Every finding on record at Shore Gardens Rehabilitation and Nursing Center

Based on interviews, medical record review, and other pertinent facility documents, it was determined that the facility failed to immediately activate their emergency response system including rapid identification of a resident's code status, initiating a code blue (facility alert system), initiating Cardiopulmonary Resuscitation (CPR) and calling emergency services/911, for a resident (Resident #142) who was found unresponsive and was a full-code status (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating), in accordance with Basic Life Support (BLS) for Healthcare Providers. This deficient practice was identified for 1 of 1 resident, (Resident #142) reviewed for death in the facility.A review of Resident #142's progress notes (PN) dated [DATE] at 6:50 PM, revealed that a Certified Nursing Assistant (CNA #1) entered Resident #142's room to answer the call bell when the resident's spouse stated, I think [Resident #142] is dead. The CNA reported this to the Registered Nurse (RN #1) who responded to the resident's room. The resident was unresponsive, eyes closed, mouth open, tongue pulled back, no rise and fall of chest, and no pulse noted. At 6:55 PM (five minutes later) CPR was initiated, and Code blue was announced. At 7:05 PM (fifteen minutes later) 911 was called. At 7:20 PM (thirty minutes later) the paramedics arrived and took over CPR. The police informed the nurse that the resident passed away and was pronounced as deceased at 7:40 PM.Interviews with the Licensed Practical Nurse Supervisor (LPN/S #1) revealed that there was a delay in initiating CPR because facility staff were unable to locate the Physician Orders for Life Sustaining Treatment (POLST) book and were not sure of Resident #142's code status. The resident's POLST indicated the resident was a full code. Interviews with the Director of Nursing (DON) confirmed that the resident's code status should have been reflected in the electronic medical record, and a code blue and 911 should have been called immediately. Interviews with the Licensed Nursing Home Administrator (LNHA) confirmed that that staff should have initiated CPR without delay upon identification of Resident #142.The facility's failure to ensure their emergency response system was activated including calling 911, posed a likelihood that serious injury, harm, impairment, or death could occur to all residents who were a full code. This resulted in an immediate jeopardy (IJ) situation.The IJ began on [DATE] at 6:50 PM, when Resident #142 was found unresponsive, and the facility failed to rapidly identify the resident's code status and immediately initiate BLS measures including CPR. The Administration was notified of the IJ on [DATE] at 3:53 PM. The facility submitted an acceptable Removal Plan (RP) on [DATE] at 1:15 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on [DATE].The evidence was as follows: A review of the facility provided Emergency Response and Initiation of CPR policy dated, [DATE], included; Verification of Advance Directives/Code Status: Prior to CPR initiation staff shall determine: Full Code, DNR (Do Not Resuscitate), POLST instructions, or Hospice status (if applicable). If uncertainty exists and no valid DNR/POLST can be immediately confirmed, emergency measures should proceed while clarification occurs according to the facility policy and applicable law. CPR Initiation: For residents designated Full Code: Initiate CPR immediately according to current certification guidelines. Direct staff to call 911. Apply AED (automated external defibrillator) (portable life-saving devices designed to treat people in cardiac arrest, a medical condition in which the heart stops beating suddenly and unexpectedly), Continue CPR until: EMS assumes care; Return of spontaneous circulation; Valid DNR (Do Not Resuscitate) order identified; Physician direction; or Staff are physically unable to continue. A review of the facility POLST Physician Orders for Life Sustaining Treatment policy, dated [DATE], included: To ensure resident treatment preferences for life-sustaining treatment are identified, documented, communicated, and honored in accordance with applicable laws and facility procedures.If uncertainty exists.Provide care until orders are clarified. On [DATE] at 10:13 AM, the surveyor reviewed the closed medical record of Resident #142. A review of the admission Face Sheet (an admission summary), reflected the resident was admitted to the facility with diagnoses that included but were not limited to; Unspecified asthma, uncomplicated, and malignant neoplasm of the bladder (cancerous and can spread to other parts of the body) and malignant neoplasm of the prostate. A review of the resident's Electronic Medical Record (EMR) failed to indicate the presence of a POLST or an advance directive which specified the resident's end of life wishes. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the resident's admission Social Work (SW) admission and Psychosocial Assessment revealed that the resident did not have an advance directive and chose not to execute one. A review of the resident's most recent untitled and unsigned quarterly SW assessment dated [DATE], revealed that the resident's code status was documented as a full code. A review of the resident's printed medical record revealed that the resident had a physician's order dated [DATE], for full code status. A review of Resident #142's individual comprehensive care plan (ICCP) included that the resident was a full code. Interventions included: Copy of each directive will be on medical chart. Encourage resident to make wishes known and document. A review of a PN dated [DATE] at 7:51 PM, documented by LPN/S #1, revealed at 6:50 PM-Call bell noted to be on, CNA went to the room and answered the call, spouse [name redacted] stated, I think [Resident #142] is dead. CNA told floor nurse and responded to room. [Resident #142] noted to be unresponsive, eyes closed, mouth open, tongue pulled back, no rise and fall of chest, no radial pulses noted. POLST noted to be Full Code. 6:55- PM, CPR initiated, and Code Blue was announced. 7:05 PM- 911 was called. 7:20 PM- Paramedics came in and took over CPR. Two [name redacted] Police Officers also came in. 7:47 PM-[name redacted] Police informed this nurse that [Resident #142] passed away and pronounced at 7:40 PM by [physician name redacted]. On [DATE] at 10:44 AM, the surveyor interviewed LPN/S #1 via telephone in the presence of the survey team. The surveyor read the [DATE] at 7:51 PM PN to LPN/S #1 and questioned the accuracy of the time stamps that were documented. LPN/S #1 stated, Yes, there was a five-minute delay, as we were looking for the resident's POLST and did not know if the resident was a Full Code or a DNR, and the resident's spouse did not know; it was a crazy day. LPN/S#1 further stated the POLST book was either kept in the cabinet or at the nurse's station and that they had found it at the nurse's station. LPN/S #1 confirmed that the code was announced via code blue and CPR was initiated once the POLST book was found. LPN/S #1 explained that when she called code blue not a lot of staff responded because it occurred in the middle of collecting dinner trays and during the medication pass. LPN/S #1 stated the other nurses performed CPR because she was pregnant at the time. LPN/S #1 stated that she was CPR certified and explained that CPR could be initiated without the POLST book, but because the resident did not have a bracelet on with their code status on it, it took five minutes before CPR was initiated. LPN/S #1 further stated, I am not sure if I can say if CPR should have been started before the POLST was found. On [DATE] at 11:07 AM, the surveyor interviewed LPN #2, who stated that when a resident was noted to be unresponsive, she would do the following: check for a pulse and respirations via the rise and fall of the chest, assess circulation, obtain vital signs, have a RN assess the resident, and check the code status. She stated code statuses were found in the EMR under the resident's name which would indicate if a resident were a full code or a DNR. She stated that then someone would initiate a code blue over the intercom system, that the nurses would respond and came up most of the time. The nurses would also get the crash cart and initiate CPR. LPN #2 stated the POLST book was kept at the nurse's station by the table in a folder. LPN #2 further stated, I do not think that I would wait five minutes to look for the POLST book because as a nurse, part of my responsibility is to save a life. On [DATE] at 11:22 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM #2) who stated that nursing should know that code statuses were kept in the POLST book and in the EMR and should be found very quickly because we have to know the code status so we know if we can initiate CPR. LPN/UM #2 stated that the POLST book should be found very quickly and should take no more than a few seconds and if it cannot be found, then the nurses should look at the computer. LPN/UM #2 stated that it should not take five minutes to locate a code status because the rescue efforts may not be successful and that would be a problem. LPN/UM #2 stated that 911 should be called immediately if the resident was unresponsive and in cardiac arrest. LPN/UM #2 stated that the resident took precedence over the medication pass and tray pick up because we are to help the resident as soon as possible. LPN/UM #2 further stated, Yes, I would consider it a delay in treatment if it took five minutes to find a POLST book to start CPR and the call to 911 was even further delayed. On [DATE] at 11:34 AM, the surveyor interviewed LPN #3 who stated that upon notification of an unresponsive resident she would immediately go to the resident to assess the situation and call 911 via cell phone. She stated if there was no pulse, she would get the automated external defibrillator (AED) and have a CNA come in to assist. LPN #3 stated that it should only take five to ten seconds to look for the POLST in the EMR or in the POLST book because it was an emergency and CPR should already be in progress. LPN #3 then demonstrated to the surveyor where to find the POLST forms and stated that it took less than 30 seconds to find it in the computer and less than 10 seconds to find it in the POLST folder. On [DATE] at 11:43 AM, the surveyor interviewed CNA #3, who stated if she found a resident to be unresponsive, she would call the nurse right away to check the resident. CNA #3 stated that the POLST was in the computer, at the nurse's station, and in the resident's chart. CNA #3 stated that when they called a code, all nurses respond. CNA #3 further stated that sometimes we get the defibrillator, and the nurse may tell me to call 911 while they were performing CPR. On [DATE] at 12:26 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who stated that she would go into the room to assess the resident who was unresponsive and check for breathing. The ADON/IP stated that if she was alone, I would initiate CPR more than likely because there was only a small amount of time to administer CPR or they are going to die. The ADON/IP stated it should be immediately that you initiate CPR and not look for the POLST until help arrives. The ADON/IP stated that 911 should also be called immediately because outside of CPR and the AED the faster the medics get here the greater the chance of survival. On [DATE] at 12:37 PM, the surveyor interviewed the DON, who stated that once a resident is found unresponsive, there should not be a delay; staff should call for help, nursing should look for the code status, call a code blue, and 911 should be called immediately. If the POLST cannot be found, the resident was considered a full code. The DON further stated that this should take less than a minute and is important because the chances of survival or reviving the resident are nonexistent if it takes five minutes. At that time, the surveyor asked the DON to review the resident's nurse's note that was written by LPN/S #1 on [DATE]. The DON read the note aloud and stated the time stamps were very scattered. She stated, it looked like five minutes passed before they started CPR. It looks like ten minutes passed before they even called 911. Then paramedics arrived at 7:20 PM, another 15 minutes. Resident not pronounced for another 20 mins. There is no evidence that the nurse did any interventions at all. On [DATE] at 12:56 PM, the surveyor interviewed RN #1, who stated she was the nurse on duty on [DATE]. RN #1 recalled that she was down at the other end of the hall during medication pass when CNA #1 called for her and reported Resident #142 was unresponsive. RN #1 stated, we brought the crash cart in, put the resident on a board, and did chest compressions and proceeded with resuscitation. RN #1 stated that she did not know the resident's code status and did not recall documenting her interventions. On [DATE] at 3:06 PM, the surveyor interviewed the LNHA who stated staff should have initiated CPR without delay upon identification of Resident #142. On [DATE] at 2:50 PM, in an interview with the DON, she confirmed that she was unable to find a POLST in the resident's closed record. The DON stated that the resident's code status should have been reflected in the resident's EMR. On [DATE] at 4:18 PM, the surveyor interviewed CNA #1 via telephone. CNA #1 stated she recalled answering the call light and Resident #142's spouse asked her to check on Resident #142 because the resident was not responding. She stated she turned on the light because the room was dark and noted the resident was unresponsive after she touched the resident. She stated she went to get RN #1 who was passing medications and told her to stop and come quickly. CNA #1 stated that RN #1 told her to get help, so she alerted her co-worker, CNA #2. CNA #1 stated they pushed the crash cart into the room, got the board and then the nurses from the second and third floor came down and assisted with CPR together with RN #1. CNA #2 stated that LPN/S #1 was inside the room as well and we gave way to the paramedics. CNA #1 stated that she was unable to recall any details regarding the time that it took to initiate CPR and emergency response because she was so surprised by the event. CNA #1 stated that residents' code status was written both in the resident's chart and in the computer. An acceptable Removal Plan was received on [DATE] at 1:15 PM, indicating the action that the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including: The facility's Emergency Response and Initiation of CPR policy was reviewed and a new policy, Identification of Resident Code Status was written to ensure all nursing staff was well informed in the event of an emergency how to find a resident's code status in the Electronic Medical Record (EMR) system, and an additional Code Status Binder was maintained on each unit to reduce loss of time. On [DATE], all nurses were educated by the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Director of Rehabilitation (DOR), on both the Emergency Response Policy and Procedure and the Identification of Resident Code Status Policy and Procedure in person or via phone. In-servicing of Certified Nursing Assistants (CNA) is ongoing and will be completed by [DATE]. The Emergency Response and Identification of Resident Code Status Policy and Procedure will be included in the New Hire Packet for nursing staff to ensure all new hires are educated in these policies. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on [DATE] at 2:03 PM.NJAC 8:39-4.1(3), 9.6(g), 14.2(b)

Complaint #3007960Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident (Resident #144), who was dependent on staff for transfers, was safely and properly transferred with two staff members via a mechanical lift. On 5/4/26, the resident was transferred by one staff member from their bed to a shower chair, which resulted in the resident sustaining a left upper extremity humeral fracture (a fracture of the left upper arm). This deficient practice was identified for 1 of 6 residents (Resident #144) reviewed for accidents and was evidenced by the following: On 6/23/26 at 9:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LHNA) a copy of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) for Resident #144.On 6/23/26 at 9:00 AM, the surveyor reviewed the FRE provided by the LHNA. The report documented that on 5/4/26 at 11:15 AM, the Certified Nursing Assistant (CNA #11) was assisting Resident #144 with a shower and observed that the resident's left upper arm appeared deformed. The finding was immediately reported to the Director of Nursing (DON), and the resident was promptly assessed by the Nurse Practitioner (NP). The NP noted an indentation of the left upper arm and abnormal movement originating from the mid-humerus (upper arm bone). The NP ordered Resident #144 to be sent to the Emergency Department (ED) for further evaluation. CNA #11 was immediately suspended pending outcome of the facilities investigation. The Resident Representative, DOH, and Ombudsman were notified.A review of the Progress Notes dated 5/5/26 at 11:07 AM, authored by the DON, revealed that the hospital indicated that Resident #144 was diagnosed with an acute fracture of the left distal humerus.The surveyor reviewed Resident #144's closed medical record which revealed the following:A review of the admission Face Sheet revealed that Resident #144 was admitted to the facility with the diagnoses which included but were not limited to; dementia, diabetes mellitus, metabolic encephalopathy (impaired brain function), and peripheral vascular disease (narrowing of the blood vessels).A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 4/8/26, revealed that the resident had short and long-term memory problems with severely impaired decision making. A further review under Section GG-Functional Abilities, revealed that the resident was dependent on tub/shower transfer meaning the helper does all the effort, resident does none of the effort to complete activity, or the assistance of two or more helpers was required for the resident to complete the activity. A review of the Activities of Daily Living (ADL) change of status forms dated 11/10/25 and 4/20/26, both indicated that the resident was dependent on sitting to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer.A review of the Occupational Therapy treatment plan dated 6/19/25 to 7/18/25, indicated that Resident #144 was to be mechanically lifted due to safety concerns.A review of the Occupational Therapy treatment plan dated 11/11/2025 to 11/26/25, indicated that Resident #144 was dependent and was transferred via (by way of) a mechanical lift.A review of the Individualized Comprehensive Care Plan (ICCP) did not include a focus area for functional ability performance and there were no interventions implemented on the type of assistance the resident required for transfers prior to 5/4/26.A review of the Progress Notes dated 5/4/26, indicated that at 10:40 AM, CNA #11 notified the nurse that the resident's left arm was swollen. Upon inspection, the nurse documented that the left arm was swollen, warm and firm to touch. The resident was grimacing during gentle tactile inspection and pulses were present. The nurse notified the NP and DON. The nurse then administered the resident Tylenol 650 milligrams (mg) for pain and discomfort. The resident was then sent to the ED for further evaluation.A review of the radiology imaging report from the hospital, dated 5/4/2026 at 1:54 PM, revealed the resident sustained an acute comminuted displaced fracture of the distal left humerus.A review of the FRE conclusion provided by the facility, indicated that Resident #144 sustained an injury during a transfer from the bed to shower chair that required necessary revisions to the functional mobility care plan, transfer status and possible need for a mechanical lift.On 6/23/26 at 12:36 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that Resident #144 had limited mobility and a contracted (refers to the shortening or tightening of a muscle or muscle fiber, which can occur in skeletal, smooth, or cardiac muscle, and is essential for movement) upper extremity. LPN/UM #1 explained that the resident was dependent on staff for ADLs and required a two-person assistance for transfers. LPN/UM #1 reported that CNA #11 was assisting Resident #144 with a shower, when the CNA observed that the resident's arm was swollen and painful. LPM/UM #1 stated that she was not involved in the subsequent investigation, and the DON and Assistant Director of Nursing/Infection Preventionist (ADON/IP) conducted the investigation. LPN/UM #1 further stated that she was not informed of the investigation's outcome.On 6/23/26 at 12:51 PM, the surveyor interviewed the ADON/IP, who stated that she participated in the investigation regarding Resident #144's left humerus. The ADON/IP reported that CNA #11 observed a deformity of the resident's left arm and immediately reported the finding. The ADON/IP stated that the investigation determined that CNA #11 had transferred Resident #144 independently by lifting the resident under the arms, which CNA #11 had demonstrated the transfer technique to the DON, Regional DON, and herself. The ADON/IP was unable to recall the required number of staff needed to safely transfer Resident #144, but stated she would obtain that information for the surveyor.On 6/23/26 at 2:24 PM, the surveyor interviewed the DON, who confirmed that Resident #144 was dependent on ADL care and required a two-person assistance for transfers. The DON acknowledged that the resident's ICCP did not include the requirement for a two-person mechanical lift transfer. The DON stated that this omission resulted from a communication error between the rehabilitation therapy department and the nursing department. The DON further stated that CNA #11 should have obtained assistance from another staff member before transferring Resident #144 and characterized the incident as a learning experience.On 6/24/26 at 10:18 AM, the surveyor interviewed LPN #2, who had provided care for Resident #144, and stated that the resident required total care and a two-person assist for all transfers to ensure the safety of both the resident and staff during transfers between bed and chair and vice versa.On 6/24/26 at 10:23 AM, the surveyor interviewed CNA #11, who stated that Resident #144 was dependent on staff for all ADLs and could not walk or feed themself. CNA #11 noted that while the resident sometimes needed a two-person transfer to get out of bed, they were small in stature, allowing her to lift them under the arms and pivot them into a chair. CNA #11 stated she was unaware that the resident required a mechanical lift, noting there were no such instructions in the EMR and that she typically checked the ICCP to determine a resident's specific care requirements.On 6/24/26 at 10:39 AM, the surveyor interviewed the Director of Rehabilitation Therapy (DOR), who stated that Resident #144 required a two-person assistance for transfers. The DOR clarified that when a non-ambulatory resident was assessed by therapy as requiring a two-person assistance, they must be lifted and transferred via a mechanical lift to ensure the safety of both the resident and the staff.On 6/24/26 at 10:57 AM, the surveyor interviewed the MDS Coordinator, who explained that when a resident was assessed as dependent it meant that the resident required two or more staff members to assist with the task. The MDS Coordinator stated that Resident #144 required at least two or more staff members to assist with all transfers, meaning a mechanical lift should have been utilized. The MDS Coordinator confirmed that instructions specifying the need for a mechanical lift should have been included in Resident #144's care profile and ICCP.On 6/25/26 at 9:56 AM the surveyor interviewed LPN/UM #1, who confirmed that Resident #144 was dependent for ADLs and transfers, defining dependent care in this context as requiring a two-person mechanical lift. LPN/UM #1 explained that the CNAs review the resident care profile in the EMR to determine necessary care levels. However, LPN/UM #1 confirmed that Resident #144' s mechanical transfer requirements were missing from both the care plan and the resident's profile. LPN/UM #1 emphasized that documenting this information was critical to ensuring resident safety during transfers.A review of the facility policy dated 2/15/26, and titled Visual Electronic Medical Record Accessing a Resident Care Profile in Visual EMR, indicated that the purpose of the policy was to establish standardized, secure and compliant procedures for accessing a resident's Care Profile within the Visual EMR system. This ensures resident privacy, supports accurate documentation, and maintains compliance with HIPAA [Health Insurance Portability and Accountability Act] and facility confidentiality standards. The policy indicated that all entries must be accurate, timely.A review of the facility policy dated 5/14/25, and titled Person Centered Care Planning, indicated that the facility was responsible to develop, implement, maintain and update an individualized interdisciplinary, person-centered plan of care for every resident that supports the resident's highest practicable physical, mental and psychosocial well-being, resident's preferences and choices. The care plan findings would be based on assessment findings and resident needs.A review of the facility policy dated 2/2026, and titled Mechanical Lift, indicated that it was the policy to ensure the safe transfer and repositioning of residents requiring the use of a mechanical lift. Mechanical lifts shall be used in accordance with the residents' assessed needs, the individualized care plan, manufacturer's instructions, and current standards of practice to prevent injury to residents and staff. Safe use of mechanical lifts is an important component of accident prevention under CMS regulations. Purpose: Promote resident safety and comfort during transfers. Reduce the risk of falls, skin injury, and musculoskeletal injuries. Protect staff from lifting-related injuries. Ensure consistent, safe transfer practices. Staff Required: Two trained staff members shall be present during all mechanical lift transfers. One staff member operates the lift while the second guides and protects the resident throughout the transfer. This is considered the best practice and is commonly expected by surveyors to reduce transfer-related injuries.A review of the facility policy dated 5/2022, and titled Incidents and Accidents. indicated that the unit manager and staff nurse must ensure that an appropriate plan of care was implemented to prevent further reoccurrence to prevent further similar incidents or accidents from occurring.NJAC 8:39-27.1(a)

