Every finding on record at Silver Healthcare Center

Complaint #: 2734069 Based on interviews, record reviews, and review of facility documents, it was determined that the facility failed to provide adequate monitoring and supervision to prevent a fall that caused a skin tear, facial bruising, and admission to the hospital for subdural hematoma (collection of blood in the tissues of the body outside of the blood vessels) to a resident who was assessed as a high risk for falls, had two previous falls in the facility, and was on one-to-one monitoring. This deficient practice occurred for 1 of 4 residents (Resident #2) reviewed for accidents. This deficient practice was evidenced by the following:Resident #2 no longer resided at the facility. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses including but not limited to: multiple fractures of ribs, left side, subsequent encounter for fracture with routine healing; laceration without foreign body of other part of the head, subsequent encounter; unspecified fall, subsequent encounter; muscle weakness; other lack of coordination; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/04/2025, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the resident had moderate cognitive impairment. The MDS revealed that Resident #2 used a wheelchair while at the facility, had impaired range of motion to their upper extremities and was dependent on a helper to move from sitting to standing. The MDS further revealed that Resident #2 had fractures related to a fall in the 6 months prior to admission. A review of Fall Risk Evaluations (FREs), Progress Notes (PNs) and the Care Plan (CP) for Resident #2 revealed the following: On 11/28/2025 the resident received a FRE score of 18, which indicated that the resident was at risk for falls. Resident #2's CP revealed a focus which indicated that the resident was at risk for falls related to confusion, gait/balance problems, and a history of falls. The initiation date was 12/01/2025. Interventions included but were not limited to anticipate the resident's needs, place the call bell within reach, and wear appropriate footwear. A PN dated 12/11/2025 at 11:24 PM, revealed that resident #2 had an unwitnessed fall, the resident stated to staff that they bumped their head and fell. Physician #1 was notified and ordered that Resident #2 go to the hospital. The resident was sent to the hospital via 911. On 12/11/2025, after the fall, Resident #2 received a FRE score of 9, which indicated that the resident was at low risk for falls. A review of Resident #2's CP revealed a focus of, Resident #2 is at risk for falls related to confusion, gait/balance problems, history of falls, with interventions including but not limited to: every two-hour toileting at night, and use of non-skid socks being initiated on 12/11/2025. A PN dated 12/12/2025 at 4:36 PM, revealed that Resident #2 had an unwitnessed fall in the bathroom. The resident had hematoma (collection of blood in the tissues of the body outside of the blood vessels) and laceration (cut or tear) to the back of their head with active bleeding. The physician was notified, and Resident #2 was sent to the hospital. On 12/12/2025 Resident #2 received a FRE score of 17, which indicated that the resident was at high risk for falls. A review of Resident #2's CP revealed a focus of, Resident #2 is at risk for falls related to confusion, gait/balance problems, history of falls, with interventions including but not limited to: one-to-one supervision being initiated on 12/12/25. A PN dated 12/29/2025 at 11:28 PM, revealed that Resident #2 had an unwitnessed fall across from the nurse's station at 11:10 PM. The PN revealed that the resident's one-to-one monitor had left. The PN further revealed that Resident #2 sustained a skin tear to their left upper arm. A PN written by Nurse Practitioner #1, dated 12/30/2025 at 11:50 AM was reviewed. The PN revealed that Resident #2 had a bruise on their forehead and a skin tear on their arm. The PN revealed that Resident #2 had new-onset aphasia (difficulty speaking or understanding what others say) and was unable to identify items which they were previously able to name. The PN further revealed that because of the neurologic change after the fall Resident #2 was to be sent to the Emergency Department via 911 for a CT scan of the brain. A PN dated 12/31/2025 at 1:02 AM, revealed that Resident #2 was admitted to the hospital for subdural hematoma. An Incident Report (IR) dated 12/29/2025 at 11:10 PM, written by Registered Nurse (RN) #1 was reviewed. The IR revealed that Resident #2 and a staff member indicated that the resident had fallen at the nurse's station. The staff member denied witnessing the fall. A handwritten statement by RN #1 dated 01/01/2026 revealed that on 12/29/2025 Resident #2 fell and injured their arm. The statement revealed that during the 3:00 PM - 11:00 PM, shift Resident #2 had one-to-one monitoring, but RN #1 was unsure when the one-to-one and Resident #2 separated. RN #1's statement revealed that Resident #2 was observed speaking to Licensed Practical Nurse (LPN) #1 prior to their fall, but RN #1 did not know if Resident #2 was placed in the care of LPN #1 when CNA #1 (who had been the resident's one-to-one monitor for the 3:00 PM- 11:00PM shift) left the unit and before her replacement arrived. The statement further revealed that at approximately 11:10 PM, Resident #2 was found on the floor asking for help. A handwritten statement by Certified Nursing Assistant (CNA) #1, dated 01/02/2026, was reviewed. The statement revealed that CNA #1 asked LPN #1 to watch Resident #2 and left the unit at the end of her shift. The statement further revealed that LPN #1 then asked another CNA (CNA #2) to watch Resident #2. An emailed statement from LPN #1 dated 01/02/2026 at 12:13PM, was reviewed. The statement from LPN #1 revealed that he arrived at work at 10:50 PM and saw CNA #1 with Resident #2 at the nurse's station. LPN #1 did his rounds and then returned to the nurse's station where he saw Resident #2, but not CNA #1. The statement further revealed that no one spoke with LPN #1 about Resident #2's care and he did not witness the resident's fall. A telephone statement from CNA #2 dated 12/30/2025, was reviewed. The statement revealed that the CNA clocked in to work at 11:02 PM, and observed Resident #2 sitting in their wheelchair across from the nurse's station. CNA #2 then observed Resident #2 stand up and walk. The resident's wheelchair spun, and Resident #2 hit their face and arm on the wheelchair before the CNA could reach the resident. CNA #2' s statement did not reveal that she was assigned as Resident #2's one-to-one monitor or that she had accepted responsibility for supervising the resident. An interview was conducted with the Unit Manager (UM) on 02/04/2026 at 1:03PM. The UM stated that a resident under one-to-one supervision should always have a staff member with them. The UM stated that if the staff assigned as a one-to-one needed to take a break or leave the resident another staff member must relieve them. A telephone interview was conducted with CNA #1 on 02/04/2026 at 2:02 PM. CNA #1 stated that when assigned as a one-to-one monitor, staff were supposed to remain with the resident all the time unless they were relieved by another staff member. CNA #1 stated that she was assigned as Resident #2's one-to-one monitor for the 3:00PM - 11:00PM shift on 12/29/2025. CNA #1 stated that before leaving the unit, she informed LPN #1 that Resident #2 needed one-to-one monitoring. CNA #1 stated that LPN #1 asked another CNA to watch Resident #2. CNA #1 could not identify the CNA that LPN #1 asked to supervise Resident #2. The Surveyor attempted to reach LPN #1 and CNA #2 for interviews but was not successful. An interview was conducted with the Director of Nursing (DON) on 02/04/2026 at 2:31PM. The DON stated that Resident #2 was on one-to-one supervision in an effort to prevent accidents. The DON stated prior to leaving Resident #2 at the nurse's station, CNA #1 told LPN #1 to supervise the resident. LPN #1's statement which denied assuming responsibility to supervise Resident #2 was reviewed with the DON. The DON offered no explanation of why LPN #1 denied witnessing Resident #2's fall or assuming responsibility for the resident's one-to-one monitoring. The DON stated that the facility's assignment sheets did not reveal which staff member was assigned as Resident #2's one-to-one monitor for the 11:00PM-7:00AM, shift on 12/29/2025. The facility policy, Continuous 1:1 Supervision with a reviewed/revised date of 01/2025 was reviewed. Under Policy, the document revealed that residents may require a temporary period of enhanced supervision to maintain their safety and the designated 1:1 monitor should be within eyesight of the resident at all times. Under Procedure, the policy revealed that the nurse in charge of each shift was responsible for assigning a staff member as the one-to-one supervisor. This section of the policy further revealed b. The staff allocated to supervise the resident/patient will not discontinue the supervision until the next staff confirms he/she has taken responsibility for supervising the resident/patient. NJAC 8:39-27.1 (a)

Based on interviews, and review of pertinent facility documents on 10/29/25, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident (Resident #2) with documented history of exit seeking behaviors; and who eloped from the facility on 10/16/2025. The deficient practice was identified for 1 of 5 residents reviewed (Resident #2).Review of facility document dated 10/16/2025 titled Incident-Elopement-Reference #2645660 revealed that on 10/16/2025 at approximately 10:20 a.m., staff went to invite the resident to join an activity program and noticed the resident was not in their room. Review of multiple staff statements revealed that staff saw Resident #2 pacing around the unit and hallways earlier in the morning prior to their elopement. According to statement from the staff member assigned to monitor the resident every 15 minutes, the last time she saw Resident #2 on the unit was at approximately 10:10 a.m. The nurse then started to search for the resident in the rooms and in the dayrooms but did not locate the resident. At that time, they initiated code gray (missing person code) and staff started to search for the resident both inside and outside of the facility building. At approximately 10:40 a.m., a staff member saw the resident who was walking in the strip mall parking lot adjacent to the facility. The resident was then assisted back inside the facility without incident. Staff completed a skin assessment on the resident which showed no skin alterations, and the resident denied pain or discomfort.The assigned Licensed Practical Nurse (LPN #1) and the assigned Certified Nursing Assistant (CNA #1) confirmed during interview that they observed Resident #2 pacing around on the unit prior to their elopement. LPN #1 stated that usually, the assigned nurse and assigned CNA monitored the resident, and if the CNA was busy doing other tasks, she would inform the nurse. LPN #1 stated that CNA #1 was busy doing care in a resident's room and did not inform her. CNA #1 confirmed that she did not inform the nurse that she was busy doing care in another resident's room; and stated she should have informed the nurse. The facility's failure to provide adequate supervision to ensure the safety of a cognitively impaired resident who was at risk for elopement, with documented history of exit seeking behaviors, posed a likelihood of serious harm, injury, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on10/16/2025 at 10:03 a.m. The facility was notified on 10/21/25 at 5:08 p.m. The facility submitted a Removal Plan (RP) on 10/28/25 at 2:10 p.m. The surveyor verified the implementation of the RP onsite on 10/29/2025 at 11:00 a.m. The evidence was as follows:A review of the facility's policy with a reviewed/revised date of 10/2025, titled Wandering/Elopement Policy indicated: Policy Statement: It is the objective of this facility to ensure the safety and protection of wandering residents by preventing their exit from the building. Purpose: The facility strives to prevent resident/patient elopement The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions . Policy Interpretation and Implementation . 2.) develop individualized interventions in the care plan to address the potential for elopement. Interventions may include but not limited to the following .Protected list of names and photographs of those at risk for elopement .Regular rounds .Staff interventions Structured group activities. Procedure 1.) Assess the security of potential internal environmental risk factors including Elevators, Exit doors .The Facility Reportable Event record (FRE) dated 10/17/2025, which the facility submitted to the New Jersey Department of Health (NJDOH), revealed on 10/16/2025, at approximately 10:30 a.m., an employee noticed that Resident #2 was not in their room. The employee inquired of the resident's whereabout at the nurse's station and when the resident could not be located, a code gray (missing person) was initiated. Staff searched the unit(s) and premises and Resident #2 was located in the adjacent strip mall's parking lot across from the facility. The resident was assisted back to the unit and assessed. No pain or injuries were noted.A facility document dated 10/16/2025 titled Incident-Elopement-Reference #2645660 included that on 10/16/2025, Resident #2 was monitored on every 15 minutes watch schedule (Q15 minute monitoring) and that staff last saw Resident #2 in their room pacing at 10:00 a.m. The Incident Report stated that around 10:13 a.m., staff went to offer coffee to the resident but did not see the resident in their room. The staff member then informed the nurse who then looked for the resident in the room and dayroom but did not locate them. At that time a code gray was initiated. A search began for Resident #2 in all rooms and the entire facility premises in accordance with facility protocol. Staff located Resident #2 at approximately 10:40 a.m. walking in a strip mall parking lot adjacent to the facility. The resident was then assisted back inside the facility without incident. Staff also completed a skin assessment which showed no skin alterations. The resident denied pain or discomfort, and both physician and family were notified. According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease with late onset, dementia, altered mental status and history of falling. According to the Minimum Data Set (MDS), an assessment tool dated 10/15/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired.According to Resident #2's admission Observation V 12 (admission Assessment) with an effective date of 10/15/2025 at 8:30 p.m., Resident #2 had a history of two or more episodes of elopement for the last six months and was at risk for elopement. A review of Resident #2's Care Plan (CP) with an initiated date of 10/15/2025, under Focus revealed that Resident #2 was an elopement risk/wanderer related to history of attempts to leave the facility unattended. The CP indicated that the resident wanders aimlessly on the unit exit seeking. The goal of the CP was that Resident #2 will not leave the facility unattended. Interventions included: staff would maintain every 15-minute monitoring. Distract resident from wandering by offering pleasant diversions and structured activities.A review of the Progress Note (PN) dated 10/15/2025 at 7:58 p.m., revealed that Resident #2 was a flight risk. The PN further stated that staff were instructed to maintain close observation and ensure safety precautions are in place, including monitoring for exit-seeking behavior and ensuring door alarms were functional.The director of admissions, during interview with the surveyor on 10/21/25 at 9:45 a.m. stated that she let department heads know that he looked like a doctor and elopement from previous facility and requires security a unit.A review of LPN #1's statement revealed that she was doing medication pass when an aide notified her that Resident #2 was missing. LPN #1 stated that she last saw the resident pacing in the hallway prior to the incident and that the resident was on Q15 minute monitoring.A review of CNA #1's statement revealed that she last saw Resident #2 in the hallway on her way to do the care of another resident which was around 9:55 a.m. CNA #1 stated she was still doing another resident's care when she was informed that Resident #2 was missing from the unit.On 10/21/2025 at 12:05 p.m., the surveyor conducted a telephone interview with Certified Nursing Assistant (CNA #1) who was assigned to Resident #2. CNA #1 stated she last saw Resident #2 at 10:05 am as they were walking in the hallway by their room. CNA #1 stated she was in another room providing care for another resident for approximately 15 minutes when the nurse notified her that Resident #2 was missing. CNA #1 stated that she was the staff assigned to care for Resident #2, and that she should have informed the nurse that she was busy doing care for other residents that day but did not. On 10/21/2025 at 12:30 p.m., the surveyor conducted a telephone interview with Licensed Practical Nurse (LPN) #1, assigned to Resident #2. LPN #1 stated that she observed Resident #2 pacing around the unit and that she and CNA #1 redirected the resident back to the dining room multiple times. LPN #1 stated usually the assigned nurse and CNA monitored the resident and if the CNA was busy doing care, they would inform her. LPN #1 stated that CNA #1 was doing care in another resident's room and did not inform her. On 10/21/2025 at 2:00 p.m., the surveyor conducted an interview with the Director of Nursing (DON) and the Administrator. The DON stated that usually, the receptionist would have to buzz visitors out when they exited the building. The DON further stated they believe the resident went along with the transport company and exited at the same time, and that the receptionist did not see Resident #2 leave. The DON indicated the resident was unable to describe how they exited the building. The facility believed the resident left the building through the main front entrance door without being noticed by the receptionist because it was around a period of increased activity near the front entrance, and that this happened around the same time a transport company was leaving the facility through the same front door. According to facility investigation summary and conclusion, the facility concluded that Resident #2 probably exited their unit by following a visitor into the elevator down to the first floor.During the unit tour on 10/21/2025 at 11:10 a.m., the surveyor observed that the facility had two elevators (elevator #1 and #2), with signage posted on Elevator #1 indicating that elevator #1 was for Staff and emergency personnel only, while visitors were supposed to use elevator #2. When the surveyor inquired about facility protocols for the locked unit elevators use prior to the resident's elopement, the DON stated that prior to the elopement event, there was no keypad code requirement in place inside the elevator. This meant the elevator was able to close and go down to the first floor if a resident or anyone enters the elevator. The DON stated there are accountability sheets with the CNA and the nurse assigned to Resident #2; and if the CNA was doing care they are supposed to communicate with the assigned nurse who would then monitor the resident. The DON stated that facility determined that Resident #2 went missing between the Q15 minute checks when the assigned CNA went to do care for another resident. The surveyor interviewed Visitor #1 on 10/21/2025 at 12:55 p.m., who stated they usually use elevator #2 but on the day of Resident #2's elopement, he used elevator #1, and that he remember someone coming on with them in the elevator but did not know who the person was.On 10/23/2025 at 9:30 a.m., the surveyor conducted an interview with the Receptionist who stated that in order for someone to leave the facility, she would have to buzz the person out the door. The receptionist further stated that she did not see Resident #2 leave the building the day of the elopement, and that they must have slipped out with transport when they were leaving the facility.An acceptable Removal Plan (RP) was received on 10/28/2025 at 2:00 pm, indicating the actions the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: 1. Resident #2 had head-to-toe assessment, placed on one-to-one monitoring for observation and emotional support. On 10/16/2025, if elevator #1 is required, the visitor, vendor and/or transportation staff will be escorted by a staff member on and off elevator #1 until elevator access could be restricted.On 10/17/2025, restricted access to elevator #1 by installing keypad inside elevator and designating only receptionists, designees who cover receptionists, and leadership staff have the code, resulting in the elevator being inoperable to all other staff, visitors and residents. All codes changed on 10/16/2025 and will be changed on the 16th of each month, or as needed. All exit doors checked by maintenance for proper functioning and locking mechanism on 10/16/2025. Facility reviewed and updated elopement binders on each unit and by the receptionist area on 10/16/2025. Facility audited EMRs for presence of resident's profile pictures on 10/16/2025.Facility audited new admissions for presence of the elopement risk evaluation and corresponding care plan (if applicable) on 10/16/2025.Facility conducted additional elopement drills on day and evening shift on 10/16/2025 and night shift on 10/17/2025. On 10/17/2025, additional security measures added to include keypads inside and outside of the elevator, restricting access to elevator operation. Court-1 (first floor) outside Elevator #1 keypad code needed to access elevator by designated staff only. Elevator #1 keypad inside elevator code needed to operate first floor button (#1) to activate elevator to access first floor when on Court-2 (second floor). Code only given to receptionist, and designees who cover receptionists, and leadership staff. Receptionist and designees who cover the desk educated not to give out keypad codes.Added alarms to all court building stairwell exit/egress on 10/16/2025. 2. Larger sign at the entrance to the elevator, redirecting visitors to the other elevator on 10/16/2025. Receptionist and designees who cover receptionists educated to wait to release the main entrance doors until anyone attempting to exit is identified as staff, visitors, vendors and authorized resident only on 10/16/2025. 3. Elopement policy reviewed 10/16/2025. ADON or designee, initiated re-education on 10/16/2025 of staff members on the elopement policy and procedure. ADON or designee, initiated education on 10/17/2025 to changes to the elevator #1 access with keypads restricting operation. Agency, PRN, and employees on PTO will be educated prior to their next scheduled working shift/day. 4.The DON or (designee) audited current residents for elopement risk and implemented immediate interventions if a high elopement risk score is triggered on 10/16/2025.The DON (or designee) audited new admissions for elopement risk and implement immediate interventions if a high elopement risk score is triggered on 10/17/2025 weekly x 4 weeks. The DON (or designee) evaluated elopement risk for residents who present with new wandering/exit seeking behaviors as soon as the behavior is identified on 10/17/2025 and weekly x 4 weeks. The DON (or designee) conducted weekly observations of staff/visitors/vendors safety practices when entering and exiting secured units on 10/17/2025 and weekly x 4 weeks. Findings from audits and observations will be reported to the monthly QAPI Committee. The surveyor verified the implementation of the RP on-site on 10/29/25 and determined that the immediacy for F 689 was removed as of 10/29/25 at 11:00 am. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 6/5/25 at 9:35 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The microwave had multicolored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledge it was not properly cleaned according to facility policy. 2. Two of two upper and lower convection ovens were soiled with baked on brown coloring on the glass doors making them opaque and not transparent. There were baked on debris on the interior corners of the units. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. The steamer unit had brown and crusted debris on the interior door and seal of door. The seal of the door was cracked and missing in some spots. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The six-burner stove top and oven were not clean. The interior of the oven had food sediment and build up on the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil that was peeling. The FSD acknowledged and stated, it was not cleaned according to facility policy. 5. The griddle grease trap had old and congealed grease with debris in it. The FSD confirmed the griddle had not been used that day and it was not cleaned according to facility policy. 6. The fryer had food debris on the ledge of the oil well. The FSD stated it had been used the night before for tater tots, she acknowledged that it was not cleaned according to facility policy. 7. The can opener blade had a metal chip on right side. The FSD stated, she changed it when she first started at the facility in October 2024. She further stated, there was not a maintenance log in place on when to replace the blade. 8. The double holder commercial plate warmer had food debris on the interior plate warmer section. The body of the unit had sticky brown debris around the rim of the plate warmer. The FSD acknowledged that the unit was not clean and that its purpose was too warm clean plates for distribution to the residents. She further stated, it was not cleaned according to facility policy. The facility has two steam tables both with four (4) water wells only one was working during tour. 9. The working steam table 4 water wells that had water ½ way up for 4 of 4 pans. Four of the four pans had white flaky debris and food particles settled at the bottom, i.e. (peas, rice, carrots). The FSD stated it was only cleaned weekly. The FSD was unaware of the manufacturer instructions or facility policy. 10. The non -working steam table had 4 water wells that were full of black liquid and sediment ½ way up for 4 of 4 pans. The FSD stated it had been down about a week and it could not be drained so the water and sediment had been stagnant. She further stated, she was unaware of the manufacturer instructions or facility policy. On 6/10/25 at 10:10 AM the surveyor interviewed the FSD, who acknowledged the surveyors finding and that the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of our residents and staff. On 6/10/25 at 11:10 AM the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment. The LNHA stated equipment should have been cleaned and maintained to prevent food borne illness, contamination, or injury. He further stated it ensured the safety of our residents and staff. On 6/11/25 at 11:04 AM, the survey team met with the LNHA, the Assistant LNHA, the Executive Director, and the Director of Nursing (DON), who all acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's, Environment policy dated, February 2025, included policy statement .All food prep areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures .The director will ensure that the kitchen is maintained in a clean and sanitary manner .ensure that employees are knowledgeable in the proper procedures for cleaning and sanitizing all food service equipment and surfaces. All food contact surfaces will be cleaned and sanitized after each use . A review of the Food Safety Requirement policy, dated January 2025, revealed . Food safety practices shall be followed throughout the facility's entire food handling process . Equipment used in the handling of food, including dishes, utensils, .and other equipment that comes in contact with food .Staff shall follow facility procedure for dishwashing and cleaning fixed cooking equipment .additional strategies to prevent foodborne illness include but are not limited to: cleaning, sanitizing and maintaining the internal components of the machines according to manufacturer's guidelines. A review of the facility's, Kitchen Equipment dated 2/2025, included policy statement . all foodservice equipment will be clean, sanitary and in proper working order. Procedures .All equipment will be routinely cleaned and maintained according to manufacturer's directions and training materials .All food contact equipment will be cleaned and maintained after every use. A review of the, undated, [name redacted] manufacturer's operation guideline policy, provided by the LNHA, for the non-working steam table, revealed cleaning; the inside of the heating compartments should be wiped out daily. A review of the, undated, [name redacted] manufacturer's operation guideline policy provided by the LNHA, for the non-working steam table, revealed Hot Food Table cleaning; to maintain appearance and increase the service life, the food warmer should be cleaned at least daily. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. This deficient practice was identified for 1 of 2 residents (Resident #40) reviewed for respiratory care and was evidenced by the following: On 6/6/25 at 8:45 AM, the surveyor observed Resident #40 lying in bed with his/her eyes closed. Resident #40 had a tracheostomy tube [a surgical opening in the neck directly into the trachea (windpipe)] and a tracheostomy (trach) collar with oxygen tubing attached to an oxygen concentrator (a medical device that extracts and concentrates ambient air. The surveyor observed that the oxygen concentrator was set to three (3) liters. On 6/9/25 at 12:26 PM, the surveyor observed Resident #40 lying in bed with his/her eyes closed. The surveyor observed the resident had a tracheostomy tube and a trach collar attached to the oxygen concentrator set to three (3) liters of oxygen (instead of two (2) liters as ordered.) On 6/9/25 at 12:40 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that the resident was ordered to have two (2) liters (L) of oxygen continuously with 28% humidification via the tracheotomy collar. The surveyor and the LPN entered Resident #40's room and the LPN confirmed that the oxygen concentrator was set to three (3) liters and stated, it should be set to two (2) liters. The LPN then proceeded to turn the concentrator dial down from 3L to 2L. On 6/9/25 at 12:51 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the nurses should check that the oxygen was set at the correct liters every time they were in the resident's room. The surveyor reviewed the medical record for Resident #40. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (oxygen deficient), encephalopathy (a broad range of brain diseases or disorders characterized by impaired brain function), tracheostomy status, and nontraumatic subdural hemorrhage (a collection of blood within the subdural space, the area between the brain and the dura mater (the outermost layer of tissue covering the brain), that does not result from a head injury). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident cognition was severely impaired. Further review of the MDS revealed the resident was dependent for activities of daily living and mobility, used continuous oxygen and received tracheostomy care. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, dated 3/18/25, that the resident had a tracheostomy. Interventions included: humidified oxygen (O2) via trach at 2 liters Fraction of Inspired Oxygen (FiO2- refers to the percentage of oxygen in the air a person is breathing) 28 % continuous. A review of the Order Summary Report (OSR), dated as of 6/1/25 to 6/30/25, included the following physician orders (PO): A PO, dated 3/18/25, for Trach collar FiO2 at 28% humidified oxygen 2 L via concentrator every shift. A PO, dated 6/5/25, for oxygen at 2 liters continuous concentrator via trach collar every shift for trach. A review of the Treatment Administration Record (TAR) revealed that the PO for oxygen inhalation at 2 liters was signed out as administered on 6/6/25 and 6/9/25 for the day shift. On 6/10/25 at 10:06 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that nursing should have assessed the oxygen concentrator and ensured that it was set to the correct setting as determined by the physician's order at the beginning of their shift and multiple times during their shift. The ADON further stated that it was important that the nurses followed the physician order for oxygen administration because the doctor gave the order based on the residents' needs. On 6/11/25 at 11:00 AM, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns that were identified with the resident's oxygen concentrator settings. A review of the facility's Oxygen Administration policy, revised May 2025, included oxygen administration will be carried out only with a physician's order. A licensed nurse or tother staff person trained in the use of oxygen will be on duty and be responsible for the correct administration of oxygen to the resident. The policy also included to check physician's order for liter flow and method of administration. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that medications were administered timely and in accordance with the medication's cautionary statement, manufacturer specifications, and physician's orders. This deficient practice was identified for 1 of 2 nurses who administered medications to 1 of 3 residents (Resident #55) on 1 of 5 nursing units (Court One) during the medication administration pass observation. This deficient practice was evidenced by the following: On 6/9/25 at 9:28 AM, the surveyor met with Licensed Practical Nurse (LPN) #1 who stated that she needed to obtain vital signs for Resident #55 prior to medication administration. LPN #1 then proceeded to place an automated blood pressure cuff on Resident #55's left upper arm and then placed a pulse oximetry probe (device used to measure the amount of oxygen in the blood) on the resident's left index finger. LPN #1 stated that the resident's blood pressure was 173/85, pulse (heart rate) was 66, and the resident's pulse oximetry was 89%. LPN #1 then stated that she needed to phone the physician prior to medication administration and she proceeded to do so. The resident left the nursing unit at that time. On 6/9/25 at 9:53 AM, the surveyor observed LPN #1 as she prepared medications for Resident #55. LPN #1 then reviewed a physician's order aloud from the resident's electronic health record (EHR) for Metoprolol Tartrate Tablet 25 mg, Give 0.5 tablet by mouth one time a day for HTN (hypertension) (1/2 tab = 12.5 mg) hold if under 60 beats per minute (bpm). LPN #1 then proceeded to remove a bingo card (blister package) from the medication cart and compared the package labeling against the physician's order in the EHR to confirm accuracy. The medication was scheduled to be administered at 8:00 AM. At that time, LPN #1 stated that a new order was obtained from the physician and she reviewed a physician's order aloud from the resident's EHR for Metoprolol Tartrate Oral Tablet 25 MG give 0.5 tablet by mouth one time only. Give 1/2 tab (12.5 mg) x 1 (one) now. LPN #1 then proceeded to prepare the medication for administration. LPN #1 then reviewed a physician's order aloud from the resident's EHR for Potassium Oral Tablet give 20 milliequivalents (meq) by mouth for supplement. LPN #1 then proceeded to remove a bingo card from the medication cart and compared the package labeling against the physician's order in the EHR to confirm accuracy. The surveyor noted that there was a cautionary statement on the packaging which specified to give the medication with meals. The medication was scheduled to be administered at 8:00 AM. LPN #1 then reviewed a physician's order aloud from the resident's EHR for Oxycodone HCL oral tablet 10 mg give one (1) tablet by mouth six (6) times a day for phantom/leg pain. LPN #1 then proceeded to remove a bingo card from the medication cart and compared the package labeling against the physician's order in the EHR to confirm accuracy. The medication was scheduled to be administered at 8:00 AM. LPN #1 then reviewed a physician's order aloud for Metformin hydrochloride (HCL) 500 milligrams (mg) give 1 tablet by mouth two (2) times a day for diabetes mellitus (DM). LPN #1 then proceeded to remove a bingo card from the medication cart and compared the package labeling against the physician's order to confirm accuracy. The surveyor noted that there was a cautionary statement on the packaging which specified to give the medication with food. The medication was scheduled to be administered at 9:00 AM. LPN #1 then reviewed a physician's order aloud for Digoxin tablet 125 micrograms (mcg) give 1 tablet by mouth 1 time a day for atrial fibrillation (Afib, an irregular heart beat). LPN #1 then proceeded to remove a bingo card from the medication cart and compared the package labeling against the physician's order in the EHR to confirm accuracy. The medication was scheduled to be administered at 9:00 AM. On 6/9/25 at 10:16 AM, Resident #55 returned to the nursing unit and the surveyor observed LPN #1 as she administered the aforementioned medications and 11 additional medications to the resident without offering food to the resident or assessing the resident's apical pulse (a stethoscope is placed on the left upper chest to determine the number of heart beats heard in one minute) as indicated according to the cautionary statements. At that time, the surveyor asked Resident #55 if he/she had eaten breakfast? The resident stated that they had eaten 60% of the breakfast meal at 9:10 AM. LPN #1 who was present stated that the resident had eaten within the hour. LPN #1 stated that this was not her usual nursing unit and she normally gave the medications to the residents when their breakfast tray was present. LPN #1 further stated that Metformin should have been given with a snack. On 6/9/25 at 12:01 PM, the surveyor reviewed the medical record for Resident #55. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included but were not limited to, diabetes mellitus due to underlying condition with diabetic autonomic (Poly) neuropathy (numbness/tingling), essential (primary) hypertension (elevated blood pressure), paroxysmal atrial fibrillation (an irregular heart beat that comes and goes), and acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 5/4/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15, which indicated that the resident was cognitively intact. A review of the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 7/29/24 for Metoprolol Tartrate Tablet 25 MG Give 1 (one) tablet by mouth two times a day for HTN (1/2 tab=12.5 mg). Hold if under 60 bpm. A PO, dated 6/9/25, for Metoprolol Tartrate Tablet 25 MG Give 0.5 tablet by mouth one time only for b/p (blood pressure) for 1 (one) day. Give 1/2 tab (12.5 mg) x 1 (one) now. A PO, dated 12/10/24, for Potassium Oral Tablet (Potassium) Give 20 meq by mouth with meals for supplement. Give with meals. A PO, dated 2/20/24, for Oxycodone HCL (an opioid controlled medication used to treat pain) oral tablet 10 mg give 1 (one) tablet by mouth six times a day for phantom/leg pain. A PO, dated 5/13/25, for Metformin HCL (hydrochloride) oral tablet 500 MG (Metformin HCL) Give 1 (one) tablet by moth two times a day for DM (diabetes mellitus). Give with meals. A PO, dated 2/2/24, for Digoxin Tablet 125 MCG Give 1 (one) tablet by mouth one time a day for AFIB. Hold for aprical [sic.] pulse < (less than) 60. A review of the Progress Notes (PN) included a nurse's note (NN), dated 6/9/25 at 12:14 PM revealed, During AM med pass, vital signs were collected. BP 173/85, HR (heart rate) 66, O2 (oxygen) 89 RA (Room Air). This nurse placed a call to doctor (name redacted). During the call, BP, O2 and narc (narcotic, referred to Oxycodone) administration scheduled for 8 am being given at 10 am was relied [sic] to MD. [Name redacted) Ok narc administration at a later time .Verbal orders to change Metoprolol Tartrate 25 mg half tab to Metoprolol 25 mg BID (twice a day) and monitor BP. Send patient out for signs or symptoms of stroke. Orders placed and carried out. On 6/9/25 at 12:57 PM, the surveyor interviewed LPN #1 who stated today was a hectic morning. LPN #1 stated that she saw that Potassium was ordered to be given with meals. LPN #1 stated that after the surveyor left she gave the resident a pack of tea biscuit crackers and a juice. When the surveyor asked LPN #1 why she had not offered the resident food at the time of medication administration she stated that she thought about it after and noted that lunch would not be served for awhile. LPN #1 further stated that it was important to administer Metformin with food because there was a chance of the resident's blood sugar dropping. LPN #1 stated that it was important to give Potassium with a meal because the chance of stomach ulcers was high and it helped to lessen the side effects of the medication. On 6/9/25 at 1:06 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that it was her expectation that medications were to be administered with meals. LPN/UM #1 stated that our breakfast trays were delivered to the nursing unit at 8 AM, and nursing was able to confirm which residents to medicate first. LPN/UM #1 stated that gastrointestinal (GI)) upset was the reason why it was important to give the medications with meals as ordered. LPN/UM #1 stated that tea biscuits was not a meal, and the medications needed to be given with something more substantial at the time of administration. On 6/9/25 at 9:51 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that if medications were scheduled to be given with food, and the resident had not eaten within the past 15 minutes, then the nurse should offer the food with the medications, or call the doctor and see what they wanted to do. The ADON stated that following the cautionary statements on the bingo cards was important for better absorption of the medication and to reduce GI side effects depending on the medication. On 6/11/25 at 9:10 AM, the surveyor interviewed LPN #2 who stated that it was important to obtain an apical pulse prior to Digoxin administration because it was more accurate to assess if it were necessary to hold the medication if the pulse were less than 60 bpm (beats per minute). On 6/11/25 at 10:15 AM, the surveyor interviewed the ADON who stated that it was her expectation that medications were given within one hour before or one hour after the scheduled administration time. On 6/11/25 at 9:13 AM, the surveyor interviewed LPN/UM #1 who stated that it was important to follow the order to obtain an apical pulse prior to Digoxin administration. LPN/UM #1 stated that a stethoscope should be used to do it because it was not an accurate reading if the blood pressure machine were used instead of a stethoscope. On 6/11/25 at 9:53 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that you wanted to give Metformin with a meal because it may cause flatulence and your stomach may hurt, but it did not cause hypoglycemia (low blood sugar). The CP stated that Potassium should be given with a meal because it caused stomach irritation. At that time, the CP stated that if there were an order to obtain an apical pulse, then a stethoscope should have been placed over the heart to obtain the pulse. The CP stated that the automated blood pressure machine provided a radial pulse (from the radial artery in the arm) and there was some difference between a radial pulse and an apical pulse. On 6/11/25 at 10:15 AM, the surveyor interviewed the ADON who stated that an apical pulse was supposed to be take if that was what the physician's order specified because we have to follow the order. On 6/11/25 at 11:01 AM, in the presence of the survey team the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the concerns with the medication administration pass observation. A review of the facility's Administering Medications policy, revised February 2025, included: Medications shall be administered safely and timely, as prescribed. Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). NJAC 8:39-29.2(d)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices during the medication administration pass observation. This deficient practice was identified for 1 of 2 nurses who administered medications to 2 of 3 residents (Resident #55 and Resident #123) on 1 of 5 nursing units (Court One) during the medication administration pass observation. This deficient practice was evidenced by the following: On 6/9/25 at 9:27 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 sanitize her hands with alcohol based hand rub (ABHR) and donn (put on) gloves before she placed an automated blood pressure cuff on Resident #55's left upper extremity. LPN #1 then proceeded to place a pulse oximetry probe (a device used to measure the amount of oxygen in the blood) on the resident's left index finger. The resident's shirt was noted to be heavily soiled with a black substance. When finished, LPN #1 reviewed the resident's vital signs (blood pressure, pulse, and pulse oximetry level). LPN #1 then proceeded to doff (remove) her gloves and she accessed the computer and reviewed the resident's Electronic Health Record (EHR) without first performing hand hygiene. At 9:34 AM, LPN #1 stated that she planned to hold off on administering any medications to Resident #55 until after she had spoken with the physician regarding the resident's blood pressure reading. LPN #1 then proceeded to the nurse's station without first performing hand hygiene and used a cell phone that was provided by another staff member to call the resident's physician. At 9:40 AM, LPN #1 returned to the nursing medication cart, accessed the computer, and then proceeded to prepare four medications for Resident #123 without first performing hand hygiene. At 9:48 AM, LPN #1 sanitized her hands with ABHR (alcohol based hand rub) and donned gloves prior to entering Resident #123's room to administer the resident's medications. On 6/9/25 at 12:57 PM, the surveyor interviewed LPN #1 who stated that cross-contamination was a concern if hand hygiene were not performed after she doffed her gloves, used the phone, and prepared medications for administration. On 6/9/25 at 1:06 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that it was an infection control issue if nursing had not sanitized or washed her hands after she doffed her gloves. The LPN/UM #1 stated that she definitely would have washed her hands after she touched the resident's dirty clothing. The LPN/UM #1 stated that she would have also sanitized her hands after she used the phone and prior to medication preparation. The LPN/UM #1 stated that there was a whole lot of germs that were passed from one object to another when the nurse failed to perform hand hygiene at the required intervals. On 6/10/25 at 9:51 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that after doffing gloves you have to perform hand hygiene with hand sanitizer or wash your hands for infection control purposes. On 6/11/25 at 11:01 AM, the surveyor in the presence of the survey team informed the Licensed Nursing Home Administrator (LNHA) of the identified concerns with infection control practices identified during the medication administration pass observation. A review of the the facility's Administering Medications policy, revised February 2025, included: .Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . A review of the facility's Hand Hygiene Policy and Procedure revised 3/24/2025, included: Effective hand hygiene reduces the incidence of healthcare-associated infections. Indications for Handwashing and use of Alcohol Based Hand Rub: .After contact with a patient's intact skin (when taking a pulse or blood pressure, and lifting a patient) . .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient After removing gloves . NJAC 8:39-19.4

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure that all Drug Enforcement Administration (DEA) 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications. This deficient practice was identified for 6 of 6 DEA 222 forms reviewed in 1 of 1 back up controlled medication storage area and was evidenced by the following: On 12/17/24 at 1:01 PM, the surveyor reviewed the facility's DEA-222 records for the back up controlled medication storage and noted that on 8/15/24, 9/4/24, 9/30/24, 11/1/24, 11/27/24, and 12/16/24, Part 5 of the forms that were required to be filled in by the purchaser failed to include the number of controlled medications received by the facility and the date that they were received. On 12/18/24 at 11:22 AM, the surveyor interviewed the Director of Nursing (DON) regarding the DEA 222 Forms. The DON stated that she did not know that she was supposed to fill in Part 5 of the DEA-222 form which indicated that it was to be filled in by the Purchaser. When the surveyor asked the DON why she had not filled in Part 5 of the DEA 222 Form she stated, no one, not even the pharmacy, ever told me that. The surveyor reviewed the instructions with the DON that were printed on the back of the form and she stated that she had not read the instructions. The DON stated that someone showed her how to complete the form previously and she followed their instructions. On 12/18/24 at 11:40 AM, the surveyor interviewed the Pharmacist of the facility's pharmacy provider, who stated that the process was for the DEA-222 forms to be filled in completely by the purchaser, or nursing home. The Pharmacist stated that the form was highlighted and specified which section of the forms needed to be completed by the purchaser. The Pharmacist stated that Part 5 had to be dated and had to specify the number of controlled medications received upon delivery. The Pharmacist stated that the Medical Director (MD) was responsible to ensure that Part 5 was filled in as the purchaser because a valid DEA Number was needed. On 12/18/24 at 12:06 PM, the surveyor interviewed the MD who stated that he only signed the DEA 222 Forms and filled out his DEA number and the DON or Assistant Director of Nursing (ADON) completed the form and sent it out to the pharmacy. The MD stated he had never seen any medications delivered to the facility. The MD stated that when the facility received the shipment from the pharmacy, nursing was supposed to count the amount of controlled medications received and put them in a secured box. The MD stated the process was like that everywhere. On 12/18/24 at 1:09 PM, the surveyor conducted a telephone interview with the Chief Executive Officer/Consultant Pharmacist (CEO/CP) who stated the DON or the person who received the delivery of the controlled medications were responsible to document the quantity received and the date they received it under Part 5. The CEO/CP stated that the MD should review but the DON, or nursing department, was confirming the quantity received. When the surveyor asked why it was important to completed Part 5 of the DEA 222 form the CEO/CP stated, you want to make sure the quantity is right and it is a Board of Pharmacy Regulation for Part 5 of the DEA-222 completion. The CEO/CP stated that it was mandatory to fill in Part 5 of the DEA-222 form. At that time, the CEO/CP stated that there were directions or on the back of the form which instructed to fill in Part 5 and indicated that it were to be completed by the receiver. The CEO/CP stated that the assigned Consultant Pharmacist (CP) who came into the facility on a quarterly basis checked to see if it were done. The CEO/CP further stated that the DEA-222 forms would have been checked by the CP, but he was not sure when. On 12/18/24 at 1:38 PM, in the presence of another surveyor and the DON, the Licensed Nursing Home Administrator (LNHA) was informed that the facility failed to completed Part 5 on six out of six DEA-222 forms. On 12/19/24 at 9:16 AM, during a follow-up interview the CEO/CP stated that the assigned CP, who was not available for an interview, had not checked the DEA-222 forms but he should have. A review of the facility's undated DEA 222 Completion policy included: Completed Required Sections #1-6 .Number of items and Date Received: Once the order is received, complete the number of items and date they were received on your photocopy. You must retain a copy of this form for your records and auditing purposes . NJAC- 8:39-29.7 (C)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) follow a physician's order and b.) adhere to professional standards of nursing practice during the medication administration observation. This deficient practice was identified for 2 of 2 nurses who administered medications to 2 residents (Residents #34 and #49) on 2 of 4 nursing units (Court 1 and Court 2) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 12/17/24 at 8:30 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 as she prepared medications to be administered to Resident #34, which included a Lidocaine 4% External Patch (used to help relieve pain) to be applied to the resident's left knee. At 8:49 AM, LPN #1 informed Resident #34 that she had to remove his/her Lidocaine Patch before she applied another patch. She proceeded to pull back the resident's blanket and removed a Lidocaine patch from the resident's left knee before she applied the scheduled dosage patch. At 8:53 AM, LPN #1 reviewed the order for Lidocaine 4% Patch with the surveyor and stated that the order specified that the patch was ordered to be removed at bedtime (HS). LPN #1 further stated, the evening shift nurses were supposed to take it off last night (12/16/24). A review of Resident #34's Order Recap Report (ORR) revealed a physician's order (PO) dated 10/25/24, for a Lidocaine External Patch 4% (Lidocaine) apply to left knee topically one time a day for pain, remove at bedtime, and remove per schedule. A review of Resident #34's Medication Administration Record (MAR) revealed an order for Lidocaine External Patch 4% (Lidocaine) apply to left knee topically one time a day for pain, remove at bedtime, and remove per schedule which had a start date of 10/26/24 and was scheduled to apply at 9:00 AM, and remove at 8:59 AM, rather than at 9:00 PM, or bedtime. Further review of the MAR revealed that the order was amended to include a removal time at 9:22 AM on 12/17/24, and the order was then discontinued. Further review of Resident #34's MAR revealed an order for Lidocaine External Patch 4% (Lidocaine) apply to left knee topically one time a day for pain remove at bedtime and remove per schedule with a start date of 12/18/24, that was scheduled to be applied at 9:00 AM and removed at 9:00 PM, after surveyor inquiry. On 12/17/23 at 10:23 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that if there was an order to remove a Lidocaine Patch at night they are supposed to take it off at night as ordered. LPN/UM #1 stated that she believed that most had orders to remove it. LPN/UM #1 further stated that she was always told by the pharmacy that it was not effective anymore if it were left on longer than the prescribed time. On 12/18/24 at 1:09 PM, the surveyor interviewed the Director of Nursing (DON) who stated that a Lidocaine 4% Patch was only good for 12 hours and would not be beneficial if it were left on for more than 12 hours. The DON stated that the expectation was for the Lidocaine 4% Patch to be removed at HS as it was ordered. On 12/18/24 at 1:38 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of another surveyor and the DON, was informed of the facility's failure to follow Resident #34's order for Lidocaine 4% Patch and properly schedule the application and removal of the medication as it were ordered. On 12/19/24 at 9:18 AM, the surveyor interviewed the Chief Executive Officer/Consultant Pharmacist (CEO/CP) who stated that an order for Lidocaine 4% Patch should be removed at HS as ordered. The CEO/CP stated that it should have been taken off because you have to follow the order. On 12/20/24 at 9:22 AM, the surveyor interviewed the DON who stated that it was determined that the nurse had a transcription error when the physician's order for Lidocaine 4% Patch was entered into the electronic health record (EHR). The DON stated that the order was scheduled for removal at 8:59 AM, and should have been scheduled at 9:00 PM, so it did not show up on the MAR for the evening shift to remove it. The DON further stated that neither the Consultant Pharmacy review or the 24 Hour chart check noticed that the wrong time was entered into the MAR for removal. 2.) On 12/17/24 at 9:37 AM, the surveyor observed Resident #49 who was seated in a chair in their room. LPN #2 entered the resident's room with permission and used an automated (electronic) blood pressure (BP) machine to obtain the resident's BP and pulse (heart rate -HR). LPN #2 stated that the resident's BP was 108/40 and the HR was 64 (the American Heart Association (AHA) recommends a target blood pressure below 120 millimeters of mercury (mm Hg) systolic (top number of BP) and 80 mm Hg diastolic (bottom number of BP); and defined hypotension (low blood pressure) as a BP of 90/60). At 9:40 AM, LPN #2 checked the resident's medication orders in the electronic health record (EHR) and noted that the resident was scheduled to receive amlodipine (used to treat high blood pressure) and Torsemide (used to treat high blood pressure, heart failure and a build up of fluid in the body). LPN #2 stated that there were no parameters (guidelines on when to hold or administer a medication based on numerical values of the systolic blood pressure, diastolic blood pressure or pulse). LPN #2 hesitated on whether or not to administer the medications based on the resident's diastolic BP reading of 40. LPN #2 then instructed the resident to take the medications without first rechecking the blood pressure to confirm accuracy or notifying the physician to relay the concern. When interviewed at that time, LPN #2 stated that she was definitely going to let the physician know and see if he wanted parameters added to the medication's orders. When the surveyor asked LPN #2 if she should have let the doctor know of her concerns with the resident's diastolic blood pressure value before or after medication administration, LPN #2 stated that since the resident did not show any signs or symptoms of distress she had waited until after the mediation was already administered to notify the physician. A review of the resident's Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: End-stage renal disease (kidney disease), dependence on renal dialysis (a treatment that removes excess water, solutes, and toxins from the blood when the kidneys no longer performed these functions). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 11/2/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/22/22, of resident has hypertension (high blood pressure) related to Chronic Kidney Disease (CKD). Interventions included: Give all hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and tachycardia (increased heart rate) and effectiveness. Obtain blood pressure readings as ordered. Take blood pressure readings under the same conditions each time. A review of the Order Summary Report (OSR) included the following physician's orders PO: A PO, dated 10/25/24, for Amlodipine Besylate Tablet 10 milligrams (MG) Give one (1) tablet by mouth one time a day every Tuesday, Thursday, Saturday, and Sunday related to Essential (primary) hypertension. Administer on non-dialysis days. A PO, dated 3/5/24, for Torsemide Tablet 20 MG Give 1 tablet by mouth one time a day for edema related to primary hypertension. On 12/17/24 at 10:07 AM, the surveyor interviewed LPN/UM #1 who stated that she would have expected for the nurse to recheck the resident's blood pressure and if it were still low, hold the medication and call the doctor. LPN/UM #1 stated that the issue would be with a blood pressure of 130/40, the BP could drop even more. LPN/UM #1 further stated that if you made a nursing judgement to check a blood pressure, she would expect the nurse to check the order and follow it all of the way through. On 12/18/24 at 11:09 AM, the surveyor interviewed the DON who stated that if a resident had a BP of 130/40, she would recheck the blood pressure to make sure that it was accurate. The DON stated that she would not have given the medication until she called the physician because the BP was already low and the medication could lower the BP even more. A review of the resident's Weights and Vitals Summary revealed that the resident's last documented blood pressure reading was on 12/15/24 at 2:16 AM, and was 136/73. Further review of the Weights and Vitals Summary revealed that the resident's diastolic blood pressure from June 2024 through December 2024 only dropped below 60 on 11/11/24 (120/59) and 11/13/24 (125/54). A review of the Progress Notes (PN) included a Nursing Progress Note (NPN), dated 12/18/24 at 3:02 PM, which included, the physician was notified of the diastolic pressure was less than 60 on 12/17 and stated that he was okay to administer the BP medication. Further review indicated the resident remained stable during the shift with no complaint of (c/o) discomfort nor dizziness. The physician was notified after surveyor inquiry. On 12/18/24 at 1:38 PM, in the presence of another surveyor and the DON, the surveyor informed the LNHA of concerns that were identified during the Medication Observation. On 12/19/24 at 1:04 PM, the surveyor interviewed the CEO/CP who stated that the nurse should have called the physician first before she administered the blood pressure medication. The CEO/CP further stated that, you should recheck the blood pressure to ensure that it was not off and alert the doctor to make extra sure because it was very, very low. A review of the facility's Administering Medications policy reviewed/revised February 2024, included: Medications shall be administered safely and timely, as prescribed. Medications must be administered in accordance with the orders, including any required time frame If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns The following information must be checked/verified for each resident prior to administering mediations .Vital signs, if necessary, per physician's order . NJAC 8:39-29.2(d)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adhere to proper infection control practices during the medication administration observation. This deficient practice was identified for 1 of 2 nurses on 1 of 2 units (Court Two) observed for medication administration and was evidenced by the following: On 12/17/24 at 8:59 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 as she prepared medications for Resident #33. LPN #1 donned (applied) gloves and obtained the resident's blood pressure (BP). LPN #1 then doffed (removed) her gloves before she returned to the computer to review the resident's physcians orders (PO) before she administered the medications to the resident. LPN #1 then proceeded to wash her hands for 15 seconds. LPN #1 stated that there was no paper towels available to dry her hands. LPN #1 then proceeded to turn the faucet off with her bare hands. LPN #1 returned to the medication cart and obtained a tissue to dry her hands. LPN #1 failed to sanitize her hands after she dried them. On 12/17/24 at 9:27 AM, LPN #1 then pushed the medication cart and blood pressure machine over to the outside of Resident #49's room. LPN #1 then proceeded to prepare the resident's medications without first performing hand hygiene. LPN #1 stated that the resident was on Enhanced Barrier Precautions (EBP, an approach of targeted gown and glove use during high resident care activities, designed to reduce the transmission of drug resistant organisms) before she donned a gown, gloves, and mask without first performing hand hygiene. LPN #1 then entered the resident's room and obtained the resident's BP without first cleaning the BP cuff. LPN #1 then doffed her gown and gloves and washed her hands in the resident's bathroom. On 12/17/24 at 9:58 AM, LPN #1 brought the blood pressure machine out into the hallway. When interviewed, LPN #1 stated that she should have used hand sanitizer after she turned the faucet off with her bare hands because there was a risk of spreading germs. When the surveyor asked LPN #1 what the process was for sanitizing the blood pressure cuff and machine, she stated that she planned to clean it after she used it for Resident #49 because the resident was on EBP. LPN #1 stated that she did not typically clean it between residents but because the resident was on precautions, she would clean it. LPN #1 further stated that if the blood pressure cuff and machine were not cleaned between residents there was a potential to spread germs. On 12/17/24 at 10:23 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that LPN #1 should have washed her hands after she touched the faucet for infection control standards of practice. LPN/UM #1 stated that the nurses were supposed to wipe down the blood pressure machine with disinfectant wipes before the shift and between each resident for infection control purposes. On 12/18/24 at 10:47 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that LPN #1 could have used a tissue product, though not effective, to shut off the water and then used hand sanitizer to clean her hands as a precautionary measure to kill bacteria on her hands. The LPN/IP stated that LPN #1 should have stopped and cleaned her hands between residents and rooms to reduce the spread of infection so that she did not bring any bacteria from one room to another. The LPN/IP further stated the blood pressure cuff should have been cleaned with a disinfectant wipe between each resident or a bleach wipe if it were used in an isolation room. The LPN/IP stated that they were not taking the proper infection control steps if the blood pressure machine were not cleaned between residents. On 12/18/24 at 11:09 AM, the surveyor interviewed the Director of Nursing (DON)who stated that she would have walked into another bathroom and washed her hands and used hand sanitizer if there were no paper towels in the restroom. The DON stated that it could have been an infection control issue because LPN #1 turned off the faucet with her hands. The DON further stated they have to disinfectant the blood pressure cuff with an antibacterial wipe between each patient. The DON stated that a failure to clean the blood pressure cuff could also be an infection control issue. On 12/18/24 at 1:38 PM, in the presence of another surveyor and the DON, the Licensed Nursing Home Administrator (LNHA) was informed of the infection control concerns that were identified during the medication administration observation. A review of the facility's Handwashing/Hand Hygiene policy reviewed/revised April 2024, included: The facility considers hand hygiene the primary means toprevent the spread of infections All personnel shall follow the Handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents; Before preparing or handling mediations; .After contact with a resident's intact skin; .After removing gloves; .Before and after entering isolation precaution settings. A review of the facility's Cleaning of Non-Critical, Reusable Resident Care Equipment policy reviewed/revised January 24 included: .Reusable patient care equipment will be cleaned, disinfected, and/or reprocessed before reuse with another patient or before being placed in storage . NJAC 8:39-19.4

