Every finding on record at Stonebridge at Montgomery Health Care Center

Repeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/25/26 at 9:19 AM, in the presence of the Director of Culinary (DOC) the surveyor observed the following:1. On the bread storage shelf, the surveyor observed an opened bag of sandwich rolls without an opened or use by label. The DOC stated all opened items should be labeled with a use by label.2. On the dry storage shelf, the surveyor observed a 42-ounce (oz) container of oatmeal with a use by date of 6/1/26. The DOC stated the oatmeal should have been discarded.3. In the walk-in freezer, the surveyor observed a significant build up of frost on the ceiling and on the condenser as well as boxed items stored above 18 inches (in) from the ceiling. Per DOC the frost build up is a reoccurring issue and maintenance is aware, and all items should be stored below 18 in from the ceiling.4. In the chef preparation area, the surveyor observed a chef with large, hooped earrings. The DOC stated large earrings are not allowed to be worn in the kitchen. The chef removed their earrings. 5. In the cooking area of the kitchen, the surveyor observed two, two door standing ovens with a sticky substance on the top of the ovens and on the top cover of the tilt skillet was observed with a blackish grease-like substance. The DOC stated all equipment is supposed to be cleaned after use and would be cleaned immediately. On 6/26/26 at 10:48 AM, during the follow up tour of the kitchen, the surveyor observed the chef check the temperature of a tray of broccoli without sanitizing the thermometer prior to use. The DOC stated the thermometer needs to be sanitized prior to and after use. The DOC discarded the tray of broccoli.On 6/29/26 at 9:20 AM, the DOC provided the surveyor with multiple facility policies. The Food and Supply Storage policy with a revised date of 1/2026, revealed under the procedures section, Cover, label and date unused portions and open packages. Store food items 6in above the floor and 18in below sprinklers. The Uniform Dress Code policy with a revised date of 1/2025, revealed under the procedures section, Earrings are not permitted. The Cleaning of Food and Nonfood Contact Surfaces policy with a revised date of 1/2025, revealed under the policy section, Food contact surfaces, to prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use. Nonfood contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of accumulation oof dust, dirt, food particles, and other debris.On 6/29/26 at 12:26 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review concerns found during the survey. The LNHA stated all kitchen concerns will be addressed immediately.On 7/1/26 at 11:00 AM, the surveyor met with the LNHA and DON for the exit conference. No further pertinent info provided. NJAC 8:39-17.2(g)

Repeat Deficiency Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress (a medical-grade mattress that uses continuous airflow to keep the skin dry, cool, and pressure-free, helping prevent and treat pressure injuries) was accurately set and monitored according to the resident's weight for 3 of 4 residents (Resident #5, #26, and #29). 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. 1. On [DATE] at 10:29 AM, the surveyor observed Resident #29 awake in bed, laying on an air mattress. Resident #29's air mattress was set at 240 pounds (lb.). Resident #29 revealed their usual body weight is around 190 lb. On [DATE] at 11:30 AM, the surveyor reviewed Resident #29's electronic medical record (e-MAR) which revealed the following: A review of the Resident #29's admission Record ((AR) an admission summary) documented that the resident was admitted to the facility with diagnoses that included: pressure ulcer of sacral region (sacral pressure ulcer is a localized injury to the skin and underlying tissue over the sacrum caused by prolonged pressure), severe sepsis (a life-threatening condition in which sepsis leads to organ dysfunction due to a dysregulated host response to infection), and multiple sclerosis (an autoimmune disease that affects the central nervous system.) A review of the admission Medicare [NAME] Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of [DATE], revealed that the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive function. The MDS further revealed under Section M, that Resident #29 had two pressure sores and was receiving a pressure reducing device for bed. A review of the [DATE] Physician Orders (PO) for Resident #26 revealed a PO dated [DATE], Air mattress to bed, monitor every shift for function. A review of the Care Plan Report (CPR) revealed a Care Plan (CP) with a focus of, I have impaired skin related to.sacral wound. And interventions including, air mattress. A review of Resident #29's vitals revealed two separate weight entries: [DATE]: 191 lb. and [DATE]: 191 lb. On [DATE] at 9:06 AM, the surveyor observed Resident #29 in bed with their eyes closed and the air mattress was set to 240 lb. 2. On [DATE] at 10:47 AM, the surveyor observed Resident #26 in bed with their eyes closed laying on an air mattress. Resident #26's air mattress was set at 320 lb. On [DATE] at 11:40 AM, the surveyor reviewed Resident #26's e-MAR which revealed the following: A review of the Resident #26's AR documented that the resident was admitted to the facility with diagnoses that included: vascular dementia (a form of dementia caused by an impaired supply of blood to the brain), dysphagia (difficulty swallowing), abnormalities of gait and mobility (unusual or impaired patterns of walking or movement that can affect balance, coordination, and overall mobility.) A review of the annual MDS, with an ARD of [DATE], revealed that the resident was unable to complete a BIMS, due to rarely being understood. The MDS further revealed under Section M, that Resident #26 was receiving a pressure reducing device for bed. A review of the [DATE] PO for Resident #26 revealed a PO dated [DATE] Air mattress-check for function. A review of the CPR revealed a CP with a focus of, I am at risk for alteration in skin integrity secondary to needing assistance with activities of daily living. And interventions including, a pressure relief mattress is on my bed. A review of Resident #26's vitals revealed four separate weight entries: [DATE]: 110.2 lb., [DATE]: 108.2 lbs., [DATE]: 109.6 lb., and [DATE]: 109.2 lb. On [DATE] at 8:55 AM, the surveyor observed Resident #26's mattress was set at 320 lb. On [DATE] at 9:42 AM, the surveyor interviewed the Registered Nurse (RN#1) who observed both Resident #26 and #29's air mattresses. RN#1 confirmed both mattresses were not set to the residents' current body weight (CBW) and revealed air mattress should be set to the residents' CBW. On [DATE] at 9:51 AM, the surveyor interviewed the Director of Nursing (DON) who also confirmed air mattresses should be set to the residents' CBW. On [DATE] at 12:25 PM, the DON provided the surveyor a facility policy titled, General guidelines wound and skin care with a revised date of [DATE]. The purpose statement of the policy revealed, 3. To promote healing of pressure ulcers and prevention of additional pressure ulcers and provide comfort for residents admitted with skin breakdown. The DON also provided the surveyor with the operator's manual for the resident's air mattress. The operating instructions revealed, 6. Determine the patient's weight and set the control knob to that weight setting on the control unit. On [DATE] at 12:26 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON to review concerns found during the survey. The DON stated all air mattresses have been checked for any weight discrepancies. On [DATE] at 11:00 AM, the surveyor met with the LNHA and DON and no further pertinent information provided. 3. On [DATE] at 10:16 AM, the surveyor observed Resident #5 seated in a wheelchair with his/her eyes closed. The resident did not respond to the surveyor's greeting. On [DATE] at 11:39 AM, the surveyor reviewed the electronic medical record (E-MAR) for Resident #5. A review of the admission Record (AR) reflected that Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; osteomyelitis (serious bone infection) of left ankle and foot; peripheral vascular disease (circulation disorder); and vascular dementia (a decline in thinking and memory caused by reduced blood flow to the brain). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], reflected that the resident had a severe cognitive impairment. The MDS further assessed that the resident had skin and ulcer treatments that included a pressure-reducing device for the bed and applications of ointments/medications. A review of the current Physician's Order (PO) reflected a PO for a Pressure Relieving Mattress as per facility protocol; to check and verify inflation and setting with a start date of [DATE]. A review of the Vital Signs reflected the resident's last weight was 140 lbs. A review of Resident #5's Care Plan included the resident had a sacral ulcer with interventions that included but were not limited to; air mattress on the bed at all times. On [DATE] at 10:10 AM, the surveyor observed Resident #5 in bed with an air mattress in place and the air pump set at 250 pounds. On [DATE] at 10:45 AM, the surveyor showed the Registered Nurse (RN) assigned to Resident #5 the gauge setting on the specialty mattress. The RN acknowledged that the setting was 250 lbs. and stated that it should have been set to the resident's current weight of 140 lbs. The RN confirmed that the specialty mattress had been ordered to prevent and assist in the prevention of pressure ulcers and stated that maintaining the correct weight setting was important to ensure the effectiveness of the device. On [DATE] at 11:50 AM, the surveyor requested the air mattress policy and procedure from the Director of Nursing (DON). The DON stated that the facility did not have a policy for specialty mattresses. On [DATE] at 12:28 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. On [DATE] at 11:02 AM, no further information was provided. NJAC 8:39-19.4(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure proper documentation of one (1) controlled dangerous substances (CDS) medications (meds) for one (1) resident; Resident #17 by 1 of 3 nurses observed during the medication administration.The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/26/26 at 9:20 AM, the surveyor observed the Licensed Practical Nurse (LPN) assigned to Resident #17 prepare and administer meds to the resident. The surveyor observed the LPN prepare the medication lorazepam .5mg tablet (an antianxiety medication), 1 tablet. The LPN stated to the surveyor that they like to give the CDS med separate from the other meds. The surveyor observed the LPN remove the med from the packaging and place it in a med cup, return the card to the locked storage, then administer the medication to the resident. The LPN then returned to the med cart, documented administration on the electronic medication administration record (eMAR), then opened the binder containing the inventory count sheets for CDS meds and documented the removal of the lorazepam on the inventory count sheet.The surveyor completed the observation. On 6/26/26 at 11:00 AM, the surveyor interviewed the facility Consultant Pharmacist (CP) by telephone. The surveyor asked the CP when the nurse should sign the inventory count sheet for a CDS med. The CP stated that the nurse should sign immediately after removal from the package, before administering to the resident. On 6/26/26 at 11:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #17. The EMR revealed the following:A Face Sheet (FS) (an admission summary), a Physician Order Sheet (POS) (a listing of the resident's current orders), which reflected a current order for lorazepam .5mg tablet to be given twice a day. An eMAR, which reflected that the lorazepam order was administered on 6/26/26 at the 9:00 AM medication administration period.On 6/29/26 at 10:31 AM, the surveyor interviewed the Director of Nursing (DON). The surveyor asked the DON when a nurse should sign the inventory count sheet for a CDS med. The DON stated that the nurse should sign for the CDS before giving med, when removing it from package, not after administration.On 6/29/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON for concerns. The surveyor notified the DON of the med pass results and the nurse signing incorrectly for the CDS.On 6/30/26 at 10:19 AM, the survey team met with the LNHA and DON for responses to concerns. The DON stated that education is to be done on the nurse about signing CDS meds the next shift they are working. The facility did not provide any further pertinent information. On 6/29/26 at 11:00 AM, the surveyor reviewed the facility policy titled Administering Medications, dated revised 2/12/26, that was provided by the DON. The policy reflected under 5. The nurse will document immediately on the controlled declining inventory sheet when administering controlled medications. NJAC 8:39-29.7(c)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication, by failing to monitor and document if the medication (med) was effective, for one (1) of five (5) residents reviewed, (Resident #16).The deficient practice was evidenced by the following: On 6/30/26 at 10:00 AM, the surveyor reviewed Resident #16's hybrid medical record, (electronic and paper), which revealed the following: An admission Record (AR), an admission summary, reflected that Resident #16 was admitted to the facility with medical diagnoses that included but were not limited to; bipolar disorder (a chronic mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels), and difficulty walking. A Quarterly Minimum Data Set (qMDS) an assessment tool, with an assessment reference date (ARD) of 6/11/26, reflected that the resident had a brief interview for mental status (BIMS) score of 1 out of 15 indicating the resident was severely cognitively impaired. Further review of the qMDS in Section H reflected that the resident was frequently incontinent of urine. A Physician Order Sheet (POS), a listing of the resident's active physician orders, dated June 2026, revealed that the resident was being administered oxybutynin 5mg tablet twice a day, a medication used to treat an overactive bladder, that relieves symptoms of sudden, uncontrollable urge to urinate, frequent urination, and urine leakage (incontinence). A Comprehensive Care Plan (CCP), (an individualized document reflecting goals, interventions and services for a resident's care) revealed that the resident was at risk for bladder incontinence. A review of Resident #16's paper chart revealed Medical Progress Notes (PN). The PN dated 1/6/26 through 6/24/26 reflected that the resident was taking the oxybutynin for overactive bladder. The PN did not reflect that the resident was still incontinent with the medication, the effectiveness or lack of effect of the oxybutynin, or a benefit vs risk for the use of a med that may have adverse side effects in an elderly person. On 6/30/26 at 11:09 AM, the surveyor interviewed the Registered Nurse (RN) who cared for and was familiar with Resident #16. The surveyor asked the RN about the resident's incontinence status. The RN stated that the resident is mostly incontinent and gets regular incontinence care every 2 hours or when requested. The RN stated that the resident sometimes will ask to be toileted but not frequently. On 6/30/26 at 11:17 AM, the surveyor interviewed the Director of Nursing (DON) about Resident #16's incontinence. The DON stated that they considered the resident as incontinent. On 7/1/26 at 10:30 AM, the survey team met with Licensed Nursing Home Administrator (LNHA) and DON for additional concerns. The surveyor notified the DON that Resident #16's medical record did not contain any PN reflecting the effectiveness or benefit vs risk for oxybutynin. The facility did not provide any further pertinent information. On 7/1/26 at 10:00 AM the surveyor reviewed the facility policy titled Physician Visits, revised 10/24/24, provided by the DON. The policy reflected under 5. The.Physician must perform relevant tasks at the time of each visit, including a review of the resident's program of care and appropriate documentation. N.J.A.C. 8:39-27.1(a)

Repeat Deficiency Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care for 1 of 1 resident (Resident #5).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 06/26/26 at 10:16 AM, the surveyor observed Resident #5 seated in a wheelchair with his/her eyes closed. The resident did not respond to the surveyor's greeting. On 6/26/26 at 11:39 AM, the surveyor reviewed the electronic medical record (E-MAR) for Resident #5.A review of the admission Record (AR) reflected that Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; osteomyelitis (serious bone infection) of left ankle and foot; peripheral vascular disease (circulation disorder) and vascular dementia (a decline in thinking and memory caused by reduced blood flow to the brain). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 4/17/26, reflected that the resident had severe cognitive impairment. The MDS further assessed that the resident had skin and ulcer treatments that included a pressure-reducing device for the bed and applications of ointments/medications. A review of the current Physician's Order (PO) reflected a PO for Enhanced Barrier Precautions and a PO to cleanse the stage 2 (partial thickness skin loss involving the epidermis and the dermis) wound with wound cleanser, apply a medical grade antibacterial honey ointment used to treat superficial to full thickness wounds) to the wound, apply zinc oxide to the periwound (tissue surrounding the wound) and cover with bordered gauze dressing daily and as needed (prn) dated 6/15/26.A review of Resident #5's Care Plan included the resident had a sacral ulcer with interventions that included but were not limited to; skin and wound treatments and specialty mattress. A review of the Weekly Wound Assessments dated 6/24/26 indicated the Stage 2 Pressure Injury was improving. On 6/29/26 at 10:10 AM, the surveyor observed signage outside of Resident #5's room which indicated that the resident was on Enhanced Barrier Precautions (EBP).staff and providers must wear gloves and a gown for High-Contact Activities .which included but were not limited to; Wound care: any skin opening requiring a dressing. On 6/29/26 at 10:15 AM, the surveyor observed the Registered Nurse (RN) perform the treatment to Resident #5's sacral wound and observed the following:The RN gathered wound care supplies, which included 4x4 gauze pads moistened with wound cleanser, petroleum jelly, and a medical grade antibacterial honey ointment and zinc oxide, and a bordered dressing. The RN, without disinfecting or cleaning the overbed table (OBT) placed a protective barrier on the OBT and then placed the wound care supplies on the barrier. The surveyor observed the RN applied alcohol-based hand rub (ABHR) and donned (put on) gloves. The RN did not don a gown prior to the treatment. The surveyor observed that after cleansing the wound, the RN removed her gloves and donned a new pair of gloves without performing hand hygiene or applying ABHR. The RN applied the medical grade antibacterial honey ointment directly to the wound bed using her gloved finger rather than an applicator. The RN then removed her gloves and donned another pair of gloves without performing hand hygiene. After completing the wound treatment, the RN did not disinfect the OBT.On 6/29/26 at 10:40 AM, the surveyor discussed the observed Infection Control breaches with the RN. The RN acknowledged that she should have donned a gown before initiating the wound treatment and should have performed hand hygiene between glove changes. The RN further acknowledged that the OBT should have been disinfected both before and after the wound treatment and confirmed that an applicator should have been used to apply the Medihoney rather than applying it with her gloved finger. On 6/29/26 at 12:28 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. On 6/30/26 at 11:00 AM, the surveyor reviewed the facility's Wound and Skin Care policy dated 2/13/26, which reflected .To prevent pressure ulcer formation in residents who are identified as high risk for skin breakdown . On 6/30/26 at 11:30 AM, the surveyor reviewed the facility's Enhanced Barrier Precautions policy dated 4/15/25, which reflected .Enhanced Barrier Precautions (EBP) refer to an intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. High contact resident care activities include, but are not limited to: bathing, dressing, transferring, changing linens, briefs .wound care including pressure ulcers . which include .wound care .Gowns and gloves are the minimum level of Personal Protective Equipment (PPE) for these high-contact resident care activities. On 6/30/26 at 11:45 AM, the surveyor reviewed the Handwashing/Hand Hygiene policy dated 3/12/25 which reflected .This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol .for the following situations .before putting on) gloves .the use of gloves does not replace hand washing/hand hygiene. On 7/1/26 at 11:02 AM, no further information was provided. NJAC 8:39- 27.1 (a)

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training education for 2 of 5 CNAs reviewed (CNA #1 and #4 ). The deficient practice was evidenced by the following: On 06/29/2026 at 12:48 PM, the surveyor reviewed the facility-provided in-service education for five randomly selected CNAs for the year 2025, which revealed the following: CNA #1 with a date of hire ( DOH) 10/31/2012 had 9.65 hours of in-service training. CNA #4 with a DOH 4/20/21 had 4.9 hours of in-service training. On 6/30/26 at 10:18 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. The LNHA stated that the Human Resource Department and the Nursing Department were responsible for ensuring the CNAs completed their 12 hours of education. On 7/1/26 at 9:30 AM, the surveyor reviewed the facility's Certified Nursing Assistant Education policy dated 1/16/26, which indicated .All CNAs participate in regularly scheduled or ad hoc in-service training classes .Annual in-services are no less than 12 hours per employment year . On 7/1/26 at 11:02 AM, no further information was provided. N.J.A.C. 8:39-43.17(b)

Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to: a.) adequately monitor and supervise a resident (Resident #15) who was identified as a high fall risk and sustained nine unwitnessed falls with four falls that resulted in injuries that required hospitalization which included; an intracranial bleed (brain injury) and a laceration that required seven sutures (stitches), a fracture to the left hip requiring surgical repair (Open Reduction and Internal Fixation - ORIF), a hematoma (collection of blood outside the blood vessels similar to a bruise) and laceration to the back of the head that was closed with stitches, and a right hip fracture; b.) revise, reassess, and re-evaluate a resident (Resident #21) who had a history of falls in the facility including falls with major injury, for appropriate interventions to prevent additional falls; c.) to ensure fall interventions were consistently implemented for residents identified as being high risk for falls who sustained injuries from falls; and d.) provide residents with care and services that ensured their safety during care. This deficient practice was identified for 4 of 5 residents reviewed for accidents (Resident #1, #15, #21 and #25), and was evidenced by the following: A review of the facility's policy titled Falls Management Program, dated last revised 4/15/25, included Policy and Procedure: 1 .Residents at high risk for falls must have an appropriate intervention protocol established immediately upon admission, documented on the Baseline Care Plan, and continued onto the comprehensive care plan .5. All fall interventions must be based on assessment results, individualized, interdisciplinary, communicated to appropriate staff and family, communicated to the resident when appropriate, and updated as needed .Post Fall a. The Interdisciplinary team, at the daily report of falls Committee will review the post fall assessment, incident report, any employee/resident statements, post fall assessment, incident report, any employee/resident statements, post-fall investigation, post fall summary, and current interventions to evaluate if they were appropriately implemented, still relevant, and effective. All changes will be communicated to the direct caregivers .d. A physical therapist will screen the resident. Results will be documented in the medical record. 12. All falls are investigated and trended for possible causative factors utilizing the Risk Watch Analysis and reported to the community Quality Improvement Committee along with appropriate actions plans. 1. On 6/16/25 at 8:50 AM, the surveyor observed Resident #15 in their room eating breakfast. The call bell was observed on the floor next to the bed and was not within reach of Resident #15. On 6/16/25 at 9:03 AM, the surveyor observed Resident #15 in bed, and the resident informed the surveyor that they had pain to their left leg. Resident #15 stated, I fell. On 6/16/25 at 9:15 AM, during an interview with the Licensed Practical Nurse (LPN #1), she stated that Resident #15 received pain management and she assessed the resident for the pain. On 6/17/25 at 8:32 AM, the surveyor observed Resident #15 in bed with bruises on their left hip, and the resident reported they had pain all over. The surveyor then observed the call bell was tied to the bedrail on the left side and was out of reach of the resident. On 6/17/25 at 11:02 AM, the surveyor reviewed Resident #15's electronic Medical Record. A review of the Face Sheet (an admission summary) reflected that Resident #15 was admitted to the facility with diagnoses which included but were not limited to; hypertension, difficulty in walking, history of falls, unspecified abnormality of gait and mobility, and vascular dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 3/20/25, reflected that Resident #15 scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was severely cognitively impaired. The electronic Medical Record for Resident #15 revealed the following documented incidents: 1. On 12/15/24 at 4:05 PM, the resident was confused since the beginning of the shift. Resident #15 was found on the floor in the bathroom, and the bathroom shower and the resident's room were flooded. The resident was transferred to the emergency room for evaluation, and a urine analysis and culture were collected and were negative. 2. On 2/7/25 at 5:15 AM, the resident was found on the floor in their room bleeding with a laceration to the right side of their forehead and top of their nose. Resident #15 was transferred to the emergency room and diagnosed with intracranial bleeding and required seven sutures to repair the laceration. A review of the incident report provided revealed that staff last observed the resident at 12:00 AM, although the resident was on frequent monitoring. The facility was not aware of how long the resident was on the floor. 3. On 3/1/25 at 2:15 AM, the resident was found on the floor. There were no documented injuries. 4. On 3/1/25 at 12:15 PM, the resident was found on the floor in the bathroom, and the resident was encouraged to call for assistance. There were no documented injuries. 5. On 3/5/25 at 9:30 AM, the resident was found on the floor next to the bed. The resident stated they were trying to get back to bed. The resident was transferred back to bed and encouraged to call for assistance. There were no documented injuries. 6. On 3/7/25 at 8:45 AM, the resident was found lying on the floor in the bathroom with their hand under their head. The resident stated, I was trying to go the bathroom. There were no documented injuries. 7. On 6/4/25 at 3:55 AM, the resident was found on the floor with a skin tear to their left upper arm and change in the range of motion of their left leg which they were unable to move and complained of pain. Resident #15 was transferred to the emergency room and diagnosed with the left hip fracture. The resident underwent an ORIF of the left hip to repair the fracture. 8. On 6/9/25 at 2:58 AM, the resident was found on the floor in their room with a laceration and hematoma to their right posterior head. The resident was hospitalized and treated for anemia. 9. On 6/17/25 at 4:58 PM, Resident #15 was found on the floor in the bathroom and they were transferred to their wheelchair with a two-person assistance. Resident #15 was re-educated to use the call light. Resident #15 was provided with a tap bell (a call light with a modified push to call button) to press for assistance. There were no documented injuries. A review of the interdisciplinary comprehensive care plan (ICCP) provided by the facility on 6/18/25, revealed a focus area that Resident #15 was at high risk for falls related to weakness and difficulty in transfers and ambulation, and the resident refused to stay in supervised areas. The goal was that Resident #15 will have no major injury from falls through the next review date. Interventions included: -Tap bell, initiated 6/17/25. -Administer antipsychotic and antidepressant as ordered and monitor for side effects and adverse reactions, initiated 7/9/24. -Call Medical Doctor as needed and assist with on putting on my non-skid footwear and remove at night, initiated 7/9/24. -Assist with transfer and physical functioning, initiated 7/9/24. -Ensure a safe and clutter free environment, initiated 7/9/24. -Lower bed to the floor, initiated 7/9/24. -Provide frequent staff monitoring, initiated 7/9/24. -Periodic assist to toilet at night, initiated 7/9/24. -Visual and verbal reminder to use call bell, initiated 7/9/24. -Place items within reach, initiated 7/9/24. -Encourage to call for assistance, initiated 7/9/24. -Provide a copy of activity schedule to choose activity, initiated 7/9/24. The ICCP was not updated after each fall to include interventions implemented after each fall to prevent additional falls. On 6/18/25 at 8:55 AM, the surveyor observed Resident #15 in bed and the resident reported pain to their right leg. The surveyor asked the resident to activate their call bell for assistance. The resident stated, I cannot see it. The surveyor observed a tap bell (modified call light) placed on the mattress behind the pillow, above the resident's head and to the left side. The tap bell was not within reach of Resident #15. On 6/18/25 at 9:15 AM, the surveyor interviewed the Certified Nurse Aide (CNA #1) and inquired about the placement of the resident's call/tap bell. CNA #1 informed the surveyor that the call/tap bell should be within reach. In the presence of another surveyor, the surveyor escorted CNA #1 to Resident #15's room where they all observed that the call/tap bell was not accessible. The resident attempted to turn and could not get access the call/tap bell. At that time, the Resident's Representative (RR) entered the room while we were discussing the call/tap bell, and they also confirmed that the call/tap bell was not accessible. The RR untied the chord for the resident's call/tap bell that was looped on their bedframe and placed it next to the resident's hand. On 6/18/25 at 10:48 AM, the surveyor interviewed CNA #1 again who cared for the resident. CNA #1 stated that Resident #15 required complete care and had to be assisted to the bathroom. CNA #1 stated the resident had a broken hip at present time and could not self-transfer to the bathroom. CNA #1 stated that the resident required a two-person assist for assistance to the bathroom and used a wheelchair for transfers. The surveyor then inquired if the resident had ever been on a toileting program, and CNA #1 stated, No. The surveyor asked CNA #1 about the last fall in the bathroom that resulted in the right hip fracture, and CNA #1 revealed that she received report that morning and was not informed that Resident #15 had another fall in the bathroom on the evening of 6/17/25. A review of the Progress Note dated 6/18/25, from the Physical Therapy department, revealed that the resident could not participate in physical therapy. The resident was complaining of pain to their right leg and was transferred back to bed by the physical therapy team. The physician was informed and ordered an X-ray of the right hip to rule out fracture. The X-ray results dated 6/18/25, were positive for a right hip fracture. Resident #15 was transferred to the emergency room for evaluation and treatment. On 6/18/25 at 10:30 AM, the surveyor requested from the Director of Nursing (DON) all Resident #15's investigations, their Fall Risk Assessments, and a timeline of their falls for review. On 6/18/25 at 12:15 PM, the following was provided and reviewed: A review of the Fall Risk Assessment guidelines revealed that a score of 10 points or above represented a high risk for falls. The resident scored a 10 or above on the following assessments: -On 12/19/24, Resident #15 received a score of 13. -On 2/9/25, Resident #15 received a score of 13. -On 3/1/25, Resident #15 received a score of 19. -On 3/5/25, Resident #15 scored 16. -On 4/7/25, Resident #15 received a score of 13. -On 6/18/25, Resident #15 received a score of 13. On 6/18/25 at 1:30 PM, the surveyor interviewed the DON regarding Resident #15's multiple falls. The DON stated that Resident #15 refused to be placed in supervised areas. The DON added that all the falls were discussed in the morning meetings. When inquired about the facility's process after a fall, the DON stated that a Registered Nurse (RN) assessed the resident after each fall, and the physician and the resident's representative were notified of the fall. The DON continued that a pain assessment was completed and if any injury was suspected, the resident was sent to the emergency room for evaluation and treatment. The DON stated that the nurse completed a fall assessment, obtained statements from all staff assigned to the unit to identify the causal factor, and implemented interventions based on the causal factor of each fall to prevent recurrence. On 6/18/25 at 9:30 AM, the surveyor asked for a timeline of the falls that outlined the date, time of the fall, the causal factor, and the interventions implemented after each fall. The DON provided the timeline. There were no revised interventions added to the ICCP after each fall. There was no investigation to identify who assisted the resident to the bathroom and the last time the resident was assisted with toileting. When inquired about the fall dated 6/17/25, where the resident again sustained a fall with major injury in the bathroom, the DON stated that she would provide the investigation. The surveyor reviewed the fall investigation dated 6/17/25 at 4:58 PM. The causal factor was not identified. The intervention added was a tap bell (modified call light) that the surveyor observed out of reach of the resident. On 6/19/25 at 8:15 AM, the surveyor reviewed the Physical Therapy notes. Resident #15's recommendations dated 10/4/24, revealed the following: Resident #15 needs supervision for all functional transfers due to decreased safety awareness. Resident #15 may ambulate with nursing staff with a (rolling walker) to the bathroom and dining room. These recommendations were not entered onto the ICCP. Resident #15 was not referred to physical therapy after the fall on 12/19/24 and 2/27/25, based on their fall management program. On 6/19/25 at 8:56 AM, the surveyor reviewed the recommendations from Physical Therapy dated 10/4/24, which revealed the following: Needs supervision for all functional transfers due to decreased safety awareness, [resident] may ambulate with nursing staff with rolling walker to the bathroom and dining room. The Physical Therapy Assessment Summary dated 3/20/25, revealed: fall 2/7/25, had a closed head injury, head computed tomography (CT scan; medical imaging technique that used specialized X-ray to produce detailed cross-sectional images of the inside of the body) which found an acute intracranial hemorrhage (brain bleed). The assessment revealed increased risk for falls and decline in function. The discharge summary signed 6/6/25, revealed the following: To continue with functional mobility and ambulate with caregivers. The resident was assessed as not being safe to ambulate independently. On 6/23/25 at 11:05 AM, the surveyor interviewed the Unit Manager (UM) regarding the type and frequency of supervision required for Resident #15. The UM stated that residents who refused to attend activities or were disruptive in activities, were left in their room close to their room door so staff could visualize them while in the hallway. The surveyor then inquired about how these residents would call for assistance, and the UM could not answer. The surveyor, accompanied by the UM, then went to Resident #15's room, and they both observed Resident #15 was alone in the room and did not have access to their call bell, while sitting in the wheelchair. The UM stated that the rooms would have to be rearranged, the call lights were not long enough for residents to access while being at the foot of their bed near the doorway. On 6/23/25 at 12:12 PM, during an interview with the Physical Therapist (PT), she stated that nurses did not refer the resident to therapy after the falls on 12/19/24 and 2/7/25. The PT could not provide any documentation of PT evaluations. On 6/25/25 at 12:30 PM, during a pre-exit conference with the administrative staff, no additional information was provided for Resident #15's falls. 2. On 6/16/25 at 9:15 AM, the surveyor observed Resident #21 wandering in a wheelchair in the hallway. Resident #21 had a communication barrier and was unable to communicate with the surveyor. On 6/16/25 at 10:30 AM, CNA #2 identified the resident as Resident #21, and informed the surveyor that the resident's dominant language was Spanish. On 6/18/25 at 10:50 AM, the surveyor reviewed Resident # 21's electronic medical record. A review of the Face Sheet reflected that Resident #21 had diagnoses which included but were not limited to; dementia, mood disturbance and anxiety, repeated falls, wedge compression fracture of second lumbar vertebra (lower back). A review of the quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. A review of the ICCP included a focus area initiated 12/11/24, for falls related to generalized weakness and poor safety awareness. The goal was for Resident #21 to not have any falls related injury for the next 90 days. Interventions included to: place my call bell within reach; I need reminders to call for assistance; keep my bed in the lowest appropriate position, wheels locked; and the upper bed rails up when in bed to enable assistance with mobility. The ICCP revealed that Resident #21 was at high risk for falls. The surveyor requested the fall investigations for the last three months for review, and the following incident reports were provided: On 2/28/25 at 3:45 AM, Resident #21 was found on the bathroom floor and reported pain in their lower back. A review of the X-ray report performed was positive for a T12 (thoracic vertebra middle of spine) fracture and a worsening of the L2 (lumbar vertebra lower spine) compression fracture when compared to the X-ray completed in 2023. The fall was not investigated to identify the causal factor and implemented measures to prevent further falls. On 3/18/25 at 4:00 PM, Resident #21 was observed with a laceration to their right calf measuring 11.5 centimeter (cm) by 6.5 cm (11.5 cm x 6.5 cm). The facility could not provide an investigation related to the above incident. No statements were attached to the incident report provided by the DON. The causal factors were not identified. An incident report dated 4/2/25 at 7:04 AM, revealed that Resident #21 was found on the floor in their room. A statement provided by the CNA who cared for the resident revealed that the resident fell at 12:30 AM. On 6/18/25 at 11:30 AM, the surveyor interviewed the Registered Nurse (RN #1), who worked on 4/2/25, during the 11:00 PM-7:00 AM shift, who stated that the resident was found on the floor around midnight and not at 7:00 AM. The surveyor reviewed the incident report with RN #1, and she confirmed that Resident #21 was unable to self-transfer out of the bed and was totally dependent on staff for transfers. The incident was not investigated, and the DON who completed the incident report could not comment on the discrepancy noted on the incident report she provided to the surveyor. The incident report reflected that Resident #21 was independent with toileting, Section GG of the MDS which assessed functional abilities and goals reflected that Resident #21 was dependent on staff and was coded as 01= dependent. On 6/18/25 at 12:30 PM, the surveyor interviewed the CNA assigned to Resident #21 on 6/18/25, and she confirmed that Resident #21 could not self-transfer or ambulate without assistance. The facility did not investigate to identify who assisted Resident #21 to the bathroom on 4/2/25. On 6/24/25 at 7:30 AM, Surveyor #1 and Surveyor #2 checked random rooms for call bell accessibility. Resident #21's call bell was noted on the floor underneath the bed and was not accessible to the resident. On 6/24/25 at 10:43 AM, the survey team interviewed the UM regarding the facility's call bell policy. The UM revealed that the call bell policy was the same for the tap bell (modified call light). The call bell should be accessible and placed within easy reach for the resident to press it. The UM also stated that the night supervisor informed her of a few call bells that were on the floor and not accessible for easy reach. On 6/25/25 at 12:30 PM, during a pre-exit conference with the administrative staff, the DON stated that Resident #21 could self-transfer to the bathroom and did not provide any additional information regarding the falls for Resident #21. 3. On 6/19/25 at 7:28 AM, the surveyor checked six random residents' room for call bell accessibility. The surveyor observed Resident #25 in their bed, and their tap bell (modified call light) was noted on top of the nightstand. The surveyor accompanied by the Nursing Supervisor (NS) entered Resident #25's room, and they observed the tap bell on top of the nightstand. The NS confirmed that the resident could not access their call light to call the staff, and the NS removed the tap bell on the nightstand and placed the tap bell on the bed by the resident. On 6/23/25 at 1:45 PM, Surveyor #2 reviewed the electronic Medical Record for Resident #25. A review of the Face Sheet revealed that the resident was admitted with diagnoses that included but were not limited to; displaced intertrochanter fracture of the right femur (type of bone fracture where the broken bone fragments are no longer in their normal alignment), vascular dementia, displaced fracture of second cervical vertebrae (a spinal fracture), bipolar disorder, difficulty in walking, and cognitive communication deficit. A review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 1 out 15, which indicated a severely impaired cognitive status. A review of the ICCP for Resident #25 dated 5/12/25, had a focus that the resident was at risk for falls and required assistance with transfers and physical functioning due to weakness and functional limitation of a fractured right hip and psychotropic drug use. On 6/2/25, the resident had a fall in room with a head injury and was sent to the emergency room. Goal was to not have fall related injuries in the next 30 days that was implemented on 5/12/25. The following interventions were implemented as of 5/12/25: administer psychotropic medications as ordered and monitor for side effects; assist with transfers and with physical functioning; ensure a safe and clutter free and well lighted environment; lower bed to the floor; provide frequent staff monitoring; verbal and visual reminder to use call bell for assistance; place call bell within reach and encourage to call for assistance; and tap call bell (modified call light). A review of the Nurses Note signed by a RN on 6/2/25 at 11:28 PM, which revealed details at time of fall: occurred 6/2/25 at 5:30 PM, in the resident's room, and the resident was alone. Resident #25 was alert to self and confused. Narrative: the writer was informed by aide about resident on the floor. The writer found resident laying prone [face down] in room, head in a pool of blood on the floor. Further assessment revealed a hematoma (bruise) to the forehead of the resident. Wound was cleansed with NSS (normal saline solution) and pressure dressing applied. A call was made to emergency services (911), and the resident was transferred to the emergency room for further evaluation. A review of the Physician Order Sheet for 6/1/25-6/30/25, included a physician's order dated 4/21/25, for divalproex 125 milligram (mg) capsule, delayed release sprinkle; give one capsule three times a day for bipolar disorder. The medication was administered on 6/2/25 at 1:00 PM, for the behavior symptom of paranoia, (extremely suspicious of others, believing others were trying to harm them). On 6/23/25 at 2:00 PM, Surveyor #2 requested all investigations for Resident #25. On 6/23/25 at 2:29 PM, the Charge Nurse (CN) provided one investigation for Resident #25, and confirmed it was the only investigation and it was the entirety of the investigation which was dated 6/2/25 at 5:30 PM. A review of the investigation revealed the following: Type: Fall; Location: Resident Room; Witness/es: None; Cognition prior to occurrence: Confused; Cognition after occurrence: Confused; Injuries: Head Trauma; Location: Center side of Forehead; Details: Head Injury: Hematoma to forehead. Immediate Actions Taken: Pressure dressing applied, notified immediate supervisor, fall risk assessment completed, placed in wheelchair, pain assessment. Notes: Entered by Registered Nurse (RN #1) at 9:24 PM, the writer was informed by aide about resident on the floor. The writer found resident lying prone in room, head in a pool of blood on the floor. Further assessment revealed a hematoma to the forehead of the resident. The wound was cleansed with [normal saline solution] and pressure dressing was applied. A 911 call was made and resident was transferred to the [emergency room] for further evaluation. The resident's statement of what happened written by the resident entered by the RN on 6/2/25 at 9:24 PM: Resident is confused at baseline but reports [they] were responding to a call by someone who told [them] to get out of [their] chair. Witness statement: not applicable (N/A_; Fall type: Found on floor; Position on Floor: [Left Blank]; Independent for toileting: no; Care prior to fall: visually observed 6/2/25 at 5:15 PM; Preventative measures at time of fall: Call light: off Conclusion: Completed by the DON on 6/3/25 at 8:13 AM, the Nursing Supervisor alerted that resident noted on the floor. The Nursing Supervisor observed resident laying on the floor in prone position with their head on the floor in a pool of blood. The resident was assessed. Vitals signs [within normal limits]. Full range of motion noted to all extremities. A hematoma was noted to forehead with fresh red blood, and the area was cleansed and pressure dressing applied. The [physician] and family notified. A new order to send resident to [emergency room] for evaluation at treatment. The resident was transferred via 911 at approximately 5:45 PM. The resident returned to facility at approximately 10:05 PM. All X-rays and scans were negative. The Physician and family notified of the resident's return to the facility. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. Root Cause: Factual description of incident added to nurse note. Due to resident action or internal risk factors: N/A; The resident's state of motion at time of fall: Transferring. How many staff were in assistance: 2. Staff Interviews: No staff interviews available. Recommendations: none noted. One Individual Statement was attached to the investigation dated 6/2/25, which revealed: Room [# redacted] at 5:30 PM, I went into resident's room to leave dinner tray and found resident on the floor. I immediately informed nurse on duty. There was no documentation in the investigation when the resident was last toileted or given fluids as both areas were documented as N/A in the section Care Plan Prior to Fall although the resident was documented as no for independent with toileting. A review of the facility provided emergency room record dated 6/2/25, revealed a CT scan of the head revealed There is a large area of left frontal scalp swelling with hematoma measuring approximately [4.5 cm x 3.7 cm]. On 6/25/25 at 9:16 AM, Surveyor #2 informed the DON and Licensed Nursing Home Administrator (LNHA) of the above findings, and asked what the root cause for the fall that was resulted in 911 transfer. The DON reviewed the incident report and statement and stated the CNA found the resident on the floor when she went to pass the meal tray. The DON stated that the resident was confused. The DON stated the resident told RN #1 that someone told them to get out of the chair, and since the resident made that statement, that was the cause of the fall. No other information was provided. 4. On 6/17/25 at 11:06 AM, the surveyor conducted a Resident Council Meeting with seven residents. During the meeting, Resident #1 showed their left arm that was wrapped and covered with a dressing to the surveyor. Resident #1 stated that they sustained the injury during care provided by CNA #3. Resident #1 further stated that they were in pain and had to be medicated with Tylenol (an analgesic) prior to the dressing change every day. On 6/17/25 at 2:03 PM, the surveyor reviewed the electronic Medical Record for Resident #1. According to the Face Sheet, Resident #1 was admitted to the facility with diagnoses which included but were not limited to; depressive episodes, age related osteoporosis (a disease that weakens the bones), sleep disorder, muscle weakness, and abnormalities of gait and mobility. According to the comprehensive MDS dated [DATE], Resident #1 had a BIMS score of 12 out of 15, which indicated that the resident had moderately impaired cognition. A further review of the MDS reflected that Resident #1 was dependent on staff for activities of daily living (ADLs). A review of the resident's ICCP dated 4/20/23, included a focus area that the resident was at risk for skin/tissue integrity status related to limited mobility and incontinence. The ICCP reflected that Resident #1 requested not to be disturbed during the night for incontinence care, and Resident #1 agreed to get changed by 7:00 AM. Resident #1 did not have a care plan for being combative with care. A review of the Nursing Progress Note dated and signed by the Registered Nurse (RN #2) on 6/9/25 at 9:10 AM, reflected that the CNA reported to RN #2 that the resident sustained a new skin tear during care to their left arm measuring 5 inches in length. Upon assessment, Resident #1 informed the nurse that they sustained the skin tear from CNA #3 who came to the room to provide care at 5:30 AM. (The resident's ICCP indicated that the resident would receive care at 7:00 AM). On 6/18/25 at 8:00 AM, the surveyor requested all investigative reports, including any reportable event records for Resident #1. On 6/18/25 at 9:00 AM, the surveyor reviewed the Incident Report (IR) dated 6/9/25 at 6:20 AM, which reflected that the Nursing Supervisor reported that Resident #1 sustained a skin tear to their left arm during care. Resident #1 informed the nurse that they sustained the skin tear during care. On 6/18/25 at 10:45 AM, the surveyor interviewed the Director of Social Services (DSS), who confirmed that Resident #1 reported the incident on 6/9/25, and requested that CNA #3 be removed from their assignment. The DSS informed the surveyor that she documented a statement and forwarded the statement to the DON. When inquired if she obtained a written statement from the resident, she stated, No. On 6/18/25 at 10:59 AM, the surveyor interviewed CNA #3, who provided care to Resident #1 on 6/9/25 at 5:30 AM. CNA #3 confirmed that she went to the room to provide incontinence care at 5:30 AM. CNA #3 stated that Resident #1 was combative with care and was flailing their hands. CNA #3 reported that the resident's t-shirt was wet with urine and needed to be changed, and the resident refused. CNA #3 stated she proceeded to provide care to the resident. During the care, the resident sustained the skin tear to their left arm. Resident #1 was holding on the t-shirt and the t-shirt got caught on the resident's wristwatch on their left hand, and they sustained the skin tear. The surveyor then asked CNA #3 what the protocol was if a resident refused care, and CNA #3 stated, I should have stopped. CNA #3 stated she was not aware at that time that she should have stopped, and informed the nurse. CNA #3 indicated that after the incident, she received in-service education on Resident Rights. On 6/18/25 at 1:03 PM, the surveyor interviewed the UM, who stated she was familiar with Resident #1. The UM stated Resident #1 could be resistive with care especially if they did not want to be disturbed at night for incontinence care. The family was made aware and agreed that the resident would receive incontinence care around 7:00 AM. On 6/18/25 at 2[TRUNCATED]

