor reviewed the week 3, Week at a Glance menu provided by the facility. The surveyor observed the main lunch meal for 04/17/2026 was lemon butter baked fish filet with roasted red skin potatoes, broccoli florets, dinner roll/bread and deluxe fruit salad. The alternate entree was smothered turkey patty, seasoned rice and roasted beets. On 04/17/2026 at 12:46 PM the surveyor received a sample lunch tray with both the main entree and the alternate lunch options. The alternate, smothered turkey patty meal did not contain the roasted beets listed on the menu but had a substitution of broccoli florets. At the same date and time, the surveyor placed a small portion of the fish filet onto a spoon to taste. The surveyor observed a small black curled hair in the piece of fish. At the same date and time, two surveyors tasted the smothered turkey patty and were unable to consume. The surveyors noted that the flavor profile did not meet the expected standards of palatability. On 04/17/2026 at 1:16 PM in an interview with the FSD, she confirmed that there was a hair in the fish entree. The FSD further stated that there should not be hair in the food. On the same date and time, the FSD stated that she had not tasted the smothered turkey patty. The FSD tasted the food upon the surveyors request and the FSD stated that she thought it was good. The FSD further stated that the turkey patty is premade, and the gravy is from a powder that water is added. The facility did not provide a policy related to the flavor or preparation of foods.NJAC 8:39-17.2(a); 17.4(a)(3)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that infection control practices were followed to prevent the potential spread of infection for a resident on contact isolation. This deficient practice was evidenced for 1 of 10 residents (Resident # 65) reviewed under the Infection Control Task. The deficient practice was evidenced by the following: A review of Resident # 65's EMR revealed under orders that he/she has an E.Coli/UTI (a bacterial infection in the urinary tract). The order clarifies that the precaution type is contact. The order was started on 4/16/2026.A review of Resident # 65's Care Plan located in the EMR revealed the resident was on isolation contact precautions.A review of Resident # 65's Care Plan located in the EMR revealed Resident # 65 had Methicillin-resistant Staphylococcus aureus (a type of staph that can be resistant to several antibiotics). The Care Plan was last reviewed 02/06/2026.A review of Resident # 65's Care Plan revealed an intervention for but not limited to, Contact isolation wear gowns and masks when changing contaminated linens, Place soiled linens in bags marked biohazard. Give antibiotic therapy as ordered, instruct visitors to wear disposable gloves and gown when in residents room and to wash hands before leaving room.On 04/17/2026 at 10:53 AM while outside the room, the surveyor observed a sign that read, For All Staff Contact Precautions in addition to standard precautions. Further the sign read, Before entering room/care zone Perform Hand Hygiene, Put on a gown, Wear gloves in accordance with standard precautions.On that date and time, the surveyor observed CNA (Certified Nurses Aide) # 1 walk into the room and speak to Resident # 65. She did not apply a gown or gloves. Upon exiting the room, the surveyor asked if she needed to wear a gown in that room. She replied that she did not have to wear a gown unless she was doing care. During the interview, another CNA, CNA # 2 also entered the room without a gown and began placing supplies on the bedside table in the room. When she exited the room, she informed the surveyor that they [staff] must wear a gown when they are hands on with the resident.On the same date at 10:58 AM during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager told the surveyor that the staff only wears personal protective equipment (PPE) when they are doing hands-on care.On 04/17/2026 at 12:29 PM during an interview with the surveyor, the Infection Preventionist confirmed that Resident # 65 was on Contact Isolation. When the surveyor asked what staff should do when entering that room, the Infection Preventionist replied, that for contact, there is a bin for that room, and it will have PPE. She clarified that before staff go into the room they have to wear it.A review of the facility policy titled, Transmission-Based (Isolation) Precautions dated 05/16/2023 revealed, d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.N.J.A.C. S 8:39-19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain an environment free of pests. The deficient practice was identified by observation of a live pest on 1 of 4 floors (2nd Floor) in the facility. The deficient practice was evidenced by the following: On 04/16/2026 at 10:40 AM while touring the 2nd floor in the hallway near the nurses station, the surveyor observed a brown insect crawling across the wall near the hand rail. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) also observed the insect when the surveyor brought it to his attention. He then used a disposable glove to dispose of the insect. The LPN/UM informed the surveyor that he will document the occurrence in the Pest Control Log. On 04/20/2026 at 12:55 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) said that pest control services are scheduled biweekly. Further, he said they have had the company come in to make a more in-depth treatment. When the surveyor asked if there is an ongoing issue with insects, the LNHA said they try to follow-up with residents in their rooms. He said when we become aware of rooms, pest control treats those specific rooms. A review of the facility-provided invoices from the pest control company for March of 2026, revealed that the facility has been treated for cockroaches. A review of the facility policy titled, Pest Control Program dated 04/02/2025 revealed that, It is the guideline of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The policy defined an Effective pest control program as, measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). N.J.A.C. S 8:39-31.5

COMPLAINT#: NJ0018543 Based on interview and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to implement the facility's Abuse, Neglect and Exploitation policy to ensure that existing staff received annual education for 1 of 2 employee files reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the Social Worker Assistant's (SWA) employee file, which included a General Orientation Checklist for All Employees dated 12/15/09. The checklist indicated that the SWA had an in-service on Resident Neglect and Abuse as part of her orientation. The employee file did not contain any additional in-services regarding this topic. On 3/21/25 at 1:02 P.M., during an interview with the SWA, she stated that although she could not recall the exact date she received an in-service on Abuse and Neglect (A/N), she knew it had been over a year. On 3/21/25, at 3:18 P.M., during an interview with the Assistant Director of Nursing (ADON), she stated that all staff were to be in-service on A/N upon hire and annually thereafter. She stated that she was responsible for in-serving staff. Additionally, the ADON said that although she kept records of the in-services for the nursing department, the head of each of the other departments was responsible for making sure that their staff were up-to-date on their trainings. The surveyor requested that the ADON provide a copy of the SWA's most recent training on A/N, and she stated that she would check. During an interview on 3/21/25, at 3:45 P.M., the Administrator stated that he expected all staff to be trained on A/N upon hire and then annually. On 3/25/25, at 10:15 A.M., the Administrator provided the surveyor with a Resident Rights/Abuse & Neglect Post Test, for the SWA, dated 3/24/25. On 3/25/25 at 10:21 A.M., during an interview with the Social Worker (SW), she stated that the department was fully staffed and consisted of herself and the SWA. She further stated that in-services on A/N were to be done at least annually, but they do them all the time at the facility. The surveyor asked if she reviewed and/or provided any in-services to the SWA regarding A/N and she stated that she never had. She also said that she did not know when the SWA last had an A/N in-service prior to 3/24/25. On 3/25/25, at 11:36 A.M., during a follow-up interview with the ADON, she stated that she had provided an A/N in-service with the SWA on the previous day [3/24/25]. According to the ADON, she searched and could not find any training for the SWA beyond the one completed in 2009 that was in the employee file, so she immediately provided the in-service. She stated that it was her expectation that all staff were to be trained annually and that they should be kept on file. She added that the purpose of the in-services was to remind staff of their obligation to report and that the main purpose was to protect the patients. A review of the facility's undated Abuse, Neglect and Exploitation policy, included under the Employee Training section, . B. Existing staff will receive annual education through planned in-services and as needed . A review of the SW's signed job description, dated 11/14/23, under the Essential Functions section, revealed that the SW was to Assume the authority, responsibility, and accountability of directing the social service department and Review and check the competence of social services personnel . NJAC 8:39-9.3(a), 13.4(c)2