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 05/29/2024 from 09:32 to 10:06 AM, the surveyor, accompanied by the interim Food Service Director (FSD) observed the following in the kitchen: 1. In the dry storage area of the kitchen on a middle shelf an opened bag of rainbow pasta had no open or use by date. The bag had a hole in it and was exposed to contamination. The FSD removed the pasta from the dry storage. 2. In the rear of the walk-in freezer an opened box of frozen pancakes and an opened box of frozen French Toast slices were placed on top of milk crates. The boxes were opened, and the pancakes and French Toast were exposed to contamination. The FSD removed the exposed products from the walk-in freezer. 3. Upon entry to the walk-in refrigerator the surveyor observed an excessive amount of dust-like debris on the fan guard on the roof of the walk-in refrigerator. The FSD stated, I contacted maintenance last week to come clean it. The surveyor asked the FSD if it was verbal or formal communication. The FSD replied, I think the administrator told maintenance to clean it. It was verbal communication. 4. On a middle shelf of what the FSD described as the freezer an opened box contained frozen breaded chicken patties. Inside the box a plastic bag was previously opened, and the chicken patties were exposed. The FSD agreed that the product should not be exposed to contamination. The product was removed from the freezer. On 05/31/2024 from 10:25 to 10:35 AM, the surveyor, accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN #3) mad the following observation in the Court 2 Pantry: 1. The surveyor opened the lid to the ice machine in the Court 2 pantry, which was used for residents residing on Court 2. The scoop was stored external. Upon inspection of the interior of the ice machine the surveyor observed a brown/green/black substance on the bottom of the white drip ledge above the clean ice supply. The surveyor used their right index finger and applied pressure in a scraping motion on the lower edge of the drip ledge. Once the surveyor removed their finger the right index finger had a green/brown slimy substance on it. The surveyor showed the UM/LPN #3 their finger who agreed that the ice machine was dirty and needed cleaning. When asked who was responsible for the cleaning of the ice machine UM/LPN #3 stated that maintenance cleans the machine and that it was done about a month ago. I'm not really sure who does what. On 05/31/2024 from 10:37 to 10:53 AM, the surveyor, accompanied by UM/LPN #1 observed the following on Court 1 pantry: 1. In a cabinet above the sink area on the top shelf the surveyor observed an opened plastic bottle of Refresher Antibac Foam (an antimicrobial hand wash). The label on the bottle stated, For external use only. The lid was removed, and the product was exposed. The Antibac foam was stored in the same cabinet as multiple single serve cold cereal packages, hand towels, artificial sweeteners (sweet' n low), sugar packets, and coffee mate. In addition, a plastic take-out style container with a clear plastic lid was next to the Antibac foam on the upper shelf. The container had a sticky note on it that stated a name (illegible) and a date of 12/9/23. There was dried food debris in the container and a metal fork. On interview the UM/LPN #1 stated, No you can't store chemicals and food together. I know that. UM/LPN #1 removed the take-out container to the trash and removed the Antibac foam from the cabinet in the presence of the surveyor. On 05/31/2024 at 12:33 PM, the surveyor conducted an interview with the facility Director of Maintenance (DOM). The DOM provided the surveyor with the following information when asked who was responsible for the ice machine maintenance. The DOM stated, I'm almost finished cleaning the ice machine. I clean them every 3 months. In fact. it was due to be cleaned next month. I'll provide you with a copy of the schedule. The DOM provided the surveyor with a schedule of cleaning for the Court 2. The documentation indicated that the Court 2 fixed ice machine was cleaned on December 29, 2023, and last cleaned on March 28, 2024. The next scheduled cleaning was to be completed June of 2024. On 06/03/2024 at 10:27 AM, the surveyor entered the facility kitchen while dish washing was actively taking place. The surveyor approached the dietary aide (DA). The surveyor asked if the dish machine that was in operation was a low temperature or high temperature dish machine. The DA stated it was a low temperature dish machine. The surveyor asked what chemical was being utilized for sanitation. The DA stated, I don't know. We ran out. The surveyor asked the DA if he was running the dish machine without any chemical sanitizer. The DA stated, Yeah, we ran out. They know about it; they said just wash the dishes anyway. The DA then pointed to the empty 5-gallon bucket under the dish machine that was to hold the chlorine sanitizer. The bucket was observed to be empty and confirmed to be empty by the surveyor picking up the bucket and looking into the opening on top of the bucket. The bucket had no chlorine. The surveyor then observed the machine wash temperature at 150 degrees Fahrenheit (F). The rinse temperature was observed to be 140 F. Rinse temperature must be 180 F or greater for heat sanitization. On 06/03/2024 at 10:35 AM, the surveyor conducted an interview with the interim FSD. The surveyor asked the interim FSD if she was aware that dish washing was being performed without chemical sanitizer with a low temperature dish machine. The interim FSD stated, I was made aware that there was no sanitizer for the dish machine this AM. Yes, I am aware that we washed the dishes without sanitizer. A review of the June 2024 Dish Machine Ware Washing - Low Temperature log the following was documented prior to dish washing at breakfast on June 3rd: Wash Temp: 135 F, Final Rinse Temp: 145 F, Chlorine Sanitizer PPM (parts per million): The Regional Director (RD) was asked to obtain a chlorine test strip to assess the chlorine level of the dish machine. A plastic pellet bottom was placed on a plastic dish rack and was sent through the dish machine for an entire wash and rinse cycle. Upon exiting the dish machine, the RD obtained a white chlorine test strip and placed it on the wet pellet lid. The test strip remained white in color, which indicated 0 ppm of chlorine. On 06/03/2024 at 10:43 AM, the RD was able to obtain liquid bleach from the housekeeping department. The 5-gallon chlorine bucket was observed to be approximately one quarter full. The surveyor observed the RD again place a plastic pellet bottom on a rack and run the rack through the dish machine for a full wash and rinse cycle. Upon the rack exiting the dish machine the RD again obtained a white chlorine test strip and placed the test strip against the wet pellet base. The white test strip turned deep purple in color indicating that the chlorine level is 50-100ppm, sufficient for sanitization. The RD went on to explain, We ran out this morning. Santec (a foodservice service company) was here Friday and had to replace the nozzles on the machine. When asked who is responsible for ensuring that the facility has an adequate supply of sanitizer the RD stated, The dietary manager is responsible for ordering the chemicals, but she just took over a week ago. The RD instructed kitchen staff to re-wash and sanitize all dishes that went through the dish machine prior to obtaining a satisfactory chlorine level. On 06/03/2024 at 10:55 AM, the surveyor conducted an interview with the facility Licensed Nursing Home Administrator (LNHA). Upon telling the LNHA that the facility was washing dirty dishes and utensils used to serve resident meals without sanitizer for the low temperature dish machine the LNHA responded, Our Regional Director (RD) told me that he tested the chlorine level this morning at 60 ppm. We ran out when the breakfast dishes were being done. We borrowed from house keeping and we are now going to re-wash and sanitize all dishes that went through the machine to ensure that they are properly sanitized. On 06/06/2024 from 9:52 to 10:12 AM, the surveyor, accompanied by the RD and the interim FSD made the following observations in the kitchen: 1. On a bottom shelf of the reach-in refrigerator a quarter pan contained grape jelly. The grape jelly had plastic wrap that only partially covered it and the grape jelly was exposed. The RD removed the grape jelly from the refrigerator and instructed the interim FSD to throw it away in the presence of the surveyor. The surveyor reviewed the facility policy titled Food Storage, undated. The following was revealed under the PROCEDURES heading: 5. Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food. 13. Food is stored a minimum of 6 inches above the floor on clean racks, dollies, or other clean surfaces, and is protected from splash, overhead pipes, or other contamination. 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded. 17. Freezer Temperatures: e. Rewrap packages of frozen food which have been opened. This prevents freezer burns and spoilage. The surveyor reviewed the facility policy titled Dishwasher Temperature, Date Reviewed/Revised: 3/24/24. The following was revealed under the heading Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. In addition, the policy further revealed the following under Policy Explanation and Compliance Guidelines: 4. For low temperature dishwashers (chemical sanitization): a. The wash temperature shall be 120 F. b. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The surveyor reviewed the facility policy titled Food Brought in from outside sources, undated. The following was observed under the heading Procedure: 4. Staff will monitor resident's room, unit pantry, refrigerator/freezer units for food and beverage for disposal. The surveyor reviewed the facility provided 'PM - Special Duty Cleaning list for May 12, 19, and 26th of 2024. The special duty cleaning list for Sunday through Saturday failed to address cleaning of the fan in the walk-in refrigerator/freezer. The surveyor reviewed the facility provided Food Service Closing Checklist for May 19, and May 26th, 2024. The closing checklist started on Sunday and ended on Monday. The Food Service Closing Checklist failed to address cleaning of the fan in the walk-in refrigerator/freezer. The surveyor reviewed the facility provided A.M. SHIFT DAILY CLEANING LIST dated June 1, June 2, and June 3/2024. The cleaning list failed to address the cleaning of the fan in the walk-in refrigerator/freezer. NJAC 18:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep all areas clean and safe. The deficient practice was identified on 4 of 4 Units (Court 1, Court 2, Pavilion, and Vent). The deficient practice was evidenced by the following: On 05/29/2024 at 10:37 AM during the initial tour of the facility on Court 1, the surveyor visited Resident # 5 in their room. At that time, the surveyor observed a trash receptacle. There was not a bag liner in the receptacle. On the other side of the room, a clear trash bag was left on the floor. There was various items of trash within the bag. On the same date at 10:48 AM during the initial tour of the facility on Court 1, surveyor # 1 visited Resident # 24 in their room. At that time, the surveyor observed food debris such as crumbs on the floor. The surveyor also observed the bathroom. The surveyor observed that the trash receptacle did not have a bag liner. At that time, Resident # 24 informed the surveyor that the staff does not sweep at all. The trash receptacle was filled with trash at the time of observation. On 06/03/2024 at 9:41 AM, surveyor # 1 visited Resident # 24 in their room. At that time, surveyor # 1 observed a trash receptacle. There was not a bag liner in the receptacle. The trash within the receptacle included but was not limited to a soiled wound care pad, commonly referred to as an, ABD Pad. The surveyor also observed the bathroom. The surveyor observed that the trash receptacle did not have a bag liner. The trash within the receptacle included but was not limited to a soiled pull-up style incontinence brief. On 06/03/2024 at 11:34 AM during an interview with surveyor # 1, the Housekeeping Director (HKD) said that rooms are cleaned daily. Secondly, the HKD included sweeping in her dictation of her expectations from staff when they clean a room. The surveyor asked if trash receptacles should have bag liners. The HKD replied, They should. The surveyor asked if soiled bandages or incontinence briefs be placed in resident room trash receptacles. The HKD replied, No, they should not. On 06/05/2024 at 9:54 AM, during an interview with surveyor # 1, the Licensed Nursing Home Administrator (LNHA) confirmed that trash receptacles should have bag liners. Also at that time, the Regional Executive Director (ED) confirmed that trash receptacles should have bag liners. Further the ED clarified that if wound care bandages are in the resident trash receptacles, Housekeeping staff would have to empty and disinfect the can. 37547 On 05/29/24 at 10:25 AM during the initial tour of the facility, surveyor # 2 entered room [ROOM NUMBER] and noted a stained ceiling tile over B bed. The bottom drawer of the resident's night stand was missing. There was a hole in the wall between the two resident's wardrobes. Surveyor # 2 noted that there were no personal effects in the resident's living space. On 05/31/24 at 10:10 AM, surveyor # 2 observed Resident #108 seated in a chair in the dining room. When interviewed, the resident stated he/she moved into room [ROOM NUMBER] a couple of weeks ago. The resident stated he/she was not happy about the missing bottom drawer in the nightstand, but had not told anyone about it. On 05/31/24 at 12:00 PM, surveyor # 2 interviewed CNA #1 who stated Resident #108 recently moved into room [ROOM NUMBER]. CNA #1 stated she had not noticed the stained ceiling tile over resident's bed, the missing bottom drawer, or broken window blinds. CNA #1 stated the resident may have done that because they were not like that. CNA #1 stated we decorated the resident's room if their family brings things in from home. CNA #1 stated she either called housekeeping or Maintenance to report needed repairs. On 05/31/24 at 12:11 PM, surveyor # 2 reviewed the Maintenance Log Book which revealed a written request was placed on 09/12/23, which indicated that the blinds in room [ROOM NUMBER] were broken and needed to be replaced. On 05/31/24 at 12:22 PM, surveyor # 2 interviewed the Maintenance Director (MD) who stated he worked at the facility for six months. The MD stated he rounded daily. The MD stated staff notified Maintenance when repairs were needed through an electronic submission. The MD stated that maintenance kept supplies on their carts and completed the work as it was received. On 06/03/24 at 10:17 AM, surveyor # 2 interviewed Maintenance in room [ROOM NUMBER]. He stated he was not aware of the stained ceiling tile that was over Resident #108's bed. He stated the stain was related to a roof leak. He stated the roof was repaired, but continued to leak. Maintenance stated he was notified of the broken blind via electronic submission, but had not gotten around to it. He stated he was also aware of the large stained ceiling tile in entryway of room. He stated the pipe was clamped, but not replaced, and continued to leak. He stated administration came in on Saturday and did walking rounds and replaced the resident's damaged night stand. He stated he recently noted a hole in the sheet rock (wall covering) that was covered by clothing and was previously missed during rounds. He stated the large ceiling tile, blind, and night stand should have been addressed prior, but it was just him here to do all of the work. On 06/03/24 at 10:59 AM, surveyor # 2 interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who stated she never saw the stained ceiling tile over Resident #108's bed. She stated it could potentially cause an allergy, as it looked rusty and could turn into mold if it sat too long. She stated the large ceiling tile had leaked in the past and has been reported to Maintenance. She stated, It was not like that when I left. LPN/UM #4 stated the window blinds were reported, and replaced, but she was unsure of which rooms were addressed. On 06/03/24 at 12:59 PM, surveyor # 2 interviewed the Licensed Nursing Home Administrator (LNHA) who stated if room [ROOM NUMBER] 's leak was bad it could leak onto the resident. He stated he was aware the blinds needed replacement, but he did not know there were broken pieces. On 06/03/24 at 1:52 PM, the LNHA provided the surveyor with Work Orders that were open and in progress. Review of the Work Orders revealed an entry dated 05/07/24, which indicated broken furniture, hole in wall, and stained tile, that was entered with high priority. On 06/04/24 at 10:31 AM, surveyor # 2 interviewed the Infection Preventionist (IP) who stated if water were to pool in the ceiling tile, then it may present a risk for bacterial growth, but she was not sure and would have to see it. She stated it was more of a safety concern if the ceiling tile pieces were to fall from the ceiling. 49712 On 05/29/2024 at 10:51 AM during initial tour on the pavilion unit, surveyor #3 observed a missing drawer to the dresser in room [ROOM NUMBER]. On 05/30/2024 at 11:54 AM while touring the pavilion unit surveyor #3 observed, the top drawer from a dresser in room [ROOM NUMBER] was missing. On 05/30/2024 at 12:06 PM in the tub room on the Pavilion Unit surveyor #3 observed, 2 out of 4 ceiling lights were not working, a shower stall missing a shower curtain, brown stains on a ceiling tile in the shower stall and a hole above a call light box. Also, in the bathroom, connected to the tub room the surveyor observed a hole in the wall behind the toilet. On 05/30/2024 at 12:30 PM in the front sunroom on the pavilion unit, surveyor #3 observed, a deteriorated windowsill with exposed rusted metal and rotted wood. On 05/31/24 at 10:54 AM, in the rear sunroom on the pavilion unit, surveyor #3 observed, a deteriorated windowsill with exposed rusted metal, rotted wood, protruding screws and jagged edges. The surveyor also observed the door frame, split with jagged edges at the bottom and a broken corner piece. On 05/31/2024 at 11:10 am during an interview with t surveyor #3, a certified nurse's aide (CNA)#1 said. When asked if it should be exposed, they replied, No, residents can get hurt. CNA#1 said it should be reported to maintenance. On 05/31/2024 at 12:22 PM during an interview with surveyor #3, the Maintenance Director stated, We do rounds every day. If we see something that needs to be fixed, we load up the cart and fix it that day. When asked if they had known about the windowsills, the Maintenance Director stated, I was notified last week, it needs to be sheet rocked When asked if it was safe for the resident's they replied, no. On 06/04/2024 during an interview with surveyor #3 the Executive Director stated, No, the drawers should not be missing, windowsills should not be exposed. Residents in that unit destroy things. We are working with Maintenance to be rounding more often and fix what they see having to do with the environment as well. 40041 On 05/30/24 at 8:50 AM during a tour of the Pavilion Unit room [ROOM NUMBER]A/B, Surveyor #4 observed the following: A broken wall panel at the bottom left of the entrance to the bathroom. A large hole in the panel located against the back wall, which was also noted to be detached from the wall. A large hole in the panel located near the radiator. An opening in the wall near the boarder. On 06/04/2024 at 12:15 PM during an interview with Surveyor #4, the Maintenance Director (MD) stated, No when asked if he was aware of the damaged panel and damaged wall near the border. The MD also stated No when asked should there be holes in the panel and the wall near the border and radiator. On 06/04/2024 at 12:35 PM during an interview with Surveyor #4, the LNHA stated Yes when asked should the brown panel, wall and boarder be intact. 40039 On 05/31/2024 at 10:10 AM Surveyor # 5 made the following observations on the Court 2 dining/activity room, The window to the left of the stairwell door has\d the wallpaper peeled away. The window to the left of the entry door is not closed completely. All windows are observed to be dirty with a whitish unidentified substance. The lower window adjacent to the activities supply cabinet has an unidentified black/green mold-like substance on the exterior of the lower window, which covers approximately the top 3-4 inches of the window. On 05/31/2024 at 12:18 PM Surveyor # 5 made the following observations on the Court 2 dining/activity room: The window to the left of the entry door and next to table #9 had unidentified debris in the window sill, including a dead bee. The wallpaper on the left side of the window is peeling away from the wall. The screen on the right side window has an approximate 4 inch x 2 inch hole. A review of a facility provided document titled, Housekeeping Daily Routine revealed that at 8:00 AM housekeeping is expected to, Walk through rooms (policing) Replenish all dispensers inside of rooms, sweep, and remove trash . A review of a facility provided document titled, 7-Step Cleaning Process revealed under number one to, PULL TRASH, Remove liners and clean inside and outside of the waste receptacle, Reline waste receptacle 3-5 bags per can. The document revealed under number five to, DUST MOP FLOOR, Dust behind all furniture and doors. Review of the facility policy, Maintenance Services (Policy NO:RF-EC-S-0704) (Last Revised/Reviewed 04/01/24) revealed the following: The Maintenance Department will operate the facility in compliance with federal, state and local laws, regulations and guidelines that include, maintaining: The building in good repair and free from hazards. The Maintenance Department will work with the facility administration and corporate Facility Services staff to establish priorities for repair and replacement of critical building components and and infrastructure. A review of a facility policy titled, Maintenance Services revealed, To ensure that the facility's buildings, grounds and equipment are always maintained in a safe and operable manner. A review of the facility provided document titled, Environment of care. revised on 04/01/2024 under Procedure that 1. The Maintenance Department will operate the facility in compliance with current federal, state, and local laws, regulations and guidelines that may include, maintaining: The building in good repair and free from hazards. S 8:39-31.4 (a)

Repeat deficiency from the recertification survey of 12/12/2023. Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to develop a comprehensive resident centered care plan for 2 of 35 sampled residents (Resident #28 and Resident #116). This deficient practice was evidenced by the following: 1. During the initial tour on 05/29/2024 at 11:07 AM, Resident #28 was observed lying in bed with the head of the bed elevated. Resident #28 had a tracheostomy (trach) (an incision in the windpipe made to relieve an obstruction to breathing) to the ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, or anesthetized). A review of the Admission Record revealed Resident #28 was admitted to the facility with diagnoses including but not limited to: Acute Respiratory Failure with Hypoxia (low levels of oxygen in your body tissues), and Dependence on Respirator (Ventilator). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 05/08/2024, indicated Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating Resident #28 was cognitively intact. Section O indicated Resident #28 was on continuous oxygen while a resident, received suctioning, trach care and, yes was marked for invasive mechanical ventilator. A review of the Order Recap Summary dated 05/01/2024-05/30/2024 revealed the following physician orders: with a start date of 04/28/2024 Ventilator settings: PCV Pressure Control Ventilation) 20/450/+5/40% PC (Pressure Control) 35 Weaning: [X]yes []no every shift. Perform assessment of tracheostomy site including skin around stoma and trach ties every shift. Perform tracheostomy care with inner cannula change every shift. Perform tracheal suction every shift AND as needed. Spot check SPO2 (oxygen) every shift AND as needed. Change ventilator circuits with bacterial filter every day shift every 4 weeks on Wednesday. Change nebulizer setup on ventilator patients every night shift every Tuesday. A review of the care plan revealed a FOCUS area: Has/At risk for respiratory impairment related to [nothing documented] with Date Initiated: 04/28/2024. Under the GOAL section: indicated Will maintain a patent airway with Date Initiated: 05/16/2024. Interventions included but were not limited to: Administer medications/treatments per physician orders with Date Initiated: 04/28/2024, Nursing staff Obtain labs/diagnostic tests as ordered then notify physician of results with Date Initiated: 04/28/2024, Nursing staff oxygen with Date Initiated: 04/28/2024, and Tracheostomy care per protocol with Date Initiated: 04/28/2024. The care plan did not include documentation or address that Resident #28 had a tracheostomy, ventilator, required suctioning, or used oxygen. During an interview with the surveyor on 06/03/2024 at 9:19 AM, Unit Manger/Licensed Practical Nurse (UM/LPN #2) was asked who is responsible for doing care plans. UM/LPN #2 responded, On admission the nurses should do the care plan based on diagnosis and needs of the residents like ADL's (activities of daily living). The surveyor asked what should be on the care plan. UM/LPN #2 responded any diagnosis, vent, trach, any psychotropic med's, diuretics', antibiotics, Intravenous lines, and ADL's. It should be done on admission, but we have 24 hours. I come in the next day and review it. I make sure they are all updated. Both the nurses and I update the care plans. On 06/03/2024 at 9:24 AM, the surveyor requested that the UM/LPN #2 UM bring Resident #28's care plan up on the computer screen. UM/LPN #2 confirmed date initiated for the vent care plan was 5/31/2024. The surveyor asked if the vent care plan was done upon admission. UM/LPN #2 said No, the vent care plan was not done at time of admission. I did this on Friday. The surveyor then asked UM/LPN #2 if the care plan should have been completed within 24 hours of admission. UM/LPN #2 said, Yes, it should have been on the care plan upon admission. 2. According to the Admission Record, Resident #116 was admitted to the facility with diagnoses including but not limited to: Acute and Chronic Respiratory Failure, dependence on Respirator (Ventilator). According to the most recent MDS dated [DATE], Resident #116 had BIMS 15/15. A review of the Order Recap Report dated 04/01/2024-04/30/2024 revealed the following physician orders: With start date of 02/27/2024 PCV 20 400 60% +5peep PC35. Trach (tracheostomy) care Qshift every shift for prevention related to tracheostomy and as needed. Titrate Fio2 to maintain SPO2>92% or greater PRN as needed related to Acute and Chronic Respiratory Failure with hypoxia. #6 Shiley XLT Proximal change Q60days and prn. A review of the care plan for Resident #116 revealed under FOCUS area with an initiated date of 02/23/2024: [Resident name] has altered respiratory status/difficulty breathing r/t (related to) chronic respiratory failure, sarcoidosis (inflammatory disease results in growth of tiny granulomas in different parts of the body, including the lungs, eyes, skin and heart), pulmonary fibrosis (a disease where there is scarring of the lungs-called fibrosis-which makes it difficult to breathe), and pneumonia. Under GOAL: The resident will have no complications related to SOB (shortness of breath) through the review date. Interventions included: Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions date initiated 02/23/2024. Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger with initiated date of 02/23/2024. The care plan did not include documentation that Resident #116 had a tracheostomy, ventilator, required suctioning, and used oxygen. During an interview with the surveyor on 06/03/2024 at 9:19 AM, UM/LPN #2 was asked who is responsible for doing care plans. UM/LPN #2 responded on admission the nurses should do the care plan based on diagnosis and needs of the residents like ADL's (activities of daily living. The surveyor asked what should be on the care plan. UM/LPN #2 responded any diagnosis, vent, trach, any psychotropic meds, diuretics', antibiotics, Intravenous lines, and ADL's. It should be done on admission, but we have 24 hours. I come in the next day and review it. I make sure they are all updated. Both the nurses and I update the care plans. The surveyor asked UM/LPN #2 to bring up Resident #116's care plan on the computer. On 06/03/2024 at 9:26 AM, UM/LPN #2 said Resident #116 was up here before I started. UM/LPN #2 confirmed there was no vent care plan just respiratory impairment. UM/LPN #2 said They need to specify he/she was on a vent. During an interview with the surveyor on 06/04/2024 at 10:28 AM, the Assistant Director of Nursing (ADON) was asked who is responsible to complete a care plan for an admission. The ADON responded we have the baseline care plan completed on the day of admission. This could be initiated by the nurse who is admitting the resident. Overall unit managers are in charge of and responsible for care plans. When asked what the process is for readmissions, the ADON said it depends on if there is a new problem, if so, we have to update. If a resident had a comprehensive care plan in place and the resident goes out to the hospital, we can update that care plan. The surveyor asked what should be on the care plan. The ADON said Active diagnoses, problems, ADL's, pain, fall, skin, oxygen. When asked if a vent should be on the care plan the ADON said, Yes, ventilator should be on the care plan. If ventilator is the primary diagnosis, yes, it should be on the baseline care plan. The ADON was unsure of when the comprehensive care plan was to be completed. During a follow up interview on 06/04/2024 at 10:49 AM, the ADON said we have 14 days to complete the MDS and 7 days after MDS completed to complete the comprehensive care plan. A review of a facility policy with subject Care Plan with reviewed date of April 2024, revealed under the Policy section: It is the policy of [facility name] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Under the Procedure section 2. They will include initial goals, MD (physician) orders, medications, treatments, dietary orders, therapy orders, social services and PASARR recommendations. NJAC 8:39-11.2(f) Repeat deficiency from the recertification survey of 12/12/2023. Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to develop a comprehensive resident centered care plan for 2 of 35 sampled residents (Resident #28 and Resident #116). This deficient practice was evidenced by the following: 1. During the initial tour on 05/29/2024 at 11:07 AM, Resident #28 was observed lying in bed with the head of the bed elevated. Resident #28 had a tracheostomy (trach) (an incision in the windpipe made to relieve an obstruction to breathing) to the ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, or anesthetized). A review of the Admission Record revealed Resident #28 was admitted to the facility with diagnoses including but not limited to: Acute Respiratory Failure with Hypoxia (low levels of oxygen in your body tissues), and Dependence on Respirator (Ventilator). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 05/08/2024, indicated Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating Resident #28 was cognitively intact. Section O indicated Resident #28 was on continuous oxygen while a resident, received suctioning, trach care and, yes was marked for invasive mechanical ventilator. A review of the Order Recap Summary dated 05/01/2024-05/30/2024 revealed the following physician orders: with a start date of 04/28/2024 Ventilator settings: PCV Pressure Control Ventilation) 20/450/+5/40% PC (Pressure Control) 35 Weaning: [X]yes []no every shift. Perform assessment of tracheostomy site including skin around stoma and trach ties every shift. Perform tracheostomy care with inner cannula change every shift. Perform tracheal suction every shift AND as needed. Spot check SPO2 (oxygen) every shift AND as needed. Change ventilator circuits with bacterial filter every day shift every 4 weeks on Wednesday. Change nebulizer setup on ventilator patients every night shift every Tuesday. A review of the care plan revealed a FOCUS area: Has/At risk for respiratory impairment related to [nothing documented] with Date Initiated: 04/28/2024. Under the GOAL section: indicated Will maintain a patent airway with Date Initiated: 05/16/2024. Interventions included but were not limited to: Administer medications/treatments per physician orders with Date Initiated: 04/28/2024, Nursing staff Obtain labs/diagnostic tests as ordered then notify physician of results with Date Initiated: 04/28/2024, Nursing staff oxygen with Date Initiated: 04/28/2024, and Tracheostomy care per protocol with Date Initiated: 04/28/2024. The care plan did not include documentation or address that Resident #28 had a tracheostomy, ventilator, required suctioning, or used oxygen. During an interview with the surveyor on 06/03/2024 at 9:19 AM, Unit Manger/Licensed Practical Nurse (UM/LPN #2) was asked who is responsible for doing care plans. UM/LPN #2 responded, On admission the nurses should do the care plan based on diagnosis and needs of the residents like ADL's (activities of daily living). The surveyor asked what should be on the care plan. UM/LPN #2 responded any diagnosis, vent, trach, any psychotropic med's, diuretics', antibiotics, Intravenous lines, and ADL's. It should be done on admission, but we have 24 hours. I come in the next day and review it. I make sure they are all updated. Both the nurses and I update the care plans. On 06/03/2024 at 9:24 AM, the surveyor requested that the UM/LPN #2 UM bring Resident #28's care plan up on the computer screen. UM/LPN #2 confirmed date initiated for the vent care plan was 5/31/2024. The surveyor asked if the vent care plan was done upon admission. UM/LPN #2 said No, the vent care plan was not done at time of admission. I did this on Friday. The surveyor then asked UM/LPN #2 if the care plan should have been completed within 24 hours of admission. UM/LPN #2 said, Yes, it should have been on the care plan upon admission. 2. According to the Admission Record, Resident #116 was admitted to the facility with diagnoses including but not limited to: Acute and Chronic Respiratory Failure, dependence on Respirator (Ventilator). According to the most recent MDS dated [DATE], Resident #116 had BIMS 15/15. A review of the Order Recap Report dated 04/01/2024-04/30/2024 revealed the following physician orders: With start date of 02/27/2024 PCV 20 400 60% +5peep PC35. Trach (tracheostomy) care Qshift every shift for prevention related to tracheostomy and as needed. Titrate Fio2 to maintain SPO2>92% or greater PRN as needed related to Acute and Chronic Respiratory Failure with hypoxia. #6 Shiley XLT Proximal change Q60days and prn. A review of the care plan for Resident #116 revealed under FOCUS area with an initiated date of 02/23/2024: [Resident name] has altered respiratory status/difficulty breathing r/t (related to) chronic respiratory failure, sarcoidosis (inflammatory disease results in growth of tiny granulomas in different parts of the body, including the lungs, eyes, skin and heart), pulmonary fibrosis (a disease where there is scarring of the lungs-called fibrosis-which makes it difficult to breathe), and pneumonia. Under GOAL: The resident will have no complications related to SOB (shortness of breath) through the review date. Interventions included: Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions date initiated 02/23/2024. Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger with initiated date of 02/23/2024. The care plan did not include documentation that Resident #116 had a tracheostomy, ventilator, required suctioning, and used oxygen. During an interview with the surveyor on 06/03/2024 at 9:19 AM, UM/LPN #2 was asked who is responsible for doing care plans. UM/LPN #2 responded on admission the nurses should do the care plan based on diagnosis and needs of the residents like ADL's (activities of daily living. The surveyor asked what should be on the care plan. UM/LPN #2 responded any diagnosis, vent, trach, any psychotropic meds, diuretics', antibiotics, Intravenous lines, and ADL's. It should be done on admission, but we have 24 hours. I come in the next day and review it. I make sure they are all updated. Both the nurses and I update the care plans. The surveyor asked UM/LPN #2 to bring up Resident #116's care plan on the computer. On 06/03/2024 at 9:26 AM, UM/LPN #2 said Resident #116 was up here before I started. UM/LPN #2 confirmed there was no vent care plan just respiratory impairment. UM/LPN #2 said They need to specify he/she was on a vent. During an interview with the surveyor on 06/04/2024 at 10:28 AM, the Assistant Director of Nursing (ADON) was asked who is responsible to complete a care plan for an admission. The ADON responded we have the baseline care plan completed on the day of admission. This could be initiated by the nurse who is admitting the resident. Overall unit managers are in charge of and responsible for care plans. When asked what the process is for readmissions, the ADON said it depends on if there is a new problem, if so, we have to update. If a resident had a comprehensive care plan in place and the resident goes out to the hospital, we can update that care plan. The surveyor asked what should be on the care plan. The ADON said Active diagnoses, problems, ADL's, pain, fall, skin, oxygen. When asked if a vent should be on the care plan the ADON said, Yes, ventilator should be on the care plan. If ventilator is the primary diagnosis, yes, it should be on the baseline care plan. The ADON was unsure of when the comprehensive care plan was to be completed. During a follow up interview on 06/04/2024 at 10:49 AM, the ADON said we have 14 days to complete the MDS and 7 days after MDS completed to complete the comprehensive care plan. A review of a facility policy with subject Care Plan with reviewed date of April 2024, revealed under the Policy section: It is the policy of [facility name] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Under the Procedure section 2. They will include initial goals, MD (physician) orders, medications, treatments, dietary orders, therapy orders, social services and PASARR recommendations. NJAC 8:39-11.2(f)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to promote resident dignity and ensure a safe, clean, comfortable, homelike, environment when a resident was transferred into a private room without a functional bathroom or accessible handwashing sink. This deficient practice was identified on 1 of 4 Units (Pavilion) and for 1 of 1 resident (Resident #37) observed for accommodation of needs. This deficient practice was evidenced by the following: On 05/29/2024 at 10:07 AM, the surveyor entered Resident #37's room and noted that the room smelled of dampness and the resident's bathroom had a sign posted on the door that depicted a toilet and the door was bolted shut from the outside. The resident was not in the room at the time of the observation. The surveyor observed Maintenance outside of the room in the hallway. When interviewed, Maintenance stated that the resident's bathroom was closed off after the sheet rock buckled due to water damage both on the inside and outside of the bathroom wall which rendered the bathroom unsafe for resident use so he locked it shut. Maintenance was unable to state when the door was locked shut. Maintenance stated that sheet rock was ordered last week and he had not yet received the materials to begin the repairs. A review of Resident #37's Admission Record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: acute respiratory failure with hypoxia (deficiency in the amount of oxygen), chronic obstructive pulmonary disease (COPD) with (acute) exacerbation (a condition involving constriction of the airways and difficulty or discomfort in breathing), chronic diastolic (congestive) heart failure (the heart's capacity to pump blood cannot keep up with the body's need), and aphasia (a language disorder that affects a person's ability to communicate). A review of Resident #37's Quarterly Minimum Data Set (MDS) an assessment tool, indicated that the resident had a brief interview for mental status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive impairment. A further review of the MDS revealed that the resident was always incontinent of bowel and bladder. On 05/31/2024 at 10:26 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated Resident #37 required minimal assistance and used a walker to transfer to and from the wheelchair. When the surveyor asked CNA #1 about the condition of the resident's bathroom, she stated the resident was supposed to change rooms soon because of a clogged toilet. On 05/31/2024 at 10:34 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #3 who stated she did not know when Resident #37's bathroom door was bolted closed. LPN #3 stated that the resident had a 50/50 continence rate and used the bathroom in the hall when needed. LPN #3 stated the resident was allowed to transfer independently or with help. On 05/31/2024 at 12:22 PM, the surveyor interviewed the Maintenance Director (MD) who stated that Maintenance brought it to his attention last week about Resident #37's bathroom and the bathroom should have a pad lock on it since the wall needed to be cut. The MD stated that we locked the resident's bathroom door shut to keep the resident safe. He further stated that the resident could use the tub room bathroom instead. On 05/31/2024 at 2:25 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a receipt dated 05/23/2024 at 11:26 AM, from a home supply store for materials needed to repair Resident #37's wall. On 06/03/2024 at 9:13 AM, the surveyor viewed Resident #37's Electronic Health Record (EHR) under the census tab and noted that the resident was moved from a semi-private room to a private room on 05/08/2024. On 06/03/2024 at 9:56 AM, in a follow up interview with Maintenance, he stated someone who no longer worked at the facility moved Resident #37 into room [ROOM NUMBER], but the resident should have never been moved into that room because the wall was buckled both at the entrance and in the bathroom and required more work than he had anticipated. He stated the work was now in progress since the resident's room had now been changed after surveyor inquiry last Saturday. On 06/03/2024 at 10:45 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who stated that the former Unit Manager moved Resident #37 from a semi-private room to a private room. LPN/UM #4 stated that the resident should have been moved from the semi-private room to a room with a bathroom for handwashing and cleanliness. LPN/UM #4 stated it was an infection control issue. LPN/UM #4 stated that both the resident and the staff needed the ability to wash. LPN/UM #4 stated she was stumped by the decision to move the resident into that room. On 06/03/2024 at 12:59 PM, the surveyor interviewed the LNHA who stated that it was an error on behalf of the former Unit Manager when Resident #37 was moved into a private room room that had damage. The LNHA stated that the room should have been locked down prior and that was what I believed happened. The LNHA stated, I was not aware. The LNHA stated he told them the resident had to have a working bath as the wall was crumbling. The LNHA further stated that was not how it should have been, as the resident needed a working bathroom for both privacy and dignity. On 06/03/2024 at 1:52 PM, the LNHA provided the surveyor with both Open and in Progress Work Orders which indicated that on 02/23/23, it was noted to be a high priority that the paneling on the wall was coming off and could result in injury to the resident in room [ROOM NUMBER]. On 05/30/2024, a second high priority request was made to Maintenance which indicated there was a hole in the wall behind the resident's door in room [ROOM NUMBER]. There was not documented evidence that the repairs were made when requested. A review of the facility policy, Environment of Care (Last Revised/Reviewed 04/01/24) revealed the following: Policy: To ensure that the facility's buildings, grounds, and equipment are always maintained in a safe and operable manner. The facility shall implement a policy to assure that the facility is periodically maintained to assure its effective and efficient operation. Procedure: The Maintenance Department will operate the facility in compliance with current federal, state and local laws, regulations and guidelines that may include, maintaining: The building is in good repair and free from hazards .The plumbing system is in good working order .The Maintenance Department will work with facility administration and corporate Facility Services staff to establish priorities for repair and replacement of critical building components of infrastructure. The Maintenance Department will provide and document routine and emergency maintenance service to all areas of the facility. The Maintenance Department will perform other tasks and/or functions that may become necessary or appropriate. A review of the facility policy, Resident Rights (Created 05/30/24) revealed the following: .The resident has a right to a safe, clean, comfortable and Homelike [sic.] environment, including but not limited to receiving treatment and supports for daily living safely. NJAC 8:39-27.1(a), 31.4(a),4.1(a)(12)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow physician's orders following hospitalization to ensure that a resident who was readmitted to the facility with a closed fracture of the fourth metacarpal bone (the bones that form the intermediate part of the hand between the fingers and wrist bones) was scheduled for a follow-up appointment with an Orthopedic Surgeon (treats muscoskeletal injuries) and resident usage of a prescribed splint. This deficient practice was identified for 1 of 1 resident (Resident #108) reviewed for a change in condition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 05/31/24 at 10:10 AM, the surveyor observed Resident #108 seated in a chair in the dining room. The resident appeared to be confused to place and time when spoken to. The resident did not have a splint on the left upper extremity at that time or upon subsequent observations throughout the survey. Review of Resident #108's Admission Record (an admission summary) revealed that the resident was readmitted to the facility with diagnosis which included but were not limited to: unspecified fracture of the fourth metacarpal bone, left hand, subsequent encounter for fracture with routine healing and unspecified dementia, unspecified severity, with psychotic disturbance. Review of Resident #108's Significant Change Minimum Data Set (MDS), an assessment tool dated 04/28/24, revealed the resident had a brief interview for mental status (BIMS) score of 3 out of 15 which indicated the resident was severely cognitively impaired. Review of Resident #108's Care Plan revealed an entry that was revised on 03/05/24, with a Focus that specified resident presented with a balance deficit limiting his/her ability to complete ADL's (activities of daily living) and functional mobility as independently as possible. The goal included resident will maximize I (independence) with all bed mobility, functional mobility, and transfers through next review date. Interventions/Tasks included: Assist x 1 with ADL's, NWB (non-weightbearing) LUE (left upper extremity), follow up with ortho for further instructions (revision dated 05/06/24). Further review of Resident #108's Care Plan revealed an entry dated 04/22/24, with a Focus which indicated the resident had a fracture of the left fourth metacarpal bone. The Goal included resident will not have increase in pain/discomfort R/T (related to) FX (fracture). Interventions included: .Will remain NWB to L arm and L hand until ortho Follow up. Review of Resident #108's Order Summary Report (OSR) dated 04/23/24 specified: F/U (follow-up) with Orthopedic Surgeon, NWB to L hand and L arm, and Ulnar Gutter Splint to be worn at all times to L hand and L arm until follow up with ortho. Assess skin integrity, pulse and circulation every shift for L fourth Metacarpal FX. Review of Resident #108's Progress Notes (PN) revealed an entry dated 4/17/24 at 12:01 PM, which indicated Primary nurse notified this nurse of resident's L hand c/o (complaint of). Upon assessment, L hand presents with +2 edema (swelling) to L thumb, L 1st digit, and L second digit, with swelling to knuckles. Slight redness noted, cool to touch. Resident c/o pain 8/10. Describes pain, hurts when I squeeze or use anything.Verbal obtained for STAT complete X-ray to L hand, noted and carried out. On 04/17/24 at 3:40 PM, Xray for left hand/wrist results came back. There was no evidence of an acute fracture or dislocation .A physician's note dated 04/19/24 at 9:47 AM, indicated resident's Xray negative for Fx, resident reported hitting a wall. Appears to be bruised with some swelling, no erythema (redness or warmth). Decreased ROM (range of motion). Resident did not report to staff he/she punched the wall, poor historian, was not witnessed. Will check u/s (ultrasound) to rule out DVT (deep vein thrombosis, blood clot). Further review of the PN revealed that on 04/20/24 at 10:13 PM, resident was transferred to ER for altered mental status and back pain. On 04/22/24 at 9:35 PM, resdient returned from hospital at approximately 8:15 PM. Resident express [sic.] no pain nor distress throughout reminder [sic.] of shift and return with fracture case to the left arm .Will continue to monitor for further changes in condition. Review of Resident #108's hospital Discharge Instructions dated 04/21/24, revealed in the Brief Summary of Hospital Course and Important Follow Up Information included .You had no repeat episodes of altered mental status or dizziness during hospitalization . You were also noted to have a fracture of your hand for which orthopedic doctors were consulted. They recommended you to follow up with them in 1 (one) week and you had a splint placed on the hand . Further review of the Discharge Instructions revealed the following: Weight bearing: Non weight bearing left arm .Keep your bandage/splint clean, dry and intact, .Follow-up as instructed. Review of Resident #108's facility Incident titled, Fracture, dated 04/22/24 at 8:45 PM, revealed Resident returned to the facility as a readmission with a Dx (diagnosis): Closed fracture of the 4th (fourth) metacarpal bone Immediate Action Taken: Orders verified and carried out per hospital instruction as follows: 1. Non-weight bearing (NWB) to Left hand and L arm 2. Returned with Ulnar Gutter Splint (type of splint) to L hand and L arm, to be worn at all times 3. Follow up with orthopedics, provider listed on D/C instructions. On 06/03/24 at 11:27 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who reviewed Resident #108's Electronic Health Record (EHR) in the presence of the surveyor and stated the resident's splint was in place. The surveyor questioned splint usage, as it was not observed on the resident. LPN/UM #4 asked a Certified Nursing Assistant (CNA) who was present at that time, who stated that resident had a splint on when they returned from the hospital. LPN/UM #4 further stated that there was no order or indication that the resident went out to see Ortho (orthopedics) for their follow-up appointment. On 06/03/24 11:41 AM, the surveyor interviewed CNA #3 who stated she had not seen Resident #108 with their splint on at all. On 06/03/24 at 11:43 AM, in a later interview with LPN/UM #4, she stated in May 2024, nursing charted that Resident #108 had not worn their splint five times. LPN/UM #4 stated on 05/04/24, nursing documented that resident removed their splint. LPN/UM #4 stated the order was never discontinued. LPN/UM #4 stated the resident should have had an Ortho consult and she was not sure why it was not done, but the rationale should have been documented by the former unit manager. LPN/UM #4 stated, The resident had Medicaid (type of insurance) and somebody would have taken him/her. LPN/UM #4 stated, I am sick. The surveyor reviewed the Medication Administration Record (MAR) for May 2024 and noted an entry for Ulnar Gutter Splint to be worn to L hand and L arm until follow up with Ortho. Assess skin integrity, pulse and circulation every shift for L 4th Metacarpal Fx was signed as administered every shift (day, evening and night) on all shifts except for day shifts on 05/16/24, 05/22/24, 05/26/24, evening shifts: 05/04/24, and 05/29/24. The order was signed as completed on all shifts in June 2024 with the exception of evening shift on 06/02/24. On 06/03/24 at 11:47 AM, the surveyor interviewed the Director of Rehabilitation (DOR) in the presence of LPN/UM #4, who stated we did not screen the resident post hospital and awaited Ortho follow-up. DOR stated they (hospital) sent a splint, and the resident took it off and refused to put it back on. LPN/UM #4 stated We did not DC (discontinue) the order for the splint and that was the problem. The DOR agreed to furnish the surveyor with the Occupational Therapists initial screening. Review of a Rehabilitation Screen Form dated 04/23/24 revealed the following: Pt screened s/p hospitalization ,d+[DATE]-[DATE] secondary to dizziness and fracture to LUE 4th (fourth) metacarpal s/p hitting wall in frustration. Patient came back NWB (non-weightbearing) with gutter ulnar cast and ortho f/u within a week .Await Ortho follow-up appt. (appointment) within a week for further instructions, orders for skilled therapy services. No therapy at this time. On 06/03/24 at 11:50 AM, the surveyor interviewed the Unit Clerk (UC) in the presence of LPN/UM #4, who stated Resident #108 was Medicaid Pending (not yet approved) and Ortho would not accept the resident. The UC stated she informed the former Unit Manager (UM) and the Business Office Manager (BOM) on 04/23/24. The UC was unable to provide the surveyor with documented evidence of her attempt to schedule the resident to be seen by orthopedics or notification of the former UM or BOM as described. On 06/03/24 at 12:26 PM, the surveyor interviewed the BOM who stated if medically necessary, the facility had to pay and send the resident to their scheduled appointment with transportation. BOM stated that she notified the former Unit Manager at morning meeting that we were responsible to follow through. BOM stated that this was not the first time that she told them that resident care was not to be interrupted. BOM stated she was not aware this was still an issue and the resident did not go to their appointment on the spot. BOM confirmed that she learned the resident's insurance was activated on 05/20/24. On 06/03/24 at 12:42 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility would have paid for the cost of the services Resident #108 required and the facility would have been reimbursed by Medicaid once approved. The LNHA stated it sounded like they did not follow-up for approval. The LNHA stated, there was no way around it, there was a delay in treatment for the resident due to either the former Unit Manager, BOM, or UC's failure to push through and ensure the appointment was made. The LNHA was unable to provide the surveyor with a policy that pertained to delay in resident treatment when requested. On 06/03/24 at 1:52 PM, After surveyor inquiry the LNHA confirmed that Resident #108 was scheduled to for a follow-up appointment with Orthopedics on 06/11/24 at 11:30 AM. On 06/04/24 at 1:03 PM, the surveyor interviewed the Regional Executive Director (RED) who stated if a resident were noncompliant with splint usage, then staff should encourage use, and if the resident still refused, they should have updated the care plan and notified the physician so that the order may have been discontinued. On 06/04/24 at 01:31 PM, the surveyor interviewed the Occupational Therapist (OT) who stated when Resident #108 returned from the hospital with a fx in the hand she was asked to screen him/her as the resident was made nwb in their upper extremity. She stated he/she had an ulnar collateral splint with ace around it, and the 4th and 5th fingers were out. She stated the fx was in 4th digit, ring finger and was covered, as that was the one with the fracture. She stated that EHR notes and hospital discharge instructions recommend follow-up with Ortho in one week. She stated if a prescription for therapy were received post-ortho follow-up, then we evaluate to see if therapy was necessary. She stated a Splint was issued from the ER. She described the splint as hard, like fiberglass, and described it as very hard to be removed independently. She further stated the splint was like fiberglass and was hard to maintain for a resident with cognitive deficits. On 06/05/24 at 10:05 AM, The surveyor interviewed the Director of Nursing (DON) who stated nursing should document splint use every shift, document removal every shift for skin assessment and document refusal if indicated. Review of the facility policy, Incident and Accident Report and Investigation (Reviewed April 2024) revealed the following: .Based on the clinical assessment conducted by the licensed professional nurse, necessary measures will be taken to address the situation in accordance with accepted standards of practice and facility policies. .All incidents and accidents reported in the facility must be investigated thoroughly to eliminate any possible mishandling and neglect that occurred with the resident. Investigations must be started as soon as the event has been reported and a final disposition/conclusion must be completed accordingly. Review of an undated policy, Splinting Procedure revealed the following: .Nursing staff in-serviced on appropriate application techniques and monitoring requirements specifically associated with equipment (signatures are obtained and a form is placed in patient chart and in therapy binder). NJAC 8:39-27.1 (a),