Based on interviews and a review of facility provided documents, it was determined that the facility failed to a). provide Saturday mail services to residents, and b) provide mail unopened. This deficient practice was identified for six (6) of six (6) residents interviewed during the Resident Council group meeting (Residents #12, # 47, 48, #62, #77, and #104) and was evidenced by the following:On 6/23/2026 at 10:30 AM, the surveyor conducted the Resident Council (RC) meeting with the residents referenced above. During RC, the surveyor asked the residents if they received their mail uponened and on Saturdays. Resident #12, #47, #48, #62, #77, and #104, all stated that they received their mail opened. They all further stated that they did not receive their mail on Saturdays.Resident #62 added that they had a package delivered, and they did not receive their package until two weeks after it was delivered. On 6/24/2026 at 10:12 AM, the surveyor interviewed the Activity Director (AD) who stated that the mail was distributed to the residents Monday through Friday. He added that he assigns someone to go around and distribute the mail once he receives it. He further stated that the mail should be handed to the residents intact unless the resident asked for assistance with opening the mail.On 6/24/2026 at 10:15 AM, the surveyor interviewed Activity Aide (AA) #5 who stated that the receptionist would get the mail first, then they gave it to the Admissions Director (AD). He added that the activity aide would then pick up the mail from the Admissions Director at 3 PM to deliver to the residents. He also stated that he did not check to see if the mail was intact at the time that he delivered it.On 6/24/2026 at 10:20 AM, the surveyor interviewed AD #2 who stated that mail was delivered to the facility Monday through Saturday. She stated that she worked at the facility Monday through Friday. She further stated that she was responsible for sorting the mail. AD #2 stated that she would bring the mail to her office, then she would separate the business office mail from the resident's mail. She added that the activity aide would get the mail at 3:00 PM to deliver it to the residents. She further stated that on her days off, the receptionist put all the mail on top of the mailboxes in the administrative area. She noted that the residents received their mail Monday through Friday, and the mail delivered on Saturdays was not delivered to the residents until Monday.On 6/26/2026 at 10:49 AM, the surveyor interviewed the Licensed Nursing Home Administrator who stated that the activities department hands out the mail to the resident's. He added that about six weeks ago, a resident reported to him that they received their mail opened. He stated that he believed that the staff no longer worked there at the facility. He added that he could not remember the staff's name. The LNHA further stated that the residents should get their mail unopened. He also stated that the recreation team works on Saturdays, so the residents should get their mail the day that it was delivered. A review of the facility's Resident Mail policy, reviewed June 6, 2025, included, .The facility supports each resident's right to send and receive mail promptly, privately, and without unnecessary delay, restriction, or censorship, in accordance with applicable federal and New Jersey regulations. Residents maintain control over personal correspondence unless restrictions are legally authorized.N.J.A.C. 8:39-4.1 (a)(19)

Based on interviews and review of pertinent documents provided by the facility, it was determined that the facility failed to implement their policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property by ensuring screening by reference checks were completed for newly hired employees. This deficient practice was identified for 53 out of 71 newly hired employee files reviewed.The deficient practice was evidenced by the following: On 6/25/2025 at 9:32 AM, Surveyor #1 reviewed 24 employee files, which revealed the following:1. Registered Nurse (RN #2), with a hire date of 7/1/2025, did not have a previous employment reference check on file.2. Activity Aide (AA #1), with a hire date of 5/2/2026, did not have a previous employment reference check on file.3. Certified Nursing Assistant (CNA #5), with a hire date of 7/9/2025, did not have a previous employment reference check on file.4. Smoking Monitor (SM #1), with a hire date of 7/28/2025, did not have a previous employment reference check on file.5. Dietary Aide (DA #1), with a hire date of 3/28/2026, did not have a previous employment reference check on file.6. SM #2, with a hire date of 3/11/2026, did not have a previous employment reference check on file.7. SM #3, with a hire date of 6/3/2025, did not have a previous employment reference check on file.8. Rehabilitation Therapist (RT), with a hire date of 6/4/2026, did not have a previous employment reference check on file.9. AA #4, with a hire date of 7/9/25, did not have a previous employment reference check on file.10. Director of Nursing (DON), with a hire date of 3/19/2025, did not have a previous employment reference check on file.11. CNA #7, with a hire date of 3/28/2025, did not have a previous employment reference check on file.12. DA #2, with a hire date of 3/19/2026, did not have a previous employment reference check on file.13. AA #2, with a hire date of 10/7/2025, did not have a previous employment reference check on file.14. AA #3, with a hire date of 1/21/2025, did not have a previous employment reference check on file.15. DA #4, with a hire date of 3/23/2026, did not have a previous employment reference check on file.16. DA #5, with a hire date of 2/7/2025, did not have a previous employment reference check on file.17. AA #4, with a hire date of 7/9/2025, did not have a previous employment reference check on file.18. DA #6, with a hire date of 7/11/2025, did not have a previous employment reference check on file.19. DA #7, with a hire date of 10/15/2025, did not have a previous employment reference check on file.20. CNA #8, with a hire date of 6/9/2025, did not have a previous employment reference check on file.21. DA #8, with a hire date of 3/28/2025, did not have a previous employment reference check on file. On 6/25/2025 at 9:30 AM, Surveyor #2 reviewed 47 employee files, which revealed the following:1. Speech-Language Pathologist (SLP), with a hire date of 9/8/2025, did not have a previous employment reference check on file.2. RS #1, with a hire date of 3/27/2026, did not have a previous employment reference check on file.3. HK #3, with a hire date of 10/20/2025, did not have a previous employment reference check on file.4. CNA #13, with a hire date of 10/17/2025, did not have a previous employment reference check on file.5. AA #7, with a hire date of 4/17/2025, did not have a previous employment reference check on file.6. AA #8, with a hire date of 3/9/2026, did not have a previous employment reference check on file.7. AA #12, with a hire date of 7/12/2025, did not have a previous employment reference check on file.8. SM #6, with a hire date of 1/24/2025, did not have a previous employment reference check on file.9. CNA #19, with a hire date of 7/24/2025, did not have a previous employment reference check on file.10. AD #2, with a hire date of 12/9/2025, did not have a previous employment reference check on file.11. AA #14, with a hire date of 4/9/2026, did not have a previous employment reference check on file.12. AA #15, with a hire date of 1/9/2026, did not have a previous employment reference check on file.13. DA #15, with a hire date of 1/20/2026, did not have a previous employment reference check on file.14. DA #16, with a hire date of 5/27/2026, did not have a previous employment reference check on file.15. AA #10, with a hire date of 12/29/2025, did not have a previous employment reference check on file.16. AA #11, with a hire date of 2/20/2026, did not have a previous employment reference check on file.17. DA #17, with a hire date of 5/28/2026, did not have a previous employment reference check on file.18. LPN #7, with a hire date of 8/7/2025, did not have a previous employment reference check on file.19. CNA #15, with a hire date of 3/31/2025, did not have a previous employment reference check on file.20. DA #14, with a hire date of 3/19/2026, did not have a previous employment reference check on file.21. DSS, with a hire date of 3/3/2026, did not have a previous employment reference check on file.22. RT #2, with a hire date of 8/15/2025, did not have a previous employment reference check on file.23. CNA #16, with a hire date of 5/12/2025, did not have a previous employment reference check on file.24. AA #16, with a hire date of 1/27/2025, did not have a previous employment reference check on file.25. CNA #14, with a hire date of 6/25/2025, did not have a previous employment reference check on file.26. SS #1, with a hire date of 10/12/2026, did not have a previous employment reference check on file.27. DA #10, with a hire date of 8/22/2025, did not have a previous employment reference check on file.28. RS #2, with a hire date of 1/16/2025, did not have a previous employment reference check on file.29. DA #12, with a hire date of 11/14/2025, did not have a previous employment reference check on file.30. SM #4, with ahire date of 6/4/2025, did not have a previous employment reference check on file.31. DA #13, with a hire date of 1/10/2025, did not have a previous employment reference check on file.32. AA #9, with a hire date of 6/5/2025, did not have a previous employment reference check on file.On 6/26/2026 at 10:35 AM, during an interview with Surveyor #1, the Director of Human Resources and Staffing Coordinator (DHR/ SC) stated that they had been responsible for the employee files for the last five years. DHR/ SC stated that the department heads checked the references for newly hired employees and reviewed the employee files. DHR/ SC further stated that they checked these files for completion when the department heads turned the employee files over to them. DHR/ SC stated that employment reference checks were very important.On 6/26/2026 at 11:29 AM, during a telephone interview with the survey team, the Medical Director (MD) stated that it was important for the facility to complete reference checks to know where the applicants came from.A review of facility policy dated 1/1/2026, titled Reference Verification included under Policy the following: The facility will conduct reference verification for all prospective employees prior to hire. Under Procedure, the following documentation requirements for references were listed: date reference was completed, name and title of individual providing reference, organization, summary of findings, staff member completing verification, and hiring determination. N.J.A.C. 8:39 - 9.3 (b)

Based on interviews and observation it was determined that the facility failed to consistently serve food at temperatures preferred by residents. Seven of 7 residents at the Resident Group Meeting complained of undesirable food temperatures. The deficient practice was evidenced by the following:On 6/23/2026 at 10:30 AM, the surveyor conducted a group meeting with 7 (seven) residents to discuss resident concerns. 7 out of 7 residents stated that food trays were not covered during transport and the meals were cold. The resident also stated that it took the Certified Nursing Assistance (CNAs) 15- 20 min to pass out the meal trays.On 6/24/2026 at 11:35 PM, the surveyor observed the Regional Food Service Director (FSD) calibrate with thermometer to measure food temps on the steam table at lunch. The surveyor observed that the food carts used to deliver food trays to the units were open carts. The Food Service Director stated that the carts were open and that a pellet system was not utilized in the facility. The surveyor also observed that the plates sit on plastic bottoms and covered with plastic dome covers during transport to the units.On 06/24/2026 at 12:15 PM, the surveyor observed the Chef obtain base food temps with the FSD on the steam table. The Chef stated that acceptable temps should be between 165-180 degrees for hot foods and 41 degrees and below for cold foods.Food temperatures were as follows on the steam table: -Ground meat: 180 degrees-Sloppy [NAME]: 180 degrees-Vegetables peas and carrots: 190 degrees-potato Tots: 122 degrees-chicken tenders: 144 degrees On 6/24/2026 at 12:30 PM, the surveyor observed the lunch meal tray leave the kitchen to the second floor. On 6/24/2026 at 12:31 PM, the staff immediately retrieved the trays from the elevator and started to pass out the meal trays to the residents. On 6/24/2026 at 12:36, the surveyor observed the last meal tray was handed out, and the FSD retrieved the test tray off the cart and began to take food temps. The food temperatures were as follows:-Sloppy [NAME]: 120 degrees-Vegetables carrots and peas: 40 degrees-Tator Tots: 100 degrees-Applesauce: 45 degrees-apple juice: 46 degreesOn 6/25/2026 at 9:37 AM, the surveyor interviewed the Chef who stated the food may be cold when it arrived on the units because there used to be a metal heating element that was placed inside the bottom of the plastic plate holder, however, they have not been available for quite some time. The Chef did not provide a time frame for how long the heating element had been missing and told the surveyor to question the administrator. He did state that the heating elements had been ordered.On 6/25/2026 at 10:11 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had no complaints from residents regarding cold food temps. The DON stated that she was not aware that the metal heating elements were missing. On 6/25/2026 at 12:10 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the heating elements for the food plates have been missing approximately 1 month and were ordered a month ago.A review of the facility policy dated 11/10/2025 and titled, Food Preparation indicated that the facility would prepare all foods in a clean, safe, and sanitary manner. Staff must follow proper hygiene, temperature control, and cross-contamination prevention practices to protect residents from foodborne illnesses. The policy specifies that temperature control to keep foods hot was above 140 degrees and to keep foods cold is less than 40 degrees.A review of the facility policy dated 9/2/2025 and titled, Food Temperatures indicated that hot foods must be maintained at 135 degree or above and cold foods must be maintained at 41 degrees or below.NJAC 8:39-4.1

