Every finding on record at The Center for Rehab & Nursing Washington Township

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to initiate and complete a thorough investigation after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for abuse.During an interview on 2/3/26 at 10:11 AM, with Certified Nursing Assistant (CNA #1), revealed Resident #123 made an allegation of physical abuse about one week ago and that CNA #1 reported the allegation to Licensed Practical Nurse (LPN #1) who didn't want to get involved. CNA #1 admitted she did not notify anyone else of the allegation after receiving that response from the LPN. On 2/3/26 at 10:45 AM, the surveyor interviewed Resident #123 who at first stated they were unable to recall the incident. The resident then stated, I can't honestly say, too much time has gone by, but I did get a couple punches from her. The resident then stated that CNA #1 probably knew who the perpetrator was and that the incident happened less than a month ago. An interview, on 2/3/26 at 11:23 AM, with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), revealed they were not aware of Resident #123's allegation of physical abuse and an investigation had not yet been started. According to a statement written by CNA #1, dated 2/3/26, Resident #123 reported the allegation of physical abuse to her on 1/23/26 at 9:15 AM. The facility's failure to implement their abuse policy by immediately investigating an allegation of physical abuse placed Resident #123, as well as all residents at risk for abuse. This posed the likelihood of serious physical and psychosocial harm, or impairment, and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 1/23/26 at 9:15 AM when CNA #1 received an allegation of physical abuse from Resident #123 and did not report it to a supervisor. The facility's administration was notified of the IJ on 2/3/26 at 4:00 PM. The facility submitted an acceptable Removal Plan (RP) on 2/4/26 at 12:37 PM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 2/4/26 at 1:15 PM. The evidence is as follows:Refer to F600 A review of the facility's Abuse Prevention Program policy, revised January 2025, included that the residents had the right to be from abuse, neglect, misappropriation of resident property, and exploitation. The policy further included, as part of the resident abuse prevention, that the administration would do the following:6. Identify and assess all possible incidents of abuse.7. Investigate and report any allegations of abuse within timeframes required by federal requirements.8. Protect residents during abuse investigations. A review of the facility's Abuse Investigation and Reporting policy, revised February 2026, included that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. The policy further included, Any allegation, regardless of how mild or severe it may seem, should be reported to administration so that an investigation can be initiated. The surveyor reviewed the medical record for Resident #123. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to; insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms and signs involving cognitive functions and awareness. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/15/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident did not experience hallucinations or delusions and did not have any physical or verbal behaviors directed towards others. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas:-Cognitive loss related to a BIMS of 8 upon admission. Interventions included: Allow adequate time to respond, do not rush or supply words, approach/speak in a calm, positive/reassuring manner, and identify self when speaking with the resident.-Right to a safe, home-like environment and to be treated with dignity and respect and to be free from neglect, abuse, and discrimination. Interventions included: Staff will encourage and inform the resident of the right to be free from discrimination.-Resistive/noncompliant with treatment/care related to cognitive impairment. Interventions included: If resisting care, leave (if safe to do so) and return later. A review of the Progress Notes (PN) dated 1/20/26 through 2/3/26, did not include any allegations of abuse. On 2/3/26 at 10:00 AM, the surveyor conducted staff interviews on the 100 unit related to the facility's abuse investigation and reporting policy. On 2/3/26 at 10:11 AM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated she was in-serviced on abuse monthly and that if she heard about a resident being abused, she would immediately report it to the Supervisor, Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The CNA then stated that about a week ago, Resident #123 reported to her that a nightshift CNA punched the resident in the ribs. The CNA stated she immediately notified Licensed Practical Nurse (LPN #1), but that he told her he didn't want to get involved. When the surveyor asked CNA #1 if she reported the allegation of abuse to anyone else after receiving that response from LPN #1, the CNA stated, no. CNA #1 then stated she believed the perpetrator was CNA #2, who worked overnight shifts and had gotten in trouble in the past related to resident care. The CNA explained it was important to report allegations of abuse to keep residents safe. On 2/3/26 at 10:45 AM, the surveyor interviewed Resident #123 who at first stated they were unable to recall the incident. The resident then stated, I can't honestly say, too much time has gone by, but I did get a couple punches from her. The resident then stated that CNA #1 probably knew who the perpetrator was and that the incident happened less than a month ago. On 2/3/26 at 10:50 AM, the surveyor interviewed CNA #6, who stated if she received an allegation of abuse she would report it to the Unit Manager (UM) to prevent further abuse. The CNA also stated Resident #123 was confused, but had never made any false accusations towards staff. On 2/3/26 at 10:55 AM, the surveyor interviewed LPN #2, who stated if she received an allegation of abuse, she would go through the chain of command and report it to the UM. The LPN then stated Resident #123 was alert and oriented, but confused and forgetful at times. The LPN further stated the resident did not make false accusations towards staff. On 2/3/26 at 11:00 AM, the surveyor interviewed CNA #7, who stated if she received an allegation of abuse she would immediately report the allegation to the nurse otherwise the investigation would be delayed. On 2/3/26 at 11:23 AM, the surveyor, in the presence of the survey team, interviewed the DON and LNHA who stated that staff were supposed to report any allegations of abuse immediately to their supervisor so that an investigation could be started. The DON and LNHA added that any staff accused of abuse should be suspended to protect the residents. At that time, the surveyor notified the DON and LNHA of Resident #123's allegation of abuse. The DON and LNHA stated they were unaware of the allegation and verified that CNA #1 should have reported the allegation of abuse to a supervisor. On 2/3/26 at 12:18 PM, the surveyor, accompanied by the Director of Social Services (DSS), conducted a follow-up interview with Resident #123, who stated an employee punched him/her in the side/back. The resident further stated that CNA #1 was aware, but all this time went by and nothing came of it, and, if it had been reported earlier, it would have been better. On 2/3/26 at 12:34 PM, the surveyor attempted to call LPN #1 and left a voicemail for him to call the surveyor back. On 2/3/26 at 12:35 PM, the surveyor attempted to call CNA #2 and left a voicemail for her to call the surveyor back. On 2/3/26 at 12:40 PM, the surveyor conducted a phone interview with the Licensed Practical Nurse/Supervisor (LPN/S), who stated she supervised the overnight shift. The LPN/S stated that if staff received an allegation of abuse, they should immediately report it to the DON and LNHA to protect the resident and initiate an investigation. The LPN/S then stated she was not familiar with Resident #123, but that she had not received any allegations of abuse. On 2/3/26 at 12:45 PM, the surveyor conducted a phone interview with CNA #9, who stated if she received an allegation of abuse, she would report it to the nurse in charge so that it could be investigated. On 2/3/26 at 1:00 PM, the surveyor conducted a follow-up interview with the DON and LNHA, who stated after becoming aware of Resident #123's allegation of abuse, they immediately started an investigation which included obtaining staff statements, assessing the resident, suspending the alleged staff, notifying the police, and initiating abuse in-service training. A review of CNA #1's written statement, signed 2/3/26, revealed Resident #123 reported the allegation to the CNA on 1/23/26 at 9:15 AM. Further review of the statement included CNA #1 reported the allegation to LPN #1, who didn't want to get involved and she did not report the allegation to anyone else. A review of the 100 Unit Daily Assignment Sheet revealed CNA #2 worked the night of 1/22/26 into the morning of 1/23/26. A review of CNA #2's personnel file revealed a written warning, dated 11/13/25, for poor customer service, ineffective communication, providing care to resident without verbalizing what she was doing, which CNA #2 refused to sign, but signed that she received education related to the write up. On 2/3/26 at 3:16 PM, during a follow-up interview with the DON and LNHA, the DON stated the abuse investigation process was overseen by the DON and LNHA and included the following: identifying the perpetrator and removing them from the schedule, assessing the resident for safety, collecting statements, notifying the police if applicable, notifying the ombudsman, and reporting the allegation to the New Jersey Department Of Health (NJDOH) within two hours. The LNHA stated it was important to investigate abuse allegations to determine if the allegation was substantiated. The LNHA further stated that staff should report allegations higher up if they felt they were not being taken seriously because everyone was responsible for safeguarding the residents. On 2/4/26 at 9:00 AM, LPN #1 returned the surveyor's phone call and stated if he received an allegation of abuse, he would report it to the supervisor to protect the residents. He further stated that reporting allegations of abuse included following the chain of command to ensure the allegation was investigated. LPN #1 denied receiving any allegations related to Resident #123 and stated Resident #123 could be difficult for the overnight staff, but had never had any behaviors of false accusations towards staff. On 2/4/26 at 12:14 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated if she received an allegation of abuse, she would report it immediately to the DON so that the DON and LNHA could investigate the allegation and ensure the resident was safe. The facility submitted an acceptable Removal Plan (RP) on 2/4/26 at 12:37 PM, which indicated the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice which included: -An investigation was initiated on 2/3/26 at 11:23 AM.-LPN #1, CNA #1, and CNA #2 were suspended on 2/3/26, pending investigation.-Resident #123 was assessed on 2/3/26, for any signs of physical or psychosocial injury or distress with no visible injuries noted at the time of assessment.-Resident #123 was provided with a trauma screen on 2/3/26, emotional support, and a psychology consult was requested. -All alert and oriented residents who received care from CNA #2 were interviewed on 2/3/26, to confirm resident safety.-The facility's Abuse Investigation policy was revised on 2/3/26, by the DON and LNHA to clarify that any allegation, regardless of severity level or resident's cognition level, triggers an immediate investigation.