COMPLAINT#: NJ00184543 Based on interview, medical record review, and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to: a.) immediately initiate an investigation of an allegation of verbal abuse, and b.) implement the facility's Abuse, Neglect and Exploitation policy. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for abuse and was evidenced by the following: Resident #2 was not at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: paraplegia, acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), anxiety, and depression. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/23/25, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. Further review of Resident #2's medical record revealed a progress note created by the Assistant Director of Nursing (ADON) on 1/11/25 at 4:36 P.M., which indicated that Resident #2, .started yelling that I had talked junk on [him/her] . On 3/21/25 at 3:45 P.M., during an interview with the Administrator, he stated that verbal abuse was a type of abuse and that it was a reportable event. He further stated that allegations of abuse and neglect were to be investigated immediately and, if a staff member was involved, they would have been suspended pending the outcome of the investigation. The Administrator stated that he was not informed that the ADON had been verbally abusive towards Resident #2. On 3/25/25 at 10:21 A.M., during an interview with the Social Worker (SW), she stated that she had been trained on Abuse and Neglect (A/N) and that if she suspected abuse she would immediately initiate an investigation and report it to the Administrator and the Director of Nursing (DON). The SW further stated that verbal abuse was a form of abuse. When asked if she had received any concerns regarding the ADON being verbally abusive towards Resident #2, she stated that sometime in January, more than one staff member reported to her that Resident #2 and the ADON had words, and, I think [the ADON] went back to apologize to the resident. The SW stated that she could not recall the exact date/time she was informed nor the names of the staff members. The SW further stated that she did not follow up with the resident or the ADON regarding what was told to her, nor did she report it to the Administrator. A review of the facility's Abuse, Neglect and Exploitation policy, implemented on 9/18/23, included under the Definitions section, 'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents . The policy further revealed under the Investigation of Alleged Abuse, Neglect and Exploitation section, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . A review of the SW's signed job description, dated 11/14/23, under the Essential Functions section revealed that the SW was to Assume the authority, responsibility, and accountability of directing the social service department . NJAC 8:39-27.1(a)

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:25 AM to 10:14 AM, the surveyor, accompanied by the Dietary Director (DD), and observed the following: 1.) In the refrigerator referred to as the reach in cooler, there were two egg salad sandwiches labeled with a use by date of [DATE], but no made on date. The DD said that egg salad sandwiches should be discarded because sandwiches can cause illness. 2.) In the dry storage area, there were four bags of unopened marshmallows with a manufacture's expiration date of ,d+[DATE]. The DD said that marshmallows should be discarded because of the expiration date. 3.) In the overstock storage area, there were 70 cases (6 gallon per case) of water with a manufacture's expiration date of [DATE]. The DD said that the Licensed Nursing Home Administrator (LNHA) is aware of the expired overstock water supply and is working on obtaining a new supply. On [DATE] at 11:35 AM, the surveyor observed the Speech Therapist (SP) in the kitchen area. The SP was not wearing a hair restraint. When interviewed by the surveyor at that time, the SP said that she is required to wear a hairnet while in the kitchen. On [DATE] at 11:49 AM, the surveyor observed the Administrator of Pediatric Medical Daycare (APMC) in the kitchen area. The APMC was not wearing a hair restraint. When interviewed by the surveyor at that time, the APMC said that she is required to wear a hairnet while in the kitchen. On [DATE] at 11:50 AM, during an interview with the surveyor, the District Dietary Director (DDD) said that the staff should have worn hair restraints while in the kitchen. The APMC always comes to the kitchen without a hairnet, and he will provide reeducation to the staff. A review of the undated facility policy titled, HCSG Label and Date In-Service, revealed under labeling food All products should be marked with a made on and use by date. A review of the facility policy dated ,d+[DATE] titled, Food Storage and Retention Guide, revealed Specialty Items Dry Storage Manufacturer Guideline. N.J.A.C 8:,d+[DATE].2 (g)

Based on observations and interviews on 11/20/2024 and 11/21/2024 in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the resident call bell system properly functioned by a.) ensuring the call bell system volume was set to a level to be heard and b.) devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at on 12/20/2024 at 12:55 PM revealed the call bell light outside of room [ROOM NUMBER] turned on when tested by the DOM, but there was no audible notification and the activation did not register at the nurse's station call bell annunciator. An observation at 1:00 PM revealed the call bell light outside of room [ROOM NUMBER] turned on when tested by the DOM, but there was no audible notification and the activation did not register at the nurse's station call bell annunciator. Additionally, visual notification of the activation is not possible from the nurse's station because it is being blocked by the hallway wall. One of 2 residents were in the room at the time of testing. An observation on 11/21/2024 at 10:47 AM revealed the call bell in room [ROOM NUMBER] did not function when tested by the DOM. In an interview at the time, the DOM confirmed that the call bell did not function and stated that the call bell box had broken pins. The resident in room [ROOM NUMBER] was in the bed at the time of the testing. NJAC 8:39-31.2(e), 31.8(c) 9

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 3 of 3 nursing units observed for environment. This deficient practice was evidenced by the following: The surveyor conducted a tour of the Fourth Floor on 1/18/2024 at 9:42 AM. Surveyor # 1 interviewed Registered Nurse/Unit Manager (RN/UM #1) who explained that the Fourth Floor consisted mostly of long term care residents. RN/UM #1 informed Surveyor # 1 that Housekeeping was responsible for cleaning/maintaining the resident rooms and daily touch surfaces and the certified nursing assistants (CNAs) were responsible for making beds, changing bed linens, and general cleanliness of the rooms. During the tour the surveyor observed the following: 1. In the central bath across from room [ROOM NUMBER], Surveyor # 1 observed two dirty wash cloths or towels on top shower chair with a dirty hair brush underneath the shower chair. 2. In room [ROOM NUMBER]-A, the surveyor observed Resident #77's mattress to have sections of blue plastic worn through to the white fibers. 3. In room [ROOM NUMBER], Surveyor # 1 interviewed Resident #90 who stated that their bathroom light does not work. Surveyor # 1 observed Resident #90 enter the room and attempt to turn on the light with no success. Resident #90 also advised that their television does not work because they do not have a remote control. Resident #90 confirmed that they have made the staff aware of the light and television but nothing came of it. On 11/20/2024 at 12:48 PM, Surveyor # 1 interviewed the Certified Nursing Assistant (CNA#1) who stated that they were responsible for ensuring the general safety and condition of the resident's room. When asked if they would check to ensure the condition of the resident mattresses and function of lights, CNA #1 confirmed. If they found something that was unsafe or broken in the room, CNA #1 stated that they would report it to the nurse and unit manager. On 11/20/2024 at 1:04 PM, Surveyor # 1 interviewed Registered Nurse (RN#1) who confirmed that they were responsible for safety checks, including the functionality of lights and condition of beds/mattresses. On 11/20/2024 at 1:13 PM, Surveyor # 1 conducted a follow-up interview with RN/UM#1 who stated that any resident room concerns would be submitted through a computerized system by the nurses. RN/UM#1 stated that the CNA's did not have access to the computer system. When asked about the functionality of resident bathroom lights or televisions, RN/UM#1 reported that he checks all the equipment in the room and would make a note if anything was out of order. On 11/20/2024 at 1:21 PM, Surveyor # 1 requested RN/UM#1 to room [ROOM NUMBER] where he confirmed that the bathroom light cannot be easily turned on and that Resident# 90's television could not be turned on since there was no remote control. On 11/20/2024 at 1:27 PM, Surveyor # 1 showed a picture of Resident #77's mattress where the plastic was worn through to white fibers. RN/UM#1 stated, I find it hard to believe the mattress [was] like that. Upon entering room [ROOM NUMBER] and viewing the mattress RN/UM#1 responded, Oh my God it is. RN/UM#1 indicated that the mattress should have been reported long ago. On 11/21/2024 at 12:00 PM, Surveyor # 1 interviewed the Director of Nursing (DON) who confirmed upon viewing the picture of the central bath that it should have been cleaned after resident use; Resident #77's mattress should have been reported by housekeeping, CNAs, everyone; and Resident #90's television and light should have been in working order. On 11/22/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the (Director of Nursing) DON and the survey team, acknowledged that the central bath should have been cleaned after resident use; Resident #77's mattress should have been reported; and Resident #90's television and light should have been in working order. 