Based on observation, interviews, and pertinent facility documentation, it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning. This deficient practice was identified on 2 of 3 floors (Second and Third Floors).This deficient practice was evidenced by the following:On 6/23/2026 at 10:30 AM, during the resident council meeting, one of the six residents stated that the call bells did not always work.On 6/24/2026 at 10:59 AM, the surveyor, accompanied by LPN/UM #1 toured the Third Floor Nursing Unit. The surveyor observed the following:room [ROOM NUMBER]-B call bell was activated. It registered at the nurse's station as 321-A.room [ROOM NUMBER]-A call bell was activated. It registered at the nurse's station as 321-B.room [ROOM NUMBER]-B call bell was activated. The call bell light indicator located in the hallway over the resident's door did not light up to indicate that the call bell system was activated. It registered at the nurse's station as 323-A.room [ROOM NUMBER]-A call bell was activated. It registered at the nurse's station as 323-B.room [ROOM NUMBER]-A call bell was activated. It registered at the nurse's station as 306-B.On 6/24/2026 at 11:31 AM, the surveyor interviewed the LPN/UM #1 who stated that the call bells should be in proper working condition so the residents can call them if they need help. She further stated that she was not aware that this was going on. She added that a company was there working on the call bells, but she did not remember when.On 6/24/2026 at 12:18 AM, the surveyor, accompanied by Registered Nurse/Unit Manager (RN/UM) #1 toured the Second Floor Nursing Unit. The surveyor observed the following:room [ROOM NUMBER]-A call bell was activated. The call bell light indicator located in the hallway over the resident's door did not light up to indicate that the call bell system was activated. The surveyor and RN/UM #1 went to the nurse's station, the call bell did not register. RN/UM stated that she was going to notify the maintenance department and provide the resident with a tap bell.The surveyor returned to room [ROOM NUMBER]-A to interview the resident. Resident #19 stated that if they needed help they would tell their roommate to get someone to assist them.On 6/24/2026 at 12:28 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) # 12 who stated that she made rounds every 2 hours. She added that the call bell system located at the nurse's station would indicate when a call bell was activated. She further stated that the light over the outside of the door would indicate that a resident needed assistance.On 6/24/2026 at 12:49 PM, the surveyor conducted a follow-up interview with RN/UM #1 who stated that they used to have a call bell system at the nurse's station that would indicate the resident's room number who needed help, but they no longer have that system. She stated that the system that they currently have, the staff would have to look up and down the hallway over the resident's door to see which light was on.On 6/24/2026 at 1:13 PM, the surveyor interviewed the Maintenance Director who stated that to his knowledge, all the call bells were in good working condition. He stated that he checked all the call bells monthly. He stated that during the monthly checks, he did not check to ensure that the call bells registered at the nurse's station accurately. He added that it was important for the call bells should be in good working condition to make sure the residents received assistance when they needed it.On 6/26/2026 at 10:49 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the call bells should be in good working condition and if any call bell was not working, the resident should be given a tap bell right away. He further stated that on the Third Floor Nursing Unit, they have a phone that should ding and show the correct room and bed number. He added that he wanted to update the whole system.A review of the facility's Call Light Response policy, dated March 10, 2025, included Equipment malfunctions will be reported immediately and repaired promptly. NJAC 8:39-31.2(e)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) ensuring that the resident's wheelchairs were cleaned and repaired in a timely manner, b.) maintain a homelike environment that was clean, safe, sanitary and free from damage. This deficient practice was identified for 3 of 3 Floors (Floor #1, Floor #2 and Floor #3) and was evidenced by the following:1.) On 6/23/2026 at 9:38 AM, Surveyor #1 was touring 3rd floor and observed Resident #91 sitting in the activities room in their wheelchair. The resident's wheelchair was observed to be visibly soiled with a pink colored substance on the right side of the cushion and the parking brake. Surveyor #1 also observed what appeared to be cobwebs, a large amount of grey hair, and dust covering the metal parts beneath the wheelchair. On 6/24/2026 at 10:06 AM, Surveyor #1 conducted a second observation of Resident #91 sitting in their wheelchair in the activities room. Surveyor #1 observed that the wheelchair was still visibly soiled with cobwebs, a large amount of grey colored hair, and dust were present on the metal parts and underneath the wheelchair. Surveyor #1 again observed a pink colored substance on the right side of the cushion and on the parking brake. The wheels on the wheelchair were visibly soiled as well with what appeared to be food particles and dust. On 6/24/2026 at 10:17 AM, Surveyor #1 interviewed the Certified Nursing Assistant (CNA #10) who confirmed the wheelchair was dirty and needed to be cleaned. The CNA said if he had noticed the wheelchair was soiled, he would have reported it to the nurse, and he would have tried to clean the wheelchair to the best of his ability. On 6/24/2026 at 10:22 AM, Surveyor #1 interviewed Licensed Practical Nurse (LPN#2) who verified the wheelchair was soiled. LPN #2 stated if she noticed the wheelchair was dirty, she would get a spare wheelchair from physical therapy for the resident to use while housekeeping cleaned the wheelchair. LPN#2 stated the wheelchairs were cleaned monthly. On 6/24/2026 at 10:30 AM, Surveyor #1 interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #3) who confirmed the wheelchair was soiled and needed to be cleaned. LPN/UM #3 indicated the housekeeping department was responsible for cleaning the wheelchairs, but she did not know how often they were cleaned. On 6/24/2026 at 10:45 AM, Surveyor #1 interviewed the Maintenance Director (MD) who verified the wheelchair was soiled and needed to be cleaned. MD stated that maintenance did not clean the wheelchairs, it was housekeeping's responsibility to clean them. MD indicated he did not know how often housekeeping cleaned them. On 6/24/2026 at 10:55 AM, Surveyor #1 interviewed the Housekeeping Director (HKD) who confirmed the wheelchair was soiled and needed to be cleaned. HKD further stated the facility had a wheelchair cleaning calendar, and wheelchairs were cleaned every Tuesday and Wednesday. HKD could not find the calendar and stated he would look for it. HKD said he did not have a log to track when the cleanings are done. On 6/24/2026 at 11:05 AM, Surveyor #1 interviewed a housekeeper (HK#1) who confirmed the wheelchair was dirty and needed to be cleaned. HK#1 stated the housekeepers did not clean the wheelchairs; it's the HKD who cleaned them weekly. HK#1 further stated the housekeepers only cleaned the wheelchairs if there was an emergency such as urine or bowel movement on them. HK#1 did not know the schedule of when the wheelchairs were cleaned. On 6/24/2026 at 11:11 AM, Surveyor #1 interviewed a housekeeper (HK#2) who indicated he was not sure how often the wheelchairs were cleaned. HK#2 stated he knew there was a wheelchair cleaning schedule posted outside the housekeeping office and claimed that if he saw a soiled wheelchair he would let the HKD know, because the HKD was the person who cleaned them. On 6/25/2026 at 11:41 AM, Surveyor #1 interviewed the Director of Nursing (DON) who was shown a picture of Resident #91's dirty wheelchair and the DON confirmed the wheelchair was dirty and needed to be cleaned. DON stated that housekeeping cleaned the wheelchairs and there was a wheelchair cleaning calendar although she was not exactly sure how often they were cleaned, but she would find out. A review of the facility's policy titled Homelike Environment, dated February 11, 2026. The purpose of this policy is to ensure that the facility provides a comfortable, welcoming, and homelike environment that supports resident dignity, independence and well-being. In section Policy: Cleanliness & Order. A review of the facility's policy titled Wheelchair Cleaning, dated June 6, 2025, Section; Purpose: To establish a standardized process for cleaning and disinfecting resident wheelchairs to reduce the risk of infection transmission, maintain resident safety, and comfort, and preserve wheelchair function. Section: Policy: Shore Gardens Rehabilitation and Nursing Center are committed to maintaining resident wheelchairs in a clean, sanitary, and safe condition through routine scheduled cleaning. Wheelchairs needing additional cleaning will be addressed on an individual basis. 2.) On 06/22/2026 at 5:36 PM during initial tour of the first floor, Surveyor #2 entered resident room [ROOM NUMBER] side A. Surveyor #2 observed the white molding above Resident #146's bed to be split on an angle along the length of the molding. Surveyor #2 interviewed Resident #146 who told the surveyor that the molding had been split since he/she had been in the room and indicated they had been in the room, approximately 3 weeks. On 06/24/2026 at 12:31 PM, Surveyor #2 observed the white molding above the bed on the A side of room [ROOM NUMBER] continues to be split on an angle along the length of the molding. On 06/24/2026 at 12:33 PM, Surveyor #2 interviewed LPN #5 who stated that the staff would alert maintenance if they observed something that needed repair and that facility had a digital reporting system to report repair needs. LPN #5 stated that she was unaware of the damaged molding and was unsure how long the molding had been damaged. On 06/24/2026 at 12:42 PM, Surveyor #2 interviewed LPN/UM #2 who stated that they were unaware of the damaged molding, and they would enter into the digital reporting system to have the molding repaired. On 06/24/2026 at 1:56 PM, Surveyor #2 interviewed the Maintenance Director (MD) who stated that staff alerted maintenance of repair needs through the digital reporting system which would produce a work order for the repair. The MD explained that environmental checks were done weekly throughout the interior and exterior of the building. The MD further stated that once the checks were completed a list was compiled of the findings. The MD stated that there was not a work order for the molding repair and he was unaware of the damaged molding. The MD confirmed that there should not be damaged molding in resident rooms and further stated that somebody hit that [molding] hard. On 06/25/2026 at 11:14 AM, Surveyor #2 interviewed the Assistant Director of Nursing/ Infection Preventionist (ADON/IP) who stated that an ambassador rounds program had been implemented by the department heads which included a survey of the entire building. The ADON/IP further stated that upon completion of the rounds, a list of the findings was compiled and provided to the corresponding department. The ADON/IP answered that building repairs were entered into the digital reporting system. The ADON/IP responded that there should, absolutely not, be any damaged molding found in resident rooms. The ADON/IP confirmed that this was important because it was not homelike and could present a safety or infection control hazard. 3.) On 6/24/26 at 12:21 PM, Surveyor #3, accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM) #3, toured the second floor and observed a football-sized damaged sheet rock over the head of the bed for resident room [ROOM NUMBER]-A. The same area of damaged sheet rock contained a hole slightly larger than a baseball. At that time, Surveyor #3 interviewed the unsampled resident who stated that the damage to the wall was there when they moved into the room approximately two weeks ago. They stated that the resident who previously resided in the room had damaged the wall. Surveyor #3 also toured the resident's bathroom and observed the black baseboard molding falling off the wall. At that time, Surveyor #3 interviewed LPN/UM #3 who stated that the condition of the black baseboard could be a potential tripping hazard. On 6/24/2026 at 1:13 PM, Surveyor #3 interviewed the Maintenance Director (MD) who stated that it was not reported to him that the wall was damaged, and he was also unaware that the baseboard was falling off in room [ROOM NUMBER]'s bathroom. He further stated that the wall and baseboard should be intact to create a home-like environment for the residents. A review of the facility provided policy titled Homelike Environment dated 02/11/2026 revealed under purpose that . ensure that the facility provides a comfortable, welcoming and homelike environment that supports resident dignity independence and well-being. The policy further revealed under Cleanliness & Order that The facility will maintain clean, orderly and pleasant living and common areas. N.J.A.C. 8:39-31.4 (a) NJAC 8:39-31.4 (a), (f) NJAC 8:39.2 (e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide incontinence care to one of three residents (Resident #29) who were unable to carry out activities of daily living (ADLs) and were dependent on staff. This deficient practice was identified for 1 of 3 residents observed during an incontinence tour on one of three floors (Third Floor). This deficient practice was evidenced by the following:On 6/25/2026 at 9:22 AM, the surveyor conducted incontinence rounds with Licensed Practical Nurse Unit Manager (LPN/UM#2) on the third floor. The surveyor observed Resident #29 lying in bed. Resident #29 was interviewed at this time and stated that they were wet with urine and needed their brief changed. The resident revealed that they were last changed at 5:00 AM and further stated that they had to wait a long time to get changed, sometimes up to 8 hours on the evening and night shift.At that time, with the resident's permission, LPN/UM #1 checked the resident's brief. LPN/UM #1 opened the resident's brief and confirmed that it was soiled with urine. LPN/UM #1 stated that she was going to inform the resident's Certified Nursing Assistant (CNA) to change them. Resident #29 stated that they were told by an 11-7 CNA that they do not do second changes, they only change the resident one time during the shift. Resident #29 further added that they reported it to the social worker, but nothing was done about it. The surveyor reviewed the electronic medical record (EMR) for Resident #29.A review of the admission Record (an admission summary) revealed the resident had diagnoses which included but was not limited to urinary tract infection.A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 4/29/2026, revealed that Resident #29's Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15, which indicated that the resident's cognition was intact. The MDS further revealed that the resident was always incontinent of urine and required substantial assistance with toilet transfers and toilet hygiene.A review of the Individualized Comprehensive Care Plan (ICCP) included a focus care area dated 4/29/2025 that indicated Resident #29 was at risk for skin breakdown. The interventions included keeping the skin clean and dry. The ICCP further revealed a care area dated 4/29/2025, that the resident was at risk for falls. The intervention included responding promptly to the residents request for assistance to toilet. The ICCP also included a care area dated 5/9/2025 that Resident #29 was at risk for developing a skin impairment. The intervention included prompt incontinence care.On 6/25/2026 at 9:58 AM, the surveyor interviewed CNA #9 who stated that the resident should be checked every two hours to see if their brief needed to be changed.On 6/26/2026 at 11:02 AM, the surveyor interviewed the Assistant Director of Nursing who stated that after assignments were provided to the CNAs, they should make incontinent rounds on their residents. She stated that toileting should be offered after meals and that residents identified as a fall risk should be checked every two hours and changed as needed.A review of the facility's undated Incontinence Care policy included, .All residents are washed and cleaned after each episode of incontinence. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to perform wound care as ordered by the physician for a resident with bilateral foot wounds. This deficient practice was identified in 1 of 1 residents reviewed for wound care (Resident #8) and was evidenced by the following: On 6/22/26 at 7:00 PM, the surveyor went to see Resident #8, the resident was in the bathroom at that time but stated they had no concerns. On 6/23/2026 at 10:20 AM, the surveyor observed Resident #8 in the room in a wheelchair. On each foot the resident had a large white bandage. The bandages on each foot had a label which was dated 6/21/26. Resident #8 told the surveyor the wound care was not completed yesterday and the nurse today said she would be in to do the wound care.A review of the admission Face Sheet revealed Resident #8 was admitted to the facility with diagnoses which included but were not limited to cellulitis of right and left lower limb, hypertension, muscle weakness, and alcohol abuse. A review of the Physician Order Form showed an order dated 5/29/26 to cleanse right foot, second toe with normal saline solution, pat dry, paint with Betadine then cover with non-adhering dressing daily. Another order dated 5/29/26 was to cleanse left foot, third toe with normal saline solution, pat dry, paint with Betadine then cover with non-adherent dressings daily. Both remained active orders. A review of the Individualized Comprehensive Care Plan (ICCP) showed a focus of actual skin breakdown initiated 5/22/26. Interventions included but were not limited to weekly skin assessments, apply ace wrap to left lower leg from toes to knees daily, and notify physician and family of any change in condition. A review of the admission Minimum Data Set (MDS), an assessment tool revealed the resident had a Brief Interview of Mental Status (BIMS) of 12/15, meaning the resident had moderate cognitive impairment. Section M of the MDS for skin conditions indicated the resident was receiving application of nonsurgical dressings to feet, with or without topical medication. A review of the Treatment Administration Record (TAR) had wound treatment to the right and left toe for the staff to sign following providing treatment. The wound care was signed as completed for 6/22/26 and 6/23/26. On 6/23/26 at 1244 PM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1) entered Resident #8 room to observe the residents' dressing to the feet. The surveyor pointed out the dates on the dressings of 6/21/26. The nurse stated, That's when I did them on Sunday. The surveyor asked how often they should be changed, and she said, Daily, I can't speak to why they didn't do them. On 6/25/26 at 11:15 AM, the surveyor informed the Director of Nursing (DON) of the wound care not being completed. She told surveyor she would reach out to the staff that were responsible.The surveyor reviewed the policy titled, Wound Care Management, dated 11/12/25. The policy stated that the facility would provide a systematic evidenced based approach to the prevention, assessment, treatment, and monitoring of wounds to promote healing, prevent complications, and improve quality of life. Under the wound treatment section of the policy, it indicated that the wound treatment was to be completed according to physician's orders.NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) follow physician orders by changing a residents urinary drainage bag weekly as ordered and b.) failing to use a privacy bag for resident dignity. This deficient practice was identified in 2 of 2 residents reviewed for urinary catheters (Resident #69 and #130) and was evidenced by the following: On 6/23/26 at 10:15 AM, the surveyor observed Resident #69 in bed. The resident told the surveyor they had a catheter and only used a leg bag. No urinary drainage bag was visible to the surveyor. A review of the admission Face Sheet revealed Resident #69 was admitted to the facility with diagnoses which included but were not limited to, altered mental status, chronic kidney disease, hypertension, and retention of urine. A review of the Physician Order Form showed an order to change suprapubic catheter every month, dated 5/22/26 and an order to change the suprapubic catheter bag one time per week dated 4/22/26. Both orders remained active orders. A review of the Individual Comprehensive Care Plan (ICCP) showed a focus of impaired urinary elimination related to the urinary catheter initiated on 4/1/26. Interventions included but were not limited to, monitor for signs of urinary tract infection, measure urine output, and change drainage bag weekly and as needed. A review of the Significant Change Minimum Data Set (MDS) an assessment tool dated 4/27/26 revealed Resident #69 had a Brief Interview of Mental Status (BIMS) of 14/15, meaning the resident was cognitively intact. Section H of the MDS for bowel and bladder indicated the resident had an indwelling catheter. A review of the Treatment Administration Record (TAR) showed the treatment order to change the urinary drainage bag weekly. The resident was scheduled to have it changed on 6/7/26, 6/14/26, and 6/21/26. The three days that the bag was to be changed were blank, meaning not signed by the nursing staff as completed. On 6/25/26 at 09:51 AM, the surveyor interviewed second floor Licensed Practical Nurse (LPN#6) regarding urinary drainage bags. LPN #6 said the bags are changed based on the physician orders and get documented in the TAR and it should be added into the progress notes. On 6/25/2026 at 10:00 AM, the surveyor met with Resident #69 in the room. The resident was fully dressed and wearing blue jeans. The resident told the surveyor they used a leg bag day and night. The surveyor asked if the staff changed the urinary drainage bag and the resident told the surveyor that they change the bag every two weeks. The surveyor asked if the bag was dated and the resident stated no. On 6/25/26 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) regarding the residents blank TAR. The DON stated it should have been done. The surveyor asked why changing the bag was important and she stated, There would be a risk for infection. The surveyor reviewed the policy titled, Urinary Drainage Bag Management, dated 4/12/25. The policy purpose was to ensure safe management of urinary drainage bags and urinary drainage systems to reduce the risk of catheter associated urinary tract infections. The policy did not include changing the urinary drainage bags. On 06/23/2026 at 10:19 AM, Resident #130 was observed lying in bed watching television. Surveyor #2 observed Resident #130's urinary drainage bag in a privacy bag attached to the base of the right side of the resident's bed, in contact with the floor. On 06/24/2026 at 10:17 AM, Resident #130 was observed sleeping in bed, the resident's urinary drainage bag was observed attached to the base of the right side of the resident's bed, not in the privacy bag, visible from the hallway. At that time, Surveyor #2 observed the privacy bag attached to the base of the right side of the resident's bed positioned behind the urinary drainage bag. On 06/24/2026 at 2:11 PM, Resident #130 was observed sleeping in bed, the resident's urinary drainage bag was observed attached to the base of the right side of the resident's bed, not in the privacy bag, visible from the hallway. At that time, surveyor #2 observed the privacy bag attached to the base of the right side of the resident's bed positioned behind the urinary drainage bag. A review of the admission Face Sheet revealed Resident #130 was admitted to the facility with diagnoses which included but were not limited to; obstructive and reflux uropathy (blockage and backward urine flow) and urinary tract infection. A review of Resident #130's Physician Order Form showed an active order to apply urinary drainage privacy bag to drainage system at all times when in bed, dated 05/19/26. A review of the Individual Comprehensive Care Plan (ICCP) showed a focus of impaired urinary elimination related to the urinary catheter initiated on 05/19/26. Interventions included but were not limited to, apply leg bag when out of bed if resident agrees, privacy bag in place at all times. A review of the Quarterly Minimum Data Set (MDS) an assessment tool dated 05/04/26 revealed Resident #130 had a Brief Interview of Mental Status (BIMS) of 14/15, meaning the resident was cognitively intact. Section H of the MDS for bowel and bladder indicated the resident had an indwelling catheter. A review of the Treatment Administration Record (TAR) showed the treatment order; privacy bag applied to drainage system at all times when in bed. The task was documented as completed on 06/24/2026 for the 07:00 AM to 2:59 PM shift. On 06/24/2026 at 2:12 PM during an interview with surveyor #2, Certified Nursing Assistant (CNA) #4 responded, the urinary drainage bags should be attached to the side of the resident's bed in a privacy bag when the resident is in bed. On 06/25/2026 at 11:14 AM during an interview with surveyor #2, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) answered the urinary drainage bag should be stored below the resident's bladder. The ADON/IP further answered yes, when asked if the urinary drainage bag should be in a privacy bag. The ADON/IP responded it was necessary to keep the urinary drainage bag in the privacy bag to maintain a resident's dignity. A review of the policy titled, Urinary Drainage Bag Management dated April 12, 2025, revealed, General Requirements; Verify physician/authorized practitioner orders for catheter use, . maintain resident privacy and dignity during all care. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure medical supplies were stored in accordance with professional standards by having loose, unidentified pills found in the drawer of a medication cart. The deficient practice was identified in 2 of 3 medication carts reviewed under the Medication Storage Task. The deficient practice was evidenced by the following:On 06/23/2026 at 12:44 PM, the surveyor inspected the first-floor medication cart in the presence of the Licensed Practical Nurse (LPN) #5 and observed three (3) loose, unidentified whole pills and one (1) loose, unidentified half pill in the medication cart drawers.At that time, the surveyor interviewed LPN # 5 who stated that there should be no loose pills found within the medication cart. The surveyor observed LPN#5 discard the loose pills. LPN stated that the medication carts were checked each shift for loose pills, and it was important to ensure there were no loose pills so that the residents received the correct medication. On 06/23/2026 at 1:01 PM, the surveyor inspected the third-floor low side medication cart in the presence of the Licensed Practical Nurse (LPN) #2 and observed 11 loose, unidentified whole pills and 1 loose unidentified separated capsule in the medication cart drawer. At that time, the surveyor interviewed LPN #2 who confirmed that there should be no loos pills found within the medication cart. LPN #2 further revealed that they were unsure how often the carts should be cleaned of loose pills but that she tried to do it as often as possible because it is unsanitary and unsafe.On 06/25/2026 at 11:14 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) answered absolutely not when asked if there should be loose pills found in the medication carts. The ADON/IP confirmed that the carts should be checked for loose pills every shift and when found should be disposed of with a gloved hand and disposed of in the pharmaceutical waste disposal system. The ADON/IP acknowledged that it was important to ensure there were no loose pills in the medication cart to prevent cross contamination and for the safety of both the residents and the staff. A review of the policy titled, Medication Labeling & Storage, dated March 2, 2026, revealed under, Medication Cart Standards, that Medication carts must: . be maintained in a clean and sanitary fashion, Not contain unlabeled containers/medications. N.J.A.C. S 8:39-29.4 (a)(b)2

Based on observation, interview and review of facility meal tickets, it was determined that the facility failed to ensure the preferences on the meal tickets were followed for 2 of 2 residents (Resident #47 and #62) observed for food concerns. This deficient practice was evidenced as follows:On 6/23/2026 at 12:25 PM, the surveyor conducted a dining observation on the first floor and observed a Certified Nursing Assistant (CNA) place Resident #62's lunch tray in their room. Resident #62 was observed sitting on their bed with the lunch tray on the overbed table.A review of Resident #62's meal ticket included, but was not limited to, 16 ounces of whole milk, 8 ounces of assorted juice, 16 ounces of coffee, and tartar sauce.Resident #62's lunch tray consisted of a 4-ounce milk carton, 4-ounce juice container, an 8 oz cup of coffee, and no tartar sauce.On 6/23/2026 at 12:33 PM, the surveyor returned to the resident's room accompanied by LPN/UM #2 who confirmed the findings and stated that Resident #62 should have gotten 16 ounces of milk, 8 ounces of juice, another cup of coffee and that they were missing tartar sauce.On 6/23/2026 at 12:41 PM, the surveyor observed Resident #47's meal ticket which included double portions and dietary fluid restriction, 240 milliliters (ML), 6 oz juice, no milk, and no coffee. Resident #47's meal tray included one (1) serving of pork, seasoned spinach. potatoes, 4 oz of juice and milk, and a cup of coffee.On 6/23/2026 at 12;53 PM, the surveyor, accompanied by LPN/UM #2 returned to Resident #47's room. LPN/UM #2 confirmed the surveyor's findings. At that time, Resident #47 adamantly stated that they did not want coffee or milk on their tray. LPN/UM #2 stated that she was going to correct the resident's lunch tray. On 6/23/2026 at 12:50 PM, the surveyor interviewed the CNA who stated that all the lunch trays were accurate. He stated that he double checked the meal tray to make sure it was accurate before giving it to the resident. He added that if the tray was inaccurate, they would return it to the kitchen. On 6/23/2026 at 12:53 PM, the surveyor conducted a follow-up interview with LPN/UM #2 who stated that the nurse and aide distributed the meal trays to the residents and were responsible to ensure the resident received everything on the meal ticket. She explained that if the tray was incorrect, the CNA would go to the kitchen to have it corrected. She stated that the residents should receive what they are supposed to receive to ensure proper nutritional intake and stable weight.On 6/26/2026 at 10:49 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that all meal trays should be accurate and in accordance with the resident's preference.A review of the facility's Tray Accuracy policy dated March 14, 2025, included It is the policy of the facility to provide each resident with the correct meal tray that is consistent with the physician/provider orders, prescribed diet, texture modifications, allergies, food preferences when applicable. Nursing staff will review trays for residents receiving therapeutic diets . NJAC 8:39-17.2(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that staff followed appropriate infection control practices for hand hygiene between residents for 2 of 5 residents (Residents #65 and #54) by 1 of 3 nurses observed during the medication pass. This deficient practice was evidenced by the following.On 06/24/2026 at 8:47 AM, the surveyor observed LPN #3 prepare Resident #65's medications and administer the medication to the resident. Following the administration of Resident #65s medications, LPN #3 did not perform hand hygiene before proceeding to Resident #54's room. On 06/24/2026 at 8:55 AM, the surveyor observed LPN #3 prepare Resident #54's medication without performing hand hygiene. LPN #3 entered Resident #54's room and informed the resident that she was preparing to administer medications and needed to obtain the resident's blood pressure prior to medication administration. LPN #3 obtained Resident #54's blood pressure and returned the blood pressure cuff to the medication cart. LPN #3 stated that she would sanitize the blood pressure cuff later. LPN #3 then administered Resident #54's medication. The surveyor confirmed that LPN #3 did not perform hand hygiene after administering medications to Resident #65 or before providing care and administering medications to Resident #54. On 06/24/2026 at 9:07 AM, the surveyor interviewed LPN #3 who acknowledged that hand hygiene should be performed between residents during medication administration. When asked whether she had performed hand hygiene after administering medications to Resident #65 and before administering medications to Resident #54, LPN #3 stated that she had not. LPN #3 further acknowledged that hand hygiene was necessary to prevent the transmission of infection. On 06/25/2026 at 11:14 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who confirmed that hand hygiene should be performed before and after the preparation and administration of medications. The ADON/IP further responded that this was necessary to prevent the transmission and spread of infection. A review of the facility provided policy titled, Hand Hygiene dated 04/15/2025 revealed under Procedure that Staff shall perform hand hygiene; before: . preparing medications. A review of the facility provided policy titled, Infection Control dated 01/01/2026 revealed under Procedure; 1. Standard Precautions (all residents); Staff will: Perform hand hygiene before resident contact, after resident contact. NJAC 8:39 -19.4 (a) (l)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the influenza vaccination was offered to residents upon admission to the facility for 1 of 11 residents (Resident #77) reviewed for immunizations. This deficient practice was evidenced by the following:Reference:Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly ReportPrevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2024-25 Influenza SeasonRecommendations and Reports / August 29, 2024 / 73(5);1-25Routine annual influenza vaccination of all persons aged >6 months who do not have contraindications continues to be recommended. All persons should receive an age-appropriate influenza vaccine (one that is approved for their age)On 6/23/2026 at 10:30 AM, during a resident council meeting, Resident #77 stated that they did not receive the influenza vaccination despite their request. They further stated that they were told that Tamiflu was available should they need it.On 6/25/2026 at 12:37 PM, the surveyor requested that the ADON/IP review Resident #77's electronic medical record (EMR). The ADON/IP confirmed that the influenza vaccine was not administered to Resident #77 and a declination form for the 2025/2026 flu season was not available. She stated that the resident should have been offered the influenza vaccination because they were eligible. The ADON/IP was unable to provide any evidence that the resident was offered the influenza vaccination. She added that if the resident refused, there would be a signed declination. She added that it was important for them to receive the influenza vaccination for infection control purposes. A review of the admission Record, an admission summary, revealed Resident #77 had diagnoses which included, but were not limited to: chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes restricted airflow and breathing difficulties).A review of the Physician's Orders (PO) included an order dated 1/7/2026 for Tamiflu oral capsule 75 MG, prophylaxis (any medical or preventive measure taken to guard against disease, infection, or a specific medical condition before it occurs).The IP failed to provide the surveyor with the resident's immunization report. A review of the facility's undated 'Influenza Vaccine policy included All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.Between October first and March 31 each year, the influenza vaccine shall be offered to residents and employees. N.J.A.C. 8:39-19.4 (h)