-Facility-wide training on Abuse Investigation was initiated on 2/3/26, by the DON. The survey team verified the implementation of the RP on-site during the continuation of the survey on 2/4/26 at 1:15 PM. NJAC 8:39-4.1(a)(5)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/29/26 at 11:43 AM, the surveyor, accompanied by the Food Service Director (FSD), conducted a spot-check of dishes in the large dining area prior to meal service. Three (3) 8 ounce (oz) blue coffee cups with brown debris and one (1) black bowl with white debris were observed. The surveyor donned a glove on her right hand and used a white paper towel to inspect the interior surfaces of the dishes intended for service. Upon inspection, brown debris from the three (3) 8 oz blue coffee cups transferred onto the white paper towel. On 1/30/26 at 9:46 AM, the surveyor observed, on the 200 Unit pantry, that the refrigerator freezer contained an open, exposed package of three lemon-flavored glycerin swab sticks (pre-moistened sticks used to moisten the mouth). On the floor between the unused ice machine and the closed dietary cart, there was brown sticky debris, an open 0.1 oz sugar packet, and an open straw. The trash can lid was partially closed and had brown sticky debris on it, exposing loose trash, and the plastic liner covered only one side of the trash can. On 1/30/26 at 12:15 PM, the surveyor observed the 400 Unit pantry area and noted that the walls had splatters of brown debris and the steam trays contained white debris. On 1/30/26 at 12:20 PM, the surveyor observed the 500 Unit pantry area. The walls and pipes had splatters of brown debris, and the floor contained loose white paper along with white and black particles. In the space between the wall and the refrigerator, there was a loose plastic cup, additional white paper, and white debris. A cabinet also had brown sticky debris, and the steam table trays contained white debris. On 1/29/26 at 11:55 AM, during an interview with the surveyor, the Food Service Director (FSD), who has worked at the facility for 2 years, stated that at times the dishwasher may not remove all residue. Dietary staff used multiple fail-safe processes, including spot-checking dishes after the dishwasher cycle. If residue was observed, items were scrubbed, rewashed, and reinspected before being served to residents. The dietary department was responsible for cleaning, stocking, and monitoring the temperatures of refrigerators and freezers in the pantries and nourishment rooms on the units. The FSD emphasized that all dishes must be thoroughly cleaned for infection control purposes. He also noted that the lemon-flavored glycerin swab sticks should not have been stored in the freezer as it was inconsistent with proper storage practices. On 2/6/26 at 9:46 AM, during an interview with the surveyor, the Housekeeping Director (HKD), who has worked at the facility for 10 months, stated that housekeeping staff were responsible for cleaning the floors, walls, and trash, including trash cans, in the pantry areas. Floors and trash cans were cleaned daily, and walls were cleaned monthly; the pantry walls were last cleaned on 1/15/26. She further stated that there was no formal cleaning schedule in place for the pantries, and the steam tables in the pantries were currently not used by the facility. She added that the current condition of the pantries and steam tables was not consistent with infection control standards or a homelike environment and should have been cleaned. A review of the facility's policy, dated 9/25, titled Homelike Environment, revealed that facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a.) a clean, sanitary, and orderly environment. A review of the facility's policy, dated 5/25, titled Labeling and Dating Food Items, revealed that, A designated dietary worker will be responsible for checking the refrigerators for expiration dates. The facility was unable to provide a policy regarding the dishwashing procedures. N.J.A.C 8:39-17.2 (g)

Based on observations, interviews, record review, and review of other facility documentation, it was determined that the facility failed to consistently administer pain medication according to the physician's order and Consultant Pharmacy recommendations for 1 of 5 residents (Resident #4) reviewed for unnecessary medications. This deficient practice was evidenced by: On 1/29/26 at 1:15 PM, the surveyor observed Resident #4 sitting in his/her room. When asked about pain, the resident stated that he/she has chronic pain in both shoulders and arthritis (joint inflammation causing pain and stiffness). The resident reported that pain is typically seven (7) out of ten (10) but is manageable with as needed medication. Resident #4 also stated that he/she receives oxycodone when pain reaches seven (7) or above. On 1/29/26 at 9:58 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #4 and the following was revealed: A review of the admission Record, an admission summary, revealed that Resident #4 had diagnoses which included, but were not limited to: Dementia with mild cognitive impairment (memory and thinking decline), Osteoarthritis (joint pain and stiffness), Major Depressive Disorder (persistent sadness), and Anxiety Disorder (excessive worry). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/25/26, included that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed Resident #4 had occasional pain with a numerical rating of seven (7) out of ten (10), the intensity was not indicated. A review of the individual comprehensive care plan (ICCP) included a focus of pain medication therapy, (oxycodone) related to severe pain, with a revision date of 11/18/24. Interventions included: administer analgesic (relieves pain) medications as ordered by physician and monitor/document/report adverse reactions. A review of the Order Summary Report (OSR), dated as of 2/6/26, included the following physician order (PO):oxycodone HCI oral tablet 5 mg (milligrams) give 1 tablet by mouth every 8 hours as needed (PRN) for severe pain. A review of the Consultant Pharmacist's Monthly Report (CPMR) dated 9/17/25 included the following recommendation: Documented pain level of 0, 2, 3, and 4 does not match PRN oxycodone indication of severe. Please follow specific order. The recommendation was initialed by BC with a completion date of 10/15/25. There was no Action Taken documented. A review of the 9/25 Medication Administration Record (MAR) revealed a PO for oxycodone 5 mg give 1 table by mouth every 8 hours as needed for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -9/4/25 at 10:00 PM for a pain level of 4-9/6/25 at 10:00 PM for a pain level of 3-9/7/25 at 10:00 PM for a pain level of 4-9/8/25 at 10:00 PM for a pain level of 3-9/11/25 at 10:11 PM for a pain level of 6-9/12/25 at 9:51 AM for a pain level of 2-9/12/25 at 11:22 PM for a pain level of 0-9/13/25 at 10;00 PM for a pain level of 3-9/14/25 at 9:53 PM for a pain level of 4-9/20/25 at 10:00 PM for a pain level of 4-9/21/25 at 10:00 PM for a pain level of 4-9/23/25 at 10:00 PM for a pain level of 3-9/25/25 at 10:20 PM for a pain level of 6 A review of the CPMR, dated 10/15/25 included the following recommendation: Documented pain level of 0, 2, 3, and 4 does not match PRN oxycodone indication of severe. Please follow specific order. The recommendation was initialed by BC with a completion date of 11/15/25. There was no Action Taken documented. A review of the 10/25 MAR revealed a PO for oxycodone 5 mg give one tablet by mouth every 8 hours as needed for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -10/1/25 at 11:43 PM for a pain level of 5-10/2/25 at 10:00 PM for a pain level of 4-10/4/25 at 11:43 PM for a pain level of 3-10/6/25 at 12:27 AM for a pain level of 0-10/9/25 at 1:11 AM for a pain level of 6-10/10/25 at 11:42 PM for a pain level of 5-10/14/25 at 10:00 PM for a pain level of 5-10/21/25 at 11:37 PM for a pain level of 5-10/25/25 at 8:41 PM for a pain level of 6-10/29/25 at 11:03 PM for a pain level of 0 A review of the CPMR, dated 11/13/25 revealed, No new medication irregularities are noted at this time. The recommendation was initialed by BC with a completion date of 12/10/25. There was no Action Taken documented. A review of the 11/25 MAR revealed a PO for oxycodone 5 mg, give one tablet by mouth for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -11/15/25 at 10:00 PM for a pain level of 6-11/16/25 at 9:27 PM for a pain level of 6-11/23/25 at 1:00 AM for a pain level of 5-11/24/25 at 10:30 PM for a pain level of 6 A review of the CPMR dated 12/17/25 did not have recommendations. A review of the 12/25 MAR revealed a PO for oxycodone 5 mg, give one tablet by mouth for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -12/11/25 at 8:38 PM for a pain level of 6-12/22/25 at 10:43 PM for a pain level of 6 A review of the CPMR dated 1/18/26, revealed, Missing indication for moderate pain with current PRN pain orders. Please clarify or update orders so that all levels of pain are covered. Please note there is only acetaminophen for mild pain and oxycodone for severe. oxycodone has been administered with documented pain levels of 0 and 6. Further review of the CPMR revealed that no initial or completion date or Action Taken was documented. A review of the 1/26 MAR revealed a PO for oxycodone 5 mg, give one tablet by mouth for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -1/7/26 at 10:33 PM for a pain level of 5-1/9/26 at 12:03 AM for a pain level of 6-1/9/26 at 9:09 PM for a pain level of 6-1/11/26 at 11:12 AM for a pain level of 0-1/12/26 at 10:00 PM for a pain level of 6-1/13/26 at 11:31 PM for a pain level of 6-1/20/26 at 9:07 PM for a pain level of 6-1/22/26 at 11:37 PM for a pain level of 5-1/31/26 at 9:45 PM for a pain level of 6 For the month of 2/26 there was no CPMR available. A review of the 2/26 MAR revealed a PO for oxycodone 5 mg, give one tablet by mouth for severe pain. The oxycodone 5 mg was signed out as administered for the following pain levels on the following dates: -2/3/26 at 9:07 PM for a pain level of 5 On 1/29/26 at 1:30 PM, the surveyor interviewed Licensed Practical Nurse (LPN) 1 who stated that severe pain was seven (7) and above. LPN #1 also indicated that he/she only had one resident on an opioid narcotic (Resident #4). When LPN #1 reviewed the PO with the surveyor, he/she commented, I see there is no numeric pain scale related to severe pain for administration. On 1/30/26 at 10:40 AM, the surveyor interviewed LPN #6. LPN #6 stated that his/her expectation of a physician order for pain medication was that he/she would expect to see pain levels mild, moderate, and severe. LPN #6 stated that severe pain was considered a level of seven to ten (7-10), severe pain was always seven (7) and above. LPN #6 continued, we just know these levels as a nursing practice. I had a resident today that rated her pain at six (6), so I gave her acetaminophen. On 2/5/25 at 12:43 PM, the survey team conducted an interview with the Director of Nursing (DON) who stated that there was no policy that addressed pain levels with associated numerical ratings. The DON added that a PO should have pain levels with prescribed pain medications, such as acetaminophen for mild pain. The DON stated that mild pain was zero to four (0-4) pain level, moderate pain five to six (5-6), and severe pain seven to ten (7-10). On 2/6/26 at 11:01 AM, the surveyor conducted an interview with LPN/Unit Manager (LPN/UM) #1 who indicated that severe pain was a pain level of seven to 10 (7-10). When asked how the staff knew the pain levels associated with mild, moderate, and