49712 On 11/19/2024 at 11:17 AM during initial while doing rounds Surveyor # 2 observed a missing drawer on the wardrobe in room [ROOM NUMBER]. During an interview on 11/21/2024 at 10:10 AM with Surveyor # 2, the 3rd floor Unit Manger (UM) said when they notice broken or missing pieces of furniture, they would send a request to maintenance through the Tells system. When Surveyor # 2 showed the UM the missing drawer the UM said she didn't know the drawer was missing. During an interview on 11/22/2024 at 10:34 AM with Surveyor # 2 the Maintenance Director (MD) said they do room rounds every three to six months and that the last one was done in July of 2024. The MD said there should be no broken furniture for the safety of the residents. During an interview on 11/22/2024 at 11:45 AM with Surveyor # 2, the Director of Nursing said there should be no missing or broken furniture in the rooms. The Licensed Nursing Home Administrator then said the nurse had reported to maintenance that day after the surveyor had brought it to her attention, and the drawer had been replaced. 43936 On 11/18/2024 at 10:34 AM during the initial tour on the second floor in the low side shower room, Surveyor # 3 observed a trash can without a bag liner. The surveyor observed disposable gloves discarded in the whirlpool tub. The sharps bin on the wall was full and not emptied. The plastic lid indicated, Full. On 11/20/2024 at 10:09 AM in the second floor shower room, Surveyor # 3 observed the sharps bin still indicating, full. On 11/20/2024 at 10:10 AM in room [ROOM NUMBER], Surveyor # 3 observed the plastic on the foot board of Resident # 229's bed separated. Resident # 229 was asleep in the bed at that time. On 11/20/2024 at 10:13 AM, Surveyor # 3 observed the high side medication cart on the second floor. At that time, Surveyor # 3 observed hair tangled in the wheels of the cart. Surveyor # 3 observed residual stains and wrappers in the attached disposable glove holder on the side of the cart. On the same date at 10:15 AM, Surveyor # 3 observed the low side medication cart on the second floor. At that time, Surveyor # 3 observed hair tangled in the wheels of the cart. 51232 On 11/19/2024 at 11:49 AM, Surveyor # 4 observed lunch in the dining room on the 4th floor. Surveyor # 4 observed staff serve the residents on meal trays and not remove the items from the tray as well as not inquiring the residents' preferences. On 11/20/2024 at 1:27 PM, Surveyor # 4 observed lunch in the dining room on the 2nd floor. Surveyor # 4 observed staff serve the residents on meal trays and not remove the items from the tray as well as not inquiring the residents' preferences. On 11/20/2024 at 1:29 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) on 2nd floor said that normally, meals are served on the trays in the dining room area. On 11/20/2024 at 1:30 PM, during an interview with Surveyor # 4, the Certified Nurse Aide (CNA) said that meals are served on the trays to residents in the dining room area. A review of the facility's undated Quality of Life- Homelike Environment policy identified that Residents are provided with safe, clean, comfortable and homelike environment [ .] and included: 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. cleanliness and order; b. comfortable (minimum glare) yet adequate (suitable to the task) lighting [ .]. A review of the facility's undated Quality of Life- Dignity policy identified that Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and dignity and included: 1. Resident shall be treated with dignity and respect at all times; 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth [ .]. NJAC 8:39-4.1 (a), 11, 12, 21.3 (a) (b), 27.2 (j), 31.2 (a-e), 31.3, 31.4 (a-f)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by 1). failing to wear a gown when providing wound care, and 2). Performing hand hygiene for residents and staff during meal service. The deficient practice was identified for 1 of 1 (Resident # 22) residents reviewed for Pressure Ulcer/Injury, and 1 of 3 floors observed for dining. (4th Floor) The deficient practice was evidenced by the following: 1.) A review of Resident # 22's diagnoses located in the Electronical Medical Record (EMR), revealed a diagnosis of but not limited to a pressure ulcer of the sacral region. A review of Resident # 27's physician's orders located in the EMR revealed that he/she was receiving Collagen (a dressing that maintains a moist wound environment that fosters healing) applied every day shift for pressure ulcer. The order further revealed to cleanse sacrum with normal saline solution, apply collagen and cover with a bordered gauze dressing. On 11/22/2024 at 08:55 AM, with permission from Resident # 22, the surveyor observed their wound care provided by the 3rd Floor Unit Manager (UM). At that time, the surveyor observed an orange sign on the room door that read, Enhanced Barrier Precautions. The sign revealed that, Everyone Must: clean their hands including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for following high-contact resident care activities: Dressing Bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. The UM entered the room without wearing a gown. During the observation of the wound care, the UM did not wear a gown throughout the entire process. At the time the wound care concluded, the surveyor asked the UM whether Resident #22 was on Enhanced Barrier Precautions. The UM replied saying I should have worn a gown. The surveyor did not observe a bin outside of the room containing any personal protective equipment such as gowns. During an interview on 11/22/2024 at 09:52 AM with the surveyor, the Infection Preventionist (IP) said staff should be wearing gowns when ever doing wound care or any direct care on residents that are on Enhanced Barrier Precautions. During an interview on 11/22/24 at 11:45 AM with the surveyor, when asked if a gown is to be worn when performing wound care on a resident on Enhanced Barrier Precautions, the Director of Nursing stated, Absolutely, and when providing any direct care. A review of the facility provided policy titled, Enhanced Barrier Precautions implemented 12/23/2022 revealed Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with multi-drug resistant organisms (MDROs) as well as those at risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy also revealed under 4. High-contact ace activities include h. Wound care: any skin opening requiring a dressing. S 8:39-19.4 (a) 51232 2.) On 11/19/2024 at 11:49 AM, Surveyor # 2 observed 3 Certified Nurse Aides (CNAs) on the 4th floor distributing meal trays to residents during lunchtime without performing hand hygiene beforehand, and the CNAs did not assist residents with hand hygiene before, during, or after the meal. On 11/19/2024 at 11:55 AM, during an interview with the Surveyor # 2, CNA # 1 said that she should have performed hand hygiene before passing out meal trays to residents. On 11/19/2024 at 12:00 PM, during an interview with Surveyor # 2, the Registered Nurse Unit Manager (RNUM # 1) on 4th floor said that CNAs should be performing hand hygiene before passing out meal trays to residents and residents should have been provided hand hygiene to prevent infection. On 11/21/2024 at 11:14 AM, during an interview with Surveyor # 2, the Infection Preventionist (IP) said that staff should wash their hands before delivering trays to residents and after any contact with residents or food. Staff should assist residents with hand hygiene before meals. On 11/23/2024 at 11:51 AM, during an interview with the surveyor, the License Nursing Home Administrator (LNHA) said that staff should wash their hands before delivering trays to residents. On 11/23/2024 at 11:51 AM, during interviews with Surveyor # 2, the Licensed Nursing Home Administrator (LNHA) said that staff should wash their hands before delivering trays to residents and the Director of Nursing (DON) added that staff should assist residents with hand hygiene before meals if they are unable to do so independently. A review of the dated facility policy 12/23/2022 titled, Hand Hygiene, revealed under Hand Hygiene Table before and after eating. A review of the dated facility policy 10/2009 titled, Assistance with Meals, revealed under Training in Safe Food Handling Practices that, All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. A review of the dated facility policy 11/29/2023 titled, Serving a Meal, revealed under 1, Prepare the room or serving area for mealtime (decrease noise level, provide lighting, position comfortably) and make sure hands and face are clean.