Complaint #: 374226Based on interviews, review of medical records, and review of other pertinent facility documents on 12/30/2025, it was determined that the facility failed to ensure that residents received care and services necessary to attain or maintain the highest practicable physical well-being, in accordance with professional standards of practice, by failing to properly assess, acknowledge pain, monitor, notify provider, and implement appropriate interventions for an identified unwitnessed fall and femur fracture.This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), as evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: dementia.According to the Minimum Data Set (MDS), an assessment tool dated 02/23/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score that was not completed. Section C0100 reveals code 0 0. No (resident is rarely/never understood) - Skip to and complete staff assessment that reveals resident #1 has long and short-term memory problems.A review of Resident #1's Progress Note (PN) dated 4/3/25 at 3:36 P.M., reveals Late entry 04/02/2025 At around 8pm, this writer [License Practical Nurse #1] was called by one of the residents. I observed [Resident #1] lying/sitting on the floor inside [their] room, upper body leaning halfway on a regular chair. [Resident #1] cannot give accurate statement at this time. Assessment done with no visible injury noted; however c/o [complains of] pain on [their] left leg; no swelling, no redness or any signs of trauma noted. Resident offered pain medications but refused x 3. [Resident #1] assisted to bed; no s/s of acute distress noted. MD [Medical Doctor] and NOK [next of kin] notified. There is no PN identified from 4/2/25 after fall noted.During an interview on 12/30/2025 at 1:37 P.M., with LPN #1, the LPN stated they found Resident #1 on the floor on 4/2/25 and Resident #1 complained of leg pain and was able to make a couple of steps to the bed. LPN #1 states that Resident #1 was offered pain medication and Resident #1 refused it. LPN #1 further states that she did not go back and check on the resident since he did not require pain medication, and she needed to complete a medication pass to the other residents. LPN #1 states she called and left a message with the physician and called the family but did not tell the physician Resident #1 was complaining of pain because [Resident #1] always complains of pain to the legs from arthritis.A review of Resident #1's Neurological Flow Sheet from the time period beginning 8:15 P.M., on 4/2/25 and ending on 11:00 A.M., on 4/3/25. Resident #1's level of consciousness is not completed from 4/2/25 at 10:30 P.M., through 4/3/25 at 3:00 A.M., with the notation of sleep. Resident #1's Movement is not completed from 4/3/25 at 12:00 A.M., until 4/3/35 at 7:00 A.M., with the notation of Refused and 3:00 A.M., slot being blank. The section labeled Initials: is left blank on:4/2/25 at 8:45 P.M.4/2/25 at 9:00 P.M.4/2/25 at 9:30 P.M.4/2/25 at 10:00 P.M.4/2/25 at 10:30 P.M.4/2/25 at 11:00 P.M.4/3/25 at 1:00 A.M.4/3/25 at 2:00 A.M.A review of Resident #1's Care Plan (CP) with a start date of 04/3/25, reveals Unwitnessed fall, MD family aware, assessment completed sent to [Hospital] for eval of left hip pain. Further review of CP with a start date of 4/9/25, reveals bed to be in lowest position to provide safety.Frequent rounding.PT/OT evaluation.During an interview on 12/30/2025 at 2:06 P.M., with the Director of Nursing (DON), the DON states for Resident #1 the desired outcome for the CP interventions were not met since Resident #1 continued to fall and no, I guess they [interventions] were not adequate if [they] kept falling. The DON further states after an injury the nurse should monitor a resident according to the neurological flow sheet and complete pain monitoring for 48 hours after an incident. The DON states no blanks should be present on the neurological flow sheet. The DON states the LPN should have spoken to the provider explaining that Resident #1 was in pain, not left a message. When asked if there is a PN from the 3 P.M. to 11 P.M. or 11 P.M. to 7 A.M. from the fall, the DON states I don't see one here.A review of the facility's policy titled Falls and Fall Risk, Managing with a revised date of December 2007, reveals under Prioritizing Approaches to Managing Falls and Fall Risk 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.A review of the facility's policy titled Assessing Falls and Their Causes with a revised date of October 2010, reveals under Steps in the Procedure 4. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . 5. Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 6. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. The policy further states under Performing a Post-Fall Evaluation: 1. After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of the effort.A review of the facility's policy titled Care Plans - Comprehensive with a revised date of September 2010, reveals under Policy Interpretation and Implementation . 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: 1 . b. When the desired outcome is not met;A review of the facility's policy titled Accidents and Incidents - Investigation and Reporting with a revised date of February 2014, reveals under Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

NJ# 184886Based on interview and review of pertinent facility documentation on 8/19/25 and 8/20/25, it was determined that the facility failed to develop and implement an effective discharge (d/c) planning process that focused on the resident's discharge goals to return to the community. The deficient practice was identified for 1 of 3 residents (Resident # 6), reviewed for community discharge. The deficient practice was evidenced by the following:During a tour on 8/20/25 at 9:30AM, Resident #6 was observed sitting up in bed watching television.On 8/20/25 at 9:40AM, Surveyor interviewed Resident #6 in the presence of their family member. Resident #6 stated that on their day of discharge, he/she was told that an Uber was going to pick them up and transport them to a local hotel. Resident #6 stated that the Uber (a type of transportation service) dropped them off in the middle of the parking lot. He/she further stated, they walked into the hotel to check, and he/she was told they needed to pay $50 in ordered to check-in. Resident #6 explained they did not have any money, so they left the building and went outside, where they fell and ultimately had to call 911. Resident #6 further stated that the facility was called and informed of the fall, and the resident was re-admitted to the facility the next day. Resident #6 denied asking their Social Worker to leave the facility or receiving prior notice of the 3/26/25 discharge.A review of Resident #6's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to repeated falls and muscle weakness.A review of Resident #6's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #6 was cognitively intact. The MDS reflected Resident #6 was independent with activities of daily living (ADLs), supervision/touch assist with transfers and ambulation.A review of a Social Services Note (SSN) written on 11/26/24 at 1:44PM, revealed the Social Worker (SW) informed Resident #6's family member of a Notice of Medicare Non-Coverage (NOMNC) letter, and informed them of the process to appeal.A Review of an SSN written on 11/29/24 at 2:11PM, revealed the SW informed Resident #6's family member of the Detailed Explanation of Non-Coverage (DENC) letter that was sent by the insurance company.A review of the Occupational Therapy Discharge Summary (OTDS) signed on 1/3/2025 at 7:35 PM, stated, Discharge recommendations: D/c secondary to change in payer source. Patient will be re-evaluated under new payer source and new goals set as appropriate. Assistance with IADLs (Instrumental Activities of Daily Living), Assistive device for safe functional mobility, elevated toilet/3 in one commode, home exercise program, home health services, long handled sponge, safety equipment: monoxide detector, smoke alarm, shower chair with back, and 24-hour care.A review of Physician Orders, reflected on order for discharge on [DATE].A review of a SSN written 3/26/25 at 1:23PM, stated, SW spoke with Resident in regards to discharge plan.A review of the Interdisciplinary Discharge Summary and Guide dated 3/26/25 at 2:17PM, reflected a referral for Visiting Nursing services. There was no documentation if Durable Medical Equipment (DME) was ordered, or any other community referrals were made.A review of SSN written 3/26/25 at 2:24PM, stated, [Resident #6] was discharged to the community. At the time of discharge to the community the resident was given a full reconciled medication list, and instructions to contact his/her PCP (Primary Care Physician) for follow-up. Resident was given transport to the community with all of his/her belongings.There was no other documentation that was provided regarding the plan for Resident #6's 3/26/25 discharge to the community.A review of a Progress Note (PN) written by the Registered Nurse (RN) Supervisor on 3/27/25 at 10:11PM, reflected Resident #6 was back at the facility after going to a local hospital due to a fall at home.During an interview with the Assistant Director of Nursing (ADON) on 8/20/25 at 10:35AM, she revealed that she was not part of Resident #6's discharge planning and was unaware of Resident #6's discharge until the day that the discharge occurred. She further stated that discharges are usually discussed at Utilization Review (UR) Meetings but does not recall if Resident #6's discharge was discussed. She further explained the Administrator, Director of Nursing (DON), ADON, Director of Social Services (DSS), MDS Coordinator, Director of Rehab (DOR), and Unit Managers, attend the UR meetings.During an interview with the DSS on 8/20/25 at 10:55AM, stated that the SW who handled the d/c planning for Resident #6 no longer works at the facility. During the interview she revealed Resident #6 was to be short-term, but did not have any place to go after discharge. The DSS explained the previous SW setup the community discharge at the resident's request to leave. She further stated that Resident #6 was discharged and transported in an Uber to a hotel that was paid for a couple of nights, but unsure of what days. She further stated that she was unable recall if Resident #6's discharge was discussed during the Interdisciplinary Care Team Meetings, where Physical therapy, nursing and social services would discuss the Resident's care, including the Resident's discharge. The DSS further stated that the facility does not normally discharge to a hotel, and that in her opinion, she would of have the resident stay until there was a safe space for the resident to be discharged . Stated that if a Resident is adamant about leaving, she would have them sign an Against Medical Advice (AMA) form. She was not sure if prior notice of the discharge was provided to Resident #6, because the discharge was Resident initiated, not a facility-initiated discharge. She stated that she does not believe an AMA form was signed due to Resident #6 being medically stable and approved for discharged by the physician. During an interview with the DOR on 8/20/25 at 1:35PM, she revealed that discharges are discussed in the facility's morning meetings. She further explained that when a Long-Term Care Resident is discharged into the community, rehab would do an evaluation prior to the discharge. She further stated that the rehab department was not notified of Resident #6's discharge, so a discharge evaluation was not completed. Stated Resident #6 was steady while walking, but he needed to rest at times, and had she been notified of Resident #6's discharge, she would have requested a new order for a rollator (a walker with four wheels and a seat).During an interview with the Administrator on 8/20/25 at 2:00PM, he stated that discharges are discussed in both IDCT meetings and UR meetings. He further stated that if a Resident requested to be discharged , then they would have been discussed in IDCT meetings. The Administrator stated that he was not able to recall if Resident #6's 3/26/25 discharge was discussed in their meetings. Administrator further stated that Resident #6 was at Prior Level of Function, and they were cleared by Rehab and Medical, and even though the resident had no other placement, they wanted to leave, and the facility cannot force them to stay. Surveyor informed Administrator that there is no documentation regarding the discussions of Resident #6 wanting to leave or understanding of their discharge location.The facility did not provide any further pertinent information. N.J.A.C. 8:39-4.1(a)30,32

REPEAT DEFICIENCY Complaint #: NJ185836; NJ186066 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility was maintained to provide the residents with a safe, clean, comfortable and homelike environment. This deficient practice was identified on 3 of 3 nursing units, and was evidenced by the following: On 5/8/25 from 9:40 AM to 10:40 AM, the surveyor toured the Second-floor nursing unit and observed the following: 1. In Resident room [ROOM NUMBER], the wall paper was peeling off the wall behind the door. 2. In Resident room [ROOM NUMBER]'s bathroom, the bathroom ceiling tiles were cracked, the grab bar (bar affixed to the wall for safety) on the left side of the toilet was coming off the wall, the paint was peeling from the left side of the sink and the right side of the soap dispenser, the paint was peeling on the inside of the bathroom door and there were black marks on the lower section of the door. Above Bed-A in the right corner, the ceiling tile was stained brown, and the nightstand, wardrobe closet and television (TV) stand dresser all had paint peeling. 3. At 9:59 AM, the surveyor observed a blackish/brown stain around the inside of the toilet bowl of Resident room [ROOM NUMBER]. At that time, the surveyor asked the Licensed Practical Nurse (LPN #1) to accompany them into Resident room [ROOM NUMBER]'s bathroom, and the surveyor asked what that substance was. LPN #1 stated all toilets look like that, and that the housekeeping staff cleaned the toilets, but it did not come off. The surveyor asked if the facility was aware of the stain, and LPN #1 stated she would assume the facility was aware, and in her opinion, the facility did not think it was an issue. 4. In Resident room [ROOM NUMBER], the two TV stand dressers, the wardrobe closet, and the chair positioned by the window for Bed-B all had paint peeling off and the chair cushion was stained. 5. In Resident room [ROOM NUMBER], the baseboard trim was peeling and the wallpaper was coming off when entering the room, and the paint was peeling behind the door. By Bed-A, the corner trim was missing and the nightstand door was coming off. In the bathroom, inside the toilet bowl was stained brownish, the hand rail to the side of the toilet was coming off, the paint was peeling off the back of the bathroom door, and by the right of the exit, the bottom of the wall (sheet rock) was crumbling off. 6. At 10:05 AM, Resident #1 reported and showed the surveyor that the bottom left drawer of their wardrobe closet was a fake drawer. Resident #1 pulled the drawer out and showed that the drawer had no bottom, it was just a frame. Resident #1 also stated that the left wardrobe closet door did not close. The surveyor asked if staff were aware, and Resident #1 stated that staff attempted to close it every time they walked by and it did not close. Resident #1 then showed the surveyor blackish colored stains on the floor between the three dressers, and stated that the room next to them had a water leak that came into their room, and the facility never cleaned it. Resident #1 also showed the surveyor their air conditioner (AC) unit that was soiled with dust, food debris, and a thumbtack. 7. In Resident room [ROOM NUMBER], the paint was peeling off the left side by the entrance to the room, the two TV stand dressers had paint peeling off, and the right wardrobe closet door did not close. Inside the bathroom, the toilet bowl was stained a blackish/brown color, the paint was peeling off the walls, there were holes in the wall, left lower trim was missing, the wall was peeling under the soap dispenser, the mirror was peeling, and the hand rail by the toilet was coming off. 8. The Second-floor dayroom had paint peeling at the entrance, wallpaper was peeling off underneath the windows, the paint was peeling off the trim to both door frames and off both doors. All eight chairs had soiled arms and stained seats. The five tables all had peeling paint. 9. In Resident room [ROOM NUMBER], the wallpaper was peeling off by entrance inside, the right trim of wall was peeling off, the paint to the frame of the bathroom door entrance was peeling, and a section of the center wall trim above Bed-A's nightstand was missing. 10. In Resident room [ROOM NUMBER], the three drawers of the TV stand dresser were broken. The unsampled resident stated that the drawers had been broken like that the entire time they had resided at the facility and they assumed the facility was aware because the condition of building was obvious. By Bed-B, the back wood of the TV dresser was coming off, the bottom of the dresser's trim was broken, and the floor around the dressers were soiled black. Underneath the AC unit, the trim was peeling off and the chair was stained with paint peeling. 11. In Resident room [ROOM NUMBER], the black trim to the right of the entrance was worn. 12. The wooden wall board across from the elevators were cracked with holes. On 5/8/25, from 10:46 AM to 10:58 AM, the surveyor toured the Third-floor nursing unit and observed the following: 13. In Resident room [ROOM NUMBER], on the floor near the entrance, appeared to be soiled clothes in plastic bags and a bag full of waste/garbage on the floor. Bed-A's headboard was broken, the pillow had a brown stain on it, the ceiling tile above the bed was coming off track, and the TV stand dresser drawers were chipped. The trim to the outside bathroom door frame, the paint was peeling off and the toilet bowl was stained with brownish/green streaks. 14. At 10:50 AM, the surveyor observed the Housekeeper (HK #1) cleaning Resident room [ROOM NUMBER], that had plastic bags filled with clothing outside. HK #1 stated that the bags were on the floor in the inside of the room, and that she had moved them into the hallway to clean the floor. HK #1 reported that she cleaned the floors and bathrooms daily in each resident room, and that the maintenance staff cleaned the AC units. The surveyor observed inside the resident room, a hole behind the door and the TV stand dresser for Bed-A's bottom trim was broken. 15. In Resident room [ROOM NUMBER], the wallpaper was peeling off the wall to the left of the entrance and the outside bathroom door frame's paint was peeling. The wardrobe closet doors did not close. 16. In Resident room [ROOM NUMBER], the nightstand was peeling. On 5/8/25 at 10:59 AM, the surveyor interviewed the Environmental Service Director (ESD), who stated stated that the housekeeping staff cleaned every resident room and bathroom daily, which included the weekends. The ESD stated that the housekeeping staff cleaned inside the AC unit's vents, and the maintenance staff changed the AC filters. The ESD stated every Friday, staff should be taking off the AC unit's covers and cleaning the dust and debris inside. On 5/8/25 at 11:02 AM, the surveyor accompanied by the ESD toured the Second-floor nursing unit and the ESD confirmed the following concerns: In Resident room [ROOM NUMBER], the ESD identified the discoloration of the toilet bowl to be rust that did not come off. In Resident room [ROOM NUMBER], the ESD identified the discoloration of the toilet bowl to be rust, and he stated that if you scrubbed the rust off, it would leave a mark on the bowl. The surveyor asked how the porcelain toilet bowl rusted, and the ESD did not know how rust would get there. At 11:05 AM, the ESD acknowledged that Resident #1's AC unit was soiled with debris and should have been cleaned by the housekeeping staff. On 5/8/25 at 11:07 AM, the surveyor interviewed HK #2, who stated that she cleaned all the residents' rooms daily which included sweeping, mopping, and the toilets. On 5/8/25 at 11:10 AM, the surveyor observed in Resident room [ROOM NUMBER], that Bed-A's bedside table had peeling paint, their TV stand dresser's paint was peeling, and there was wallpaper missing from the walls. On 5/8/25 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated she was aware the condition of the residents' furniture, and stated that she was informed in a morning meeting that the facility was getting new furniture. The LPN/UM stated that the facility used a computerized work order system [name redacted] to put in maintenance requests. The LPN/UM stated that a lot in the facility was broken because the residents broke it, because it was a behavioral unit. The LPN/UM stated she was aware of the missing paint and trims, and that the Maintenance Director (MD) was out of the facility on leave. On 5/8/25 at 11:17 AM, the surveyor interviewed the Maintenance Staff (MS), who stated that the facility used a computerized work order system [name redacted] to put in maintenance requests. The MS stated that he recently changed all the AC units' filters and vacuumed it. On 5/8/25 from 11:20 AM to 11:29 AM, the surveyor and MS toured the facility, and he acknowledged the following observations: In Resident room [ROOM NUMBER], the MS confirmed the paint along the frame of the bathroom door needed to be painted, and he stated he did not recall a work order put in. In Resident room [ROOM NUMBER], the MS confirmed the holes in the walls and the paint coming off in the bathroom. The MS stated that the facility was like this when he started working there, and that he conducted rounds and did repairs that he saw were needed. The MS stated he mainly put drawers back together, changed bed remotes, and ceiling tiles. In Resident room [ROOM NUMBER], the MS acknowledged the stained ceiling tile, and stated it should have been changed. The MS confirmed that Resident #1's drawer was missing, and that the resident's aide should have reported that. The MS stated that the debris in the resident's AC unit should have been cleaned by housekeeping, and he confirmed the door was coming off of Bed-A's nightstand. The surveyor asked the MS if it was a clean, homelike environment, and the MS stated how was when I got here. On 5/8/25 at 11:30 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that if anything was broken, she was supposed to put it in the computerized work order system [name redacted] for maintenance. CNA #1 stated she was aware of the broken furniture, but did not put it in the system for maintenance. On 5/8/25 at 11:32 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that the facility was aware of the broken furniture and needed paint. The ADON stated that the work was to be done for the facility's plan of correction (POC) from the previous survey, but the work had not been completed. The ADON thought the work might have started on the first floor. On 5/8/25, from 11:34 AM to 11:41 AM, the surveyor toured the First-floor nursing unit and observed the following: 17. In Resident room [ROOM NUMBER], the outside wood of the door was coming off. 18. In the Shower Room (C-17), there was a rusted metal rack outside the shower, a hole in the shower curtain, a broken patched soap holder in the shower wall that was rough to touch, stained blue flower grips on the shower and tile floor that were soiled black and ripped, and missing grout in-between the tiles and shower. 19. At 11:41 AM, the surveyor asked CNA #2 and CNA #3 what the exposed metal piping that had a broken frame around it was at the entrance to Resident room [ROOM NUMBER]. CNA #3 stated it use to be a vent or something, and CNA #2 confirmed the condition should be reported to maintenance. On 5/8/25 at 11:50 AM, the surveyor reviewed the facility's previous statement of deficiencies and POC from their last survey dated 2/14/25. The facility was cited for multiple concerns regarding the residents' furniture, soiled floors, molding and baseboards coming off the wall, as well as the shower room, which it was determined that the facility failed to ensure a clean, homelike environment. The facility's POC with a completion date of 4/3/25, indicated that the facility was going to educate the ESD on the facility's policies on keeping the resident's areas clean and presentable, all resident rooms will have a full maintenance and housekeeping audit done monthly to ensure all aspects of the room are functioning properly, the first floor shower room will be checked and cleaned daily, as well as, the shower curtain was replaced. On 5/8/25 at 12:03 PM, the surveyor, accompanied by the Licensed Nursing Home Administrator (LNHA) toured the First-floor nursing unit, and the following was acknowledged: In Resident room [ROOM NUMBER], the LNHA stated that he was unsure what the broken unit with exposed metal piping was, and he stated that it must have recently broken off. The surveyor asked if it should look like that, and the LNHA responded cannot ask me that. In the Shower Room (C-17), the surveyor informed the LNHA of the concerns with the rusted metal rack, shower curtain, soap holder, flower grips, and missing grout, and stated that the facility was previously cited for that. The LNHA responded that the facility was only cited for the shower curtain that was replaced, and the surveyor pointed out that the shower curtain had a hole in it. The LNHA asked what was wrong with the flower grips (which were soiled black and ripped). The LNHA acknowledged the missing grout. In Resident room [ROOM NUMBER], the LNHA acknowledged that the outside of the door to the room was chipping and there were broken tiles in the hallway outside the Activity Office. The LNHA also acknowledged the condition of Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]'s room doors. On 5/8/25 at 12:09 PM, the surveyor, accompanied by the LNHA, toured the Second-floor nursing unit, and the following was acknowledged: In Resident room [ROOM NUMBER] and #234, the LNHA acknowledged the wallpaper should not be peeling. In Resident room [ROOM NUMBER], the LNHA confirmed the condition of the bathroom and furniture, and he stated that the facility had ordered all new furniture that should arrive within thirty days. The surveyor and LNHA also observed Resident Room #'s 229, 230, 231, 234, and Dayroom, and the LNHA confirmed the concerns. On 5/8/25 at 12:25 PM, the LNHA stated that he was aware of the environmental issues, and the facility was in the process of fixing it. The surveyor asked the LNHA if it was a clean, homelike environment, and the LNHA responded I hear you. On 5/8/25 at 12:27 PM, the surveyor, accompanied by the LNHA, toured the Third-Floor nursing unit, and the following was acknowledged: In Resident room [ROOM NUMBER], the surveyor asked what was in the plastic bags on the residents' floor, if it was soiled laundry or refuse, and the LNHA was unsure. In Resident room [ROOM NUMBER], the surveyor informed the LNHA of the identified concerns as well as the soiled bed sheets with the fly flying around it. The LNHA stated that no resident had hurt themselves on the broken furniture, and stated that maintenance did do rounds. The LNHA acknowledged the multiple holes in the residents' walls as well as, the wallpaper was peeling throughout the building. A review of the undated facility provided Quality of Life - Homelike Environment policy included that the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .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.) clean sanitary and orderly environment; c.) inviting colors and decor; d.) personalized furniture and room arrangements; e.) clean bed and bath linens that are in good condition . NJAC 8:39-4.1(a)11; 27.2(j); 31.2(e)