severe pain, the LPN/UM #1 stated that he/she had placed laminated pain scales on each medication cart. LPN/UM #1 also stated that he/she was responsible for reviewing the CPMR and that he/she reviewed them once a month. Furthermore, once the Pharmacy Consultant reports were available, they were posted on the portal, and he/she got an alert. LPN/UM #1 added that he/she reviewed the recommendations, initialed, and dated, and if necessary, called the physician with recommendations. On 2/6/26 at 12:32 PM, the survey team conducted an interview with the DON and Licensed Nursing Home Administrator. The DON stated that his/her expectations of a physician order for a controlled substance/narcotic/pain medication should include medication dose, indications for use, and any additional information, as well as defining mild, moderate, and severe pain. When asked by the surveyor if a pain medication should be administered for a pain scale of zero (0) the DON replied it depended on the situation and if the resident requested pain medication with a pain scale of 0, the nurse should call the doctor, and document why the pain medication was administered in contrary to the physician order. A review of the facility policies related to pain medication did not address or define pain scale levels. NCAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 2 of 5 units (200 and 300 units).Complaint # 2578091 This deficient practice was evidenced by the following: On 1/30/26 at 9:46 AM, the surveyor observed the following on the 200 Unit. In room [ROOM NUMBER], the bedroom window had a thin linear crack across the windowpane, allowing air to pass through, and the walls contained multiple areas patched with white spackling. In the hallway, several areas were also patched with white spackling, and a drop ceiling tile was brown-stained. Above the shower room entrance door, a crack was noted, and above the nursing supplies room entrance door, two cracks were present and covered with white spackling. In the shower room, one shower stall had white debris on the shower bed, and items stored on the floor included, but were not limited to, eight uncovered pillows, two pillows wrapped in plastic, a black metal device, and an air-pressure mattress pad. Additionally, near the sink next to the soap dispenser, a piece of wall paint had been ripped away. On 1/30/26 at 12:05 PM, the surveyor observed two brown-stained drop ceiling tiles in the hallway leading to the 300 Unit, with white material coming through the ceiling tiles. On 1/29/26 at 1:00 PM, during an interview with the surveyor, the Maintenance Director (MD), who had worked at the facility for 28 years, stated that cracks above doorways were settled cracks that occurred annually. Spackling observed in room [ROOM NUMBER] and throughout the unit was related to planned painting, while spackling in the hallways and areas of ripped wall paint in the shower room resulted from relocating and replacing hand sanitizer dispensers; repairs had begun one to two months earlier. A replacement window for room [ROOM NUMBER] had been ordered six months prior but was delayed due to required financial approval and partial vendor payment. The delivered window had incorrect measurements, and a replacement was still pending. The MD stated that the necessary repairs were needed to maintain a homelike environment. He further indicated that limited maintenance staffing, consisting of three employees, had slowed repair progress, which remained ongoing at the time of the interview. On 2/6/26 at 9:46 AM, during an interview with the surveyor, the Housekeeping Director (HKD), who had worked at the facility for 10 months, stated that housekeeping staff were responsible for cleaning the shower rooms daily and that nursing staff were responsible for cleaning the shower room after each resident use. The condition of the shower room was not consistent with infection control standards and did not meet the requirements for a homelike environment. A review of the facility's policy dated 9/25, titled Homelike Environment, revealed that facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a.) a clean, sanitary, and orderly environment. N.J.A.C. 8:39-31.4(a)

Complaint #: 2731697 Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure residents were protected after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for abuse. The evidence is as follows:Refer to F610 The surveyor reviewed the medical record for Resident #123. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to; insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms and signs involving cognitive functions and awareness. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/15/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident did not experience hallucinations or delusions and did not have any physical or verbal behaviors directed towards others. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas:-Cognitive loss related to a BIMS of 8 upon admission. Interventions included: Allow adequate time to respond, do not rush or supply words, approach/speak in a calm, positive/reassuring manner, and identify self when speaking with the resident.-Right to a safe, home-like environment and to be treated with dignity and respect and to be free from neglect, abuse, and discrimination. Interventions included: Staff will encourage and inform the resident of the right to be free from discrimination.-Resistive/noncompliant with treatment/care related to cognitive impairment. Interventions included: If resisting care, leave (if safe to do so) and return later. A review of the Progress Notes (PN), dated 1/20/26 through 2/3/26, did not include any allegations of abuse. On 2/3/26 at 10:00 AM, the surveyor conducted staff interviews on the 100 unit related to the facility's abuse prevention policy. On 2/3/26 at 10:11 AM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated she was in-serviced on abuse monthly and that if she heard about a resident being abused, she would immediately report it to the Supervisor, the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The CNA then stated that about a week ago, Resident #123 reported to her that a nightshift CNA punched the resident in the ribs. The CNA stated she immediately notified Licensed Practical Nurse (LPN #1), but that he told her he didn't want to get involved. When the surveyor asked CNA #1 if she reported the allegation of abuse to anyone else after receiving that response from LPN #1, the CNA stated, no. CNA #1 then stated she believed the perpetrator was CNA #2 who worked overnight shifts and had gotten in trouble in the past related to resident care. The CNA explained it was important to report allegations of abuse to keep residents safe. On 2/3/26 at 10:45 AM, the surveyor observed and interviewed Resident #123 who at first stated they were unable to recall the incident. The resident then stated, I can't honestly say, too much time has gone by, but I did get a couple punches from her. The resident then stated that CNA #1 probably knew who the perpetrator was and that the incident happened less than a month ago. On 2/3/26 at 10:50 AM, the surveyor interviewed CNA #6, who stated Resident #123 was confused, but had never made any false accusations towards staff. On 2/3/26 at 10:55 AM, the surveyor interviewed LPN #2, who stated Resident #123 was alert and oriented, but confused and forgetful at times. The LPN further stated the resident did not make false accusations towards staff. On 2/3/26 at 11:23 AM, the surveyor, in the presence of the survey team, interviewed the DON and the LNHA who stated that staff were supposed to report any allegations of abuse immediately to their supervisor so that an investigation could be started. The DON and the LNHA added that any staff accused of abuse should be suspended to protect the residents. At that time, the surveyor notified the DON and the LNHA of Resident #123's allegation of abuse. The DON and the LNHA stated they were unaware of the allegation and verified that CNA #1 should have reported the allegation of abuse to a supervisor. On 2/3/26 at 12:18 PM, the surveyor, accompanied by the Director of Social Services (DSS), conducted a follow-up interview with Resident #123 who stated an employee punched him/her in the side/back. The resident further stated that CNA #1 was aware, but all this time went by and nothing came of it, and, if it had been reported earlier, it would have been better. On 2/3/26 at 12:34 PM, the surveyor attempted to call LPN #1 and left a voicemail for him to call the surveyor back. On 2/3/26 at 12:35 PM, the surveyor attempted to call CNA #2 and left a voicemail for her to call the surveyor back. On 2/3/26 at 12:40 PM, the surveyor conducted a phone interview with the Licensed Practical Nurse/Supervisor (LPN/S) who stated she supervised the overnight shift. The LPN/S stated that if staff received an allegation of abuse, they should immediately report it to the DON and the LNHA to protect the resident and initiate an investigation. The LPN/S then stated she was not familiar with Resident #123, but that she had not received any allegations of abuse. On 2/3/26 at 1:00 PM, the surveyor conducted a follow-up interview with the DON and the LNHA who stated that after becoming aware of Resident #123's allegation of abuse, they immediately reported it to the New Jersey Department of Health (NJDOH) and started an investigation. A review of CNA #1's written statement, signed 2/3/26, revealed Resident #123 reported the allegation to the CNA on 1/23/26 at 9:15 AM. Further review of the statement included CNA #1 reported the allegation to LPN #1 who didn't want to get involved and she did not report the allegation to anyone else. A review of the 100 Unit Daily Assignment Sheet revealed CNA #2 worked the night of 1/22/26 into the morning of 1/23/26. A review of CNA #2's personnel file revealed a written warning, dated 11/13/25, for poor customer service, ineffective communication, providing care to resident without verbalizing what she was doing, which CNA #2 refused to sign, but signed that she received education related to the write up. On 2/4/26 at 9:00 AM, LPN #1 returned the surveyor's phone call and stated that if he received an allegation of abuse, he would report it to the supervisor to protect the residents. He further stated that reporting allegations of abuse included following the chain of command to ensure the allegation was investigated. LPN #1 denied receiving any allegations related to Resident #123 and stated Resident #123 could be difficult for the overnight staff, but had never had any behaviors of false accusations towards staff. A review of the facility's Abuse Prevention Program policy, revised January 2025, included that the residents had the right to be from abuse, neglect, misappropriation of resident property, and exploitation. The policy further included, as part of the resident abuse prevention, that the administration would do the following:1. Protect residents from abuse by anyone, including facility staff.2. Conduct employee background checks.3. Develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment of residents.4. Require staff training/orientation programs that include topics such as abuse prevention and identification and reporting of abuse.5. Implement measures to address factors that may lead to abusive situations.6. Identify and assess all possible incidents of abuse.7. Investigate and report any allegations of abuse within timeframes required by federal requirements.8. Protect residents during abuse investigations.9. Establish and implement a QAPI (Quality Assurance and Performance Improvement) review and analysis of abuse incidents and implement changes to prevent future occurrences of abuse.10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. NJAC 8:39-4.1(a)(5)