Complaint #: NJ 175572 Based on interview, record review and review of facility documents, it was determined that the facility failed to ensure that a resident who did not have a Pressure Ulcer (PU) upon admission and who was identified at risk of developing a PU, received care and services in accordance with professional standards of practice to prevent PUs. Resident # 147 developed a facility aquired Stage 3 left hip PU that was identified during an outpatient (outside) wound care physician visit/consult on 5/22/24. This deficient practice was identified for 1 of 1 resident (Resident #147) reviewed for wound care and was evidenced by the following: The surveyor reviewed the closed Medical Record (MR) for Resident #147. According to the admission Record, Resident #147 was admitted to the facility with diagnoses which included but were not limited to; cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), lymphedema (a long-term or chronic condition that causes abnormal and persistent swelling in your body), difficulty in walking and weakness. A review of the admission Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/1/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had intact cognition. Further review of the MDS indicated that Resident #147 did not have any pressure ulcers upon admission, but the resident was at risk of developing pressure ulcers. A review of the New Jersey Universal Transfer Form (a form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs) dated 4/24/24 at 3:45 PM, indicated that Resident # 147 had vascular skin conditions to the bilateral lower extremities. There was no indication that the resident had a stage 3 left hip PU during the transfer from the acute hospital to the facility. A review of the May 2024 Physician Order Sheet reflected the following physician orders: Santyl-Polysporin 1:1 (10 Topical; Instructions: clean left thigh wound with Normal Saline Solution (NSS), apply a pea amount of Santyl to wound Bed BID (twice a day) until healed. Diagnosis (Dx): left thigh wound with a start date: 5/21/24. Triamcinolone Acetonide 0.1% topical cream (1) cream (Gram) Topical; Instructions: Apply pea amount to surrounding site BID (twice a day) until healed. Dx: Wound, with a start date: 5/21/24. A review of the Nursing admission Evaluation (head to toe assessment completed when a new resident is admitted at the facility) dated 4/24/24 at 4 PM, reflected under skin condition on page two that Resident #147 had redness to sacrum, peri area, redness to bilateral heels . and Right hip open area. An admission evaluation did not reveal that the resident had any wounds or open areas to their Left hip. A review of the Baseline Care Plan (CP) dated 5/10/24, indicated under skin concerns that Resident #147's skin was not intact. Under other skin concerns or wounds it revealed that resident had bilateral lower legs venostasis ulcers. The Baseline CP did not indicate that Resident #147 had a left hip PU upon admission. A review of the Comprehensive CP created on 5/21/24, reflected under Problem: I am at risk for skin breakdown due to bladder incontinence and impaired mobility. Goals included: I will not have skin breakdown and my skin will remain intact in the next 30 days. Interventions included but were not limited to: Monitor skin during care and weekly. A review of the Wound care physician consultation report dated 5/22/24, revealed a note marked with an asterisk (*) that the patient has NEW pressure ulcer (PU) on Left hip area probably from wheelchair. The wheelchair is too small. The patient needs a Bariatric wheelchair to accommodate his/her size. This ulcer needs to be washed daily, pat dry, apply thin layer of Santyl ointment (a topical medicine used to help clean and remove dead tissue from long-lasting skin wounds (ulcers)), and cover with mepilex dressing (used for draining wounds, such as pressure ulcers, leg and foot ulcers). The wound care physician underlined that the Ulcer is Stage 3 (ulcer involve full-thickness skin loss potentially extending into the subcutaneous tissue layer). There was no documented evidence of a wound measurement of the left hip stage 3 PU. A review of the Nurses Change in Condition Progress Note (PN) dated 5/22/24 at 7:38 PM, indicated that the nurse documented the resident came back from a wound consult. The PN revealed Identify Intervention: New recommendations received, transcribed and noted. Resident is alert and verbally responsive. No distress noted. Care continues. The PN was signed by a Licensed Practical Nurse (LPN). There was no documented evidence of a wound measurement of the left hip stage 3 PU. A review of the May 2024 Treatment Administration Record (TAR) revealed that skin Assessments were performed two times weekly for Resident #147 on the following dates: 5/1/24, 5/4/24, 5/8/24, 5/11/24, 5/15/24, 5/18/24, and 5/22/24. Under Action for skin intact .the nurses had checked Yes indicating that resident's skin was intact during the assessment dates. On 6/18/25 at 9:18 AM, the surveyor interviewed the Registered Nurse (RN) who stated the head-to-toe skin assessments were done twice a week during shower days. The RN further stated if the resident had any skin issues observed during morning care, then the resident's Certified Nurse Aide (CNA) would call me, and I would assess and document any skin breakdown. The RN stated the skin assessment would not be documented if the skin was intact. On 6/24/25 at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated skin assessments were performed by the nurses twice a week during shower days. The LPN/UM further stated there was an order in the Treatment Administration Records (TARs) for skin assessments, and if there were alterations noted during the skin assessments, then the nurses would document and complete an incident report in the computer. The LPN/UM stated nurses would complete a skin assessment on Day 1 (upon admission) and if a resident had any wounds, skin condition/alterations including edema (swelling) would be documented. The LPN/UM further stated if the resident had a new alteration to their skin during an assessment, that would also be documented. If the skin was not open, there would not be any measurements completed but if the skin was open or had breakdown and it was measurable then the measurements would be documented. The LPN/UM stated if the resident was admitted with open skin/ wounds, incident reports are not done but everything would be documented that was seen on day one and after that the wound care physician would be consulted depending on the severity of the wound. The LPN/UM stated she was familiar with Resident #147. The surveyor inquired about Resident #147's Stage 3 Left hip PU which was identified by the outpatient wound care physician on 5/22/24. The LPN/UM stated, I do not believe that it was measured and documented in our computer and further stated that the resident came back from the wound care doctor and the orders were carried out. The LPN/UM stated Resident #147's shower days were Wednesdays and Saturdays, and resident had shower on Wednesday before the resident went out for their wound consult on 5/22/24. The LPN/UM stated that the nursing staff was expected to do a skin assessment on the shower days. In the presence of the surveyor, the LPN/UM reviewed the TARs, which reflected that the staff had documented that Resident #147 had skin intact prior to their outpatient wound consult. The LPN/UM stated the aides (CNAs) and the nurses performed the full body assessment and would report if they observed any abnormalities or skin alterations. The LPN/UM stated she was not at the facility on 5/22/24, and the resident went out to their wound care physician and the wound orders were carried out and the Nurse Practitioner (NP) was notified of the new orders. The LPN/UM further stated, I don't believe there are any measurements. The LPN/UM further stated if a new wound was discovered, the staff would measure the wounds for progress, but the measurements would not be documented. The LPN/UM stated that the Director of Nursing (DON) was responsible for investigating new wounds. The LPN/UM was not able to explain for how long and/or when Resident #147 developed the Left hip Stage 3 PU. There were no treatments that had been ordered for the Left hip Stage 3 PU prior to 5/22/24. On 6/24/25 at 2:15 PM, two surveyors met with the DON and the Regional Nurse. The DON stated the skin assessments were performed on shower days. The Regional Nurse stated if the aide noted any skin discoloration on shower days, they would notify the nurse because CNAs could not perform skin assessments. The Regional Nurse further stated if the resident had their skin intact documented for Resident #147 prior to leaving for their outpatient wound care appointment, and the resident returned with a documented new stage 3 PU or a new skin breakdown, then the wound assessments and investigations should have been done. On 6/25/25 at 8:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and discussed the above concerns. The DON stated the nurses should be doing physical assessments upon admission. The DON stated, I did not know about the Stage 3 pressure ulcer. The DON further stated that she was never made aware of the wound consult and confirmed there were no measurements for the Stage 3 PU. The DON further stated the nurse should have completed an incident report with the wound measurements when the resident returned from their wound care consultation. A review of the facility provided policy, General guidelines wound and skin care, revised 6/2025, included but was not limited to; Purpose: 1.) To provide a systematic approach for assessment of risk and monitoring skin integrity and pressure ulcer care. 2.) To prevent pressure ulcer formation for resident admitted without pressure ulcers, unless clinically unavoidable, by identifying those residents who are at risk for pressure ulcers and developing appropriate preventative interventions. 3.) To promote healing of pressure ulcers and prevention of additional pressure ulcers and provide comfort for residents admitted with skin breakdown. Objective: To maintain the integrity of residents skin admitted without wounds and promote wound healing on residents admitted with skin breakdown. Under section Documentation: 1. A complete wound assessment and documentation will be done weekly on all pressure ulcers until they are healed. The criteria to be included: a) site/location b) stage- this applies only to pressure ulcers. Wound healing is to be described by changes in the wound c) Size- length, width and depth measure in centimeters. The length is listed first d) Undermining/tunneling e) Drainage/exudates describe the amount, color, consistency and odor. A review of the facility provided Charting and Documentation included but was not limited to; Purpose: The purpose of charting and documentation is to provide: 1.) A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2.) Guidance to the physician in prescribing appropriate medications and treatments. 3.) The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. Under section Rules for Charting and Documentation reflected: 1.) Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. 20. Skin Lesions: Documentation pertaining to skin lesions (decubitus ulcers, abrasion, etc.) should include: a.) specific location of the skin care problem; b.) number, size, degree, and measurement of decubitus ulcers; f.) Documentation of the cause of decubitus ulcers developed in-house, as well as substantiation of preventing interventions; h.) any changes in the resident's condition or response to treatment; i.) Dates of occurrences of a skin problem or pressure sore as well as the date the problem was solved; j.) Progress, deterioration, or the development of new problems; l.) The cause of any bruise or wound. Section Nursing Summaries and/or Assessments included: When charting nursing summaries, or making assessments, included (as they may apply) the following data for: 18.) Skin-Hair-Scalp-Nails: Dry . Be descriptive of lesions, edema; discuss locations, size, depth, color, amount, and status of tissue and surrounding. Indicate type of treatment and how often treatment is administered. At 6/25/25 at 11:45 AM, the survey team met with the LNHA and the DON for additional responses. The LNHA and the DON did not provide any additional information. N.J.A.C. 8:39-27.1 (a)(e)