Complaint #: NJ185836, NJ186066 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's Quality of Life - Homelike Environment policy and procedures to ensure the safety and well-being of all residents by providing a safe, clean, comfortable, and homelike environment. This deficient practice was identified for 3 of 3 nursing units, and was evidenced by the following: Refer F 584 A review of the facility's undated Administrator Job Description included the purpose of your position is to direct day-to-day function of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times. Delegation of Authority: As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Duties and Responsibilities: plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the Regional Administrator. Develop and maintain written policies and procedures and professional standards of practice that govern the operations of the Facility .Ensure that all employees, residents, family members, visitors, and general public follow the Facility's established policies and procedures .Assist in developing plans of corrections for cited deficiencies. Ensure such plans incorporate timetables and methods of monitoring to ensure such deficiencies do not recur .Safety and Sanitation .Ensure that the building and grounds are maintained in good repair .Equipment and Supply Functions .Ensure that the Facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that the necessary equipment and supplies are maintained to perform such duties and services . A review of the undated facility provided Quality of Life - Homelike Environment policy included that the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .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.) clean sanitary and orderly environment; c.) inviting colors and decor; d.) personalized furniture and room arrangements; e.) clean bed and bath linens that are in good condition . On 5/8/25 from 9:40 AM to 10:40 AM, the surveyor toured the Second-floor nursing unit and observed multiple resident rooms with wallpaper and paint peeling, furniture that was broken or paint peeling, door frames with paint peeling, chairs that were soiled and paint peeling, soiled floors, toilet bowls that were stained with a black/brown discoloration, grab bars (bars affixed to the wall for safety) next to toilets coming of the walls, holes in walls, missing trim, and discolored ceiling tiles. On 5/8/25 at 9:59 AM, the surveyor observed a blackish/brown stain around the inside of the toilet bowl of Resident room [ROOM NUMBER]. At that time, the surveyor asked the Licensed Practical Nurse (LPN #1) to accompany them into Resident room [ROOM NUMBER]'s bathroom, and the surveyor asked what that substance was. LPN #1 stated all toilets look like that, and that the housekeeping staff cleaned the toilets, but it did not come off. The surveyor asked if the facility was aware of the stain, and LPN #1 stated she would assume the facility was aware, and in her opinion, the facility did not think it was an issue. On 5/8/25 at 10:05 AM, Resident #1 reported and showed the surveyor that the bottom left drawer of their wardrobe closet was a fake drawer. Resident #1 pulled the drawer out and showed that the drawer had no bottom, it was just a frame. Resident #1 also stated that the left wardrobe closet door did not close. The surveyor asked if staff were aware, and Resident #1 stated that staff attempted to close it every time they walked by and it did not close. Resident #1 then showed the surveyor blackish colored stains on the floor between the three dressers, and stated that the room next to them had a water leak that came into their room, and the facility never cleaned it. Resident #1 also showed the surveyor their air conditioner unit (AC) that was soiled with dust, food debris, and a thumbtack. On 5/8/25 at 10:30 AM, in Resident room [ROOM NUMBER], the three drawers to the television (TV) dresser were broken. The unsampled resident stated that the drawers had been broken like that the entire time they had resided at the facility and they assumed the facility was aware because the condition of building was obvious. By Bed-B, the back wood of the TV dresser was coming off; the bottom of the dresser's trim was broken; and the floor around the dressers was soiled black. Underneath the AC unit, the trim was peeling off and the chair was stained with paint peeling. On 5/8/25, from 10:46 AM to 10:58 AM, the surveyor toured the Third-floor nursing unit and observed multiple resident rooms with peeling wallpaper and paint, furniture that was broken or paint peeling, door frames with paint peeling, toilet bowls that were stained with a black/brown discoloration, and soiled bed linen. On 5/8/25 at 10:59 AM, the surveyor interviewed the Environmental Service Director (ESD), who stated stated that the housekeeping staff cleaned every resident room and bathroom daily, which included the weekends. The ESD stated that the housekeeping staff cleaned inside the AC unit's vents, and the maintenance staff changed the AC filters. The ESD stated every Friday, staff should be taking off the AC unit's covers and cleaning the dust and debris inside. On 5/8/25 at 11:02 AM, the surveyor accompanied by the ESD toured the Second-floor nursing unit and the ESD confirmed the following concerns: In Resident room [ROOM NUMBER], the ESD identified the discoloration of the toilet bowl to be rust that did not come off. In Resident room [ROOM NUMBER], the ESD identified the discoloration of the toilet bowl to rust, and he stated that if you scrubbed the rust off, it would leave a mark on the bowl. The surveyor asked how the porcelain toilet bowl rusted, and the ESD did not know how rust would get there. On 5/8/25 at 11:05 AM, the ESD acknowledged that Resident #1's AC unit was soiled with debris and should have been cleaned by the housekeeping staff. On 5/8/25 at 11:07 AM, the surveyor interviewed the Housekeeper (HK #2), who stated that she cleaned all the residents' rooms daily which included sweeping, mopping, and the toilets. On 5/8/25 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated she was aware the condition of the residents' furniture, and stated that she was informed in a morning meeting that the facility was getting new furniture. The LPN/UM stated that the facility used a computerized work order system [name redacted] to put in maintenance requests. The LPN/UM stated that a lot in the facility was broken because the residents broke it, because it was a behavioral unit. The LPN/UM stated she was aware of the missing paint and trims, and that the Maintenance Director (MD) was out of the facility on leave. On 5/8/25 at 11:17 AM, the surveyor interviewed the Maintenance Staff (MS), who stated that the facility used a computerized work order system [name redacted] to put in maintenance requests. The MS stated that he recently changed all the AC units' filters and vacuumed it. On 5/8/25 at 11:30 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that if anything was broken, she was supposed to put it in the computerized work order system [name redacted] for maintenance. CNA #1 stated she was aware of the broken furniture, but did not put it in the system for maintenance. On 5/8/25 at 11:32 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that the facility was aware of the broken furniture and needed paint. The ADON stated that the work was to be done for the facility's plan of correction (POC) from the previous survey, but the work had not been completed. The ADON thought the work might have started on the first floor. On 5/8/25, from 11:34 AM to 11:41 AM, the surveyor toured the First-floor nursing unit and had multiple observations of broken resident doors and the Shower Room (C-17) had a rusted metal rack, shower curtain with a hole in it, a broken patched soap holder in the shower wall that was rough to touch, stained blue flower grips on the shower and tile floor that were soiled black and ripped, and missing grout in-between the tiles and shower. On 5/8/25 at 11:50 AM, the surveyor reviewed the facility's previous statement of deficiencies and POC from their last survey dated 2/14/25. The facility was cited for multiple concerns regarding the residents' furniture, soiled floors, molding and baseboards coming off the wall, as well as the shower room, which it was determined that the facility failed to ensure a clean, homelike environment. The facility's POC with a completion date of 4/3/25, indicated that the facility was going to educated the ESD on the facility's policies on keeping the resident's areas clean and presentable, all resident rooms will have a full maintenance and housekeeping audit done monthly to ensure all aspects of the room are functioning properly, the first floor shower room will be checked and cleaned daily, as well as, the shower curtain was replaced. On 5/8/25 at 12:03 PM, the surveyor, accompanied by the Licensed Nursing Home Administrator (LNHA) toured the First-floor nursing unit, and the following was acknowledged the surveyor's findings. On 5/8/25 at 12:07 PM, in the Shower Room (C-17), the surveyor informed the LNHA on the concerns with the rusted metal rack, shower curtain, soap holder, the soiled and ripped flower grips, and missing grout, and stated that the facility was previously cited for that. The LNHA responded that the facility was only cited for the shower curtain that was replaced, and the surveyor pointed out that the shower curtain had a hole in it. The LNHA asked what was wrong with the flower grips (which were soiled black and ripped). The LNHA acknowledged the missing grout. On 5/8/25 at 12:09 PM, the surveyor, accompanied by the LNHA, toured the Second-floor nursing unit, and the LNHA acknowledged the surveyor's concerns. On 5/8/25 at 12:25 PM, the LNHA stated that he was aware of the environmental issues, and the facility was in the process of fixing it. The surveyor asked the LNHA if it was a clean, homelike environment, and the LNHA responded I hear you. On 5/8/25 at 12:27 PM, the surveyor, accompanied by the LNHA, toured the Third-Floor nursing unit, and the LNHA acknowledged the surveyor's concerns. A review of the computerized work order system [name redacted] for maintenance Work Orders report from 4/1/25 to present, did not indicate the day the work request was made, and it did not include all of the surveyor's identified concerns. The work order did include several resident rooms needed furniture repaired which included: Resident room [ROOM NUMBER], #218, #306, #203, #314, and #233. On 5/8/25 at 1:37 PM, the LNHA in the presence of the Regional LNHA provided the surveyor with a quote for furniture. The LNHA stated that the facility was aware that the furniture all needed to be replaced and that was why the facility got a quote. The Regional LNHA confirmed that the facility needs a lot of work. When the surveyor asked the LNHA what his responsibilities and role at the facility was, the LNHA responded that he was responsible for the facility which included; staff, residents, and the condition of the facility. The surveyor reviewed the Quote dated 3/11/25, with an invoice #250895, which included the cost of the furniture, with the vendor name listed as the facility and to ship to the facility. There was no evidence that the furniture was actually purchased. The surveyor reviewed a copy of a check provided by the LNHA, that he indicated was a deposit for the furniture payment dated 3/13/25. There was no evidence provided that this check was provided to the vendor. NJAC 8:39-4.1(a)11; 9.2(a); 9.3(a); 27.2(j); 31.2(e)

Based on observation, interview and review of pertinent facility documentation it was determined that the facility failed to provide a safe, clean and comfortable homelike setting. This deficient practice was identified for 3 of 3 units, and was evidenced by the following: 1. On 2/5/25 at 9:00 AM, the surveyor entered the facility and observed the lobby floor to be dirty with scuff marks and discolored tiles. The elevator floors were also observed to be dirty and discolored and the walls of elevators were observed to be soiled. On 2/5/25 at 9:15 AM, during initial tour of the Third-floor nursing unit, the surveyor observed the following environmental issues: In Resident room [ROOM NUMBER]-A, the floor was observed to be soiled and sticky with liquid spills on the floor. The unsampled resident's trash was overflowing and there was trash on the floor under the bed. In Resident room [ROOM NUMBER] A and B, the surveyor observed that the resident's clothes drawers were broken; peeling Formica on the dresser; no drawer front on the bedside table; drawers were broken and hanging awkwardly and could not be closed. The floor was stained dirty with brown substance behind A bed; molding and baseboard off the wall were lying on the side of the resident's bed in bed B. The surveyor lifted the board and underneath the boards on the floor was very dirty and dusty with used straws and silver money on the floor. The ceiling bed curtain track was broken and hanging from ceiling with no middle privacy partition curtain and two ceiling tiles hanging and buckling. The surveyor observed in Resident room [ROOM NUMBER], the bedside table was broken. On 2/5/25 at 9:15 AM, the surveyor interviewed the Registered Nurse (RN), who stated that maintenance and housekeeping concerns were verbally told to the perspective departments when issues were noted in residents' rooms. The RN stated that she was aware about the concerns related to housekeeping and maintenance issues in Resident room [ROOM NUMBER], #306, and #311, however she did not fill out the concerns in the computer system to notify the housekeeping or maintenance regarding these issues. On 2/5/25 at 9:30 AM, the surveyor attempted to interview the housekeeping staff on the Third-floor nursing unit, and they indicated that they could not speak English. On 2/5/25 at 9:45 AM, the surveyor interviewed the Maintenance Assistant (MA), who stated that no one reported the maintenance concerns or the condition of the resident's furniture in rooms 306 or 311. The MA stated that maintenance issues were reported into the computer system. The MA accompanied the surveyor to Resident room [ROOM NUMBER], and he stated that he had not received any work orders or reports regarding the condition of that room. On 2/5/25 at 9: 50 AM, the surveyor interviewed the Housekeeping Director (HD), who accompanied the surveyor to Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] to observe the uncleanliness of the unsampled resident's rooms. The HD stated that he did the best he could with the staff he had to work with. The HD stated that the floors were cleaned daily and maybe the housekeeper did not get to those rooms yet. The HD then directed the housekeepers to clean the floors in the residents' rooms. The HD stated that all rooms were carbolized once a month, however staff kept taking the signs down. The HD did not have an explanation why the floors were not clean. On 2/13/25 at 10:02 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that if the staff saw that the floors were dirty or needed cleaning, the staff should be notifying the housekeeping department to clean those rooms first. The LPN/UM stated that if there was broken furniture or broken items in a resident's room, that the staff should be reporting it to maintenance through the computer system that produced maintenance work orders. The LPN/UM explained that if the maintenance or housekeeping department did not respond timely to concerns, then she would verbally remind them. The LPN/UM stated that she had told the administration about the poor condition of the dining room chair and the administration did buy new chairs. The LPN/UM stated that the condition of Resident room [ROOM NUMBER] was embarrassing and the room should not have been in that condition. On 2/13/25 at 10:18 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated that she was aware that the furniture in the resident's rooms were not in good condition. The CNA bought the surveyor to Resident room [ROOM NUMBER] and showed the surveyor the molding on the resident's wall behind bed B, which was broken, missing pieces and in disrepair. The CNA also went room to room and showed the surveyor the dirt that was underneath the multiple resident's dressers and stated that she did not know why the housekeepers did not pull the furniture out to clean under the dressers. The CNA stated that the HD was aware of the issues and that he was notified of the concerns regarding the cleanliness of the floors. She also stated that when there was a maintenance issue, the staff filled out the work form on the computer system, but the concerns did not always get fixed. On 2/13/25 at 12:28 PM, the surveyor interviewed the Maintenance Director (MD), who stated that the facility's work order computer system instructed him to perform 20 weekly tasks. The MD stated that maintenance rounds were driven by the computer system and environmental rounds were conducted in August 2024, with Licensed Nursing Home Administrator (LNHA). The MD stated that during those rounds, the LNHA and himself generated a list of maintenance issues which were completed a week later for each floor. The MD stated that the LNHA and himself were aware that the furniture in the resident's room needed to be replaced and he had brought it up in Quality Assurance and Performance Improvement (QAPI) meeting. The MD stated that after maintenance received a work order, he would have expected it to be completed within 24 hours. The surveyor showed the MD pictures of the condition of Resident room [ROOM NUMBER] and he confirmed that it was unacceptable. On 2/14/25 at 10:58 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the environment was awful and the LNHA stated that he had conversations with corporate regarding getting new furniture, however, could not provide additional information regarding the purchasing of new furniture to the surveyor. 49094 2. On 2/5/25 at 11:06 AM, the surveyor observed the Second-floor nursing unit and identified the following concerns: In Resident room [ROOM NUMBER] bed B, the base board detached from the wall behind the bed frame. The nightstand located near the resident's bed had the bottom door hanging awkwardly which could not be properly closed and the Formica (laminated plastic used to make cabinets) was peeling off the bottom of the nightstand. On 2/13/25 at 9:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that when there was an environmental problem or broken items in a resident's room, we reported it to the maintenance department. The LPN further stated that they used a computer system to report things to maintenance. The LPN acknowledged that the baseboards should not be detached from the wall and that the nightstands should not have the doors hanging off. On 2/13/25 at 12:27 PM, the surveyor interviewed the MD in the presence of the survey team, who stated that the facility used a computer program where staff entered a concern for the maintenance department. The MD stated that the computer system instructed him to perform 20 weekly tasks. The MD stated that maintenance rounds were driven by the computer system and environmental rounds were conducted in August 2024, with the LNHA. He stated that during those rounds, the LNHA and himself generated a list of maintenance issues which were completed a week later for each floor. The MD further stated the resident's rooms should be kept clean, well kept, and have a homelike environment. The MD stated that the LNHA and himself were aware that the furniture in the resident's rooms needed to be replaced and he had brought it up in the QAPI meeting. The MD stated that after the maintenance received a work order, he would have expected it to be completed within 24 hours. The surveyor showed the MD pictures regarding the condition of Resident room [ROOM NUMBER], and he stated that it was unacceptable. On 2/14/25 at 10:59 AM, the DON, in the presence of the LNHA and the survey team, stated that the environment was awful and the LNHA stated that he had conversations with corporate regarding getting new furniture. The DON and LNHA acknowledged the surveyor's environmental concerns. 44833 3. On 2/5/25 at 11:05 AM, during initial tour of the facility, the surveyor observed Resident #128 in their room resting in bed. Next to the bed was a nightstand which appeared to be in disrepair. The nightstand was missing the drawer with the resident's personal belongings that were set on the shelf where there would have been a drawer. The resident was unable to verbalize to the surveyor how they felt about the condition of their furniture. On 2/13/25 at 11:44 AM, during dining observation, the surveyor observed the main dining room on the Third-floor nursing unit to have damaged walls with the wallpaper peeling up and away from the wall starting from the baseboard trim. There were also holes in the wall with drywall showing and areas patched with mismatched materials. On 2/13/25 at 11:47 AM, the surveyor interviewed the Activities Aide (AA), who stated that she was not sure how long the wall had been in that condition; that it had been that way since she was hired at the facility six months ago. On 2/13/25 at 12:28 PM, the surveyor interviewed the MD, who stated that the facility work order computer system instructed him to perform 20 tasks weekly. The MD stated that maintenance rounds were driven by the computer system and environmental rounds were conducted in August 2024, with the LNHA. The MD stated that during those rounds, the LNHA and himself generated a list of maintenance issues which were completed a week later for each floor. The MD stated that the LNHA and himself were aware that the furniture in the resident's room needed to be replaced new and he had brought it up in the QAPI meeting. The MD stated that after the maintenance received a work order, he would have expected it to be completed within 24 hours. On 2/14/25 at 10:58 AM, the surveyor interviewed the DON, who stated that the environment was awful and the LNHA stated that he had conversations with corporate regarding getting new furniture, however, could not provide additional information regarding the purchasing of new furniture to the surveyor. 45208 4. On 2/5/25 at 12:04 PM, the surveyor observed a coded door lock that had push buttons falling out to get into the First-floor shower room. The surveyor entered the shower room and observed: dirty tile floors; a rusted metal rack holding a used blue/green bar of soap; blue flower grip stickers that were discolored black on the floor of the shower; a broken shower hook to hold the handheld shower nozzle that had sharp jagged edges; a broken patched soap holder in the shower wall that was rough to the touch and a shower curtain that had brown and orange discoloration throughout on the interior shower side, it also revealed brown discoloration stripes in the middle of the curtain. On 2/12/25 at 12:13 PM, the surveyor interviewed with HD, who stated that he had a monthly schedule in place to change the communal resident's shower curtain. The HD could not provide an accountability log and could not determine when the last time the shower curtain was changed. He further stated that the shower rooms were cleaned daily by staff. On 2/12/25 at 10:47 AM, the surveyor interviewed the MD, who stated that he made rounds throughout the facility regularly and inspected the residents' rooms and shower rooms. If there was a maintenance issue or something was broken, all staff had access to the electronic maintenance system. The MD stated that the system provided the maintenance department with a work order if something needed to be fixed. The shower room was not on the electronic maintenance system. On 2/12/25 at 12:41 PM, the surveyor interviewed the First-floor nursing unit's LPN/UM, who stated that staff used the electronic maintenance system sometimes, sometimes they told the maintenance staff verbally in the hallway or they wrote the concern in a maintenance log. The surveyor observed the maintenance log and Shower Room C1-17 was not listed. On 2/12/25 at 12:47 PM, the surveyor accompanied by the LPN/UM toured Shower Room C1-17. LPN/UM stated that the shower room was not clean, and did not have a homelike feel. I would not shower in here. On 2/13/25 at 12:27 PM, the surveyor conducted a follow-up interview with the MD, who stated that the maintenance log system should not be used; that the electronic maintenance system was used for notification. The MD stated if staff approached him in the hallway to fix something, he directed them to add a work order in the electronic system. On 2/14/25 at 10:58 AM, the survey team met with the LNHA and the DON, who both acknowledged the surveyor's concerns. They were unable to provide additional information. A review of the facility's undated Director of Maintenance job description indicated that the purpose of the position was to maintain the orderly functioning of all equipment in the facility to include the kitchen; laundry; heating; air conditioning and elevators as well as purchasing necessary supplies for repairs, maintenance, and emergencies within budgetary. A review of the facility's undated Director of Housekeeping job description reflected that the HD was responsible for planning, directing, coordinating, reporting, budgeting, and physical management of the housekeeping departments employees and equipment in a way that maximum cleanliness and order throughout the building and laundry services for both resident clothing and facility linen. A review of the facility's undated Cleaning and Disinfection of Environmental Surfaces policy included that environmental surfaces would be cleaned and disinfected according to the current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities and Occupational Health and safety Administration (OSHA) bloodborne pathogens standard . A review of the facility's undated Quality of life-Homelike Environment policy included residents would be provided with a safe, clean and comfortable homelike environment .facility staff and management shall maximize to the extent possible, the characteristics of the facility to reflect a personalized homelike setting. These characteristics include: Clean and sanitary and orderly environment and inviting color and decor . NJAC 8:39-31.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 2/5/25 at 9:26 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the walk-in freezer, one opened box of raviolis and one opened box of chicken breasts in the manufacturer's box. Both products were in bags that were not sealed closed exposing the contents to air with ice crystals. Neither products were labeled with an opened or use by dates. The FSD was unable to say when the packages were opened. 2. The steam table with one main water well and six pan capacity had white murky water with sediment of food particles on the bottom and green food particles floating on the top of the water. The FSD stated the steam table water was drained and changed daily at the end of the day, and she acknowledged that it had not been done yet. The FSD could not provide work accountability logs and was unaware of the last time it was changed. 3. Four plastic colored cutting boards were deeply pitted and discolored white from use. On 2/5/25 at 10:28 AM, the surveyor interviewed the FSD who acknowledged that the freezer items should have been labeled with an opened date and if only part of the bag was used, it should be resealed and labeled. The FSD acknowledged that the cooking equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination. On 2/14/25 at 10:58 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's undated Sanitation Policy included food service areas shall be maintained in a clean and sanitary manner .for fixed equipment that does not fit in the dishwasher machine, equipment should be disassembled to allow detergent solution of all parts . A review of the facilities Refrigeration and Freezers policy dated revised November 2022, included all food is appropriately dated to ensure proper rotation . Expiration dates on all unopened food and use by dates are indicated when food is opened . A review of the facility's undated Sanitation Policy included food service employees shall prepare and serve in a manner that complies with safe food handling practices . food preparation staff will adhere to proper hygiene and sanitary practices to prevent food borne illness . NJAC 8:39-17.2(g)