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of abuse after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for abuse and was evidenced by the following:Refer to F600 and F610 The surveyor reviewed the medical record for Resident #123. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms and signs involving cognitive functions and awareness. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/15/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident did not experience hallucinations or delusions and did not have any physical or verbal behaviors directed towards others. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas:-Cognitive loss related to a BIMS of 8 upon admission. Interventions included: Allow adequate time to respond, do not rush or supply words, approach/speak in a calm, positive/reassuring manner, and identify self when speaking with the resident.-Right to a safe, home-like environment and to be treated with dignity and respect and to be free from neglect, abuse, and discrimination. Interventions included: Staff will encourage and inform the resident of the right to be free from discrimination.-Resistive/noncompliant with treatment/care related to cognitive impairment. Interventions included: If resisting care, leave (if safe to do so) and return later. A review of the Progress Notes (PN), dated 1/20/26 through 2/3/26, did not include any allegations of abuse. On 2/3/26 at 10:00 AM, the surveyor conducted staff interviews on the 100 unit related to the facility's abuse investigation and reporting policy. On 2/3/26 at 10:11 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated she was in-serviced on abuse monthly and that if she heard about a resident being abused, she would immediately report it to the Supervisor, Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The CNA then stated that about a week ago, Resident #123 reported to her that a nightshift CNA punched the resident in the ribs. The CNA stated she immediately notified Licensed Practical Nurse (LPN) #1, but that he told her he didn't want to get involved. When the surveyor asked CNA #1 if she reported the allegation of abuse to anyone else after receiving that response from LPN #1, the CNA stated, no. CNA #1 then stated she believed the perpetrator was CNA #2 who worked overnight shifts and had gotten in trouble in the past related to resident care. The CNA explained it was important to report allegations of abuse to keep residents safe. On 2/3/26 at 10:45 AM, the surveyor interviewed Resident #123 who at first stated she was unable to recall the incident. The resident then stated, I can't honestly say, too much time has gone by, but I did get a couple punches from her. The resident then stated that CNA #1 probably knew who the perpetrator was and that the incident happened less than a month ago. On 2/3/26 at 10:50 AM, the surveyor interviewed CNA #6 who stated if she received an allegation of abuse, she would report it to the Unit Manager (UM) to prevent further abuse. The CNA also stated Resident #123 was confused but had never made any false accusations towards staff. On 2/3/26 at 10:55 AM, the surveyor interviewed LPN #2 who stated if she received an allegation of abuse, she would go through the chain of command and report it to the UM. The LPN then stated Resident #123 was alert and oriented, but confused and forgetful at times. The LPN further stated the resident did not make false accusations towards staff. On 2/3/26 at 11:23 AM, the surveyor, in the presence of the survey team, interviewed the DON and the LNHA who stated that staff were supposed to report any allegations of abuse immediately to their supervisor so that an investigation could be started. At that time, the surveyor notified the DON and LNHA of Resident #123's allegation of abuse. The DON and the LNHA stated they were unaware of the allegation and verified that CNA #1 should have reported the allegation of abuse to a supervisor. On 2/3/26 at 12:18 PM, the surveyor, accompanied by the Director of Social Services (DSS), conducted a follow-up interview with Resident #123 who stated an employee punched him/her in the side/back. The resident further stated that CNA #1 was aware, but all this time went by and nothing came of it, and, if it had been reported earlier, it would have been better. On 2/3/26 at 12:34 PM, the surveyor attempted to call LPN #1 and left a voicemail for him to call the surveyor back. On 2/3/26 at 12:35 PM, the surveyor attempted to call CNA #2 and left a voicemail for her to call the surveyor back. On 2/3/26 at 12:40 PM, the surveyor conducted a phone interview with the Licensed Practical Nurse/Supervisor (LPN/S) who stated she supervised the overnight shift. The LPN/S stated that if staff received an allegation of abuse, they should immediately report it to the DON and LNHA to protect the resident and initiate an investigation. The LPN/S then stated she was not familiar with Resident #123 but that she had not received any allegations of abuse. On 2/3/26 at 1:00 PM, the surveyor conducted a follow-up interview with the DON and the LNHA who stated after becoming aware of Resident #123's allegation of abuse, they immediately reported it to the New Jersey Department of Health (NJDOH). A review of CNA #1's written statement, signed 2/3/26, revealed Resident #123 reported the allegation to the CNA on 1/23/26 at 9:15 AM. Further review of the statement included she reported the allegation to LPN #1 who didn't want to get involved and she did not report the allegation to anyone else. On 2/3/26 at 3:16 PM, during a follow-up interview with the DON and the LNHA, the DON stated the abuse investigation process was overseen by the DON and LNHA and included reporting the allegation to the NJDOH within two hours. The LNHA further stated that staff should report allegations higher up if they felt they were not being taken seriously because everyone was responsible for safeguarding the residents. On 2/4/26 at 9:00 AM, LPN #1 returned the surveyor's phone call and stated if he received an allegation of abuse, he would report it to the supervisor to protect the residents. He further stated that reporting allegations of abuse included following the chain of command to ensure the allegation was investigated. LPN #1 denied receiving any allegations related to Resident #123 and stated Resident #123 could be difficult for the overnight staff but had never had any behaviors of false accusations towards staff. On 2/4/26 at 12:14 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated if she received an allegation of abuse, she would report it immediately to the DON so that the DON and LNHA could investigate the allegation and ensure the resident was safe. A review of the facility's Abuse Investigation and Reporting policy, revised 2/2026, included, Allegations of abuse/neglect will be reported to local, state, and federal agencies (as defined by current regulations). Further review of the policy included: All alleged violations involving abuse, neglect, exploitation, or mistreatment will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility . An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a care plan that was comprehensive and individualized for 1 of 30 residents (Resident #3) reviewed for care plans. This deficient practice was evidenced by the following:On 1/29/26 at 12:19 PM, the surveyor observed Resident #3 sitting in his/her room. The resident stated he/she was on a long-term use antibiotic and had no concerns. The surveyor reviewed the medical record for Resident #3. According to the admission Record, an admission summary, Resident #3 had diagnoses which included, but were not limited to, fusion of spine, bacterial pneumonia, and osteomyelitis of vertebra (bone infection of the spine). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/16/25, included the resident had a Brief Interview for Mental Status score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident was taking an antibiotic medication. A review of the individualized comprehensive care plan (ICCP), included an incomplete focus, dated 11/10/25, of, Infection of, which did not specify the type of infection the resident had. In addition, the only intervention listed for the incomplete focus was, Administer medication per physician's order. It did not include any other interventions to assess, monitor, or treat the resident's infection. Further review of the ICCP revealed the following additional incomplete focuses and/or interventions: Need for feeding tube/potential for complication of feeding tube use related to dated 11/10/25. Nursing Nutritional Care Plan and the only intervention included, Diet type: (specify diet type, texture, and fluid consistency) dated 11/10/25. Impaired vision related to dated 11/10/25. At risk for alteration in hydration related to dated 11/10/25. Requires assistance/Potential to restore functioning (specify) for toileting related with an intervention of Toileting: total dependence (specify # of staff) dated 11/10/25. ADL Self care deficit related to with interventions that included: Assist of (specify # of staff) with ADL's [activities of daily living] and, Bed Mobility: Extensive assist of (specify # of staff assist) dated 11/10/25. At risk for falls due to initiated 11/10/25. Pain (specify location) related to and the only intervention included, Administered pain medication per physician orders, dated 11/10/25. Anticoagulant therapy to treat: dated 11/10/25. Anticonvulsant therapy to treat: dated 11/10/25. Endocrine system related to dated 11/10/25. Diuretic therapy to treat: dated 11/10/25 On 2/6/26 at 10:13 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated the ICCP was initiated by the admitting nurse during the resident's admission assessment and updated by the nurses or supervisors. The LPN further stated the facility ensured the ICCP was resident specific by updating the ICCP according to the resident's care and creating interventions specific to the resident. The LPN then explained the importance of the ICCP was to make sure the staff were caring for and addressing any issues with the resident. On 2/6/26 at 10:17 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated the admitting nurse was responsible for initiating the ICCP at the time of the resident's admission. The LPN/UM was unsure how often the ICCP was updated or how the facility ensured the ICCP was resident specific. The LPN/UM stated the importance of the ICCP was because it was specific to the resident's diagnoses, medications, and care. On 2/6/26 at 11:54 AM, the surveyor interviewed the Director of Nursing (DON) who stated all supervisors, including the DON, were responsible for initiating the ICCP upon the resident's admission. The DON explained that the ICCP was updated through a team approach any time there was a change in the resident that required an update. The DON then stated the facility ensured the ICCP was resident specific by including interventions that were specific to the resident and that the importance of the ICCP was to coordinate and document the resident's care and needs. At that time, the surveyor notified the DON of the incomplete ICCP for Resident #3 and the DON stated the ICCP should have been completed in its entirety and should be resident specific. A review of the facility's Care Plans, Comprehensive, Person-Centered, policy, revised 8/2025, included, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Further review of the policy included, 8. The comprehensive, person-centered care plan will:.g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. and, 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times for 1 of 2 residents (Resident #116) reviewed for dialysis. This deficient practice was evidenced by the following:On 1/29/26 at 12:15 PM, the surveyor observed Resident #116 sitting in his/her room. The resident stated he/she went to dialysis on Mondays, Wednesdays, and Fridays. The surveyor reviewed the medical record for Resident #116. According to the admission Record, an admission summary, the resident had diagnoses which included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. Further review of the MDS included the resident received dialysis treatments. A review of the individualized comprehensive care plan (ICCP) included a focus The resident needs dialysis r/t [related to] renal failure dated 12/28/25. Interventions did not include the resident's medication schedule to accommodate dialysis times. A review of the Order Summary Report, as of 2/5/26, included the following physician's orders (PO):-Hemodialysis via wheelchair Monday, Wednesday, Friday pickup 7:15 AM, dated 12/24/25.