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain an environment that protected and valued a residents' private space along with their personal property. This deficient practice was identified for 1 of 28 residents reviewed for Resident Rights (Resident #77). During initial tour of the Fourth Floor on 11/18/2024 at 10:55 AM, the surveyor observed a housekeeper wiping the inside of Resident #77's bedside drawer that was located across from the resident's bed. The surveyor immediately requested the assistance of the Registered Nurse Unit Manager (RN/UM#1) and upon the return to the resident's room, the surveyor and RN/UM#1 heard Resident #77 yell to the housekeeper to get out of the drawer and that they didn't give permission to go in there. The surveyor inquired if housekeeping has permission to go inside of resident's personal drawers. RN/UM #1 responded that they can open resident's drawers if the room was set to be carbolized (terminal cleaned). The surveyor inquired if room [ROOM NUMBER] was scheduled to be carbolized, to which RN/UM#1 denied and confirmed that housekeeping should not go into resident drawers without permission. The surveyor attempted to interview the housekeeper, but was unable due to language barrier. On the above date and time, the surveyor requested to speak with the Housekeeping Director (HD). The HD confirmed that room [ROOM NUMBER] was not scheduled to be terminally cleaned and that it was common knowledge that Resident #77 did not like for her room to be cleaned or touched. HD also confirmed that housekeeping should not open and enter resident's personal drawers. The surveyor reviewed the medical record for Resident #77. A review of the Admission Record face sheet (an admission summary) reflected that Resident #77 was admitted to the facility with diagnosis that included, but not limited to paranoid schizophrenia, anxiety disorder, and bipolar disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 8/31/24, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident is cognitively intact. On 11/21/2024 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who advised that housekeeping should not be in resident drawers without permission. The DON further acknowledged that she is familiar with the Resident #77 and can tell you [they] would not have wanted [their] drawer cleaned. On 11/22/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the (Director of Nursing) DON and the survey team, acknowledged that residents have an expectation of privacy when it comes to personal property. A review of the facility's Environmental Services Operational Manual document, revised 6/2016, included under Daily Patient Room Cleaning section Additional Information included: Remember, the housekeeper may be the major part of the Resident's social contact; be kind and courteous . A review of the facility's undated Resident Rights policy identified that Employees shall treat all residents with kindess, respect, and dignity and included: Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . NJAC 8:39-4.1(a)12

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the call bell within reach for 1 of 28 sampled residents, (Resident #90). This deficient practice was evidenced by the following: On 11/18/2024 at 10:49 AM, upon initial tour of the Fourth Floor, the surveyor observed Resident #90's call bell on the floor under the bed. When asked about their call bell, Resident #90 was unsure where it was and if they had one. On 11/19/2024 at 11:17 AM, the surveyor observed the call bell on the floor underneath the resident's bed. On 11/20/2024 at 12:26 PM, the surveyor observed the call bell on the floor underneath the resident's bed. The surveyor reviewed the medical record for Resident #90. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: delusional disorder, psychotic disorder with delusions due to known physiological disorder and Diabetes Mellitus. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/28/2024, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, that the Resident is at risk for falls/injury related to: impaired balance, impaired mobility with interventions that included: place call light within reach at all times and remind resident to use call light when attempting to ambulate or transfer. On 11/20/2024 at 12:48 PM, the surveyor interviewed the Certified Nursing Assistant (CNA#1) who confirmed that call lights are to be within resident's reach at all times. On 11/20/2024 at 1:04 PM, the surveyor interviewed the Registered Nurse (RN#1) who stated that call bells are to be on the bed at all times. On 11/20/2024 at 1:21 PM, the surveyor requested Registered Nurse Unit Manager (RN/UM#1) to accompany them to Resident #90's room. The surveyor inquired about the location of the call bell where RN/UM#1 located it on the floor under Resident #90's bed. RN/UM#1 confirmed that the call bell should be located within Resident #90's reach and it should not be on the floor under the bed. On 11/21/2024 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that call bells should be within reach of the resident and that the call bells have clips that secure them to the bed. On 11/22/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the (Director of Nursing) DON and the survey team, acknowledged that call bells should be within reach of the resident. A review of the facility's Call Lights, Accessibility and Timely Response policy, revised 8/28/24, included 5. Staff will ensure he call light is within reach of the resident and secured, as needed [ .]. NJAC 8:39-31.8 (c) (9)

Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had a witnessed fall. This deficient practice was identified for 1 of 4 Residents (Resident #8) reviewed for accidents and was evidenced by the following: On 11/19/2024 at 12:PM, the surveyor requested all accidents and/or investigations during the timeframe of 10/14/2024 to 11/17/20204. The facility provided information related to Resident #8 sustaining a fall without injury on 11/9/2024. Upon review of the fall investigation titled, Witnessed Fall with Head Injury dated 11/9/2024 at 2:19 PM revealed under Incident Description: Heard a noise from the hall and got up to check and saw resident sitting on the floor. There was an aide sitting in the hallway and witness resident falling. Per aide resident's shoe came off while walking and she saw resident going on the floor and the back of [their] head hit the wall. The surveyor reviewed the medical record for Resident #8. A review of the Admission Record face sheet (an admission summary) reflected that Resident #8 was admitted to the facility with diagnosis that included, but not limited to cerebral infarction (stroke), hemiplegia (complete paralysis of one entire side of the body.) and hemiparesis (weakness of one entire side of the body) and dementia. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 8/31/24, reflected a brief interview for mental status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. A review of the electronic medical record progress notes did not include a nurse's note for the witnessed fall. On 11/19/2024 at 3:34 PM, the surveyor interviewed Licensed Practical Nurse Supervisor (LPN/S#1), who advised that they were familiar with Resident #8's fall on 11/9/2024. LPN/S#1 recounted that she was called to the floor by the nurse assigned to Resident #8 and that the fall was witnessed by the certified nursing assistant. LPN/S#1 confirmed that vital signs were obtained, and the resident was evaluated for injuries. The LPN/S#1 acknowledged that the assigned nurse was responsible for entering the assessment into the progress notes. On 11/21/2024 at 11:22 AM, the surveyor interviewed Licensed Practical Nurse Unit Manager (LPN/UM#1) who advised that they were familiar with Resident #8's fall on 11/9/2024. LPN/UM#1 explained that following a fall, everyone that was a witness is expected to write a statement including the assigned nurse and certified nursing assistant. LPN/UM#1 advised that the nurse assigned to the fallen resident will start the investigation and gather all the statements. The supervisor was expected to then review everything for completeness and submit to the Director of Nursing (DON). The surveyor requested that LPN/UM#1 review the fall investigation that was provided by the DON on 11/19/2024. The LPN/UM#1 confirmed that Resident #8's assigned nurse did not provide a statement detailing the fall. On 11/21/2024 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that a thorough fall investigation was not completed since all witness statements were not obtained and the lack of documentation in the progress notes. On 11/22/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the (Director of Nursing) DON and the survey team, acknowledged that a thorough fall investigation was not completed. A review of the facility's Accidents and Supervision policy, implemented 12/29/2022, did not provide guidance or specifics on how to conduct a thorough investigation. NJAC 8:39-9.4(f)