C#: NJ00179177, NJ00179069 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 11/11/2024, 11/12/2024, and 11/22/2024, it was determined that the facility failed to investigate an allegation of Resident-to-Resident sexual abuse between two residents, a cognitively impaired resident (Resident #1), who wanders and requires frequent monitoring and Resident #4, who has moderate cognitive impairment. On 9/24/2024 at 8:35 p.m., the License Nursing Home Administrator (LNHA) received a grievance by email written by Resident #1's family member, which included an alleged allegation of sexual interaction between Resident #1 and Resident #4. The LNHA forwarded the email to the Social Worker (SW) with instructions to write a Grievance. However, the grievance was not addressed, and an investigation was never initiated into the allegation. The facility's failure to address the grievance and investigate the sexual abuse allegation and follow its policies titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, and Abuse Prevention Program, and the LNHA and SW job description placed Resident #1 and all other residents in an immediate jeopardy (IJ) situation. This IJ was identified and reported to the facility's Director of Nursing (DON) on 11/22/24 at 6:15 p.m. The DON was presented with the IJ template, which included information about the issue. The IJ began on 9/24/2024 when Resident #1's family member emailed LNHA about the allegation and continued through 11/27/2024 when the facility submitted an acceptable Removal Plan to the New Jersey Department of Health. This deficient practice was identified for 1 of 7 residents (Resident #1) On 11/29/2024, the Surveyor verified the Removal Plan was implemented. The facility implemented the Removal Plan, which included the following: Initiating an investigation related to the grievance/ allegation of the resident to resident sexual abuse on 9/25/2024. Based on the outcome of the investigation, the facility was unable to substantiate the allegation of abuse and neglect. Completing an assessment related to any signs and symptoms of psycho-social concerns. Initiating in-services for the SW and all staff on the facility's policy on Abuse and Neglect, Investigating and Reporting, the Abuse Prevention Program Policy, and the Grievance Policy and Procedure. Auditing of the last thirty days of incidents and accident reports and grievances to ensure there were not any additional unresolved investigative allegations of abuse, abuse, and neglect identified. 1. According to the Admission Record (AR), Resident #1 was admitted on [DATE] with diagnoses which included but were not limited to: Altered Mental Status, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool, dated 9/27/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0/15, which indicated that the Resident's cognition was severely impaired. The MDS also showed Resident #1 needed partial to moderate assistance and one-person physical assistance with most Activities of Daily Living (ADLs) and assistance with locomotion on and off the unit. A review of the Resident's Care Plan (CP) initiated on 01/26/2023 revealed under Indicator: Resident #1 Wander on unit occasionally into other's rooms. Under Goal, indicated: Provide a safe environment for wandering through the next review date; Under Interventions, included: Involve in programs of interest, Frequent room checks during overnight shift, Room change discussed with family who refused, Redirect, and engage in conversation when trying to enter another resident's room, Behavior Monitoring Activity Aide will redirect and involve in activities and place stop banner on most frequented rooms. 2. According to the AR, Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Altered Mental Status, Schizoaffective disorder, Unspecified Dementia, and Schizophrenia. According to the MDS dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the Resident's cognition was moderately impaired. The MDS also showed Resident #4 is independent with ADLs. A review of the Resident's CP initiated on 07/31/2023 revealed under Indicator: Resident #4 Wander on unit occasionally into other's rooms. Under Goal, indicated Provide a safe environment for wandering through the next review date; Under Interventions, included: Find out what the Resident is looking for, involve in the program of interest, Use STOP sign at the doorway and Wander guard placed on left wrist. Review of an Email Grievance dated 9/24/2024 at 8:35 p.m., presented to the Surveyor from the License Nursing Home Administrator (LNHA), revealed documentation from Resident #1's family member, which included a complaint of an incident she observed between Resident #1 and Resident #4. According to the email, the family member went to the Resident's room (date unknown) and observed the door closed with Resident #1 and Resident #4 in the room. The family member wrote that when she walked into the room, Resident #4 popped up quickly and ran out of the room. She continued, I then found my [Resident #1] half-naked and frazzled, [chest area] exposed with [his/her] shirt twisted and half off [his/her] body, and [the] waistband to [his/ her] pants was half down The family member further wrote that a staff member told me [Resident #4] always goes in there [Resident #1's room] and that [Resident #1] doesn't know what is going on because he/she doesn't understand, she [staff member] finds them (Resident 1 and Resident #4] . doing sex stuff and leaves them be until they're done Further review of the email showed that on 9/25/2024 at 10:06 a.m., the LNHA forwarded the email from Resident #1's family member to the Social Worker (SW). The LNHA wrote: Please write a grievance for Resident #1. Review of a Grievance Timeline, undated from the SW, on 9/25/2024, she received an email from the LNHA about a grievance; she then reached out to the family member by telephone and in person and suggested the best way to address all of the issues on the grievance is to have an Interdisciplinary Care Team (IDCT) meeting. The family member, in return, informed the SW she was coming in person to the facility to take care of other matters. On 09/26/2024, the SW initiated a Record of Concern Form, which describes, Investigation will begin after IDCT has taken place for more clarity of the issues and concerns. According to the SW's statement, the family member was provided with the date of the IDCT meeting via email; she further informed the SW she could not attend the meeting. During an interview on 11/12/2024 at 11:00 a.m., the Unit Manager / Licensed Practical Nurse (LPN) stated Resident #1 ambulates and wanders into other Resident's rooms and tends to take [his/her] clothes off. UM further stated Resident #1 has been in Resident #4 room before, unaware of any Resident-to-Resident sexual abuse. During an interview on 11/13/2024 at 10:37 a.m., Resident #4 stated he/she did not recall any resident in his/her room. During an interview on 11/22/2024 at 11:50 a.m., the Behavioral Monitoring Aide (BMA) stated he redirected the residents wandering in the hallway, assisted other residents in the dayroom, and watched the doors; BMA stated that he had not heard of any resident-to-resident sexual abuse. During an interview on 11/22/2024 at 12:02 p.m., Resident #1, assigned CNA, stated that the Resident ambulates and sometimes wanders into other residents' rooms. She explained that a BMA in the hallway always monitors the residents and assists them. The CNA further stated that she had never seen Resident #1 and Resident #4 together. During an interview on 11/22/2024 at 1:43 p.m., the LNHA stated on 09/24/24, at 8:35 p.m., he received a complaint via email from Resident #1 family member but did not read the complaint. On 09/25/2024 at 10:06 a.m., he forwarded the email to the SW. The Administrator further stated, his expectation was for the SW to do a full investigation and write a grievance. During an interview on 11/22/2024 at 1:53 p.m., the Director of Nursing (DON) stated he was not aware of the grievance presented by a family member of Resident #1. According to the DON, the SW should have completed the grievance process, and the IDCT should have met and reviewed the complaint at the next meeting. During an interview on 11/22/2024 at 2:11 p.m., the SW stated on 09/25/2024 at 10:06 a.m., she received an email from the LNHA which included an allegation of Resident-to-Resident sexual abuse between Resident #1 (the alleged victim) and Resident #4 (the alleged perpetrator). The SW further stated she spoke with the CNAs in the unit, as she actively tries to reach out to Resident #1's family. She further stated that she did not speak to the nurses, DON, Unit manager, or Administrator. Review of an undated facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, included the following: Under: Policy Statement: All reports of Resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations and documentation are reported. Under Policy Interpretation and Implementation Investigating Allegations: 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. 4. The Administrator is responsible for keeping the Resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator ensures that the Resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. Review of the facility's policy titled Abuse Prevention Program revealed the following: Under the Policy Statement section the policy revealed, Our Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the Resident's symptoms. Under Policy Interpretation and Implementation included As part of the Resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. 2. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 3. Identify and investigate all possible incidents of abuse. 4. Protect residents during abuse investigations. Review of the facility's Director of Social Service Job Description. Under: the Job Summary revealed: The primary focus of the Director of Social Services is to assist in the Resident's adjustment to the facility and maintain the highest possible level of psycho-social functioning within the facility environment. Under: Job Requirements included: 1. An understanding of the psycho-social dynamic of the geriatric population and ability to empathize and provide guidance to them. 4. Maintain grievance book, perform other related duties as directed by the Administrator . Under: Main Duties revealed: 3. Keep Resident's rights current and up-to date with state and federal regulation. 6. Perform other related duties as directed by the Administrator. Review the facility's Administrator Job Description. The Purpose of Your Job Position revealed: 1. The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Under Delegation of Authority included: 1. As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Under: Job Function showed: 1. Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. Under the Duties and Responsibilities. Administrative Function included: 1. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. 2. Assist department directors in the development, use and implementation of departmental policies and procedures and professional standards of practices. 4. Interpret the Facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary. 5. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. 8. Conduct daily meeting with appropriate staff during Facility inspections to discuss survey finding and formulation of plans of action and correction. Under the Personnel Function revealed: 1. Delegate Administrative authority, responsibility, and accountability to other staff personnel as deemed necessary to perform their assigned duties. 1. Review accident and incident reports (e.g., falls, injuries of an unknown source, abuse, etc.). Monitor to determine the effectiveness of the facility's risk management program. Under Resident Rights included 1. Review resident complaints and grievances and make written reports of action taken. Discuss actions with the Resident and family as appropriate. NJAC 8:39-9.4(f)