Based on observation, interview and document review it was determined that the facility failed to store food in a sanitary manner, and maintain the kitchen equipment and environment in a clean and sanitary manner to prevent contamination from foreign substances and the potential for the development of food borne illness. This deficient practice affected all residents who resided at the facility, and was evidenced by the following: On 6/16/25 at 8:17 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Assistant Director of Dining (ADD) and observed the following: 1. The white ceiling tiles in the food preparation area had visible debris affixed to the tiles and dust like debris on the ceiling vents. The ADD stated, I can see it. 2. The metal racks with varied equipment stored on them, had embedded debris on the racks and debris was observed on the floor underneath the racks. The ADD acknowledged the observations and stated, It should not look like that. 3. Two white rolling storage bins, one containing flour, were soiled on the exterior of the bins and lid. One of the bins was open and product was exposed inside. 4. The non-metal food storage shelves contained crumb type debris on the shelves by the spices, inside of the 1/2 opened boxes that contained evaporated milk on top of the small cans of tomato soup, and on the outside of the plastic bin that contained individual ketchup. 5. Three plastic type storage containers for breadcrumbs were located next to the non-metal food storage rack on the lower rack of a metal table. There were crumbs outside of the bins and on the metal table. All three lids had debris on top of the lids, and one of the lids was open to air with food breadcrumbs exposed. 6. The can rack containing the large cans had visible debris on the racks. 7. There were two rolling black carts in the kitchen that had gloves, pans and food items on the shelves of the carts. One cart had a cracked, broken and melted exposed areas. Both carts were visibly soiled with debris. 8. The white baffle on the large ice machine had a pink colored substance on it. 9. A water well next to the ice cream freezer (used to wet ice cream scoops when in use) contained an ice scoop. The ADD stated that should not be there. 10. A tray of frozen smoked salmon, located in the walk-in freezer, was open to air and the salmon was exposed. 11. The reach in refrigerator located in the healthcare pantry had a ripped door gasket. On 6/16/26 at 9:24 AM, the ADD provided the surveyor with the Closing Manager/Supervisor Kitchen Checklist, dated: 6/9/25-6/15/25 which revealed: Sunday, 6/15/25 as checked as completed: Spice area cleaned and organized, all worktables and shelves cleaned and organized, entire kitchen floor swept and mopped, all food properly broken down, covered, labeled, dated and stored. The surveyor showed the checked off areas to the ADD, who confirmed the areas checked off as being clean were not observed as being clean. On 6/18/25 at 8:43 AM, the surveyor conducted a follow-up kitchen observation with the Executive Chef (EC) and Director of Dining (DD) and observed the following: The dish machine was in use and one staff person (FS #1) was observed loading the machine with metal pans and other kitchen items, and with the same gloves removed the clean items from the other side of the dish machine. Then, FS #1 proceeded to re-load soiled items with the same gloves. At that time, the Executive Chef (EC) was present and the surveyor observed the dish machine temperature gauges for the wash tank temperature and the final rinse temperature gauges. FS #1, then wearing the same gloves, loaded soiled pans into the dish machine and the wash temperature gauge was 148 degrees Fahrenheit (F), another two loads of dishes were sent through and the wash gauge was 148 F, then 149 F. The Dish machine Temperature Record for June, affixed to the wall, revealed Wash Temp; 160 F. The EC stated that the facility had a service call in for the machine, and per what he had been informed the dish machine needed a part, and although the machine did not reach the proper wash temperature per the gauge, they used a puck (a digital temperature monitoring device that goes through the machine) and test strips to check the temperature to make sure the machine was working. The surveyor then requested the Dietary Director (DD), who then joined the tour at 8:48 AM. The DD stated a 3rd party consultant group had identified the problem that the machine, was reading the wrong temperature, and stated the puck would show the correct temperature. The DD then placed the yellow digital puck into the dish machine, the surveyor asked the DD what the wash temperature should be and the DD stated, it is supposed to reach 160- 170 F. The DD removed the puck from the clean side of the dish machine and both the surveyor and the DD observed the digital puck displayed 149 F. When asked the DD why it was important to ensure the dish machine was operating with the proper temperatures he stated, to make sure bacteria is being killed. When asked if the dish machine was cleaning properly, he stated with this puck, no. The surveyor asked the DD if it was okay if FS #1 was handling soiled dishes and clean items with the same gloves, and the DD stated that gloves were supposed to be changed when going from dirty dishes to clean dishes. On 6/18/25 at 9:02 AM, the DD stated the dish machine was not going to be used because it was not reaching the proper temperature. On 6/25/25 at 9:27 AM, the Liscensed Nursing Home Administrator was informed of the above findings and no additional information was provided. The Sanitation and Infection Prevention/Control Policy for Dish machine temperatures revealed the multi-tank conveyor, multi-temperature machine wash temperature -150 F. NJAC 8:39-17.2(g)

Based on observation, interview, and document review, it was determined that the facility failed to follow appropriate hand hygiene during the meal service to prevent the spread of potential infection, and failed to ensure their Water Safety Management program included a process to prevent the potential transmission of Legionella (a bacteria found in contaminated water that causes a severe lung infection). This deficient practice had the potential to effect all residents who resided at the facility and was evidenced by the following: a) Surveyor #1 On 6/16/25 at 12:09 PM, the surveyor observed a Certified Nurse Aide (CNA) deliver the lunch tray to a resident in room [ROOM NUMBER] and then exited the resident's room without performing hand hygiene (HH). The CNA then returned to the meal cart picked up another tray and delivered the tray to room [ROOM NUMBER], placed the meal tray on the table and moved the table close to the resident and the CNA then exited resident's room without first performing HH. Then the CNA then pushed the meal cart towards right hallway, removed a tray and entered room [ROOM NUMBER] and then placed the lunch tray on the bedside table and exited without first performing HH prior to exiting the room. The CNA, without first performing HH returned to the meal cart and removed another tray and delivered the tray to room [ROOM NUMBER]. The CNA then placed the tray on the table and moved the table closer to resident's recliner chair and exited the room without first performing HH. The surveyor then observed the CNA, without first performing HH, put on gown and gloves before entering into an Enhanced Barrier Precaution (infection-control practices to prevent the spread of Multi Drug Resistant Organisms in nursing homes) room [ROOM NUMBER] with a lunch tray. The CNA, then without performing HH, delivered a tray to room [ROOM NUMBER], assisted the resident with opening their soda and exited out of the resident's room, without performing HH. Next, the CNA returned to the meal cart and removed another meal tray and delivered it to room [ROOM NUMBER] and placed it on the tray table. The CNA fixed resident's pillow behind their back, elevated the head of bed with a remote control, opened a drawer to take a straw out of tray table, and adjusted the tray table in front of the resident. Then, the CNA exited resident's room without performing HH. The surveyor observed the CNA, again, returned to the meal cart and remove a meal tray and entered room [ROOM NUMBER] and closed the door. Then, the surveyor observed the CNA come out of resident's room with a tray in her hands and placed it on top of the meal cart. The CNA did not perform HH upon exiting resident's room. Then, the CNA wheeled the meal cart to the side and delivered a meal tray to room [ROOM NUMBER]. The surveyor observed the CNA move the tray table to the side and exited out of the room. The CNA was not observed performing HH prior to exiting the resident's room. On 6/16/25 at 12:40 PM, during an interview with the surveyor, the CNA stated, I washed my hands before I deliver the meal trays and before I assist the residents with their meals. The CNA stated, cleaning hands was important because you touch the resident's chair, and your hands could be dirty with germs and for infection control. The surveyor inquired if the CNA performed any HH during the resident meal tray delivery. The CNA pointed towards wall mounted hand sanitizers in the hallway and stated, Yes, I clean my hands also that's why they have hand sanitizers in the hallway. The surveyor informed the CNA of above-mentioned observations during meal delivery, and the CNA did not provide a response. On 6/23/25 at 2:10 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated HH would be performed before and upon exiting the resident's room, during medications, before and after physically touching the patient, before the CNA would assist the resident with feeding. The LPN/UM further stated HH was important for hygiene and for infection control. The surveyor informed the LPN/UM of the above-mentioned concerns. The LPN/UM verified that if the CNA was making a physical contact with the tray table or the resident during meal delivery, then she should have performed HH or handwashing before and after resident contact. b) Surveyor #2 On 6/16/25 at 12:13 PM, the surveyor observed Healthcare Food Service Supervisor (HFS) in take plated meals from the from the food service area, and distribute meals to residents who were seated in the dining room. The HFS did not have all facial hair covered on the sides and over his mustache area. The HFS was observed wearing gloves into the dining room and then placed the meal in front of the resident, then re-entered the pantry and picked up another plate while wearing the same gloves, and proceeded to serve another resident a meal. On 6/16/25 at 12:27 PM, the surveyor observed the HFS touching multiple trays with gloves on, then removed the gloves and placed new gloves on his hands without first washing his. On 6/16/25 at 12:31 PM, the surveyor interviewed the Assistant Dining Director (ADD) regarding the above observations. The ADD stated the HFS was supposed to have all facial hair covered and confirmed that staff were supposed to wash hands before putting on gloves. On 6/25/25 at 9:46 AM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). During an interview with the surveyor, the DON stated the staff should be performing HH when they pass the meal trays. The DON further stated HH was important because when the staff goes into resident's room, they move things around and for infection control. The DON verified that the Infection Preventionist started staff education and in-services regarding HH. At 6/25/25 at 11:45 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON for additional responses. The LNHA and the DON did not provide any additional information. A review of the facility's policy titled, Handwashing/ Hand Hygiene revised date 3/25 revealed under Purpose: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Procedure: 7.) Use an alcohol-based hand rub . or, alternatively, soap and water for the following: b. before and after direct contact with residents; f. before donning gloves; o. before and after eating or handling food; p. before and after assisting a resident with meals. c)Surveyor #3 On 6/23/25 at 11:30 AM, the surveyor interviewed the Housekeeping Director (HD)and inquired regarding Legionella Prevention. The HD showed the surveyor the log for the water diagram and in-services education completed regarding Legionella prevention. The Surveyor requested the last testing done for the water system. The HD informed the surveyor that the Licensed Nursing Home Administrator (LNHA) was in charge of the water testing for Legionella Prevention. On 06/24/25 at 10:10 AM, the surveyor met with the LNHA, and requested all information regarding the facility measures that were in place to prevent Legionella. The LNHA provided the Policy titled, Legionella Policy and procedures initiated 7/1/17 and last revised 1/19/24. The LNHA was not aware that the water had to be tested for Legionella. According to the facility's policy on Legionella Prevention, the following were documented: Purpose: Develop a Legionella Prevention Water Safety Management program to ensure compliance with the Center for Medicare and Medicaid Services Directive and considers ASHRAE (American Society of Heating and Air-Conditioning Engineers) 188 2015 standards. ASHRAE, it is a standard developed to provide guidelines for managing the risk of Legionnaires' disease in building. According to ASHRAE 188 2015 standards, the following requirements had to be met for Legionella Testing Requirements: 1. Maintain proper water temperatures. 2. Ensuring adequate disinfectant residual. 3. Implementing water management program. Regularly testing the water for Legionella bacteria to assess bacterial levels and ensure detection of potential outbreaks. Adhering to Legionella testing requirements helps identify and address contamination promptly. The LNHA who was unable to provide any documentation that the water had been tested for Legionella. The administrator provided a proposal dated 6/24/25, after the surveyor requested the water testing program. According to the facility policy the Water System diagram was to be reviewed semi-annually as part of the overall Compliance Audit. NJAC 8:39-19.4 (a)(m)

Based on observation, interviews and record review, the facility failed to ensure that all residents had their call light (a button used to contact staff) within easy reach and accessible at all times. while in their room. This deficient practice was identified for 7 of 15 resident's reviewed (Resident #12, #15, #19, #21, #22, #25 and #31) and was evidenced by the following: 1) On 6/16/25 at 8:30 AM, Surveyor #1 observed Resident #15 in bed, the call light was observed on the floor. Surveyor #1 observed that the call bell light was not within the resident's reach. On 6/18/25 at 8:10 AM, Surveyor #1 entered Resident #15's room. The resident reported pain to the right hip, and Surveyor #1 asked the resident to activate the call light to contact the staff. The resident stated, I cannot see the call light. Surveyor #1 observed a tap bell (a type of call bell with a flat button) that was looped around the rail, by the pillow at the head of the bed and outside of Resident #15's reach. On 6/18/25 at 9:15 AM, the surveyor accompanied the CNA assigned to Resident #15's room. The CNA observed that the resident did not have their call bell within reach. The resident's representative, then entered the room and confirmed the tap bell was not accessible, and untied the tap bell and placed it next to Resident #15's hand. On 6/18/25 at 11:15 AM, Surveyor #1 reviewed Resident #15's Electronic Medical Record (EMR). The admission Face Sheet reflected that the resident had a diagnosis, which included, but were not limited to, dementia and cognitive impairment. Resident #15's Care Plan had an Intervention to have the tap bell within reach. 2) On 6/19/25 at 7:24 AM, Surveyor #1, Surveyor #2 and the Registered Nurse/ Supervisor of Nursing (RN/SON) checked randomly 6 residents room for call bell accessibility and observed the following: On 6/19/25 at 7:25 AM Surveyor #1, and #2 along with the RN/SON entered Resident #12's room. The tap bell was observed underneath the pillow. At that time the RN/SON confirmed that Resident #12 could not reach the tap bell, and the RN/SON moved the tap bell next to the resident's hand. On 6/19/25 at 11:00 AM, Surveyor #2 reviewed EMR for Resident #12. According to the admission Record face sheet (an admission summary), Resident #12 was admitted to the facility with diagnoses which included but were not limited to; weakness, hypertension (high blood pressure) and abnormalities of gait and mobility. A review of the resident's individual Care Plan dated 3/21/25, included a focus area that the resident was at risk for falls due to weakness. Resident had history of falls. One of the interventions was to have all items within reach and encourage the resident to call for assistance On 6/19/25 at 7:27 AM, Surveyor #1, Surveyor #2 and the RN/SON entered Resident #19's room and all observed the call bell looped around the upper siderail and the call bell was not accessible to the resident. The RN/SON confirmed that the resident could not reach the call bell. A review of Resident #19's EMR revealed that Resident #19 had diagnoses which included but were not limited to; syncope (fainting and passing out) and collapse, generalized arthritis, and abnormalities of gait and mobility. A review of the Care Plan dated 1/7/25, included a focus area that the resident had decline in their physical functioning due to weakness and fatigue after hospitalization following a fall. Interventions included place call bell within reach, encourage to use call bell for assistance and answer promptly. On 6/19/25 at 7:28 AM Surveyor #1, Surveyor #2 and the RN/SON entered Resident #25's room. Resident # 25 was observed in bed. The tap bell was observed on top of the nightstand. The RN/SON confirmed that the resident could not access the call light to call the staff. The RN/SON removed the tap bell from the nightstand and placed the tap bell on the bed by the resident's hand. On 6/19/25 at 7:29 AM, Surveyor #1, Surveyor #2 and the RN/SON entered Resident #21's room and observed the call light underneath the bed. The resident could not access the call light. The RN/SON confirmed that the call light was not accessible. On 6/19/25 at 7:30 AM, Surveyor #1, Surveyor #2 and the RN/SON entered the room and observed Resident #22 in bed. The call bell was looped on the siderail and not within reach of the resident. The RN/SON confirmed that the call bell was not accessible. The RN/SON untied the call bell and placed it on the bed next to the resident. A review of Resident #22's EMR reflected that Resident #22 was admitted to the facility with diagnoses which included but were not limited to; Dementia, anemia and malaise. A review of the resident's Care Plan dated 5/25/23, included a focus for Activities of Daily Living related to functional decline and generalized weakness. Interventions included to place resident's call bell within easy reach and resident needed reminders to call for assistance. 3) On 6/24/25 at 8:59 AM, Surveyor #2 observed Resident #31 resting in their bed. The surveyor observed Resident #31's call bell on the floor. On 6/24/25 at 10:25 AM, Surveyor #2 went back to Resident #31's room and observed the resident's call bell was still in the same position as observed at 8:59 AM. On 6/24/25 at 10:29 AM, Surveyor #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding call bell accessibility. The LPN/UM stated, All residents should have easy access to their call bells. The surveyor then shared the above observation with the LPN/UM. On 6/24/25 at 10:35 AM, Surveyor #2 accompanied the LPN/UM to Resident #31's room and we all observed the call bell was on the floor as was observed at 8:59 AM and 10:29 AM. The LPN/UM confirmed that Resident #31 could not reach the call bell. The LPN/UM picked up the call bell from the floor and then placed it next to the resident. On 6/24/25 at 10:55 AM, Surveyor #2 reviewed EMR for resident #31 which revealed: According to the admission Record, Resident #31 was admitted to the facility with diagnoses which included but were not limited to; muscle weakness, mood disorder,depression and abnormalities of gait and mobility. A review of The Care Plan dated 11/21/23, included a focus area that the resident needed assistance with ADLs care related to decline in their strength and recent hospitalization. The care plan included also a focus for falls related to generalized weakness. One of the intervention was to have the call bell within easy reach. On 6/25/25 at 9:30 AM, the survey team met with the Licensed Nursing Home Administration (LNHA) and the Director of Nursing (DON) and discussed the concerns regarding resident's call bell and tap bell accessibility. The LNHA stated the call bell should be easily accessible for residents to use. A review of the facility's Call Bell System policy, revised on 1/17/25 reflected under Procedure: 6) Prior to leaving the resident, ensure that the resident is safe and has access to the call bell NJAC 8:39-31.8 (c)