-Insulin Lispro 100 unit/milliliter (unit/ml) Inject 3 units subcutaneously with meals for diabetes mellitus type 2, dated 12/25/25.-Sevelamer 800 milligrams (mg) Give two tablets by mouth with meals for end stage renal disease, dated 12/23/25.-Timolol Maleate Ophthalmic Solution 0.5% Instill one drop in both eyes two times a day for glaucoma, dated 12/23/25. A review of the January and February 2026 Medication Administration Records (MAR) included the above PO were documented as not administered during the resident's dialysis dates and times as follows: Timolol Maleate Ophthalmic Solution 0.5% on:1/2/26 at 8:00 AM1/5/26 at 8:00 AM1/7/26 at 8:00 AM1/9/26 at 8:00 AM1/12/26 at 8:00 AM1/14/26 at 8:00 AM1/16/26 at 8:00 AM1/21/26 at 8:00 AM1/23/26 at 8:00 AM1/28/26 at 8:00 AM1/30/26 at 8:00 AM2/2/26 at 8:00 AM2/4/26 at 8:00 AM Insulin Lispro 100 unit/ml 3 units on:1/2/26 at 8:00 AM and 12:00 PM1/5/26 at 8:00 AM and 12:00 PM1/7/26 at 8:00 AM and 12:00 PM1/9/26 at 8:00 AM and 12:00 PM1/12/26 at 8:00 AM and 12:00 PM1/14/26 at 8:00 AM and 12:00 PM1/16/26 at 8:00 AM and 12:00 PM1/21/26 at 8:00 AM and 12:00 PM1/23/26 at 8:00 AM and 12:00 PM1/26/26 at 12:00 PM1/28/26 at 8:00 AM and 12:00 PM1/30/26 at 12:00 PM2/2/26 at 8:00 AM and 12:00 PM2/4/26 at 8:00 AM and 12:00 PM Sevelamer 800 mg on:1/2/26 at 8:00 AM and 12:00 PM1/5/26 at 8:00 AM and 12:00 PM1/7/26 at 8:00 AM and 12:00 PM1/9/26 at 8:00 AM and 12:00 PM1/12/26 at 8:00 AM and 12:00 PM1/14/26 at 8:00 AM and 12:00 PM1/16/26 at 8:00 AM and 12:00 PM1/19/26 at 8:00 AM1/21/26 at 8:00 AM and 12:00 PM1/23/26 at 8:00 AM and 12:00 PM1/26/26 at 12:00 PM1/28/26 at 8:00 AM and 12:00 PM1/30/26 at 8:00 AM and 12:00 PM2/2/26 at 8:00 AM and 12:00 PM2/4/26 at 8:00 AM and 12:00 PM On 2/6/26 at 10:13 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated dialysis residents' medications were scheduled depending on their dialysis days/times. The LPN further explained that medications were scheduled either before or after dialysis so that doses weren't missed. The LPN stated that if a medication was scheduled during a resident's dialysis time, she would report it to the supervisor or physician to review the medications for the appropriate schedule. On 2/6/26 at 10:17 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated dialysis residents' medications were scheduled according to their dialysis days/times to ensure the resident received the necessary medications. The LPN/UM further stated that if a medication was scheduled during the resident's dialysis time, the nurse should speak with the Assistant Director of Nursing (ADON) or the physician to have the medication time adjusted according to the resident's dialysis schedule. On 2/6/26 at 11:54 AM, the surveyor interviewed the Director of Nursing (DON) who stated dialysis residents' medications were scheduled according to their dialysis times to prevent missed doses of medications. The DON stated that if a medication was scheduled during a resident's dialysis time, the nurse should notify the physician to see if the medication time could be changed to a more appropriate time. At that time, the surveyor notified the DON of Resident #116's medications that were being documented as not administered during the resident's dialysis days and the DON stated that the medications should be sequenced to when the resident was in the facility with the physician's approval. A review of the facility's Administering Medications policy, revised 2/2025, included, Medications must be administered in accordance with the orders, including any required time frame, and, Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. NJAC: 8:39-11.2(b), 27.1(a), 29.2(d)

Based on observation, interviews, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services (services for the safe management of medications in a healthcare setting) in accordance with professional standards to ensure that a rationale was documented when a medication was not administered for 1 of 5 residents (Resident #149) reviewed for unnecessary medications. 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 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 1/29/26 at 10:46 AM, the surveyor observed Resident #149 sitting in a wheelchair in the unit lounge.The surveyor reviewed the medical record for Resident #149.According to the admission Record, an admission summary, the resident had diagnoses which included but were not limited to atrial fibrillation (irregular, rapid heartbeat), hypertension (high blood pressure), and disorientation.A review of the admission Minimum Data Set (MDS), an assessment tool, dated 1/14/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired.A review of the Individual Comprehensive Care Plan (ICCP), dated 1/8/26, indicated the resident had cardiac disease (heart condition) related to hypertension, atrial fibrillation, and congestive heart failure (heart's reduced pumping ability). Interventions included administering medications per physician orders.A review of the Order Summary Report, as of 2/6/26, included the following physician's orders with an order date of 1/8/26:Cardizem CD extended Release 24 hour 120 milligrams (mg) Give one tablet by mouth one time a day for Hypertension (HTN).Metoprolol Succinate ER tablet Extended release 24-hour 50 mg Give one tablet by mouth one time a day for HTN.A review of the Medication Administration Record (MAR) for 1/26 included the above Cardizem and Metoprolol orders were documented with a Code 9 on the following dates:On 1/9/26 at 9:00 [NAME] 1/12/26 at 9:00 [NAME] 1/13/26 at 9:00 [NAME] 1/16/26 at 9:00 AMThe Metoprolol order was also documented with a Code 9 on the following dates:On 1/22/26 at 9:00 [NAME] 1/23/26 at 9:00 [NAME] 1/24/26 at 9:00 AMFurther review of the January MAR revealed a list of chart codes indicating a Code 9 = Other/ See Progress notes.A review of the progress notes for the corresponding dates above did not include a rationale of why the medication was not administered.On 1/30/26 at 12:00 PM, the surveyor interviewed Licensed Practical Nurse (LPN #8) who stated that if a code of 9 was used during medication administration, it could mean that the medication was not available or maybe the blood pressure was too low. LPN #8 further stated that when Code 9 was used, the nurse should write a progress note of why the medication was not administered.On 2/6/26 at 10:57 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated that Code 9 would be used if the medication was not available or of a refusal and the nurses should write a progress note of why the medication was not administered.On 2/6/26 at 11:54 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Assistant Director of Nursing (ADON) who stated when a Code 9 was used during medication administration, the nurse should write a progress note of why the medication was not administered. The DON further stated that it was important to write a progress note of why the medication was not administered to keep an accurate record and documentation.On 2/9/26 at 12:27 PM, the surveyor interviewed the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, who acknowledged that a progress note should have been written when a Code 9 was used in the MAR. The DON further stated that the facility did not have a policy reflecting the specific codes used during medication administration.A review of the facility's Administering Medications policy, revised 2/2025, included, if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate such on the MAR.NJAC 8:39-29.2(d)

Based on interviews, record review and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by ensuring an allegation of physical abuse was reported, and a thorough investigation was initiated after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #123). The evidence is as follows:Refer to F600 and F610A review of the Administrator's Job Description included; Summary: Lead and direct the overall operations of the facility in accordance with government regulations and company policies. Essential Duties and Responsibilities: Monitor each departments activities, communicate policies, evaluate performance provide feedback and assist, observe, coach, and discipline as needed; Oversee regular rounds to monitor delivery of nursing care.and ensure resident needs are being addressed A review of the Director of Nursing's (DON) Job Description included, In the absence of the Administrator and Assistant Administrator, assume the responsibility of the facility. On 2/3/26 at 10:11 AM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated she was in-serviced on abuse monthly and that if she heard about a resident being abused, she would immediately report it to the Supervisor, the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The CNA then stated that about a week ago, Resident #123 reported to her that a nightshift CNA punched the resident in the ribs. The CNA stated she immediately notified Licensed Practical Nurse (LPN #1), but that he told her he didn't want to get involved. When the surveyor asked CNA #1 if she reported the allegation of abuse to anyone else after receiving that response from LPN #1, the CNA stated, no. CNA #1 then stated she believed the perpetrator was CNA #2, who worked overnight and had gotten in trouble in the past related to resident care. The CNA explained it was important to report allegations of abuse to keep residents safe. On 2/3/26 at 10:45 AM, the surveyor interviewed Resident #123, who at first stated they were unable to recall the incident. The resident then stated, I can't honestly say, too much time has gone by, but I did get a couple punches from her. The resident then stated that CNA #1 probably knew who the perpetrator was and that the incident happened less than a month ago. On 2/3/26 at 11:23 AM, the surveyor, in the presence of the survey team, interviewed the DON and the LNHA, who stated that staff were supposed to report any allegations of abuse immediately to their supervisor so that an investigation could be started. The DON and the LNHA added that any staff accused of abuse should be suspended to protect the residents. At that time, the surveyor notified the DON and the LNHA of Resident #123's allegation of physical abuse. The DON and the LNHA stated they were unaware of the allegation and verified that CNA #1 should have reported the allegation of abuse to a supervisor. On 2/3/26 at 12:40 PM, the surveyor conducted a phone interview with the Licensed Practical Nurse/Supervisor (LPN/S), who stated she supervised the overnight shift. The LPN/S stated that if staff received an allegation of abuse, they should immediately report it to the DON and the LNHA to