Complaint # 172764 Based on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool used to facilitate care. This deficient practice was identified for 2 of 31 residents (Residents #98 and #41) reviewed and was evidenced by the following: 1.On 11/21/2024 at11:49 AM, the surveyor observed Resident #98 with a Wander guard to his/her left ankle. According to the Admission Record, Resident #98 was admitted to the facility with diagnoses including but not limited to dementia and cerebral vascular accident (stroke). Resident #98 had a Physician Order (PO) dated 04/10/24 to apply a Wander guard to the left ankle. A review of the April 2024, June 2024, and September 2024 Medication Administration Record reflected that the Wander guard was signed out as completed. A review of the Quarterly MDS dated [DATE] for Resident # 98 reflected under Section P0200 that the resident was coded as 0 indicating there was no wander/elopement alarm. A review of the Annual MDS dated [DATE] for Resident #98 reflected under Section P0200 that the resident was coded as 0 indicating there was no wander/elopement alarm. . During an interview on 11/22/2024 at 10:45 AM, the MDS Coordinator stated that alarms are coded on the MDS. She confirmed that Resident has a PO for a wander guard dated 04/10/24. The MDS Coordinator further confirmed that the Quarterly MDS dated [DATE] and the Annual MDS dated [DATE] were coded incorrectly. During an interview with the Director of Nursing on 11/22/2024 at 11:54 AM, she acknowledged that Resident #98's wanderguard should have been coded on the MDS's. NJAC 8:39-11.1 45209 2. On 11/18/24 at 10:37 AM, the surveyor observed Resident #41 wearing oxygen via nasal cannula while walking in the hallway. On 11/19/24 at 11:11 AM, the surveyor observed Resident #41 laying in their bed. Resident #41 stated that they relied on oxygen for breathing due to history of Chronic Obstructive Pulmonary Disorder (also known as COPD a chronic lung disease). The surveyor reviewed the medical record for Resident #41. A review of the Admission Record face sheet (an admission summary) reflected that Resident #41 was admitted to the facility with diagnosis that included, but not limited to respiratory failure, COPD, and Myocardial Infection (heart attack). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/6/24, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated the resident is cognitively intact. Section O of the MDS for Oxyen was coded as No, which identified that the resident did not use oxygen. A review of the Order Summary Report (OSR), dated as of 11/24/2024, included the following physician orders (PO): A PO, dated 3/4/2020 for [Oxygen] at 2 [liters per minute] continuous every shift for [shortness of breath] . A review of the resident's individual comprehensive care plan (ICCP) included a focus area, that the [Resident is] on oxygen therapy [related to] smoking, lifestyle choices with interventions that included: [ .oxygen] via nasal prongs/mask [at] 2 [liters per minute] continuously . On 11/22/24 at 10:44 AM, the survey team interviewed the MDS Coordinator who confirmed that Resident #41 had a PO for continuous oxygen since 3/4/2020 and acknowledged that the October MDS Quarterly Assessment was coded No for oxygen use. On 11/22/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the (Director of Nursing) DON and the survey team, acknowledged that Resident #41 wears oxygen that it should have been identified as yes in Section O on the MDS. A review of the facility's Conducting an Accurate Resident Assessment policy, dated 10/22/2023, stated, to assure that all residents receive an accurate assessment refeclective of the resident's status at the time of the assessment, by staff qualified to assesss relevant care areas. NJAC 8:39-11.1

Based on observation, interviews and record review, it was determined that the facility failed to protect residents from the potential exposure to excessive hot water temperatures measured to be 124-143 degrees Fahrenheit. This deficient practice was identified on the second floor (room 238 and the shower room); third floor (rooms 301, 329 and the shower room) and the fourth floor (room 126 and the shower room) which were checked by the surveyor and the Assistant Maintenance Director for excessive hot water temperatures. This resulted in an Immediate Jeopardy situation which was identified on 9/2/2016 at 10:35 a.m., and corrected on the same date, 9/2/2016 at 4:35 p.m., based on an acceptable plan of correction, which was implemented by the facility. This deficient practice was evidenced by the following: On 9/2/2016 at 9:15 a.m., the surveyor and the Acting Maintenance Director (AMD) both using their own individual calibrated thermometers took the temperature of the hot water in the room sink of resident's room 301 and found it to be 130 degrees Fahrenheit (F). The surveyor immediately informed the AMD of the unacceptable temperatures. The AMD stated that he was not sure why the temperatures were so high in this section. The surveyor and the AMD both continued to take temperatures in resident rooms and shower rooms on this floor and the 2nd and 4th floors with the following results: 9:40 a.m., room 326 = 125 degrees F (room sink) 9:42 a.m., spa room = 124 degrees F (shower room sink) 9:44 a.m., room 229 = 138 degrees F (room sink) 9:58 a.m., room 2nd floor = 138 degrees F (spa room sink) 10:08 a.m., room 419 = 139 degrees F (room sink) 10:11 a.m., room 4th floor = 143 degrees F (spa room sink) At 10:15 a.m., the 2nd, 3rd and 4th floor Unit Managers were informed by the Director of Nursing not to use the hot water in residents rooms and in the shower rooms until the investigation was completed and temperatures normalized. In addition an in-service to all staff on the hazards of hot water in the Health Care setting. At 10:35 p.m., the surveyor reviewed the daily maintenance logs for the month of August and September. According to the logs, all the water temperatures recorded were in acceptable range of up to 118 degrees F. The log also showed that the affected floors and rooms with the unacceptable hot water temperatures was last checked on 9/2/16 at which time the temperatures were between 112-118 degrees F. The surveyor reviewed the facility policy for taking hot water temperatures which reflected that temperatures were taken daily. On 9/2/2016 at 10:45 a.m., the AMD stated that they have been having problems with the involved domestic boiler mixing valve and that he was did not know the temperature being delivered to the involved resident rooms. The AMD stated that the Maintenance Director was out sick and he was just filling in for the day. On 9/2/16 at 11:00 a.m., the surveyor interviewed the Unit Managers (UM) from all 3 floors involved and all three UM stated that they had not received any complaints of the water being too hot. All three UMs stated that it was the protocol for staff to report any such findings to them and also to the maintenance department. On 9/2/16 at 11:05 a.m., the Administrator called the plumbing company to investigate the high water temperatures. On 9/2/16 at 12:30 p.m., the surveyor interviewed the Director of Nursing who provided a list of residents residing on each floor. According to the census on the second floor, the DON identified a total of four residents who were confused and could either independently ambulate or self-propel in a wheelchair. The 3rd floor had 13 residents who were confused and could either independently ambulate or self-propel in a wheelchair, and the 4th floor had one resident who was confused and could either independently ambulate or self-propel in a wheelchair. The DON confirmed that the 18 confused residents had the ability to independently operate a sink faucet and could potentially use any sink on the units. On 9/2/16 at 1:08 p.m., the surveyor interviewed 6 Certified Nursing Aides (CNA) assigned to residents on the 2nd, 3rd and 4th floors. All 6 of the CNAs stated that they check water temperatures using their hands, wrists or elbows before using the water on any of the residents for a bed bath or showers and that they have never had a problem with water being too hot in the past. On 9/2/16 at 2:00 p.m., The Plumber identified the problem and fixed the involved boiler and the hot water temperature was being delivered at 118 degrees F on all 3 floors by 2:45 p.m. The AMD was directed by the Administrator to take hot water temperatures in random four rooms on each floor and shower rooms every four hours for 24-hours. The surveyor notified the facility administration on 9/2/16 at 10:35 a.m., of the immediate jeopardy due to extreme hot water. A formal plan of correction was accepted at 4:35 p.m. The immediate plan of correction included the following: 1. All residents have the potential to be affected by this practice. 