C# NJ Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility co-habitated 3 of 6 Residents (Resident #1, Resident #5 and Resident #7) who were assessed as smokers who needed to be supervised when smoking and were not allowed to keep smoking paraphernalia in their room with roommates (Residents #2, #6 and #8) who were able to keep their smoking paraphernalia in their room and did so in unlocked cabinet drawers. Additionally, according to a pre-admission packet that was provided to the facility from the discharging facility, prior to Resident #1's admission on 9/24/14, indicated that Resident #1 had a history of [REDACTED]. On 2/8/15, the facility sprinkler system activated in Resident #1's bathroom, which resulted in the evacuation of all 148 residents and staff. Resident #1 sustained burns on 2/8/15 and on the day of survey was still hospitalized at an acute care hospital. This resulted in an immediate jeopardy situation which began for Resident #1 and all the residents in the facility on 2/3/15, when the facility co-habitated Resident #1 who required supervised smoking with Resident #2 who did not. In addition Resident #5 and Resident #7 were also in an immediate jeopardy situation related to being assessed as smokers who needed to be supervised when smoking and were not allowed to keep smoking paraphernalia in their room co-habitated with roommates, Residents #6 and #8 who kept their smoking paraphernalia in cabinet drawers that lacked a locking mechanism. On 2/18/15, the surveyor identified the immediate jeopardy which began on 2/8/15 to the Administrator and the Director of Nursing on 2/18/15 at 2:03 PM. This deficient practice was evidenced by: According to an interview with the Nursing Supervisor (NS) on 2/18/15 at 11:15 AM, the NS stated that on 2/8/15 at 8:10 AM, she was alerted to Resident #1's room by a fire alarm. Upon arrival to the room, the NS noted the sprinkler was on in the bathroom. The NS did not see Resident #1 in the room at that time and closed the door. Moments later, the NS felt uncomfortable that the fire alarm system was indicating a fire in Resident #1's room and went back to re-check it. At that time, Resident #1 was discovered alone in the room by the NS, sitting on the bed with the breakfast tray in front of him/her. The NS noted the resident was wet, his/her hair was shorter and singed, the ears were burned and the face, hands and legs were red. The NS also noted the resident was wearing a Johnny coat on top of his/her clothing and his/her clothes underneath were burned. The Resident #1 was removed from the room, placed in a chair and a blanket and oxygen was applied. The Resident #1 was transported to the ER for further evaluation. The Resident #1 was then air lifted to a hospital in another state. The facility residents were all evacuated and transported to other facilities. In the "Reportable Event Record/Report" faxed in by the facility to the Department of Health on 2/9/15 stated: "The investigation was done & it appears resident (#1) lit cigarette in the bathroom & caught clothing on fire." 1. The surveyor reviewed the preadmission packet for Resident #1 on 2/10/14 at 11:12 AM. According to the pre-admission packet that was provided to the facility from the discharging facility, prior to Resident #1's admission on 9/24/14, the information reflected that resident #1 had a history of [REDACTED]. A review of the nurses notes from the previous facility indicated the following: On 8/10/14, "Pt admitted to smoking in room when questioned, took lighters and locked in cart." On "8/13/14 at 7 AM, Q (every) 15 (minute checks) done and no smoking in room or behavior issues noted. 8/13/14 at 10 PM, Q 15 min (minute) checks done. No smoking in (Resident #1's) room noted or reported. 8/14/14 at 7:15 AM, no attempts to smoke in room, Q15 min checks done. 8/15/14, no smoking noted. 8/17/14, no smoking noted, no signs of smoking in room. Resident went outside x 3 (three times) on shift to smoke. 8/18/14, Resident noted with burns to sides of 3rd and 4th fingers. The Resident admits (Resident #1)(that she/he) picks up already smoked cigarettes and smokes them. Offered a cigarette tip clip, Res (Resident#1) refused. 8/22/14 Resident noted outside picking up already used cigarettes to smoke, resident offered leather gloves and again offered cigarette tip clip, refused x 2 (two times). 9/14/14 CNA approached this writer and stated she smelled smoke in res room a strong smell of cigarette smoke and found a cup with water, ashes and cigarette butts. Res admitted to smoking in room. Nursing staff confiscated resident's lighters, searched Res belongings for lighters, placed Res on Q 15 min checks... 9/15/14 Q 15 min checks maintained. Resident cooperative with giving lighter and cigarette to the nurse to be kept in the cart. 9/16/14 Q 15 min checks with no episodes of smoking. 9/23/14, resident on Q 1/2 hour shifts per administrator. 9/24/14, 11 - 7 (11 PM to 7 AM) Q 30 min checks continued. No episodes of smoking in room. 9/24/14, 7-3 (7 AM to 3 PM) Resident observed on Q 30 min checks for numerous days. No further incident, removed from Q 30 min checks". This was instituted on 9/24/14, the same day of discharge. A review of Resident #1's Clinical Notes (at present facility) dated 9/24/14 at 6 PM indicated but was not limited to the following: "admitted (Resident #1) from (Previous) Rehab and Nursing Center. On 9/25/14 at 6:30 AM Resident wanted to smoke but told (Resident #1) that smoking time is not till later. There was no documentation present in this facility's medical record indicating that Resident #1 had prior history of smoking in his/her room at the previous facility. The surveyor reviewed the medical record of Resident #1 on 2/10/15 at 11:08 AM. The "Face Sheet" revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 12/29/14 indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #1 had intact cognition. According to the MDS, Resident #1 required staff supervision for Activities of Daily Living (ADL's). A review of Resident #1's Interdisciplinary Care Plan (ICP) initiated 9/2014 (no day indicated), in the column entitled "Goals" stated Resident #1 "will smoke safely and comply with supervised smoking rules. The "Intervention" column indicated the following, but was not limited to: Resident "will smoke in designated areas. Will surrender all smoking paraphernalia to staff. Smoking agreement discussed and signed. Remind Pt. (patient) of smoking rules and regulations and loss of privilege with non compliance. Designated smoke times with supervision. Redirect Pt. of safe extinguishing of cigarette." The "Evaluation" column dated, 12/29/14, indicated "supervised smoking continued." The facility failed to address in Resident #1's ICP, the resident's history of smoking in the room at the previous facility. The care plan further failed to indicate that there was a potential for unsafe smoking for Resident #1 who required supervised smoking and was co-habitated with resident #2 who did not require supervised smoking. A review of the "Safe Smoke Evaluation", indicated 13 categories, of which 6 categories were completed for Resident #1. According to the Safe Smoking Evaluation document, a score of 0-20 = Supervised Smoking. A score of 20-25 = Cigarettes need to be lit by staff. A score of 26-28 = Can safely smoke without supervision. Resident #1's score was documented with a score of 8 on 9/25/14, 1/5/15 and on 1/23/15 which indicated that supervision while smoking was required. Resident #1 was not available for an interview with the surveyor secondary to Resident #1's hospitalization since 2/8/15. The surveyor conducted an interview with the Nursing Supervisor (NS) #1 on 2/18/15 at 11:15 AM. During the interview, the NS stated that the "smoking assessment is done on all residents upon admission. We interview the resident and give them the smoking policy. The unsupervised residents are allowed to keep all their smoking material with them. For the supervised residents, all their smoking material is kept by the nurse." The Nursing Supervisor #1 indicated that on 2/8/15 at about 8:10 AM she heard the fire alarm. "I went to the panel to check which room the fire was coming from and then we smelled something burning. We approached the room (Resident #1's room) and saw a river coming from the bathroom. We didn't see the resident yet so we closed the door and moved all residents to the other side of the building. Moments later I felt uncomfortable and felt like I should check the room again. When we opened the door for the 2nd time, we saw the resident (Resident #1) sitting on her bed eating her breakfast. The water in the room was above the staff ankles. They (staff) saw a lighter in the roommates drawer. The Resident #1 refused to come out of the room. We took her out of the room and sat her on a chair by the elevator. That is when we saw her hair was burned, her glasses were burned and the frames were melted. Her face was red and her ears were red and burned." The surveyor conducted an interview with CNA #1 on 2/18/15 at 9:55 AM. The CNA #1 indicated that the fire alarm went off at 8:06 AM on 2/8/15. "The intercom announcement instructed us to go to room (Resident #1's room). Staff ran to the room with fire extinguishers and blankets. The Resident (Resident #1) was burned on her face and legs. Ten minutes prior to the incident, I checked the Resident (#1) and saw the Resident sitting on the bed. She never smoked in the room prior to this incident and I was not aware that she did this before. She may have stolen the smoking material from the roommate (Resident #2). Before this incident the non supervised smokers were able to keep their cigarettes." The surveyor conducted an interview with CNA #4 on 2/18/15 at 11 AM. CNA #4 indicated that, "the water was in the hallway and I smelled smoke. I saw water coming out of (Resident #1's) room and saw the Resident sitting on the bed. I placed a blanket on the Resident who was wearing a sweater and a Johnny coat. The clothes were burned. I saw the Resident's (Resident #1) hair burned and the hands were red. The roommate was not in the room at that time." The surveyor conducted an interview with CNA #5 on 2/18/15 at 3:25 PM. CNA #5 indicated that "Residents who were not supervised were allowed to keep their smoking material with them. Resident (#1), was on supervision for smoking because of not being steady with ambulation. I was not aware that Resident (#1) had history of doing this before." The surveyor conducted an interview with LPN #1 on 2/18/15 at 3:45 PM. The LPN #1 confirmed that during an assessment of a new admitted resident, "we ask if they are a smoker. If they state yes, we do a safe smoking evaluation. Supervised smokers are those who are cognitively impaired and also according to the score obtained from the safe smoking evaluation. Alert residents were allowed to have the cigarettes and I am not sure about the lighters but I have seen some residents with lighters. I am not aware of resident's (Resident #1) history of smoking inside the facility." The surveyor reviewed the Police report on 2/20/15 at 11:40 PM. According to the police report, the police arrived at the facility on 2/8/15 and were directed to the unit. According to the document, the police stated, "As I approached the room I observed the door closed and water pouring out from underneath the door. I opened the door and observed water pouring out from the ceiling inside the bathroom, as well as, smelled a strong smell of something burning, but did not locate anything on fire. I was then directed down the hall to where the victim was located. I observed that (Resident #1's) entire body, from head to toe, was burned black, as well as, (Resident #1's) hair was gone." 2. The surveyor reviewed the medical record of Resident #2 on 2/18/15 at 12:50 PM. The "Face Sheet" revealed the Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 2 was the roommate of Resident #1 from 2/3/15 until the Reportable Event of 2/8/15 when Resident #1 was transferred to the hospital after unsafe smoking. A Minimum Data Set (MDS), an assessment tool, dated 12/2/14 indicated a BIMS score of 15 indicating that Resident #2 had intact cognition. According to the MDS, Resident #2 required staff supervision for ambulation and eating and limited staff assist for transfers,dressing and hygiene. A review of the Safe Smoking Evaluation dated 11/26/14 indicated that Resident #2 had a total score of 28. On the bottom of the documentation, the legend indicated that a "score of 26-28 = Can safely smoke without supervision." The Safe Smoking Policy indicated that residents can keep cigarettes and lighters in their possession. A review of Resident #2's Interdisciplinary Care Plan on 2/18/15 at 12:50 PM revealed that there was no care plan or intervention for safe smoking for Resident #2 available on the day of survey. When requested by the surveyor, the Director of Nursing was unable to provide a safe smoking care plan for Resident #2. When the surveyor attempted to interview Resident # 2, she was told by the DON that the resident was not in the facility and had been hospitalized for [REDACTED]. On 2/19/15 at 2:06 PM, the facility faxed to the surveyor, an Interdisciplinary Care Plan for Resident #2 for smoking. The undated "Problems/Needs" page of the Interdisciplinary Care Plan, an entry numbered #12 (which was the last entry on the page) indicated, "Supervised smoker R/T (related to) smoking 1/2 cigarette and keeping butts in pocket of coat. The care plan entry #12 was dated 2/11/15 and indicated in the Goals column: "Will smoke safely with supervision and place unsmoked parts of cigarette in ash tray." The following information was noted in the Interventions column: Explain new smoking policy when needed and reinforce PRN (as needed). Encourage to abide by smoking contract. Observe (Resident #2) putting out cigarettes and that they are in ashtrays. Do not let (Resident #2) put cigarettes in pocket of coat. Remind (Resident #2) that safe smoking is important. Encourage (Resident #2) to verbalize her feelings about new smoking policy. The Evaluation column was left blank. Resident #1 care plan failed to indicate that there was a potential for unsafe smoking for Resident #1 who required supervised smoking and was co-habitated with Resident #2, who did not require supervised smoking. On 2/18/15 at 1:45 PM the DON confirmed that Resident #2 assessed as unsupervised smoking and Resident #1 was assessed as supervised smoking. 3. The surveyor reviewed the medical record of Resident #5 on 2/20/15. The "Face Sheet" revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 1/15/15 indicated a BIMS score of 15, indicating that Resident #5 had intact cognition. According to the MDS, Resident #5 required staff supervision for transfers, ambulating and eating with limited assist of one staff for dressing and hygiene. A review of Resident #5's Interdisciplinary Plan of Care indicated that the care plan was initiated on 1/2013 ( no day indicated) and last date entry of 1/2014 (no day indicated). The goals section stated, "PT. (patient) will smoke safely x (for) 90 days, Hx (history) hallucinations/delusions. Likes to smoke cigarettes down to filter." The Intervention column of the care plan, indicated the following: "Assess Pt. while smoking. Explain smoking policy to customer. Monitor Pt for compliance to smoking policy. Attempt to inform Pt. of stop smoking material. Supervise Pt. while smoking. Staff to hold all smoking material. Supervise to monitor that cigarette is not smoked down to filter. Encourage to put out cigarette in ashtray." In the Evaluation column, "4/23/13 and 7/22/13, supervised smoking continued. 1/20/15, continue with supervised smoking." The care plan failed to indicate that there was a potential for unsafe smoking for resident #5 who required supervised smoking, and was co-habitated with Resident #6 who did not require supervised smoking and possessed his/her own smoking material. 4. The surveyor reviewed the medical record of Resident #6 on 2/20/15. The "Face Sheet" revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum data Set (MDS), an assessment tool, dated 1/23/15 indicated a BIMS score of 15, indicating that Resident #6 had intact cognition. According to the MDS, Resident #6 required supervision for ADL's. A review of Resident #6's Interdisciplinary Care Plan dated 2/15/15 indicated in the Goals column stated Resident (#6) will continue to smoke safely. The Interventions column listed interventions that had check off boxes next to the intervention. There were no checks in the boxes that stated: "Resident may smoke unsupervised. Resident must be supervised while smoking. No smoking apron is required. Smoking apron is required." The facility failed to indicate a clear and concise plan for this resident by not indicating which interventions were appropriate for Resident #6. The Evaluation column for this care plan was also blank indicating how compliance with the plan will be evaluated. Resident #6 (the roommate) was allowed to keep smoking paraphernalia in an unlocked area making it accessible to Resident #5. On 2/18/15 at 1:45 PM the DON confirmed that Resident #6 was assessed as unsupervised smoking and Resident #5 was assessed as requiring supervised smoking. 5. The surveyor reviewed the medical record of Resident #7, which was faxed by the facility to the surveyor, after the date of survey, on 2/20/15. The "Face Sheet" revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 7 was the roommate of Resident # 8. A Minimum Data Set (MDS), an assessment too, dated 1/7/15 indicated a BIMS score of 13, indicating that Resident #7 had an intact cognition. According to the MDS, Resident #7 required staff limited assist for ADL's and supervised after setup for eating. A review of Resident #7's Interdisciplinary Care Plan initiated on 7/12 (sic 2012) (no day indicated) and last date entry was 4/2014 (no day indicated). The Goals column stated, Resident #7 "will maintain safety while smoking." The Intervention column of the care plan indicated the following: Resident "will smoke in designated areas only. Smoking agreement signed. Will have cigarettes lit... by staff. Will abide by smoking contract and surrender all cigarettes and lighters to staff. Will understand reasons for smoking safely. Will get cigarettes from smoke monitor." In the Evaluation column, dated "10/12 (sic 2012) (no day specified) Continue to be a supervised smoker. 1/18/13, smoking supervised. 4/16/13 Supervised smoking continues. 7/22/13 Supervised smoking continues. 10/15/13 Compliant with smoking. 1/21/14 No issues. 7/15/14, continues on supervised smoking. 11/4/14 continues to be supervised during smoking. An entry dated 2/18/15 in the evaluation column indicated, "based on new smoking policy, safe smoking evaluation of 1/7/15, (Resident #7) needs to have cigarettes lit by monitor and is considered a safe smoker at this time." The care plan failed to indicate that there was a potential for unsafe smoking for Resident #7 who required supervised smoking and was co-habitated with Resident #8 who did not require supervised smoking and possessed his/her own smoking material. 6. The surveyor reviewed the medical record of Resident #8, which was faxed by the facility to the surveyor, after the date of survey, on 2/20/15. The "Face Sheet" revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment too, dated 1/7/15 indicated a BIMS score of 15, indicating that Resident #8 had intact cognition. According to the MDS, Resident #8 required supervision with eating and extensive assistance of one staff for transfer, dressing, and hygiene. A review of Resident #8's Interdisciplinary Care Plan initiated on 2/15/15, the Goals column stated resident will continue to smoke safely. The Interventions column indicated the following: Asses residents ability to smoke safely and independently. Resident may smoke unsupervised. No smoking apron is required. There was no indication that a smoking care plan was implemented prior to 2/15/15. Resident #8 was the roommate of Resident #7 and was allowed to keep smoking paraphernalia in an unlocked area making it accessible to Resident #7. On 2/18/15 at 1:45 PM, the DON confirmed that Resident #8 was assessed as unsupervised smoking and Resident #7 was required to have supervised smoking. The Immediate Jeopardy which began on 2/3/15 was identified by the surveyor on 2/18/15, who notified the facility DON and the Administrator, of the immediate jeopardy on 2/18/15 at 2:03 PM. The Immediate Jeopardy was lifted on 2/18/15 at 4:49 PM with the implementation of an acceptable Plan of Correction as follows; 1. Upon return, the facility will complete Safe Smoking Evaluation, have contract signed and explain new smoking policy to Resident #1. All smoking paraphernalia will be held by facility. Resident #1 will not be placed in room with an unsupervised smoker. 2. All residents have the ability to be affected. 3. New Smoking Policy developed to include the facility to control all smoking paraphernalia. A smoking monitor will control cigarettes and lighters from 7:00 AM to 11:00 PM and the Nursing Supervisor will control it from 11:00 PM to 7:00 AM. All staff and smoking residents were in-serviced on the new policy. All supervised smokers will cohabitate with non smokers or other supervised smokers. The Social Service Director will ensure all contracts are signed and new smoking rules are explained to new residents. A list of supervised and unsupervised smokers will be kept by the Social Service Director. 4. The Administrator will make rounds on patio during supervised smoking times to monitor compliance daily and meet monthly with unsupervised smokers to discuss continued compliance and effectiveness of the program. He will report these results to the QA Committee Quarterly for 1 year. The Revised New Smoking policy: 1. "When a resident is admitted to the facility, a smoking assessment will be completed. The assessment will determine whether the resident is "safe/unsupervised" or "unsafe/supervised". 2. "Safe/Unsupervised" residents are residents who are able to score 26 - 28 on the safe smoking evaluation. "Unsafe/Supervised" residents score 25 and below. this includes residents that are not able to light their own cigarettes. 3. Smoking is not allowed within the building. The designated area is the "patio", which is located off the lobby. 4. The facility smoking agreement will be signed and witnessed by the resident, regional director, social worker and/or family if applicable. If the resident does not follow the agreement, smoking privileges will be revoked, and/or possible discharge from the facility. 5. All smoking paraphernalia must be surrendered to the nurses and/or admissions upon admission. These items will be kept in plastic bags labeled with the resident's name. These bags will be kept in two (2) tackle boxes. These tackle boxes will be with the Smoking Monitor or supervisor at all times. 6. The smoking area will be monitored by a Smoking Monitor from 7:00 am to 11:00 PM and staff members from 11:00 PM to 7:00 am (for safe/unsupervised smokers only). 7. Safe smokers are allowed to light their own cigarettes but they are required to turn in their matches and/or lighters immediately after use. Any refusal will result in revocation of smoking privileges." NJAC 8:39-27.1 (a)

C # NJ Based on interview and record review, it was determined that the facility failed to develop an accurate and/or revise care plans to address safe smoking for 2 of 8 sampled Residents (Resident #1 and Resident #6) identified as smokers. Resident #1 was assessed for requiring supervised smoking and surrendering smoking paraphernalia in the room. The careplan failed to include the resident's past history of smoking in Resident #1 room at a previous facility. On 2/3/15, Resident #1 received a new roommate (Resident #2) who was allowed to keep smoking paraphernalia in the room. In the "Reportable Event Record/Report" faxed in by the facility to the Department of Health on 2/9/15 stated: "The investigation was done & it appears resident (#1) lit cigarette in the bathroom & caught clothing on fire." On 2/15/15, the care plan initiated for Resident #6 contained conflicting instructions for staff to follow, creating the potential for unsafe smoking for Resident #6. The lack of documentation on Resident #1's careplan regarding a history of smoking in the resident's room at another facility, and the new roommate who was allowed to keep smoking paraphernalia in the room and who did so in an unlocked bedside table making it accessible to Resident #1. This created an immediate jeopardy situation for Resident #1 which began on 2/3/15, was identified by the surveyor on 2/18/15 and was communicated to the Administrator and the Director of Nursing the same day at 2:03 PM. The deficient practice was evidenced by: 1. The surveyor reviewed the medical record of Resident #1 on 2/10/15 at 11:08 AM. The "Face Sheet" revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 12/29/14 indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #1 had intact cognition. According to the MDS, Resident #1 required staff supervision for Activities of Daily Living (ADL's). A review of Resident #1's Interdisciplinary Care Plan (ICP) initiated 9/2014 (the day not documented), the "Goals" column stated Resident #1 "will smoke safely and comply with supervised smoking rules." The "Intervention" column indicated the following, but was not limited to: Resident "will smoke in designated areas. Will surrender all smoking paraphernalia to staff. Smoking agreement discussed and signed. Remind Pt. (patient) of smoking rules and regulations and loss of privilege with non compliance. Designated smoke times with supervision. Redirect Pt. of safe extinguishing of cigarette." The "Evaluation" column indicated, 12/29/14, "supervised smoking continued." The facility failed to address in Resident #1's ICP, the resident's history of smoking in his/her room at a previous facility. The care plan further failed to indicate that there was a potential for unsafe smoking for Resident #1 who required supervised smoking and was co-habitated with Resident #2 who did not require supervised smoking and possessed his/her own smoking material. According to a pre-admission packet that was provided to the facility from the discharging facility prior to Resident #1's admission on 9/24/14, the information reflected that Resident #1 had a history of [REDACTED]. As per DON on 2/18/15 at 1:45 PM, Resident #1 was initially co-habitated with a roommate who was a non smoker. On 2/3/15 the facility co-habitated Resident #1, who required supervised smoking, with a resident who did not (Resident #2). Resident #2 had no cognitive deficits, ambulated independently, was a non-supervised smoker and was allowed to keep smoking materials in his/her room. Resident #2 (the roommate) kept cigarettes and lighting material in a bed side table, that had no locking mechanism, making it accessible to Resident #1. In addition, staff stated they were not aware of Resident #1's history of smoking in his/her room at the previous facility. The surveyor interviewed CNA #1, CNA #5 and LPN #1 on 2/18/15, who indicated that they were not aware of his/her history of unsafe smoking. During an interview, the Nursing Supervisor (NS) stated that she was alerted to Resident #1's room by a fire alarm on 2/8/15 at 8:08 AM. Upon arrival to the room, the NS noted the sprinkler was on in the bathroom. The NS did not see Resident #1 in the room at that time and closed the door. Moments later, NS felt uncomfortable that the fire alarm system was indicating a fire in Resident #1's room and went back to re-check it. At that time, Resident #1 was discovered alone in the room by the NS, sitting on the bed with the breakfast tray in front of him/her. The NS noted the resident was wet, his/her hair was shorter and singed, the ears were burned and the face, hands and legs were red. The NS also noted the resident was wearing a Johnny coat on top of his/her clothing and his/her clothes underneath were burned. The resident was removed from the room, placed in a chair and a blanket and oxygen was applied. The resident was transported to the ER for further evaluation. The Resident #1 was then air lifted to a hospital in another state. This incident required the evacuation and relocation of all residents to other Health Care facilities and/or home with family, until environmental remediation due to water damage was complete. The surveyor interviewed the DON (Director of Nursing) on 2/18/15 at 9:07 AM. The DON indicated that the facility had a meeting with all the alert non supervised residents on 2/13/15 regarding the new smoking policy. "All residents agreed to the revised smoking policy and understood the reasons for it. With the new policy initiated on 2/13/15, all cigarettes and lighters are now held downstairs. We now have a smoking monitor who holds all smoking material from 7 AM to 11 PM. The supervisor gets all smoking material after 11 PM. The unsupervised residents can smoke in the middle of the night with staff supervision. All residents are supervised by staff during the time of 11 PM to 7 AM. No one is holding any smoking material as of Friday 2/13/15. Staff were in-serviced on the new smoking policy on 2/17/15." The surveyor interviewed the DON on 2/18/15 at 12:47 PM. The DON stated that Resident #2, "was currently in the hospital." Prior to hospitalization , Resident (#2) "denied giving smoking material to the roommate (Resident #1)." The DON further indicated that Resident #2 "was not in the room when the fire alarms went off." 2. The surveyor reviewed the medical record of Resident #6 on 2/20/15. The "Face Sheet" revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum data Set (MDS), an assessment tool, dated 1/23/15 indicated a BIMS score of 15, indicating that Resident #6 had intact cognition. According to the MDS, Resident #6 required staff supervision for ADL's. A review of Resident #6's Interdisciplinary Care Plan dated 2/15/15 indicated in the Goals column stated Resident (#6) will continue to smoke safely. The Interventions column listed interventions that had check off boxes next to the intervention. There were no checks in the boxes that stated: "Resident may smoke unsupervised. Resident must be supervised while smoking. No smoking apron is required. Smoking apron is required." The facility failed to indicate a clear and concise plan for this resident by not indicating which interventions were appropriate for Resident #6. The Immediate Jeopardy which began on 2/3/15 when Resident #1 and Resident #2 became roommates was identified by the surveyor on 2/18/15, communicated the same day at 2:03 PM to the Administrator and the Director of Nurses was lifted at 4:49 PM upon implementation of an acceptable plan of correction as follows; 1. Upon return, the facility will develop a individualized Care Plan for smoking based on Safe Smoking Evaluation for Resident #1. 2. All smoking residents have the ability to be affected. 3. Safe Smoking Evaluations are to be completed on each resident. Residents that smoke will have a care plan that specifies reason(s) for supervision. All nurses will be in-serviced on completing Care Plans for residents that smoke. (In-services were started on 2/17/15) 4. The DON or designee will monitor Care Plans for residents that are smokers within 48 hours of admission and quarterly to ensure they are specific. The results will be reported to the QA Committee Quarterly for 1 year. The Revised New Smoking policy stated the following: 1. "When a resident is admitted to the facility, a smoking assessment will be completed. the(sic) assessment will determine whether the resident is "safe/unsupervised" or "unsafe/supervised". 2. "Safe/Unsupervised" residents are residents who are able to score 26 - 28 on the safe smoking evaluation. "Unsafe/Supervised" residents score 25 and below. this includes residents that are not able to light their own cigarettes. 3. Smoking is not allowed within the building. The designated area is the "patio", which is located off the lobby. 4. The facility smoking agreement will be signed and witnessed by the resident, regional director, social worker and/or family if applicable. If the resident does not follow the agreement, smoking privileges will be revoked, and/or possible discharge from the facility. 5. All smoking paraphernalia must be surrendered to the nurses and/or admissions upon admission. These items will be kept in plastic bags labeled with the resident's name. These bags will be kept in two (2) tackle boxes. These tackle boxes will be with the Smoking monitor or supervisor at all times. 6. The smoking area will be monitored by a Smoking Monitor from 7:00 am to 11:00 PM and staff members from 11:00 PM to 7:00 am (for safe/unsupervised smokers only). 7. Safe smokers are allowed to light their own cigarettes but they are required to turn in their matches and/or lighters immediately after use. Any refusal will result in revocation of smoking privileges." NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to develop a care plan based on individual assessment and the use of the Minimum Data Set (MDS), with interventions to address the specific needs of the resident. The facility failed to develop interventions for a resident who had a history of [REDACTED]. This deficient practice was identified in 1 of 24 residents, Resident #18, and was evidenced by the following: During the initial tour on 11/27/12 at 10:00 a.m., the surveyor was informed that Resident #18 had behavior issues which included a history of wandering, hitting, and spitting. Resident #18 had [DIAGNOSES REDACTED]. with behavioral disturbances. On 11/29/12 and 11/30/12 at 11:00 a.m., the surveyor observed the resident seated in a wheelchair with a lap buddy in place in the activity room. On 11/30/12 at 11:30 a.m., the surveyor reviewed the clinical record which revealed that the resident had a behavior of wandering thoughout the halls and into other residents room. On 11/30/12 at 11:30 a.m., the surveyor reviewed the care plan for Resident # 18. The behavior of wandering was not identified. On 12/3/12 at 10:00 a.m., the Director of Nursing (DON) confirmed that there were no care plan interventions to address the resident's wandering behavior. Refer to F323 NJAC 8:39-11.2 (e) `