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received appropriate care and sufficient services based upon current standards of practice for a urinary catheter. The deficient practice was identified for 1 of 1 residents (Resident # 64) investigated under the Urinary Catheter investigation. This deficient practice was evidenced by the following: On 05/29/2024 at 10:21 AM, during the initial tour of the facility, the surveyor observed Resident # 64 in bed in their room. At that time, the surveyor observed a catheter drainage bag (collection bag for urine from an indwelling catheter) inside a blue, privacy bag in contact with the floor. The catheter drainage bag plastic hook was not secured to the bed frame. On 05/30/2024 at 11:28 AM, the surveyor observed Resident # 64 in bed in their room. At that time, the surveyor observed the catheter drainage bag maintained outside of the privacy bag exposing the collection bag and it's contents. The privacy bag was located further up the bed frame from the drainage bag. A review of Resident # 64's Electronic Medical Record (EMR) revealed under, Orders that there was a Physician's Order that indicated, Foley Urinary bag below bladder off floor with privacy bag every shift. The order was started on 03/13/2024. A review of Resident # 64's Care Plan located in the EMR revealed an intervention for staff to, Ensure drainage bag is positioned below the bladder and off the floor. That intervention was initiated on 02/21/2023. The Care Plan revealed another intervention for staff to, Utilize dignity bag when OOB [Out of Bed] and when in low bed. That intervention was initiated on 02/21/2023. On 06/03/2024 at 10:33 AM, during an interview with the surveyor, the Infection Preventionist stated, It shouldn't be on the floor. after reviewing the surveyor's observations. On 06/05/2024 at 09:54 AM, during an interview with the surveyor, the Director of Nursing (DON) replied, No after the surveyor asked if catheter drainage bags should be in contact with the floor. The DON replied, Risk infection after the surveyor asked if there was any reason why the catheter drainage bag should not be in contact with floor. A review of the facility policy titled Urinary Catheters dated 04/2024 revealed under procedure that, 6. Do not allow the catheter tubing, bag, or spigot to touch the floor. The policy concludes under General Information that, Residents requiring a urinary catheter are at higher risk for infection. NJAC 8:39-27.1 (a)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a) continuous oxygen was administered to an oxygen dependent resident in accordance with physician's orders in a safe and sanitary manner b) residents who were dependent upon oxygen via a tracheostomy tube (a surgically created hole (stoma) in the windpipe (trachea), received oxygen in accordance with professional standards of practice, ensured respiratory equipment was properly dated and obtained a physician order for oxygen delivery. This deficient practice was identified for 2 of 4 residents (Resident #37 and Resident #33) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. During the initial tour of the facility on 05/29/24 at 10:17 AM, the surveyor observed Resident #37 seated in a wheelchair in the dining area. The resident had a portable oxygen tank on the back of their wheelchair and no oxygen tubing was noted on or around the resident's face to indicate that oxygen was actively being delivered to the resident. On 05/29/24 at 10:19 AM, the surveyor observed a staff member who approached Resident #37 and told the resident he/she was supposed to have their oxygen on. The staff member then placed a nasal cannula (part of the oxygen tubing that is inserted into the resident's nostrils for oxygen delivery) into the residents nostrils. Review of the Admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: acute respiratory failure with hypoxia (deficiency in the amount of oxygen), chronic obstructive pulmonary disease (COPD) with (acute) exacerbation (a condition involving constriction of the airways and difficulty or discomfort in breathing), chronic diastolic (congestive) heart failure (the heart's capacity to pump blood cannot keep up with the body's need), and aphasia (a language disorder that affects a person's ability to communicate). Review of Resident #37's Quarterly Minimum Data Set (MDS) an assessment tool, indicated that the resident had a brief interview for mental status (BIMS) score of 6 out of 15, which indicated that the resident was severely, cognitively impaired. Further review of the MDS revealed that the resident received oxygen therapy. Review of Resident #37's Order Summary Report revealed an order dated 02/19/24, for Oxygen inhalation (via nasal cannula @ 3 LPM (liters per minute) every shift for hypoxia. A second order dated 01/31/24, was noted for Oxygen equipment-Change tubing every 7 (seven) days every night shift every Mon (Monday) for Change O2 (oxygen) tubing (Date O2 tubing). Review of Resident #37's Care Plan revealed an entry dated 04/24/22, which indicated the resident was at risk for respiratory distress related to COPD diagnosis. The Goal was for the resident to be free of s/s (signs and symptoms) of respiratory distress through the review date (Target date 07/31/24). Interventions/Tasks included but were not limited to: Administer oxygen as ordered and Monitor for difficulty breathing (dyspnea) on exertion . On 05/31/24 at 10:22 AM, the surveyor knocked on Resident #37's closed door and entered with resident permission. The surveyor observed Resident #37 lying in bed awake. The surveyor observed the resident received oxygen via nasal cannula from an empty oxygen tank that was on the back of the resident's wheelchair at the bedside. The surveyor observed an oxygen concentrator (a device used for continuous oxygen delivery) at the foot of the resident's bed that was not in use with oxygen tubing attached to it that was dated 05/14/24. The resident's call bell was noted on the floor behind the bed and was out of the resident's reach. On 05/31/24 at 10:26 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that Resident #37 required minimal assistance to transfer with a walker to the bed or wheelchair. CNA #1 stated that when she got here the resident was not in their room and she had not been in the resident's room yet. CNA #1 then proceeded to reach behind the resident's bed and then handed the resident their call bell. CNA #1 stated that if she noted the resident's oxygen tank were empty she informed the nurse to replace the oxygen canister. CNA #1 observed the oxygen gauge attached to the oxygen tank and stated that it needed to be refilled. CNA #1 stated I will put the oxygen concentrator on the resident now and inform the nurse. CNA #1 then proceeded to remove the resident's oxygen tubing from the portable oxygen tank on the back of the resident's wheelchair and attached it to the oxygen concentrator which she attempted to set at three liters. The concentrator beeped and a red light flashed with a wrench symbol that flashed off and on and the meter was set at zero. On 05/31/24 at 10:34 AM, Licensed Practical Nurse (LPN) #3 entered Resident #37's room. When interviewed, she stated she checked the resident's oxygen tank every 30-40 minutes to ensure it was full. LPN #3 looked at the portable oxygen tank on the back of the resident's wheelchair and confirmed that it was empty. LPN #3 stated that the resident was not supposed to be in bed and only used the concentrator when in bed. LPN #3 stated she was unaware that the resident was in bed. LPN #3 stated the resident was allowed to transfer independently or with help. LPN #3 stated CNA #1 was not supposed to touch the concentrator and was instead supposed to let the nurse know. LPN #3 then turned the liter flow on the concentrator to 3 liters, and confirmed that it was set at zero prior. The oxygen tubing was dated 05/14/24, according to LPN #3 and was supposed to be changed weekly by night shift. LPN #3 stated that the tubing was not current. LPN #3 stated the resident was last seen on oxygen at 9:15 AM and their pulse oximetry (percentage of oxygen in the blood obtained by a probe placed on the index finger) was 97% on three liters of oxygen at that time when the resident received their medications in their wheelchair. LPN #3 stated that the resident's call bell should have been clipped to their bed to call for help. LPN #3 further stated that if the resident's oxygen tank were empty and the call bell was out of reach that could mean trouble for the resident. LPN #3 then proceeded to bring a portable oxygen tank into the room and offered to assist the resident into the wheelchair and the resident declined. The resident did not appear to be in immediate distress and attempted to converse with both the LPN #3 and the surveyor. LPN #3 failed to further assess the resident at that time. Review of Resident #37's Treatment Administration Record (TAR) revealed an order for Oxygen Equipment Change tubing every 7 (seven) days every night shift every Mon for Change O2 Tubing (Date O2 Tubing) that was signed as administered on 05/13/24 and 05/27/24. On 05/31/24 at 2:03 PM, the surveyor interviewed the Director of Nursing (DON) who stated the resident's assigned nurse was responsible for oxygen function. The DON stated the nurse was responsible to place the resident on the oxygen concentrator once the resident was back in bed. The DON stated that the aides should not have touched the oxygen controls because they have to know the liter flow. The DON stated the issue was that the resident went without oxygen and could not get to the call bell. The DON stated the aide should have gotten the nurse immediately and should not have touched the concentrator. The DON stated that oxygen tubing on the concentrator was changed weekly by the 11-7 nurse. The DON stated that if the oxygen tubing on the concentrator were dated 05/14/24, it was not changed weekly. The DON stated that if nursing documented that the tubing were changed weekly and it was not, then it was false documentation. On 06/03/24 at 10:45 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 who stated staff were supposed to check the portable oxygen tank to ensure it was full based on the duration of the tank. LPN/UM #4 questioned why the resident went to bed by themselves. LPN/UM #4 stated that the aide was not allowed to touch the oxygen concentrator because they were not educated on oxygen administration. LPN/UM #4 stated that the call bell should have been on the resident's bed because hypoxia was a concern. 41442 2. During the initial tour on 05/29/24 at 10:07 AM, inside Resident #33's room, the surveyor observed Resident #33 in bed. There was a tracheostomy mask over the tracheostomy (surgical incision in the neck used to facilitate breathing) that was attached to ribbed tubing which was connected to a humidification compressor (a machine that humidifies oxygen) which was attached to oxygen tubing and connected to the oxygen concentrator (a machine that delivers oxygen). The oxygen concentrator was set to deliver 5 liters of oxygen per minute (lpm). The humidification compressor was set at 28%. There was no date written on the canister of sterile water and the date on the tubing indicated that it had last been changed 4/28/24. According to the Admission Record, Resident #33 was admitted to the facility with diagnoses which include, Chronic Respiratory Failure with Hypoxia, Tracheostomy, Morbid Obesity, Cerebral Infarction with Hemiplegia and Hemiparesis, Bipolar Disorder, Anxiety, and Alzheimer's Disease. Review of Resident #33's Annual Minimum Data Set (MDS) an assessment tool dated 05/2024, under section O, Special Treatments, Procedures, and Programs, it identified that Resident #33 received, Oxygen therapy, suctioning, and Tracheostomy care. Review of Resident #33's Care Plan (CP) with an initiation date of 03/20/23 and a revision date of 06/03/24, revealed the following: Focus: Tracheostomy: Change oxygen tubing, humidification bottle, oxygen filter, in-line suctioning tubing and yankauer weekly. In addition, the intervention for Oxygen settings indicated: 28% trach collar #4 Shiley. The Oxygen flow rate was not addressed. Review of Resident #33's Order Summary Report revealed the following physician order; TRACH COLLAR 28% AROUND THE CLOCK PMSV AS TOLERATED DAILY FIO2 28% SHILEY TITRATE FIO2 TO MAINTAIN 02 SATURATION GREATER THAN 92%. There was no order pertaining to Oxygen flow rate, dating/changing of respiratory equipment. On 05/31/2024 at 01:28 PM, during an interview with the surveyor, the Infection Control Preventionist Nurse (IP) was present in Resident #33's room and verified that the respiratory equipment was not dated appropriately or according to professional standards of practice. The IP stated that the respiratory equipment should be changed weekly and dated. On 06/05/2024 at 09:49 AM, during an interview with the surveyor, the Unit Manager (LPN/UM #1) acknowledged that there was no order for Oxygen and stated that the Physician would be called. Review of the facility policy, Oxygen Administration (Revised/Reviewed April 2024) revealed the following: Purpose: To safely administer oxygen to the resident when insufficient oxygen is carried by the blood to the tissues. .A licensed nurse or other staff person trained in the use of oxygen will be on duty and be responsible for the correct administration of oxygen to the resident. .At regular intervals, check and clean oxygen equipment, change and label masks, tubing and cannulas weekly. Check resident's respirations and oxygen saturation levels and observe at regular intervals to assess need for further oxygen therapy PRN (as needed) as well as after oxygen has been discontinued. Check physician's order for liter flow and method of administration. Under Care and Use of Prefilled Disposable Humidifiers, letter I: Label humidifier with date and time opened. Change humidifier and tubing weekly. NJAC 8:39- 19.4(a); 27.1(a), 11.2(b)

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with facility policy. This deficient practice was identified for 2 of 4 medication carts reviewed and was evidenced by the following: On 5/30/24 at 9:29 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1), reviewed the Pavilion nursing unit's medication cart #1 and the narcotic logbook for that cart. The following was observed: May 2024 Narcotic Book Shift to Shift Signature Sheet missing a nursing signature for 5/5 3-11 Out column and 5/30 pre-signed nursing signatures in the 7-3 Out and 3-11 In columns. May 2024 Shift to Shift Count/Sign in Sheet 5/13 column for Out 7A-3P was missing documentation for Initials Cards # Bottles # and Patches # At that time LPN #1 confirmed to the surveyor that there should be no pre-signed sections, nor should there be any missing nursing signatures or count documentation for past nursing shift. She stated that the incoming and outgoing nurses are to count the narcotics in the medication cart together and sign the shift log confirming the count at the time the count is completed. On 5/30/24 at 10:51 AM, the surveyor, in the presence of LPN #2, reviewed the Vent nursing unit's medication cart #2 and the narcotic logbook for that cart. The following was observed: May 2024 Narcotic Book Shift to Shift Signature Sheet missing a nursing signature for 5/12 7-3 In and 7-3 Out and 5/26 7-3 Out columns. At that time LPN #2 stated that every incoming and outgoing nurse should be completing narcotic counts for the medication cart together and signing the shift-to-shift log sheet together for accountability of the narcotic count. LPN #2 further confirmed that if its not documented, it's not done. On 06/04/24 at 9:58 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that during counts of narcotics, the incoming and outgoing nurses count together and sign the logs together. The ADON said the expectation is there should be no missing signatures for previous counts, and there should be no pre-signed for later in the shift or day. A review of the facility's Controlled Substances policy with a reviewed/revised date of 1/2024, included, but was not limited to, nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store and properly label opened multidose medications. This deficient practice was identified in 1 of 4 medication carts and 1 of 2 medication storage rooms reviewed for medication storage and labeling and was evidenced by the following: On 5/30/24 at 10:51 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN #2), observed the Vent nursing unit's medication cart #2. The following was observed: Three (3) opened prescription fluticasone propionate nasal spray bottles (medication used to treat seasonal allergies), which were not dated with opened date or labeled with resident identifying information on the medication container. At that time LPN #2 stated once multi-dose medications are opened, the nurses are to date the medication container and ensure the resident's name is on it as well as on the outside box or bag it came in. LPN #2 stated this is to ensure proper identification of when the medication was opened and the resident for whom it was prescribed in case the box and the medication get separated. On 5/30/24 at 11:35 AM, the surveyor, in the presence of Unit Manager/LPN (UM/LPN #1), observed the Court 1 nursing unit's medication storage room. The following was observed: One (1) opened and undated vial of tuberculin purified protein (PPD) (a medication used to test for tuberculosis) which was stored in the medication refrigerator. At that time, UM/LPN #1 stated that this medication vial should be dated with the opened date on the medication vial and not just the box as it is possible for the vial to be mixed into a different box. On 06/04/24 at 9:58 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that once multi-dose medication containers are opened, expectation is to date it with the date its opened. She further stated that the PPD should have been labeled with the opened date on the vial itself since it will be used for different people. She explained that the purpose is that some medications have a shorter expiration date than what is labeled from the manufacturer once it is opened. A review of the facility's Storage of Medications policy with a reviewed/revised date of 1/2024, included but was not limited to: Policy statement: the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Furthermore, the policy included: drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. N.J.A.C. 8:39-29.4

Based on observation, interview, and record review, it was determined that the facility failed to a) adhere to accepted standards of infection control practices for the proper storage of respiratory tubing after use, and b) perform proper hand hygiene during respiratory care treatment. This deficient practice was observed for 2 of 4 residents (Resident #33 and Resident #42) reviewed for respiratory care. This deficient practice was evidenced by the following: a.) During the initial tour of the facility on 05/29/2024 at 10:07 AM, the Surveyor #1 observed Resident #33 in his/her bedroom, lying in bed. Surveyor #1 observed a portable suction machine on the bedside table with tubing leading to the bottom drawer of the table. The suction catheter (Yankauer) used to orally suction secretions from the mouth, was found lying exposed, open to air, touching the contents of the drawer. The Yankauer was not dated. On 05/30/2024 at 09:07 AM, Surveyor #1 observed Resident #33's suction catheter lying in the bottom drawer of the bedside table, uncovered, directly touching the inside of the bottom drawer. On 05/31/2024 at 08:16 AM, Surveyor #1 observed Resident #33's suction catheter lying in the bottom drawer of the bedside table, uncovered, directly touching the inside of the bottom drawer. A review of the Admission Record medical record Resident #33 was admitted with a diagnosis that included but not limited to, Chronic Respiratory Failure with Hypoxia, Tracheostomy. The medical record also revealed that the resident had a tracheostomy, requiring Oxygen (O2) and suctioning. On 05/31/2024 at 1:28 PM, during an interview with Surveyor #1, the Infection Preventionist (IP) who was present in Resident #33's room, was questioned as to whether the suctioning respiratory equipment (Yankauer) was stored properly. At that time, the IP observed the suction catheter lying in the bottom drawer of the bedside table, uncovered, open to air, touching other items in drawer. The IP responded, No, the Yankauer is not being stored properly. That is an infection control concern. It should be stored in a bag/container for the health and safety of the client. 06/03/24 at 10:28 AM, during an interview with Surveyor #1, the Respiratory Therapist (RT #1) was questioned as to the procedure for oral suctioning. RT #1 responded, it's not a sterile procedure, but is clean. After suctioning, the catheter (Yankauer) must be put into the plastic sleeve and then into a bag. RT #1 added that the care of respiratory equipment is based on standards of care and policy. 06/03/24 10:41 AM, during an interview with Surveyor #1, the Unit Manager/Licensed Practical Nurse (UM/LPN#1) was questioned as to the proper care of suctioning equipment. The UM/LPN #1 stated that it is based on facility policy. The UM/LPN #1 verified that the storage of suctioning equipment after each use is to be stored in the original sleeve and/or clean bag. A review of a policy provided by the facility titled, Suctioning: Oral, with a revised date of 1/2024, revealed under procedure: Once the Yankauer is out, flush it through with water to remove secretions and place the packaging back on to keep it clean. 44833 b.) A review of Resident #42's Admission Record indicated the resident was admitted to the facility with diagnosis which included but was not limited to: chronic respiratory failure with hypoxia (low oxygen levels), tracheostomy (trach) (an incision in the windpipe made to relieve an obstruction to breathing) and dependence on respirator [ventilator]. A Review of the resident's quarterly Minimum Data Set (MDS) a comprehensive assessment tool dated 4/7/24, indicated Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact and required tracheostomy care and mechanical ventilator. A review of the physician's orders included an order with start date of 3/21/24 for tracheostomy care as needed and every shift related to tracheostomy status. A review of the Resident #42's care plan focus areas included but not limited to: ventilator dependence, trach-dependent, enhanced barrier precaution related to trach, and impaired immunity related to trach and ventilator status. On 06/04/2024 from 11:30 AM to 11:38 AM, Surveyor #2 observed RT #2 perform tracheostomy care for Resident #42. The following was observed: At 11:31 AM, RT #2 approached the resident's room door where there was a bin outside the room door containing disposable personal protective equipment including, disposable gowns, gloves, masks, and a bottle of alcohol-based hand rub (ABHR) (sanitizing solution used for hand hygiene). After performing hand hygiene with the ABHR, RT #2 donned (put on) a clean gown and gloves and proceeded to obtain a disinfectant wipe and entered the resident's room to wipe down the bedside tray table in preparation to place the tracheostomy care products. After wiping the table, RT #2 disposed of the sanitizing wipe, doffed (took off) the gloves and disposed of them as well. She then went back to the bin outside the resident's room, obtained new clean gloves, and without using ABHR or any other form of hand hygiene, donned the new gloves and brought in the tracheostomy supplies and placed them on a clean barrier pad which she placed on the recently sanitized tray table. She then proceeded with the ordered tracheostomy care. At 11:39 AM, Surveyor #2 interviewed RT #2 and inquired about hand hygiene in between the glove change. RT #2 stated it was not necessary as her procedure she follows does not indicate it. RT #2 provided Surveyor #2 with a copy of this document titled Advantage Respiratory Care Services Policy Procedure Manual 'Tracheostomy care, decannulation, suctioning, cuff care, weaning trial methods/procedures' with a revised date of October 15, 2016. When asked if this is the most up to date revision and how often this policy and procedure is reviewed and revised, RT #2 stated she was unsure. On 06/04/2024 at 11:48 AM, Surveyor #2 interviewed the IP, who stated that all the residents on the ventilation (vent) unit are on an enhanced barrier or contact precaution depending on their individual diagnosis, and that hand hygiene should be done upon entering and exiting the resident's rooms as well as in between all glove changes. The surveyor inquired about the policy and procedure document provided by RT #2, to which the IP reviewed and stated, this is an old policy, and respiratory care should be done following the updated policy. The IP stated she would provide Surveyor #2 with the most current and updated policy that is to be followed. A review of the facility's undated Hand Hygiene Policy and Procedure document provided by the IP included but was not limited to: under the section titled Indications for alcohol based hand rub included use of ABHR after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves. NJAC 8:39-19.4 (a) (1, 2)

Based on interview and record review, it was determined that the facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission to the facility to prevent incidence of pneumonia for 1 of 5 residents (Resident #100) reviewed for immunization administration. This deficient practice was evidenced by the following: On 05/29/2024 at 10:44 AM, during the initial tour of the facility, the surveyor observed Resident #100 lying in bed with stitches noted over their left eyebrow. When interviewed, the resident was unable to state how the injury occurred. A review of Resident #100's Admission record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Alzheimer's Disease, unspecified, altered mental status, unspecified, and a personal history of COVID-19. A further review of the Admission Record revealed that the resident had no known allergies. A review of Resident #100's immunization status within the Electronic Health Record (EHR), revealed an undated entry for Pneumovax 20 (an active immunizing agent used to prevent infection caused by certain types of bacteria (streptococcus pneumoniae) administration which indicated Pneumovax 20 Immunization Req. A review of Resident #100's Annual Minimum Data Set (MDS), an assessment tool, revealed that the resident had both a both short-term and long-term memory problem. A further review of the MDS revealed that the resident's pneumonia vaccine was not up to date, as resident was determined to be ineligible, due to an unspecified medical contraindication. On 05/31/2024 at 11:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) # 3 who reviewed Resident #100's immunization status in the presence of the surveyor in the EHR. LPN #3 stated that the resident required consent to receive the Pneumovax 20 vaccination. LPN # 3 further stated that she was unsure who was responsible to obtain consent for immunization administration. LPN #3 further stated that she knew that it was definitely not the nurse's responsibility to obtain consent for immunization administration. On 05/31/2024 at 11:48 AM, the surveyor interviewed the Infection Preventionist (IP) who stated Resident #100 should have been offered the Pneumovax 20 vaccination upon admission to the facility. The IP stated the resident's family member was required to sign consent on behalf of the resident if the resident was deemed to be cognitively impaired. The IP reviewed Resident #100's EHR and stated that the reason for the delay in Pneumovax 20 may have been related to a need for family consent. The IP stated that either the Unit Manager, Social Worker or the IP was responsible to follow-up to ensure consent was obtained. The IP further stated there was currently no Unit Manager assigned to the nursing unit. On 06/04/2024 at 8:23 AM, in a later interview with the IP, she stated that Resident #100 did not receive the Pneumovax 20 vaccination upon admission to the facility as consent was not obtained on behalf of the resident. The IP confirmed that after surveyor inquiry, the resident's responsible party was contacted, and the resident received the Pneumovax 20 vaccination yesterday. The IP further stated that she was unsure why the consent was not completed timely, as the need for consent should have come up on a check list on three subsequent shifts following admission for supervisor review to ensure completion. A review of a facility policy titled, Pneumococcal Immunization Vaccine (Revised 03/2024) revealed the following: All residents shall be offered pneumococcal vaccines to aide in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents shall be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, shall be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status shall be conducted within five (5) working days of the resident's admission if not conducted prior to admission. .Pneumococcal vaccines shall be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. .Administration of the pneumococcal vaccines or revaccinations shall be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. NJAC 8:39-19.4 (h) (i)

Part A Based on observation, interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure the appropriate mechanically altered diet for a resident who was at risk for aspiration (when material such as food or drink enters the airway or lungs). This deficient practice was identified for 1 of 5 residents reviewed for accidents and accident prevention (Resident #22). According to the resident's medical record, Resident #22 had an individualized comprehensive care plan and physician's order for a ground dietary texture due to difficulty swallowing and a risk for aspiration. However, on 05/16/23 at 12:25 PM, Surveyor #1 observed a meal ticket for Resident #22 on their lunch tray which indicated pureed sauerkraut. At that time, the Surveyor #1 observed the resident eating a regular textured sauerkraut from his/her lunch tray. The sauerkraut was long and stringy in appearance. The facility staff did not verify the meal ticket with the contents on the lunch tray prior to delivering the lunch tray to Resident #22 to ensure safety and dietary accuracy to prevent aspiration. The facility's failure to ensure a resident with a history of dysphagia (difficulty swallowing) received the appropriate mechanically altered diet posed a serious and immediate threat for an adverse outcome, including choking and aspiration, which is likely to result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation that began on 05/16/23 at 12:25 PM, when Resident #22 was served the incorrect textured sauerkraut without staff verifying the accuracy of the meal ticket at the time of meal plating and service to the resident. The facility's administration was notified of the IJ on 05/16/23 at 4:29 PM. The facility submitted an acceptable written Removal Plan on 05/16/23 at 7:37 PM. The survey team verified the implementation of the Removal Plan through observation and interview during the continuation of the on-site survey on 05/17/23. This deficient practice was evidenced by the following: On 05/16/23 at 12:25 PM, Surveyor #1, who was standing approximately five feet away, observed Certified Nursing Assistant (CNA) #1 deliver a lunch tray to Resident #22 in the Court 1 dining room. The resident immediately picked up the fork from the tray and began eating the sauerkraut, which was long and stringy in appearance. The facility staff in the dining room were not observed directly supervising or assisting the resident with his/her meal. The surveyor approached Resident #22 and observed the resident's tray further consisted of a ground texture meat, mashed potatoes, but it had regular textured sauerkraut. The surveyor reviewed the resident's meal ticket and before the resident took another bite of sauerkraut, the surveyor immediately called over CNA#1 to check the resident's meal ticket against the lunch tray. CNA #1 then verified the resident's meal ticket indicated the resident was on a ground texture diet and should have received Pureed Sauerkraut (Soft & Drained) - 4 oz. When asked about the texture of the sauerkraut on the resident's tray, CNA#1 stated, It's not pureed. The CNA then removed the lunch tray from Resident #22 and Licensed Practical Nurse (LPN)#1 took the lunch tray to the kitchen. When LPN#1 returned, she delivered a new lunch tray to Resident #22, and stated the sauerkraut on the original lunch tray was not pureed and that the resident was supposed to receive a mechanically altered diet to prevent choking. According to the Admission Record (an admission summary), Resident #22 had diagnoses which included, but were not limited to, muscle wasting and atrophy, unspecified dementia, transient ischemic attack (mini stroke), cerebral infarction (stroke), and muscle weakness. Review of a Speech Therapy Discharge Summary, dated 03/02/23, included a diet recommendation for Mechanical Soft/Ground textures, and, Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: alteration of liquid/solids. Further review of the discharge summary included, Supervision for Oral Intake = Distant Supervision. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/22/23, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated that the resident's cognition was severely impaired. Further review of the MDS included the resident required supervision and setup help with eating. It further revealed that the resident was on a mechanically altered diet which required a change in texture of food or liquids. Review of the Medical Nutrition Therapy Assessment, dated 03/24/23, included the resident had a diagnosis of dysphagia, was on a ground texture diet, and was at risk for malnutrition related to swallowing difficulty and chewing difficulty. Further review of the nutrition assessment included a note from the Registered Dietician (RD) which indicated Resident #22, continues on ground texture diet with nectar thick liquids - tolerates mechanically altered diet for history of dysphagia. Review of the resident's individualized. comprehensive Care Plan included a focus of, [Resident #22] has a nutritional problem or potential nutritional problem r/t [related to] need for mechanically altered diet and thickened liquids, initiated on 09/17/20, with an intervention to, provide and serve diet as ordered: regular, ground texture, nectar thick liquids. Further review of the individualized, comprehensive Care Plan included a focus that [Resident #22] has oropharyngeal dysphagia r/t [related to] dementia, initiated on 01/31/22, and that Resident is at risk for aspiration related to: dysphagia, initiated 08/10/22. An intervention included to, supervise and or provide assistance to resident during meal times. Review of the Physician's Order Form, dated 05/2023, included a diet order for, Ground Solids, Nectar Thickened Liquids, with an order date of 01/20/23. Review of the May 2023 Medication Administration Record (MAR) included the corresponding physician's diet order for Ground Solids, Nectar Thickened Liquids. During an interview with Surveyor #1 on 05/16/23 at 12:57 PM, CNA#1 stated that during meal service, the CNAs passed out the trays and were supposed to check the resident's meal ticket against the meal tray to ensure it was correct. CNA#1 further stated that the meal tickets included the residents' prescribed diet texture and that it was important that the resident received the correct diet texture to prevent choking. When asked about Resident #22's lunch tray, CNA#1 stated that Resident #22's lunch tray did not match the meal ticket and had to be sent back to the kitchen and replaced with the correct tray. During an interview with Surveyor #1 on 05/16/23 at 1:01 PM, LPN#1 stated that during meal service, the nurses and CNAs passed out the trays. She further explained that the nurse was supposed to check the meal ticket against the meal tray to ensure the resident's diet matches the texture of the food on the tray. Afterwards, the CNAs checked the meal ticket against the meal tray again before serving the resident. LPN#1 also stated that it was important to ensure residents received the correct diet texture to prevent aspiration. When asked about Resident #22's lunch tray, LPN#1 stated that CNA#1 took the meal tray from the meal cart before she could check the ticket against the tray. During an interview with Surveyor #1 on 05/16/23 at 1:04 PM, the Registered Nurse/Unit Manager (RN/UM) stated that during meal service, the kitchen aides brought the meal cart to the unit and then the nurse or CNA checked the meal ticket against the meal tray before serving the resident. The RN/UM further explained that the meal ticket included the resident's allergies, prescribed diet texture, and the food items included on the tray. The RN/UM then stated that multiple checks were performed to prevent the resident from receiving the wrong diet texture and choking. When asked about Resident #22, the RN/UM stated the resident has a diagnosis of dysphagia and was on a prescribed ground texture diet with nectar thickened liquids to prevent choking. During an interview with Surveyor #2 on 05/16/23 at 1:04 PM, the Registered Dietician (RD) stated that during meal service, dietary staff delivered the meal cart to the unit and then the unit staff passed out the trays to the residents. The RD further explained that the UM would check the meal ticket against the meal tray to ensure that the resident's name, allergies, and mechanically altered food matched appropriately. The RD also stated that it was important that residents received the correct diet texture to prevent choking. During an interview with Surveyor #3 on 05/16/23 at 1:06 PM, the Speech Language Pathologist (SLP) explained the different types of diet textures included pureed (mashed potato consistency), ground (tuna salad consistency), and chopped (diced consistency). The SLP further stated that the importance of serving the correct altered consistency diet was to prevent choking or aspiration. When asked about the resident meal service, the SLP stated it was the dietary staff's responsibility to ensure they were preparing the correct consistency diet and the nursing staff's responsibility to ensure they were serving the correct consistency diets by verifying the meal tickets against the meal trays. During an interview with Surveyor #4 on 05/16/23 at 1:14 PM, the Dietary Aide (DA) stated that during meal service, the dietary staff were supposed to read the meal ticket before putting food on the meal tray to ensure it was the correct diet texture. The DA further stated that it was important to make sure the diet texture was accurate to prevent residents from choking. During an interview with Surveyor #4 on 05/16/23 at 1:19 PM, the Cook stated that during meal plating in the kitchen the first dietary staff told the Cook the resident's diet based on the meal ticket. Then a second dietary staff would check the meal tray to ensure it matched the meal ticket; a third dietary staff would follow up with a triple check. The Cook further stated that if a resident was on a mechanically altered diet due to swallowing concerns, the resident was at risk for choking. The Cook added that any residents on a ground texture diet would be required to have pureed sauerkraut to prevent choking. During an interview with Surveyor #5 on 05/16/23 at 1:31 PM, the Certified Dietary Manager/Certified Food Protection Professional (CDM/CFPP) stated that it was important that the dietary staff ensure the meal tray matched the meal ticket to prevent a resident with a swallowing issue from choking. During an interview with Surveyor #4 on 05/16/23 at 1:33 PM, the Food Service Director (FSD) stated that during meal plating, the DA would call out the food listed on the resident's meal ticket and that the meal ticket included the resident's name, type of diet, texture/consistency of the food and drinks, and the resident's allergies. The FSD further explained that after the DA called out the food, the meal tray would go to a second dietary staff who would add dessert to the tray, then the tray would go to the Cook who plated the food according to the meal ticket. The FSD stated that lastly the tray would go to another dietary staff who added the juice items before the tray was placed on the meal cart. The FSD also stated that it was important to provide the appropriate food textures to prevent choking and aspiration. During an interview with Surveyor #4 on 05/16/23 at 1:42 PM, the Assistant Food Service Director (AFSD) stated that during meal service, there was a DA that would review the resident's meal ticket on the tray line and call out the food items listed. The ASFD further explained that the meal tray would go down the line to a second dietary staff who would put desserts and lids on the tray, then the tray would go to the Cook who would put the food onto the tray. The AFSD added that lastly the tray would go to another dietary staff who would put the beverages on the tray and review the meal ticket to ensure it matched the tray before being placed on the meal cart. The AFSD stated that nurses and CNAs were also responsible for checking the meal ticket against the meal tray to ensure it matched, because if the resident was on a mechanically altered diet, the resident could choke if they received the incorrect food texture. During a follow-up interview with the survey team on 05/16/23 at 2:43 PM, the SLP stated that a resident on a ground texture diet would require pureed sides if it were specified on the meal ticket. The SLP further stated that because sauerkraut was more of a raw vegetable, it would need to be pureed due to the tougher, fibrous-nature of the skin of the vegetable for someone on a ground texture diet to prevent choking. During an interview with Surveyor #1 and #5 on 05/16/23 at 2:54 PM, the Director of Nursing (DON) stated the dietary staff checked the meal trays prior to leaving the kitchen, then the nurse on the unit checked the meal ticket against the meal tray for accuracy, and lastly, the CNA serveed the meal trays to the residents. The DON further stated that it was important to make sure the resident received the correct diet texture to prevent choking. During an interview with Surveyor #1 and #5 on 05/16/23 at 2:59 PM, the Executive Director (ED) stated the dietary staff delivered the meal cart to the unit, then the nurse on the unit checked to make sure the meal tray matched the meal ticket, and lastly, the CNA served the meal trays to the residents. The ED further stated that the dietary tray line is the first line of defense, and the nursing staff are the second line of defense to ensure the meal trays are accurate to prevent any safety risks. Resident #22 did not have any incidents of choking during the 05/16/23 lunch observation, and review of the resident's medical record indicated the resident did not have any previous incidents of choking in the past. On 05/16/23 at 4:29 PM, the facility's administration was notified that the facility's failure to ensure a resident with a history of dysphagia received the appropriate mechanically altered diet posed a serious and immediate threat for a serious adverse outcome, including choking and aspiration, which are likely to result in serious harm, impairment, or even death. An acceptable Removal Plan was received on 05/16/23 at 7:37 PM and verified by the survey team though observation and interview during the continuation of the on-site survey on 05/17/23. Review of the facility's Nutritional Services policy, last reviewed 02/01/23, included, Remove one tray at a time from the food cart; check tray card for the resident's name and room number; type of diet, consistency, food preferences; check for utensils and appropriate condiments. Review of the facility's National Dysphagia Diet (NDD) document, undated, included a section titled Food Textures for NDD Level 2: Dysphagia Ground, which indicated to avoid, broccoli, cabbage, brussels sprouts, asparagus, or other fibrous, non-tender or rubbery cooked vegetables. 37218 Part B Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure water temperatures were within an appropriate, safe range to prevent scalding and burns to residents' skin. This deficient practice was identified for 3 of 3 residents reviewed (Resident #16, #62, and #128) on 1 of 4 nursing units (the Pavilion unit) when resident room water temperatures when tested ranged from 142 to 152 degrees Fareinheit, which was outside the acceptable water temperature ranges and not in accordance with the facility's water temperature policy. Interviews with the Certified Nursing Aides (CNA)s, Licensed Practical Nurses (LPN) and a housekeeper on the Pavilion unit indicated that at times there were temperature inconsistencies with the water on the unit. CNA#2 informed the surveyor that Resident #19, #62, and #128 were all able to independently operate the sink in their bathrooms. The facility's failure to maintain appropriate water temperatures placed residents on the Pavillion Unit at a likelihood of scalding or skin burns which could result in serious harm, impairment, or death. Vulnerable residents are more prone to burns due to decreased skin thickness, decreased skin sensitivity, peripheral neuropathy (loss of sensation in arms, hands, and lower limbs), reduced reaction time, decreased cognition, decreased mobility, and decreased communication. This deficient practice resulted in an Immediate Jeopardy (IJ) situation that began on 05/24/23 at 10:18 AM when the Life Safety Code (LSC) surveyor identified the elevated water temperatures on the Pavilion unit. The facility's administration was notified of the IJ on 05/24/23 at 3:54 PM. The facility submitted an acceptable written Removal Plan on 05/25/23 at 12:26 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 05/25/23. The findings were as follows: A review of the facility's undated Water Temperature Policy inclucded that, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. It further included that water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit, or the maximum allowable temperature per state regulation. On 05/24/23 at 9:23 AM, the Life Safety Code (LSC) surveyor toured the Pavilion (Behavioral) unit in the presence of the Maintenance Director (MD). At 10:18 AM, the LSC surveyor in the presence of the MD tested the water temperature in resident room [ROOM NUMBER] on the Pavilion unit. The water temperature read 152 degrees Fahrenheit in the resident's bathroom. At 10:20 AM, the LSC surveyor in the presence of the MD went to another resident room, and tested the water temperature. The surveyor observed that in the resident bathroom of room [ROOM NUMBER], the water temperature tested 142 degrees Fahrenheit. At 10:25 AM, the Corporate [NAME] President of Environmental Services (CVP/ES) joined the tour with the LSC surveyor and MD on the Pavilion unit and observed in resident room [ROOM NUMBER] a water temperature of 149 degrees Fahrenheit. This indicated a seven (7) degree temperature increase. The LSC surveyor informed the MD to immediately turn off the domestic hot water supply to the five (5) bathroom sinks located on that hall on the Pavilion unit. At 10:44 AM, Surveyor #4 interviewed CNA#3 who stated that she gave a resident a shower during her shift that day and the water in the shower room was lukewarm. CNA#3 told Surveyor #4 that sometimes she would turn the water on in the resident's bathrooms on the Pavilion unit and the water would be burning hot. CNA#3 further stated that this didn't happen too often and the last time she recalled it happening was about a week ago. Surveyor #4 asked CNA#3 if she told anyone that the water coming from the faucet was burning hot and she stated that she thought she might have told an agency nurse. At 10:49 AM, Surveyor #4 interviewed LPN#2 who worked the high side rooms on the Pavilion unit. LPN#2 informed the surveyor that sometimes when she washed her hands on the Pavilion unit there were temperature inconsistencies and at times, water would come out too hot. LPN#2 stated the water had never burned her skin. At 10:52 AM, Surveyor #4 interviewed LPN#3 who worked the low side rooms on the Pavilion unit. Surveyor #4 asked LPN#3 about the hot water temperatures this morning LPN#3 stated that she did not identify that the water in the resident's rooms were hot that day and no residents had voiced concerns regarding the water temperature. LPN#3 told the surveyor that when she washed her hands, she preferred the water to be very hot. At 11:03 AM, Surveyor #4 interviewed the Housekeeper working on the low side of the Pavilion unit (rooms [ROOM NUMBERS]), who stated, she noticed that the water temperatures were hot that morning. The Housekeeper further stated that sometimes she would turn on the water, and it would be hot, and other times she would turn on the water, and it would be cold. At 11:07 AM, Surveyor #4 interviewed the Licensed Practical Nurse/Unit Manger (LPN/UM) for the Pavilion unit who stated that the shower room had a thermometer by the shower head, so the water temperature was monitored to make sure it was not hot while giving the residents a shower. The LPN/UM further stated that there were no residents or staff that complained of hot water that day. At 1:39 PM, the surveyor interviewed the MD who stated that the thermometers used during the tour with the LSC surveyor were functional and were used daily to monitor temperatures throughout the building. The MD further stated that when he was with the LSC surveyor, his calibrated thermometer temperatures in rooms [ROOM NUMBERS] were reading elevated temperatures within two to three degrees of the LSC surveyors thermometer recording. The MD stated that he assumed room [ROOM NUMBER] through 405 were high temperatures so he shut off the hot water supply to the sinks in those five rooms. At 3:00 PM, Surveyor #4 in the presence of the LPN/UM observed Resident #19 lying in bed and smiling. The LPN/UM asked the resident if he/she could turn the water on in the bathroom sink independently. Surveyor #4 and the LPN/UM observed Resident #19 ambulate (walk) to the bathroom and turn the water on to the sink independently. At 3:03 PM, Surveyor #4 observed Resident #62 sitting peacefully in a chair on the Pavilion unit looking out of the window. The LPN/UM asked the resident if he/she could turn the water on in their bathroom. The resident shook his/her head up and down indicating, yes. The LPN/UM then asked the resident if he/she could return demonstrate, and Resident #62 shook his/her head from side to side indicating, no. At 3:06 PM, Surveyor #4 observed Resident #128 seated in the day room on the Pavilion unit with his/her head resting on their hand. The resident exhibited nonverbal cues that they did not want to be disturbed. At that time, the LPN/UM stated that the resident would probably not cooperate and turn on the water, even if she asked the resident to do it, so the surveyor did not interfere with the resident's non-verbal cues for privacy. At 03:07 PM, Surveyor #4 conducted a follow up interview with CNA#2 who stated that Resident #19, Resident #62, and Resident #128 could all turn the water on in their bathrooms independently. The surveyor reviewed the medical record for Resident #19. A review of the resident's Admission Record reflected that the resident had resided at the facility for over ten years and had diagnoses which included but were not limited to dementia with other behavior disturbances, hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone which disrupts heart rate, body temperature, and all aspects of metabolism), anoxic brain damage (brain damage caused by lack of oxygen to the brain, and hypertension (high blood pressure). A review of the resident's quarterly MDS dated [DATE], indicated that the resident's cognitive skills for decision making were severely impaired. A review of Resident #19's Care Plan revised 01/30/19, reflected a focus area that the resident had potential to skin integrity related to frail, fragile skin, and poor safety awareness. The goal of the resident's Care Plan was the resident's skin would remain free from injury. Interventions included to identify and document potential causative factors and eliminate them so the resident's skin would remain intact. The surveyor reviewed the medical record for Resident #62. A review of the residents Admission Record revealed that the resident had resided at the facility for over four years and had diagnoses which included but were not limited to Alzheimer's disease, dementia with other behavioral disturbances, lack of coordination, and age-related bilateral nuclear cataracts (clouding that develops in the center of the eye causing vision impairment). A review of Resident #62's quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 02 out of 15 which indicated the resident had severely impaired cognition. A review of the resident's Care Plan dated 04/05/22, indicated a focus area that the resident was at risk for skin impairment to skin integrity related to fragile skin. The goal of the residents Care Plan was that the resident's skin would be free from breakdown through the next review date. The interventions included to use caution during transfers and bed mobility to prevent striking arms, legs, and hands. A further review of Resident #62's Care Plan reflected a focus area dated 04/05/22, that the resident had impaired cognitive function or impaired thought process related to Alzheimer's and difficulty making decisions. The goal of the residents Care Plan indicated that the resident would be able to communicate basic needs and have their needs anticipated through the review date. Interventions in the residents Care Plan included to cue, reorient, and supervise as needed. The surveyor reviewed the medical record for Resident #128. A review of the resident's Admission Record reveled that the resident had resided at the facility for a few months and had diagnoses which included but were not limited to adjustment disorder with mixed disturbances of emotions and conduct. Personal history of traumatic brain injury and altered mental status. A review of the resident's admission MDS dated [DATE], indicated that the resident had a BIMS score of 07 out of 15 which indicated that the resident had severely impaired cognition. A review of the resident's Care Plan dated 04/04/23, revealed a focus area that the resident was having an adjustment difficulty to the facility as evidenced by verbal aggression and throwing chairs. The goal of the resident's Care Plan was the resident would express satisfaction with placement in the nursing facility within the next 90 days. Interventions in the residents Care Plan included to orient the resident to routines and provided one-to-one visits. A review of the Daily Resident Rooms Temperature and Logs from 05/12/23 through 05/23/23 indicated that random checks on the Pavilion Unit were within normal range. A further review of the Daily Resident Rooms Temperature and Logs revealed the following: -On 05/12/23, room [ROOM NUMBER] had a water temperature of 99.8 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 100.9 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 90.6 degrees Fahrenheit. -On 05/13/23, room [ROOM NUMBER] had a water temperature of 99.6 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 98.7 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 99.5 degrees Fahrenheit. -On 05/14/23, room [ROOM NUMBER] had a water temperature of 99.1 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 98.8 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 99.5 degrees Fahrenheit. -On 05/15/23, room [ROOM NUMBER] had a water temperature of 102.3 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 101.6 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 100.4 degrees Fahrenheit. -On 05/16/23, room [ROOM NUMBER] had a water temperature of 100.3 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 101.4 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 100.2 degrees Fahrenheit. -On 05/17/23, room [ROOM NUMBER] had a water temperature of 103.8 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 102.7 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 101.8 degrees Fahrenheit. -On 05/18/23, room [ROOM NUMBER] had a water temperature of 103.2 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 100.6 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 101.3 degrees Fahrenheit. -On 05/19/23, room [ROOM NUMBER] had a water temperature of 102.6 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 103.5 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 103.8 degrees Fahrenheit. -On 05/20/23, room [ROOM NUMBER] had a water temperature of 100.3 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 100.1 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 99.8 degrees Fahrenheit. -On 05/21/23, room [ROOM NUMBER] had a water temperature of 99.8 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 98.7 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 100.1 degrees Fahrenheit. -On 05/22/23, room [ROOM NUMBER] had a water temperature of 98.9 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 96.2 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 95.8 degrees Fahrenheit. -On 05/23/23, room [ROOM NUMBER] had a water temperature of 100.3 degrees Fahrenheit, room [ROOM NUMBER] had a water temperature of 100.2 degrees Fahrenheit, and room [ROOM NUMBER] had a water temperature of 100.1 degrees Fahrenheit. According to the CMS's Table 1. Time and Temperature Relationship to Serious Burns, a water temperature of 140 degrees Fahrenheit only requires 5 seconds of contact before a third degree burn occurs; a temperature of 148 degrees Fahrenheit requires only 2 seconds of contact before a third degree burn occurs, a water temperature of 155 degrees Fahrenheit only requires 1 second of contact before a third degree burn. NJAC 8:39-17.4(a)(2);27.1(a);31.7(h) 21428