2. The hot water in the facility has been shut off while the immediate correction is taking place. All alert and oriented residents have been notified that there will be an interruption in the hot water while it is being worked at 1:14 p.m. Confused, ambulatory residents were identified and were placed in the day room under supervision until the temperatures are in range. Staff will escort these residents to the restroom to assure their safety. The plumber has addressed the issue and brought the temperature within the acceptable range 118 at 2:45 p.m. 3. The Maintenance Director or designee will continue to monitor and log the temperature in random four room per floor along with the shower rooms every 4 hours for the next 24 hours and then daily thereafter. Any temperature at 110 or above is to be immediately addressed and the Administrator and a plumber will be notified. The maintenance director and designee will be in-serviced along withe nursing staff on appropriate temps, and reviewing and updating the policy and will revise and update as needed. 4. Over the next 72 hours water temps will be taken by a designee to assure the water temp is within appropriate range and a plumber will be notified as needed. 5. The Administrator will review the temperature log during the quarterly review. A Quality Assurance and Performance Improvement (QAPI) will be done to see what the root of the issue was and what can be done to prevent reoccurrence. Any issues or concerns identified during the review will be immediately addressed. In-services will be ongoing till completed. Completion Date: September 2, 2016 NJAC 8:39-27.1 (a)

Complaint #NJ 325 Based on observation, interviews and record review, it was determined that the facility failed to protect a resident from abuse. Resident #1 was forcibly held down and dragged from the nurse's station, down the hallway and to his/her room by 2 staff members while yelling and thrashing around on the floor. The facility risked further abuse to the resident by the facility's staff who witnessed the incident, failing to report, investigate and protect residents from potential future abuse for a period of 17 days. This resulted in an immediate jeopardy situation and was identified for (Resident #1) 1 of 3 records reviewed for abuse, and was evidenced by the following: On 9/2/16 at 9:40 a.m., the surveyor observed Resident #1 in his/her room sitting in a wheelchair and licking a ball. The Unit Manager (UM) stated that the resident was alert and confused and that the resident required full staff assistance for all areas of activities of daily living. The UM also told the surveyor that Resident #1 was being discharged to another facility on 9/2/16. The surveyor observed that the resident had a bruise to the right side of his/her forehead and was not wearing any head devices. The UM stated that Resident #1 had the behavior of banging his/her head against the floor which caused the injury his/her head. The UM added that Resident #1 was suppose to be wearing a helmet. When asked, the UM stated that she did not know why the resident was not wearing his/her helmet and that resident would not keep the helmet on his head. A review of the medical record, Resident #1 was admitted to the facility with the following diagnoses, Dow[DIAGNOSES REDACTED] and Anxiety. A review of the Minimum Data Set (MDS), an assessment tool dated 6/26/16, revealed that Resident #1 had severe cognitive deficits, and required extensive assistance from 2 staff members for bed mobility and for moving from the bed and into a chair. A review of the Universal Transfer Form dated 8/16/16, revealed that Resident #1was sent out to the hospital for a change in mental status on that date. The surveyor reviewed the facility's Progress Note (PN) dated 8/16/16 at 5:46 p.m., revealed that Resident #1was very agitated on that date and was constantly walking around and putting him/herself on the floor, and grabbing hard onto other residents. The nurse notified Resident #1's physician and an order was obtained to send the resident out to the hospital for an evaluation. During an interview conducted by the surveyor on 9/2/16 at 10:35 a.m., the Administrator stated that on 8/16/16, he was told by the supervisor on duty that Resident #1 was sent out to the hospital for a change in mental status. When asked, the Administrator stated that there were cameras in all of the common areas in the facility and on each the nursing units and the dayrooms. When interviewed further, the Administrator showed the surveyor the recorded video footage dated 8/16/16 at 1:30 p.m. from the 2nd floor nursing unit. At this time, the surveyor and the Administrator viewed the video recorded on 8/16/16 together. The video showed Resident #1seated on the floor with his/her legs crossed and licking the floor with his/her tongue, and grabbing at staff as they walked by him/her. There were 6 staff members present during the time this incident took place. There were 2 Certified Nursing Assistants (CNAs) who, were identified by the Registered Nurse Educator (RNE) as CNA#1 and CNA #2. Resident #1 could be seen grabbing at CNA#1 and CNA#2's legs. The CNAs could be seen forcibly removing the resident's hands from their pants and pushing his/her arm way from them. CNA #1 and CNA#2 were seen throwing their arms up in the air and walking around and away from the resident. The video also showed another staff member, who was identified by the RNE as being a unit manager, entering into the area were the resident was sitting on the floor. At this time, the UM, CNA #1 and CNA #2 were seen lifting the resident up by the belt loops of the pants that the resident was wearing. Resident #1 would not stand-up for the staff and was seen lowering him/herself to the floor. The UM walked away, and as she did; she threw her hands in the air. The surveyor and administrator continued to watch the video that was time stamped for 1:45 p.m. on 8/16/16. CNA #1 and CNA #2 were seen in the presence of nurses and other CNAs grabbing Resident #1 underneath the arms and dragging the resident from the nurse's station and down the hallway. When interviewed at this time, the administrator said I don't want to say it! But this was abuse of Resident #1. The Administrator stated that he had not seen the video prior to this date and that no one had made him aware of this incident. The Administrator stated that he only looks at the video camera randomly or if he suspects something was going on in the facility with the residents or staff. The Administrator added that someone should have reported this incident to a supervisor or to him directly. The Administrator stated that it was the facility's policy for staff to report incidences of abuse. There would have been a thorough investigation done, and the staff members involved would have been sent home immediately. At this time, the Administrator told the surveyor that the time recorded on the video was not the correct time. The Administrator stated that there was a 30-45 minute delay on the camera's timer. On 9/2/16 at 11:30 a.m., RNE also viewed this video and identified all of the facility's staff shown on the video. The RNE stated after watching the video that she agreed that this was a case of abuse. The RNE stated that CNA #1 had no longer worked at the facility and was terminated a few months ago for poor attendance. The RNE added that the UM involved was not available for interview because she was on medical leave and had no scheduled date to return. There was Licensed Practical Nurse (LPN #1) who was assigned to Resident #1 who was observed watching as CNA #1 and CNA #2 dragged the resident to the room. There was a Therapy Aide (TA) who was seen ambulating another resident in the hallway. On 9/2/16 at 12:15 p.m., the surveyor interviewed CNA #2 who stated that she was assigned to Resident #1 on 8/16/16. CNA #2 stated that the resident was sitting on the floor and grabbing at staff and other residents. CNA #2 stated that although Resident #1 could walk, he/she had refused to walk on that date. CNA #2 stated that she had called the UM to come and to help them with Resident #1, but the UM became frustrated and left. CNA #2 stated that they were trying to make Resident #1 stand up and walk to the room, but the resident would not stand-up. CNA #2 stated that was when the UM became frustrated and walked away from them. CNA #2 stated that was when they dragged Resident #1 to his/her room. CNA #2 told the surveyor that the reason they did not transport the resident's in a wheelchair was because the resident's wheelchair was broken. CNA #2 stated that she had reported to maintenance that the resident's chair was broken, and nothing was done. CNA #2 told the surveyor that she could not recall when she reported to maintenance that the resident's wheelchair was broken. CNA #2 stated that since seeing the video, she should not have dragged the resident to his/her room. CNA #2 added that she was frustrated with Resident #1 and the resident was very difficult to care for. During an interview on 9/2/16 at 12:25 p.m., CNA#3 stated that she did not see CNA #1 and CNA #2 dragging Resident #1 to