Based on interviews, and review of pertinent facility documentation on 6/16/25 and 6/19/25, it was determined that the facility failed to report falls that resulted in injury and required hospitalization to the New Jersey Department of Health (NJDOH) as required, and report injuries of unknown origin within 2 hours for 3 of 3 residents reviewed for injury of unknown origin, (Resident #15, #25 and #44). The deficient practice was evidenced by the following: Refer to F610 1. According to the facility admission Face Sheet (an admission summary), Resident #15 was admitted to the facility with diagnoses which included but not limited to; Hypertension, difficulty in walking, history of falls, unspecified abnormality of gait and mobility and vascular dementia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 3/20/25, Resident #15 had a Brief Interview for Mental Status (BIMS) score of 7/15 indicating Resident #15 had a severe cognitive impairment. Normal Score15. The MDS documentation also identified that Resident #15 required staff assistance for Activities of Daily Living (ADL). A review of an Electronic Progress Notes dated 2/7/25, timed at 5:15 AM, revealed that Resident #15 was found on the floor bleeding and had a hematoma to the forehead. Resident #15 was transferred to the emergency room and diagnosed with intracranial bleeding. A CT (X-Ray with computer imaging) scan performed at the hospital confirmed the diagnosis of intracranial bleeding. A review of a Progress notes dated 6/4/25 and timed 3:55 AM, indicated Resident #15 was found on the floor with a skin tear to the left arm and change in the range of motion of the left leg while complaining of pain. Resident #15 was transferred to the emergency room for evaluation and treatment. The X-ray performed at the hospital revealed a left hip fracture. On 6/17/25 at 4:58 PM, Resident #15 was found on the floor in the bathroom. Resident #15 reported pain to the right hip. On 6/18/25 Resident #15 was still complaining of pain, and was unable to participate in physical therapy. A Right hip X-Ray (electromagnetic radiation) performed was positive for right intertrochanteric fracture. Resident #15 was transferred to the hospital and admitted with a right hip fracture. A review of the incident reports provided by the Director of Nursing (DON) did not include documentation that the New Jersey Department of Health (NJDOH) was notified of the injury of unknown origin. On 6/23/24 at 11:30 AM, the survey team asked for any reportable event that the facility reported to NJDOH. The DON informed the survey team that the incidents were not reported. On 06/23/25 at 1:45 PM, Surveyor #2 reviewed the electronic medical record for Resident #25 which revealed: A Nurses Note signed by a Registered Nurse on 6/2/25 at 11:28 PM, which revealed details at time of fall: Occurred 6/2/25 at 17:30 (5:30 PM) in the resident's room and the resident was alone. Resident #25 was alert to self and confused. Narrative: Writer was informed by aide about resident on the floor. Writer found resident laying prone [face down] in room, head in a pool of blood on the floor. Further assessment revealed a hematoma (bruise) to the forehead of the resident. Wound was cleansed with NSS (normal saline solution) and pressure dressing applied. A 911 call was initiated and the resident was transferred to the emergency room. On 6/23/25 at 2:00 PM, Surveyor #2 requested all investigations for Resident #25. On 6/23/25 at 2:29 PM, the Charge Nurse (CN) provided one investigation for Resident #25, and confirmed it was the only investigation and it was the entirety of the investigation which was dated 6/2/25 at 5:30 PM. The investigation revealed: Type: Fall; Location: Resident Room; Witness/es: None; Cognition prior to occurrence: Confused; Cognition after occurrence: Confused; Injuries: Head Trauma; Location: Center side of Forehead; Details: Head Injury: Hematoma to forehead; Immediate Actions Taken: Pressure dressing applied. Notified immediate supervisor. Fall risk assessment completed. Placed in wheelchair, Pain assessment. Notes: Entered by Registered Nurse (RN #1) at 9:24 PM, Writer was informed by aide about resident on the floor. Writer found resident lying prone in room, head in a pool of blood on the floor. Further assessment revealed a hematoma to the forehead of the resident. Wound was cleansed with [normal saline solution] and pressure dressing was applied. A 911 call was made and resident was transferred to the [emergency room] for further evaluation. Resident statement of what happened entered by RN on 6/2/25 at 9:24 PM: Resident is confused at baseline but reports [they] were responding to a call by someone who told [them] to get out of [their] chair. Witness statement: N/A; Fall type: Found on floor; Position on Floor: [Left Blank]; Independent for toileting: no; Care prior to fall: visually observed 6/2/25 at 5:15 PM; Preventative measures at time of fall: Call light: off; Conclusion: Completed by the Director of Nursing (DON) on 6/3/25 at 8:13 AM; Nursing supervisor alerted that resident noted on the floor. Nursing supervisor observed resident laying on the floor in prone position with head on the floor in a pool of blood. Resident assessed. Vitals signs [within normal limits]. Full range of motion noted to all extremities. Hematoma noted to forehead with fresh red blood. Area cleansed and pressure dressing applied. [Physician] and family notified. New order to send resident to [emergency room] for evaluation at treatment. Resident transferred via 911 at approximately 5:45 PM. Resident returned to facility at approximately 10:05 PM. All x-rays and scans negative. Physician and family notified of return to facility. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. Root Cause: Factual description of incident added to nurse note, Due to resident action or internal risk factors: N/A; Resident state of motion at time of fall, Transferring; How many staff were in assistance, 2; Staff Interviews: No staff interviews available; Recommendations: none noted. One Individual Statement was attached to the investigation, dated 6/2/25, which revealed: room [ROOM NUMBER] at 5:30 PM, I went into resident's room to leave dinner tray and found resident on the floor. I immediately informed nurse on duty. A review of the facility provided emergency room record dated 6/2/25, revealed CT (Computed Tomography- a detailed picture using scans and computer) of the head revealed There is a large area of left frontal scalp swelling with hematoma measuring approximately 4.5 X 3.7 centimeters. On 06/25/25 at 9:16 AM, Surveyor #2 informed the DON and LNHA of the above findings and asked what the root cause for the fall was that resulted in the 911 transfer. The DON reviewed the incident report and statement and stated the Certified Nurse Aide found the resident on the floor when she went to pass the meal tray, and the DON stated that the resident was confused. The DON stated the resident told RN #2 that someone told them to get out of the chair. The DON stated since the resident made that statement that was the cause of the fall. and the facility did not report it. No other information was provided. c. On 06/18/25 at 1:12 PM, Surveyor # 2 reviewed the closed electronic medical record for Resident # 44 which revealed a Care Plan, Effective 9/10/24, with a Problem: Recent fall prior to admission, at risk for further falls due to difficulty with transfers and ambulation, weakness following hospitalization; 11/4/2024, Fall in bathroom skin tear to right elbow. A review of the Face Sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; vascular Dementia, altered mental status, repeated falls, cognitive communication deficit, history of falling, and muscle weakness. The Quarterly MDS dated [DATE] revealed the resident was moderately cognitively impaired and required assistance for bed mobility, transfer and toileting. At that time, Surveyor #2 then requested all investigations for Resident #44. On 6/19/25 at 9:00 AM, the surveyor reviewed the paper closed medical records along with two investigations provided by the facility which revealed the following: 1. On 11/4/24 at 12:35 AM, Resident #44 was confused and sustained an unwitnessed fall and sustained a skin tear to the right elbow, circular, measuring 1.1 x .5 centimeters (cm). The Nurses Note of what happened was documented by RN # 1 on 11/4/24 at 2:40 AM, which revealed: Aide called writer's attention about resident on the floor. Writer found resident on the floor in [their] bathroom, sitting up with [their] back against the toilet. Resident was confused and could not recollect exactly what happened. Resident was helped back into [their] bed. Resident had a skin tear measuring 1.1 x .5 cm to right elbow. Skin tear was cleaned with normal saline and covered with [gauze]. Resident denied hitting head, denied any other pain apart from the skin tear. Neuro checks initiated . Resident statement of what happened on 11/4/24 at 2:24 AM, Resident stated [they] were trying to go to bathroom. Resident confused, sometimes non-compliant to safety measures. The Conclusion documented by the DON on 11/4/24 at 11:45 AM, revealed the CNA alerted the primary nurse that resident noted sitting on the floor. Primary nurse observed resident sitting in an upright position on the bathroom floor with [their] back against the toilet. Resident assessed . Resident denies any pain or discomfort at this time. Resident denies hitting [their] head. Skin tear noted to right elbow with fresh red blood noted. Skin tear cleansed and treatment in place. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. There was one statement attached and signed by the CNA on 11/4/24, which revealed the date and time of incident, Room # 236 on 11/4/24 at 12:35 AM. The section titled to tell us step by step in your own words what happened . revealed: Resident's bathroom call bell was on and I entered the room, and saw blood on the floor next to the bed and then saw resident on bathroom floor sitting up with back against toilet. Resident stated [they] fell when trying to go to bathroom. Resident was bleeding from right elbow area. Nurses and supervisor was made aware. Care Prior to Fall: Visually Observed, 11/4/24 at 12:10 AM; Toiled: NA; Given Fluids: N/A: Repositioned: N/A. Preventable Mesures at time of fall: call light off. 2. On 2/9/25 at 6:45 PM, Resident #44 sustained a skin tear to the left lower leg while an Agency CNA provided care and the Nurse documented on 2/9/25 at 11:31 PM, that This writer was informed by aide that resident had sustained a skin tear during care. Upon arrival resident was bleeding. Site was treated. Measuring 9 X 1 centimeter . Resident statement of what happened, doesn't know. Witness statement of what happened written by CNA, I saw a bleeding from the resident due to skin tear. Conclusion: signed by DON on 2/10/25 at 9:05 AM: Primary nurse alerted by CNA resident noted with skin tear. Primary nurse assessed resident .Skin tear noted to [left] lower leg measuring 9 X 1 cm with fresh red blood. Resident in bathroom by self when skin tear was noted. Skin tear was noted in direct line of door frame .Resident encouraged to call for assistance. One statement was attached from the Agency CNA, dated 2/9/25, which revealed: Resident was in the bathroom by self when I went to provide care. I noticed was bleeding due to skin tear on leg. I quickly notified the nurse of the incident around 6:54 PM. I saw bleeding from the resident due to skin tear. The investigation did not address that the CNA reported the resident sustained the skin tear during care to the nurse, and the activity that was documented as occurring was Dressing, or why the resident was found alone in the bathroom. On 06/18/25 at 2:41 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA) who stated the DON was responsible to complete all investigations and he was responsible to ensure they were completed. On 06/19/25 at 9:28 AM, Surveyor #2 interviewed the [NAME] President of Clinical Services (VPC) and the DON, in the presence of the survey team, and asked what is the investigative process that occurs after an unwitnessed fall occurs. The DON stated the staff alerted the nurse to do an assessment after a fall and Surveyor #2 asked who was responsible for obtaining statements? The DON stated the primary nurse was supposed to take statements from the CNA and nurse for the resident, and the surveyor asked about any statements from other CNAs related to Resident #44's fall? The DON stated, they just do the primary CNA. Surveyor #2 asked what the purpose of an investigation and the DON stated to investigate what happened. On 06/19/25 at 9:47 AM, Surveyor #2 read the CNA's statement regarding the incident and asked the DON if there was an investigation regarding the blood that was observed next to the resident's bed? The DON stated when she completed her investigation the following morning that she did not see the blood by the bed, and stated it was an Agency CNA. Surveyor #2 asked if the blood next to the bed was important to review and to determine what was the causal factor? The DON did not respond. Surveyor #2 then asked about the skin tear documented as happening during care of Resident #44 what was determined as the causal factor of the skin tear; and what specific interventions were implemented as a result? The VPC requested to further review both investigations prior providing any response. On 6/25/25 at 9:24 AM, the survey team interviewed the LNHA and DON and asked what the facility was responsible to report to the NJDOH? The DON stated injuries of unknown origin were reported, abuse, neglect and disruption of service. The surveyor asked when Resident #25 and #44 sustained unwitnessed falls with injuries. The DON stated, when the statements are completed, it is not reported. The Incident Reporting Policy, effective 10/15/00 revealed under State Notification: 1. follow the state appropriate reportable event notification process for each governing body. NJAC 8:39-27.1(a)