C#: NJ158549 Based on interviews, medical records review, and review of other pertinent facility documents on 10/6/2022 and 10/12/2022, it was determined that the facility failed to protect a resident (Resident #2), who requires 1:1 Supervision for aggressive behaviors according to the Physician's Order, is cognitively intact with a known history of aggressive behavior, diagnosis of Bipolar Disorder, Major Depressive Disorder and Anxiety Disorder from physical abuse from a staff member (Certified Nursing Assistant- CNA). On 9/20/2022 at approximately 6:00 p.m., Resident #1, a cognitively impaired resident with a known history of aggressive behaviors and diagnosis of Dementia with Behavioral Disturbance, and Resident #2 got into a Resident-to-Resident altercation where Resident #1 pushed the dining room table into Resident #2's chest. Resident #2 shoved the table back at Resident #1. According to the CNA, Resident #2 then swung his/her fist at Resident #1, picked up the table, and threw the table, but he/she caught the table in mid-air and swung the table around in the air. Resident #1 moved back, and he didn't know how Resident #2 ended up on the floor. The CNA told Resident #2 to get his/her ass off the floor, and the Resident started kicking. The CNA stated he told the Resident to go to his/her room. According to the Registered Nurse (RN) assigned to Resident #1 and Resident #2 at the time of the incident, she was in the bathroom and heard a plate drop to the floor around dinner time. When she came out of the bathroom, she saw the CNA kicking Resident #2 on the floor. She yelled, Hey, hey! The CNA stopped kicking Resident #2. She then counseled the CNA about using excessive force; it could be considered abuse. She stated the CNA said he used that force because Resident #2 hit a woman. The RN continued to say Resident #2 was shaken up after the incident, but she assessed the Resident, and there was no complaint of pain or injury. The RN further stated she wanted to tell the Supervisor, but she didn't. According to the RN, she didn't know the facility's protocol for abuse. She told the oncoming Licensed Practice Nurse (LPN #1) about the incident, and he stated that's the way Resident #2 is with behaviors. However, LPN #1 said the RN told him the CNA may have been rough with Resident #2. LPN #1 stated being rough with a resident is abuse. He did not know he had to report it because he thought the RN had reported it. According to Resident #2, on 9/20/2022, the incident happened in the dining room. Resident #2 stated, I got in a fight, and I got hurt. A CNA slammed me to the ground and began kicking me because I pushed my tray into a girl. The Resident stated my whole right leg and calf hurt. According to the Staffing Coordinator (SC), on 9/22/2022, I was on the unit around 6:00 p.m. the RN asked the SC did the CNA get suspended. The RN then told the SC about the altercation on 9/20/2022 between Resident #2 and the CNA. According to the SC, she asked the RN why she did not report the altercation. The RN stated she did not tell anyone because she did not want to get the CNA in trouble. After the SC heard about the incident, she reported it to the Director of Nursing (DON). The DON then assessed Resident #2 on 9/22/2022, two days after the incident occurred. The DON observed multiple discolorations on the Resident's thigh, hip, and pelvic area. The CNA who physically abused and assaulted Resident #2 was allowed to continue working the entire 3:00 p.m.-11:00 p.m. shift and the 11:00 p.m.-7:00 a.m. shift from 9/20/2022 into 9/21/2022, on the same unit as Resident #2. The CNA was also scheduled to work the 3:00 p.m. to 11:00 p.m. shift on 9/22/2022 but called out sick. According to the Physician's Order, Resident #2 needed 1:1 Supervision due to behaviors, but this was not in place at the time of the incident. The facility also failed to follow the PO's and placed Resident #2 on 1:1 Supervision after the altercation with Resident #1 occurred to ensure Resident #1 was safe and failed to follow its policies titled Abuse Prevention, Incidents and Accidents, Physician's Orders and Mood & Behavior Monitoring. The facility's failure to protect Resident #2 from physical abuse and failure to place Resident #2 on 1:1 Supervision placed Resident #1, Resident #2 and all other residents placed Resident #2, and all other residents at risk for physical abuse and in an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on 10/12/2022 at 5:06 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 9/20/2022 and continued through 9/22/2022 when the physical abuse was reported, and the CNA was removed from the schedule. On 10/18/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating facility staff on the Abuse Prevention Policy and Timely Reporting of Abuse. So, the noncompliance remained on 10/18/2022 as a level G for actual harm that is not an IJ based on the following: the RN and CNA no longer work at the facility, the New Jersey State Board of Nursing was notified, and the facility staff has been educated on the Abuse Prevention Policy and Timely Reporting of Abuse. This deficient practice was identified for 2 of 4 residents (Resident #1 and #2) and was evidenced by the following: According to the Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents dated 9/22/2022, with an event date of 9/20/2022 and a time of event of 6:00 p.m., revealed the following: On 9/20/2022, at approximately 6:00 p.m., there was a Resident-to-Resident altercation between Resident #1 and Resident #2, and it was related to the Staff-to-Resident altercation between the CNA and Resident #2. These two events were reported at 6:20 p.m. on 9/22/2022. Upon notification of the Resident-to-Resident altercation on 9/22/2022, Resident #1 was moved to the opposite side of the unit from Resident #2. The Police was also notified of the Staff-to-Resident altercation. A review of the Medical Records (MR) for Resident #1 revealed the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia with Behavioral Disturbance, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Delusional Disorders. According to the Minimum Data Set (MDS), an assessment tool dated 08/18/2022, Resident # 1 had no Brief Interview of Mental Status (BIMS) score, which indicated the Resident had a memory problem. The MDS also showed Resident #1 needed supervision and one person's assistance with most Activities of Daily Living (ADLs). A review of Resident #1's Care Plan (CP) initiated on 5/24/2022 revealed under Focus: Resident #1 is at risk for and/or has behavior related to Dementia, Paranoid Schizophrenia as evidenced by the potential to be physically aggressive towards staff/resident, non-compliant with care, putting self on the floor, intrusive to others' space, yelling/screaming. Under Goal, indicated: The Resident will demonstrate effective coping skills through the review date. The Resident will verbalize understanding of the need to control physically aggressive behavior and noncompliance with care through the review date. Under Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness with a date initiated 05/24/2022. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document with a date initiated 05/24/2022, Assess and address for contributing sensory deficits, date initiated 05/24/2022, Assess and anticipate Resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc., date initiated 08/27/2022. Attempt redirecting Resident #1 when he/she becomes agitated/aggressive. If there is no success, remove other residents away for safety, date initiated 09/22/2022, Communication: Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assist in verbalizing the source of agitation, and assist in setting goals for more pleasant behavior. Encourage seeking out staff member when agitated; date initiated 05/24/2022, Monitor Resident #1 for aggressive behavior and attempted intervention in Behavior log; date initiated 05/24/2022. Psychiatric/ Psychogeriatric consult as indicated; date initiated 08/27/2022. A review of Resident #1's Progress Notes (PNs) revealed the following: On 9/23/2022 at 1:14 p.m., the Nurse Practitioner Progress Notes (NPPNs) written by the NP revealed Resident #1 was seen at the request of nursing. Provider met with (the) patient [Resident], he/she is non-cooperative during the encounter, .no visible injury noted on (the) exposed area. Nursing denies any acute events. A review of Resident #1's PNs dated 9/23/2022 at 4:59 p.m. written by the Director of Nursing (DON) revealed a Telephone call was placed to [the] resident's daughter to inform her of the resident-to-resident and room change. A review of Resident #1's PNs dated 9/23/2022 at 9:39 p.m., written by LPN #2, revealed Resident #1 was moved to another room. A review of the MR for Resident #2 revealed the following: 2. According to the AR, Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Bipolar Disorder, Unspecified Major Depressive Disorder, Recurrent and Unspecified Anxiety Disorder. According to the MDS, dated [DATE], Resident # 2 had a BIMS score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed supervision and one person assistance with most ADLs. A review of Resident #2's CP initiated on 03/30/2022 revealed under Focus: Resident #2 is at risk for and/or has the potential to exhibit behaviors r/t bipolar disorder, major depressive disorder and anxiety as evidenced by verbal and physical aggression, sexually inappropriate, demanding, poor impulse control, refuses care, will place self on the floor, demands excess coffee. 9/20/2022 [Resident #2] was verbally abusive/shoved a table toward another resident. Under Goal: Resident #2 will have a noted decrease in behaviors by the review date. Resident #2 will have fewer episodes of physical and verbal aggression towards other residents by the review date. Under Interventions: 1:1 observation for safety/behavior PRN (as needed), date initiated 06/17/2022, Administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated 09/27/2022. Anticipate and meet the Resident's needs, dated initiated 03/30/2022. Attempt to minimize episodes of target behavior by anticipating Resident #2's needs, i.e. [for example] offer beverage of choice as appropriate, invite and assist to out-of-room activities of interest, offer assistance with ADLs as indicated, etc.; date initiated 07/04/2022. Caregivers should consider supportive interventions such as redirection, support/reassurance, reduced stimulation, allow Resident #2 to express his/her feelings, family involvement, etc .; date initiated 06/17/2022. Caregivers to provide opportunity for positive interaction and attention. Stop and talk with Resident #2 as passing by; date initiated 06/17/2022; Encourage Resident #2 to approach staff with concerns about other residents and staff. Praise efforts, date initiated 09/22/2022. Explain all procedures to the Resident before starting and allow the resident time to adjust to changes; date initiated 03/30/2022. If reasonable, discuss the Resident's Behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the Resident, date initiated 03/30/2022. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to (an) alternate location as needed, date initiated 03/30/2022. Monitor behavior episodes and Attempt to determine (the) underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, date initiated 09/27/2022, Monitor target behaviors-sexually inappropriate, physical aggression, demanding, poor impulse control, refuse care, will place self on floor, demands excess coffee, date initiated 03/30/2022, pain assessment q (every) shift administer analgesic PRN (as needed), date initiated 09/27/2022, Praise any indication of the Resident's progress/improvement in behavior, date initiated 03/30/2022, Provide a program of activities that is of interest and accommodates residents status. (easy listening music, sports/football, TV), date initiated 03/30/2022, S-COPE (Statewide-Clinical Outreach Program for the Elderly) eval [evaluation] and psych [psychiatrist] consult as needed, date initiated 06/17/2022, Resident #2 can be offered a cup of ice or small snack if he/she is becoming agitated, date initiated 08/08/2022. A review of Resident #2's Physician's Order Form (POF) dated 09/2022 revealed a Physician's Orders (PO's) for 1:1 Supervision every shift r/t (related to) behaviors. A review of Resident #2's Medication Administration Record (MAR) for 9/2022, revealed there were blank spaces for the entire month for 1:1 Supervision every shift, indicating the PO's order for 1:1 Supervision was not implemented. A review of Resident #2's PNs for July and September 2022 revealed the following: On 9/15/2022 at 9:44 p.m., the Physician Progress Notes (PPNs) written by the Physician revealed Resident #2 is intrusive and can escalate without warning. Staff are able to re-direct him/her .cont. (continue) to monitor behavior. On 9/20/2022 at 8:24 p.m., the PNs, Behavior Note written by the RN, revealed Resident #2, post-dinner became involved in hitting match with female Resident. Medicated and advised to go to his/her room, refused, stating, I need (a) snack. Assessed for c/o (complaint of) pain and signs of injury none noted. On 9/25/2022 at 5:20 p.m., the PNs, Behavior Note written by LPN #3, revealed, at 2:30 p.m. technician from came to do an ultrasound for the pt.[patient] (resident). Pt refused to go to his/her room to get the Ultrasound done . Ultrasound not done after several attempts. On 10/6/2022 at 10:14 a.m., the Advanced Nurse Practitioner (ANP) 's Acute/Follow-up Visit revealed she had a DOS (Date of Service) on 9/23/2022 with Resident #2 at the request of the facility DON for bruises on R (right) foot, thigh, and RLQ (right lower quadrant). Resident #2 denies any pain or discomfort; nursing denies any n/v (nausea/vomiting), HA (headache), CP (chest pain), fever and chills, (and) no visible distress noted. During an interview on 10/6/2022 at 9:02 a.m., Resident #2 stated, I got in a fight. The CNA slammed me to the floor, and I didn't have a concussion; it happened in the dining room while I was waiting for my medication then I went to my room. When the CNA threw me to the ground, I hurt my whole leg and my calf, I think it was my right leg, and I had black and blue marks on my hip. He hit me because I put my tray into a girl. The CNA said, Don't put your hands on a girl (Resident #1). He just picked me up and threw me on the ground. During an interview on 10/6/2022 at 9:02 a.m., Resident #4, who has a BIMS of 10 indicating he/she has moderate cognitive impairment and was present at the time of the incident, stated Resident #2 and the staff was fighting. Resident #4 hit the staff, and the staff put him down. The staff put (Resident #2) face down on the floor and then beat him up. During an interview on 10/6/2022 at 11:33 a.m., the Staffing Coordinator (SC) stated, on the next day, the RN told her what happened. The RN stated she was in the ladies' room and heard something break. Then she saw Resident #2 on the floor, and the CNA was kicking him/her, so the RN told him to stop. The SC stated the RN said she didn't tell anyone because she did not want to get the CNA in trouble, so she verbally counseled him. The SC stated she asked the RN why she did not tell her Supervisor. The RN repeated she did not want to get the CNA into trouble. After the RN said this, I called the DON immediately, and she came down to the unit; it was the 3:00 p.m. - 11:00 p.m. shift, around 6:00 p.m. During an interview on 10/6/2022 at 1:25 p.m., the DON stated, the SC was collecting assignment sheets when the RN told her between 6:00 p.m.-7:00 p.m. on 9/22/2022 the story of what happened. The DON explained that the SC then told her that the RN went to the bathroom on Pod B, on the opposite side of the unit, heard a plate [fall] on the floor, and heard a scuffle. She opened the bathroom door and saw the CNA kicking Resident #2. The RN yelled, hey, hey, and the CNA stopped kicking the Resident mid-kick, and he stopped. The RN told the CNA that it could be considered abuse, and excessive force, so she counseled the CNA. In the same interview, the DON stated I asked the RN if she knew the nursing Supervisor, and she replied yes, but she did not report to her because she was trying to protect the CNA. The DON continued to say the SC was there, and I called the Corporate Nurse to report it and the Police Department. The Police arrived between 9:00 p.m.-10:00 p.m., and I assessed Resident #2 and saw a large discoloration on his/her right side, calf, and pelvic area. The DON asked the Resident what had happened, and he/she replied that he/she was sitting at the table. Resident #1 sat down and pushed the table into him/her, so he/she shoved the table back; then the CNA came across the room shouting at Resident #2, pushed the Resident to the floor, and began kicking him/her. The RN broke it up, and he/she retreated to his/her room. Resident #2 continued, I don't know if I got anything for pain. The DON further stated, on 9/22/2022, Resident #2 could walk and had no pain. The RN was almost done with her shift, gave the report, and left. Both the RN and CNA are agency [staff] and have been placed on a Do not return list as of 9/23/2022. During a telephone interview on 10/6/2022 at 1:48 p.m., the CNA stated that on 9/20/2022 at approximately 6:00 p.m., Resident #1 was aggravating Resident #2 and pushed the dining room table into Resident #2's chest. Resident #2 shoved the table back at Resident #1. Resident #2 then swung his/her fist at Resident #1, picked up the table, and threw the table, he (the CNA) caught the table in mid-air and swung the table around in the air. Resident #1 moved back, and he didn't know how Resident #2 ended up on the floor. The CNA explained Resident #4 (a third resident that was present at the time of the incident) was going after Resident #2 trying to protect Resident #1. The CNA continued to say I was in between Resident #4 and Resident #2. Then, I told Resident #2 to get his/her ass off the floor, and the Resident started kicking. The CNA told him/her to go to his/her room. No other staff was present. The CNA continued to say, I was yelling and screaming, the nurse (RN) was behind the nurse's station on the computer, and the nurse said to me, you look like you had everything under control. He further stated, I was in a panic. Resident #4 can punch [you] out. If he/she started punching me, I yelled out for help. The Nurse waited three days later to tell someone. If it was abuse, I would've been removed from the facility. On Friday, the Nurse complained about me with a resident to the staffing agency; I had never met her before. Why didn't the Nurse call the Supervisor? There was no report. She thinks I mentioned it to someone else. There was no incident report . If you saw all this, why wasn't it written down? When I come in, I huddle with the residents; Resident #2 likes ginger ale. I asked the Nurse why you didn't help me, and I told other aides later on - where were you at? The only visible [person] was the Nurse (RN), agency, like me. In the same telephone interview, when the Surveyor asked the CNA did he kick Resident #2, the CNA replied, No, I did not kick the Resident. I had to stop the table from coming down on me. Resident #2 was 10 feet from me, and Resident #4 was 15 feet from me. Resident #4 hits and Resident #2 was on the floor, I had to tend to Resident #4 first, and I told Resident #2 to go to his/her room. I can take Resident #4 to his/her room. The table was swinging. The Nurse (RN) gave Resident #2 his/her medication. Resident #2 wanted his/her medication, but it was not time for it. Resident #2 gets rowdy with someone new. The CNA continued to say Resident #2 was at one table, and Resident #4 was sitting separately at another table. Then Resident #1 came up and aggravated Resident #2 . even if the Nurse (RN) could not see it, she could still hear. I had no assistance; the only time I saw her was when everything was over. You had it under control, she said. I said I did not have it under control. The CNA continued, I worked a double shift that night, 11:00 p.m. - 7:00 a.m. [shift] was calm. On Friday, I was called by the Staffing Agency for a complaint by the Nurse, and the facility called and asked me to email a statement about the incident. On 9/20/2022, the 11:00 p.m.- 7:00 a.m. shift nurse was LPN #1, a regular there, and nothing was mentioned to him about what happened. He got a report from the RN, I was sitting there, and she left. The facility gave us information on Abuse training in-service about three months ago with Resident to Resident, handle problems together; you never handle a situation by yourself. During a telephone interview on 10/11/2022 at 8:37 a.m., when the Surveyor asked the RN what happened on 9/20/2022, she stated the following: I was in the bathroom, and I heard a plate fall on the floor around dinner time; I saw the CNA kicking Resident #2, who was already on the floor. I yelled, hey, hey. The CNA is a 7-foot-tall guy, and no other staff was there. They were at lunch; it happened in the common area. I talked to the CNA and told him that is excessive force. The CNA replied that Resident #2 hit a woman, no name given to her, so that is why he used that force, and Resident #2 has a history of striking [a] nurse in the face, and he/she tends to be violent. Resident #2 was on the ground, and the CNA was kicking the Resident, but the CNA stopped when I yelled, hey, and Resident #2 was shaken up after. The RN continued to say, I wanted to tell the Supervisor, but I didn't. I told the night shift nurse (LPN #1) that Resident #2 was beaten up by the CNA. LPN #1 said that's the way Resident #2 is with behaviors. I didn't know the facility protocol or that facility had a behavior unit, and I didn't know LPN #1's name. I thought that the CNA would be OK with my in-service on abuse. My training him was enough. She continued to say, I thought the patient [Resident] was OK. Resident #2 did not complain of pain; I assessed him/her and wrote a note on the assessment. During the same telephone interview, the Surveyor asked the RN if she was protecting the CNA. The RN replied, No, I wasn't protecting the CNA; this was the first time I worked with him, and the CNA stated this is how Resident #2 is with behaviors. The RN explained the next day; she asked the SC if the CNA was here or did he get suspended. The SC didn't know why the RN asked that question, so I told her about the altercation with Resident #2 and the CNA. According to the RN, the SC said she had to call the DON. Then she asked me why didn't I call the DON or a Supervisor; I told her that I didn't know the protocol or the facility's procedure. I wasn't trained in behavior or dealing with those people [residents]. I never knew the facility had a behavior unit; I'm an agency nurse and refuse to answer any more questions. During a telephone interview on 10/12/2022 at 9:16 a.m., LPN #1 stated, I was not present; I came into work, the Nurse [RN] told me something happened with the CNA and Resident #2, the CNA might have hit Resident #2 was reported to me by the Nurse (RN), she thought he [CNA] might have been rough with him/her. I don't remember the agency nurse's name, and I believe the CNA was on the assignment; I didn't check the previous [shift] assignment. LPN #1 further stated he thought the RN's exact words were the CNA was a little rough with Resident #2. When the Surveyor asked if being rough was abuse? LPN #1 replied rough with a resident is abusive. But I didn't witness it When asked by the Surveyor if he told anyone else about the incident, LPN #1 stated, No, I didn't tell anyone else; I didn't know I had to report it; I thought she [RN] reported it to the Supervisor. He further explained the RN did not tell him that she reported the incident to the Supervisor. But, he knew neuro (neurological) checks were initiated, and the RN was doing paperwork. I assumed that she did an incident report, did it on the computer, and called a supervisor. I didn't report it because I assumed the 3:00 p.m. - 11:00 p.m. shift nurse [RN] did it . After it happened, Resident #2 said nothing to me; he/she did not complain of pain, and I did not see the CNA that night. During a second interview on 10/12/2022 at 9:31 a.m., the DON stated, the protocol for Abuse, Behavior, and Dementia education is the same for the facility and agency staff. She continued, when she assessed Resident #2, it was only documented in the FRE; there is no separate assessment. She stated there were bluish discolorations to the calf, thigh, and pelvic area, followed up by the Nurse Practitioner (NP). As noted in the Abuse Policy, we don't have an Abuse Investigative Report. The CNA should never have done it, the CNA should have reported it to the Nurse, the Nurse should have said the resident-to-resident to the Supervisor, and it should never have escalated to a staff-to-resident. During an interview on 10/12/2022 at 10:35 a.m., the NP stated, I was asked to assess Resident #2 on 9/23/2022. Resident #2 did not complain of pain, and he/she did not tell me what happened. Because of his/her mental state, he/she was all over the place. Resident #2 asked me if the staff got fired, and I said, yes, I saw his/her bruises on the right foot, RLQ (right lower quadrant), and upper thigh bruises. She stated the bruises did not look yellow. They looked 24-48 hours old, with purple [color] around the surrounding tissue. I didn't measure the bruises; I just looked at them. I ordered a KUB (Kidneys, Ureters, Bladder) ultrasound near the bladder to check the bladder for injury. During an interview on 10/12/2022 at 2:08 p.m., the RN Supervisor (RNS) stated, I wasn't aware until the next day. The Supervisor has to make sure the Resident is safe. The Nurse (RN) should have told me, and I would report it to the DON or Administrator. The investigation would come from me, and the Nurse (RN) writes the incident. She continued, I was not aware of either incident, resident-to Resident or staff-to-resident, until 9/23/2022. It is a serious staff-to-resident. I was asked to write a statement. During a second interview on 10/12/2022 at 3:50 p.m., the DON stated she could not find a one-to-one for (Resident #2) done in September. She further stated the Resident stayed in his/her room after the incident and was not socializing. Resident #2 was not on one-to-one on the assignment sheet. On 10/18/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating facility staff on the Abuse Prevention Policy and Timely Reporting of Abuse. So, the noncompliance remained on 10/18/2022 as a level G for actual harm that is not immediate based on the following: the RN and CNA no longer work at the facility, and the facility staff has been educated on the Abuse Prevention Policy and Timely Reporting of Abuse. A review of the facility policy titled Abuse Prevention with a reviewed/revised date 05/22 revealed the following: Under Policy: included It is the policy of the facility not [to] tolerate any form of Resident abuse, neglect, or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse, neglect, exploitation, misappropriation of property, and injuries of unknown origin in compliance with State and Federal regulations and the mission and philosophy of this facility. All employees are expected to immediately report any sign of injury sustained by a resident whether or not the nature of the injury is known. An employee witnessing any form of abuse is required to promptly report the incident to the Nurse or Supervisor. Any staff member failing to report an incident will be subject to disciplinary action which may include termination.The following Definitions are acknowledged: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm or pain or mental anguish or deprivation by an individual of goods or services that are necessary for the Resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. This presumes that instances of abuse of any reside, even those in a coma, cause physical harm, pain, or mental anguish. Physical Abuse: Any inappropriate physical contact with a resident, such as hitting, slapping, striking with an open or closed hand, pinching, biting, kicking, rough handling, pulling of hair, twisting of limbs, or punching. This also includes controlling behaviors through the infliction of corporal punishment. Verbal Abuse: Any use of oral, written, or gestured language which is threatening, profane, degrading, loud, and/or using nicknames when the Resident does not approve of them. This includes the willful use of disparaging or derogatory terms toward residents or their families, or within the hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to, threats of hard or comments to frighten a resident. Under Reporting and Investigation Protocols indicated: Any employee of this facility who has knowledge of, or reasonable cause to believe or suspect that a resident is being, or has been a victim of mistreatment, abuse, neglect, exploitation or any other criminal offense shall report or ensure that a report is made of the alleged mistreatment or offense to the Administrator, the Director of Nurses or the charge nurse or Supervisor of the facility .Suspected abuse or incidents of abuse are to be reported promptly to the Nurse in charge .The charge nurse will document all pertinent information on the Abuse Investigation Report, including the names of the individuals interviewed, description of the allegation, and assessment finding . A review of the updated facility policy titled Accidents and Incidents revealed the following: Under Definition: included Incidents and Accidents - any event or unusual occurrences that occur that may cause potential harm or injury to a resident which includes but not limited to falls, skin tears, bruises, etc. Under Policy: included All incidents and accidents will be recorded, investigated, and reported accordingly. Necessary interventions will be put in place to prevent reoccurrence. Under Procedure: 1. The facility staff will document all incidents and accidents, or unusual incidents experienced by the Resident on an Incident/Accident Report. 2. Any employee who witnessed any incidents/accidents or assigned to a resident with potential or actual injuries must report their findings to the Nurse on the unit or the Nursing Supervisor. 3. The form must be completed immediately or no later than the shift that the incident occurred or when the event has been discovered. Und [TRUNCATED]

An Immediate Jeopardy (IJ) was identified for F689 during the recertification survey conducted on 08/29/22. Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death by failing to ensure a janitor closet, which contained hazardous chemicals for use by the housekeeping department, was securely closed and latched on 1 of 4 units, the Pavilion unit, which is a secured behavior unit that included cognitively impaired residents, placing all residents at risk for ingestion of chemicals or death. The census on the unit was 29, with 22 residents independently ambulatory and 4 residents who were able to self-propel the wheelchair. No residents were in the immediate area of the janitor closet at the time it was not securely closed and latched. This deficient practice was evidenced by the following: This resulted in an IJ situation that was identified on 08/05/22 when the facility failed to securely safeguard hazardous chemicals from vulnerable and independently mobile residents by ensuring the janitor door was flush with the door casing and allowing the door to close and latch securely. The facility's Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON) were notified of the IJ on 08/05/22 at 3:13 PM. A Removal Plan was received on 08/5/22, and the survey team verified the implementation of the Removal Plan on 08/05/22. On 08/05/22 at 4:24 PM, two surveyors confirmed/verified, in the presence of the Licensed Practical Nurse Unit Manager, that the janitor door self closes and locks. This was cited at a level K as the deficient practice was cited at the last standard survey of 11/01/21. On 08/05/22 at 10:08 AM, the surveyor observed the janitor closet on the Pavilion unit to be ajar. The surveyor entered the closet, and the door was observed to have an automatic closure mechanism. The door, when let to close by itself, struck the door jam on the latch side of the door and would not securely close and latch. There was a keypad lock that would require a code to open the door if the door were securely closed and latched. At that time, the surveyor observed six bottles of hand wash liquid inside the closet, one bottle of hydrogen peroxide, one opened bottle of deodorizer, four uncapped bottles of floor chemicals, and one white bottle unlabeled on the floor. There was a wall mounted chemical dispensing machine containing chemicals in separate door-type compartments. An activity staff was present in the Pavilion B common area but was facing away from the closet door. A housekeeper (HK #1) was in a resident room (room [ROOM NUMBER]) adjacent to the closet at 10:15 AM. HK #1 came out of the room, and the surveyor requested her to enter the janitor closet door and asked if the door was supposed to be open. HK #1 said, no, the door was not supposed to be open. She went on to say, that she wasn't the last one to be in and out of the janitor's closet. The surveyor requested HK #1 get her supervisor. During an interview with the surveyor on 08/05/22 at 10:17 AM, the Floor Tech Supervisor (FTS) came to the janitor closet and, in the presence of the surveyor, confirmed the door was not securely closed and latched, and it should not be open. When asked how long it has been that the door did not shut correctly, the FTS said he doesn't know how long the door has not shut correctly. The FTS identified the unlabeled white bottle on the floor as bleach and confirmed the above identified bottles observed to be chemicals used by the housekeeping staff. The FTS said that residents would have access to the chemicals if the door was not locked or shut tightly. The FTS said he told maintenance about the problem with the door a while ago but did not fill out a maintenance request form; it was verbal. He confirmed the door has auto closure on it, but at this time, the door won't shut on its own without the door being pushed closed. He said staff should push on the door to ensure it closes. The FTS said this was never addressed; however, everyone (staff) knows about the door not latching correctly. The surveyor reviewed the unit maintenance logbook for the past 4 months, and there was no documentation to indicate maintenance was notified of the janitor door not closing. During an interview with the surveyor on 08/05/22 at 10:27 AM, the maintenance staff on duty said he had been at the facility for six months. He said the process for staff to report necessary repairs was to use the logbook (on the units) or the new phone app (application) launched in the past three weeks, and requests can be submitted via the phone. During a follow-up interview on 08/05/22 at 1:05 PM, the maintenance staff said he just became aware today that the janitor closet door on the Pavilion wasn't closing correctly. He said we worked on it a few months ago and never got the new door that his prior supervisor requested. During an interview, in the presence of the survey team, on 08/05/22 at 03:09 PM, the LNHA said the janitor door should be kept closed and locked to prevent anyone from accessing anything inside. During an interview in the presence of the survey team on 08/17/22 at 9:34 AM, the Director of Environmental Services (DEVS) said her expectations are the janitor closets are to be kept clean with daily checks for cleanliness and being put together correctly, and they should be locked. A review of a facility provided Quality Assurance folder revealed a document titled 100% Pavilion Environmental Rounds 6/13/22 that indicated that the janitors closet by room [ROOM NUMBER] (same closet as noted above) containing hazardous chemicals doesn't close flush (priority). A review of a facility policy titled Janitors Closet with a creation date of 9-12-14 and the last date revised 8/5/22, included under procedure section 7. Ensure that the door closes properly and is kept locked when unsupervised. Any maintenance issue with the door should be addressed with maintenance or supervisor, and the door monitored until the door can be repaired. NJAC 8:39-31.2(e)

An Immediate Jeopardy (IJ) was identified for F760 during the recertification survey conducted on 08/29/22. Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to follow a physician's order for Nectar Thick Liquids, as documented on the Medication Administration Record while administering medications. This deficient practice was identified for 1 of 3 nurses (Licensed Practical Nurse #1) on 1 of 4 units (Court 2) during the medication administration pass. On 08/04/22, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #7 while providing the resident with thin (unthickened) liquids. LPN #1 did not follow the physician's order for Nectar Thick Liquids (NTL) documented on the Medication Administration Record (MAR). This posed a serious and immediate threat for residents on a physician's ordered altered liquid consistency diet. The Immediate Jeopardy (IJ) began on 08/04/22 at 8:25 AM and continued until 08/05/22. The Licensed Nursing Home Administrator (LNHA) and Assistant Director of Nursing (ADON) were notified of the IJ on 08/04/22 at 3:56 PM. LPN #1's failure to follow a physician's order for NTL during the medication administration pass placed residents on a physician's ordered altered liquid consistency diet at risk for choking, aspiration (when material such as food or drink enters the respiratory tract), or death. An acceptable removal plan was received on 08/05/22 and verified by the survey team. This IJ was cited at a level K as the deficient practice was cited at the last standard survey of 11/01/21. This deficient practice was evidenced by the following: On 08/04/22 at 08:15 AM, the surveyor observed LPN #1 (an agency nurse) dispense seven oral (PO) medications into a medicine cup and pour water (a thin liquid) into a plastic cup for Resident #7. At 8:25 AM, the surveyor accompanied LPN #1 into Resident #7's room. The LPN handed the resident the medicine cup, and the resident put all seven PO medications into their mouth. The resident took a small sip of the water from the plastic cup but did not swallow the medications. The resident then alternated taking sips of thin liquids (coffee and orange juice) from their breakfast tray but did not swallow the medications. As the resident's mouth was full of the medications and thin liquids, LPN #1 encouraged the resident to either swallow or spit out the medications, but the resident refused. At 8:45 AM, LPN #1 called LPN #2 from the hallway into Resident #7's room to assist with medication administration. LPN #2 immediately grabbed one of the thickening packets from the resident's breakfast tray and thickened the resident's water that was brought in by LPN #1. LPN #2 also thickened the resident's coffee and orange juice on the breakfast tray. Afterward, LPN #2 gave the resident a pre-thickened health shake from the breakfast tray and encouraged the resident to swallow the medications. The resident coughed as they held the medications and liquids in their mouth, attempting to keep their mouth closed. At 8:57 AM, Resident #7 swallowed the medications and liquids held in their mouth. According to the Admission Record, Resident #7 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Transient Ischemic Attack (mini-stroke) and Cerebral Infarction (stroke). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/19/22, revealed Resident #7 had a Brief Interview for Mental Status score of 9 which indicated that the resident's cognition was moderately impaired. Further review of the MDS included the resident received a Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the Care Plan, initiated 03/26/13, included a focus on potential nutrition problem r/t [related to] need for mechanically altered diet, thickened liquids, with an intervention dated 09/18/18, to provide diet as ordered: Regular, chopped texture, nectar thick liquids. Review of the Physician's Order Form, dated 08/2022, included a diet order, dated 07/06/22, for Regular, Chopped Texture, Nectar Thick Liquids. Review of the August 2022 MAR included the aforementioned diet order but did not require nurses to sign their initials to acknowledge the order. Review of the Diet Requisition Form, dated 07/06/22, included the resident's diet was changed to Regular, Chopped Texture, and Nectar Thickened Liquids. Review of Resident #7's Breakfast Meal Ticket, dated 08/04/22, included Nectar Thickened Liquids. Review of the Nutrition Progress Note, dated 02/08/22, included, Resident is on mechanically altered diet with NTL for dysphagia [difficulty swallowing] and tolerates it. Review of the Speech Therapy SLP (Speech Language Pathology) Evaluation & Plan of Treatment, dated 07/24/20, included a diagnosis of dysphagia, a precaution of aspiration risk, and a recommendation for NTL. Review of the Speech Therapy Discharge Summary, dated 09/18/20, included, Pt [patient] was educated on importance of increasing efficiency of swallow (initiation) to minimize risk of aspiration, and discharge recommendations for NTL. During an interview with the surveyor on 08/04/22 at 9:00 AM, LPN #2 stated that she was the regular nurse for Resident #7. She further stated that LPN #1 should have been made aware of the resident's NTL order during the report but that it is also included on the MAR. LPN #2 stated the importance of following a physician's order for NTL was because the resident was on aspiration precautions. During an interview with the surveyor on 08/04/22 at 10:31 AM, LPN #1 stated that nurses are made aware of altered liquid consistencies from the MAR or the resident's chart. LPN #1 acknowledged that Resident #7 should have received NTL to prevent the risk of aspiration. During an interview with the surveyor on 08/04/22 at 10:36 AM, Registered Nurse/Unit Manager (RN/UM) #1 stated that nurses should know if a resident has an order for an altered liquid consistency because the diet order is included on the MAR. RN/UM #1 further stated that LPN #1 should have checked the MAR for the diet order and used the thickening powder located in the medication cart to thicken Resident #7's liquids during the medication administration pass due to the risk of aspiration. During an interview with the surveyor on 08/04/22 at 11:58 AM, the ADON stated that agency staff are provided a Welcome to Orientation packet upon working in the facility and are also required to complete a medication pass test. A review of the Welcome to Orientation packet signed by LPN #1, dated 05/05/22, included a Medication Administration policy dated 11/2021. The policy revealed, The nurse is to prepare medications prior to medication pass. Preparation includes; (a) the review of orders . Review of the Medication Pass test completed by LPN #1, dated 05/05/22, did not include altered liquid consistencies. During an interview with the surveyor on 08/04/22 at 2:40 PM, Speech Therapist (ST) #1 stated that when the ST makes a recommendation for an altered diet, the ST will handwrite the order on the Physician Order Sheet, and the nurse is responsible for transcribing the order. The ST also stated giving thin liquids to Resident #7, who is ordered NTL, would be contraindicated and not safe. During a follow-up interview with the surveyor on 08/04/22 at 3:41 PM, the ADON stated that during medication administration, the nurse should know if the resident requires an altered liquid consistency and thicken the liquids based on the diet order written in the MAR. The ADON further stated that providing residents with the correct liquid consistency is essential due to the risk of aspiration. On 08/04/22 at 3:56 PM, the LNHA and ADON were notified that LPN #1's failure to follow a physician's order for NTL, as documented on the MAR during the medication administration pass, constituted as an IJ situation that placed residents on a physician's ordered altered liquid consistency diet at risk for choking, aspiration, or death. An acceptable Removal Plan was received on 08/05/22 and verified by the survey team. Review of the facility's Medication Administration policy, reviewed 05/2022, included, Follow appropriate medication administration guidelines. Review of the facility's Thickened Liquids policy, reviewed 05/2022, included, Facilities will serve thickened liquids to residents as ordered by the physician. Review of the facility's Therapeutic Diet Orders policy reviewed 05/2022 included, Therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. 36000 PART B Based on interview and record review, it was determined that the facility failed to order one PRN (as needed) psychotropic medication for a 14-day period. This deficient practice was identified for 1 of 8 residents reviewed for medication regimen review (Resident #114) and was evidenced by the following: According to the Admission Record, the resident was admitted to the facility with diagnoses that included but was not limited to generalized anxiety disorder. Review of the Physician's Order Form, dated 07/2022, for Resident #114 reflected an order dated 05/24/22 for Lorazepam (Ativan) (an antianxiety medication) 0.5 mg (milligrams) to administer one tablet every eight hours as needed for anxiety. The surveyor observed that the order did not contain a duration of 14 days. Review of the June 2022 Medication Administration Record (MAR) reflected that Resident #114 received the as needed medication on 06/08/22, 06/10/22, 06/11/22, 06/13/22, 06/14/22, 06/15/22, 06/16/22, 06/17/22, 06/18/22, 06/19/22, 06/20/22, 06/21/22, 06/22/22, 06/24/22, 06/25/22, 06/26/22, 06/27/22, 06/28/22, 06/29/22, and two times on 06/30/22. Review of the July 2022 MAR reflected that Resident #114 received the as needed medication on 07/01/22 and 07/02/22. During an interview with the surveyor on 08/08/22 at 10:41 AM, LPN #3 stated that if there was a psychotropic medication ordered PRN, then it should be initially ordered for 14 days and then reevaluated by the physician. LPN #3 further stated that if the resident was receiving the PRN medication regularly and it was helping the resident, she would call the physician to see if the physician would change the order to a standing order. During an interview with the surveyor on 08/08/22 at 10:43 AM, the LPN/UM stated that a psychotropic medication should be ordered initially for 14 days and then reevaluated by the physician. When the medication was evaluated, the physician either wrote a new prescription or discontinued the order. During an interview with the surveyor on 08/10/22 at 9:45 AM, the ADON, in the presence of the LNHA, stated that a new prescription for a PRN psychotropic medication should be ordered for 14 days, reviewed by the physician, and then renewed or discontinued. The ADON stated that the physician must write a rationale as to why they continued the medication and include a duration in the order. The ADON stated that it was essential to monitor a PRN psychotropic medication to see if it was needed by the resident. Review of the facility's Antipsychotic Medication Use policy, revised in December 2016, reflected that The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. NJAC 8:39-11.2(b); 27.1(a)