Based on observation, interview and record review, it was determined that the facility failed to identify the presence of pressure ulcers or ensure weekly skin integrity assessments were accurately documented. Pressure sores were not identified prior to the discovery of Stage II and Satge IV. This deficient practice was identified for 2 of 6 sampled residents (Residents' #3 and #11) reviewed for pressure sores and was evidence by the following: 1. On 11/27/12 at 9:45 a.m.; during the initial tour of the facility, the nurse told the surveyor that Resident #11 had an unstageable facility acquired pressure sore to the left buttock area. The resident was observed in bed positioned on the left side. A [DEVICE] suction device was noted on the bedside table. The surveyor reviewed the medical record of Resident #11 on 11/28/12 at 10:15 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. A Nurse's Note dated 6/20/12 at 6:30 p.m., revealed the resident was found with a pressure sores to the left buttock area which measured 3 centimeter (cm) x 3 cm. Further review of the clinical record revealed an order for [REDACTED]. On 11/28/12 at 11:15 a.m., the surveyor reviewed the Minimum Data Set ((MDS) dated [DATE] and 10/15/12, which revealed that the resident's ability to perform activities of daily living (ADL) was impaired. The resident required total assistance of staff for bed mobility and transfer, and was incontinent of bladder and bowel. Both MDS assessments indicated that Resident #11 was at risk to develop pressure sores but the resident's skin was intact until 6/20/12. A review of the Nurse's Notes from 4/25/12 to 6/20/12 did not document or identify redness or skin impairment. A review of the Braden Scale for predicting pressure sore risk dated 7/14/12 revealed that the resident was assessed as a "12" or considered to be at risk for the development of pressure sores. On 11/28/12 at 12:30 p.m., the surveyor further reviewed the clinical record which indicated on the weekly skin assessment dated from 6/2/12 to 6/20/12 that the resident's skin was intact even on the day the pressure sore was identified. The pressure sore was found on 6/20/12 and described as "unstageable." A wound consult dated 6/21/12 one day after the pressure sore was identified documented the following: " Wound at least 5 days duration, necrotic tissue removed. " On 11/28/12 at 1:30 p.m., the unit manager told the surveyor that the resident was provided with an air mattress on 6/21/12. A review of the Nurse's Note dated 6/21/12 confirmed the same. On 10/29/12 at 9:30 a.m.; the surveyor reviewed a Physician order [REDACTED]. On 11/29/12 at 11:00 a.m.; the surveyor reviewed a form titled, "Wound Care Specialist Evaluation" dated 6/21/12, which was an "Initial Evaluation." In the area of (History of Present Illness) the Wound Consultant documented, "..patient has an unstageable (due to necrosis) of the left buttock of at least 5 days duration. There are light serous exudates associated with the wound." (Etiology) indicated "Pressure." Under (Additional Information) the Wound Consultant documented, "discussed with nursing staff the use of group 2 or higher mattress to decrease the pressure in the sacral area. Reposition the patient every1-2 hours as per facility protocol, Roho cushion while sitting, limit sitting to 30 minutes at a time... " On 11/29/12 at 11:30 a.m; the surveyor interviewed the Unit Manager Nurse (UMN) who stated that the pressure sore was facility acquired and was identified as unstageable on 6/20/12. The UMN provided the surveyor with the wound tracking form dated 6/21/12 which identified the pressure sores of the left buttock. The following measures were documented, 4.5 centimeter (cm) x 3.5 cm. A review of a Nurse's Note dated 6/2012 revealed that the 3-11 staff alerted the nurse of the pressure sore. There was no documentation in the clinical record from the previous shift that the resident had a change in skin integrity to the left buttock area. On 11/29/12 at 12:30 p.m; the CNA who provided cared for the resident told the surveyor that Resident #11 was bedridden due to the wound suction device. The surveyor reviewed the Activities of Daily Living Flow Sheet (ADL) with the CNA, there was no documented evidence or knowledge that prior to the development of the pressure sore a turning schedule was implemented to alert the staff of how often the resident should be turned/repositioned. An additional interview with the Unit Manager on 11/29/12 at 1:00 p.m. indicated that a turning schedule was implemented and placed in the resident's room only after the wound was identified. The resident received a Roho cushion for the wheelchair on 6/21/12. On 11/29/12 the surveyor observed the nurse perform a dressing change to the resident's left buttock. The left butock's wound measured, 0.9 x0.1 x0.6 cm. A wound suction device had been in place to facilitate wound healing. There was no documentation in the clinical record regarding any change in the skin condition. A dietary note written on 6/19/12 documented the resident's skin was intact, appetite better, weight 132lbs. Laboratory values drawn on 6/22/12 revealed a pre-[MEDICATION NAME] of "8" . A review of the meal intake section from 4/18/2012 to 4/31/2012 revealed no entries. On 4/22/12 there was an entry for the lunch meal which indicated that the resident consumed 80% of the dinner. On May 16, 17, 18, the meal monitor form revealed that there was no documentation regarding the resident's intake for breakfast and lunch. For the month of June the ADL's Flow Sheet was not provided to the surveyor for review. A Nurse's Note dated 6/28/12 at 10:10 a.m., revealed the resident was admitted to the hospital with [REDACTED]. 2. During the initial tour of the facility on 11/27/12 the nurse told the surveyor that Resident #3 had a stage II facility acquired pressure sores to the right buttock area. On 11/28/12 at 10:15 a.m., the surveyor reviewed the resident's clinical record. A Nurse's Notes dated 11/5/12 revealed that the resident was found with multiple blisters on both feet. an order for [REDACTED]. Right buttock 3 cm x 2 cm, cluster and sacrum 0.3 cm x 1 cm. A review of the admission assessment record dated 9/12/12, revealed the resident's skin was intact on admission. The Braden Scale Assessment for predicting pressure sores dated 9/11/12 indicated the resident was a low risk for pressure sores development. A review of the Bi-Weekly Skin Assessment from 11/2/12 to 11/20/12 indicated that the resident's skin was intact. A review of the Weekly Wound Audit initiated on 11/21/12 revealed that the resident was found with a stage II pressure sore to the left sacrum which measured 0.8 x 0.5 cm, a stage III pressure sore to the left buttock measuring 2 cm x 1cm x 0.2 cm., a stage II right buttock cluster measuring 3cm x 2cm x 0.1 cm., and a stage III sacrum pressure sore measuring 1x 0.3x 0.1 cm. A review of an Interdisciplinary Care Conference dated 10/04/12 revealed the resident required extensive assistance with ADLs and was incontinent of bladder and bowel. On 11/28/12 at 11:15 a.m.; the CNA confirmed that the resident required extensive assistance from staff for bed mobility and transfer. On 11/28/12 at 11:30 a.m., the nurse told the surveyor that the CNAs were responsible to report any skin condition to the nurse. The UMN informed the surveyor that he/she was not made aware of the pressure sores until 11/20/12. A review of the Activities of Daily Living Flow Sheet (ADL) did not contain data referencing skin assessment/documentation. There was no documentation or assessment in the clinical record regarding the residents sacral pressure sore until 11/20/12. A review of the facility's "Wound Care Policy and Procedures" (revised in 2007) on 12/2/12 did not include preventive measures to prevent pressure sores. The Policy did not address staff' responsibilities in regard to skin assessment and documentation. On 12/2/12 the administrative staff told the surveyor that they were aware of the concerns with documentation. The Director of Nursing told the surveyor that going forward, staff would be in-serviced and measures would be implemented. NJAC:8:39-27.1(e)

Based on observation, interview and record review, it was determined that the facility failed to a.) monitor and supervise a cognitively impaired resident who was identified with unpredictable behavior of wandering to other residents' rooms and being disruptive, and b.) ensure that preventive measures were in place to prevent residents identified as high fall risk for falls from becoming injured. The failed practice resulted in Resident #18 sustaining a right toe fracture from pulling a television from another resident room. In addition, Resident #10 was left in bed without a side rail and fell sustaining a right hip fracture. Resident #14 was left unupervised in the room without a lap buddy and fell sustaining 3 skin tears to the right hand. This deficient practice was identified for 3 of 3 residents reviewed for accident/injury, Resident #10, #14 and #18 and was evidenced by the following: 1. During the initial tour of the facility on 11/27/12 at 10:00 a.m., the Unit Manager (UM) told the surveyor that the resident was alert to self with confusion to time, place and surroundings. Resident # 18 had a [DIAGNOSES REDACTED]. The surveyor reviewed the medical record of Resident # 18 on 11/30/12 at 11:00 a.m., which revealed the resident had [DIAGNOSES REDACTED]. dementia and syncope. The medical record also confirmed that the resident had a history of [REDACTED]. Review of a timeline provided to the surveyor by the Director of Nurses (DON) on 12/3/12 at 10:00 a.m., revealed that the resident was observed by the Administrator in another resident's room and sat self on floor. Resident was assessed and was able to be redirected. On 3/6/12 the resident was noted to be pacing and wandering. On 4/15/12 resident was noted to be wandering into another resident's room when he/she lost her balance and fell on his/her buttocks. Resident was assessed and found to have no injuries. New intervention was for therapy screen for unsteady gait. On 5/14/12 resident was noted on floor in the hallway with hemotoma present to posterior head. According to the incident report provided to the surveyor by the facility, the resident was sent to the emergency room (ER) for evaluation. According to the discharge instructions from the ER, the resident required staples to close the wound. Resident was noted to have wandered from the Behavior Management Aide (BMA) program. Intervention post fall was to continue to encourage resident to remain in the BMA program. The surveyor reviewed Resident #18's care plan on 11/30/12 at 11:30 a.m. The behavior of wandering about the unit and in and out of residents' rooms was not addressed on the care plan nor were interventions implemented. According to Resident # 18's Clinical Notes he/she ambulated into room 333 on 6/6/12 at 10:00 a.m. and pushed a television over onto the floor. He/she did not sustain any injuries from this incident. The resident was escorted back to the BMA program. When asked, the facility was unable to supply an incident report of this event. According to the Clinical Notes for Resident #18 on 7/6/12 at 11:15 a.m., the nurse was alerted to a bang in room 321. The resident was found to have pulled the TV off the stand and it landed near her great left toe causing a 3 cm x 3cm open area at the nail bed area. The clinical note also indicated that the resident had attempted the same behavior earlier in the day and was redirected. According to the incident report provided by the facility the resident was sent to the hospital via ambulance. According to the Clinical notes dated 7/6/12 3:30 p.m., the resident had sustained a fractured great left toe and required 3 sutures to the left lateral toe. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour of the facility on 11/27/12 at 10:45 a.m., the nurse identified the resident as being at risk for falls. The surveyor observed the resident in bed; the bed was placed against the wall with two full side rails up. The nurse told the surveyor that the family requested that full side rails be used for the resident. The surveyor reviewed the medical record of Resident #10 on 11/28/12 at 11:30 a.m., which revealed that the resident sustained [REDACTED]...4:30 a.m., heard noise. Found patient on floor by the bed, bed alarm in place but not alarming. Resident was put back in bed and went to sleep." There was no documented evidence or evidenced offered by the facility staff that the resident was assessed post fall. On 11/29/12 at 10:45 am; the surveyor reviewed the investigative report provided by the facility. According to the report, the resident did not have side rails in place prior to the fall. A review of the physician's sheet dated 11/5/12 revealed an order for [REDACTED]. A review of a form titled, "Side rail Assessment" dated 11/5/12 revealed that the resident was assessed and side rails would be used as enabler. A review of the resident's care plan initiated 11/6/12 listed the following interventions: a) Keep the bed in the lowest possible position b) ? side rails up when in bed On 11/29/12 at 11:30 a.m., the surveyor observed the resident in bed; the Certified\Nursing Assistant (CNA) was at the bedside assisting the resident with care. The CNA told the surveyor that the resident required extensive assistance with all activities of daily living. The Minimum Data Set (MDS) a resident assessment tool coded the resident as required extensive assistance with care. The resident's admission assessment dated [DATE] revealed that the resident was lethargic and sleepy on admission. Interview with the CNA on 11/28/12 at 10:30 a.m., confirmed the same. On 11/29/12 at 12:30 p.m; the surveyor interviewed a family member who revealed that the resident fell because staff failed to have the side rails in place on 11/7/12. At approximately 12:15 on 11/29/12 the surveyor interviewed the unit nurse who indicated that the fall occurred on the 11-7 shift and could not provide any information on the status of the side rails prior to the fall. An interview with the nurse, who worked the 11-7 shift the day of the fall on 12/3/12 at 2:40 p.m., revealed the resident did not have side rails in place prior to the fall. The nurse told the surveyor that a full side rail was applied after the fall to ensure the resident's safety. She added that the resident was left in bed without the side rails on 11/7/12, fell and sustained a fall which resulted in a right hip fracture. A review of the CNA's statement dated 11/7/12 did not indicate that the resident had ? side rails in place prior to the fall. According to the Interdiciplinary Progress Note dated 11/9/12 at 9 a.m., the resident was admitted to the hospital and underwent surgery for [REDACTED]. The resident returned to the facility on ,[DATE] /12. 3. On 11/27/12 at 11:15 a.m., while on the initial tour the nurse told the surveyor that Resident #14 had history of falls and wandered at times. The resident was observed seated in the hallway with a lap buddy in place. On 11/28/12 at 11:30 a.m., the surveyor reviewed the medical record of Resident #14 which revealed that the resident had [DIAGNOSES REDACTED]. On 11/28/12 at 12:30 p.m. and 11/29/12 at 10:15 a.m., the surveyor reviewed the investigative summary report provided by the facility. The following was noted: According to the Incident/Accident Report dated 10/13/11, the resident was observed exiting the room with a laceration to the right eye. The resident later confirmed that he was assaulted by his/her roommate. On 1/26/12 the resident struck another resident in the face and was sent to the ER for evaluation and was admitted . On 3/7/12 the resident was found in the roommate's bed with a laceration to the right eyebrow. The causative factor was not identified. The facility could not provide evidence of an investigation regarding the incident. On 4/2/12, the resident was noted with a discoloration and abrasion to his forehead. There was no documented evidence the resident's aggressive agitated behavior was re-addressed or interventions were re-assessed. On 4/23/12 the resident fell and sustained a laceration to the forehead. A review of the Incident/Accident Report revealed that no protective equipment was in use at the time of the fall. The facility could not provide any explanation for the lap buddy not being in place. According to an incident summary of events provided to the surveyor on 12/2/12, the lap buddy placement was unknown. According to that same summary of events the resident continued to lose his/her balance and fall sustaining an abraision to the left eye on 5/19/12 and again on 8/24/12 when the resident was left unsupervised in the room without the lap buddy, fell , and sustained 3 skin tears to the hand. According to a Restraint Committee summary dated 12/11, the team addressed safety issues for this resident. The summary indicated that a lap buddy should be continued to address the residents activity of getting up and trying to walk "..all the time. The resident has an unsteady gait." According to a summary of events provided to the surveyor on 12/2/12, a lap buddy was ordered for the resident on 11/23/11. There was no documentation indicating this intervention was consistently followed. An interview with the Certified Nursing Assistant, who cared for the resident on 11/29/12 at 12:30 p.m., revealed that the resident could be difficult to redirect and needed constant supervision. During a discussion of the above with facility Administrative staff on 12/3/12 at 10:15 a.m., the DON revealed that the facility identified the issues with supervision and documentation. The DON further stated that the staff would be in serviced on the application of safety devices, intervention assessment, and documentation of same. N.J.A.C.8:39-27.5(b) 29.1 27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide nourishment via a Gastrostomy Tube (GT) in accordance with physician orders [REDACTED].#12 and an unplanned weight loss for Resident #16. This deficient practice was evident for 3 of 4 residents reviewed for Gastrostomy feeding as follows: 1. During the initial tour on 8/29/11 at 10 a.m., the unit nurse told the surveyor that Resident #12 was totally dependent on a Gastrostomy Tube for all nutritional needs. The resident was observed in the hall in a recliner chair. The feeding pump, which had been disconnected and turned off, was observed in the resident's room with a bottle of [MEDICATION NAME] 1.5 hanging on the pump. There was approximately 200 cc remaining in a 1000 cc bottle which had been started at 6 p.m. the evening before. The pump was set at 60 cc per hour and showed that a total volume of 818 cc had been given. At 1 p.m. the surveyor reviewed Resident #12's medical record. The resident had a physician order [REDACTED]. The order included to start the feeding at 6 p.m. and to infuse it for 14 hours for a total volume of 840 cc of formula (providing 1260 calories.) The corresponding Medication Administration Record (MAR) was being signed daily by the nurses at 6 p.m. when the feeding was started and at 8 a.m., 14 hours later, when the feeding was stopped. The MAR did not include the actual volume which had infused. On 8/30 at 8:20 a.m. the surveyor observed the unit nurse provide medications to Resident #12 via the GT. The nurse told the surveyor that the feeding was scheduled to stop at 8 a.m. and disconnected the feeding. The nurse did not check the volume infused on the pump. After the nurse left the room the surveyor observed the feeding pump which indicated that 770 cc of formula had infused. That was 70 cc and 105 calories less than the resident was scheduled to receive. On 8/29, the resident received 22 cc and 33 calories less than prescribed. On 9/1 at 8 a.m. the surveyor interviewed the unit nurse who stated that the feeding was disconnected at 8 a.m., according to the scheduled time. The Director of Nurses (DON), who was present when the nurse was interviewed, stated that the feeding should stop when the total volume was infused, not at 8 a.m. each day. The DON confirmed to the surveyor that the nurses were not recording the volume infused on the MAR and were signing that the feeding was discontinued at 8 a.m. daily. On 8/30 the surveyor reviewed the resident's monthly weights. From 2/11, when the GT was placed, thru 8/22/11, the resident's weights were recorded as stable between 170 and 176 lbs. On 9/1 at 2 p.m. in the presence of the surveyor, the resident was weighed using a mechanical lift. The resident weighed 159.2 lbs., a 13 lb. weight loss from the previous weight of 172.2 lbs recorded on 8/22/11. The surveyor interviewed the unit nurse who stated that the resident was always weighed with the mechanical lift scale. The facility was unable to provide accountability for the volume of formula infused for Resident #12 who had a weight loss and was totally dependent on the GT for all nutritional needs. 2. During the initial tour on 8/29/11, the nurse unit manager stated that Resident #16 was cognitively impaired, required total care with all activities of daily living, and received all nutrition via gastrostomy tube. The unit manager stated that the pump was started at 4 p.m. and taken down at 8 a.m. The surveyor reviewed the medical record on 8/30/11 and noted a physician order [REDACTED]. The corresponding Medication Administration Record (MAR) was being signed daily by the nurses at 4 p.m. when the feeding was started and at 8 a.m., 16 hours later, when the feeding was stopped. The MAR did not include the actual volume which had infused. At 10:40 a.m. the surveyor observed the feeding tube pump which indicated that the rate set was 52 cc/hr; the volume to infuse was set at 832 cc; but the total amount actually fed was 767 cc, less than ordered by the physician. During a review of the resident's weight record, the surveyor noted that in April,2011 the resident weighed 141 lbs; May 142 lbs; June 140 lbs; July 138 lbs; and in August, the resident weighed 136 lbs. On 8/31, the surveyor asked to have the resident weighed and observed the resident being weighed via Hoyer lift/weight scale at 1:20 p.m. According to the nurse's aide, the resident was always weighed via the Hoyer scale. The weight registered 131.4 lbs, a 5 lb weight loss in 1 month and a 9 lb weight loss in 3 months. The surveyor spoke to the Director of Nursing (DON) at 1:30 p.m. After explaining the total volume infused discrepancy, the surveyor asked if there was a medical reason for Resident #16's weight loss. The DON stated she would investigate. On 9/1/11 at approximately 12:30 p.m., the DON stated that the resident's weight had been stable prior to this month and that the interdisciplinary team would have implemented interventions after the weight loss had been noted. The surveyor again asked if there had been any medical reason for the unplanned weight loss for the resident who was dependent upon staff for all care needs. The DON was unable to give an explanation. 3. Resident #6 was admitted to the facility for status [REDACTED]. The surveyor reviewed the resident's medical record which revealed a physician's orders [REDACTED]. On 8/30/11 at 7:50 a.m. and 8/31/11 at 7:45 a.m., the surveyor observed no tube feeding formula being infused and the feeding pump settings were set at zero. Review of the medication administration records revealed no accountability of the amount infused. During interview, the Licensed Practical Nurse (LPN) was unable to tell the surveyor the total volume infused of the tube feedings for 8/30/11 or 8/31/11 for Resident #6. NJAC 8:39-17.4(a)1

Based on interview and record review it was determined that the facility failed to protect a resident from a fall that occurred during an improper transfer which resulted in a fracture of the right leg. This deficient practice was found in 1 out of 9 residents sampled (Resident #1) for falls/ fractures/ abrasions/ bruises. Evidence was as follows: 1. Resident # 1 was a [AGE] year old resident with [DIAGNOSES REDACTED]. During the initial tour, the unit manager described the resident as having a fall, had an immobilizer in place, was non weight bearing, and was able to get out of bed to a recliner. The resident was also on Hospice services. The medical record contained an Interdisciplinary note dated 6/2/10 at 2:15 p.m. revealing that the hospice aide notified the nurse that, during the transfer from the geri chair to the bed, the resident's leg buckled underneath her and the aide assisted the resident to the floor. Review of the fall investigation of 6/2/10 at 2:15 p.m. indicated that after the resident was lowered to the floor, the resident's leg looked mal-aligned. The resident was sent to the emergency room and was admitted with a right femoral fracture. The annual Minimum Data Set (MDS, an assessment tool) dated 4/2/10 indicated that the resident was cognitively impaired, needed total assistance for activities of living, and needed extensive assistance of 2 for transfers. The resident's care plan, updated 3/10, noted 2 assists for transfers or mechanical lift. The hospice documentation dated 5/26/10 indicated that the assistance of one was required for transfers. There was no documented evidence or evidence provided by the facility regarding transfers to reflect coordination between hospice and the facilities plan of care. During an interview on 9/27/10 at 12:00 p.m., the unit nurse stated that on the day the resident fell she heard the Certified Nurse Assistant (CNA) yelling for help. When the nurse entered the resident's room she observed the CNA lowering the resident to the floor. The CNA was trying to transfer the resident by herself. The unit nurse stated " I don't know why she (hospice CNA) was doing that, she usually calls me to help her to transfer the resident." When questioned how the CNA finds out how to care for the resident, the nurse opened the resident's closet door and pointed to the "Resident care card" located in a plastic holder. The card noted transfers: assist of 2 or mechanical lift. NJAC 8:39- 27.1 (a)