protect the resident and initiate an investigation. The LPN/S then stated she was not familiar with Resident #123, but that she had not received any allegations of abuse. A review of CNA #1's written statement signed 2/3/26, revealed Resident #123 reported the allegation to the CNA on 1/23/26 at 9:15 AM. Further review of the statement included she reported the allegation to LPN #1, who didn't want to get involved and she did not report the allegation to anyone else. On 2/3/26 at 3:16 PM, the surveyor, in the presence of the survey team, interviewed DON and the LNHA. The LNHA explained that his job included: managing the operations of the building, ensuring a homelike environment, managing the employees, ensuring staff education was completed, and ensuring the policies and procedures were being followed. The DON explained that her job included overseeing the following: the clinical side of the facility, medications, incidents and accidents, admissions and discharges, that staff were following policies and procedures, and that staff were completing education and competencies. At that time, the surveyor, in the presence of the survey team, continued to interview the DON and the LNHA. The DON stated staff were educated to report abuse allegations to their supervisors who would then report it to the New Jersey Department of Health (NJDOH) and start the investigation. She further stated that all staff were educated to go to the next higher supervisor if they felt the allegations were not being handled properly. The LNHA stated that all staff were mandatory reporters of any incident and ensured the policy was followed to keep the residents safe. He acknowledged he was responsible for the overall management of the facility and to ensure staff followed the policies. A review of the facility's Abuse Prevention Program policy, revised January 2025, included that the residents had the right to be from abuse, neglect, misappropriation of resident property, and exploitation. The policy further included, as part of the resident abuse prevention, that the administration would do the following:6. Identify and assess all possible incidents of abuse.7. Investigate and report any allegations of abuse within timeframes required by federal requirements.8. Protect residents during abuse investigations. A review of the facility's Abuse Investigation and Reporting policy, revised February 2026, included that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. The policy further included, Any allegation, regardless of how mild or severe it may seem, should be reported to administration so that an investigation can be initiated.NJAC 8:39-9.2(a)NJAC 8:39-9.3(a)NJAC 8:39-27.1(a)

Complaint #: NJ184057 Based on interview, record review, and review of other pertinent facility documents on 03/05/2025 and 03/06/2025, it was determined that the facility failed to: a.) obtain a Physician's Order for a wound care recommendation which resulted in worsening of the wound; b.) implement recommendations from the wound care consultant to prevent worsening of facility acquired pressure injury. This deficient practice occurred for 1 of 1 resident reviewed for pressure ulcer (Resident #4). This deficient practice was evidenced by the following: Resident #4 was identified as having a skin alteration within the sacral region on 01/23/2025. The Licensed Practical Nurse (LPN) failed to transcribe the verbal order obtained for wound care. On 01/28/2025 during a wound consult, Resident #4's sacral wound measured 2 centimeters (cm) x 2 cm x 0.5 cm and progressed to 3 cm x 3 cm x 1 cm on 02/04/2025. Review of Resident #4's Order Summary Report (OSR) from 01/23/2025 through 02/04/2025 showed no evidence for wound care order in place for the resident's sacral wound. On 02/13/2025, Resident #4 was seen by the Physician and transferred out to the emergency room for sacral wound debridement. According to the hospital records, Resident #4 was admitted to the hospital on 02/13/2025 with a diagnosis of Sacral Wound. This deficient practice was evidenced by the following: A review of the Admission Record (an admission summary) reflected that Resident #4 was admitted to the facility with diagnoses that included but were not limited to; Anemia (low healthy red blood cells and hemoglobin), Depression (feeling of sadness), and Muscle Weakness. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care dated 01/12/2025, reflected that the resident had a Brief Interview for Mental Status score of 14 out of 15, indicating that the resident was cognitively intact. Section M0100 revealed no pressure ulcer. A review of Resident #4's Progress Notes (PNs) dated 01/23/2025 revealed the following written by LPN #1: Aide [certified nursing assistant] informed me today that patient [Resident #4] has a skin tare in the sacral area. Cleaned with NSS [normal saline solution], and applied Medi honey and dry border gauze. Risk management note done and wound consult in chart. A review of Resident #4's wound care notes with an effective date of 01/28/2025 revealed the following: Wound Location: Sacrum Etiology: old pilonidal cyst reopened Signs of infection: none Size: 2 cm x 2 cm x 0.5 cm Tissue type: necrotic Drainage: mod serous Peri wound: intact Edema: none Description: none Dressing: Dakin's dressing Review a wound care notes with an effective date of 02/04/2025 revealed the following: Wound Location: Sacrum Etiology: old pilonidal cyst reopened Signs of infection: none Size: 3 cm x 3 cm x 1 cm Tissue type: necrotic/ purple edges Drainage: mod serous Peri wound: intact Edema: none Description: none Dressing: Santyl/Dakin's dressing A review of Resident #4's OSR and TAR revealed no evidence the wound care recommendations were implemented for the resident's sacral wound care from 01/23/2025 through 02/04/2025. A review of Resident #4's PNs dated 02/02/2025 revealed: pt [Resident #4] AAO x3 [alert, awake, oriented to person, place and time], all medications tolerated whole with water. C/O [complained of] pain in their sacral area. Dressing cleaned and changed. Further review of Resident #4's PNs dated 01/23/2025 through 02/04/2025, showed no further evidence wound care was provided. A review of Resident #4's OSR with an order date of 02/05/2025, revealed the following order: Wound care: Dress sacrum with Santyl to base then cover with Dakin moist gauze then ABD [abdominal dressing] pad post NSS [normal saline solution] cleanse. One time a day for sacrum break down. A review of Resident #4's TAR dated 02/05/2025 revealed the aforementioned order for wound care. On 03/05/2025 at 3:49 P.M., during an interview with LPN#1, she confirmed to the surveyor that she received a verbal order from the physician for Medi honey with border gauze for Resident #4's sacral wound and did not put the order in Point Click Care (PCC) as per facility's policy. LPN #1 stated once a wound is observed, the process is to evaluate the wound, notify the resident's Physician of the wound and obtain an order for wound care. She said the expectation is for the nurse to put the order in PCC where it's transcribed to the TAR for implementation. She further stated, all new wounds and existing wounds should have a treatment order in place. When asked by the surveyor if the order she received on 01/23/205 for Resident #4 should have been put in PCC and transcribed to the TAR, she said, yes. LPN#1 said the nurse is responsible to notify the physician of recommendations for wound care and obtain a Physician's Order for the recommendations. LPN#1 said she was unsure why the physician was not notified for Resident #2's wound recommendations. LPN#1 said, if wound care is not provided as ordered, the wound could get worse On 03/05/2025 at 4:10 P.M., during an interview with the Director of Nursing (DON), she said, if there is a skin alteration, the nurse will evaluate and notify the Physician, get a new treatment order, start the risk management and request a wound consult. The DON said, the expectation is if a nurse obtains a new wound care order from the Physician, the order should be placed in PCC and carried out on the TAR as per physician specifics. The DON said there should be a treatment order in place for all skin alteration and the resident's wound could get worse if there is no treatment in place. The DON also said wound care recommendations should be carried out on the TAR, and wounds care provided as ordered. The DON confirmed there was no treatment order on the TAR from 01/23/2025 through 02/04/2025. On 03/13/2025 at 10:00 A.M., during an offsite interview with Resident #4's Physician, he said the expectation is, wound care orders should be followed as ordered. He said once the nurse receives a verbal order for wound care, the order should be implemented immediately. He said it is unacceptable if wound care is not done or followed. The Physician said, if wound care is not started immediately, the wound could get worse. During the same interview, the Physician said there should be an order in place for all wounds. A review of the facility's policy title Wound Care with a revised date of 04/2024 under Policy revealed the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote wound healing. A review if the facility's policy with a revised date of 12/2024 titled Medication and Treatment Order under Policy Interpretation and Implementation revealed: 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, date and time of the order. A review of the facility's policy titled Charting and Documentation under policy Statement revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's' medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. NJAC 8:39-27.1

Complaint#: NJ182815 Based on observations, interviews, and review of other facility documentation on 3/5/2025 and 3/6/2025, it was determined that the facility failed to maintain a homelike environment for residents that included access to clean linens. The deficient practice was identified for 1 of 1 nursing units observed. This deficient practice was evidenced by the following: During a tour of the 500 Unit on 3/5/2025 at 10:55 AM, the surveyor asked what the resident census was on the unit, and the Resource Nurse/Registered Nurse (Resource/RN) stated 30 residents. At 11:36 AM, the surveyor toured the 500 High Hallway Linen Room and observed four wash cloths on the shelf. At 11:38 AM, the surveyor toured the linen room for the 500 Low Hallway Linen Room and observed three wash cloths on the shelf. The surveyor reviewed the Resident Council Meeting Minutes dated 12/19/2024, 1/3/2025, and 1/30/2025 which revealed resident complaints on the lack of linens available for resident care. On 3/5/2025 at 1:07 PM, the surveyor interviewed the Housekeeper (HK) who was working in the laundry room. The HK stated that the linen was delivered to the units twice a day. The HK indicated that PAR levels (the amount of inventory established by the facility) were used to determine the number of linens that go on each linen cart. The HK stated that there were always resident complaints about linens and that there were not enough towels and washcloths in the facility. On 3/5/2025 at 2:41 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that there were three washcloths in the linen room this morning. CNA #1 indicated the linens were delivered to the unit late every day, usually after 10:30 AM. CNA #1 indicated there were times, when she had to wait for linen to come to the unit, which resulted in her cutting a bath blanket to be able to provide care to the residents. On 3/5/2025 at 3:17 PM, the surveyor interviewed the Housekeeping Director (HD) who stated that the PAR levels for the linen were low and identified there needed to be changes