An Immediate Jeopardy (IJ) was identified for F808 during the recertification survey conducted on 08/29/22. Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to ensure that residents at risk for aspiration (when material such as food or drink enters the respiratory tract) received the appropriate altered liquid consistency diet. This deficient practice was identified for 2 of 9 residents (Resident #7 and #99) reviewed for altered liquid consistency diets. On 08/04/22 during the breakfast meal, Surveyor #1 observed Resident #7 drink thin liquids from his/her breakfast tray. The facility staff did not follow the instructions on the meal ticket for Nectar Thick Liquids (NTL) and appropriately thicken the liquids prior to providing the resident with the breakfast tray. On 08/04/22 during the lunch meal, Surveyor #2 observed Resident #99 drink a thin liquid from his/her lunch tray. The facility staff did not follow the instructions on the meal ticket for NTL and appropriately thicken the liquid prior to providing the resident with the lunch tray. This posed a serious and immediate threat for residents on an altered liquid consistency diet who are at risk for aspiration. The Immediate Jeopardy (IJ) began on 08/04/22 at 8:25 AM and continued until 08/05/22. The Licensed Nursing Home Administrator and Assistant Director of Nursing (ADON) were notified of the IJ on 08/04/22 at 3:56 PM. The facility's failure to ensure the appropriate liquid consistency diet was provided during meals placed residents at risk for choking, aspiration, or death. An acceptable removal plan was received on 08/05/22 and verified by the survey team. This deficient practice was evidenced by the following: 1.) On 08/04/22 at 8:25 AM, Surveyor #1 accompanied Licensed Practical Nurse (LPN) #1 into Resident #7's room during the medication administration pass. The LPN handed the resident a medicine cup and the resident put all of the oral medications into his/her mouth. The resident then took a small sip of the water from a plastic cup provided by the LPN, but did not swallow the medications. The resident then alternated taking sips of thin liquids (coffee and orange juice) from his/her breakfast tray, but did not swallow the medications. As the resident's mouth was full of the medications and thin liquids, LPN #1 encouraged the resident to either swallow or spit out the medications, but the resident refused. At 8:45 AM, LPN #1 called LPN #2 from the hallway into Resident #7's room to assist with the medication administration. LPN #2 immediately grabbed one of the thickening packets from the resident's breakfast tray and thickened the resident's water that was brought in by LPN #1. LPN #2 also thickened the resident's coffee and orange juice on the breakfast tray. Afterwards, LPN #2 gave the resident a pre-thickened health shake from the breakfast tray and encouraged the resident to swallow the medications. As the resident was holding the medications and liquids in his/her mouth, he/she coughed while maintaining to keep his/her mouth closed. At 8:57 AM, Resident #7 swallowed the medications and liquids in his/her mouth. At 9:06 AM, Surveyor #1 observed Resident #7 cough while his/her breakfast tray was in front of him/her. According to the Admission Record, Resident #7 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Transient Ischemic Attack (mini stroke) and Cerebral Infarction (stroke). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/19/22, revealed Resident #7 had a Brief Interview for Mental Status score of 9/15 which indicated that the resident's cognition was moderately impaired. Further review of the MDS included the resident received a Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the Care Plan, initiated 03/26/2013, included a focus of, potential nutrition problem r/t [related to] need for mechanically altered diet, thickened liquids, with an intervention dated, 09/18/2018, to, provide diet as ordered: Regular, chopped texture, nectar thick liquids. Review of the Physician's Order Form, dated 08/2022, included a diet order, dated 07/06/22, for Regular, Chopped Texture, Nectar Thick Liquids. Review of the Diet Requisition Form, dated 07/06/22, included the resident's diet was changed to Regular, Chopped Texture, and NTL. Review of Resident #7's Breakfast Meal Ticket, dated 08/04/22, included, Nectar Thickened Liquids. Review of the Nutrition Progress Note, dated 02/08/22, included, Resident is on mechanically altered diet with NTL for dysphagia [difficulty swallowing] and tolerates it. Review of the Speech Therapy SLP (Speech Language Pathology) Evaluation & Plan of Treatment, dated 07/24/2020, included a diagnosis of dysphagia, a precaution of aspiration risk, and a recommendation for NTL. Review of the Speech Therapy Discharge Summary, dated 09/18/2020, included, Pt [patient] was educated on importance of increasing efficiency of swallow (initiation) to minimize risk of aspiration, and discharge recommendations for NTL. During an interview with the surveyor on 08/04/22 at 9:00 AM, LPN #2 stated that she was the regular nurse for Resident #7. She further stated that during meals, the Certified Nursing Assistants (CNA) pass out and set up the meal trays for residents. LPN #2 explained that the meal trays were sent from the kitchen with thin liquids and for Resident #7, the nurse must thicken the liquids on his/her tray outside of the room otherwise the resident will get upset. The LPN then verified that when she entered Resident #7's room, she had to thicken the liquids on the resident's breakfast tray and stated that the CNA should have called the nurse to thicken the liquids on the tray prior to giving the resident his/her breakfast. LPN #2 further stated that it was important to thicken Resident #7's liquids because the resident was on aspiration precautions. During an interview with the surveyor on 08/04/22 at 9:59 AM, the Director of Nutritional Services (DNS) stated that the kitchen staff are responsible for providing a thickening packet for each beverage on the meal tray and then the nursing staff are responsible for thickening the liquids when the tray arrives to the nursing unit. During an interview with the surveyor on 08/04/22 at 10:19 AM, CNA #1 stated that CNAs are responsible for passing out the meal trays, checking the meal tickets for accuracy, and thickening liquids on the meal tray. CNA #1 also stated that CNAs know if the resident requires thickened liquids because it is written on the meal ticket and the meal tray comes with thickening packets. The CNA further stated that it is important to thicken liquids if the resident has swallowing issues. During an interview with the surveyor on 08/04/22 at 10:23 AM, CNA #2 stated that CNAs are responsible for passing out the meal trays, checking the meal tickets for accuracy, and thickening liquids on the meal tray. CNA #2 also stated that CNAs know if the resident requires thickened liquids because it is written on the meal ticket and the meal tray comes with thickening packets from the kitchen. The CNA further stated it is important to thicken liquids to prevent the resident from aspirating. During an interview with the surveyor on 08/04/22 at 10:31 AM, LPN #1 stated that any facility staff can pass out the meal trays, but that nurses are responsible for thickening the liquids on the meal tray. LPN #1 further stated that Resident #7 should have received NTL to prevent the risk for aspiration. During an interview with the surveyor on 08/04/22 at 10:36 AM, Registered Nurse/Unit Manager (RN/UM) #1 stated that CNAs or nurses can pass out meal trays and check the meal tickets for accuracy, but that the nurse is responsible for thickening the liquids on the meal tray. RN/UM #1 further stated that the nurse should have thickened the liquids on the meal tray prior to giving Resident #7 his/her breakfast due to the risk of aspiration. During an interview with the surveyor on 08/04/22 at 2:40 PM, Speech Therapist (ST) #1 stated that when the ST makes a recommendation for an altered diet, the ST will handwrite the order on the Physician Order Sheet and the nurse is responsible for transcribing the order. The ST also stated giving thin liquids to Resident #7, who is ordered NTL, would be contraindicated and not safe. 38679 2.) According to the Admission Record, Resident #99 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Diabetes Mellitus (DM), and Chronic Obstructive Pulmonary Disease. Review of the Admission MDS, dated [DATE], reflected that Resident #99 was moderately impaired cognition and required extensive assist of staff for eating. Review of the Care Plan (CP), initiated 06/27/22, included a focus of, nutritional problem or potential nutritional problem r/t [related to] need for therapeutic diet, mechanically altered diet, thickened liquids, with history of DM and Alzheimer's. The CP included an intervention, dated 06/27/22, to, provide, serve diet as ordered: NAS [no added salt], CCD [carbohydrate-controlled diet], ground texture, nectar thick liquids. Review of the SLP Evaluation & Plan of Treatment (Speech therapy (ST) evaluation), dated 07/11/22 - 08/09/22, included a diagnosis of dysphagia and indicated the reason for referral was exacerbation of decreased pharyngeal (swallowing) function, decreased functional activity tolerance, coughing/choking during oral intake and increased need for assistance from others. The ST evaluation included recommendations for close supervision for oral intake, mechanical soft/ground textures, and NTL. Review of the POF, dated 07/06/22, included an order, dated 07/11/22, for ST evaluation and treatment for dysphagia, downgrade diet to ground texture, NTL, feeding assistance with all meals, and aspiration precautions. Review of the Diet Requisition Form, dated 07/11/22 and 07/14/22, included the resident's diet was changed to Carbohydrate Controlled (CCD), Ground texture, and NTL. On 08/04/22 at 12:30 PM, Surveyor #2 observed the lunch meal service on Court 1. Surveyor #2 observed a facility staff enter Resident #99's room with a meal tray. She set up the resident's lunch meal tray on the overbed table, exited the room and walked down the hallway. Surveyor #2 then entered Resident #99's room and observed the resident in bed with the head of bed elevated eating his/her meal. Surveyor #2 observed the resident as he/she took a spoon of the food and drank from a disposable white cup (cup). Resident #99 then placed the cup alongside the plate after drinking from it for a third time. At which time, Surveyor #2 observed that Resident #99's cup contained clear thin liquids (water). Surveyor #2 further observed an unopened packet of instant thickened coffee and an unopened packet of instant food thickener on the resident's tray. The facility staff did not follow the instructions on the meal ticket for Nectar Thick Liquids (NTL) and appropriately thicken the liquids prior to providing the resident with the lunch tray. Review of Resident #99's Lunch Meal Ticket (meal ticket), dated 08/04/22, revealed documented and highlighted in yellow, Nectar Thickened Liquids, Nectar Thickened Skim Milk, Nectar Thickened Apple Juice, and Nectar Thickened Coffee. On 08/04/22 at 12:33 PM, CNA #6 entered Resident #99's room and stated she was there to assist the resident with the lunch meal tray. CNA #6 immediately grabbed the instant thickened coffee packet from the resident's tray and thickened the water in the cup. When interviewed, CNA #6 stated the thin liquid in the disposable cup was water for the resident's instant coffee. CNA # 6 further stated Resident #99 required NTL and that the thin liquids in the cup should have been thickened with the instant thickened coffee prior to giving it to the resident. CNA #6 added that Resident #99 should not have been given thin liquids. 08/04/22 at 12:41 PM, Surveyor #2 interviewed the facility staff who set up Resident #99's lunch meal tray. The facility staff identified herself as the Admissions Director (AD) and stated she regularly passed trays on the units. The AD stated she looks at the resident's meal ticket and compare it to the tray for accuracy. The AD added that you would open the thickening packets and mix it with the appropriate liquids. The AD further stated the liquid consistency was documented on the meal ticket and that the person setting up the meal tray was responsible for making sure the that the resident was receiving the correct consistency. The AD stated she would remove the tray if she was unsure of the consistency and would follow up the nursing staff. When question about her setting up Resident #99's lunch meal tray, the AD stated she was not familiar with the resident and that she exited the room to get the CNA. The AD did not provide an explanation why she did not thicken the resident's coffee or remove the resident's tray before leaving the room. During an interview with Surveyor #1 and #2 on 08/04/22 at 3:41 PM, the ADON stated that CNAs and nurses were responsible for passing out the meal trays, but that the nurse were responsible for checking the meal ticket for accuracy and ensuring the correct thickening packets are on the meal tray. The ADON further stated that staff should not provide a meal tray with thin liquids to a resident who is on an altered liquid consistency diet due to the risk of aspiration. During an interview with Surveyor #2 on 08/05/22 at 8:58 AM, the ADON stated the AD was recently hired and completed the New Employee Orientation education. The ADON added that passing trays was not part of the education packet and that the AD should not have been passing trays on the units. Review of the facility's Thickened Liquids policy, with reviewed date of 05/2022, included, Facilities will serve thickened liquids to residents as ordered by the physician, and, For beverages which must be thickened, such as coffee, tea, cocoa and soup, the beverage will be thickened by the Dietary staff prior to leaving the kitchen. Review of the facility's Therapeutic Diet Orders policy, with reviewed date of 05/2022, included, Therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. Review of the facility's Meal Services policy,with reviewed date of 05/2022, included, A record of all residents' diet order and a list of those residents on thickened liquids or fluid restrictions will be kept in each unit in a manner that ensures privacy. NJAC 8:39-17.4(a)(2)

Reference F689K, 760K, F808K, Based on observations, interviews, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility's policies and procedures were implemented to ensure resident safety and well-being, by failing to: a.) ensure safe meal delivery for Residents #7 and #99, who were at risk for aspiration, according to the physician's prescribed diet order to include nectar thickened liquids, b.) perform medication administration according to professional standards of practice, and c.) maintain and provide a safe environment for the residents by ensuring chemicals were locked and secured. This posed a serious and immediate threat to the safety and well-being of all the residents who receive thickened liquids from choking, aspirating or dying and all the residents on the Pavilion Unit from ingesting chemicals and becoming seriously ill or death. The failure of the LNHA to ensure the facility established and maintained systems that were effective and efficient to operate the facility in a manner to safely meet resident's needs in compliance with federal, state and local requirements as outlined in the Administrator Job Description, resulted in an Immediate Jeopardy (IJ) that was identified on 08/08/22 at 2:19 PM . A Removal Plan was received on 08/10/22 at 8:48 AM and the survey team verified the implementation of the Removal Plan on 08/10/22 at 2:00 PM. This deficient practice was evidenced by the following: A review of the facility's policy titled Administrator Job Description, undated, revealed that the duties of the Administrator included but not limited to: a)Operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations. b)Establish systems to enforce the facility policies and procedures. c)Follow facility Resident Rights policies d)Perform other related duties as directed by the governing body Refer F760K On 08/04/22, the LNHA failed to ensure the facility followed a physician's order for Nectar Thick Liquids, as documented on the Medication Administration Record, while administering medications. This deficient practice was identified for 1 of 3 nurses (Licensed Practical Nurse #1) on 1 of 4 units (Court 2) during the medication administration pass. On 08/04/22, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #7 while providing the resident with thin liquids. LPN #1 did not follow the physician's order for Nectar Thick Liquids (NTL) documented on the Medication Administration Record (MAR). This posed a serious and immediate threat for residents on a physician's ordered altered liquid consistency diet. The Immediate Jeopardy (IJ) began on 08/04/22 at 8:25 AM and continued until 08/05/22. The Licensed Nursing Home Administrator (LNHA) and Assistant Director of Nursing (ADON) were notified of the IJ on 08/04/22 at 3:56 PM. LPN #1's failure to follow a physician's order for NTL during the medication administration pass placed residents on a physician's ordered altered liquid consistency diet at risk for choking, aspiration (when material such as food or drink enters the respiratory tract), or death. An acceptable removal plan was received on 08/05/22 and verified by the survey team. This was cited at a level K as the deficient practice was cited at the last standard survey of 11/01/21. This deficient practice was evidenced by the following: On 08/04/22 at 08:15 AM, the surveyor observed LPN #1 (an agency nurse) dispense seven oral (PO) medications into a medicine cup and pour water (a thin liquid) into a plastic cup for Resident #7. At 8:25 AM, the surveyor accompanied LPN #1 into Resident #7's room. The LPN handed the resident the medicine cup and the resident put all seven PO medications into his/her mouth. The resident took a small sip of the water from the plastic cup, but did not swallow the medications. The resident then alternated taking sips of thin liquids (coffee and orange juice) from his/her breakfast tray, but did not swallow the medications. As the resident's mouth was full of the medications and thin liquids, LPN #1 encouraged the resident to either swallow or spit out the medications, but the resident refused. At 8:45 AM, LPN #1 called LPN #2 from the hallway into Resident #7's room to assist with the medication administration. LPN #2 immediately grabbed one of the thickening packets from the resident's breakfast tray and thickened the resident's water that was brought in by LPN #1. LPN #2 also thickened the resident's coffee and orange juice on the breakfast tray. Afterwards, LPN #2 gave the resident a pre-thickened health shake from the breakfast tray and encouraged the resident to swallow the medications. As the resident was holding the medications and liquids in his/her mouth, he/she coughed while maintaining to keep his/her mouth closed. At 8:57 AM, Resident #7 swallowed the medications and liquids in his/her mouth. According to the Admission Record, Resident #7 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Transient Ischemic Attack (mini stroke) and Cerebral Infarction (stroke). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/19/22, revealed Resident #7 had a Brief Interview for Mental Status score of 9 which indicated that the resident's cognition was moderately impaired. Further review of the MDS included the resident received a Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the Care Plan, initiated 03/26/13, included a focus of, potential nutrition problem r/t [related to] need for mechanically altered diet, thickened liquids, with an intervention dated, 09/18/18, to, provide diet as ordered: Regular, chopped texture, nectar thick liquids. Review of the Physician's Order Form, dated 08/2022, included a diet order, dated 07/06/22, for Regular, Chopped Texture, Nectar Thick Liquids. Review of the August 2022 MAR included the aforementioned diet order, but did not require nurses to sign their initials to acknowledge the order. Review of the Diet Requisition Form, dated 07/06/22, included the resident's diet was changed to Regular, Chopped Texture, and Nectar Thickened Liquids. Review of Resident #7's Breakfast Meal Ticket, dated 08/04/22, included, Nectar Thickened Liquids. Review of the Nutrition Progress Note, dated 02/08/22, included, Resident is on mechanically altered diet with NTL for dysphagia [difficulty swallowing] and tolerates it. Review of the Speech Therapy SLP (Speech Language Pathology) Evaluation & Plan of Treatment, dated 07/24/20, included a diagnosis of dysphagia, a precaution of aspiration risk, and a recommendation for NTL. Review of the Speech Therapy Discharge Summary, dated 09/18/20, included, Pt [patient] was educated on importance of increasing efficiency of swallow (initiation) to minimize risk of aspiration, and discharge recommendations for NTL. During an interview with the surveyor on 08/04/22 at 9:00 AM, LPN #2 stated that she was the regular nurse for Resident #7. She further stated that LPN #1 should have been made aware of the resident's NTL order during report, but that it is also included on the MAR. LPN #2 stated the importance of following a physician's order for NTL was because the resident was on aspiration precautions. During an interview with the surveyor on 08/04/22 at 10:31 AM, LPN #1 stated that nurses are made aware of altered liquid consistencies from the MAR or the resident's chart. LPN #1 acknowledged that Resident #7 should have received NTL to prevent the risk for aspiration. During an interview with the surveyor on 08/04/22 at 10:36 AM, Registered Nurse/Unit Manager (RN/UM) #1 stated that nurses should know if a resident has an order for an altered liquid consistency because the diet order is included on the MAR. RN/UM #1 further stated that LPN #1 should have checked the MAR for the diet order and used the thickening powder located in the medication cart to thicken Resident #7's liquids during the medication administration pass due to the risk of aspiration. During an interview with the surveyor on 08/04/22 at 11:58 AM, the ADON stated that agency staff are provided a Welcome to Orientation packet upon working in the facility and are also required to complete a medication pass test. Review of the Welcome to Orientation packet signed by LPN #1, dated 05/05/22, included a Medication Administration policy, dated 11/2021. The policy revealed, The nurse is to prepare medications prior to medication pass. Preparation includes; (a) the review of orders . Review of the Medication Pass test completed by LPN #1, dated 05/05/22, did not include altered liquid consistencies. During an interview with the surveyor on 08/04/22 at 2:40 PM, Speech Therapist (ST) #1 stated that when the ST makes a recommendation for an altered diet, the ST will handwrite the order on the Physician Order Sheet and the nurse is responsible for transcribing the order. The ST also stated giving thin liquids to Resident #7, who is ordered NTL, would be contraindicated and not safe. During a follow-up interview with the surveyor on 08/04/22 at 3:41 PM, the ADON stated that during medication administration, the nurse should know if the resident requires an altered liquid consistency and thicken the liquids based on the diet order written in the MAR. The ADON further stated it is important to provide residents with the correct liquid consistency due to the risk of aspiration. On 08/04/22 at 3:56 PM, the LNHA and ADON were notified that LPN #1's failure to follow a physician's order for NTL, as documented on the MAR during the medication administration pass, constituted as an IJ situation that placed residents on a physician's ordered altered liquid consistency diet at risk for choking, aspiration, or death. An acceptable Removal Plan was received on 08/05/22 and verified by the survey team. Review of the facility's Med Administration policy, reviewed 05/2022, included, Follow appropriate medication administration guidelines. Review of the facility's Thickened Liquids policy, reviewed 05/2022, included, Facilities will serve thickened liquids to residents as ordered by the physician. Review of the facility's Therapeutic Diet Orders policy, reviewed 05/2022, included, Therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. Refer F808K On 08/04/22, the LNHA failed to ensure that residents at risk for aspiration (when material such as food or drink enters the respiratory tract) received the appropriate altered liquid consistency diet. This deficient practice was identified for 2 of 9 residents (Resident #7 and #99) reviewed for altered liquid consistency diets. On 08/04/22 during the breakfast meal, Surveyor #1 observed Resident #7 drink thin liquids from his/her breakfast tray. The facility staff did not follow the instructions on the meal ticket for Nectar Thick Liquids (NTL) and appropriately thicken the liquids prior to providing the resident with the breakfast tray. On 08/04/22 during the lunch meal, Surveyor #2 observed Resident #99 drink a thin liquid from his/her lunch tray. The facility staff did not follow the instructions on the meal ticket for NTL and appropriately thicken the liquid prior to providing the resident with the lunch tray. This posed a serious and immediate threat for residents on an altered liquid consistency diet who are at risk for aspiration. The Immediate Jeopardy (IJ) began on 08/04/22 at 8:25 AM and continued until 08/05/22. The Licensed Nursing Home Administrator(LNHA) and Assistant Director of Nursing (ADON) were notified of the IJ on 08/04/22 at 3:56 PM. The facility's failure to ensure the appropriate liquid consistency diet was provided during meals placed residents at risk for choking, aspiration, or death. An acceptable removal plan was received on 08/05/22 and verified by the survey team. This deficient practice was evidenced by the following: 1.) On 08/04/22 at 8:25 AM, Surveyor #1 accompanied Licensed Practical Nurse (LPN) #1 into Resident #7's room during the medication administration pass. The LPN handed the resident a medicine cup and the resident put all of the oral medications into his/her mouth. The resident then took a small sip of the water from a plastic cup provided by the LPN, but did not swallow the medications. The resident then alternated taking sips of thin liquids (coffee and orange juice) from his/her breakfast tray, but did not swallow the medications. As the resident's mouth was full of the medications and thin liquids, LPN #1 encouraged the resident to either swallow or spit out the medications, but the resident refused. At 8:45 AM, LPN #1 called LPN #2 from the hallway into Resident #7's room to assist with the medication administration. LPN #2 immediately grabbed one of the thickening packets from the resident's breakfast tray and thickened the resident's water that was brought in by LPN #1. LPN #2 also thickened the resident's coffee and orange juice on the breakfast tray. Afterwards, LPN #2 gave the resident a pre-thickened health shake from the breakfast tray and encouraged the resident to swallow the medications. As the resident was holding the medications and liquids in his/her mouth, he/she coughed while maintaining to keep his/her mouth closed. At 8:57 AM, Resident #7 swallowed the medications and liquids in his/her mouth. At 9:06 AM, Surveyor #1 observed Resident #7 cough while his/her breakfast tray was in front of him/her. According to the Admission Record, Resident #7 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Transient Ischemic Attack (mini stroke) and Cerebral Infarction (stroke). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/19/22, revealed Resident #7 had a Brief Interview for Mental Status score of 9/15 which indicated that the resident's cognition was moderately impaired. Further review of the MDS included the resident received a Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the Care Plan, initiated 03/26/2013, included a focus of, potential nutrition problem r/t [related to] need for mechanically altered diet, thickened liquids, with an intervention dated, 09/18/2018, to, provide diet as ordered: Regular, chopped texture, nectar thick liquids. Review of the Physician's Order Form, dated 08/2022, included a diet order, dated 07/06/22, for Regular, Chopped Texture, Nectar Thick Liquids. Review of the Diet Requisition Form, dated 07/06/22, included the resident's diet was changed to Regular, Chopped Texture, and NTL. Review of Resident #7's Breakfast Meal Ticket, dated 08/04/22, included, Nectar Thickened Liquids. Review of the Nutrition Progress Note, dated 02/08/22, included, Resident is on mechanically altered diet with NTL for dysphagia [difficulty swallowing] and tolerates it. Review of the Speech Therapy SLP (Speech Language Pathology) Evaluation & Plan of Treatment, dated 07/24/2020, included a diagnosis of dysphagia, a precaution of aspiration risk, and a recommendation for NTL. Review of the Speech Therapy Discharge Summary, dated 09/18/2020, included, Pt [patient] was educated on importance of increasing efficiency of swallow (initiation) to minimize risk of aspiration, and discharge recommendations for NTL. During an interview with the surveyor on 08/04/22 at 9:00 AM, LPN #2 stated that she was the regular nurse for Resident #7. She further stated that during meals, the Certified Nursing Assistants (CNA) pass out and set up the meal trays for residents. LPN #2 explained that the meal trays were sent from the kitchen with thin liquids and for Resident #7, the nurse must thicken the liquids on his/her tray outside of the room otherwise the resident will get upset. The LPN then verified that when she entered Resident #7's room, she had to thicken the liquids on the resident's breakfast tray and stated that the CNA should have called the nurse to thicken the liquids on the tray prior to giving the resident his/her breakfast. LPN #2 further stated that it was important to thicken Resident #7's liquids because the resident was on aspiration precautions. During an interview with the surveyor on 08/04/22 at 9:59 AM, the Director of Nutritional Services (DNS) stated that the kitchen staff are responsible for providing a thickening packet for each beverage on the meal tray and then the nursing staff are responsible for thickening the liquids when the tray arrives to the nursing unit. During an interview with the surveyor on 08/04/22 at 10:19 AM, CNA #1 stated that CNAs are responsible for passing out the meal trays, checking the meal tickets for accuracy, and thickening liquids on the meal tray. CNA #1 also stated that CNAs know if the resident requires thickened liquids because it is written on the meal ticket and the meal tray comes with thickening packets. The CNA further stated that it is important to thicken liquids if the resident has swallowing issues. During an interview with the surveyor on 08/04/22 at 10:23 AM, CNA #2 stated that CNAs are responsible for passing out the meal trays, checking the meal tickets for accuracy, and thickening liquids on the meal tray. CNA #2 also stated that CNAs know if the resident requires thickened liquids because it is written on the meal ticket and the meal tray comes with thickening packets from the kitchen. The CNA further stated it is important to thicken liquids to prevent the resident from aspirating. During an interview with the surveyor on 08/04/22 at 10:31 AM, LPN #1 stated that any facility staff can pass out the meal trays, but that nurses are responsible for thickening the liquids on the meal tray. LPN #1 further stated that Resident #7 should have received NTL to prevent the risk for aspiration. During an interview with the surveyor on 08/04/22 at 10:36 AM, Registered Nurse/Unit Manager (RN/UM) #1 stated that CNAs or nurses can pass out meal trays and check the meal tickets for accuracy, but that the nurse is responsible for thickening the liquids on the meal tray. RN/UM #1 further stated that the nurse should have thickened the liquids on the meal tray prior to giving Resident #7 his/her breakfast due to the risk of aspiration. During an interview with the surveyor on 08/04/22 at 2:40 PM, Speech Therapist (ST) #1 stated that when the ST makes a recommendation for an altered diet, the ST will handwrite the order on the Physician Order Sheet and the nurse is responsible for transcribing the order. The ST also stated giving thin liquids to Resident #7, who is ordered NTL, would be contraindicated and not safe. 2.) According to the Admission Record, Resident #99 was admitted with diagnoses that included, but were not limited to, Dementia with Behavioral Disturbance, Diabetes Mellitus (DM), and Chronic Obstructive Pulmonary Disease. Review of the Admission MDS, dated [DATE], reflected that Resident #99 was moderately impaired cognition and required extensive assist of staff for eating. Review of the Care Plan (CP), initiated 06/27/22, included a focus of, nutritional problem or potential nutritional problem r/t [related to] need for therapeutic diet, mechanically altered diet, thickened liquids, with history of DM and Alzheimer's. The CP included an intervention, dated 06/27/22, to, provide, serve diet as ordered: NAS [no added salt], CCD [carbohydrate-controlled diet], ground texture, nectar thick liquids. Review of the SLP Evaluation & Plan of Treatment (Speech therapy (ST) evaluation), dated 07/11/22 - 08/09/22, included a diagnosis of dysphagia and indicated the reason for referral was exacerbation of decreased pharyngeal (swallowing) function, decreased functional activity tolerance, coughing/choking during oral intake and increased need for assistance from others. The ST evaluation included recommendations for close supervision for oral intake, mechanical soft/ground textures, and NTL. Review of the POF, dated 07/06/22, included an order, dated 07/11/22, for ST evaluation and treatment for dysphagia, downgrade diet to ground texture, NTL, feeding assistance with all meals, and aspiration precautions. Review of the Diet Requisition Form, dated 07/11/22 and 07/14/22, included the resident's diet was changed to Carbohydrate Controlled (CCD), Ground texture, and NTL. On 08/04/22 at 12:30 PM, Surveyor #2 observed the lunch meal service on Court 1. Surveyor #2 observed a staff member enter Resident #99's room with a meal tray. The staff member set up the resident's lunch meal tray on the overbed table, exited the room and walked down the hallway. Surveyor #2 then entered Resident #99's room and observed the resident in bed with the head of bed elevated eating his/her meal. Surveyor #2 observed the resident as he/she took a spoon of the food and drank from a disposable white cup. Resident #99 then placed the cup alongside the plate after drinking from it for a third time. At which time, Surveyor #2 observed that Resident #99's disposable white cup contained clear thin liquid. Surveyor #2 further observed an unopened packet of instant thickened coffee and an unopened packet of instant food thickener on the resident's tray. Review of Resident #99's Lunch Meal Ticket (meal ticket), dated 08/04/22, revealed documented and highlighted in yellow, Nectar Thickened Liquids, Nectar Thickened Skim Milk, Nectar Thickened Apple Juice, and Nectar Thickened Coffee. On 08/04/22 at 12:33 PM, CNA #6 entered Resident #99's room and stated she was there to assist the resident with the lunch meal tray. CNA #6 immediately grabbed the instant thickened coffee packet from the resident's tray and thickened the water in the disposable white cup. When interviewed, CNA #6 stated the thin liquid in the disposable cup was water for the resident's instant coffee. CNA # 6 further stated Resident #99 required NTL and that the thin liquids in the disposable white cup should have been thickened with the instant thickened coffee prior to giving it to the resident. CNA #6 added that Resident #99 should not have been given thin liquids. 08/04/22 at 12:41 PM, Surveyor #2 interviewed the staff member who set up Resident #99's lunch meal tray. The staff member identified herself as the Admissions Director (AD) and stated she regularly passed trays on the units. The AD stated she looks at the resident's meal ticket and compare it to the tray for accuracy. The AD added that you would open the thickening packets and mix it with the appropriate liquids. The AD further stated the liquid consistency was documented on the meal ticket and that the person setting up the meal tray was responsible for making sure the that the resident was receiving the correct consistency. The AD stated she would remove the tray if she was unsure of the consistency and would follow up the nursing staff. When question about her setting up Resident #99's lunch meal tray, the AD stated she was not familiar with the resident and that she exited the room to get the CNA. The AD did not provide an explanation why she did not thicken the resident's coffee or remove the resident's tray before leaving the room. During an interview with Surveyor #1 and #2 on 08/04/22 at 3:41 PM, the ADON stated that CNAs and nurses were responsible for passing out the meal trays, but that the nurse were responsible for checking the meal ticket for accuracy and ensuring the correct thickening packets are on the meal tray. The ADON further stated that staff should not provide a meal tray with thin liquids to a resident who is on an altered liquid consistency diet due to the risk of aspiration. During an interview with Surveyor #2 on 08/05/22 at 8:58 AM, the ADON stated the AD was recently hired and completed the New Employee Orientation education. The ADON added that passing trays was not part of the education packet and that the AD should not have been passing trays on the units. Review of the facility's Thickened Liquids policy, with reviewed date of 05/2022, included, Facilities will serve thickened liquids to residents as ordered by the physician, and, For beverages which must be thickened, such as coffee, tea, cocoa and soup, the beverage will be thickened by the Dietary staff prior to leaving the kitchen. Review of the facility's Therapeutic Diet Orders policy, with reviewed date of 05/2022, included, Therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. Review of the facility's Meal Services policy,with reviewed date of 05/2022, included, A record of all residents' diet order and a list of those residents on thickened liquids or fluid restrictions will be kept in each unit in a manner that ensures privacy. NJAC 8:39-17.4(a)(2) Refer F689K An Immediate Jeopardy (IJ) was identified for F689 during the recertification survey conducted on 08/25/22. On 08/05/22, the LNHA failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death by failing to ensure a janitor closet, which contained hazardous chemicals for use by the housekeeping department, was securely closed and latched on 1 of 4 units, the Pavilion unit, which is a secured behavior unit that included cognitively impaired residents, placing all residents at risk for ingestion of chemicals or death. The census on the unit was 29 with 22 residents independently ambulatory and 4 residents who were able to self-propel the wheelchair. No residents were in the immediate area of the janitor closet at the time it was not securely closed and latched. This deficient practice was evidenced by the following: This resulted in an IJ situation that was identified on 08/05/22 when the facility failed to securely safeguard hazardous chemicals, from vulnerable and independently mobile residents by ensuring the janitor door was flush with the door casing and allowing the door to securely close and latch. The facility's Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON) were notified of the IJ on 08/05/22 at 3:13 PM. A Removal Plan was received on 08/5/22 and the survey team verified the implementation of the Removal Plan on 08/05/22. On 08/05/22 at 4:24 PM, two surveyors confirmed/verified, in the presence of the Licensed Practical Nurse Unit Manager, the janitor door self closes and locks. This was cited at a level K as the deficient practice was cited at the last standard survey of 11/01/21. On 08/05/22 at 10:08 AM, the surveyor observed the janitor closet on the Pavilion unit to be ajar. The surveyor went into the closet and the door was observed to have an automatic closure mechanism. The door, when let to close by itself, struck the door jam on the latch side of the door, and would not securely close and latch. There was a keypad lock that would require a code to open the door if the door were securely closed and latched. At that time, the surveyor observed inside the closet were six bottles of hand wash liquid, one bottle of hydrogen peroxide, one opened bottle of deodorizer, four uncapped bottles of floor chemicals and one white bottle unlabeled on the floor. There was a wall mounted chemical dispensing machine with chemicals contained in separate door type compartments. There was an activity staff in the Pavilion B common area but was facing away from the closet door. There was a housekeeper (HK #1), in a resident room (room [ROOM NUMBER]) adjacent to the closet. At 10:15 AM, HK #1 was in the room next to the closet, and when she came out of the room, the surveyor requested her to come to the janitor closet door and asked if the door was supposed to be open. HK #1 said, No, the door was not supposed to be open. She went on to say, I wasn't the last one to be out the door. The surveyor requested HK #1 get her supervisor. During an interview with the surveyor on 08/05/22 at 10:17 AM, the Floor Tech Supervisor (FTS) came to the janitor closet and, in the presence of the surveyor, confirmed the door was not securely closed and latched and it should not be open. When asked how long it has been that the door did not shut correctly, the FTS said he doesn't know how long the door has not shut correctly. The FTS identified the unlabeled white bottle on the floor to be bleach, and confirmed the above identified bottles observed to be chemicals used by the housekeeping staff. The FTS said that if the door was not locked or shut tightly, residents would have access to the chemicals. The FTS said, he told maintenance about the problem with the door a while ago but did not fill out a maintenance request form, it was verbal. He confirmed the door has auto closure on it; but at this time, the door won't shut on its own without the door being pushed closed. He said staff should be pushing on the door to make sure it closes. The FTS said, this was never addressed and everyone knows about the door not closing correctly. The surveyor reviewed the unit maintenance logbook for the past 4 months and there was no documentation to indicate maintenance was notified of the janitor door not closing. During an interview with the surveyor on 08/05/22 at 10:27 AM, the maintenance staff said he has worked at the facility for six months. He said the process for staff to report necessary repairs was to use the logbook or use a new phone app (application) in place for the past three weeks and requests can be submitted via the phone During an interview with the surveyor on 08/05/22 at 10:27 AM, the maintenance staff on duty said he had been at facility for six months. He said the process for staff to report necessary repairs was to use the log book (on the units) or to use the new phone app (application) started in the past three weeks and requests can be submitted via the phone. During a follow up interview on 08/05/22 at 1:05 PM, the maintenance staff said he just became aware today that the janitor closet door on the Pavilion wasn't closing properly. He said we worked on it a few months ago and never got a new door that his prior supervisor requested. During an interview, in the presence of the survey team, on 08/05/22 at 03:09 PM, the LNHA said the janitor door should be kept closed and locked to prevent anyone from accessing anything inside. During an interview, in the presence of the survey team, on 08/17/22 at 9:34 AM, the Director of Environmental Services (DEVS) said her expectations are the janitor closets are to be kept clean with daily checks for cleanliness and being put together in proper way, and they should be locked. A review of a facility policy titled Janitors Closet with a creation date of 9-12-14 and last date revised of 8/5/22, included under the procedure section 7. Ensure that the door closes properly and is kept locked when unsupervised. Any maintenance issue with the door should be addressed with maintenance or supervisor and the door monitored until the door can be repaired. NJAC 8:39-31.2(e)

Complaint # NJ 5 Part A. Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death, by failing to a.) ensure all hallway handrails (used by residents as mobility enablers and assist with ambulation or standing) were securely mounted to the walls for 15 of 25 handrails on the Court #2 Dementia Unit, and ensure hallway handrails were in good repair and free from sharp, jagged edges with exposed nails and missing pieces for 26 of 50 handrails on the Court #2 Dementia Unit, exposed nails on a piece of wood located within a handrail located on the Court #1 Unit, and improperly secured and loose handrails identified on 3 of 5 resident units (Court #1 Unit, #2 Unit and Pavilion), b.) ensure that electrical outlets were covered with outlet covers in 6 of 6 resident rooms (rooms 215, 218, 230, 231, 238, and 240), and an appropriate cover protected a bathroom light fixture to prevent exposed live wires (identified in 1 of 36 resident rooms, room # 229, on, 1 of 5 units (Court #2 Dementia Unit). The facility's failure to provide securely mounted handrails in good repair, free of jagged edges, missing pieces, and free of exposed nails on wood located inside a handrail, posed a serious and immediate threat to the safety and wellbeing of all residents who resided in the facility. A serious adverse outcome was likely to occur/occurred as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 10/08/21 at 5:00 PM. It was also identified that the IJ situation began on 07/18/21, when a resident sustained a fall due to a broken handrail on the Pavilion unit, which remained in disrepair. The facility submitted an acceptable removal plan via electronic mail (e-mail) on 10/22/21 at 5:38 PM. The removal plan was verified by the survey team during a removal plan revisit on 11/1/2021. See Example 1. Part B Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death, by failing to c.) ensure that 2 supply closets containing hazardous materials were securely locked and free from the likelihood of resident access. The two supply closets were observed to be in unsafe, unsanitary conditions and contained items that would be detrimental to the health and safety of the residents for 2 of 25 residents (Resident #49 and 109), who were cognitively impaired and ambulated independently on the Court 1 unit, and d.) consistently implement fall interventions per a resident's care plan, complete an incident report and documentation per facility policy for a resident with a history of falls and who sustained a fall (Resident #141). The facility administrator was made aware of the immediate jeopardy (IJ) related to the unsecured supply closets on 10/19/2021, a removal plan was submitted on 10/20/2021 and verified by the surveyors on 10/20/2021. See Example 1. Part C Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death, by failing to e.) ensure a safe environment for residents throughout the facility when an active gas leak was identified in the facility laundry room. The faulty ill-maintained conditions of the dryers in combination with the active gas leak posed a serious and immediate threat to all residents who resided in the facility. This resulted in an Immediate Jeopardy (IJ) situation that began on 10/19/21 at 9:10 AM and continued until 10/19/21 at 10:15 AM, when the gas company responded and subsequently issued a violation. See Example 1. PART D Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe physical environment to prevent the likelihood of serious injury, harm or death, by failing to f.) securely safeguard hazardous materials, chef knives, over-the-counter medications, and potentially dangerous equipment (self-closing door device) and devices (belts) from vulnerable and ambulatory residents by ensuring a functional locking mechanism was installed, maintained, or utilized on the respective doors to keep residents safe and free of serious injury, harm, impairment, or death, on 3 of 5 units (Court 1, Atrium, and Pavilion Unit). The facility's failure to identify the environmental hazards posed a serious and immediate threat to the safety and wellbeing of all residents residing on the identified units. A serious adverse outcome was likely to occur as the identified non-compliance was occurring on a unit identified as having residents diagnosed with dementia or psychiatric diagnoses, who were also able to ambulate independently around the unit. This resulted in an IJ situation that began on 10/24/21 when the Two (2) knives were observed in the unsecured drawer in the unlocked Medication Room. The IJ continued facility alleged complete implementation of the elements of their removal plan accepted on 10/29/21 and verified by the survey team. The facility administration was notified of the Immediate Jeopardy situation on 10/24/21 at 4:00 PM. The facility failed to securely safeguard hazardous chemicals, chef knives, over-the-counter medications, and potentially dangerous equipment (self-closing door device) and devices (belts) from vulnerable and ambulatory residents by ensuring a functional locking mechanism was installed, maintained, . After consultation with the office, it was determined that an Immediate Jeopardy (IJ) situation was identified on 10/24/2021 at 4:00 PM. An acceptable removal plan was received on 10/27/21 (for hazardous knives) and the removal plan was verified onsite on 10/29 /21. See Example 1. The evidence is as follows: Part A 1. On 10/08/21 at 9:15 AM, Surveyor #1 conducted a tour of the Court 2 Unit. Surveyor #1 interviewed a staff member who was sitting at the nursing station who identified herself as the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that the Court 2 Unit was comprised of residents who had Dementia (a cognitive impairment) and some of the residents had behavioral disturbances that were related to the Dementia. The LPN/UM stated that the current resident census was 58, and 33 of the 58 residents ambulated independently on the unit. Surveyor #1 observed the following: a. Resident room: #215, #218, #230, #231, #238, and #240 had uncovered exposed electrical outlets that were accessible to residents. b. Resident room #229 had an uncovered bathroom electrical light fixture with exposed electrical wires which were at the ground level and accessible to vulnerable residents. c. The hallway A and hallway B on the Court 2 unit had 15 of 25 handrails that were observed as being loose and were not securely mounted to the walls and some of the handrails were observed as hanging off of the wall; and 26 out of 50 hallway handrails were broken with sharp, jagged edges, and missing pieces with exposed nails. At that time, the surveyors observed multiple residents ambulating through the halls and using the handrails as enablers for ambulation. On 10/08/21 at 9:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that she was assigned to provide care to the residents in rooms 221 through 231. She stated that if she noticed any maintenance issues that she would report concerns to the nurse so that the nurse could notify the maintenance staff. She added that she was unaware that electrical outlets in rooms 230 and 231 needed to be covered and stated that she did not report it because she was not aware. She stated that the uncovered light fixture in room 229 had been that way (did not specify length of time) and that she did not report it because she did not know that it should have been covered. On 10/08/21 at 10:25 AM, Surveyor #1 interviewed that Maintenance Director (MD) who stated that he was unaware that there were uncovered electrical outlets in rooms #215, #218, #230, #231, #238, and #240. He further stated that he was unaware that there was an uncovered light fixture with exposed electrical wires in room 229. He stated that those concerns would be a hazard because of the confused residents that resided on the Court #2 Unit. At that time, the MD, Director of Nursing (DON), Infection Preventionist (IP) and LPN/UM accompanied the surveyor on a tour of the Court 2 Unit and confirmed the surveyors observations regarding the handrails on the A and B hallways that were not securely mounted to the walls, were loose and broken. The MD stated to Surveyor #1, at that time, that he was not aware that so many handrails in the halls were broken and had jagged, sharp edges. He admitted that the handrails were in disrepair and that they needed to be addressed right away to prevent someone from getting injured. He also revealed that the building was in bad shape when the new owner took over, but that was no excuse. The DON, IP and LPN/UM were all in agreement that the aforementioned areas of concern were a hazard to the residents safety on the Court 2 unit. On 10/08/21 at 11:30 AM, the Surveyor #1 interviewed a CNA who stated that maintenance issues were reported through a computer system and the maintenance department was supposed to check the system and fix the concerns. She stated that she was unsure on how to enter the concerns in the computer system, but that she would report it to the nurse so the nurse could notify the maintenance department. She stated that the environmental conditions on Court #2 were horrible and that even when issues were reported nobody did anything about it. The CNA did not elaborate about what the horrible conditions were and at that time, made a hand gesture and pointed around the unit to the handrails that were in disrepair. On 10/08/21 at 11:35 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) who had been employed in the facility for 7 years and who worked on the Court 2 Unit. The LPN stated that she reported concerns to the maintenance staff directly about the broken handrails and they don't fix them. On 10/08/21 at 11:40 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who had been employed at the facility for one week. She stated that she was not educated on how to enter maintenance concerns into the computer but that she would verbally tell the maintenance staff about the issues concerning the broken, loose handrails in the hallways on the Court #2 unit. She added that nothing happens. On 10/08/21 Surveyor #3 reviewed three randomly selected facility investigations for resident accidents. Surveyor #3 reviewed an investigative report (IR) dated 07/18/21. The IR report reflected under Nursing Description the following documentation was noted: Resident [referring to Resident #1] stood up out of wheelchair and attempted to hold onto rail outside of his/her room to close his/her door, when the rail fell causing him/her to lose balance and fall on his/her buttocks to the floor. The IR indicated that the nursing supervisor was notified. The IR also indicated that the resident had no injury apparent and that the Resident did not hit his/her head. A statement obtained from Resident #1 on 07/18/21, the day of the fall indicated the following: I was trying to close my room door and grabbed hold of the rail to support me and it fell , causing me to fall. The causal factor on the IR form identified by the facility was a faulty handrail and the intervention indicated on the IR was to notify maintenance to fix the handrail. A review of the medical record of Resident #1 revealed the resident was admitted to the facility with diagnoses which included vascular dementia with behavioral disturbances, Hypertension, Dysphasia following other cardiovascular disease. The quarterly Minimum Data Set (MDS), an assessment tool dated 07/06/21, revealed that Resident #1 was awake, alert, and able to make his/her needs known. Resident # 1 scored 14/15 on the Brief Interview for Mental Status ( BIMS ) which indicated the resident was cognitively intact. Resident #1's Care Plan (CP) for falls was initiated on 07/20/21. The goal was for Resident #1 to resume usual activities without further incident. The interventions were as follows: 1. Continue the interventions on the at-risk plan. 2. Educate Resident #1 to call for assistance when attempting to close doors. 3. For no apparent acute injury, determine and address causative factors of the falls. On 10/08/21 at 2:30 PM, Surveyor #1 interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he was unaware about the exposed electrical outlets in rooms #215, #218, #230, #231, #238, #240, or about the bathroom light that uncovered in room #229 with exposed live wires. He also denied having any knowledge that some of the hallway handrails were loosely mounted to the walls and that a lot of the handrails were broke with sharp jagged edges. The LNHA stated that he made environmental rounds on 10/04/21, with the facilities Regional Director of Operations (RDO) and Regional DON. He revealed that the MD was not included in the environmental rounds. He then added that they found a few dirty rooms, but admitted that he did not go into every room. At this time, the LNHA viewed pictures that the surveyor had taken of the environmental hazards on Court 2 Unit. The LNHA admitted that the aforementioned areas of concern were a hazard to the residents' safety on the Court 2 Unit and that a resident could get hurt. When the surveyor asked the LNHA why they could get hurt on the Court 2 unit, he verified that the residents were cognitively impaired. On 10/12/21 at 9:42 AM, Surveyor #1 interviewed the RDO who provided the surveyor with an email that he gave the LNHA concerning the environmental rounds that the RDO and LNHA conducted on 10/04/21. The email was titled, Housekeeping Rounds and was dated 10/05/2021 at 11:13 AM. There were no maintenance issues documented on the email. When the surveyor asked the RDO about the maintenance issues, he stated that they did not see any broken, loose, or jagged sharp handrails nor did they see any uncovered electrical outlets or light fixtures. He then admitted that they had to do a better job and that lack of staff was a huge part as to why things were not getting done. We are trying to hire more staff and a higher rate. He then stated that this was no excuse and that these aforementioned concerns should have been identified and fixed. On 10/12/21 at 12:45 PM, Surveyor #3 conducted a tour of the Pavilion Unit where Resident #1 resided. Surveyor #3 conducted an interview with Resident #1 at that time, while Resident #1 was seated in the hallway across from Resident room #409. Resident #1 stated to the surveyor that he/she recalled the incident when he/she fell , and proceeded to point to the handrail where the incident occurred. At that time, Surveyor #3 touched the handrail identified by Resident #1, and the handrail fell from the wall to the floor. Resident #1 further stated the nurse can tell you all about the incident. On 10/12/21 at 1:15 PM, Surveyor #3 interviewed the Licensed Practical Nurse (LPN) who revealed that maintenance staff attempted to re-attach the handrail on the morning of 10/12/21. Upon further inquiry the LPN indicated that the handrail was never repaired after Resident #1 fell . The LPN could not elaborate on whether or not a work order was generated for the repair of the handrail after it fell from the wall on 07/18/21. On 10/12/21 at 2:10 PM, Surveyor #3 interviewed the MD who indicated that he was not aware that a broken handrail on the Pavilion Unit needed to be repaired. He further stated that he was not aware that Resident #1 had sustained a fall on 07/18/21, due to a faulty handrail. The surveyor inquired about the process for repair and escorted the MD to the Pavilion Unit where both observed the handrail on the floor. The MD stated to the surveyor that he did not have a work order for the handrail and he stated that he toured the Pavilion Unit twice weekly. The MD stated there was no maintenance book as the facility implemented an electronic reporting system and he would review the electronic report, look at the timeframe and request the materials needed to complete the work. He further added, If you can get the material, the work would be completed. The MD stated he was clearly not aware of the broken handrail. The hand rail identified as the causal factor for the fall of 07/18/21, was not repaired until 10/12/21 at 3:00 PM. The facility's failure to identify the environmental hazards posed a serious and immediate threat to the safety and wellbeing of all residents on all the units and resulted in an immediate jeopardy situation that began on 7/18/21, when Resident #1 on the Pavilion Unit had a fall caused by a broken handrail which was not corrected by the facility and the facility handrails continued to be in disrepair until 10/26/21, during the standard survey. On 10/18/21 to 10/19/21, Surveyor #14 observed the following: 1. On 10/18/21 At 09:41 AM, the surveyor observed a 1-foot linear section of handrail located by the Medical Supply room and Resident room #329, that was loose and not anchored securely to the wall when tested . The edge of the handrail was missing its protective cover and produced a sharp edge. 2. On 10/19/21 at 01:52 PM, the surveyor observed a loose corner handrail by Resident rooms #252 and #253. 3. On 10/19/21 at 03:28 PM, the surveyor observed the closed section of unoccupied resident rooms # 335, 336, 337, 338, 339, 340, 341, 342, 343, and 344, the corridor was still maintained as an active exit in the event of an emergency. The entire top protective cap to the handrails was missing approximately 50' on each side. The missing protective cap now produced sharp edges and would hinder residents that used that exit in the event of an evacuation. These findings were acknowledged and confirmed by the Maintenance Director in an interview during the observation. He stated that the section of handrail cap was missing as the protective caps were being used in other areas of the facility. On 10/18/21 at 11:00 AM, Surveyor #5 observed the handrail by room #107, on the Court #1 Unit. The handrail had a piece of broken molding-type wood that had exposed nails located inside of the resident handrail, and the handrail outside of the residents room was broken and was not securely fastened to the wall. At that time, the facility IP was on the unit and Surveyor #5 interviewed the IP about the broken handrail and wood with exposed nails in the handrail. The IP stated she was unaware of the broken hand rail, looked at the piece of wood with the nails and removed it and stated yes it is confirming the handrail was broken and confirmed there was ambulatory residents on the unit and stated Resident #19 and #37 were ambulatory. On 10/18/21 at 12:31 PM through 12:55 PM, Surveyor #1 and #5 observed the following on the Court #1 Unit: 1. The handrail near the staffing office near the dining room, lifted off of the wall when the surveyor touched it. 2. There was an unstable, loose handrail near the fire door by the nurses station. 3. The push panic bar on both fire doors had pieces missing and there was sharp edges on both doors. 4. There was a broken handrail with sharp edges located in between the janitors closet and the soiled utility room. The facility's failure to ensure that electrical outlets in 6 of 6 resident rooms (#215, #218, #230, #231, #238 and #240) and exposed live wiring in 1 resident room (#229) posed a serious and immediate threat to vulnerable residents and resulted in an immediate jeopardy situation was identified on 10/08/2021 at 5:14 PM. The facility provided an acceptable IJ Removal Plan on 10/12/2021 at 4:00 PM. The IJ removal plan was verified on-site on 10/12/2021. Part B 1. On 10/19/2021 at 9:45 AM, Surveyor #15 and Surveyor #16 observed an unlocked room labeled supply closet during a tour of the Court #1 unit. The surveyors observed a lock was present and attached to the door, in a locked position, but was not in a fixed position to lock and secure the door. The supply closet was found to be unsafe, and with unsanitary conditions. The supply closet was in disarray. The following was observed upon entry: a. A used housekeeping cart with wet mop bucket. b. A wet vac type of vacuum with the hose was lying across the entry way which the surveyor tripped over upon entry into the closet. c. A mop bucket containing a soiled mop. d. Trash and gloves were located on the floor throughout the room. e. Open boxes of toilet paper and paper towels f. 2- Cleaning chemicals located on the shelving. g. A large trash can without a liner, that contained used gloves. i. Boxes that contained broken equipment. j. (2)- 5-gallon unopened drums of an undetermined cleaning chemicals. k. The air conditioning/heating unit was uncovered with exposed metal and internal parts. l. Boxes turned upside down strewn around the room. m. Exposed wood pallets that had closed and opened boxes of paper towels and toilet paper. n. Sharp metal objects were observed in a box near the window. Another door was observed across the hall from the supply closet. The surveyors opened the un-secured door, which was not locked and observed multiple boxes that were not intact and appeared to have been previously wet, then dried which were labeled OXICIDE, daily disinfectant cleaner, used for C-difficile 96 ounce (oz). OXYCIDE DAILY DISINFECTANT CLEANER was, according to the MSDS (Material Data) sheet, toxic if swallowed or if inhaled. The surveyor also observed an open gallon of Blue Streak Free Glass and window cleaner, an open container of Shake Down, an odor eliminator, and a ladder propped against the supplies. A basket was observed on the floor that contained a bag of potato chips in a plastic bag, an open box of tea was also observed on the floor. The floor was covered in unidentified debris. During an interview on 10/19/2021 at 9:50 AM, the Housekeeping Director (HD) was shown the aforementioned and he confirmed the surveyor's findings. He stated that the supply closet was supposed to be locked. He revealed it has been broken since a week ago. He stated that the facility had not had a working vacuum since he started in April. In addition, he revealed that the facility did not have working buffers to thoroughly clean the floors. When asked why he didn't have working equipment, he revealed that he didn't have what he needed to do his job, and he keeps getting the run around from administration. He stated that when he took over in April the floors had not been done in forever. The HD revealed that you can see that they are yellow. The HD director had no explanation as to the condition of the supply rooms and confirmed it was an infection control issue, combining clean supplies with soiled supplies. The surveyors then reviewed the medical records for the following residents that had access to the unlocked/unsecured closet which contained caustic chemicals. These residents had cognitive impairments and were ambulatory (walked independently): A review of Resident # 49's Minimum Data Set (MDS), dated [DATE], reflected the resident had a Brief Interview for Mental Status (BIMS) score of 5 of 15, which indicated a severe cognitive impairment. The MDS reflected the resident ambulated independently. According to the resident's current care plan (not-dated), the resident has diagnoses which included but were not limited to; unspecified dementia without behavioral disturbances. On 10/27/21 at 12:38 PM, the surveyor observed the resident seated on the edge of his/her bed with the resident's tray table in front on him/her. The surveyor observed the resident eating lunch. A review of Resident # 109's MDS, dated [DATE], reflected the resident had a BIMS score of 5 of 15, which indicated a severe cognitive impairment. The MDS reflected the resident ambulated independently. On 10/27/21 at 1:11 PM, the surveyor observed Resident #109 lying in bed, bed in low position, with his/her eyes closed. The resident's legs were bent at the knees and the resident's right arm was placed up above his/her head. A blanket covered the resident's body. The surveyor did not attempt to interview the resident because the resident appeared to be sleeping. According to the resident's current care plan (not-dated), the resident had diagnoses which included but were not limited to, [CONDITION(S)] disorder [CONDITION(S)] type and major depressive disorder. This presented an immediate jeopardy (IJ) situation for the identified residents for the likelihood that the residents would access the unsecured supply closets. The facility administrator was made aware of the IJ on 10/19/2021, a removal plan was submitted on 10/20/2021 and verified by the surveyors onsite on 10/20/2021. On 10/24/21 at 10:51 AM, two surveyors toured the Atrium Unit in a hallway where multiple residents resided. Close to a vacant resident room (Room 301) there was an unlocked closet labeled as a Housekeeping closet. The door was fit with a standard door knob and a key-lock system. The two surveyors entered the housekeeping closet and immediately observed four (4) one-gallon bottles of chemicals, one of them was empty. There was one bottle of window cleaner, one bottle of a multi-surface cleaner plus disinfectant with a label that read, keep out of reach of children, and one bottle of a concentrated floor cleaner. In addition, in the Housekeeping closet was also a utility sink which was connected to a chemical release system which had three additional chemicals, an odor eliminator, a floor disinfectant and a window cleaner. The chemicals were easily accessible to any resident who may wander into the unlocked Housekeeping closet. At 10:54 AM, the two surveyors observed the LNHA #2 enter the hallway of the unlocked Housekeeping closet. The LNHA stated that the Housekeepers are the ones responsible for locking the doors to the Housekeeping closets. He stated that he checked all the doors last night and all of them were locked. The surveyors requested that he check the Housekeeping closet on the Atrium Unit together. As the surveyors and the LNHA walked down the hallway toward the Housekeeping closet, the LNHA walked past the unlocked Housekeeping closet. The surveyors summoned him back and he stated that he didn't realize this door was here and that he missed this one during his door check last night. He then opened the door and confirmed that there were chemicals stored in the housekeeping closet and that the door should always be locked if not in use. He then locked the Housekeeping closet and the surveyors tested the door and it locked properly. He could not speak to why it was unlocked or for how long. On 10/24/21 at 11:22 AM, the two surveyors toured the Pavilion Unit together and observed the following: At 11:25 AM, the two surveyors accessed an unlocked Soiled Utility room. Upon entry through the door was a standard dining chair with two large pieces of metal that were later identified to be Self-Closing door hinge devices (which could potentially be used as a weapon or could cause other injury). The unlocked Soiled Utility room was easily accessible to any ambulatory resident on the unit. At 11:28 AM, the surveyors interviewed a CNA who stated that the soiled utility room door was usually unlocked and that it could be locked. The CNA confirmed it was not locked. The surveyor's showed the CNA the two self-closing door devices in the Soiled Utility Room, and she stated that the surveyors should notify the Housekeeper down the hallway to handle it, indicating that he would be able to better answer why they may be there. She could not speak to how long they may have been there. At 11:30 AM, the surveyors interviewed the housekeeper who was mopping the floor and he introduced himself as the Floor Technician. The surveyors took him to the unlocked Soiled Utility room on the Pavilion Unit. Upon opening the door he acknowledged that there was a self-closing door device left on the chair there. He stated that he would remove it immediately and place it in his locked janitor closet on the other end of the unit. He further added that he was not sure how long it had been there, but that it probably should not be there because it could pose a hazard. He stated that the Soiled Utility Room should be locked in this particular unit due to the various needs of the residents on the unit. The surveyors observed him take the two metal devices down the hallway and store it in his locked janitor's closet. At 12:18 PM, the surveyor observed in the presence of the LNHA Resident #31 in his/her wheelchair self-propelling as he/she exited the unlocked Soiled Utility Room where the metal door hinges were stored. The resident stated that he/she was looking for the bathroom. The surveyor observed the LNHA redirect the resident out of the unlocked Soiled Utility Room so he/she could be toileted. At that time, the LNHA acknowledged that the Soiled Utility room was to be locked and that he would have the contractor fix it right now. The surveyor discussed that there were two metal door devices (self closing door hinge) stored in that unlocked Soiled Utility room that had been removed by the housekeeper previously in there. The LNHA stated that they were working on restoring the function of all the locks on the unit. On 10/24/21 at 12:26 PM, the two surveyors observed on the Pavilion unit a door easily accessible to residents in the resident area adjacent to the nurses station. The door was labeled as a Restroom and was marked for male or female use. The door was unlocked and there was a small hole in the door. There was also a tongue blade sitting in the wedge of the molding next to the door. The surveyors easily entered the bathroom and observed that there was no emergency pull cord installed in the bathroom. It was not labeled as a staff bathroom either. At that time, the DON came around the corner and the surveyors pointed it out to her. The DON acknowledged that it was not labeled as a staff bathroom, but she believed it was intended for staff. She confirmed that if it was not locked and had no functioning lock residents would be able to easily access it. She could not speak to why there was a tongue blade on the wall next to the door, except that maybe it was just because staff are lazy and left it there. She then removed the blade. She stated that they would have to get a new lock for that bathroom, so it would not be accessible to residents especially since it did not have an emergency pull cord installed. She stated that they would relabel the door to indicate it was for staff use only because there was no emergency call bell system installed. The DON was unsure if any residents had entered or used the bathroom in the past, adding that she had only been working here for a few weeks. Part C 1. On 10/19/21 at 9:10 AM, Surveyor #14 conducted a tour of the facility laundry room with the Maintenance Director (MD). The large laundry room contained four commercial clothes dryers. There was a small enclosed room in the back of the four dryers that was vented with outside air. The surveyor identified an odor of what seemed like natural gas. The surveyor in the presence of the MD, who had been employed by the facility for 6 months, initially stated he did not smell the odor of natural gas, but then confirmed he did smell something, but