Complaint #: NJ 175572 Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure thorough investigations were conducted to ensure abuse or neglect had not occurred for a) a resident who was identified as having a new stage 3 wound that was identified during an outpatient (outside) physician visit conducted on 5/22/24 (Resident # 147), b) when a severely cognitively impaired resident was found laying on the floor in a pool of blood, from an unwitnessed fall that resulted in a head injury and required emergent transfer to the hospital on 6/2/25 (Resident #25), c.) Resident #44) who sustained an unwitnessed fall in the bathroom, and blood was also identified at the bedside on 11/4/24; and on 2/9/25 sustained another unwitnessed fall with skin tear. This deficient practice occurred for 3 of 3 residents reviewed for investigations and was evidenced by the following: a. On 6/18/25 at 4:10 PM, the surveyor reviewed the closed medical record (Electronic and Paper) for Resident #147. According to the admission Record, Resident #147 was admitted to the facility with diagnoses which included but were not limited to; Cirrhosis (a condition in which the liver is scarred and permanently damaged) of liver, Lymphedema (a long-term or chronic condition that causes abnormal and persistent swelling in your body), difficulty in walking and weakness. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/1/24, revealed that Resident #147 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. Further review of the MDS indicated that Resident #147 did not have any pressure ulcer to the Left hip upon admission. A review of the Nursing admission Evaluation (head to toe assessment) completed on admission, and dated 4/24/24 at 4:00 PM, reflected under skin condition, on page 2, that Resident #147 had redness to sacrum, peri area, redness to bilateral heels . and Right hip open area. There was no documented skin impairment to the Left hip area. A review of a wound consultation report dated 5/22/24, revealed the following: the patient has New pressure ulcer (PU) on Left hip area probably from wheelchair. The wheelchair is too small. The patient needs a Bariatric wheelchair to accommodate their size. Ulcer is Stage 3. (Stage 3 ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer). There were no measurements for left hip stage 3 pressure ulcer documented on the consultation report. The facility did not measure Resident #147's PU upon return from the consultation. On 6/18/25 at 9:18 AM, the surveyor interviewed the Registered Nurse (RN #1) who stated a head to toe skin assessment was completed twice a week during shower days for all residents. RN #1 further stated the Certified Nurse Aide (CNA) would call the nurse during morning care if the resident had any new skin issues, then the nurse would assess the resident's skin and document any skin breakdown. RN #1 stated the nurse would initial the TAR if the skin was intact. If a skin breakdown was observed, the nurse would write a note and entered in the back of the TAR the documentation regarding the skin breakdown. On 6/24/25 at 10:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in chrage of the unit. The LPN/UM confirmed that skin assessments were completed by the nurses twice a week during the shower days. The LPN/UM further stated there was an order in the Treatment Administration Records (TARs) to complete skin assessments, and if there were any alteration in skin integrity, the nurses would document and complete an incident report in the computer. The LPN/UM added, nurses were to complete a skin assessment on Day 1 (upon admission) and if a resident had any wounds, skin conditions/ alterations including edema (swelling) upon assessments all skin alteration would be documented. The LPN/UM further stated, if the resident had a new alteration to their skin during an assessment, that would also be documented. If the skin was not open, there would not be any measurements, but if the skin was open and it was measurable then the measurements would be documented. The LPN/UM stated if the resident was admitted with open skin/wounds, incident reports are not done but any skin alteration would be documented. The wound Care Team would be consulted depending on the severity of the wound. The LPN/UM stated she was familiar with Resident #147. The LPN/UM showed the surveyor the handwritten Receiving Report from the Hospital Form dated 4/24/24, which did not reflect any skin alterations to Resident #147's Left hip. The LPN/UM stated that her expectation from the admitting nurse would be to perform a head to toe assessment upon admission and document any skin breakdown. The surveyor inquired about the Stage 3 Left hip PU which was identified by the outside consultant physician on 5/22/24. The LPN/UM stated, I do not believe that it was measured after the resident returned from their visit. The LPN/UM stated Resident #147's shower days were Wednesdays and Saturdays, and resident had shower on Wednesday 5/22/24, before the resident went out for their vascular wound consult. The LPN/UM stated that the nursing staff was expected to do skin assessment on the shower days. In the presence of the surveyor, the LPN/UM reviewed the TARs, and could not find any documentation regarding the Stage 3 pressure ulcer identified during the vascular consultation. The nurse initialed the TAR that Resident #147 had intact skin prior to their outpatient vascular wound consult on 5/22/24. On 6/24/25 at 1:27 PM, the LPN/UM stated that she was not at the facility on 5/22/24 during the resident assigned shower day and could not comment on the incident. The LPN/UM further stated the recommendations from the vascular wound consult were reviewed by the nurse and discussed with the Nurse Practitioner (NP). The surveyor then inquired if the Left hip wound was measured upon Resident #147's return to the facility and the LPN/UM stated, I don't believe there were any measurements. The LPN/UM stated that the Director of Nursing (DON) was responsible for investigating new wounds. On 6/24/25 at 2:15 PM, two surveyors interviewed the DON and the Regional Nurse, the DON stated the skin assessments were performed on shower days. The Regional Nurse stated if the CNA observed any skin discoloration on shower days, they would notify the nurse because CNAs were not allowed to assess. The Regional Nurse further stated if Resident #147's skin was intact during the shower day of 5/22/24 and the resident returned with a Stage 3 PU to their Left hip, the wound should have been assessed, measured and an investigation should have been completed. On 6/25/25 at 8:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and presented the above-mentioned concerns. The DON stated, I was not aware of the Stage 3 PU to Left hip. The DON further stated that she was not made aware of the wound consult that identified the new stage 3 PU to Resident #147's Left hip. The surveyor reviewed the TAR with the DON, and the DON verified that there were no measurements for the Stage 3 PU. The DON informed the survey team that the nurse who received and reviewed the recommendation, should have completed an incident report, measured the wound and report the incident to the Unit Manager for follow up. The DON acknowledged that she did not investigate Resident #147's wound. On 06/25/25 at 11:54 AM, during the pre-exit conference the LNHA and the DON informed the survey team that they did not have any additional information to present regarding Resident #147's wound. b. On 06/23/25 at 1:45 PM, Surveyor #2 reviewed the electronic medical record for Resident #25 which revealed: A Nurses Note signed by a Registered Nurse on 6/2/25 at 11:28 PM, which revealed details at time of fall: Occurred 6/2/25 at 17:30 (5:30 PM) in the resident's room and the resident was alone. Resident #25 was alert to self and confused. Narrative: Writer was informed by aide about resident on the floor. Writer found resident laying prone [face down] in room, head in a pool of blood on the floor. Further assessment revealed a hematoma (bruise) to the forehead of the resident. Wound was cleansed with NSS (normal saline solution) and pressure dressing applied. A 911 call was made and Resident #25 was transferred to the emergency room. A review of the Face Sheet (an admission summary) for Resident #25 revealed the resident was admitted with diagnoses including, but not limited to; Displaced intertrochanter fracture of the right femur, vascular Dementia, displaced fracture of second cervical vertebrae, bipolar disorder, difficulty in walking, and cognitive communication deficit. A review of the Initial Care Plan for Resident #25, Effective: 5/12/25, revealed a Problem: Resident at risk for falls. Requires assistance with transfers and physical functioning due to weakness and functional limitation of a fractured right hip and psychotropic drug use, dated 6/2/25; Fall in room, head injury sent to emergency room, Active 5/12/25; Goal: Will not have fall related injuries falls in the next 30 days, Active 5/12/25; The following Interventions, Active as 5/12/25: Administer psychotropic medications as ordered and monitor for side effects; Assist with transfers and with physical functioning; Ensure a safe and clutter free and well lighted environment; Lower bed to the floor. Provide frequent staff monitoring. Verbal and visual reminder to use call bell for assistance; Place call bell within reach and encourage to call for assistance; Tap call bell. A review of the admission MDS (an assessment tool) dated 4/22/25 revealed a Brief Interview for Mental Status Score of 1 which indicated a severely impaired cognitive status. A review of the physician order sheet for 6/1/25-6/30/25 revealed the following: Divalproex, 125 mg capsule, delayed release sprinkle (1 capsule), three times per day, Order Date: 4/21/2025; Instructions: Diagnoses Bipolar Disorder was administered on 6/2/25 at 13:00 (2:00 PM) for the Behavior Symptom: Paranoia (extremely suspicious of others, believing others are trying to harm you). On 6/23/25 at 2:00 PM, Surveyor #2 requested all investigations for Resident #25. On 6/23/25 at 2:29 PM, the Charge Nurse (CN) provided one investigation for Resident #25, and confirmed it was the only investigation and it was the entirety of the investigation which was dated 6/2/25 at 5:30 PM. The investigation revealed: Type: Fall; Location: Resident Room; Witness/es: None; Cognition prior to occurrence: Confused; Cognition after occurrence: Confused; Injuries: Head Trauma; Location: Center side of Forehead; Details: Head Injury: Hematoma to forehead; Immediate Actions Taken: Pressure dressing applied, Notified immediate supervisor, Fall risk assessment completed, Placed in wheelchair, Pain assessment; Notes: Entered by Registered Nurse (RN #1) at 9:24 PM, Writer was informed by aide about resident on the floor. Writer found resident lying prone in room, head in a pool of blood on the floor. Further assessment revealed a hematoma to the forehead of the resident. Wound was cleansed with [normal saline solution] and pressure dressing was applied. A 911 call was made and resident was transferred to the [emergency room] for further evaluation. Resident statement of what happened written by resident entered by RN on 6/2/25 at 9:24 PM: Resident is confused at baseline but reports [they] were responding to a call by someone who told [them] to get out of [their] chair. Witness statement: N/A; Fall type: Found on floor; Position on Floor: [Left Blank]; Independent for toileting: no; Care prior to fall: visually observed 6/2/25 at 5:15 PM; Preventative measures at time of fall: Call light: off; Conclusion: Completed by the DON on 6/3/25 at 8:13 AM; Nursing supervisor alerted that resident noted on the floor. Nursing supervisor observed resident laying on the floor in prone position with head on the floor in a pool of blood. Resident assessed. Vitals signs [within normal limits]. Full range of motion noted to all extremities. Hematoma noted to forehead with fresh red blood. Area cleansed and pressure dressing applied. [Physician] and family notified. New order to send resident to [emergency room] for evaluation at treatment. Resident transferred via 911 at approximately 5:45 PM. Resident returned to facility at approximately 10:05 PM. All x-rays and scans negative. Physician and family notified of return to facility. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. Root Cause: Factual description of incident added to nurse note, Due to resident action or internal risk factors: N/A; Resident state of motion at time of fall, Transferring; How many staff were in assistance, 2; Staff Interviews: No staff interviews available; Recommendations: none noted. One Individual Statement was attached to the investigation, dated 6/2/25, which revealed: room [ROOM NUMBER] at 5:30 PM, I went into resident's room to leave dinner tray and found resident on the floor. I immediately informed nurse on duty. There was no documentation in the investigation when the resident was last toileted or given fluids as both areas were documented as N/A, in the section Care Plan Prior to Fall although the resident was documented as no for independent with toileting. A review of the facility provided emergency room record dated 6/2/25, revealed CT (Computed Tomography- a detailed picture using scans and computer) of the head revealed There is a large area of left frontal scalp swelling with hematoma measuring approximately 4.5 X 3.7 centimeters. On 06/25/25 at 9:16 AM, Surveyor #2 informed the DON and LNHA of the above findings and asked what was the root cause for the fall that resulted in 911 transfer. The DON reviewed the incident report and statement and stated the Certified Nurse Aide found the resident on the floor when she went to pass the meal tray and the DON stated that the resident was confused. The DON stated the resident told RN #2 that someone told them to get out of the chair, The DON further stated that was the cause of the fall. The facility did not identify the causal factor of the fall. No other information was provided. c. On 06/18/25 at 1:12 PM, Surveyor # 2 reviewed the closed electronic medical record for Resident # 44 which revealed a Care Plan, Effective 9/10/24, with a Problem: Recent fall prior to admission, at risk for further falls due to difficulty with transfers and ambulation, weakness following hospitalization; 11/4/2024, Fall in bathroom skin tear to right elbow. A review of the Face Sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; vascular Dementia, altered mental status, repeated falls, cognitive communication deficit, history of falling, and muscle weakness. The Quarterly MDS dated [DATE] revealed the resident was moderately cognitively impaired and required assistance for bed mobility, transfer and toileting. At that time, Surveyor #2 then requested all investigations for Resident #44. On 6/19/25 at 9:00 AM, Surveyor #2 reviewed the electronic medical record, the paper closed medical records along with two investigations provided by the facility which revealed the following: 1. On 11/4/24 at 12:35 AM, Resident #44 was confused and sustained an unwitnessed fall and sustained a skin tear to the right elbow, circular, measuring 1.1 x .5 centimeters (cm). The Nurses Note of what happened was documented by RN # 1 on 11/4/24 at 2:40 AM, which revealed: Aide called writer's attention about resident on the floor. Writer found resident on the floor in [their] bathroom, sitting up with [their] back against the toilet. Resident was confused and could not recollect exactly what happened. Resident was helped back into [their] bed. Resident had a skin tear measuring 1.1 x .5 cm to right elbow. Skin tear was cleaned with normal saline and covered with [gauze]. Resident denied hitting head, denied any other pain apart from the skin tear. Neuro checks initiated . Resident statement of what happened on 11/4/24 at 2:24 AM, Resident stated [they] were trying to go to bathroom. Resident confused, sometimes non-compliant to safety measures. The Conclusion documented by the DON on 11/4/24 at 11:45 AM revealed the CNA alerted the primary nurse that resident noted sitting on the floor. Primary nurse observed resident sitting in an upright position on the bathroom floor with [their] back against the toilet. Resident assessed . Resident denies any pain or discomfort at this time. Resident denies hitting [their] head. Skin tear noted to right elbow with fresh red blood noted. Skin tear cleansed and treatment in place. Resident encouraged to call for assistance. All safety precautions in place and maintained. Care plan reviewed and updated. Medications reconciled. There was one statement attached and signed by the CNA on 11/4/24, which revealed the date and time of incident, Room # 236 on 11/4/24 at 12:35 AM. The section titled to tell us step by step in your own words what happened . revealed: Resident's bathroom call bell was on and I entered the room, and saw blood on the floor next to the bed and then saw resident on bathroom floor sitting up with back against toilet. Resident stated [they] fell when trying to go to bathroom. Resident was bleeding from right elbow area. Nurses and supervisor was made aware. Care Prior to Fall: Visually Observed, 11/4/24 at 12:10 AM; Toileted: NA; Given Fluids: N/A: Repositioned: N/A. Preventable Mesures at time of fall: call light off. 2. On 2/9/25 at 6:45 PM, Resident #44 sustained a skin tear to the left lower leg while an Agency CNA provided care and the Nurse documented on 2/9/25 at 11:31 PM, that This writer was informed by aide that resident had sustained a skin tear during care. Upon arrival resident was bleeding. Site was treated. Measuring 9 x 1 centimeter . Resident statement of what happened, doesn't know. Witness statement of what happened written by CNA, I saw a bleeding from the resident due to skin tear. Conclusion, signed by DON on 2/10/25 at 9:05 AM. Primary nurse alerted by CNA resident noted with skin tear. Primary nurse assessed resident .Skin tear noted to [left] lower leg measuring 9 x 1 cm with fresh red blood. Resident in bathroom by self when skin tear was noted. Skin tear was noted in direct line of door frame .Resident encouraged to call for assistance. One statement was attached from the Agency CNA, dated 2/9/25, which revealed: Resident was in the bathroom by self when I went to provide care. I noticed resident was bleeding due to skin tear on leg. I quickly notified the nurse of the incident around 6:54 PM. I saw bleeding from the resident due to skin tear. The investigation did not address that the CNA reported the resident sustained the skin tear during care to the nurse, and the activity that was documented as occurring was Dressing, or why the resident was found alone in the bathroom. On 06/18/25 at 2:41 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA) who stated the DON was responsible to complete all investigations and he was responsible to ensure that an investigation was completed. On 06/19/25 at 9:28 AM, Surveyor #2 interviewed the [NAME] President of Clinical Services (VPC) and the DON, in the presence of the survey team, and inquired regarding the investigative process following an unwitnessed fall. The DON stated, the staff would alert the nurse and the nurse would complete an assessment of the resident. Surveyor #2 then asked who would be responsible to obtain statements. The DON stated the primary nurse was responsible to obtain statements from the CNA and the nurse would obtain resident's statement. According to the DON, the facility did not collect statements from any other staff on duty on the day of the incident. Surveyor #2 then asked the DON what was the purpose of an investigation? The DON replied, to investigate what happened. On 06/19/25 at 9:47 AM, Surveyor #2 read the CNA's statement regarding the incident and asked the DON if there was an investigation regarding the blood that was observed next to the resident's bed? The DON stated when she completed her investigation the following morning that she did not see the blood by the bed, and stated it was an Agency CNA. Surveyor #2 asked if the blood next to the bed was important to review and to determine what was the causal factor? The DON did not respond. Surveyor #2 then asked about the skin tear documented as happening during care, and what was determined as the causal factor of the skin tear, and what specific interventions were implemented as a result? The VPC requested to further review both investigations prior to proceeding with the surveyor inquiries. On 06/19/25 at 9:57 AM, Surveyor #3 asked the VPC when an injury of unknown origin occurs, who do you collect statements from? The VPC stated, we usually do a 24-hour look back and collect statements. On 06/25/25 at 11:54 AM, during a meeting with the LNHA and the DON, in the presence of the survey team, they did not have any additional information to provide regarding the causal factor for Resident #25 and #44's unwitnessed falls with injury, and for Resident #147's Stage 3 PU that was identified during an outpatient visit, to determine if the injuries were not related to neglect. The Incident Reporting Policy Revised 9/16/24 revealed: Purpose: Incidents are defined as any event, occurrence, situation or circumstance, which is unusual or inconsistent with the policies, practices and routine operation of the community. It may be an accident or situation which may or may not result in bodily injury and/or property damage. Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated. 2. Assure incidents are recorded and reported to the proper agencies and internal departments. 3. Analyze all incidents for risk potential implementing corrective and/or preventative actions as required. Procedure: Significant Event/Injury: A resident transported to a local medical facility for treatment related to the injury event. A fall that results in a fracture and or/multiple contusions. Event/injury related death. Incident Report Investigation Forms: 1. An investigation shall be initiated on all reported incidents. An incident investigation shall be completed at the time of the incident. 2. Document in the investigation section if facts relating the cause of the incident are known. Possible causes may be investigated but not documented until substantiated by facts. 3. All staff members assigned to the unit/area on the shift the incident occurred having knowledge of the incident should completed written statements. It is not necessary to obtain written statements from everyone, only those individuals with knowledge of the incident. Written statements should document the facts surrounding the incident. All statements must be signed by the authors/writers, including any statements obtained from residents. 4. All injuries of unknown origin, including skin tears and bruising, must be investigated immediately. All staff caring for the injured resident for the past 24 hours shall be interviewed and write and sign a statement regarding their knowledge of the injury and/or whether it was present during their shift. Further investigation and statements may be necessary based on findings and analysis of information obtained. Abuse Investigation. 1. An investigation shall be initiated by the community/ facility within twenty-four hours of the discovery of a resident with any injury of a suspicious or unknown origin or receipt of an allegation of abuse . NJAC 8:39-4.1(a)(5)

Based on interview and document review it was determined that the facility failed to submit the required Minimum Data Set (MDS) assessment within the appropriate timeframe for 3 of 7 system selected MDS' reviewed (Resident #4, Resident #8, and Resident #24) and was evidenced by the following: On 06/16/25 at 2:27 PM, the surveyor requested the Validation report for Resident #4, for the admission dated 7/13/22; Resident #8 for the admission dated 8/4/21; and Resident #24 for the admission dated 7/6/22. On 06/18/25 at 11:49 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (MDSRN) who stated she has been employed at the facility since May, 2025. At that time, the surveyor reviewed Validation reports with the MDSRN who confirmed: - Resident #4 required a Quarterly MDS to be completed by 1/20/25, and it was completed on 2/4/25. The MDSRN stated it was completed late. - Resident #8 required a Quarterly MDS to be completed by 2/11/25, and it was completed 2/26/25. The MDS RN confirmed it was completed late. - Resident #24 required and Annual MDS to be completed on 7/12/24, and it was completed on 7/30/24. The Validation report revealed the Target Date: 7/12/22 and Assessment Completed Late: for this admission Assessment . (completion date) is more than 13 days after . (entry date). The Discharge Assessment was due 7/24/24 and it was completed 8/12/24 which was also completed late per the MDSRN. A review of the facility policy MDS Assessment Schedule, revised 10/15/24 revealed the MDS Coordinator/designee will be assigned the responsibility for completion and distribution of the Medicare MDS Assessment schedules according to the following procedure. 3. When determining MDS assessment reference dated, grace days may be utilized as long as the dates are in compliance with the . MDS guidelines. On 06/25/25 at 11:45 AM, during the exit conference held with the Director of Nursing and Licensed Nursing Home Administrator, they had no additional information to provide. NJAC 8:39-11.1

Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure that accurate the medial record accurately documented the care provided to a resident who was having difficulty breathing and required transfer to the hospital. This deficient practice occurred for 1 of 1 closed resident record reviewed for hospitalization (Resident #44) and was evidenced by the following: On 06/18/25 at 1:12 PM, the surveyor completed an initial review of the electronic medical record (EMR) and reviewed an Other Change in Condition note completed by a Registered Nurse (RN) on 3/20/25 at 11:56 PM which revealed the following: Residents's condition is getting worse. [Their] cough is getting worse and very congested. Contatcted [General Practioner] to request lab work . Checked [vital signs] as follows: [Blood Pressure} 105/65, [Pulse] 72, [Respirations] 18, SpO2 (the blood oxygen level) 93% (normal range -95-100%) . Due medications given as ordered. [As needed] Gertissuin given at 2000 H [8:00 PM]. Noticed that resident is having difficulty breathing. Resident unable to expel secretions. Rechecked [vital signs] at 2150 [9:50 PM] and as follows: . SpO2- 85% . Contacted [General Practioner] to send to hospital . taken to hospital at around 2251 H [10:51 PM]. The surveyor reviewed the remainder of the EMR and could not locate any documentation regarding any other treatment or care provided to the resident when the resident had difficulty breathing and was unable to expel secretions. On 06/19/25 at 10:00 AM, the surveyor reviewed the paper closed medical record for Resident #44 and was unable to locate any additional information related to the care provided by the RN prior to sending the resident to the hospital on 3/20/25. On 6/19/25 at 1:51 PM, the surveyor interviewed the Director of Nuring (DON) and Liscensed Nursing Home Administrator (LNHA) regarding where the information would be documented regarding a change in condition for a resident. The DON stated the nurse would document in the progress note. The surveyor asked what the change in condition policy was for a resident who had breathing difficulty and could not expel secretions? The DON stated the nurse would conduct a change in condition assessment and call the doctor. The DON stated if a person had difficulty breathing the nurse could use the suction machine and suction the resident and it would be documented in the progress notes along with all care that was provided. The surveyor asked if a resident was sent to the hospital did the facility review the medical record. The DON and LNHA confirmed there was no formal review of the medical record. On 06/19/25 at 2:04 PM, the surveyor asked the DON and LNHA if they had any additional information related to any care provided to Resident #44 when they experienced breathing difficulty and required transfer to the hospital. On 6/25/25 at 11:45 AM, the DON and LNHA provided two statements, one was dated for care provided to resident #44 on 3/20/25, and was dated 6/19/25 by the RN who cared for Resident #44. The statement revealed information that was not documented in the medical record [NAME] included: .Resident is coughing and getting more congested at 2130 H [7:30 PM. Resident was unable to expel secretion on own. Secretions were suctions and congestion decreased. Another statement, documented by a different Registered Nurse revealed on 3/20/25 at around 9:30 PM. I was called by my co-worker that [Resident #44] is having a respiratory distress. [head of bed] elevated. Oxygen level was 85% on [room air]. [Oxygen at 2 liters per minute via nasal canula administered. Lung sounds auscultated. Congestion noted. Suctioned [as needed] copious thick clear secretions obtained. Oxygen level rechecked and it was 90% on oxygen at 2 liters per minute. The Charting and Documentation Policy, undated, revealed the Purpose: 1. A complete account of the resident's care, treatment, response to treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Rules for Charting and Documenation: 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medications, etc. as well as routine observations. 17. Oxygen Administration: Documenation pertaining to oxygen administration should included: a. Date, time started, and time stopped. b. Rate of flow, route, and rationale. f. Reasons (s) for [as needed ] administration. 22. Suctioning; Documentation pertain to suctioning should included: a. Date and time resident was suctions, i. all pertinent observations. NJAC 8:36- 35.2(d)(6)(9)