made. On 3/5/2025 at 4:10 PM, the surveyor interviewed the Director of Nursing (DON) who stated she was aware of not having enough linens in the facility. The DON indicated that the facility investigated and found that the staff were throwing away linens due to improperly labeled bins in the soiled linen room. On 3/6/2025 at 10:20 AM, the surveyor toured the 500 Low Hallway Linen Room and observed no washcloths and three towels. At 12:07 PM, the surveyor conducted a tour of the 500 Unit High hallway Linen Room and observed no washcloths and three towels. At 12:10 PM, the surveyor did a follow-up tour of the 500 Low Hallway Linen Room and observed no washcloths and towels. On 3/6/2024 at 12:11 PM, the surveyor interviewed the Resource/RN who confirmed there were no washcloths and three towels in the 500 Unit High Hallway Linen Room and no washcloths and towels in the 500 Unit Low Hallway Linen Room. The Resource/RN indicated that the lack of linens had been an ongoing issue and staff would have to call the laundry to bring more linens to the unit. The Resource/RN stated there were times when the staff had to cut bath blankets to provide resident care. On 3/6/2025 at 1:58 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and the survey team who stated that he was aware of the issue with the lack of linen, and it was brought up in the last Resident Council meeting. The LNHA stated that he had ordered more linens to help resolve the issue. The LNHA indicated that linens should always be readily accessible to residents. The LNHA stated that he thought the staff calling laundry for linens was considered readily accessible. On 3/6/2025 at 2:05 PM, the DON in the presence of the LNHA and the surveyor team stated that it was not acceptable for staff to use bath blankets to provide care to the residents in place of towels and washcloths. NJAC 8:39-21.3 (a)

Complaint #: NJ184057 Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation on 03/05/2025 and 03/05/2025, it was determined that the facility failed to update and revise a resident's care plan, specifically for a newly identified wound, for 1 of 1 resident reviewed for comprehensive person-centered care plans, (Resident #4). This deficient practice was evidenced by the following: A review of the Admission Record (an admission summary) reflected that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Anemia (low healthy red blood cells and hemoglobin), Depression (feeling of sadness), and Muscle Weakness. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care dated 01/12/2025, reflected that the resident had a Brief Interview for Mental Status score of 14 out of 15, indicating that the resident was cognitively intact. Section M0100 revealed no pressure ulcer. A review of Resident #4's Care Plan (CP) initiated on 01/06/2025 included under Focus At risk for alteration in skin integrity related to fragile skin and immobility. A review of Resident #4's Progress Notes (PNs) dated 01/23/2025 revealed the following written by LPN #1: Aide [certified nursing assistant] informed me today that patient [Resident #4] has a skin tare in the sacral area. Cleaned with NSS [normal saline solution], and applied Medi honey and dry border gauze. Risk management note done and wound consult in chart. A review of Resident #4's wound care notes with an effective date of 01/28/2025 revealed the following wound care recommendations: Wound Location: Sacrum Etiology: old pilonidal cyst reopened Signs of infection: none Size: 2 cm x 2 cm x 0.5 cm Tissue type: necrotic Drainage: mod serous Peri wound: intact Edema: none Description: none Dressing: Dakin's dressing A review of Resident #4's CP showed no updates with interventions of the aforementioned. On 03/05/2025 at 4:03 P.M., during an interview with the Resource Nurse/Registered Nurse, the surveyor asked what was the importance of the CP and who was reposnsible to update the CP? In the presence of another surveyor, the Resource Nurse/ Registered Nurse said she was unable to answer the question. On 03/05/2025 at 4:05 P.M., during an interview with the Director of Nursing (DON), she stated the importance of the CP is how the team stays updated on the resident's needs, and what care needs to be provided for the resident. The DON stated the CP should be updated or revised with any new change in a resident's condition. When presented Resident #4's CP, the DON confirmed the CP was not revised or updated to reflect an actual skin breakdown on 01/23/2025. She said the CP should have been updated and revised once the resident (Resident #4) developed a wound. The observation of the wound and interventions should have been on the CP. She further stated the Interdisciplinary Team (nurses, social worker, therapist,) is responsible to initiate and/or revise the CP A review of the facility's policy with a revised date of 01/2025 titled Care Plans, Comprehensive, Person-Centered under Policy Statement reveals A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation #13. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents' NJAC 8:39-27.1(a)

Complaint #: NJ184057 Based on observation, interview, and review of pertinent facility documents on 03/05/2025 and 03/05/2025, it was determined that the facility failed to: a.) ensure the treatment cart was secured during wound care observation, b.) initial, date, and time a dressing prior to applying on a resident (R#4) in accordance with professional standards of clinical practice. The facility also failed to follow its policies titled Storage of Medications and Wound Care This deficient practice was identified for 1 of 1 resident observed for wound care. 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 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 03/05/25 at 12:00 P.M., the surveyor observed the Registered Nurse (RN#1) parked the treatment cart outside the door of Resident #4's room. RN#1 performed hand hygiene, don clean gloves, and gathered all supplies needed and proceeded to the resident's room to perform wound care. RN#1 left the treatment cart unlocked and walked to Resident #4's room who was in bed and pulled the resident's privacy curtain. The treatment cart was out of the line of sight of RN#1 and no residents were observed present in the hallway and by the treatment cart. RN#1 was observed performed wound care after which she applied a clean dressing to the resident's wound without initials, date or time. On 03/05/2025 at 12:45 P.M., during an interview with RN#1, she stated the treatment cart should always be locked. She said its important to keep the treatment and medication carts always locked to avoid residents from getting into the carts. RN#1 acknowledged the treatment cart was unlocked and left unattended while performing wound care for Resident #4. RN#1stated if a treatment cart is left unlocked, a resident could get an ointment to ingest or rub causing harm or injury to the resident. During the same interview, RN#1 confirmed the dressing for Resident #4 was not initial, dated or time prior to application on the resident's wound. She stated the importance of dating, timing and writing the initial on a dressing is so that other staff caring for the resident knows the last time the wound care was performed for the resident. She stated, I should have initial, timed and dated the dressing prior to applying the dressing on the resident's wound. On 03/05/2025 at 1:00 P.M., during an interview with the Resource Nurse/RN, she stated all wound dressings should have an initial, date and time written on it prior to applying on a resident's wound. She stated it was important so that staff are aware of the last time the dressing change was completed. The Resource Nurse/RN also stated the medication and treatment carts should be locked unless I am standing there, it is important for safety. If a resident got into a medication cart or treatment cart, there could be a potential for harm or injury to the resident. On 03/05/2025 at 4:10 P.M. during an interview with the Director of Nursing (DON), she stated my expectation is for all dressings to be dated with the nurse's initials and time prior to applying the dressing. The DON also said the medication and treatment carts should be locked by the nurse when not in use. Its is important because of the safety of the residents. A review of the facility's policy titled Storage of Medications with a revised date of 6/2024, under Policy Interpretation and Implementation 7. Compartments (including drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport items shall not be left unattended if open or otherwise potentially available to others. A review of the facility's policy titled Wound Care with a revised date of 04/2024 under Steps in the Procedure 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time and date and apply dressing. NJAC 8:39-29.4(h)

Complaint#: NJ182815 Based on observations, interviews, and review of other facility documentation on 3/5/2025, it was determined that the facility failed to: a.) ensure that food items were dated, b.) ensure outdated food items were discarded, and c.) ensure refrigerator temperatures in the kitchen were completed to prevent foodborne illnesses. This deficient practice was evidenced by the following: On 3/5/2025 from 10:08 AM to 10:40 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following during a tour of the kitchen: 1. On the bread rack, the surveyor observed: - an unopened loaf of sliced rye sandwich bread with a use by date of 2/22/25. - an opened gluten free white wide slice bread with a use by date of 2/11/25. -an opened bag of 8 English muffins with no label and no expiration date. 2. The surveyor observed a temperature log sheet outside the walk-in refrigerator that had a blank space for 3/4/2025, for PM temperatures. 3. The surveyor and DD entered the walk-in refrigerator that contained milk and juice. The surveyor observed a cart in the walk-in refrigerator that contained the following: - a pitcher of orange juice that had no date on it. -an opened 64 oz. cranberry apple juice bottle with no date on it. -an opened 64 oz. cranberry raspberry juice bottle with no date on it. On 3/5/2025 at 10:30 AM, the surveyor interviewed the DD who stated that all food and juice items should have been dated once opened. The DD indicated that gluten free items have a longer shelf date, and the gluten free bread had the incorrect use by sticker on it. The DD agreed that any food items past the use by date should have been discarded. The DD confirmed the blank space on the walk-in refrigerator temperature log sheet and indicated the PM temperature for 3/4/2025 should have been recorded. Review of the facility food service policy titled, Dating/Labeling of Food Items with a reviewed/revised date of 01/2025 revealed under Policy Explanation and Compliance Guidelines for Staffing, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of the facility job description titled, Dietary Director dated April 2020 revealed under Essential Duties and Responsibilities, Monitor food preparation and food storage areas to be sure that health and sanitation regulations are being met. NJAC 8:39-17.2 (g)