Reference F689, F700, F760, F880, F908. Based on observations, interviews, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) the residents environment was safe and free from accidents/hazards by ensuring all handrails were properly secured throughout the facility after the LNHA was made aware that improperly secured handrails caused a fall on 7/18/2021, and during survey on 10/08/2021, surveyors observed the handrail that caused the fall on 7/18/2021, remained improperly secured. A total of 15 of 25 handrails were observed as not secured to the walls, and 26 of 50 handrails had jagged edges; b.) exposed outlets and electrical wires were covered to prevent serious injury; c.) provide effective environmental, housekeeping, pest control measures to limit the spread of infections; d.) ensure staff follow a system to inform the [CONDITION(S)] Center of contagious infection diseases upon resident transfer; e.) staff adhered to the appropriate transmission based precautions during resident care and environmental cleaning for the Ventilator Unit; f.) ensure a system to install and maintain bed rails in a safe and secure manner was followed; g.) a system for identifying an active gas leak was in place in the facility laundry room; and, h.) the facility clothes dryers were maintained in a safe operating manner. The failure of the LNHA to ensure the facility operated in manner that ensured residents were cared for in a manner and in an environment that enabled residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being posed a serious and immediate threat to the health, safety and welfare of all residents who resided in the facility, as well as ensure the staff followed Policy & Procedures for the above, as outlined in the Facility Administrator Job Description, resulted in an initial immediate jeopardy (IJ) that was identified on 10/08/21 at 5:00 PM. Additional deficient practices that rose to the IJ level were identified during the on-site visit on 10/12/2021, and the facility was notified on 10/14/21 at 1:30 PM. The facility submitted a removal plan by e-mail on 10/14/2021 however, the LNHA administrator of record resigned on 10/19/2021 and a new administrator of record was in place on 10/22/2021. The survey team conducted a removal plan revisit on 11/1/2021 and verified the removal plan. Part A Refer to F689J, F880L, F700J, 760J. On 10/12/2021, The LNHA further failed to ensure that effective housekeeping and environmental services were provided in the facility to prevent the transmission and spread of infectious disease on 1 of 5 units reviewed (Court 2, Dementia unit where 58 residents resided and 33 were ambulatory) by ensuring: hallway floors, walls, resident rooms (210, 216, 218, 221, 234) and bathrooms on Court 2 were free from dried feces on surfaces throughout the unit, loose trash was removed and discarded, individual resident HVAC (Heating, Ventilation & Air Conditioning) units (room [ROOM NUMBER] and 223) had covers to prevent the excessive buildup of dust and debris within their filters, privacy curtains were free from stains and dirt, and resident rooms were on a carbolization (deep cleaning) schedule (this was not occurring for months per staff interviews due to a lack of functioning cleaning equipment). This immediate jeopardy was identified on 10/08/2021 and the facility was notified of the IJ on 10/14/2021. The LNHA resigned on 10/19/2021. Findings included: 1. The facility administrator failed to protect residents from accidents hazards. The facility Administrator failed to ensure that the environment was safe and free of accidents hazards. During the tour on 10/08/2021, the surveyors observed that handrails used by residents on the Dementia Unit were broken; that 25 of the 50 handrails on Court 2 (Hall A, Hall B) were not properly mounted to the wall; and that 12 of the hand rails were observed with jagged sharp edges creating a potential for injury. Surveyor #1 conducted a tour of the Court 2 Unit on 10/8/21 at 9:15 AM. The surveyor interviewed a staff member who was sitting at the nursing station who identified herself as the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that the Court 2 Unit was comprised of all Dementia (cognitively impaired) residents and some residents that had behavioral disturbances related to dementia. She stated that the census was 58 residents and that 33 of the residents ambulated independently. During the tour the Surveyors #1 and #3 identified the following: The surveyor observed residents' rooms: #215, #218, #230, #231, #238, and #240 had uncovered exposed electrical outlets accessible to residents. The surveyor also observed that in resident room [ROOM NUMBER] there was an uncovered bathroom electrical light fixture with exposed live electrical wires which was at ground level and accessible to residents. The surveyor observed that on hallway A and hallway B of the Court 2 unit there were 15 of 25 hallway handrails that were loose and not securely mounted to the walls. Some handrails were loose while others were hanging off the wall. There were also 26 out of 50 hallway handrails that were broken with sharp and jagged edges exposed. The surveyors also observed multiple residents ambulating through the halls and using the handrails as enablers for ambulation. On 10/8/21 at 9:30 AM, Surveyor #1 interviewed the Certified Nursing Assistant (CNA) who stated that she was assigned to provide care to the residents in rooms 221 to 231. She stated that if she noticed any maintenance issues that she would report concerns to the nurse so that the nurse could notify the maintenance staff. She added that she was unaware that electrical outlets in rooms [ROOM NUMBERS] needed to be covered. She also stated that she did not report it because she did not know about it. She revealed that the uncovered light fixture in room [ROOM NUMBER] had been that way and that she did not report it because she did not know that it needed to be covered. On 10/8/21 at 10:25 AM, Surveyor #1 interviewed that Maintenance Director (MD) who stated that he was unaware that there were uncovered electrical outlets in rooms #215, #218, #230, #231, #238, and #240. He also stated that he was unaware that there was an uncovered light fixture with exposed electrical wires in room [ROOM NUMBER]. He revealed that these issues would be a hazard because of the confused residents that resided on the Court 2 Unit. At this time, the MD, Director of Nursing (DON), Infection Preventionist (IP) and LPN/UM accompanied Surveyor #1 on a tour of the Court 2 Unit and acknowledged that a lot of the handrails on the A and B hallways were not securely mounted to the walls, were loose and broken. The MD stated to the surveyor at this time, that he was not aware that so many handrails in the halls were broken with jagged, sharp edges. He admitted that the handrails were in disrepair and needed to be addressed right away to prevent someone from getting injured. He also revealed that the building was in bad shape when the new owner took over, but that was no excuse. The DON, IP and LPN/UM were all in agreement that the aforementioned areas of concern were a hazard to the residents safety on the Court 2 unit. On 10/8/21 at 11:30 AM, Surveyor #1 interviewed the CNA who stated that maintenance issues were reported through a computer system and the maintenance department was supposed to check the system and fix the concerns. She stated that she was unsure on how to enter the concerns in the computer system, but that she would report it to the nurse so the nurse could notify the maintenance department. She added that the environmental conditions on the Court 2 were horrible and that even when issues were reported nobody does anything about it. The CNA did not elaborate about the horrible conditions but made hand gestures and pointed around the unit to the handrails that were in disrepair. On 10/8/21 at 11:35 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) who had been employed in the facility for 7 years and who worked on the Court 2 Unit. The LPN stated that she reported concerns to the maintenance staff directly about the broken handrails, however they don't fix them. On 10/8/21 at 11:40 AM, Surveyor #1 interviewed the LPN/UM who had only been employed in the facility for one week stated that she was not educated on how to put maintenance concerns in the computer but that she would verbally tell the maintenance staff about the issues concerning the broken, loose handrails in the hallways on the Court two unit. She added that nothing happens. She also denied knowing about the uncovered electrical outlets and uncovered light fixture with exposed live wires. On 10/8/21 at 2:30 PM, Surveyor #1 interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he was unaware of the exposed electrical outlets in rooms #215, #218, #230, #231, #238, and #240 or about the bathroom light uncovered in room [ROOM NUMBER] with exposed live wires. He also denied having any knowledge that some of the hallway handrails were loosely mounted to the walls and that a lot of the handrails were broke with sharp jagged edges. The LNHA stated that he made environmental rounds on 10/4/21, with the facilities Regional Director of Operations (RDO) and Regional DON. He revealed that the MD was not included in the environmental rounds. He then added that they found a few dirty rooms but admitted that he did not go into every room. At this time the LNHA viewed pictures that the surveyor had taken of the environmental hazardous on Court 2 Unit. The LNHA admitted that the aforementioned areas of concern were a hazard to the resident's safety on the Court 2 Unit and that a resident could get hurt. When the surveyor asked the LNHA why they could get hurt on the Court 2, he verified that the residents on that unit had decreased cognition. During the complaint survey conducted on 10/12/2021, the surveyor reviewed three random investigations for accidents and hazards, for Resident #1 who was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 07/06/2021, revealed that Resident #1 was awake, alert, and able to make his/her needs known. Resident #1 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. On 10/08/2021 at 2:30 PM, Surveyor #1 reviewed a random investigative report dated 07/18/2021. Under Nursing Description the following was noted: Resident [referring to Resident #1] stood up out of wheelchair and attempted to hold onto rail outside of his/her room to close his/her door, when the rail fell causing him/her to lose balance and fall on his/her buttocks to the floor. Supervisor notified. No injury apparent. Resident did not hit his/her head. A statement obtained from the resident on 07/18/2021, the day of the fall indicated the following: I was trying to close my room door and grabbed hold of the rail to support me and it fell , causing me to fall. The causal factor identified by the facility was a faulty handrail and the intervention was to notify maintenance to fix the handrail. On 10/12/2021 at 12:45 PM, Surveyor #1 toured the Unit to ensure the handrail was fixed and interview the resident. The surveyor observed Resident #1 sitting in the hallway across from room [ROOM NUMBER]. The resident told the surveyor that he/she recalled the incident and pointed to the handrail where the incident occurred. The surveyor went and touched the handrail, and the handrail fell on the floor. The resident further stated that the nurse can tell you all about the incident. During an interview on 10/12/2021 at 1:15 PM, the LPN assigned to the unit revealed that staff attempted to re-attach the handrail this morning. Upon further inquiry the LPN indicated that the handrail was never repaired after the fall. The LPN could not elaborate on whether or not a work order was generated for repair. On 10/12/2021 at 2:10 PM, Surveyor #1 interviewed the Maintenance Director (MD) who indicated that he was not aware that a broken handrail on the Pavilion Unit needed to be repaired. He was not aware that a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor inquired about the process for repair. The surveyor escorted the MD to the Pavilion Unit where both observed the handrail on the floor. The MD told the surveyor that he did not have a work order for the handrail. He went on to say that he toured the Pavilion Unit twice weekly. There was no maintenance book as the facility implemented an electronic report system. He will review the electronic report, look at the timeframe and requested the materials needed to complete the work. He further added, If you can get the material the work would be completed. For the broken handrail he stated clearly he was not aware of it. Resident #1 had a care plan for fall initiated on 07/20/2021. The goal was for Resident #1 to resume usual activities without further incident. The interventions were: 1. Continue the interventions on the at-risk plan. 2. Educate Resident #1 to call for assistance when attempting to close doors. 3. For no apparent acute injury, determine and address causative factors of the falls. (The hand rail identified as the causal factor for the fall of 07/18/2021, was not repaired until 10/12/2021 at 3:00 PM.) On 10/12/21 at 9:42 AM, the surveyor interviewed the RDO who provided the surveyor with an email that he gave the LNHA concerning the environmental rounds that the RDO and LNHA conducted on 10/04/21. The email was titled, Housekeeping Rounds and was dated 10/5/2021 at 11:13 AM. There were no maintenance issues documented on the email. When the surveyor asked the RDO about the maintenance issues, he stated that they did not see any broken, loose, or jagged sharp handrails nor did they see any uncovered electrical outlets or light fixtures. He then stated that he believed, someone was sabotaging us and breaking the equipment on purpose. He then admitted that they had to do a better job and that lack of staff was a huge part as to why things were not getting done. We are trying to hire more staff and a higher rate. He then stated that this was no excuse and that these aforementioned concerns should have been identified and fixed. 2. During the tour Surveyor #1 identified the following: 1.) Hallway floors in front of the nurse's station on the A and B hallways were sticky, dirty with brown dried substance that the staff identified as feces. It appears that someone walked in the feces and tracked it through the unit. There were pieces of trash, needle covers, tissues and cups on the floors throughout the halls. 2.) The resident bathroom that was located on the B hallway had dried feces on the toilet and cups and trash were on the floor. 3.) room [ROOM NUMBER]'s floor was wet with black substance and debris and tissues were on the floor. The resident was confused and laying in bed and was not able to be interviewed. 4.) room [ROOM NUMBER], there were black skid marks and scuffs over the entire floor and under the beds. There were smears of feces all over the floors and walls and some trash located on the floors. The mattress on the bed was faded, ripped with foam coming out the side. The trim on the wall behind the bed was broken and coming off the walls. Dried feces were observed smeared on the walls. 5.) room [ROOM NUMBER] and #223, the air conditioning unit covers were missing, and the inside of the air conditioning units were exposed and were full of dust and debris. 6.) room [ROOM NUMBER], there was a large brown spill with dried drips running down the wall and the floor was covered in brown dried debris, food particles and red stains. 7.) room [ROOM NUMBER], there were deep gouges in the walls and floors were dirty. 8.) room [ROOM NUMBER] the walls had deep gouges. Some gouges were observed to be spackled but unpainted. 9.) room [ROOM NUMBER], the walls had deep gouges and the wallpaper was torn in multiple areas. 10.) room [ROOM NUMBER] A, the siderail at the top of the resident's bed on the left side near the top of the bed was loose and twisted. 11.) room [ROOM NUMBER], the floor was dirty, discolored with scuff marks, smears of feces on the floor in multiple areas and there were brown feces smears observed on the wall near the door. 12.) The furniture in residents' rooms such as beds, cabinets were worn, broken, chipped, and rust on the bedframes. 13.) The wallpaper located in front of the nurse's station and throughout the A and B hallways were torn and peeling off the walls. 14.) The resident's wheelchair in room [ROOM NUMBER] A, was dirty, dusty with a torn seat cushion and torn arm rest with foam coming out from the tears. 15.) rooms [ROOM NUMBERS], had broken blinds and bed sheets were being utilized as curtains. 16.) The privacy curtains in most rooms were stained, dirty and unclean. 17.) room [ROOM NUMBER] had smeared feces in and around the toilet from 10/8/21 until 10/12/21. On 10/8/21 at 9:30 AM, Surveyor #1 interviewed a CNA who acknowledged the uncleanliness and unsanitary condition of the B hallways floors and resident bathroom and stated that it was the housekeeper's responsibility to clean those areas. She identified that the brown dried substance that was located on the floor of the hallway was dried feces. She stated that it was there that morning and she reported it. During this interview the housekeeper for Court 2 B hallways approached Surveyor #1 who conducted an interview with her at that time. The B hallway housekeeper confirmed that the hallway floors were dirty with food, debris, and dried areas of feces. She also accompanied Surveyor #1 to the resident's bathroom on the B hallways and confirmed that the toilet had dried feces all over the seat and trash on the floor. She explained that she came in late and did not have a chance to clean the unit. She added that she used a string mop to clean the floors but that it was the floor technician's responsibility to deep clean the floor with an electric floor scrubber, but they did not have a floor scrubber at this time. She also added that any staff member could have wiped up the dried feces that was located throughout the halls. (during the interview, Surveyor #1 observed multiple staff members walking throughout the halls and past the dried feces that was located on the hallway floors). The housekeeper did not have an explanation about the cleanliness of the unit. On 10/8/21 at 10:15 AM, Surveyor #1 conducted a tour of the A and B hallways of the Court Unit with the housekeeper from the B hallway and the Housekeeping Director (HD.) At the time of tour, the Housekeeping Director could not locate the housekeeper from the A hallway. During the tour, the HD confirmed that the hallways and the resident room floors were very, very dirty and unsanitary. He stated that he relayed his concerns to corporate office that he needed the proper supplies and assistance to sanitize and scrub the floors in the halls and the resident's rooms. He stated that he only had string mops instead of microfiber mobs. He said that the microfiber mobs were effective at preventing cross contamination. He also added that resident rooms were supposed to be carbolized (deep cleaned), but that it has not been done for months. He said that when a resident's room was carbolized that all the furniture from the resident's room was removed, bedside curtains were cleaned and that floors were stripped and rewaxed. He revealed that this had not been done in months because he did not have the staff to do the job and he did not have a floor scrubber to be able to clean the floor properly. He added that the floor scrubber broke a few months ago and that he has been asking the cooperate office for a new one but has not received yet. On 10/8/21 at 10:25 AM, the Director of Nursing (DON), the Infection Preventionist (IP), the LPN/UM and the MD accompanied Surveyor #1 to tour Court 2-unit, A and B hallways. All staff members voiced that they were very concerned about the cleanliness of the hallway's floors and floor in the resident's rooms. All disciplines agreed and confirmed that the cleanliness of the floors and walls in the hallways and in resident rooms were unacceptable. The MD confirmed that the facility has not had a floor scrubber, but that it was ordered. The IP stated that it was an infection control issue because of the excessive amount of fecal matter present and urine on the floor within the resident's environment posed an infection control issue. On 10/8/21 at 11:30 AM, Surveyor #1 interviewed CNA#3 who stated that maintenance issues were reported through a computer system and the maintenance department were supposed to check the system and fix the concerns. She stated that she was unsure on how to enter the concerns in the computer system, but that she would report it to the nurse so the nurse could notify maintenance. She added that the environmental conditions on the Court 2 were horrible and that even when issues were reported nobody does anything about it. On 10/8/21 at 11:35 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) who had been employed in the facility for 7 years and who worked on the Court 2 Unit. The LPN stated that she reported concerns to the maintenance staff directly about the broken handrails, however, they do not fix them. The LPN also revealed that the resident rooms have not been carbolized for months. On 10/8/21 at 2:30 PM, Surveyor #1 interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that he and the Regional Directors of Operations conducted an environmental round together on 10/4/21. The LNHA stated that a few dirty rooms were identified but admitted that they did not go into all the resident rooms. The LNHA provided Surveyor #1 with an email dated 10/5/21 at 11:13 AM from the Regional Director of Operations (RDO) and titled, Housekeeping Rounds. The email contained the following information: 1.) room [ROOM NUMBER] needs better floor cleaning. 2.) room [ROOM NUMBER] needs cleaning. 3.) room [ROOM NUMBER] needs to be carbolized (carb) ASAP (as soon as possible) 4.) room [ROOM NUMBER] needs to be carbolized ASAP 5.) room [ROOM NUMBER] total carb needs to be done ASAP 6.) Vent hallway needs to be stripped. 7.) room [ROOM NUMBER] total carb needed ASAP. 8.) room [ROOM NUMBER] total carb needed ASAP. 9.) room [ROOM NUMBER] total carb needed ASAP. The email indicated that the work needed to be done by the end of the week, however, this was not done and this was confirmed by the LNHA. The LNHA admitted that the environmental and housekeeping concerns identified by himself and the RDO were not rectified because the facility did not have the proper floor scrubber. The LNHA then provided Surveyor #1 with a receipt dated 10/6/21 for a floor scrubber. The LNHA could not provide Surveyor #1 with any documentation as to when the residents rooms on the Court 2 Unit were last carbolized. On 10/12/21 at 9:30 AM, Surveyor #1 interviewed the LNHA who stated that he did not have the staffing to carbolize resident rooms and stated that he was not a, Slum Lord. He then stated that it would be important to assure that resident rooms were carbolized and deep cleaned to prevent the spread of germs and admitted that the rooms were dirty, but did not give a detailed explanation as to why. He did indicate that he felt that someone was doing it on purpose because he did make sure that things were fixed and cleaned but had no evidence to this claim. Surveyor #1 interviewed the RDO on 10/12/21 at 9:42 AM, who stated that when environmental rounds were conducted on 10/4/21, he provided the LNHA with a list of concerns. He could not answer as to why the environmental concerns were not fixed but felt that it was sabotage or vandalism, but had no evidence to this statement. He then stated that the rooms should have been carbolized and cleaned as per the carbolization schedule and that a lack of staff was a huge factor as to why the environment was not clean or sanitary. He then added that it was not an excuse and that a lot of work needed to be completed in the facility. On 10/18/21 at 12:31 PM, Surveyor #1 observed the following on the Court 1 Unit: 1.) The handrail near the staffing office broke off from the wall when the surveyor touched it. 2.) There was an unstable, loose handrail near the fire door by the nurses station. 3.) The push bar on the fire doors had pieces missing and there was sharp edges on both doors. 4.) There was a broken handrail with sharp edges located in between the janitors closet and the soiled utility room. On 10/08/2021 at 10:30 AM, Surveyor #3 conducted the tour after the breakfast meal and observed the following: Hall A on the Court Unit (Dementia Unit ) the double door leading to the resident rooms, the Aluminum cover was missing exposing jagged sharp edges creating a potential for injury. Observation on 10/08/2021 at 10:45 AM, Hall A revealed flooring with brownish stains, stained wallpaper, and furniture in disrepair. Observations on 10/08/2021 at 11: 00 AM, revealed missing blinds in room [ROOM NUMBER]. Observations on 10/08/2021 at 11:15 AM, revealed hands rails not mounted properly to the wall. 15 of the 25 handrails on Hall A were not properly mounted to the wall. 12 of the 25 handrails were broken exposing jagged edges. Observations on 10/08/2021 at 11:30 AM, of room [ROOM NUMBER] and # 223 revealed 2 broken air conditioning units. The air conditioning covers were missing, large amounts of dust and debris were noted inside the air conditioning units. Observations on 10/08/2021 at 11:35 AM, of Resident rooms # 215 and # 218, revealed 2 uncovered electrical outlets. Observations on 10/08/2021 at 11:40 AM, of Resident room # 210, revealed a clogged toilet covered with feces. The toilet was observed in the same condition on 10/12/2021 at 08:30 AM. Observation on 10/08/2021 at 11:45 AM, revealed a discolored, torn mattress in room # 207. Observation on 10/08/2021 at 11:50 AM, of Resident room [ROOM NUMBER], revealed a brown substance splattered on the wall and brown substance on the floor. Observations on 10/08/2021 at 11:55 AM, of Resident room # 219, a black substance on the floor. On 10/18/21 at 12:42 PM, Surveyor #5 observed that the panic door bar on the Court 1 Unit had sharp, jagged areas. Surveyor #1 conducted a tour of Court 1 Unit on 10/18/21 at 12:31 PM, and observed the following: 1.) The staffing office hallway had a broken handrail. The surveyor touched the handrail, and a piece of the handrail broke off. 2.) The surveyor observed that there were multiple loose handrails in the staffing hallway. 3.) On Court 1 the surveyor observed a loose handrail near the nurse's station near the double fire doors. 4.) Both air conditioning units were broken in the small sitting room in front of the nurse's station. 5.) The push bar on fire doors had pieces missing which exposed sharp edges on both doors. 6.) The wallpaper in the dining room was peeling off the walls, cobwebs were observed in the corners of walls and water stains were observed on the ceiling tiles. 7.) The air conditioning unit in the TV room was broken on the wall. 8.) Broken handrail with sharp edges located between the janitor's closet and soiled utility room. 9.) The call bell system was not functioning in resident rooms and bathrooms in rooms 105, 106, 107, 108, 112, and 116 B. 10.) The toilet in room [ROOM NUMBER] was not flushing correctly. The resident in that room stated that he/she was manually pouring water down the toilet so that it would flush. 11.) The fish tank in the staffing hallway was without a proper filtration system. The water was stagnant and dirty with algae. There was a live fish in the tank. 10/18/21 at 1:00 PM Surveyor #5 interviewed the Registered Nurse (RN) on Court 1. She stated she was the only nurse on the unit, responsible for 25 residents. She stated she knew the call bells did not work and the unit was shut down during covid, and then opened back up 1-2 months ago and the call bells were not functioning. She stated she has addressed this a couple of times and stated the LNHA's last day was on Friday. She stated that the maintenance told her they were getting a new system. She further stated that she tried to do rounds and it gets a bit difficult. She stated other units have tap bells and I have not seen any down on this unit. The RN further stated, it was a problem and repeated it was a problem. The surveyor interviewed a Certified Nurse Aide who stated staff complains of paper towels not being available in the staff bathroom, the residents do not have soap, linens and we do who shifts without towels. On 10/18/21 at 3:47 PM Surveyor #5 interviewed the LNHA and the Operation Manager for the management company (OM) . The Surveyor discussed the concerns with the OM and LNHA. The OM stated all of the issues you have seen, are issues, I totally agree and they need to be taken care of. On 10/19/21 at 8:23 AM, Surveyor #5 entered the building and observed that the OM was at the LNHA's office an approached the surveyor. The OM stated he was gone and referred to the LNHA. The OM stated that the LNHA had given his notice a few weeks ago and he was not going to deal with the survey. The OM stated the LNHA sent an email last night to the State LNHA board and he pulled his LNHA license from the facility. The OM stated the LNHA has not reached out and that the OM was not listed as the current LNHA of the facility. On 10/08/2021 at 12:05 PM, Surveyor #3 conducted an interview with a CNA assigned to the unit who stated, Life is nasty here. Since I start working here, no trash bag to place the dirty linen. You cannot get clean linen every day. We do not have gown or wash cloth. We had feces on the floor since Monday. We had asked housekeeping to clean the floor, we were told , 'I am not assigned to this hall.' We are working short of staff every day. On 10/08/2021 at 12:15 PM, Surveyor #3 conducted an interview with the LPN/UM assigned to the Court 2 Dementia Unit. The LPN/UM stated that the feces had been on the floor on Court 2 Unit since Monday. The LPN/UM stated that the housekeeping staff were informed but she did not reach out to the Housekeeping Director (HD) for follow-up. On 10/08/2021 at 12:30 PM, Surveyor #3 observed a housekeeping staff in the soiled utility room. An interview with the staff revealed that housekeeping staff were scheduled to work the day shift only. There was no staff assigned on the 3:00-11:00 PM shift. The housekeeping staff went on to state that the facility did not have the staff to perform the required cleaning, We do not have the supplies. On 10/08/2021 at 1:15 PM, Surveyor #3 interviewed the Housekeeping Director (HD). The HD stated that he scheduled eight staff for work that day, but only 4 staff reported to work. The HD further stated that housekeeping staff were expected to clean resident rooms and common areas daily and follow a cleaning schedule. However, he indicated that staff failed to report to work almost every day. He acknowledged that the floor had not been scrubbed because the facility did not have the equipment needed to clean the floor. Upon further inquiry, the HD revealed that he did not have the staff to complete the work. During a follow-up interview on 10/08/2021 at 2:30 PM, the HD stated that he was aware of the condition of the unit and he kept requesting supplies from the Administrator and was left empty handed. He went on to say, It is a travesty, imagine having a family member that lived in that condition. Behavior or not, the condition of the room, fully operational things, the simple décor, cracking walls, and over all the customer service. The facility needs to be staffed better. These are