Based on observations, interviews and review of facility documentation it was determined that the facility failed to a.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness; b.) maintain kitchen equipment in a manner to prevent microbial growth, and c.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 1/30/24 at 9:54 AM, the surveyor, in the presence of a second surveyor and the Director of Dining services (DDS) toured the kitchen, and observed the following: In walk-in freezer #1: 1. A 22-quart plastic food storage container containing, what was identified by the DDS as, rice soup. The container was not labeled or dated. At this time the DDS stated, that should have been labeled. 2. One (1) opened 20-pound (lb) box of wax beans labeled with a received date of 1/15/24, containing a plastic bag of wax beans which was opened to air, to which the DDS stated it should not be opened to air like that. On a drying rack adjacent to the dish washing area were two large stainless steel mixing bowls and two clear plastic food storage containers all wet nested (stacked on top of each other while still wet). At that time, the DDS stated these should not be stored like that. On a storage rack adjacent to the three-compartment sink were four cutting boards with scrapes, gouges, and black discoloration. The DDS stated there were new cutting boards on order and had a kitchen staff member remove these cutting boards from use. On 2/2/24 at 10:10 AM, the surveyor in the presence of a second surveyor and the ADDS, observed in the emergency food supply room a one-pound bag of cereal which was not in it's original shipping box and not labeled or dated. At this point the ADDS stated it should be labeled. On 2/6/24 at 10:01 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated they had a new dining company and are still working out the kinks. Review of the facility's policy titled Food and Supply Storage with revised date 1/22 included but was not limited to, all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . cover, label and date unused portions and open packages. Review of the facility's policy titled Storage of Pots, Dishes, Flatware, Utensils with revised date 1/22 included but was not limited to, air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. Review of the facility's policy titled Cutting Boards with revised date 1/22 included but was not limited to, replace all cutting boards with grooves and pits 1/8-inch or deeper that cannot be cleaned and sanitized using routine cleaning and sanitizing procedures. NJAC 8:39-17.2(g)

Based on observation, interview, record review, as well as a review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was transferred using the correct mechanical lift device and utilized the sufficient required staff assistance to prevent accidents and injury for 1 of 3 residents reviewed; (Resident #14). On 6/23/21, Resident #14 was improperly transferred by 1 staff instead of 2, which resulted in significant bruising on the left axillary region, a left chest wall hematoma (a collection of blood outside of the vessels caused by an injury to the wall of the blood vessel, prompting blood to seep out of the vessel into the surrounding tissues) and complaints of pain that resulted in emergency room services and hospitalization . This deficient practice was evidenced by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath their back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary), the resident was initially admitted to the facility on ,d+[DATE], and had diagnoses which included but were not limited to: Alzheimer's Disease with late-onset, generalized anxiety disorder, and muscle weakness. According to the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 7/12/21, Resident #14 was readmitted to the facility on [DATE], from an acute hospital. Further review of the MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident was severely, cognitively impaired and had behaviors that included rejection of care. A review of the Functional Status portion of the MDS noted that the resident was totally dependent for transfers and required two-person assistance to transfer from the bed to wheelchair. A review of the Care Plan report effective 7/14/21 to present, revealed that Resident #14 required help with activities of daily living (ADLs) due to cognitive deficits related to Alzheimer's diagnosis. An intervention was added to the entry on 5/13/21, for two-person assistance with transfers via Hoyer Lift. Further review of the Care Plan Report included another entry that specified that the resident was at risk for alteration in skin integrity secondary to needing assistance with ADLs, incontinence of bowel and bladder, and was on medications that may cause bruising. The entry included: On 6/23/21-bruise to left great toe: x-ray negative and 6/25/21-bruise to left breast/axillary area. Goals included; Bruises to the resident's left great toe and left breast area will resolve without any complications, and the resident will not have a skin impairment x 90 days through 10/31/21. Interventions included that during shower times, the resident's CNA would use 2 assist to move the resident with the Hoyer lift to carry [Resident #14] from one place to another. A review of the Facility's Accident/Incident Report, dated 3/16/21 and timed 8:00 AM, indicated that Resident #14 had injuries that included a reddish-purple bruise to the left side of the chest and axilla (space below the shoulder or armpit). The Nurse's Note from the what happened portion of the form detailed that the CNA called the nurse to inspect the resident's skin when the resident received morning care. Nursing documented that a bruise was observed on the left lateral side of the breast [sic.] and axilla. There was reddish-purple discoloration with yellowing to the outer perimeter. No mass presented under discoloration upon palpation. The resident demonstrated no signs of discomfort. The Skin Issue Type was described as a bruise on the left side of the chest that measured 12 x 7 x 0 cm. The wound was further described as a reddish-purple bruise to the left lateral breast and axilla. The Conclusion was dated 3/22/21 at 3:42 PM, and detailed that through investigation it was identified that some staff used the Sit to Stand (a device used to transfer patients from one seated surface to another) in which the straps fit underneath the arms, using a stand and pivot technique in which two people interlock their arm underneath the bilateral armpit or the Hoyer Lift device in which resident is positioned on a sling device and mechanically lifted applying no contact to the armpit. Resident #14 was assessed [No date specified] by PT (Physical Therapy) and identified to be a Hoyer Lift [sic.] only for safety. It included that the resident was on aspirin therapy, denied pain at the site, and the Root Cause was no-fault. A review of an additional Accident/Incident Report, dated 6/25/21 and timed 6:20 PM, indicated that Resident #14 had an injury that included a bruise to the left upper arm. The Nurse's Note portion of what happened on the form detailed that the resident's assigned aide notified the nurse to assess the resident's left arm (axillary area). Upon entering the resident's room, the resident had a bruise to the left axillary, and the left breast was swollen; and noted discoloration with a visible lump on top of the left breast, which was tender to touch and warm. The resident screamed while nursing assessed the lump on the breast. There was no pain with movement to the left arm except with touch. The resident was alert, disoriented, and not able to explain how the bruise occurred. The physician was called and informed and ordered to transfer the resident to the hospital for further evaluation. The Conclusion was dated 7/21/21 at 3:59 PM and detailed that Resident #14 sustained a bruise on the left under the shoulder area from the skin pad area when the aide transferred [sic.] without another assistant [sic.] using the sit to stand [sic] lift. The aide was educated on the proper use of devices. The root cause was Human Error. During an interview with the surveyor on 9/03/21 at 11:55 AM, Resident #14's Certified Nursing Assistant (CNA) stated that Resident #14 was dependent for activities of daily living which included bathing, oral care, and feeding assistance. She noted that the prior year, the resident was able to be transferred with the aid of two staff members without the use of a transfer assistive device. The CNA explained that not too long ago, she utilized a Sit to Stand Transfer Assistance Device alone without a second caregiver to transfer the resident to a shower chair, and the resident hurt their shoulder during the transfer. The CNA stated that she did not know that the resident was injured at the time of the transfer. She noted that the resident only said, Put me down. She stated that she lowered the resident down as directed and transferred the resident into the shower chair. She noted that the resident did not like the machine. She further stated the resident later complained of shoulder pain and was sent to the hospital. She said that she was unsure which shoulder was affected, and when the resident returned from the hospital, she noted that the resident had bruising, which resolved in one week. She stated that the facility provided her with in-service training and informed her that she was required to use a Hoyer lift to transfer the resident. She stated that the resident did not like the Hoyer lift and did not want it every time, but once the resident was up in the chair, the resident was okay. During a subsequent interview, that day, with the surveyor at 1:18 PM, the CNA explained that she knew that she was required to have a second staff member present to assist when she transferred Resident #14 with the use of the Sit to Stand or Hoyer Lift because she had used both devices for this resident. She further stated that before the resident was hospitalized , she transferred the resident alone with the Sit to Stand without the aid of another staff member because she could not find anyone available to help at that time. So, she transferred the resident alone instead. During an interview with the surveyor on 9/03/21 at 1:23 PM, the Licensed Practical Nurse (LPN) stated that she had begun working at the facility in July of this year, and Resident #14 was dependent for ADLs and required two CNAs to transfer with the Hoyer Lift. She stated that one CNA was needed to spot the resident, and one was responsible for handling the machine itself and guiding it to avoid bumps and falls. She stated that the Sit to Stand was not permitted to be utilized for Resident #14. She further stated that she was unsure how the CNA's knew what care to provide for the residents as they had worked at the facility longer than her. She further stated that nursing was required to inform them if there were any changes in the resident's care plan. During an interview with the surveyor on 9/03/21 at 1:33 PM, the Registered Nurse Unit Manager (RNUM) stated that Resident #14 required total care and two-person assistance for transfers using a Hoyer Lift. She noted that the nurses gave the CNAs report in the morning and advised them of any change in the resident's condition. She stated that the resident's care plan illustrated that the resident required two-person assistance to be transferred with the Hoyer Lift. She further noted that a Sit to Stand could not be used for this resident as the Hoyer Lift was ordered with two-person assistance. She explained that the resident was required to be hospitalized after their chest was bruised. The Director of Rehabilitation (DOR) stated during an interview with the surveyor on 9/03/21 at 3:22 PM, that Resident #14 was seen by Therapy after a decline in functional status was noted in the resident post-hospitalization from [DATE] through 7/01/21. She said that the resident could not sit on the edge of the bed independently and required two-person assistance. She stated that the resident had a variable psyche, and the staff often went by the resident's wishes. She maintained the resident was assessed in November 2020 and required a Hoyer lift for all transfers. She said the resident was unsafe to use a Sit to Stand transfer device as of 11/25/20 after the resident demonstrated non-compliance for therapy sessions. She further stated that a Nursing and CNA Communication was completed at that time, though she was unsure if she had a copy. A review of an Occupational Therapy (OT) Daily Treatment Note dated 11/25/20, revealed that the DOR, an Occupational Therapist, documented that Resident #14 demonstrated noncompliance for therapy sessions, Sit to Stand Lift and difficulty for transfers. The Hoyer Lift was recommended as a safe and optimal mode of transfer. During an interview with the surveyor on 9/07/21 at 10:38 AM, the DOR stated that the Administrator confirmed a Nursing to Therapy Referral was done in March 2021, and staff received training specific to Resident #14 and the use of the Hoyer Lift for transfer. When the surveyor inquired why Resident #14 was determined not to be safe to use the Sit to Stand Transfer Device, the DOR stated that a person must be able to stand up and hold onto the bars while standing for the device to be deemed appropriate for resident transfers. She explained that the resident must have some ability to bear weight and have shoulder range of motion. The machine helped them to bear weight. She explained that if a resident was not compliant or not cognitively intact, they may give up, and it was a safety risk if the resident fell , or staff may have to lift them. She stated that the resident might not fall on the ground because they were harnessed, but they may try to let go or try to sit down. She stated that the resident must have the ability to follow directions and that two people were needed during transfers if something went wrong. The DOR further explained that a Hoyer Lift was used for a resident with total dependence, with no partial control. She stated that therapy would not even consider a Sit to Stand if a resident was dependent. She said two people were needed to guide the Hoyer Lift and the sling if they acted up or something went wrong for safety. She stated that if the resident was prone to behaviors and was noncompliant with a Sit to Stand Device, it could cause pressure on the skin and cause bruising. She further stated that the aides must follow the instructions that they have been given. During an interview with the surveyor on 9/07/21 at 10:54 AM, the Director of Nursing (DON) stated the probable cause of the injury was related to the resident transfer. She stated that the staff received a follow-up staff in-service in August 2021 after the CNA used the Sit to Stand alone instead of with two persons as required for both resident and staff safety so that no one got hurt. She stated that the CNA transferred Resident #14 alone, which resulted in bruising and a mass. She stated that the nurse saw the swelling and the bruising and sent the resident to the hospital as the resident screamed non-stop. She noted that the resident held their shoulder and that the nurse reported swelling and discoloration of a slight bruise, but the cause was unknown. She stated, initially, we thought that it was a fall, then we thought someone fought her. Then the Administrator reviewed the cameras that were present in the hallway and saw two persons go into the resident's room. Further review of the video revealed that the CNA took the resident to the shower room via wheelchair. She stated that when she got to the shower room, she took the Sit to Stand into the shower room alone. When interviewed, the CNA admitted that she transferred the resident alone with the Sit to Stand because she could not find anyone to assist her. The DON stated that the CNA did not want to wait for another aide to be free and transferred the resident by herself. The DON said that the resident had a visible mass when they called the hospital the next day. She further stated that was why they reviewed the camera. The DON said that the nurse documented the incident in the 24-Hour Report and called her to inform her of the resident's condition. A review of the 24-Hour Report dated 6/25/21, documented on the 3-11 PM shift under Safety Precautions, revealed the following: Patient (Resident #14) had a bruise to the left axillary area. Left breast swollen with discoloration and lump on top of the left breast. Tender to touch and warm. Patient screams for [sic.] pain when touched. Doctor informed, ordered to transfer the patient to the hospital. POA (Power of Attorney) and DON informed. During an interview with the surveyor on 9/07/21 at 11:50 AM, the Administrator stated that he was informed by the assigned Registered Nurse (RN) that Resident #14 had a bruise and that the doctor wanted to send the resident out to evaluate the visible mass noted on the left breast. He stated that he initiated an investigation and did not suspect abuse based on the information presented to him. During an interview with the surveyor on 9/07/21 at 12:51 PM, the MDS RN stated that Resident #14 was recently sent out to the hospital and experienced an overall decline after readmission to the facility. She stated that the resident had required the total assistance of two persons to transfer with a Hoyer Lift. She said that meant that the resident was totally dependent and was unable to participate in transfers. She stated that the resident was determined to have required extensive assistive of two persons according to the quarterly MDS dated [DATE], as the resident may not have needed staff assistance and was lifted instead. She stated that she obtained the information from observation and interview with nurses and staff and documentation review. She further stated that in April 2021, the resident either did not require a Hoyer Lift Transfer or if, the resident got scared and refused, two aides may have assisted the resident in transferring instead of using a Hoyer Lift. She further stated that she reviewed a seven-day look-back period which indicated that she would have coded the observation accordingly as a 3/3, extensive assistance of two persons rather than a 4/3, total dependence of two-person physical assistance as the resident has been coded since that time period. During a later interview with the surveyor on 9/07/21 at 3:19 PM, the Administrator stated that he obtained statements from the CNAs. He said through investigation, he learned of an error that occurred when Resident #14 was transferred improperly. He stated that this led to 1:1 education, abuse education, and disciplinary action for the involved CNA. He said that the CNA had an in-service in March about transfers, abuse, and following the Care Plan. He further stated that the CNA noted that she did not see anyone outside of the shower room and thought she could transfer the resident with the Sit to Stand by herself and made a poor decision not to transfer the resident the right way. The Administrator could not provide the surveyor with documented evidence of the CNA's in-service in March 2021. During a phone interview with the surveyor on 9/08/21 at 9:04 AM, the Registered Nurse (RN) stated that she recalled that she sent Resident #14 out to the hospital during the 3 to 11 PM shift when the CNA informed her that the resident had a bruise around the left breast. She stated that when she touched the affected area, the resident screamed. She said that the bruise was huge from the left chest to the back. She stated that it looked like the resident fell or someone grabbed him/her. The RN further noted that the resident screamed loudly in pain, which was out of character for them. She stated that she observed a purple mass on the left breast that was hard to touch. She said that she reported it to the DON and called the physician. During a phone interview with the surveyor on 9/08/21 at 9:25 AM, Resident #14's physician described the resident as elderly, with thin skin. He stated that the resident had bruising over the breast, which was a hematoma. He noted that the resident was sent to the ER, where the hospital indicated that there had been trauma. He stated that the resident was unable to communicate what happened due to Dementia. He noted that the resident had an abscess (a small cyst) that was treated with antibiotics. A review of Resident #14's Hospital Records for admitted [DATE] through discharge date of [DATE] revealed that the principle discharge diagnoses was Chest wall hematoma. Details of Hospital Stay/Hospital Course included: .According to transfer papers, the staff at the skilled nursing facility noticed a chest wall mass that was nontender, and the patient was transferred to the hospital for evaluation. There were no signs of [CONDITION(S)]. They were, however, noted to have severe bruising around the left shoulder and upper arm, and it was unclear if they fell at the nursing home. An ultrasound showed a large hypoechoic lesion (a mass that appeared darker on the ultrasound than the tissue) with a small internal focus of vascularity (supplied with blood vessels). An x-ray of the shoulder showed suspected chronic rotator cuff tear with no evidence of acute fracture or dislocation. CT (CAT Scan) of the chest showed a large left anterior chest wall hematoma. Patient was evaluated by surgery, and no acute intervention was recommended .Patient is stable for transfer back to the skilled nursing facility. A review of a Physician's Progress Note dated 7/3/21 revealed that Resident #14's attending physician saw the resident after readmission to the facility and documented that the resident's left breast mass was evaluated by surgery and was felt to be a hematoma. On 9/08/21 at 9:52 AM during an interview with the surveyor , in the presence of the survey team, the CNA stated that nursing did rounds with her in the morning before she began her day to inform her of resident care needs. However, she stated that did not happen every day. She said that she used a Hoyer Lift to get Resident #14 out of bed since last year. She stated that prior to that, the resident was able to participate in transfers a little and was able to bear some weight with two-person assistance. When the resident became difficult to transfer, she reported it to the nurse. Therapy evaluated the resident and told her that the resident required a Hoyer lift to get out of bed and into bed. She stated that when she took the resident into the shower room, she had to use the Sit to Stand because she could not use the Hoyer Lift in the shower room; She used a shower chair because the facility did not have a shower bed. She stated that Therapy did not instruct her to use the Sit to Stand in the shower, but she knew how to use it, and that nursing delegated approval to use the Sit to Stand in the shower. She stated that she had access to the resident's Care Plan on the computer but had not reviewed it. She said that she received a write-up, disciplinary action, and 1:1 training due to improper resident transfer of Resident #14. She stated that she had not utilized the Sit to Stand since that time and had instead washed the resident in the bed. The surveyor reviewed the facility policy, Mechanical Lift For Transfers (revised November 2017), which revealed the following: Policy: To safely transfer elders who are unable to stand and pivot and/or require lifting to move from bed to chair. Procedure: At least two people are required to transfer an elder using a mechanical lift. NJAC 8:39-27.1(a)