his/her room. CNA #3 stated that she was on the unit to escort another resident to a doctor's appointment. CNA #3 stated had she witnessed the incident she would have reported it to the supervisor. On 9/2/16 at 1:31 p.m., LPN #2 stated that she saw Resident #1 sitting on the floor and the resident was known to grab and hit staff. LPN #2 stated that she had witness the incident and did not intervene on Resident #1's behalf. LPN #2 stated that she left the nurse's station to pass medications at the other end of the hallway. When interviewed on 9/2/16 at 1:55 p.m., LPN #1 stated that she has only been working for the facility a few weeks. LPN #1 stated that she had been a nurse for over [AGE] years. LPN #1 told the surveyor that she had received an abuse in-service during her orientation to the facility. LPN #1 stated that she had witnessed CNA #1 and CNA #2 dragging the resident on the floor to his/her room and that she did not stop them. LPN #1 stated after viewing the video that this incident was a case of abuse and that she did not report this incident to anyone. When asked, LPN #1 stated that she did not stop the CNAs or report the incident to anyone because she was newly hired at the facility, and that she did not want to make any waves. LPN #1 stated she should have stopped that CNAs and reported the incident to the supervisor on duty. When interviewed further, LPN #1 stated that Resident #1's behaviors were very, very frustrating and time consuming and that she did not know what to do with the resident. LPN #1 stated that she did not tell anyone that she was having difficulty caring for the resident either. During an interview conducted on 9/2/16 at 4:00 p.m., the administrator stated that Resident #1's wheelchair was fully operational and that he did not know why; the CNAs did not place the resident in his/her chair. During a post- survey on 9/6/16, 9/7/16 and 9/18/16, the surveyor called the TA for an interview, and the TA did not return any of the telephone calls. According to the facility's Abuse Policy dated 2013 defined abuse as the willfully withholding of care/willfully infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. 1. The purpose of the policy was to ensure the residents residing at the facility were free from abuse by anyone, including: Staff, Visitors, Other residents, Consultants, Volunteers and Contracted staff 2. To provide a safe and secure environment for those who reside at the facility. It is with this intent that all avenues of inquiry will be pursued. Any employee who knowingly or negligently brings harm or injury to a resident will be suspended pending the outcome of the investigation and their employment may be terminated. Employee that raise a concern but could not be directly implicated in an incident will be monitored by their director and management. According to this policy, the facility will endeavor to provide an environment that prohibits the incident of resident abuse. In addition it will provide a system that encourages residents, staff and families to report their concerns, incidents grievances without fear of reprisal. The facility will provide adequate supervisory staff to oversee the care of the resident. Supervisory staff has been trained to detect inappropriate staff behavior. Supervisory staff shall monitor, counsel and report on all staff who display inappropriate behavior towards residents. Progressive disciplinary action will be taken that may include employment termination for continual inappropriate behavior. Residents with special needs are identified and direct care staff has been apprised of how to best interact with those residents to reduce the incidents of aggressive behaviors and potential abuse situations .Staff members have been advised of their responsibility as care givers to report all suspected or reportable abuse. Confidentiality is to maintained to protect the person reporting said behaviors. The Immediate Jeopardy began on 8/16/16 and was identified on 9/2/16 when the facility staff failed follow the facility's protocol to protect all residents from abuse. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 9/2/16 at 1:14 p.m. The Immediate Jeopardy was lifted and corrected on 9/2/16 at 4:30 p.m., after the facility removed the accused staff from access to all residents and took appropriate action per facility policy. The Plan of Correction (POC) submitted by the facility on 9/2/2016 at 4:00 p.m. included the following actions: 1. All resident have the potential to be affected. The identified resident has been transferred to another facility. Resident #1 was transferred to a care center on 9/2/16. The discovery of the incident was found from reviewing the cameras on 9/2/16 regarding the 8/16/16 incident. 2. An immediate in-service has been initiated for all staff on abuse and will be ongoing till completed. The in-service content includes what is abuse, who do you report abuse to and on preventing abuse. The 6 employees identified have been suspended pending a thorough investigation. One employee no longer works here and one is out on leave. Any employee that is terminated will be reported to the appropriate authorities. 3. The facility will continue to conduct background checks on all potential employees prior to employment. All new employees will be oriented to the facility and will attend a thorough orientation on abuse. The facility will in-service on abuse every quarter for that next year and then bi-annually thereafter. If any alleged abuse is brought to the attention of any staff members they will immediately report it to their immediate supervisor. 4. The administrator or designee will review the cameras to observe interaction between staff and residents three times a week. 5. Any alleged reports of abuse will be investigated by the Administrator, DON or designee and as appropriate the video cameras reviewed. A quality assurance meeting will be held today to discuss and determine the root cause to prevent reoccurrence. In-servicing will be ongoing. Completion Date: September 2, 2016 NJAC 8:39 - 4.1 (a) 5 Refer to- F-225 and F-282

Complaint #NJ 325 Based on interviews, review of the medical record, and pertinent facility documentation, it was determined that the facility staff failed follow the facility's policy for Abuse by not protecting Resident #1 and immediately reporting an incident of staff to resident abuse. In addition, the facility failed to protect residents from potential abuse for a period of 17 days by allowing CNA #1 and CNA #2 to continue to care for residents. In addition, there were nurses and CNAs who witnessed this incident of abuse and failed to intercede or report this incident of abuse. This deficient practice was identified for (Resident #1) 1 of 3 sampled residents for an incident that occurred on 8/16/16. This was identified as an immediate jeopardy to health and safety of residents when two Certified Nursing Assistants (CNA #1) and (CNA #2.) were assigned to provide care to residents. The deficient practice is further evidenced by the following: At this time, the surveyor and the Administrator viewed the 8/16/16 video from the camera together. The video showed Resident #1 seated on the floor with his/her legs crossed and licking the floor with his/her tongue, and grabbing at staff as they walked by him/her. There were 6 staff members present during the time this incident took place. There were 2 Certified Nursing Assistants (CNAs), who were identified by the Registered Nurse Educator (RNE) as CNA#1 and CNA #2. Resident #1 who could be seen grabbing at CNA#1 and CNA#2's legs. The CNAs could be seen forcibly removing the resident's hands from their pants and pushing his/her arm away from them. CNA #1 and CNA#2 were seen throwing their arms up in the air and walking around and away from the resident. The video also showed another staff member, who was identified by the RNE as being a unit manager, entering into the area were the resident was sitting on the floor. At this time, the UM, CNA #1 and CNA #2 were seen lifting the resident up by the belt loops of the pants that the resident was wearing. Resident #1 would not stand-up for the staff and was seen lowering him/herself to the floor. The UM walked away, and as she did; she threw her hands into the air. The surveyor and administrator continued to watch the video that was time stamped at 1:45 p.m. on 8/16/16. CNA #1 and CNA #2 were seen in the presence of nurses and CNAs Resident #1 underneath the arms and dragging the resident from the nurse's station and down the hallway. When interviewed at this time, the administrator said I don't want to say it! But this was abuse of Resident #1. The Administrator stated that he had not seen the video prior to this date and that no one had made him aware of this incident. The Administrator stated that he only looks at the video camera randomly or if he suspects something was going on in the facility with the residents or staff. The Administrator added that someone should have reported this incident to a supervisor or to him directly. The Administrator stated that it was the facility's policy for staff to report incidences of abuse. There would have been a thorough investigation