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to operate in a manner to limit the spread of infectious disease by failing to ensure: a.) effective housekeeping, environmental services, and pest control program were provided for 5 of 5 units (Atrium Unit, Pavilion Unit, Court 1 Unit, Court 2 Unit, and Ventilator Unit). b.) a system for communication was followed to inform the [CONDITION(S)] Center prior to transferring two residents who had a contagious infectious disease ([MEDICATION(S)] Aureus-a multidrug-resistant organism), for 2 of 2 residents (Resident #28 & Resident #127) who were transferred from the facility Ventilator Unit to the [CONDITION(S)] Center. c.) staff wore appropriate personal protective equipment (PPE) upon entering residents' rooms who were on transmission-based precautions (TBP) for 3 staff (Respiratory Therapist, Certified Nurse Aide and Housekeeping Staff), on 2 of 5 units (Pavilion and Ventilator Unit). d.) the Certified Nursing Assistant (CNA) went from a person under investigation (PUI) for COVID -19 to a non-PUI resident room wearing inappropriate PPE. Part A The facility's failure to identify the housekeeping and environmental hazards posed a serious and immediate threat to the safety and well-being of all residents who resided on the Court 2 Unit. A serious adverse outcome was likely to occur as the identified non-compliance occurred on a unit identified by the facility as having 58 residents diagnosed with dementia, and 33 out of the 58 residents that resided on the Court 2 Unit ambulated independently. This resulted in an Immediate Jeopardy (IJ) situation that began on 10/08/21 and continued during an on-site re-visit on 10/12/21. The facility was notified of the continued IJ situation after further investigation on 10/14/21 at 1:30 PM. On 10/18/21, during an on-site survey, the survey team determined the IJ situation continued. The facility submitted an acceptable removal plan via electronic mail (email) on 10/22/21 at 5:38 PM. The IJ removal plan was verified as implemented during an on-site re-visit on 10/29/21. The non-compliance remained on 10/29/21 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following; reference F880 The evidence was as follows: Two surveyors (Surveyor #1 and #3) conducted a tour of the Court 2 Unit on 10/08/21 at 9:15 AM. Surveyor #1 interviewed a staff member sitting at the nursing station and identified herself as the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated the Court 2 Unit comprised residents with Dementia (a cognitive impairment) and residents with behavioral disturbances related to dementia. She stated that the unit census was 58, and 33 of the residents ambulated independently. The LPN/UM identified the two hallways as A and B hallway. The surveyors observed the following: 1. The hallway floors located in front of the nurse's station and on the A and B hallways had debris scattered throughout, and a sticky feel underfoot was noted, with dried brown substances throughout, that was identified by the Certified Nurse Aides, the Licensed Practical Nurse, and unit housekeeper as feces. The surveyors observed that it had appeared as if someone had walked through feces and tracked it throughout the floors of the unit. There were pieces of trash, orange-colored plastic-type needle covers, tissues, and plastic cups on the floors throughout the hallways. 2. The resident bathroom in the B hallway had dried feces on the toilet and cups and trash on the floor. 3. Resident room [ROOM NUMBER], with an unsampled resident lying on the bed closest to the door, had a puddle of liquid on the floor with an unknown black substance between the resident's bed and nightstand. The resident did not respond to the surveyor at that time. Debris and tissues were on the floor. The unsampled resident's bedside table, directly adjacent to the wall, was covered with the black substance throughout the lower metal part of the table. The lower baseboard area of the wall that met the floor was lifted with an unknown black substance coming out of the seam, and the lower portion of the nightstand, adjacent to the floor, had the black substance on the area that touched the floor at the base of the nightstand. The resident was confused and was lying in bed. The surveyor was unable to conduct an interview. 4. Resident room [ROOM NUMBER] had black marks and scuffs throughout the floor's entire surface and under both beds. There were multiple smears of a brown substance, identified by the CNA, as feces located on the floors and walls and trash located on the floor. The mattress on the bed by the door was uncovered, faded, and ripped at the side seams with foam coming out of the seams. As identified by the CNA, dried feces was smeared on the wall to the left side of the bed. 5. Resident room [ROOM NUMBER] and 223, with two unsampled residents in the beds, had missing air conditioning unit covers, and the inner workings of both air conditioning units were exposed and imbedded with dust and debris. 6. Resident room [ROOM NUMBER] had a brownish beige splatter that extended from one wall to the other and had dried drips running down the wall to the floor, which was located next to the resident's occupied bed by the door. The entire floor was covered in brownish beige dried debris, food particles, and red stains. The unsampled resident from the door bed was ambulating in the room at the time and did not respond to the surveyor's interview. 7. Resident room [ROOM NUMBER] was soiled with debris, discolored with scuff marks, smears of feces, identified by the CNA at that time, were located on the floor in multiple areas and on the wall near the door. 8. Resident room [ROOM NUMBER] A had a resident's wheelchair soiled, covered with dust, had a torn seat cushion and armrest with foam sticking outside of the torn areas. 9. Resident rooms [ROOM NUMBERS] had bedsheets utilized as window coverings. 10. The privacy curtains in all the A hallway rooms were soiled, with visible stained areas throughout. 11. room [ROOM NUMBER] had smeared feces on the toilet seat and throughout the exterior of the toilet. 12. On 10/8/21 at 10:15 AM, Surveyor #1 observed that the air conditioning units in room [ROOM NUMBER] and #211 covers were missing, and the inner part of the units were exposed and covered with dust and debris. On 10/08/21 at 9:30 AM, Surveyor #1 interviewed a Certified Nursing Assistant (CNA) regarding the observations made on B hallway. The CNA acknowledged that the unit was unclean and unsanitary regarding the condition of the B hallways floors and resident bathroom. The CNA stated that the housekeeper's responsibility was to clean those areas and identified the brown dried substance located throughout the hallway floor as dried feces. She reported it to the nurse and maintenance and could not offer specifics as to when she reported it. During this interview, the housekeeper for the Court 2B hallway approached the surveyor, and the surveyor conducted an interview at that time. The Court 2B housekeeper confirmed that the hallway floors were dirty and had food debris and dried feces. She accompanied the surveyor to the resident's hallway bathroom on the B hallway and confirmed that the toilet had dried feces all over the seat and trash was on the floor. She stated that she came into work late and did not have a chance to clean the unit. The Court 2B housekeeper added that she used a string mop to clean the floors. The floor technician's responsibility was to deep clean the floor with an electric floor scrubber and stated the facility currently did not have a floor scrubber. She stated that any staff member could have wiped up the dried feces that was located throughout the halls. During this interview, the surveyor observed multiple staff members walking throughout the hallway and directly past the dried feces that was located throughout the hallway floors. The Court 2B housekeeper did not provide an explanation about the cleanliness of the unit. On 10/08/21 at 10:15 AM, Surveyor #1 conducted a tour of the A and B hallways of the Court 2 Unit with the Court 2B housekeeper and the Housekeeping Director (HD). The HD could not locate the housekeeper from the A hallway at that time. During the tour, the HD stated that the hallways and the resident room floors were very, very dirty and unsanitary. He stated that he relayed his concerns to the corporate office that he needed the proper supplies and assistance to sanitize and scrub the floors in the hallways and the resident rooms. He stated that he only had string mops instead of microfiber mops. The HD stated that the microfiber mops were more effective at preventing cross-contamination. He also added that resident rooms were to be carbolized (deep cleaned) but had not been done for months. He stated that when a resident's room was carbolized, all the furniture from the resident's room was removed, bedside curtains were cleaned, and floors were stripped and re-waxed. He revealed that this had not been done in months because he didn't have the staff to do the work, and he didn't have a floor scrubber to be able to clean the floor properly. He added that the floor scrubber broke a few months ago and that he has been asking the corporate office for a new one, but it has not been provided. On 10/08/21 at 10:25 AM, the Director of Nursing (DON), the Infection Preventionist (IP), the LPN/UM, and the Maintenance Director (MD) accompanied the surveyors to tour the Court 2-unit, A and B hallways. They all agreed and voiced that they were very concerned about the cleanliness of the hallway floors and floors in the resident's rooms. They confirmed that the cleanliness of the floors and walls in the hallways and resident rooms were unacceptable. The MD confirmed to the surveyors that the facility had not had a floor scrubber but it was ordered. The IP stated that it was an infection control issue because of the excessive amount of fecal matter and urine on the floor within the resident's environment posed an infection control issue. The IP stated that the condition of the Court 2 was an infection control issue because of the excessive amount of fecal matter present and stated the urine on the floor within the resident's environment posed an infection control issue. On 10/08/21 at 11:30 AM, the surveyor interviewed a CNA who stated that maintenance issues were reported through a computer system. The maintenance department was supposed to check the system and fix the concerns. The CNA stated that she was unsure how to enter the concerns into the computer system but would report it to the nurse to notify maintenance. She added that the environmental conditions on Court 2 were horrible and that even when issues were reported, nobody did anything about it. On 10/8/21 at 11:35 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) who had been employed in the facility for 7 years and who worked on the Court 2 Unit. The LPN stated that she reported concerns to the maintenance staff directly about the broken handrails; however, they don't fix them. The LPN also revealed that the resident rooms have not been carbolized for months. On 10/08/21 at 2:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that he and the staff member who identified himself as the Regional Directors of Operations conducted an environmental round together on 10/04/21. The LNHA stated that a few dirty rooms were identified but admitted that they did not go into all the resident rooms. The LNHA provided the surveyor with an email dated 10/05/21 at 11:13 AM from the Regional Director of Operations (RDO) and titled, Housekeeping Rounds. The email contained the following information: 1.) room [ROOM NUMBER] needs better floor cleaning. 2.) room [ROOM NUMBER] needs cleaning. 3.) room [ROOM NUMBER] needs to be carbolized ASAP (as soon as possible) 4.) room [ROOM NUMBER] needs to be carbolized ASAP 5.) room [ROOM NUMBER] needs to be carbolized ASAP 6.) Vent hallway needs to be stripped. 7.) room [ROOM NUMBER] needs to be carbolized ASAP 8.) room [ROOM NUMBER] needs to be carbolized ASAP 9.) room [ROOM NUMBER] needs to be carbolized ASAP The email further indicated that the work needed to be done by the end of the week. The LNHA admitted that the environmental and housekeeping concerns he identified along with the RDO were not rectified because the facility did not have the proper floor scrubber. The LNHA then provided the surveyor with a receipt dated 10/06/21 for a floor scrubber. The LNHA could not provide the surveyor with any documentation as to when the residents' rooms on the Court 2 Unit were last carbolized. On 10/12/21 at 8:30 AM, Surveyor #3 observed the following on the Pavilion Unit: room [ROOM NUMBER] toilet soiled with feces. room [ROOM NUMBER] with smeared feces on the toilet seat, and the toilet remained clogged with feces as observed on 10/8/21. On 10/12/21 at 9:30 AM, the surveyor interviewed the LNHA, who stated that he did not have the staffing to carbolize resident rooms and stated that he was not a slum lord. He then stated that it would be important to ensure that resident rooms were carbolized and deep cleaned to prevent the spread of germs and stated that the rooms were dirty but did not provide a detailed explanation as to why. The surveyor interviewed the RDO on 10/12/21 at 9:42 AM, who stated that when environmental rounds were conducted on 10/05/21, he provided the LNHA with a list of concerns. He could not answer as to why the environmental concerns were not addressed. He then stated that the rooms should have been carbolized and cleaned as per the carbolization schedule and that a lack of staff was a huge factor as to why the environment was not clean or sanitary. He then added that there was no excuse and that a lot of work needed to be completed in the facility. On 10/18/21, from 10:05-12:57 PM, during a tour of the Pavilion unit, Surveyors #3 and #4 observed the following: On the Pavilion unit in room [ROOM NUMBER] soiled sink with brown stains. A black fly was observed on Resident #31 while the resident was lying in bed in the resident's room, the floor was stained with dark substances, and the toilet was filled with feces. Multiple flies were observed on Resident #17's hands, shoulder, and arms while seated in a recliner chair in the Pavilion side 2 day room. The room also had debris on the floor and a plastic cup on the floor which looked as if it contained feces with smears of the same in several areas of the floor. The walls and molding of the room was soiled with various debris. An unoccupied resident room, room [ROOM NUMBER], had a mattress on the floor, and the toilet was filled with feces in the bow and on the seat. An unsampled resident's room, room [ROOM NUMBER], had a stained floor, had a urine odor, and multiple black flies were in the room. Resident #4's room had trash strewn on the floor, and the toilet was soiled with a dark substance. In room [ROOM NUMBER], an unsampled resident, had a torn floor mat on the floor, the floor was soiled with various colored debris, black flies were in the room, there was no blinds for the window. Resident #442's room had broken blinds and had a stained floor. Resident #101's room had a stained floor, feces were on the bathroom floor, and the toilet bowl. Resident #95 was sitting in a chair on the Pavilion side 1 day room. The back cover of the chair was missing, and the resident had a fly on his/her head. On 10/18/21 at 10:41 AM, Surveyor #5 observed: An unsampled resident's room on the Pavilion unit, room [ROOM NUMBER]. The resident was in bed, with a ripped, uncovered bed pillow on the bed, and the stuffing of the pillow was exposed. There was debris, including paper towels and other debris on the floor, and multiple black flies were in the room. The floor was soiled with embedded marks of a dark substance, and the walls and baseboard were stained and soiled with various colored debris throughout. The surveyor then observed Resident #40's room, with garbage and debris strewn about the entire floor. There were wet areas throughout the floor, and the floor had a sticky feel. The surveyor brought the Unit Manager Licensed Practical Nurse (UMLPN) to observe the resident rooms. During the observation of room [ROOM NUMBER], the UMLPN stated, I don't think it is clean. I am not gonna lie. During Resident #40's room observation, the UMLPN stated, it is bad. On 10/18/21 at 8:28 AM- 9:20 AM, Surveyors #1, #3, and 4 observed the following on Court 2: A large, approximately 200-gallon fish tank was located by the nursing station. The fish tank was not filtering, and there was brown, blackish-colored water in the tank with the top of the tank open to the air. There was a large fish observed at the bottom of the tank. At that time, the Maintenance Director and Surveyor #14 were present. Surveyor #1 interviewed the MD about the fish tank. The MD stated, The facility is not taking care of the fish tanks, and the facility had no food for the fish. He stated, I guess they are just letting the fish die. room [ROOM NUMBER] had debris was on the floor, and the floor was very sticky with splatters. room [ROOM NUMBER] had debris on the floor, the floor underneath the bed was stained with a dark-colored substance. room [ROOM NUMBER] had a stained, discolored floor with various trash strewn about the entire floor. Resident #114 was observed lying in bed with a fly on the resident. There was a strong odor of urine in the room and brown stains on the floor. On 10/18/21 at 12:16 PM, surveyor #3 observed Resident #140 on the Atrium unit with flies on their pillow while the resident was lying in bed. On 10/18/21, during a tour of Court 1, from 10:50 AM to 1:00 PM, Surveyors #1 and # 5 observed the following: Both air conditioning units were visibly broken in the small sitting room in front of the nurse's station, and debris was embedded inside both units. A large, approximately 200-gallon fish tank was located by the nursing station. The fish tank was not filtering, and there was brown, blackish-colored water in the tank with the top of the tank open to the air. There was a large fish observed at the bottom of the tank. Resident #104 stated the toilet did not flush correctly, and they were manually pouring water down the toilet so that it would flush. At 12:45 PM, the dining room closest to the front of the unit was observed, with two unsampled residents consuming the lunch meal. There was a loosened piece of wallpaper a few feet away from the resident's table, and the loose piece of wallpaper exposed a wall covered with blackened areas under the wallpaper. There was a large cob-web and a water-type stain on the wall and ceiling tile, where the blackened area was located under the exposed wallpaper. There was a visibly broken air conditioning unit that was visibly soiled with embedded debris inside the unit's vents. Resident #99 was observed eating lunch with an unsampled resident in the second dining area. Resident #99 stated there was bugs all over the place, the bathroom clogged, and the call bells did not work. The surveyors observed many flies in the day room where the residents were consuming lunch. At 12:55 PM, Resident #12 was observed watching television in their room and stated the call bell hasn't worked for over a year, very, very uncomfortable, and there were flies all over the place. At that time, the surveyor observed flies in the resident's room. On 10/19/21, Surveyor #5 observed the following environmental concerns on Court 1 Unit: At 10:21 AM, Surveyor #5 conducted an interview with Resident #141 while the resident was seated in their wheelchair by the Court 1 nursing station. Surveyor #5 observed the resident's wheelchair was soiled with embedded soiled areas throughout the exterior of the wheelchair. At 10:25 AM, during an observation of Resident #18's room with the resident's attending physician. The surveyor interviewed the physician regarding the cleanliness of the building, and the physician stated it was lacking a little bit, and all you would have to do is look at the floor. At that time, the physician pointed to the floor located at the end of the resident's bed. The surveyor observed brown stains on the floor, and what appeared to be white and orange crushed pill debris, the physician indicated that is what it looked like it was crushed pill debris. At that time, a fly landed on Resident #18, and the physician stated, this is the type of thing, and shooed the fly away. On 10/19/21, Surveyor #3 observed the following environmental concerns on the Pavilion Unit: At 11:30 AM, Resident #98 had a stained privacy curtain. Surveyor #3 again observed Resident #98's room on 10/21/21 at 10:51 AM, and the privacy curtain remained in the same condition. On 10/20/21 at 8:45 AM, Surveyor #3 observed the following on the Pavilion unit: Resident #39's bed was covered with flies, and the bathroom had dried feces on the toilet and the floor. In room [ROOM NUMBER], there was a strong odor of urine in the room. room [ROOM NUMBER], flies were covering the bed, and the bathroom had dried feces on the floor and the toilet. On 10/21/21 at 8:50 AM- 9:08 AM, Surveyor #9 observed the following on Court 1: Surveyor #9 interviewed Resident #99 in the resident's room while the resident consumed the breakfast meal. The resident stated their toilet was clogged. The Surveyor observed feces in the toilet with multiple flies around the toilet. Flies were flying around the resident while the resident was consuming the meal and flies were observed on the resident's water cup. Resident #21 was interviewed in the resident's room, and a fly landed on the resident's head. The resident stated that every time the toilet was fixed, it only worked for a day or two and overflows on the floor and stated the odor was terrible. The resident further stated that the flies have been bad all summer, there was no pest control. Resident #12 was interviewed in the resident's room while they were sitting up in bed. Resident #12 (resided in the same room as Resident #21) stated the toilet was broken and could not be used, and they needed to use the bathroom across the hall, which was very inconvenient. The resident stated the flies were a pain in the [exploitive] and didn't know why the flies were there, and they never saw anyone from pest control spraying. On 10/21/21 at 9:14 AM, Surveyor #9 interviewed a CNA who stated she had been employed at the facility since September. The CNA stated the floor had an issue with flies mainly within the last few weeks. She stated that pest control was here the week before last, and there was a pest control book at the nurses' station. At that time, the surveyor reviewed the pest control book as directed by the CNA. The log for October 5th and 12th had No Reports. On 10/21/21 at 11:26 AM, Surveyor #9 interviewed the MD, who stated he worked at the facility for 7 months. The surveyor inquired as to how are issues were reported to maintenance. The MD stated there was a computer system, and anytime something was reported, it went to the maintenance phone, and staff were not supposed to report it any other way. The MD stated the computer system was used for three months, and staff were taught not to use the books. The surveyor inquired about the state of the toilets on Court 1 and for Resident's #12, #21, and #99. The MD stated Resident's #12, #21, and #99's toiled would be replaced soon and that the toilets jet had been corroded. The MD stated the Court 1 unit had not been used in over one year, and it was just opened two months ago. The Surveyor requested the computer maintenance logs from the MD at that time, and he stated he would print them tomorrow. On 10/21/21 at 9:30 AM through 10:30 AM, Surveyor #3 observed the Pavilion unit and observed: Resident #17 was in bed on the Pavilion Unit. The resident was screaming and was covered with flies. The Surveyor accompanied the Director of Nursing (DON) to the room to observe the flies on the resident. The DON stated to the surveyor that she had never seen anything like that. The surveyor observed that Resident #17 sitting on a unit chair that was visibly soiled, and feces were observed on the floor. room [ROOM NUMBER] was observed with flies on the bed and in the room. The day room was observed with brown substances on the floor. On 10/18/2021 at 10:30 AM, Surveyor #3 toured the Ventilator Unit and observed that the curtain in room [ROOM NUMBER] was visibly soiled and stained. The surveyor inquired about the soiled curtain on the Ventilator Unit. The nurse told the surveyor that she reported it to housekeeping staff six months ago, and nothing had been done about it. The surveyor requested the housekeeping log for review. The nurse informed the surveyor that there was no book on the floor. An interview with the Housekeeping Director (HD) on 10/19/2021 at 12:30 PM revealed that all housekeeping issues/work orders were documented in the QAPI book. The HD further stated that the QAPI book was replaced by an electronic version: TELS one month ago. The surveyor reviewed the QAPI book and could not find any documentation regarding a schedule to clean the resident's care equipment, including cleaning/ replacing curtains in the resident's room as needed. The HD was also asked to download any communication from the TELS that addressed all issues observed in the resident's environment during the tour, for example, resident's care equipment such as wheelchair cleaning, IV poles, room cleaning and carbolization schedule, none was provided. On 10/21/21 at 09:59 AM, Surveyor #2 observed in room [ROOM NUMBER]-W on the Ventilator Unit that the resident's privacy curtain was soiled with a large amount of dried brown liquid splatter marks. The Registered Nurse (RN) stated it was pointed out yesterday that the privacy curtain needed to be changed. It has probably been here a while. It's dark and looks old. The RN indicated that she did not report it to anyone. The RN also stated that since the unsampled resident in that room had a ventilator that it could cause mold and respiratory issues. She again revealed that she did not report it to housekeeping or maintenance. On 10/21/21 at 10:05 AM, Surveyor #2 interviewed a Respiratory Therapist (RT) who stated she personally did not report that the curtain was heavily soiled and stated that the former Unit Manager (UM) contacted the HD. She also added that the former floor guy used to change and wash curtains, but he left a long time ago. On 10/21/21 at 10:11 AM, Surveyor #2 interviewed the CNA, who stated she reported the soiled curtains in rooms: #251, #252, #253, #255, #257, #259. She stated that she reported it to the RN/UM maybe twenty times. On 10/21/21 at 10:17 AM, Surveyor #2 interviewed the RN, who stated that the rooms on the Ventilator Unit were not terminally cleaned. To her knowledge and that room [ROOM NUMBER] and 255 were observed to have soiled curtains. The CNA stated that she just thought the other rooms should have the curtains washed even though they were not visibly soiled. On 10/21/21 at 10:33 AM, the CNA reported that room [ROOM NUMBER] had a soiled privacy curtain. She also revealed that the resident who resided in that room was positive for [MEDICATION(S)] Auris. The surveyor observed that the privacy curtain had dried, brown, splattered debris. On 10/21/21 at 10:25 AM, Surveyor #2 interviewed the housekeeper who worked in the facility for 9 yrs. The housekeeper stated that she had worked on the ventilator unit 2 yrs. She added that the HD usually took the curtains down and washed them. Once I report it and let them know, it is up to him to get it done. She stated that she reported that the privacy curtain in room [ROOM NUMBER] needed to be cleaned because the resident went to the hospital and had [MEDICATION(S)] Auris. She then revealed that the room should have been carbolized after the resident was discharged to the hospital. On 10/21/21 at 11:09 AM, Surveyor #2 interviewed the who stated that last Friday, he was made aware and that he must have overlooked the soiled curtains on environmental grounds. I must have overlooked it. He stated that the curtains have not been washed since August. He said that he thought the debris on the curtains were either tube feeding or possibly respiratory secretions. He confirmed that it was a health risk and created an environment for pests. On 10/22/21 at 9:00 AM, Surveyor #9 conducted a follow-up interview with Resident #21 in the resident's room while the resident was in a wheelchair next to the bed. The surveyor observed two flies on the resident's bed and one on the resident's privacy curtain. On 10/22/21 at 10:51 AM, Surveyor #5 interviewed the DON in the presence of the survey team regarding the presence of the flies observed in the resident's food. The DON stated that flies were not acceptable to be on the resident's food because it was not hygienic. The DON stated it was an infection control issue. On 10/22/21 at 9:08 AM, Surveyors #3 and #4 observed Resident #60 sitting in the dayroom [ROOM NUMBER] on the Pavilion unit eating breakfast. Both surveyors observed flies on their food and drink. There were flies on the resident's coffee cup, on the spoon inside the oatmeal, and on top of the oatmeal. In addition, there were flies on the resident's shoulder and the chair they were sitting in. On 10/22/21 at 10:51 AM, in the presence of the survey team, the Director of Nursing (DON) stated it was not acceptable for flies to be in the resident's food because it is not hygienic. She acknowledged it posed an infection control issue but was unable to elaborate on it further. On 10/22/21 at 1:15 PM, Surveyor #3 conducted an interview with the facility Infection Preventionist Nurse (IPN) regarding the flies observed at mealtime throughout the survey. The IP stated that since she had started here, the flies were discussed with the former administrator, and it was a major concern. She stated, nothing is being done, it was unacceptable to have staff swatting flies while feeding residents. She stated that flies could lay eggs, and that can cause maggots. On 10/25/21 at 8:40 AM, Surveyors #3 and 4 observed the following on the Pavilion Unit: Flies were flying around an unsampled resident while the resident consumed the breakfast meal in the dining room. The flies were on the resident's tray, the spoon located in the coffee, and the chair. Resident #3 was observed in the common area. Surveyor #3 accompanied the resident's CNA to Resident #3's room. The CNA applied gloves to remove the sheets from the resident's bed, and the resident's mattress had a rip by the zipper. The CNA turned the mattress over, and it was stained/discolored and had holes. On 10/25/21 at 1:26 PM, the Licensed Nursing Home Administrator (LNHA) stated the facility had fly zappers but was unsure of the current number. The LNHA acknowledged since he started, the flies have been a big issue. The LNHA stated he felt the main issue was the soiled utility rooms having soiled linens and trash, especially during the off shift. He concluded, there was currently no housekeeping schedule, but he was working with the HD. On 10/26/21, Surveyors #3 and 4 observed the following on the Pavilion Unit: On 10/26/21 at 9:40 AM, HD stated the nursing staff were supposed to put in the maintenance/housekeeping application (app) any issues. The HD concluded he conducted six (6) weeks of quality assurance rounds for the entire facility. On 10/26/21 at 9:50 AM, Surveyor #3 observed an unsampled resident eating at the dining room table with flies on the table, on the resident's plate, and the resident's toast. The surveyor asked the LPN to come and observe, and the LPN confirmed the same. On 10/26/21 at 9:51 AM, Surveyors #3 and #4 observed Resident #95 sitting at a table in the

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that clothes dryers located inside the laundry department were maintained in safe operating conditions. On 10/19/2021 at 11:45 AM, the life safety code (LSC) surveyor and Surveyor #5 toured the laundry area and observed 3 of 4 large commercial grade clothes dryers that were operational. The interior of the clothes dryer drums had large areas located in the dryer drums of embedded potentially combustible debris. The surveyor observed various colors of brown and white potentially combustible debris that was embedded and blocking the airflow pockets of the drum. The LSC surveyor also smelled a gas-like odor, the gas company [name redacted] was notified upon surveyor identification, and it was determined by the gas company representative the interior gas line attached to the dryer was positive for an active gas leak due to a gas valve that was in disrepair. The gas company representative issued a violation. The violation reflected the following: This appliance or section of gas piping has been SHUT OFF due to an unsafe condition. DO NOT operate until the noted condition(s) have been corrected and RE-INSPECTED by [Gas Company name redacted]or your local building code official. REMARKS: Replace the flex connection on the dryer At that time, the life safety code surveyor interviewed the maintenance director regarding a procedure to maintain the integrity of the interior of the dryer drums. The Director of Maintenance (DM) stated there was no policy, procedure, or process to ensure the dryer drums were regularly maintained or monitored for condition. On 10/21/2021 at 2:01 PM, the DM provided Surveyor #5 with a copy of a Tumble Dryers, Installation/Operation/Maintenance Manual dated April 2019. The Maintenance Section of the manual revealed, Daily, 1. Inspect the area surrounding tumble dryers, remove all combustible materials, including lint, before operating the machines, Bi-Annually 2. Check gas connections for leakage. On 10/22/2021 at 9:25 AM, Surveyor #5 interviewed the contracted maintenance technician (MT) in the presence of the Housekeeping Director (HD) in the laundry department. The surveyor inquired to the MT regarding the state of the dryer drums. The MT stated cleaning is a nightmare. He referred to the imbedded debris on the dryer drums and stated that it is hours and hours of debris and it was plastic at one point, now melted on there. The MT stated he would not recommend to use the dryers, they are past the point of being cleaned. The MT stated he has not cleaned the drums in the state they were in and recommended to replace the drums on the dryers or replace the dryers because the debris blocked the heat source. The MT stated he could not clean the drums when they were in the condition they were in. Surveyor #5 reviewed a Laundry Report (LR), dated 10/22/2021 which was completed by the MT. The LR revealed the dryer baskets were covered with melted plastic, we will give an estimate to replace baskets or replace drums. The facility's failure to maintain the commercial-grade clothes dryers (dryers), located inside the laundry department, in safe operating condition by ensuring the dryer drum air vents remained free of embedded potentially combustible debris that blocked the airflow for 3 of 4 operational dryers. This deficient practice posed a serious and immediate threat to the safety and wellbeing of all residents who resided in the facility. This situation resulted in an Immediate Jeopardy (IJ) that began on 10/19/2021. The facility was notified of the IJ situation on 10/20/2021. The facility submitted an acceptable removal plan via electronic mail (e-mail) on 10/22/2021. The IJ removal plan was confirmed prior to receiving the facility's written removal plan and verified onsite by the survey team on 10/20/2021. The non-compliance remained on 10/21/2021 at a lower scope and severity, with no actual harm but the potential for more than minimal harm that was not immediate jeopardy. The evidence was as follows: Based on observation, interview, and record review from 10/18/2021 to 10/19/2021, in the presence of facility management, it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in a safe and optimal condition for 90 of 100 units observed. This deficient practice was evidenced by the following: While touring the facility from 10/18/2021 to 10/19/2021, the surveyor observed that PTAC units had clogged and dirty filters. The Maintenance Director indicated that the PTAC unit filters were not cleaned and that he needed help. He was asked if he had a filter cleaning log or a policy and procedure on the maintenance of PTAC units but did not provide any documents at that time. NJAC 8:39-31.2(e) NJAC 8:39-31.4(b)

Based on observation, interview, and record review, it was determined that the facility failed to: Part A.) ensure side rails were installed and maintained in a safe, secure manner and without gaps between the side rails and the mattress to prevent entrapment risks for 3 of 38 residents reviewed for quality of care (Resident #3, #17, and #18) on 2 of 5 units (Court 1 and Pavilion Unit). In addition, the facility failed to reduce additional entrapment risks when durable medical equipment (a geri-chair and a wheelchair) were locked and adjacent to the bed frames on the low ends of the bed. The surveyors observed one of the residents with their head in the gap between the mattress and the side rail, the side rail padding was covering their face, and the resident was screaming. None of the residents were assessed for an entrapment risk with the use of the side rails. This posed a serious and immediate risk for all residents who used side rails for 2 of 5 units. On 10/19/21 at 10:25 AM, Surveyor #5 entered Resident #18's room with the resident's attending physician (MD). At that time, the surveyor and MD observed the resident was lying in bed, and the resident's right side rail was not in vertical alignment with Resident #18's mattress. Surveyor #5 and the MD further observed that the side rail was diagonally positioned to the resident's mattress, and there was a gap between the mattress and the side rail. Surveyor #5 observed that the resident's head was positioned about three to four inches from the right edge of the gap between the side rail and the mattress. Surveyor #5 questioned the MD regarding the position of the resident's side rail and the gap observed between the side rail and bed. The MD acknowledged that the side rail was leaning away from Resident #18's bed, and at that time, Surveyor #5 inquired to the MD if the side rail posed a risk for entrapment. The MD stated yes and said Resident #18 had dementia and a history of falls, and the side rails should have been protected. This deficient practice placed this resident at risk for the likelihood of serious harm or death and posed a serious and immediate risk for all residents who use side rails. This situation resulted in an Immediate Jeopardy (IJ) situation identified on 10/19/21 and again on 10/24/21; Resident #18 and Resident #3. The department received an acceptable removal plan on 10/29/21 that was verified that day by the survey team. The evidence was as follows: On 10/21/21 at 11:03 AM, Surveyor #5 interviewed the Director of Maintenance (DM) regarding the process for the placement of side rails on residents' beds. The DM stated that was kind of a gray zone and further noted that when he received a request for side rail installation, not all the facility beds supported side rails and that there were no side rail manuals available. The DM stated that he usually went and checked that the side rail was correctly installed because if the incorrect side rails were installed, it would put a resident in jeopardy. He also stated that when he assessed the appropriateness of the side rails, the side rails could be changed to different beds if they needed to. Additionally, that manual beds are currently used in the facility, and the manual beds did not have the ability to have side rails affixed to them. Surveyor #5 asked the DM if there was a process for a side rail assessment to determine the appropriate side rail for the bed. The DM replied that there was no formal mechanism for an assessment. The DM stated that when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . That same day, Surveyor #5 inquired to the DM regarding the leaning right side rail on Resident #18's bed observed by the physician and Surveyor #5 on 10/19/21 at 10:30 AM. Surveyor #5 showed the DM a photograph of Resident #18's bed taken by Surveyor #5 on 10/19/21 at 10:30 AM. The DM stated the side rails on Resident #18's bed were universal side rails that were not adjusted appropriately. He noted the universal rails were supposed to be fitted tightly against the bars on the side rail and should only allow for one fingertip to be inserted between the side rail and the bed. The DM referred to Resident #18's bed and stated, there was no assessment done on the bed and, I was never even told about [the resident's] bed doing that. Surveyor #5 reviewed a Bed Safety policy with the DM. The policy was titled from another healthcare company and was provided to Surveyor #5 on 10/19/21 at 1:10 PM by the facility Infection Preventionist Nurse. The DM said that was not the facility policy and stated, I had a different procedure. On 10/21/21 at 12:50 PM, Surveyor #5 interviewed an Occupational Therapist (OT) regarding whether or not rehabilitation is involved with an assessment for side rail use. The OT stated if she thought a resident would benefit from side rail use for mobility and transfers, she could request them from maintenance. The OT further noted that she knew Resident #18 and stated the resident was very confused and that she had not completed a side rail assessment on the resident. She provided a side rail assessment for Resident #18, dated 10/19/21, completed by a Physical Therapist. The assessment revealed, referred by nursing for a bedrail [side rail] assessment, and the side rails were an enabler for the patient for independence with bed mobility. Surveyor #5 reviewed the medical record for Resident #18, which revealed the following: An admission record revealed Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/27/21, revealed the resident had scored a 10/15 on the Brief Interview for Mental Status, which indicated the resident was moderately cognitively impaired. The Functional Status section revealed the resident required limited assistance and a one-person physical assist for bed mobility and required extensive assistance of one person for transferring. The restraint section of the MDS was coded not used for side rails. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An electronic Order Summary Report dated 10/24/21 revealed an Active Verbal Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A handwritten Treatment Record for Resident #18 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic Treatment Administration Record for October 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 07:00 (7:00 AM) on 10/19/21 was left blank. A review of Resident #18's Care Plan revealed the following focus Areas: Nutrition- Revised 10/20/21, Skin-Revised 10/25/21, Pain-Revised 10/25/21, Falls-Revised 10/25/21, Discharge-Revised 10/25/21, Bladder Incontinence-Revised 10/25/21. The Care Plan did not include the intervention for side rails as an active or resolved intervention. A review of an Physician's Progress note dated 10/19/2021, at 10:58 AM, revealed the resident had side rails up at this time, falls discussed with nursing and discussed to apply protectors to bed rails. A 10/19/2021, 18:02 (6:02 PM) Nurses Note authored by the Director of Nursing revealed a discussion with the resident's Physician regarding the side rails. The Physician agreed the bed rails were not needed and did not help with bed mobility for the resident. A 10/21/2021, 11:49 AM physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A Side Rails assessment completed on 10/08/21 at 12:31 PM signed by the former unit manager nurse revealed the side rails were indicated to provide safety. On 10/25/21 at 09:50 AM, Surveyor #5 observed Resident #18 in bed, eyes were closed. The resident's bed was in the lowest position, and there was a floor mat on the right side of the bed. The bed did not have side rails. The CNA who was present in the room told Surveyor #5 that the resident only needed the mat on the right side of the bed. On 10/25/21 at 11:39 AM, Surveyor #5 interviewed the DON and Social Worker regarding if a side rail consent was completed for Resident #18. The Social Worker and DON were not sure and stated they would look into it. 2. On 10/24/21 at 11:45 AM, two surveyors, could hear screaming from the hallway coming from the semi-private room of Resident #3. The surveyor observed Resident #3 in bed with the bed positioned against the wall. The bilateral upper half side rails were in the up position. There was a full-length padded side rail covering the resident's face, and the bottom end of the full-length padding was velcroed to a locked geri-chair positioned on the lower half of their bed. The surveyor observed that the resident was pulling at their incontinent brief, and the back of the resident's head was positioned in a gap between the upper side rail and mattress. The resident continued to scream unintelligible sounds. The surveyors further observed on the opposite side of the resident's bed against the wall, that there was a triangular wedge positioning device tucked under the fitted mattress sheet. This positioning device positioned the resident in a manner that kept the resident from accessing that side of the bed and closer to the side of the bed where the surveyor observed gapping between the mattress and side rail causing an entrapment risk. The surveyors observed more closely and noted that the geri-chair was also locked and positioned on the lower end of the bed while the resident was in the bed. The surveyor attempted to gently push the geri-chair to evaluate the chair's mobility, but it was securely locked and not easily moved. This situation created an unsafe gapping between the lower end of the bed frame, causing a further entrapment risk if the resident rolled or attempted to get out of bed. There was no space at the end of the bed for the resident to safely get out of bed, and the gaps between the chair device and the bed frame and mattress created a further entrapment risk for Resident #3. At approximately 11:50 AM, the surveyors observed a Certified Nursing Aide (CNA) enter the resident's room. The surveyors asked the CNA about the resident, their positioning, and the screaming. The CNA indicated that the resident's screaming was typical and associated the screaming with the resident's known behaviors. She stated that Resident #3 was not originally on her assignment today but was given to her when an Agency CNA had to do a one-to-one observation for another resident on the same Pavilion unit (Resident #446). She confirmed that the side rail padding was covering the resident's face, the resident was positioned sideways, and the back of their head was in a gap between the mattress and side rail. The CNA then stated that she would reposition the resident. The CNA then began to remove the full-length side rail padding from the resident's bed and geri-chair. The surveyor asked about the locked geri chair, the CNA responded, this was here when she got on for the start of her shift and implied that the night shift had set it up for the resident this way. She stated the geri-chair gets locked at the end of her bed to keep [Resident #3] in bed. One of the surveyors then asked if the resident was fed breakfast that morning. The CNA replied, yes, and the surveyor followed up with a second question regarding how the resident was fed breakfast if the geri chair was positioned in that manner since the night shift? The CNA then stated that she fed the resident breakfast and backtracked to state that she moved the geri-chair back to the bottom of the bed and locked it (and not the night shift staff). She justified her statement by adding, I do what everyone else is doing. She confirmed that the other staff set the resident up with the locked geri-chair in the same manner, to keep the resident from getting out of bed. The surveyors then observed the CNA reposition the resident, pulling them out of the gap between the mattress and side rail. The CNA then unlocked the geri-chair and moved it out of the way. The CNA could not speak to the gaps between the side rails and the mattress or the safety risk/entrapment hazard with having a locked geri-chair positioned at the bottom of the bed. The surveyor then observed the resident's roommate, Resident #17, sitting up in bed with their back against the upper half side rails in the up position. The head of the bed was flat. The surveyor observed that the resident's bed was also positioned against the wall, preventing the resident from getting out on one side of the bed. The other side of the bed had the half-side rails in the up position, and there was a locked wheelchair on the bottom end of the bed, creating a gap between the mattress and the wheelchair. The surveyor attempted to gently push on the wheelchair to determine if it could easily move, and the wheelchair was firmly locked and unable to be easily moved. The surveyor observed the CNA remove the locked wheelchair from beside the lower end of the bed. The surveyor asked the CNA about this resident's locked wheelchair. The CNA could not speak to the potential entrapment hazard for the resident if the resident attempted to climb out of bed or fell out of bed with the wheelchair present. The surveyor reviewed the medical record for Resident #3. A review of the Admission Record face sheet (an admission summary) for Resident #3 revealed that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/23/21 which reflected that the resident was unable to be assessed for a brief interview for mental status (BIMS), so staff assessed the resident's cognition status. The MDS revealed that the resident was assessed to have a short- and long-term memory problem with a severely impaired decision-making capacity. It further revealed that the resident required an extensive one-person physical assist for bed mobility and transfers. The section to record if bed rails were used as a physical restraint indicated there were none used. A review of the resident's individualized, comprehensive care plan revised on 10/21/21 included that the resident was at high risk for falls related to a gait/balance problem, poor safety awareness, impulsiveness, and a decreased cognitive and functional ability. Interventions dated 11/15/20 included, Bed against the wall to promote boundaries and floor mat next to the bed. The care plan also included that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] In addition, the care plan revised on 9/12/2020 included that the resident has a potential for impairment to skin integrity related to poor safety awareness and frail, fragile skin. Interventions included Pad bed rails, wheelchair arms, or any other source of potential injury if possible .[Resident #3] rips off any and all padding staff places on wheelchair. Attempt to replace as needed. The care plan for Side rails included that the resident utilized bilateral half side rails as an enabler for mobility and positioning initiated on 10/1/2018. Interventions included to explain the risk and benefits to the resident or resident representative .Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It did not address assessing the bed rails and mattress for any entrapment risks. A review of the most recent side rail assessment dated [DATE] included that the resident was non-ambulatory, had an altered safety awareness due to a cognitive decline, has difficulty sitting on or moving to the side of the bed, poor trunk control, and currently uses side rails for independent positioning or to assist with positioning. Under the section for alternatives, it was blank. The Recommendations included bilateral half side rails are indicated at present to promote independence. The side rail assessment did not include a section to evaluate for entrapment risk. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic Assessments dated 8/1/18 (the date when the physician ordered the side rails) did not include evidence of an entrapment risk assessment. The surveyor reviewed the medical record for Resident #17. A review of the Admission Record face sheet revealed that Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 0 out of 15, indicating a severely impaired cognition. There was no staff assessment for cognitive functioning conducted. The MDS assessment further revealed that the resident required a total one-person physical assist for bed mobility and total dependence of two people for transfers. The section to record if bed rails were used as a physical restraint indicated there were none used. A review of the resident's individualized, comprehensive care plan revised on 10/20/21 included that the resident has poor safety awareness, rocks back and forth in the wheelchair, and has frail, fragile skin causing them to be at risk for skin impairments. A review of the care plan initiated on 10/1/2018 included that the resident used bilateral half side rails as an enabler for mobility and positioning. Interventions included to explain the risk and benefits to the resident or resident representative .Obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It did not address assessing the bed rails and mattress for any entrapment risks. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a side rail assessment dated [DATE] included that the resident was non-ambulatory, had an altered safety awareness due to a cognitive decline, has difficulty sitting on or moving to the side of the bed, poor trunk control, and currently uses side rails for independent positioning or to assist with positioning. Under the section for alternatives, it was blank. The Recommendations included bilateral half side rails are indicated at present to promote independence. The side rail assessment did not include a section to evaluate for entrapment risk. A review of the electronic assessments dated 10/1/18 (date when the side rails were added to the resident's care plan) did not include evidence of an entrapment risk assessment. On 10/24/21 at 1:30 PM, the surveyors requested any evidence of entrapment risk assessments or follow-up regarding the surveyor's findings with Resident #3 and #17 with the Interim Director of Nursing (DON) . The DON acknowledged that the locked geri-chair and locked wheelchair should not have been positioned at the lower end of the resident's beds due to an injury hazard or entrapment hazard. It was confirmed that it wasn't addressed in a care plan or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 3:45 PM, no additional documentation or information was provided to the surveyors in response to the surveyor's findings from the DON or the LNHA. At 4:00 PM, the two surveyors notified the Interim DON and the LNHA of the facility's failure to ensure Resident #3 and #17 were assessed for the risk for entrapment when side rails were ordered and in place, the failure to prevent equipment from being locked adjacent to the resident's beds which caused a potential entrapment hazard, and the failure to ensure that Resident #3 who was known to remove side rail padding had no gaps between the bed rails and mattress when and if the padding was removed. This failure caused Resident #3 to be observed by two surveyors to have their head positioned within the gap between the side rail and mattress, which posed a serious and immediate threat to the safety and well-being of both residents due to an entrapment risk hazard. This resulted in an Immediate Jeopardy (IJ) situation that began on 10/24/21 when Resident #3 was observed to have their head in the gap between the mattress and side rail; There was no side rail entrapment assessment. The IJ continued until 10/25/21 when the facility alleged complete implementation of the elements of their removal plan was accepted on 10/29/21 and verified by the survey team. The facility administration was notified of the Immediate Jeopardy situation on 10/24/21 at 4:00 PM. On 10/26/21 at 4:07 PM, Surveyor #5 requested any entrapment risk assessments, side rail consent for Resident #18, and a copy of the current facility side rail policy, including maintenance, installation, and monitoring. On 10/27/21, the Administrator (LHNA) provided a Physical Restraint Policy, dated 01/05, which revealed: It is the policy of this facility to refrain from the use of physical restraints. Physical restraint is defined as the use of any device on or near the resident's body, which inhibits freedom of movement or free access to his/her person. The policy did not include the use of side rails as enablers, maintenance of side rails, installation, monitoring, or entrapment risk assessments. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined the facility failed to: a.) protect residents from the potential for significant medication errors by not following the standards of practice for the administration of medication, and b.) implement the facility policy for Medication Administration when 1 of 5 nurses (an Agency Licensed Practical Nurse) on 1 of 4 units (Court 1) observed during a medication pass observation prepared and attempted to give high-risk medications to the wrong resident. On 10/19/21 the surveyor observed the Agency Licensed Practical Nurse (LPN #1) attempt to administer two medications that were specific for lowering blood pressure, an anticoagulant (blood thinner) medication, and a medication to lower [MEDICATION(S)] levels in the blood. The Agency LPN #1 did not follow the six rights of medication administration by identifying the correct resident with the correct medications. The six rights include the following: the right resident, the right drug, the right dose, the right route, the right time and the right indication for use. The surveyor intervened before the medications could be administered to Resident #66. Interviews with the Agency LPN #1 revealed it was her first day at the facility, and she was neither oriented to the facility's system of medication administration, nor had she completed a medication pass competency at the facility prior to an assignment on the Court 1 medication cart. This posed a serious and immediate threat for all the residents on Court 1. The immediate jeopardy (IJ) began on 10/19/21 at 9:50 AM and continued until 10/20/21. The Director of Nursing (DON) was notified of the IJ on 10/19/21 at 2:40 PM. The lack of orientation and training for an agency nurse that never worked at the facility previously and the failure of LPN #1 to follow the six rights of medication administration in accordance with professional standards of nursing practice that must be used to reduce the risk of medication errors and harm (identifying a resident prior to administering medications) constituted an Immediate Jeopardy situation. The failure to identify a resident prior to administering medications is likely to cause serious injury, harm, impairment or death to the residents on Court 1 unit due to the risk associated with a resident receiving the wrong high-risk medications not prescribed to to them by their physician or receiving a medication that may be associated with a medication allergy. An acceptable removal plan was received on 10/20/2021 and verified by the survey team on 10/20/2021 and throughout the remainder of the survey. This deficient practice was evidenced by the following: On 10/19/21 at 9:50 AM, the surveyor observed an agency LPN (LPN#1) during a medication pass on Court 1 unit. The surveyor observed her open to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN #1 prepared [MEDICATION(S)] 10 milligram (mg) (a medication used to lower blood pressure and treats heart failure), [MEDICATION(S)] 25 mg ([MEDICATION(S)]; a medication used to lower blood pressure by slowing the heart rate), [MEDICATION(S)] 5 mg (a medication that thins the blood) and [MEDICATION(S)] 800 mg (a medication typically used for residents that are dependent on [CONDITION(S)] and aids in lowering elevated [MEDICATION(S)] levels in the blood). At that time at 9:50 AM, the surveyor observed Resident #91 sitting upright in bed eating breakfast. The surveyor then observed LPN#1 turn to a different resident (Resident #66) who was sitting in a wheelchair next to her medication cart. Without identifying the resident by asking their name or checking the resident's identification (ID) bracelet, she began to hand the medications to Resident #66, which were ordered and prepared for Resident #91. The surveyor immediately stopped LPN#1 and asked her if this was the correct resident. The surveyor then observed LPN#1 ask Resident #66 their name. The resident correctly identified him/her-self by name as Resident #66. At 10:00 AM, the surveyor interviewed LPN#1 who stated that she should have identified the resident either by asking the resident for their name or checking the ID bracelet. LPN #1 also told the surveyor that she was an agency nurse and that it was her first day at the facility. When asked by the surveyor, she also stated that she had not received an orientation or in-service training prior to starting her shift. LPN#1 stated that she was also confused with the facility's paper form of the Medication Administration Records and that when she started her 7 AM to 3 PM day shift, the night shift (11 PM to 7 AM) nurse just handed her the keys for the medication cart with no further instruction. On 10/19/21 at 10:20 AM, the surveyor reviewed the Admission Record face sheet (an admission summary) for Resident #91 which indicated that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record reflected that the resident had no known allergies. A review of the resident's October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a.) [MEDICATION(S)] ([MEDICATION(S)]) 25 mg one tablet by mouth three times daily for hypertension; b.) [MEDICATION(S)] 10 mg one tablet by mouth once daily for hypertension, c.) [MEDICATION(S)] 5 mg one tablet by mouth twice daily for AFib, and d.) [MEDICATION(S)] ([MEDICATION(S)]) 800 mg one tablet by mouth three times daily with food for [CONDITION(S)] ([CONDITION(S)])/hemodialysis. The surveyor reviewed the Quarterly Minimum Date Set (MDS), an assessment tool used to facilitate the management of care dated 8/7/21 for Resident #91, which reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15 indicating that the resident had a fully intact cognition. The surveyor reviewed Resident #91's interdisciplinary care plan (IDCP) dated 7/12/21 that revealed under the focus area of potential nutritional problem that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/21 at 10:30 AM, the surveyor reviewed the Admission Record face sheet for Resident #66 which indicated that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record revealed that the resident had no known allergies. A review of the October 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a.) Aspirin 81 mg one tablet by mouth daily for coronary artery disease dated 11/2/2017, b.) [MEDICATION(S)] ([MEDICATION(S)]) 3.125 mg one tablet by mouth twice daily (a cardiac medication typically used for hypertension) dated 9/15/21, c.) [MEDICATION(S)] 1000/milliliter (ml) inject 1 ml (10,000 units) three times weekly on Tuesday, Thursday and Saturday at Hemodialysis for [CONDITION(S)] (low red blood cell count) due to [CONDITION(S)] dated 7/31/2020, d.) [MEDICATION(S)] (Keppra; an anti-[CONDITION(S)] medication) 100 mg/ml solution, 5 ml (500 mg) by mouth once daily for seizures dated 7/31/2020. e.) In addition, the PO revealed that Resident #66 went for [CONDITION(S)] on Tuesday, Thursday, and Friday at 5:30 AM. (There was no evidence from the corresponding PO sheets for October 2021 that Resident #66 was receiving any of the same morning medications as Resident #91). The surveyor reviewed the Quarterly MDS dated [DATE] for Resident #66, which reflected the resident had a BIMS score of 15 out of 15 indicating that the resident had a fully intact cognition. The surveyor reviewed Resident #66's IDCP with a target date 10/18/21 had a focus area which included, ADL self-care performance deficit, activity intolerance, confusion, fatigue, impaired balance and musculoskeletal impairment with a Goal to maintain current level of function in bed, mobility, transfers, eating, dressing, toilet use and personal hygiene. The resident also had a focus area that addressed the risk of falls, unsteady gait and seizures that had a target date of 10/18/21, the interventions revealed under mobility that the resident uses a wheelchair on [CONDITION(S)] days for navigation on the unit for energy conservation. A review of the electronic Progress Notes for the last six months (April 2021 to October 2021) for Resident #91 and Resident #66 did not reveal any evidence of inappropriate medication responses. On 10/19/21 at 1:45 PM, the surveyor interviewed the DON regarding an orientation package and in-services that was provided to LPN#1 prior to starting her shift. The DON stated that LPN#1 was provided no in-servicing or an orientation package prior to starting her day shift. On 10/19/21 at 2:40 PM, the surveyor, in the presence of the survey team, discussed the medication pass errors with the DON. The DON stated that she would have expected all nurses to read the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to provide documented evidence of any in-service education or competency for medication pass prior to being assigned a medication cart on the unit for LPN #1. The DON acknowledged the serious risk associated with giving the wrong high-risk medications to a resident. At that time, the DON was notified that the lack of orientation and training for an agency nurse that never worked at the facility previously and the failure of LPN#1 for not following the six rights of medication administration that should be used to reduce the risk of medication errors and harm (specifically identifying a resident prior to administering medications) constituted as an Immediate Jeopardy situation that could impact all residents on Court 1 unit due to the likelihood for serious injury, harm, impairment or death caused by improper administration of medication procedures. A review of the facility's policy dated as reviewed/revised on 6/2009 for Medication Administration-Policy and General Guideline that was provided by the DON revealed that medications are to be prepared, administered, and recorded by licensed nurses who have successfully completed a Medication Pass Observation upon hire and annually. In addition, the policy revealed that Positive resident identification should be ensured prior to medication administration. An acceptable Removal Plan was received on 10/20/2021 and verified by the survey team on 10/20/2021 and throughout the remainder of the survey. The Removal Plan included the following: The Agency nurse who failed to properly check a resident's identification prior to administering medication was stopped by the surveyor and the nurse was immediately removed from passing medications on the morning of 10/19/21, was taken off the schedule and removed from building. This nurse will no longer be allowed to provide services at the facility. The agency that employed the nurse was immediately notified the morning of 10/19/21 and informed of the error and not to send this nurse to the facility in the future. Agency nurses will be required to provide proof of med pass competency prior to the first time they come to the facility. Contract staffing agencies must ensure licensed nurses have passed a med pass competency evaluation that includes checking resident identification band or picture of each resident prior to administering any medications. Licensed nurses received re-education on 10/19/21 regarding checking resident identification to verify the right resident is being administered the right medication prior to any medication administration. On 10/20/21 at 9:45 AM, the survey team verified that the LPN #1 was not working at the facility and in-service education had begun. A review of the LPN#1 time card report indicated that she worked the entire day shift 7 AM to 3 PM shift on 10/19/21. On 10/21/21 at 10:30 AM, the surveyor conducted a Resident Council Group Meeting with five residents, including the resident council President. The residents did not address a concern in regard to medication pass administration or receiving wrong medications. N.J.A.C. 8:39-11.2 (b)