Based on interview and record review it was determined that the facility failed to report three injuries of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for accident and incidents (Resident #14). This deficient practice was evidenced by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary), the resident was initially admitted to the facility in 11/2016 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 7/12/21, Resident #14 was readmitted to the facility on [DATE] from an acute hospital. Further review of the MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident was severely, cognitively impaired and had behaviors which included rejection of care. Review of the Functional Status portion of the MDS indicated that the resident was totally dependent for transfers and required two-person assistance to transfer from the bed to wheelchair. A review of the Care Plan Report effective 7/14/21 to present, revealed that Resident #14 required help with activities of daily living (ADLs) due to cognitive deficits related to Alzheimer's diagnosis. An intervention was added to the entry on 5/13/21 for two-person assistance with transfers via Hoyer Lift. Further review of the Care Plan Report included another entry which specified that the resident was at risk for alteration in skin integrity secondary to needing assistance with ADLs, incontinence of bowel and bladder, and was on medications which may cause bruising. The entry included: 6/23/21-bruise to left great toe: x-ray negative and 6/25/21-bruise to left breast/axillary area. Goals included: Bruises to the resident's left great toe and left breast area will resolve without any complications and resident will not have a skin impairment x 90 days through 10/31/21. Interventions included: During the shower times the resident's CNA (Certified Nursing Assistant) would use 2 assist to move the resident with the Hoyer lift to carry me from one place to another. The surveyor reviewed an incident investigation dated 3/16/21 at 8:00 AM, which detailed that it was related to a Skin Issue that was described as a bruise on Resident #14's left side of chest and further detailed that there was a reddish purple bruise to the left lateral breast and axilla that measured 12 x 7 x 0 cm. Immediate Actions Taken included pain and skin assessment. The Nurse's Note of what happened portion of the form detailed that the CNA who provided morning care to the resident called the nurse to inspect the resident's skin and a bruise to the left lateral side of the breast and axilla which had discoloration described as reddish purple with yellowing to the outer perimeter with no mass noted under the discoloration upon palpation (when pressed upon). Further review of the document revealed that there were no witnesses to the event and the resident was unable to explain what happened. The nurse documented that the resident demonstrated no sign of discomfort at that time and both the resident's family member and physician were notified. Review of the Conclusion portion of the form revealed that Resident #14 was alert and able to make his/her needs known and denied any trauma when interviewed. Through investigation, it was identified that some staff used the Sit to Stand in which the straps fit underneath bilateral armpit and hoyerlift device in which resident was positioned on a sling device and mechanically lifted and applied no contact to the armpit. The resident was assessed by PT (Physical Therapy) and identified to be a Hoyerlift only for safety on an unspecified date. All staff were in-serviced on the preferred technique for transfer. The resident was noted to have been on aspirin therapy. The surveyor reviewed a second incident investigation dated 6/23/21 at 6:00 PM, which detailed that it was related to an Injury of Unknown Origin, that was described as a bruise on Resident #14's left great which further detailed a purple bruise and swelling. Immediate Actions Taken included the following: Pain when ROM (range of motion) performed, pain and skin assessment, physician notified and an x-ray was ordered to rule out fracture of the left foot and great toe, and the Administrator was notified. The Nurse's Note of what happened portion of the form detailed that the CNA reported a bruise on the resident's left great toe. On assessment, the nurse noted purple discoloration and swelling. Resident complained of pain to touch and movement. Physician was notified, a new order for x-ray of left foot was obtained and the resident's family was notified. Further review of the form revealed that the resident was unable to verbalize what happened and that there were no witnesses to the event. Review of the Conclusion portion of the form revealed that the resident looked like he/she was, going through an infection. The surveyor reviewed a third incident investigation dated 6/25/21 at 6:20 PM, which detailed that it was related to a Skin Issue that was described as a bruise on Resident #14's left upper arm. The Nurse's Note of what happened portion of the form detailed that the assigned aide requested that the nurse assess the resident's left arm in the axillary region (armpit). The nurse documented that that the resident had a bruise to the left axillary, left breast was swollen with discoloration, lump on top of left breast, tender to touch and warm and the resident screamed when the nurse assessed the area. Further review of the entry, revealed that the resident was disoriented and not able to explain how the bruise occurred. The nurse documented that the physician was called and ordered to transfer the resident to the hospital for further evaluation. She documented that the DON (Director of Nursing) was notified. Further review of the document revealed that there were no witnesses to the event. During an interview with the surveyor on 9/07/21 at 10:54 AM, the surveyor asked the DON if the facility reported the injuries that were detailed in the incident investigations that pertained to Resident #14 which were dated 3/16/21, 6/23/21 and 6/25/21 to the NJDOH or Office of the Ombudsman for the Institutionalized Elderly. The DON then asked the LNHA in the presence of the surveyor if the aforementioned incidents were reported and he stated that he had not reported any reportable events to the NJDOH since November 2020. The DON further stated that when Resident #14 was sent to the hospital for swelling and bruising, initially, we thought that it was a fall, then we thought someone fought her. She stated that the facility did not immediately know that it was not abuse until after the hospital was called and reported that the resident was being observed for a mass, then the facility decided to view the cameras. She stated that she might have reported the incident. She further stated that the Administrator was responsible for reporting, but stated, I can too. During an interview with the surveyor on 9/07/21 at 11:50 AM, the Administrator stated that on 6/25/21 he was informed by the Registered Nurse (RN) when he phoned the facility to check on staffing, that Resident #14 had a bruise and the physician wanted to send the resident out to the hospital to evaluate a mass. He stated that he needed to do an investigation. He stated that he was able to see the hospital documentation in real time and saw that that the resident had a mass. He stated that he did not suspect abuse, so he did not call the DOH to report suspected abuse. He stated that he based his decision according to the information that was provided to him. The surveyor asked the Administrator why he reviewed the camera footage if abuse was not suspected? He stated that he viewed the camera to determine the cause of the mass and bruising. The surveyor reviewed the facility policy, Abuse (Elder Abuse) (Revised 10/12/2020) which revealed the following: Guidelines for recognizing an Abused Elder: Unexplained bruises. A written report will be submitted to: New Jersey-the Office of the Ombudsman and the State Department of Health within 72 hours. The surveyor reviewed the facility policy, Incident Reporting (Revised 02/01/21) which revealed the following: A completed Reportable Event Form, Incident Investigation Form and any collaborating statements shall be sent to the NJHHSS and the Office of the Ombudsman for the Institutionalized Elderly within 72 hours. NJAC 8:39-9.4(f)

Based on observation, interview and review of facility documentation it was determined that the facility failed to: a) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses; and, b) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 8/31/21 from 9:42 AM until 10:46 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. In the freezer there was one 18.75 pound unsealed, opened box of cinnamon roll dough with the inner clear plastic bag opened with the rolls visible and exposed to air and no opened date. There was one 20 pound unsealed, opened box of oatmeal raisin cookies that were dated opened 8/16 with the inner clear plastic bag opened and the rolls visible and exposed to air. There was one 18 pound unsealed, opened box of Italian loaf rolls with the inner clear plastic bag opened with the rolls visible and exposed to air and no opened date. There was one opened, unsealed brown bag that the FSD identified as French fries that were not labeled or dated. There was one clear plastic bag of French fries wrapped in clear plastic wrap that had no open date. During an interview at that time, the FSD acknowledged the boxes should have opened dates so they know the food items are not old. 2. In the dry storage area on a metal rack, there were two 6 pound 10 ounce cans of mandarin oranges that were dented. The FSD acknowledged they were dented and moved them to the dented can section. On another metal rack, there were six tied clear plastic bags the FSD identified as cranberries with no label or dates. There was one untied clear plastic bag with contents that fell to the floor, with no label or date which the FSD identified as cranberries. On a metal rack was one opened bag of linguine wrapped in clear plastic wrap with no opened date. During an interview at that time the FSD stated the cranberries should have been sealed to keep them safe from bacteria. The FSD further stated that the cranberries and the linguini should have had an open and use by date. 3. On the spice rack there was: one opened 12 ounce jar of gumbo file spice with no open date, one opened 18 ounce jar of mild chili powder with no open date, one opened 17 ounce jar of smoked paprika with no open date, one 14 ounce jar of ground cumin with no open date, one 14 ounce jar of whole fennel seeds with no open date, and one 16 ounce jar of whole caraway seeds with no open date. The FSD acknowledged the spices did not have open dates and stated they should have been dated when opened. 4. In the free-standing ice cream freezer there was one opened 3 gallon covered container of chocolate ice cream with no open date. There was one opened 3 gallon covered container of vanilla ice cream with no open date. There was one opened 3 gallon covered container of moose tracks ice cream with no open date. The FSD stated he was unsure when they were opened and they would be discarded. 5. On the top convection oven there was a brown sticky substance on the outer panel of the right door, a brown substance on both inner glass doors and a brown substance on the surrounding trim. On the lower convection oven there was a brown substance on both inner glass doors and a brown substance on the surrounding trim. The FSD acknowledged they were dirty and stated they were cleaned weekly. 6. On the top rack of the drying rack was one third pan that was nestled on top of another pan. The FSD separated the two nesting pans where the surveyor observed moisture between the pans. The FSD acknowledged they were wet with water, stated it should be dry and removed the pan to the dishwashing area. 7. There was one large white cutting board with several thin brown lines and one large yellow cutting board with a few thin brown lines and two black smudges. The FSD acknowledged they were dirty, stated they would be cleaned, and removed them to the sanitizing sink. 8. At the cook's station was: one 6 ounce jar of rubbed sage with no opened date, one 18 ounce jar of ground cinnamon with no opened date, one 12 ounce jar of crushed red pepper with no opened date, one 18 ounce jar of mild chili powder with no opened date, and one 18 ounce jar of cajun seasoning with no opened date. 9. There was black debris on the can opener and black debris on the base connected to the counter. The FSD stated it was not clean and it should be cleaned after every use so you don't cross contaminate. 10. There was a clear plastic bag covering the meat slicer. The FSD removed the bag and the surveyor observed red and brown debris on the blade and on the food tray. During an interview at that time, the FSD acknowledged the slicer had debris and it was not clean. He stated it was important to clean and bag the slicer after use so no one gets sick. On 9/01/21 from 12:02 PM until 12:24 PM, the surveyor toured the kitchen in the presence of the Executive Chef (EC) and observed the following: 1. In the freezer was one metal dessert rack with two metal trays each containing 15 individual clear plastic containers that the EC identified as containing one sticky bun and one muffin, all with no label or date. There was one metal tray containing 10 individual clear plastic containers that the EC identified as containing assorted desserts, all with no label or date. There was one metal tray containing 5 individual clear plastic containers that the EC identified as containing assorted desserts, all with no label or date. The EC stated that the containers would be disposed of. There was one 4 inch half pan containing 15 meat patties individually wrapped in clear plastic that the EC identified as Canadian bacon, with no label and no dates. The EC threw the patties in the garbage. During an interview at that time the EC acknowledged there were no tags and stated it was important to label items correctly so everyone would know if it was good or bad, to prevent freezer burn, and so it would have an expiration date. 2. In the walk-in refrigerator there was one 4 inch six pan containing a thick red gelatinous material that the EC identified as pureed tomato with no label and no date. The EC stated it should be labeled and dated and threw it away. A review of the facility's policy General Food Preparation and Handling, with a revision date of 5/23/2018, revealed Procedure: 1.a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. 3. Food preparation: e. cutting boards will be cleaned and sanitized after each use, following the dish machine or 3 compartment sink method, and will be air dried before storing. k. The can opener will be cleaned and sanitized daily and/or as needed. 5. Equipment: a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. A review of the facility's policy Food Safety and Sanitation, with a revision date of 5/30/2018, revealed 3. Bulging or leaking cans, cans with severe dents on the seams, or broken containers of food will not be used. They will be returned to the vendor or discarded. 4. Food storage: when a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. A review of the facility's policy Cleaning Dishes/Dish Machine, with a revision date of 5/30/2018, revealed Procedure: 11. Dishes should not be nested unless they are completely dry. A review of the facility's policy Cleaning Instructions: Slicers, with a revision date of 5/24/2019, revealed Policy: the slicer will be cleaned and sanitized after each use. Review of the facility's policy Accepting Food Deliveries, with a revision date of 5/23/2018, revealed Procedure: 4. Perishable foods will be properly covered, labeled and dated and promptly stored in the refrigerator or freezer as appropriate. A review of the facility's policy Food Storage, with a revision date of 5/24/2019, revealed Procedure: 3. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetable, and various bulk foods. All containers must be legible and accurately labeled and dated. 6.b. Food should be dated as it is placed on the shelves. 6.c. Food should be dated when the original container or packaging is opened. 6.d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be used will be visible on all high-risk food. 10.d. Refrigerated foods will be dated and stored upon delivery. 10.g. All foods should be covered, labeled, and dated. 11.c. Frozen foods will be dated upon delivery. 11.d. All foods should be covered, labeled and dated. NJAC 8:39-17.2(g)

Based on interview and record review it was determined that the facility failed to complete a thorough investigation related to an injury of unknown origin for 1 of 3 residents reviewed for accidents and incidents, (Resident #14). This deficient practice was identified by the following: On 9/01/21 at 10:11 AM, the surveyor observed Resident #14 seated in a wheelchair at the bedside. The resident had a fabric transfer sling (a device that is used in conjunction with a mechanical lift to transfer a patient between various surfaces such as a bed to chair) placed beneath his/her back and lower body in the wheelchair. The resident was very hard of hearing and was unable to be interviewed. According to Resident #14's Face Sheet (an admission summary) the resident was initially admitted to the facility in 11/2016 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 7/12/21, Resident #14 was readmitted to the facility on [DATE] from an acute hospital. Further review of the MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident was severely, cognitively impaired and had behaviors which included rejection of care. Review of the Functional Status portion of the MDS indicated that the resident was totally dependent for transfers and required two-person assistance to transfer from the bed to wheelchair. A review of the Care Plan Report effective 7/14/21 to present, revealed that Resident #14 required help with activities of daily living (ADLs) due to cognitive deficits related to Alzheimer's diagnosis. An intervention was added to the entry on 5/13/21 for two-person assistance with transfers via Hoyer Lift. Further review of the Care Plan Report included another entry which specified that the resident was at risk for alteration in skin integrity secondary to needing assistance with ADLs, incontinence of bowel and bladder, and was on medications which may cause bruising. The entry included: 6/23/21-bruise to left great toe: x-ray negative and 6/25/21-bruise to left breast/axillary area. Goals included: Bruises to the resident's left great toe and left breast area will resolve without any complications and resident will not have a skin impairment x 90 days through 10/31/21. Interventions included: During the shower times the resident's CNA would use 2 assist to move the resident with the Hoyer lift to carry me from one place to another. The surveyor reviewed three incident investigations that pertained to Resident #14. One of which was dated 6/23/21 at 6:00 PM, which pertained to an Injury of Unknown Origin. The Registered Nurse (RN) documented that the CNA (Certified Nursing Assistant) reported a bruise on the resident's left great toe. On assessment, the nurse documented that she noted purple discoloration and swelling with resident complaint of pain with both touch and movement. The RN documented that the resident was unable to verbalize what happened and that there were no witnesses to explain the bruising. The RN documented that she notified the physician who ordered an x-ray of the resident's left foot and great toe to rule out fracture. Further review of the investigation revealed that the resident's last skin check was conducted on 6/23/21 at 8:00 AM and illustrated that the resident's skin was intact. A review of the Conclusion portion of the investigation contained in the attached Follow up Report, revealed that on 6/24/21 at 2:02 PM, the Director of Nursing (DON) documented that resident looked like he/she was going through an infection. The Root Cause was documented as no fault. In the area provided if abuse was suspected, the DON documented no. There were no staff interviews available according to the documentation reviewed. During a later interview with the surveyor on 9/07/21 at 3:19 PM, the Administrator stated on 6/23/21 the staff should have provided statements with in the past 24 hours according to facility policy to determine if there were any changes or if something occurred that caused the injury. The DON, who was present during the interview, stated that an x-ray was done of Resident #14's left foot which was negative. She stated that she concluded that the bruise that was reported on the resident's left foot was related to a history of gout (a disease in which defective metabolism of uric acid causes arthritis in the smaller bones of the feet). She stated that she thought that maybe it was an infection in that toe. She further stated that the staff should have been interviewed and thought that maybe the resident kicked somebody or something because the resident kicked a lot. She concluded by stating that if she had viewed the proper description of the affected area then she would have interviewed the staff as required. The DON could not provide documented evidence of infection when requested. The surveyor reviewed the facility policy, Abuse (Elder Abuse) (Revised 10/12/2020) which revealed the following: Guidelines for recognizing an Abused Elder: Unexplained bruises. A written report will be submitted to: New Jersey-the Office of the Ombudsman and the State Department of Health within 72 hours. The Administrator and/or a nursing supervisor will conduct a thorough investigation. The investigation will include but not be limited to, .interviewing all staff, elders and visitors who are believed to have knowledge of the event .Also, a review of any past allegations, patterns of unexplained injuries, or unusual events will be conducted if appropriate. All bruising or injuries of unknown etiology will be investigated in a manner similar to patient/elder abuse or neglect. The surveyor reviewed the facility policy, Incident Reporting (Revised 02/01/21) which revealed the following: Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated. Assure incidents are recorded and reported to the proper agencies and internal departments. Procedure: Incident Documentation: All sections of the form must be completed. State Notification: Unexplained injury. Significant Event/Injury: A resident transported to a local medical facility for treatment related to the injury event. NJAC 8:39-4.1(a)5