done and the staff members involved would have been sent home immediately. On 9/2/16 at 11:30 p.m., the Registered Nurse Educator (RNE) also viewed this video and identified all of the facility's staff shown on the video. The RNE stated after watching the video that she agreed that this was a case of abuse. The RNE stated that CNA #1 had no longer worked at the facility and was terminated a few months ago for poor attendance. The RNE added that the UM involved was not available for interview because she was on medical leave and had no scheduled date to return. There was Licensed Practical Nurse (LPN #1) who was assigned to Resident #1 who was observed watching as CNA #1 and CNA #2 dragged the resident to the room. There was a Therapy Aide (TA) who was seen ambulating another resident in the hallway. On 9/2/16 at 12:15 p.m., the surveyor interviewed CNA #2 who stated that she was assigned to Resident #1 on 8/16/16. CNA #2 stated that the resident was sitting on the floor and grabbing at staff and other residents. CNA #2 stated that although Resident #1could walk, he/she had refused to walk on that date. CNA #2 stated that she had called the UM to come and to help them with Resident #1, but the UM became frustrated and left. CNA #2 stated that they were trying to make Resident #1 stand up and walk to the room, but the resident would not stand-up. CNA #2 stated that was when the UM became frustrated and walked away from them. CNA #2 stated that was when they dragged Resident #1 to his/her room. CNA #2 told the surveyor that the reason they did not transport the resident's in a wheelchair was because the resident's wheelchair was broken. CNA #2 stated that she had reported to maintenance that the resident's chair was broken, and nothing was done. CNA #2 told the surveyor that she could not recall when she reported to maintenance that the resident's wheelchair was broken. CNA #2 stated that since seeing the video, she should not have dragged the resident to his/her room. CNA #2 added that she was frustrated with Resident #1 and the resident was very difficult to care for. On 9/2/16 at 1:31 p.m., LPN #2 stated that she saw Resident #1 sitting on the floor and was known to grab and hit staff. LPN #2 stated that she had witness the incident and did not intervene on Resident #1's behalf. LPN #2 stated that she left the nurse's station to pass medications at the other end of the hallway. When interviewed on 9/2/16 at 1:55 p.m., LPN #1 stated that she has only been working for the facility a few weeks. LPN #1 stated that she had been a nurse for over [AGE] years. LPN #1 told the surveyor that she had received an abuse in-service during her orientation to the facility. LPN #1 stated that she had witnessed CNA #1 and CNA #2 dragging the resident on the floor to his/her room and that she did not stop them. LPN #1 stated after viewing the video that this incident was a case of abuse and that she did not report this incident to anyone. When asked, LPN #1 stated that she did not stop the CNAs or report the incident to anyone because she was newly hired at the facility, and that she did not want to make any waves. LPN #1 stated she should have stopped the CNAs and reported the incident to the supervisor on duty. When interviewed further, LPN #1 stated that Resident #1's behaviors were very, very frustrating and time consuming and that she did not know what to do with the resident. LPN #1 stated that she did not tell anyone that she was having difficulty caring for the resident either. During an interview conducted on 9/2/16 at 4:00 p.m., the administrator stated that Resident #1's wheelchair was fully operational and that he did not know why; the CNAs did not place the resident in his/her chair. Refer to F-223 and F-282 NJAC 8:39-27.1(a)

Based on observation and interview, it was determined the facility failed to ensure the air temperature in the facility was maintained between 71 to 81 Degrees Fahrenheit (DF). During a tour by the surveyor, there were 13 areas of the building, including resident rooms and common areas, that had temperature readings ranging from 82 to 88 DF. On 7/7/16 at 4:45 p.m. an Immediate Jeopardy (IJ) was identified by the surveyor due to high temperatures in resident areas, and reported to the Administrator (Admin) and Maintenance Director (MD). The IJ was lifted the same day when the facility implemented an acceptable plan of correction (POC). This deficient practice is evidenced by the following: On 7/7/2016 during the entrance conference at 3:05 p.m. a request was made to the Administrator (Admin.) and Maintenance Staff (MS) to obtain a Facility thermometer and accompany the Surveyor along the tour to record air temperatures. During the building tour with the Facility MS, the Surveyor observed and recorded the following air temperatures in the following locations: 1. At 3:18 p.m. in the 4th. floor Dining room air temperature was recorded as - Surveyor dial thermometer 82 DF. - Surveyor digital thermometer 81 DF. - MS dial thermometer 81 DF. 2. At 3:29 p.m. Resident room [ROOM NUMBER] air temperature was recorded as, - Surveyor dial thermometer 84 DF. - Surveyor digital thermometer 84.5 DF. - MS dial thermometer 84 DF. 3. At 3:31 p.m. in the 4th. floor Sensor room air temperature was recorded as, - Surveyor dial thermometer 84 DF. - Surveyor digital thermometer 84.8 DF. - MS dial thermometer 84 DF. 4. At 3:37 p.m. in the 3rd. floor corridor all 3 thermometers were placed on top of the hand rail (35 above the floor) between Resident rooms #322 and #323. The thermometers readings were - Surveyor dial thermometer 82 DF. - Surveyor digital thermometer 83.6 DF. - MS dial thermometer 83 DF. 5. At 3:41 p.m. Resident room [ROOM NUMBER] air temperature was recorded as, - Surveyor dial thermometer 85 DF. - Surveyor digital thermometer 85.5 DF. - MS dial thermometer 85 DF. 6. At 3:48 p.m. 3rd. floor Nursing station air temperature was recorded as, - Surveyor dial thermometer 83 DF. - Surveyor digital thermometer 83.4 DF. - MS dial thermometer 83 DF. 7. At 3:49 p.m. Sample Resident #2 approached the Surveyor in the 3rd. floor corridor and said, It's hotter then hell here. 8. At 3:59 p.m. in the 3rd. floor dining room air temperature was recorded as, - Surveyor dial thermometer 85 DF. - Surveyor digital thermometer 84.7 DF. - MS dial thermometer 85 DF. 9. At 4:19 p.m. an interview with Sampled Resident #1 was conducted. The Surveyor asked, How is the air temperature in the room. Sampled Resident #1 said, It was hot. The Surveyor observed and recorded the following temperatures in his room, - Surveyor dial thermometer 82 DF. - Surveyor digital thermometer 83.7 DF. - MS dial thermometer 82 DF. Later at 4:35 p.m. the facility Maintenance Director (MD) arrived to the Facility and an interview was conducted. The Surveyor asked the MD, how many Resident rooms have non-functioning air conditioning units. The MD said all Resident rooms are part of a loop connected into a cooling tower system. Each Resident room has their own thermostats so the Residents can control the temperature with in the room. There are 19 Resident rooms with problems. The MD also said, we installed window air conditioning units in some of the these rooms. A second tour of the Facility with the Admin. and MD to inspect the 19 Resident rooms was conducted. The Surveyor observed and recorded the following temperatures on the individual room thermostats mounted on the walls, 1. At 6:01 p.m. Resident room [ROOM NUMBER] had 84 DF. 2. At 6:05 p.m. Resident room [ROOM NUMBER] had 84 DF. 3. At 6:04 p.m. Resident room [ROOM NUMBER] had 86 DF. 4. At 6:10 p.m. Resident room [ROOM NUMBER] had 88 DF. 5. At 6:11 p.m. Resident room [ROOM NUMBER] had 83 DF. The immediate jeopardy was corrected on 7/7/16 at 7:00 PM based on an acceptable plan of correction. 1. On 7/7/16, window units were put into resident rooms that were identified with temperatures that exceed the regulatory number. Prior to the surveyors arrival, window air conditioner units were purchased. After the IJ was called, additional window air conditioner units were purchased and all resident rooms that were identified by the surveyor, as having temperatures that exceed the regulatory number, had window air conditioner units placed in them. 2. On 7/7/16, a log sheet was initiated to log temperatures throughout the building. 20% of the resident rooms per floor plus a common area will be checked every hour. In the event a room does not meet regulatory temperatures a window air conditioner unit will be installed. 3. On 7/7/16, hydration stations were set up on each unit. Staff will check on the residents every 30 minutes and as needed. Licensed nurse will contact the resident's Physician for further orders or direction with any resident that is ordered a fluid restriction. Staff will increase checking water cups from once a shift to twice a shift. Licensed nurses on the units have been instructed to monitor and observe their assigned residents for signs and symptoms of dehydration. Licensed nurses will also give the Certified Nurses Aide (CNA) report at the start of the shift that includes monitoring and observing for signs and symptoms of dehydration. NJAC 8:39 -31.8.