Complaint Intake NJ 8 Based on observations, record reviews, interviews, and facility policy review, it was determined the facility failed to provide a safe environment to prevent resident-to-resident abuse for 5 (Residents #3, #14, #15, #16, and #17) of 5 sampled residents for resident-to-resident abuse. Resident #13 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents #3, #14, #15, #16, and #17 were assaulted by Resident #13. Some of the assaults resulted in minor injuries, including bruising, abrasions and laceration that required sutures. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.12 (Freedom from Abuse, Neglect and Exploitation) at a scope and severity of J. The IJ began on 07/29/2021 when the resident's physician indicated the resident was no longer appropriate for skilled nursing facility placement due to aggression, with multiple altercations with other residents. The resident needed long-term psychiatric placement for stabilization, but the resident remained in the facility. The resident assaulted another resident on 08/08/2021. On 08/08/2021 at 12:00 PM, an IJ was identified. At 5:16 PM, the facility Administrator and Assistant Director of Nurses (ADON) were provided with the completed IJ template and notified of the existence of an IJ for abuse. The Administrator signed the template and returned the original to the survey team. On 08/11/2021 at 1:41 PM, a Removal Plan was accepted by the New Jersey Department of Health (NJDOH). The IJ continued until 08/09/2021 at 10:00 PM, when the facility alleged the elements of the Removal Plan had been implemented. On 08/13/2021 at 9:30 AM, a surveyor conducted an onsite revisit to verify the Removal Plan had been implemented. Resident #13 had been removed from the facility on 08/08/2021. The facility implemented the Removal Plan, which included education for certified nursing assistants (CNAs), nursing assistants (NAs), and licensed nursing staff for the Atrium, Court Two, and Pavilion and Vent Units on how to properly monitor residents who were on one-to-one behavior monitoring. CNAs, NAs, and licensed staff were being educated on staying within arm's reach of a resident, never leaving a resident alone, ensuring that the one-to-one was covered by another staff member when going to break, and documenting whereabouts and behaviors. The facility had an updated seating chart of the Pavilion Unit to include any resident on one-to-one will have a seating plan during meals and recreational activities to lessen the chance of another resident being harmed by impulsive behaviors. The facility will continue with the current psychiatry group for continuity of care. The noncompliance remained on 08/13/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The facility had not implemented all areas of the Removal Plan that included the at-risk weekly meeting to discuss behaviors, care plans, and possibly new interventions, and the monthly [CONDITION(S)] meetings with psychiatrists, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers (UMs) to discuss any actual and potential issues which may include medication changes or additional interventions. Findings included: A review of a Facility Reported Event (FRE) sent to the New Jersey Department of Health (NJDOH) on 05/31/2021 revealed the following: Resident #3 was the victim of an unproved assault by Resident #13. The attack resulted in Resident #3 being transferred to a local hospital for suture repair of a laceration above the left eyebrow. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated Resident #13 had a BIMS (Brief Interview for Mental Status) score of 10 out of 15, which indicated the resident was moderately impaired in cognition. The resident was independent with bed mobility, transfers, walking in room, and toileting. The resident required supervision with walking on the corridor, locomotion off the unit, and personal hygiene. The MDS revealed the resident had no range of motion impairments and used a walker. On 08/06/2021 it was observed Resident #13 resided on a locked dementia unit, not a locked behavioral unit. 1. A facility incident report dated 04/22/2021, reported by an eyewitness (another resident), indicated Resident #13 had slapped a female resident (Resident #15) across the face, while waiting for dinner in the activity room. Resident #15's statement revealed Resident #13 smacked Resident #15 in the face. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated Resident #13 denied the allegation at first then changed the story. The resident stated Resident #15 had touched Resident #13's food so Resident #13 smacked Resident #15. There were no staff witnesses. The report did not state whether Resident #15 received injuries. The resident's care plan dated 04/22/2021 indicated the resident could become aggressive toward staff and other residents. The interventions put in place were: 1. Anticipate when this resident and Resident #15 were not getting along, separate them, and redirect both parties to keep from having a resident-to-resident altercation. 2. Allow the resident to have quiet time alone in their room if they request to be alone. 3. Allow the resident to vent feelings in a private place. 4. Redirect attention when the resident starts to get upset. The resident's care plan also indicated Resident #13 initiated acts of physical aggression on 04/22/2021. A physician's progress note dated 04/23/2021 issued two new orders: 1. Resident #13 was to be placed on 1-on-1 for behaviors, and 2. Discontinue 1-on-1 and place on Q 1-hour checks. No one-on-one monitoring documentation was provided by the facility after inquiries. 2. A facility incident report dated 04/28/2021 at 4:30 PM revealed both residents were in the dining room when Resident #13 hit Resident #16 in the face. Resident #16 retaliated and started hitting Resident #13 in the face. Resident #16 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted Resident #13 had abrasions to the forehead and right side of the face. The residents were separated, but later in the same mealtime, Resident #13 tried to hit Resident #16 again. Resident #16 started throwing punches at Resident #13. Both residents were placed on 1-on-1, and 911 was called to transfer Resident #13 to a local crisis center. The incident report indicated the resident was held at the crisis center but returned to the facility later in the night (no time given). The resident's care plan updated on 04/28/2021 revealed additional interventions: 1. The resident was educated not to physically hit another resident but to seek assistance from a staff member if the resident has any issues. 2. Always keep the resident away from Resident #16. 3. Place the resident on Q (every) 15-minute checks until the resident can be evaluated by a psychiatrist. 4. Render first aid for injuries. The resident's care plan also indicated Resident #13 initiated acts of physical aggression on 04/28/2021. The only new intervention was to place the resident on Q 15-minute checks. The report did not report a time frame for Q 15-minute checks to be conducted. The other interventions had already been recommended. The incident report for Resident #16 revealed Resident #13 would be placed on one-on-one when returned to the facility. No one-on-one monitoring documentation was provided by the facility after inquiries. Per the care plan, one-on-one was not a new intervention, and no time frame was provided related to how long one-on-one would be provided. The incident report did not indicate if Resident #13 was still on Q one-hour checks per a physician order dated 04/23/2021. A physician's order dated 04/30/2021 indicated Resident #13 was to be placed on Q 15-minute checks for behaviors. 3. A facility incident report dated 05/31/2021 at 2:42 PM indicated around 10:00 AM, a nurse went to the activity room to retrieve Resident #13 to escort the resident to the resident's room for wound treatment. The nurse left Resident #13 behind as she left to move the treatment cart to the resident's room. Resident #13 was walking unattended as Resident #3 walked by Resident #13 in the hallway. The nurse heard a sound, turned around and saw that Resident #13 had hit Resident #3 in the face. The attack was unprovoked. The incident report indicated the residents were separated and Resident #3 was transported to a local emergency room for evaluation of an injury above the left eyebrow. Resident #3 was returned to the facility around 2:00 PM. Resident #13 refused to be transported to the crisis center. One-on-one observation was initiated, per physician order, until evaluated by psychiatric consult. No psychiatric consult note was provided by the facility after inquiries. No one-on-one monitoring documentation was provided by the facility after inquiries. A nurse's note dated 05/31/2021 at 8:28 PM indicated Resident #3 returned to the facility with stitches above the left eyebrow to repair a laceration. Resident #13's care plan revealed the intervention was to place Resident #13 on one-on-one until evaluated by a psychiatrist. This intervention was not new. A physician's progress note dated 05/31/2021 indicated Resident #13 was to be placed on one-on-one until cleared by psychiatric consultant related to aggression. The care plan contained no new interventions. A nurse's note written by the Director of Nurses (DON) on 07/07/2021 at 3:00 PM indicated Resident #13 was to be placed on Q 15-minute checks for 72 hours for behavior monitoring and safety surveillance. Unsafe or belligerent behaviors were to be documented every shift. 4. A facility incident report dated 07/13/2021 at 4:30 PM reported Resident #13 was walking past Resident #14 when Resident #13 started hitting Resident #14. The staff separated the residents, but Resident #13 continued to threaten the other resident. Both residents were sent out to a local crisis center. Neither resident had injuries and they were both placed on one-on-one when they returned to the facility. The report indicated Resident #14 had redness to the right side of the forehead and tenderness to the right shoulder. No one-on-one monitoring documentation was provided by the facility after inquiries. Resident #14 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's care plan contained no new interventions. A physician's order dated 07/15/2021 (no time) indicated Resident #13 was a danger to others and to send the resident to a crisis center. No reports were in the medical record that indicated the resident had been sent to the crisis center. A physician's order dated 07/29/2021 indicated Resident #13 was to be kept on one-on-one due to aggression with multiple altercations with other residents. The resident needed long-term psychiatric placement for stabilization. The resident was not suitable for placement at this skilled nursing facility (SNF). A social worker should work with the family for placement. The above handwritten physician's order had a large circle drawn around the order, with a large star and a big check mark drawn beside it. On 08/07/2021 at 9:45 AM, Resident #13 was observed by the surveyor to be seated without one-on-one in the dining/activities room. There were other residents seated in the dining/activities room with the resident. On 08/07/2021 at 12:11 PM, Resident #13 was observed by the surveyor walking in the hallway near the dining/activities room without supervision. It was observed there was no staff member providing one-on-one. On 08/08/2021 at 10:00 AM, the Administrator was asked why Resident #13 was not immediately transferred to another facility when the physician wrote an order (on 07/29/2021) to find a long-term psychiatric facility for the resident because the unit the resident was in was not suitable for the resident. He stated the physician spoke with him on 07/29/2021 and did not express to him the resident needed to be transferred out immediately. The Administrator stated he contacted a sister facility the following day (07/30/2021) and arranged for the resident to be transferred to [named facility]. On Thursday of the following week (08/05/2021), the family refused to allow the resident to be transferred. He stated the resident had a [CONDITION(S)], which made it more difficult to find placement for the resident. The Administrator stated he had not made any additional arrangements to transfer the resident out of the unit. The Administrator was asked why the resident was not transferred to the facility's behavior unit. He stated he had tried but the physician in charge of the unit would not accept the resident. He added he thought the physician had said the resident needed two diagnoses, and he would not accept him. The Administrator stated he did not remember when he spoke with the physician at the behavior unit. He said when the resident was sent out to the crisis center, the center only kept the resident a few hours. Then they send the resident back to the facility, and the facility is required to take the resident back. The Administrator was asked to provide documentation of attempts to provide placement for the resident. He stated everything was verbal. There was no documentation of anything. A facility incident report dated 08/08/2021 at 11:10 AM revealed Resident #13 repeatedly hit Resident #17 on the right side of the face. This episode occurred in the activities/dining room. Resident #13 was observed to stand up, approach Resident #17 and start punching Resident #17 in the face. Resident #13 was transferred to a local crisis center at a local hospital. Resident #17 was transferred to a local hospital for evaluation and treatment. The incident report revealed Certified Nurse Aide (CNA) #6 (who was assigned to provide one-on-one) provided a written statement which indicated she was not with Resident #13 when Resident #13 started hitting Resident #17 in the face. Resident #17 was cognitively impaired in cognition and required the use a wheelchair. On 08/08/2021 at 11:30 AM, Unit Manager #3 stated CNA #6 had been assigned to provide one-on-one for Resident #13. During the survey, multiple attempts were made to reach CNA #6. On 08/20/2021 at 1:00 PM, two more attempts were made to contact CNA #6. Multiple attempts had been made to contact the CNA. It sounded as though the call was hung up on. On 08/08/2021 at 4:15 PM, Resident #17 had returned from the hospital and was observed sitting in the dining/activity room. The left side of the face was swollen, with redness and bruising above the left eye and on the right corner of the mouth. On 08/09/2021 at 10:00 AM, three CNAs (CNAs #1, #7, and #8) who provided direct care for Resident #13 stated the resident was unpredictable. There was no way to predict what would set the resident off. If another resident got too close, the resident would jump up and hit the other resident. If a resident walked by, the resident would strike out and hit the other resident. Resident #13 did not like for other residents to be near. Sometimes Resident #13 just did not like the way another resident looked at the resident. Resident #13 was very fast. On 08/09/2021 at 11:20 AM, Resident #13's physician was contacted by phone. He stated he was on vacation, he didn't have the medical record with him, and he didn't remember anything. On 08/09/2021 at 2:00 PM, the Administrator and the DON (Director of Nurses) both verbalized the physician's order did not indicate the transfer needed to be immediate. They added the physician had spoken with each of them, and he did not tell them to transfer the resident immediately. They were asked if there was documentation of constant supervision for Resident #13, such as one-on-one. They stated they did not have a form that recorded one-on-one, but the resident was always on one-on-one. They were asked if interventions had been reviewed, and if new interventions had been put in place after every altercation. They stated the resident was always on one-on-one. On 08/20/2021 at 2:15 PM, the resident's physician stated he had recommended Resident #13 be transferred to a psychiatric unit because the resident was a danger to the other residents. The physician added the resident had been to a crisis center multiple times and that was not effective. The facility had been unable to prevent assaults on other residents by placing the resident on one on one. The physician stated he had discussed medication changes with the resident and a family member, and they had refused, because they felt the resident did not need medications. The physician stated since everything had failed the resident needed to be transferred out as quickly as possible, immediately if possible. The physician stated he had inquired about placement in the facility behavior unit downstairs. He stated he was told there were insurance issue, and the resident did not qualify. The physician stated he did speak with the Administrator, DON, and the social worker. He stated he verbalized the resident needed to be transferred quickly, because he was a danger to others. He stated his job was to make recommendations, it was up to the facility to decide how to handle them. The facility's abuse policy, updated 05/17/2021, indicated: POLICY 1. Residents of Silver Healthcare Center have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion in accordance with State and Federal regulations. 2. Silver Healthcare Center will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. 3. All alleged or suspected incidents of abuse, neglect, mistreatment, or misappropriation of residents' property will be thoroughly investigated, and findings documented in a report format. 4. Any case in which abuse, neglect, mistreatment, or misappropriation of residents' property has been suspected will be reported in accordance with State and Federal regulations. DEFINITIONS ABUSE: The infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychological well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish There was no facility policy on one-to-one monitoring. On 08/11/2021 at 1:41 PM, a Removal Plan was received and accepted by the NJDOH. Removal Plan: Resident #13 is no longer in the building and has been out of the building since 8/8/21. The likelihood for serious harm no longer exists as of 8/09/21 by 10:00pm. Resident #13 was sent to emergency department for further psych evaluation and treatment. Resident #13 will not be returning to Silver Healthcare Center. The facility currently has one resident on one to one observation because he is a fall risk and has poor safety awareness. Residents at risk for safety compromising behavior will be audited and their care plans will be updated if appropriate on 8/09/21 by 10:00PM. The facility started education for CNAs, NAs, and licensed nursing staff for the Atrium, Court two , Pavilion and vent unit on how to properly monitor residents who are on one to one behavior monitoring. CNAs, NAs, and license staff are being educated on staying within arm's reach of the resident, never leaving a resident alone, ensuring that the one to one is covered by another staff member when going to break, and document whereabouts and behaviors. This education was initiated on 8/8/21 and will be completed by 8/9/2021 by 10:00 PM. Behaviors will be discussed, care planned, and new interventions initiated weekly during at risk meetings. The attendees of these meeting are the Medical Director, social workers, DON, IP, ADON, Dietician, and Unit Managers. Clinical Interdisciplinary team (IDT) attending the at risk meetings will relay the outcome through kardex via point click care when care plans are updated with new or revised interventions to the floor nurses, NAs, and CNAs. Communication will also take place verbally and may even be written as orders or in-services when appropriate. Monthly [CONDITION(S)] meetings with psychiatrists, DON, ADON, and Unit Managers to discuss any actual and potential issues which may include medication changes or additional interventions. Any resident displaying aggressive or other behaviors that may be detrimental to others will have an arranged seating plan during meals and recreational activities. Any resident on one to one will also have a seating plan during meals and recreational activities to lessen the chance of another resident being harmed by impulsive behaviors. We will continue with the current psychiatry group for continuity of care. Admissions will communicate with Administrator, DON, ADON and Unit Managers to determine whether the facility can properly care for residents with behaviors. Residents with history of aggression who are deemed a danger to other residents and staff, who are no longer appropriate for SNF placement will be sent to crisis for further evaluation immediately. If the psychiatrist still feels that the resident is a danger to others, then the facility will not be accepting the resident back. On 08/13/2021 at 9:30 AM, a surveyor conducted an onsite revisit to verify the Removal Plan had been implemented. Resident #13 had been removed from the facility on 08/08/2021. The facility implemented the Removal Plan, which included education for certified nursing assistants (CNAs), nursing assistants (NAs), and licensed nursing staff for the Atrium, Court Two, and Pavilion and Vent Units on how to properly monitor residents who were on one-to-one behavior monitoring. CNAs, NAs, and licensed staff were being educated on staying within arm's reach of a resident, never leaving a resident alone, ensuring that the one-to-one was covered by another staff member when going to break, and documenting whereabouts and behaviors. The facility had an updated seating chart of the Pavilion Unit to include any resident on one-to-one will have a seating plan during meals and recreational activities to lessen the chance of another resident being harmed by impulsive behaviors. The facility will continue with the current psychiatry group for continuity of care. The noncompliance remained on 08/13/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: The facility had not implemented all areas of the Removal Plan that included the at-risk weekly meeting to discuss behaviors, care plans, and possibly new interventions, and the monthly [CONDITION(S)] meetings with psychiatrists, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers (UMs) to discuss any actual and potential issues which may include medication changes or additional interventions. New Jersey Administrative Code § 4.1 (a)(5)

Complaint Intake: NJ 8Based on observations, record review, and interviews, it was determined the facility failed to provide supervision to prevent resident-to-resident altercations for 5 (#3, #14, 15, 16, 17, and #19) of 5 residents whose records were reviewed for resident-to-resident abuse. This had the potential to affect all residents who resided in the facility. Findings included: A review of a Facility Reported Event (FRE) sent to the New Jersey Department of Health (NJDOH) on 05/31/2021 revealed the following: Resident #3 was the victim of an unproved assault by Resident #13. The attack resulted in Resident #3 being transferred to a local hospital for suture repair of a laceration above the left eyebrow. Resident #13 had diagnoses which included [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], and anxiety disorder. The admission Minimum Data Set (MDS), dated [DATE], indicated Resident #13 had a BIMS (Brief Interview for Mental Status) score of 10 out of 15, which indicated the resident was moderately impaired in cognition. The resident was independent with bed mobility, transfers, walking in room, and toileting. The resident required supervision with walking on the corridor, locomotion off the unit, and personal hygiene. The MDS revealed the resident had no range of motion impairments and used a walker. On 08/06/2021 it was observed Resident #13 resided on a locked dementia unit, not a locked behavioral unit. 1. A facility incident report dated 04/22/2021, reported by an eyewitness (another resident), indicated Resident #13 had slapped a female resident (Resident #15) across the face, while waiting for dinner in the activity room. Resident #15's statement revealed Resident #13 smacked Resident #15 in the face. Resident #15 had diagnoses which included dementia and the resident required supervision with transfers and ambulation. The report indicated Resident #13 denied the allegation at first then changed the story. The resident stated Resident #15 had touched Resident #13's food so Resident #13 smacked Resident #15. There were no staff witnesses. The report did not state whether Resident #15 received injuries. The resident's care plan dated 04/22/2021 indicated the resident could become aggressive toward staff and other residents. The interventions put in place were: 1. Anticipate when this resident and Resident #15 were not getting along, separate them, and redirect both parties to keep from having a resident-to-resident altercation. 2. Allow the resident to have quiet time alone in their room if they request to be alone. 3. Allow the resident to vent feelings in a private place. 4. Redirect attention when the resident starts to get upset. The resident's care plan also indicated Resident #13 initiated acts of physical aggression on 04/22/2021. A physician's progress note dated 04/23/2021 issued two new orders: 1. Resident #13 was to be placed on 1-on-1 for behaviors, and 2. Discontinue 1-on-1 and place on Q 1-hour checks. 2. A facility incident report dated 04/28/2021 at 4:30 PM revealed both residents were in the dining room when Resident #13 hit Resident #16 in the face. Resident #16 retaliated and started hitting Resident #13 in the face. Resident #16 had a diagnosis of dementia and was independent with transfers and ambulation. It was noted Resident #13 had abrasions to the forehead and right side of the face. The residents were separated, but later in the same mealtime, Resident #13 tried to hit Resident #16 again. Resident #16 started throwing punches at Resident #13. Both residents were placed on 1-on-1, and 911 was called to transfer Resident #13 to a local crisis center. The incident report indicated the resident was held at the crisis center but returned to the facility later in the night (no time given). The resident's care plan updated on 04/28/2021 revealed additional interventions: 1. The resident was educated not to physically hit another resident but to seek assistance from a staff member if the resident has any issues. 2. Always keep the resident away from Resident #16. 3. Place the resident on Q (every) 15-minute checks until the resident can be evaluated by a psychiatrist. 4. Render first aid for injuries. The resident's care plan also indicated Resident #13 initiated acts of physical aggression on 04/28/2021. The only new intervention was to place the resident on Q 15-minute checks. The report did not report a time frame for Q 15-minute checks to be conducted. The other interventions had already been recommended. The incident report for Resident #16 revealed Resident #13 would be placed on one-on-one when returned to the facility. One-on-one was not a new intervention, and no time frame was provided related to how long one-on-one would be provided. The incident report did not indicate if Resident #13 was still on Q one-hour checks per a physician order dated 04/23/2021. A physician's order dated 04/30/2021 indicated Resident #13 was to be placed on Q 15-minute checks for behaviors. 3. A facility incident report dated 05/31/2021 at 2:42 PM indicated around 10:00 AM, a nurse went to the activity room to retrieve Resident #13 to escort the resident to the resident's room for wound treatment. The nurse left Resident #13 behind as she left to move the treatment cart to the resident's room. Resident #13 was walking unattended as Resident #3 walked by Resident #13 in the hallway. The nurse heard a sound, turned around and saw that Resident #13 had hit Resident #3 in the face. The attack was unprovoked. The incident report indicated the residents were separated and Resident #3 was transported to a local emergency room for evaluation of an injury above the left eyebrow. Resident #3 was returned to the facility around 2:00 PM. Resident #13 refused to be transported to the crisis center. One-on-one observation was initiated, per physician order, until evaluated by psychiatric consult. A nurse's note dated 05/31/2021 at 8:28 PM indicated Resident #3 returned to the facility with stitches above the left eyebrow to repair a laceration. Resident #13's care plan revealed the intervention was to place Resident #13 on one-on-one until evaluated by a psychiatrist. This intervention was not new. A physician's progress note dated 05/31/2021 indicated Resident #13 was to be placed on one-on-one until cleared by psychiatric consultant related to aggression. The care plan contained no new interventions. A nurse's note written by the Director of Nurses (DON) on 07/07/2021 at 3:00 PM indicated Resident #13 was to be placed on Q 15-minute checks for 72 hours for behavior monitoring and safety surveillance. Unsafe or belligerent behaviors were to be documented every shift. 4. A facility incident report dated 07/13/2021 at 4:30 PM reported Resident #13 was walking past Resident #14 when Resident #13 started hitting Resident #14. The staff separated the residents, but Resident #13 continued to threaten the other resident. Both residents were sent out to a local crisis center. Neither resident had injuries and they were both placed on one-on-one when they returned to the facility. The report indicated Resident #14 had redness to the right side of the forehead and tenderness to the right shoulder. Resident #14 had a diagnosis of anxiety disorder and was independent with transfers and ambulation. Resident #13's care plan contained no new interventions. A physician's order dated 07/15/2021 (no time) indicated Resident #13 was a danger to others and to send the resident to a crisis center. A physician's order dated 07/29/2021 indicated Resident #13 was to be kept on one-on-one due to aggression with multiple altercations with other residents. The resident needed long-term psychiatric placement for stabilization. The resident was not suitable for placement at this skilled nursing facility (SNF). A social worker should work with the family for placement. The above handwritten physician's order had a large circle drawn around the order, with a large star and a big check mark drawn beside it. On 08/07/2021 at 9:45 AM, Resident #13 was observed to be seated without one-on-one in the dining/activities room. There were other residents seated in the dining/activities room with the resident. On 08/07/2021 at 12:11 PM, Resident #13 was observed walking in the hallway near the dining/activities room without supervision. It was observed there was no staff member providing one-on-one. On 08/08/2021 at 10:00 AM, the Administrator was asked why Resident #13 was not immediately transferred to another facility when the physician wrote an order (on 07/29/2021) to find a long-term psychiatric facility for the resident because the unit the resident was in was not suitable for the resident. He stated the physician spoke with him on 07/29/2021 and did not express to him the resident needed to be transferred out immediately. The Administrator stated he contacted a sister facility the following day (07/30/2021) and arranged for the resident to be transferred to [named facility]. On Thursday of the following week (08/05/2021), the family refused to allow the resident to be transferred. He stated the resident had a [CONDITION(S)], which made it more difficult to find placement for the resident. The Administrator stated he had not made any additional arrangements to transfer the resident out of the unit. The Administrator was asked why the resident was not transferred to the facility's behavior unit. He stated he had tried but the physician in charge of the unit would not accept the resident. He added he thought the physician had said the resident needed two diagnoses, and he would not accept him. The Administrator stated he did not remember when he spoke with the physician at the behavior unit. He said when the resident was sent out to the crisis center, the center only kept the resident a few hours. Then they send the resident back to the facility, and the facility is required to take the resident back. The Administrator was asked to provide documentation of attempts to provide placement for the resident. He stated everything was verbal. There was no documentation of anything. A facility incident report dated 08/08/2021 at 11:10 AM revealed Resident #13 repeatedly hit Resident #17 on the right side of the face. This episode occurred in the activities/dining room. Resident #13 was observed to stand up, approach Resident #17 and start punching Resident #17 in the face. Resident #13 was transferred to a local crisis center at a local hospital. Resident #17 was transferred to a local hospital for evaluation and treatment. The incident report revealed Certified Nurse Aide (CNA) #6 (who was assigned to provide one-on-one) provided a written statement which indicated she was not with Resident #13 when Resident #13 started hitting Resident #17 in the face. Resident #17 was cognitively impaired in cognition and required the use a wheelchair. A facility incident report dated 08/08/2021 at 11:10 AM reported CNA #6 provided a written statement which indicated she was not with Resident #13 when Resident #13 started hitting Resident #17 in the face. On 08/08/2021 at 11:30 AM, Unit Manager #3 stated CNA #6 had been assigned to provide one-on-one for Resident #13. On 08/08/2021 at 4:15 PM, Resident #17 had returned from the hospital and was observed sitting in the dining/activity room. The left side of the face was swollen, with redness and bruising above the left eye and on the right corner of the mouth. On 08/09/2021 at 10:00 AM, three CNAs (CNAs #1, #7, and #8) who provided direct care for Resident #13 stated the resident was unpredictable. There was no way to predict what would set the resident off. If another resident got too close, the resident would jump up and hit the other resident. If a resident walked by, the resident would strike out and hit the other resident. Resident #13 did not like for other residents to be near. Sometimes Resident #13 just did not like the way another resident looked at the resident. Resident #13 was very fast. On 08/09/2021 at 11:20 AM, Resident #13's physician was contacted by phone. He stated he was on vacation, he didn't have the medical record with him, and he didn't remember anything. On 08/09/2021 at 2:00 PM, the Administrator and the DON (Director of Nurses) both verbalized the physician's order did not indicate the transfer needed to be immediate. They added the physician had spoken with each of them, and he did not tell them to transfer the resident immediately. They were asked if there was documentation of constant supervision for Resident #13, such as one-on-one. They stated they did not have a form that recorded one-on-one, but the resident was always on one-on-one. They were asked if interventions had been reviewed, and if new interventions had been put in place after every altercation. They stated the resident was always on one-on-one. New Jersey Administrative Code § 8:39-5.1(a)

C#NJ 006 Based on interview and record review, it was determined that the facility failed to monitor a resident with a change in condition which resulted in a delay of treatment for [REDACTED].#26). This deficient practice is evidenced by: Review of the hospital record faxed to the Department of Health on 4/4/17 at 11:47 a.m. reflected a History and Physical (H&P) dated 11/24/16. The H&P reflected that The patient in the emergency room found to have systolic blood pressure in 60s and 70s and did not respond well to IV fluid boluses and was started on the IV [MEDICATION NAME] (medication used to treat life-threatening low blood pressure) after placing a right IJ (IV placed into the internal jugular vein) central line. The patient blood pressure is now stable but remains on the IV [MEDICATION NAME]. On 11/22/2016 at approximately 2:08 p.m., Resident #26 was admitted to the facility for a respite stay with [DIAGNOSES REDACTED]. The 11/24/16 Discharge Return Anticipated Resident Assessment (an assessment tool) reflected that the resident made independent decisions and his/her memory was intact. Resident #26 was admitted to the facility with the following narcotics: [MEDICATION NAME] 5 mg every 6 hours as needed for moderate pain, [MEDICATION NAME] 60 mg every 8 hours, hold for sedation, for chronic pain and Medicinal Marijuana 1 pinch to vaporizer 4 times daily as needed for severe pain. Contained in the medical record was a Skilled Nursing Chart Note (SNCN) dated 11/11/16 prepared by the attending physician's Advanced Practice Nurse (APN). The SNCN reflected that prior to Resident #26's respite stay, resident was hospitalized and admitted to a subacute facility. The SNCN reflected that the resident is here following a hospitalization for which (he/she) had an acute [MEDICAL CONDITION] (swelling of the brain) secondary to uncontrolled overdose. The SNCN further reflected in the Impression and Plan that the resident is prone to over sedation and that Resolved acute [MEDICAL CONDITION] secondary unintentional overdose. We will continue to remain judicious and changes to (his/her) pain management regimen. We will continue to monitor. Contained in the medical record was a Respite Long-Term Care Admission History and Physical (Respite H&P) dated 11/23/16 prepared by the attending physician's APN. The Respite H&P reflected that resident was admitted to the facility for respite care while (his/her) family travels over the holidays. The Respite H&P further reflected under Impression and Plan that resident has Chronic pain. Continue combination of narcotic and medical marijuana. The surveyor reviewed the resident's ongoing Care Plan with an initiation date of 11/23/16. The Care Plan reflected a focus that resident uses anti-anxiety medications r/t (related to) Anxiety disorder with interventions to Monitor/document side effects and effectiveness and that resident is taking Anti-anxiety meds which are associated with an increased risk of confusion and cognitive impairment. Monitor Q (every) Shift for safety. The Care Plan further reflected a focus that resident was at risk for alteration in comfort r/t Advanced MS ([MEDICAL CONDITION]), chronic pain, anxiety with interventions to Administer pain med (medication) as per orders and to Monitor/document for side effects of pain medication. The Care Plan did not address resident's prior history of at risk for narcotic overdose. On 11/24/16 at approximately 8:10 a.m., the resident was observed to be lethargic, drowsy. The surveyor reviewed the 11/24/16 08:10 IDT Note documented by the Registered Nurse (RN Supervisor). The 08:10 IDT Note reflected that the RN Supervisor assessed the resident. Resident's blood pressure was 80/40 with a temperature of 102.6 F and pulse ox (percentage of oxygen in the blood) of 87%. The 08:10 IDT Note further reflected that the RN Supervisor administered 2L (liters per minute) of oxygen to the resident via nasal cannula, elevated the head of the bed 45 degrees, provided fluid to the resident and administered two Tylenol 650 mg at 6:30 a.m. The RN Supervisor assessed the resident at 7:20 a.m. and documented that the resident's temperature was 98.6F. The 11/24/16 08:10 IDT Note further reflected that the resident was alert and verbal and the resident stated that (he/she) does not want to go to the hospital and that (he/she) is feeling much better. On 11/24/16 at approximately 08:49 the resident was observed by the Registered Nurse (RN) laying in bed, hyperhidrosis (excessive sweating) and lethargic. The RN assessed the resident. The resident's blood pressure was 80/40, pulse ox 87% with 2L of oxygen via nasal cannula, temperature decreased to 98.6 F and the resident had no pain. The 11/24/16 08:49 IDT Note reflected that the Patient deoxygenating regardless of 2L, increasing oxygen to 4L. The 11/24/16 08:49 IDT Note further reflected Furthermore, upon assessment noticed more lethargic, drooling, hyperhidrosis, and patient non-responsive to painful stimuli. Patient unable to answer any questions. Notified the son, (Emergency Contact #1) clarified code status, patients is a full code and if need be wants (him/her) to be sent out to the hospital for evaluation. MD's service was called, awaiting a call back. On 11/24/16 at approximately 09:55, the Advanced Practice Nurse (APN) called the Unit. The surveyor reviewed the 11/24/16 09:55 IDT Note which reflected that the APN suggested for patient to be sent out for evaluation. The 11/24/16 09:55 IDT Note further reflected that the APN advised to change medications and 'keep an eye on the patient and to let her know of any changes.' The 11/24/16 09/55 IDT Note further revealed that new orders were received and documented appropriately. The 11/24/16 09:57 IDT Note reflected the telephone verbal orders of the APN included 1. [MEDICATION NAME] 30 mg ER (Extended Release) PO (by mouth) q (every) 8hrs PRN (as needed); 2. [MEDICATION NAME] 0.25 mg PO BID (two times a day) PRN; 3. Oxygen at 4L NC (nasal cannula) at all times; 4. Check Pulse ox q shift; 5. Keep O2 (oxygen) at 90% at all times. On 11/24/16 at approximately 10:00, the RN called the MD's service again and requested to speak with the on call practitioner. The surveyor reviewed the 11/24/16 10:00 IDT Note which revealed that the APN returned the RN call and requested to speak with the Licensed Practical Nurse (LPN) on the other side. The 11/24/16 10:00 IDT Note further revealed that the resident's family member was visiting stated that he wanted him/her to go to the hospital. The LPN rushed to assess the patient, notified the NP (APN) of situation. The 11/24/16 10:00 IDT Note further reflected As per LPN, patient must be sent via 911 for evaluation. The physician's orders [REDACTED]. The 11/24/16 10:33 IDT Note reflected that EMS (Emergency Medical Services) arrived shortly on the scene. All paperwork given to them, requested for patient to go to hospital. On 11/24/16 at approximately 13:12 (1:12 p.m.) the RN called the hospital. The surveyor reviewed the 11/24/16 13:12 IDT Note which revealed that the resident will be admitted [DIAGNOSES REDACTED]. The surveyor interviewed the Director of Nursing (DON) in the presence of the Administrator and Corporate Nurse on 3/30/17 at 1:20 p.m. The DON stated that the resident should have been sent out immediately if a code status is unknown. The surveyor interviewed the Unit Manager (UM) in the presence of the DON, Administrator and Corporate Nurse on 3/30/17 at 1:43 p.m. The UM stated that a new admission should come in with a code status. The UM further stated that she remembers there was some question with the code status. The resident's primary POA was out of state, the nurse called the primary POA for code status clarification and the POA stated that his brother is in the area and the facility can contact his brother with any questions. The UM further stated that they spoke with the brother and he clarified the resident's code status was full code and said, Yes send (him/her) out. The UM further stated that when it comes to sending a resident out without a code status, you should follow, When in doubt, send the resident out. The surveyor interviewed the RN Supervisor on 3/30/17 at 2:05 p.m. The RN Supervisor stated that he remembers he went to the resident's room to check on the resident and the resident did not want to go to the hospital. The RN Supervisor further stated that he then left the resident and was aware that he/she was eventually sent out but does not know what time. The RN Supervisor further stated that he knows the resident was sent out in the morning. The surveyor reviewed the facility's undated Respite Care policy which reflected that It is the policy of this facility to provide continuity of care to short-term residents whose regular caregivers are participating in a respite care program. The policy further reflected that The facility will follow the resident care plan provided by the attending physician. NJAC 8:39 - 27.1(a)

C # NJ C # NJ Part A Based on observation, interviews, record review and review of other facility documentation, it was determined that the facility failed to follow the facility's procedure to not reheat resident meal trays on the unit for 1 of 8 sampled residents (Resident #8). Resident #8 was burned after a Certified Nurses Aide (CNA) reheated a cup of the resident's water (for coffee). Resident #8 spilled the cup of hot coffee on herself resulting in a second degree burn with blistering to the Resident #8's left lower leg which required a doctor's order for treatment with Silvadene cream and a dry dressing, as well as medication for pain management. Part B In addition, based on observation, interviews, and other facility documentation it was determined that the facility failed to consistently monitor the facility's unlocked front doors, reception desk, and the lobby area, potentially creating an unsafe environment in which anyone could exit or enter the facility without staff knowledge for 3 of 3 sampled egress doors in the lobby. The deficient practice is evidenced by the following: Part A 1. The surveyor reviewed Resident # 8's medical record on 4/28/15. Resident # 8's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 1/27/15 indicated that the resident was cognitively intact with a score of 15 out of 15, and was non-ambulatory. Resident #8 required assistance with the set up of her food tray, but was able to feed herself. According to Resident #8's Care Plan, the resident was able to make her needs known, was often demanding of staff, and exhibited poor impulse control. Resident #8 preferred the comfort of her room, ate all meals in her room, and refused to get out of bed unless she was going to have a shower. Review of the medical record indicated that on 4/22/15, at 9:30 a.m., the Certified Nurses Aide (CNA) was called to Resident #8's room. The resident had spilled hot coffee on herself. The resident was assessed by the Charge Nurse (CN) and treatment provided, area cleansed with cool water after removal of wet garments. The medical record (MR) revealed that initially the affected area, measuring 17.5 centimeters (cm) x 4.5 cm had intact skin with [DIAGNOSES REDACTED], and the Unit Manager (UM), Medical Doctor (MD), and the family were made aware. Resident #8 was re-checked again an hour later and the area had blistered. The MD was called again, and new orders for Silvadene cream and dry dressing were obtained. The family and the UM were made aware of the change. Resident #8 was medicated for pain with Dilaudid 2 milligrams (mg) by mouth immediately following the incident that was effective. The Incident Report included in a statement, dated 4/24/15 Resident spilled coffee on herself. Resident request to have staff frequently reheat coffee. Staff inserviced regarding heating up liquids for resident, all liquids must be requested from kitchen, resident made aware as well. Occupational Therapy (OT) consulted for possible adaptive equipment. The investigation report, dated 4/22/2015, at 9:30 a.m. completed by the CN, described the injury as, blistered area of skin on Left lower leg- posterior, measuring 17.5 cm x 4.5 cm., the type of pain described as throbbing, and the resident's statement was- I spilled it. The CNA that reheated the water was the resident's aide for that date. Probable cause of incident was described as coffee too hot & resident lost her grip on coffee cup. Interventions taken were listed as 1. MD notified & order obtained for treatment. Silvadene applied with Kling wrap. 2. Care plan updated. 3. OT consult ordered for feeding devices; possible sippy cup. Resident refused. During an interview with Resident #8 on 4/28/15, day 2 of the survey at 10:55 a.m. Resident #8 reported that she was burnt with hot coffee. She stated, I asked the girls to get me coffee.(I) went to reach for the coffee and it got pushed off the overbed table onto my leg.5 minutes in the microwave, I think she thought I wanted it that hot. Now they are wrapping my leg twice a day with a cream. Resident #8 refused to allow the surveyor to observe the burn on her leg. Interview with the CNA on 5/19/15, at 9:35 a.m., indicated that on the day of the accident, the resident wanted her entire tray warmed up. I warmed it, but she fell back asleep as soon as I returned it to her room. The coffee water got cold again, 'the resident uses her own Folger's crystals', and she asked me to heat it again. I heated it for about a minute. The surveyor asked the CNA what the water looked like after being heated. The CNA stated that the water was warm, no bubbles, it wasn't boiling, there was just a little steam. The CNA was asked if she took the temperature of the water and she replied, we don't have a thermometer. The CNA then mixed the resident's coffee and left the room. Per the CNA, a few minutes later she heard yelling from the resident's room and went to check on her. The CNA reported that the resident had spilled the coffee onto her left leg and she (the CNA) told the nurse right away. The CNA then stated, we are not allowed to heat anything now for residents, we were all in-serviced, everything must come from the kitchen. The surveyor asked the CNA if she recalled an inservice in March of 2015 that food cannot be reheated on the units. The CNA denied remembering any inservice about it. I (CNA) have worked here for 6 years, nothing like this has ever happened before and I've worked on almost every floor. Review of the inservice, Dining With Dignity/Fine Dining/Dining Room Experience, dated 3/3/15 revealed that the CNA signed that she attended the inservice regarding food not being reheated on the unit. An interview with Assistant Director of Nursing (ADON)/Staff Educator (SE) on 5/19/15 at 10:25 a.m. revealed that the facility staff was formally inserviced regarding the resident's food 2 times in March of 2015. The first in-service entitled Dining with Dignity/Fine Dining/Dining Room Experience on 3/3/15 which included a list of 16 Points to remember. Number 15 stated Food cannot be reheated on the units. This written inservice record included the signature of the CNA involved in the incident. The second written inservice, Tray temps and food tray delivery, dated 3/26/15 did not have the CNA's signature on the sign in sheet. The content of this inservice was not presented to the surveyor. The ADON/SE informed the surveyor that there were no other written inservices regarding heating or reheating after the burn incident; only verbal (inservice) to the facility staff. During an interview on 5/19/15 at 9:35 a.m., the UM stated that staff is called to reheat food, (solids & liquids) at least once, sometimes twice a shift. The UM's signature was not on the 2 inservices given in March 2015. During an interview with a Staff Registered Nurse (RN) on 5/19/15, she indicated that the kitchen reheats everything. We don't do it. It was also revealed that the RN did not sign the attendance sheet for the Dining With Dignity/Fine Dining/Dining Room Experience inservice dated 3/3/15 nor was her signature on the inservice attendance sheet for Tray temps and food tray delivery dated 3/26/15. During an interview, CNA #2, stated we are not allowed to reheat foods or liquids of residents. CNA #2's signature was on the attendance sheet for the Dining with Dignity/Fine Dining/Dining Room Experience dated 3/3/15, but was not on the attendance sheet for the inservice entitled Tray temps and food tray delivery, dated 3/26/15. During a second interview on 5/19/15 at 12:35 p.m. with the ADON/SE, the surveyor questioned whether item # 15 on the Dining With Dignity- Fine Dining inservice was intended to address the heating of liquids. The ADON stated that #15 only referred to solid foods, not liquids. On 5/19/15, the 3rd day of the survey at 1:35 p.m. the surveyor attempted to interview the resident involved in the incident. The surveyor knocked on the resident's opened door and the resident stated she spilled soda all over herself and was all wet, my bed is wet, my clothes are wet. As the surveyor exited the room, a nurse was coming in, followed seconds later by another nurse to assist the resident. The surveyor did not interview Resident #8 after she was changed by the staff. During Interview #3 with the ADON/SE on 5/19/15, at 2:45 p.m., the surveyor inquired how resident's liquids would get heated or reheated. The ADON/SE responded, I'm not sure what we were doing with liquids. They had no direction on how to heat liquids. During an interview with the Director of Nursing (DON) on 5/19/15 at 3:15 p.m., the surveyor inquired as to how facility staff would accommodate a resident's request for warmer food/fluids. The DON stated in March 2015 we decided to have the kitchen bring up an entire tray, instead of reheating. The surveyor informed the DON that the ADON/SE had stated that the March inservices were regarding only the heating or reheating of solid foods, and that according to the ADON/SE there was no direction provided on the heating or reheating of liquids for residents. The DON later spoke to the ADON/SE in another room and returned to the conference room on 5/19/15 at 3:50 p.m. with a typed statement signed by the DON which stated, May 19, 2015 I clarified with (ADON), that during inservice on Fine Dining she discussed with staff all items on dietary tray which included liquids. Staff also was instructed that they are to call kitchen to provide coffee and tea throughout the day if requested by residents. (DON's name and title was typed and there was also a handwritten signature ) On 5/19/15 the DON provided a written summary clarifying facility procedure regarding the heating or reheating of resident food and liquids. The heating and reheating procedure includes all items on the resident's dietary tray, which include liquids. Staff is also instructed to call the kitchen to provide coffee and tea throughout the day if requested by residents. The ADON/SE was present in the room when the DON gave the surveyor of the typed statement signed by the DON and the written summary clarifying facility procedure, and the ADON/SE did not dispute, deny, or add any other information. The Food Temperature policy stated that all food is to be prepared and served within the appropriate ranges set forth in this manual. The Test Tray Audit sheet revealed that the required temperature for hot beverages was 140 degrees. At 12:45 p.m. on 5/19/15, the Administrator informed the surveyor that the policy was for dietary staff only. Part B 1. The surveyor entered the lobby of the facility on April 21, 2015 at 9:05 a.m. and observed the following: The three front doors to the exterior of the facility were not locked. One door was a sliding door that opened automatically via sensor, and the other two doors were unlocked push bar doors that opened into a partially enclosed patio/seating area. These doors were located on either side of the sliding door. After exiting the doors there was a sidewalk which slopes down to the driveway and parking lot. There was no receptionist at the front desk in the lobby area. The surveyor also did not observe any residents and/or staff in or around the lobby area. The surveyor stood waiting by the reception desk until 9:15 a.m. when a staff member entered the lobby and asked the surveyor if anyone was assisting her. The surveyor informed the staff member that no one had assisted her. The surveyor introduced herself and asked to see the Director of Nursing (DON) or the Administrator. The staff member stated I will get her for you, I will be right back. At 9:20 a.m., the DON came to the lobby, introduced herself and apologized for the surveyor's wait. The DON also stated that the receptionist had called out and the facility was waiting for a replacement, who was on her way. The DON confirmed that there was a wanderguard system. The DON informed the surveyor that she could use the Administrator's office, since the Administrator was not in that day. The Administrator's office was immediately adjacent to the lobby and the surveyor could observe the lobby area. The surveyor observed from 9:05 a.m. until 9:20 a.m. that the lobby doors were unattended. On 4/21/15 at the surveyor asked the DON about the facility's front doors and the DON stated that the doors are unlocked at 8 a.m. and locked nightly at 8 p.m. The DON reported that the doors are on a timer for automatic locking and unlocking. During an interview at 3:55 p.m., the replacement receptionist stated that she entered the facility that morning at approximately 9:30 a.m. and sat at the front desk in the lobby. An interview with the DON revealed that the receptionist duties include signing people in and out, looks up room numbers of residents for visitors, and is mindful of who is able to go out. Review of the Receptionist's job description indicated that the receptionist #7. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's needs and rights. NJAC 8:39-27.1 (a)

Based on observation, interviews and a review of pertinent facility documents, it was determined that the facility failed to provide a safe and adequately maintained environment regarding 6 of 9 exit doors (Doors #3, #4, #5, #6, #8 and a Atrium exit door). The 6 exit doors malfunctioned and would have failed to alert staff that a door leading to the outside was open. This deficient practice resulted in an immediate jeopardy to the safety of residents who had the potential to exit the facility without staff knowledge. The immediate jeopardy was identified on day one of the survey, 6/26/11, and lifted on 6/26/11 based on an acceptable plan of correction and is evidenced by the following: A. 1. The surveyor entered the facility on 6/26/11 at 10:45 AM and noted a strobing light flashing on the A wing in the Court Section of the building, no alarm was sounding and the wall panel, located at the nursing station and labeled, "ZONE ANNUNCIATOR, EXIT DOOR AJAR, ALARM," identified Door #6 with a red light illuminated. When questioned by the surveyor, the nursing staff, sitting at the nursing station, stated they did not know why the light was on. During an interview with the surveyor on 6/26/11 at 10:55 AM, the Weekend Supervisor stated that she was unsure as to why the light was strobing on the A wing, adding maybe an employee had exited the building. The Supervisor informed the surveyor that the door alarm sounds and the strobing light is activated when someone has opened the outside door. The Supervisor reset the alarm on the wall panel for Door #6 and demonstrated how the alarm system operated. However, when the outside door was again opened, the door failed to alarm and only the strobing light and the panel light were activated. The Supervisor was unaware of any system malfunction or how long the strobe light was on prior to the surveyor bringing this concern to her attention. At 11:00 AM, the Supervisor instructed her staff to do a resident head count and posted a staff member at Door #6 until the malfunction was investigated. At 11:15 AM, the Nursing Supervisor, accompanied by the surveyor, checked the functioning of the alarm system for exit Doors #4, #7 and #8. After opening exit Doors #4 and #8, the strobe light did not activate and the alarm did not sound. Exit Door #7 appropriately sounded and the strobe and panel lights were activated. On 6/26/11 at 11:45 AM, the surveyor noted that exit Door #4 had been repaired and functioning with alarm, strobe and panel lights. During a tour on 6/26/11 at 12:00 PM, accompanied by the Director of Maintenance, exit Doors identified as #1, #2, #3 and #5 were tested for functioning. The alarms for exit Doors #1 and #2 sounded and the strobe and panel lights were activated. However, the doors identified as #3 and #5 did not alarm, there were no strobe lights wired to those exit doors and the panel did not light identifying that the exit doors had been opened. On an exit door leading to the outside, located in the Atrium section of the building, a sign was posted which stated, "Hold the door handle for 10 seconds, alarm will sound and door will open." In addition, a keypad was observed by the surveyor to be located to the left of the same exit door. However, when the surveyor pushed the exit door handle, the door immediately opened without using the keypad or any alarm sounding. Another exit door leading to the outside, located to the right in the Resident Lounge, opened without pushing the "Exit" button located on the wall to the left of the exit door. This exit door also did not alarm when opened. On 6/26/11 at approximately 11:00 AM, the surveyor observed Resident #4 ambulating in the resident lounge area. According to the medical record, Resident #4 had [DIAGNOSES REDACTED]. A Minimum Data Set, an assessment tool, dated 6/13/11, showed that Resident #4 had wandering behaviors. An Interdisciplinary Plan of Care, dated 3/15/11, identified wandering and risk for elopement as a problem for Resident #4. Interventions included, but were not limited to, Wanderguard, check placement and function every shift; redirect away from doors and elevators. On 6/26/11 at 12:15 PM, the surveyor observed that the exit button for the door to the right of the Resident Lounge had been repaired and was now functioning. However, the surveyor was informed by the Director of Maintenance that this exit door was not one of the doors identified as needing an alarm or strobe light. During an interview with the surveyor at the same time, the Director of Maintenance stated that he has been employed with the facility since November 2010 and had not checked the 8 alarmed exit doors associated with the wall panel for functioning "as it was the Nursing Department's responsibility." Furthermore, the Atrium exit door should have required the use of the keypad before holding down on the door handle for it to open. Additionally, he stated that the exit door to the right in the Resident Lounge should not have opened without pressing the "Exit" button and he had not known this door to have an alarm. He advised the surveyor that he will check the wiring for both doors. During an interview with the surveyor on 6/26/11 at 12:15 PM, the Director of Nursing stated that she was not aware of Nursing's responsibility for the routine checks on the 8 alarmed exit doors noted on the panel. A review of the facility form, titled "Daily Rounds Air/Water Temperatures-Wanderguard (WG)," under the heading, "Keypads/ Security Doors," revealed that the only door checked in the "Court" was the Court Entrance. This was the only door connected to the WG. In an interview with the surveyor on 6/27/11 at 1:30 PM, the Director of Maintenance stated that the WG system is only on at the front doors, no other doors are affected by the WG system. Facility policy, titled "Door Alarms" which is dated 5/07, states, "It is the policy of this facility that our door alarms are functioning properly and are tested daily by maintenance. 1. Maintenance or designee is to check alarms on exits daily to assure they are being maintained and functioning properly. 2. A log is to be kept identifying the doors that are being tested along with the date and outcome of the test. 7. At no time shall an exit door be non operational without an employee safeguarding door so that residents are not a risk of hurting themselves." During an interview with the surveyor on 6/27/11 at 1:30 PM, the Director of Maintenance and the Regional Director of Maintenance stated that exit Doors #3 and #5 had been misidentified by the Director of Maintenance on 6/26/11. Exit Door #5 on the panel should have been the exit door identified on 6/26/11 as the door to the right in the Resident Lounge. However, on 6/26/11, the Director of Maintenance had indicated to the surveyor that the only maintenance required on that door were repairs to the Exit button, which were completed on 6/26/11, and did not require an alarm. Since staff were posted at the exit door originally identified as Door #5, the correct Door #5 can be seen by the same staff. Door #5 was functioning at the wall panel. Exit Door #3 was actually the exit door by the loading dock. The surveyor observed this exit door with disconnected wiring and no strobe light. Door #3 was not functioning at the wall panel. The Immediate Jeopardy (IJ) to the residents health and safety was identified on 6/26/11, day one of survey. The IJ was lifted 6/26/11 when an acceptable plan of correction was provided. B. The deficiency continues at a scope and severity level of "E" as evidenced by the following: 1. All of the identified exit doors were immediately repaired or staff were posted at the exit doors to prevent any residents from leaving without staff knowledge until all door repairs are completed. An Addendum was requested on 6/27/11 to correctly identify exit Doors #3 and #5. Staff were posted at exit Doors #3, #5 and #8 until repairs could be completed. 2. A Staff Education Program was conducted on 6/27/11 for all staff. The education included Responding to Dome Lights (strobe lights). 3. Beginning immediately, the Nursing Supervisor and or designee will do routine checks on door alarms every shift (every 12 hours). Any malfunction of the door alarms will be reported to the Administrator, Director of Nursing and the Maintenance Director immediately. A staff member will be posted at the exit door continuously until repairs are completed. 4. Beginning immediately, an audit tool will be utilized to record the operation of the door alarm. The supervisor and or designee will ensure this practice. 5. The results of the audit tool will be reviewed at the QA meetings and changes made by the interdisciplinary team will be presented at this time. NJAC 8:39-31.2(e)