Complaint #: NJ184057 Based on observation, interview, and review of pertinent facility documents on 3/5/2025 and 3/6/2025, it was determined that the facility staff failed to maintain appropriate infection control practices specifically by not properly discarding an opened pack of unused 4x4 gauze after a wound care observation to prevent the potential spread of infection in accordance with the Center for Disease and Control prevention guidelines and Standards of Clinical Practice. The facility staff failed to follow their policy titled Infection Prevention and Control Program. This defiant practice was identified during 1 of 1 wound care observation. On 3/5/2025 at 12:00 P.M., the surveyor observed the Registered Nurse (RN#1) complete a wound care treatment. Upon completion of the wound care, RN#1 was observed gathering and returned an opened pack of unused 4x4 gauze and placed it in the treatment cart. On 03/05/2025 at 12:45 P.M., during an interview with RN#1, she stated the opened pack of unused 4x4 gauze from the resident's room should have been discarded and not placed in the treatment cart. She further started it was important not to put the opened pack of unused 4x4 gauze back on the treatment cart to avoid cross contamination. On 03/05/2025 at 1:31 P.M., during an interview with the Infection Preventionist (IP), she stated all unused treatment supplies should be discarded once not used during a wound care. The IP stated the expectation is to take only items needed during a treatment with the treatment cart outside the door to obtain extra supplies if needed. Opened unused gauze should not be placed back on the treatment cart once it was previously taken in the resident's room, it is important because of infection prevention. On 03/05/2025 at 4:10 P.M., during an interview with the Director of Nursing (DON), she stated unused wound supplies should be discarded after a wound dressing. When asked by the surveyor if an opened pack of unused 4x4 gauze should be returned to the treatment cart, the DON stated, no, the nurse should not put unused wound supplies back on the treatment cart. It's important to prevent cross contamination. A review of the facility policy with a revised date of 01/2025, title Infection Prevention and Control Program under Purpose revealed: To ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and state requirements. NJAC 8:39-19.1

Complaint #: NJ182815 Based on observations and interviews on 3/5/2025 and 3/6/2025, it was determined that the facility failed to ensure their wireless call bell system communicated calls directly to the staff. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of unspecified part of neck of left femur, sarcoidosis (an inflammatory disease of the lungs and lymph nodes), and hypertension. A review of resident #1's Minimum Data Set (MDS), an assessment tool dated 2/28/2025, revealed a Brief Interview of mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident was dependent for toileting hygiene. On 3/5/2025 at 11:21 AM, the surveyor interviewed Resident # 1 in the presence of the resident's family member. The resident stated he /she was admitted to the facility several weeks ago. Resident #1 indicated that the day before it took staff 50 minutes to answer his/her call light. Resident #1 further stated that this was not the first time this occurred and that he/she had reported it to the nurse. The surveyor had Resident #1 ring his/her call bell. The surveyor returned to the resident's room at 11:35 AM and observed the call bell light still on with no audible sound present. The resident stated no staff had answered his/her call bell yet. Resident #1 further indicated that the staff had come to his/her room about ten minutes prior to the surveyor coming to the room the first time. Resident #1 stated the staff probably were not going to come back since she called for them earlier and they had already responded. 2. According to the AR, Resident #3 was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (a lung condition caused by damage to the airways, due to smoking or other irritants), anemia, and hyperlipidemia. A review of Resident #3's MDS, an assessment tool dated 2/13/2025, revealed a BIMS score of 12 out of 15, which indicated the resident's cognition was moderately impaired. The MDS further revealed the resident needed substantial assistance for toileting hygiene. 3. According to the AR, Resident #7 was admitted to the facility with diagnoses that included but were not limited to: diabetes, morbid obesity, and unspecified falls. A review of Resident #7's MDS, an assessment tool dated 1/10/2025, revealed a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident was dependent for toileting hygiene. On 3/6/2025 at 10:01 AM, the surveyor interviewed Resident #7 who stated that sometimes it took the staff more than ten minutes to answer his/her call bell. The resident further indicated that there were times his/her call bell was not answered by the staff. The resident further stated this mostly had occurred on the evening shift. On 3/5/2025 at 11:23 AM, the surveyor interviewed Resident # 3 who stated he/she had been a resident of the facility previously and recently came back. Resident #3 indicated that it took a long time for staff to answer his/her call light and sometimes the staff never came to the room to answer the light. Resident #3 further stated that he/she had made the charge nurse aware. On 3/5/2025 at 2:52 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #2) who stated the call bells on the 500 Unit did not ring to the staff work areas. CNA #2 proceeded inside a resident room and rang the call bell. The surveyor observed a green light illuminate with no audible sound present on the ceiling in front of the resident room. CNA #2 indicated that the green light meant the resident would be calling from their room and if the light was red, it was calling from the resident bathroom. CNA #2 stated the only way she was aware that the call bell was ringing was if she looked up at the ceiling while standing in the hallway when she was not busy providing care to other residents. On 3/5/2025 at 3:00 PM, the surveyor did not observe any staff at the designated staff work areas on the 500 Unit Low and High Hallways. On 3/6/2025 at 9:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated she was unable to see two rooms (room [ROOM NUMBER] and 514) call lights from the staff work area in the 500 High Hallway. The LPN indicated a staff member would have to sit in the middle of the hallway to see if the call lights would illuminate from those two rooms. The LPN confirmed that there was no call bell system at the workstation to alert the staff that the residents were ringing their call bells. On 3/6/2025 at 10:12 AM, the surveyor interviewed the Registered Nurse (RN#1) who stated she was unable to see the call lights for two rooms (room [ROOM NUMBER] and 504) from the staff work area in the 500 Low Hallway. RN #1 indicated that the staff should be in the hallways to monitor the call bells since they were not audible and do not ring to any main location. On 3/6/2025 at 10:16 AM, the surveyor interviewed the Resource Nurse/Registered Nurse (Resource/ RN) who indicated that she was aware that the residents had complained about their call bells not being answered for more than ten minutes especially on the 7pm-7am shift. The Resource/ RN stated that the staff were supposed to be monitoring the call lights hourly as the call bells were not audible on the unit and were to respond in a timely manner. On 3/6/2025 at 1:58 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated she was not aware of any resident complaints regarding the call bells not being answered. The DON further indicated that the staff were expected to respond to the call bells in a timely manner. The DON stated it was everyone's responsibility to answer the call bells and that staff had received training on responding to the resident call bells. On 3/6/2025 at 1:58 PM, the surveyor interviewed the LNHA that confirmed the call bells in the new building which consisted of the 400 and 500 unit, did not ring to a centralized location and that staff had to visually see if the call bell was ringing. Review of the facility's policy titled, Communication-Call System with a reviewed/revised date of 01/2025 revealed under Purpose, To provide a mechanism for residents to promptly communicate with nursing staff. Under Procedures, 7. Nursing staff will answer call bells promptly . NJAC 8:39-27.1 (a)

Complaint NJ #'s: 168276, 169388, 173735 and 174353 Based on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure all residents reached their highest practical wellbeing by failing to: a) provide timely incontinence care to 1 out of 4 residents (Resident #47) reviewed for Activities of Daily Living, and (b) sufficient nursing staff for 5 of 5 weeks of staffing prior to the recertification survey date of 11/22/24. The deficient practice was evidenced by the following: Refer to S0560 1.) On 11/19/24 at 11:04 AM, the surveyor observed the resident #47 lying in bed with his/her eyes closed. observed resident in bed. The surveyor observed the resident's family member at the bedside. The family member repositioned Resident #47 and showed the surveyor Resietn #47 incontinence brief which was saturated with urine and urine had leaked onto the cloth underpad. The resident's family meember stated that the resident was usually washed, dressed, and up in their wheelchair by this time. At 11:08AM, the assigned Licensed Practical Nurse (LPN #1) entered the room and confirmed that the incontinence brief was saturated with urine and had leaked urine onto the cloth underpad. At that time, the assigned Certified Nursing Assistant (CNA #1), along with another CNA, entered the room and confirmed the incontinence brief was saturated with urine and urine had leaked onto the cloth underpad. At that time, the surveyor along with the family member exited the room so the CNAs could provide incontinence care to Resident #47. On 11/19/24 at 11:24 AM, the surveyor observed Resident #47 dressed and sitting in his/her wheelchair. At that time, the surveyor interviewed CNA #1 who stated that she usually does ADLS with Resident #47 first thing in the morning but today she had to get rehabilitation residents up first, so they were ready for therapy. CNA #1 stated that she had a total of 13 residents that day which included 7 long term care residents who were dependent for ADL's and 3 rehabilitation residents (residents who were admitted for therapy) who also dependent in their ADL's. CNA #1 further stated that 4 of her 13 assigned residents also needed total assist with feeding. A review of the CNA Assignment Sheet, dated 11/19/24, indicated that CNA #1 was assigned 12 residents. On 11/18/24 at 11:24 AM, the surveyor reviewed the medical record for Resident #47. A review of the Admission Record (an admission summary), revealed the resident had diagnoses which included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), muscle weakness, mild cognitive impairment of unknown etiology, unspecified psychosis, and major depressive disorder. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 10/8/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was dependent in all activities of daily living, non-ambulatory, and always incontinent of bladder. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/11/23, that the resident was incontinent of bowel and bladder. Interventions included: clean peri-area with each incontinence episode. On 11/20/24 at 12:28 PM, the surveyor conducted d a follow up interview with CNA #1 who stated that on this day she was assigned a total of 10 long term care residents which included 8 residents who were dependent for all care. On 11/21/24 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, who stated that the nurse's on the unit will make the assignment for the CNA's. The DON stated that the CNA's should perform incontinence rounds on their residents every 2 hours and as needed. The DON stated that she was aware of the New Jersey (NJ) Mandated staffing ratios of one (1) CNA for every eight (8) residents on day shift. The DON confirmed that CNA #1 should not have been assigned 13 residents per the NJ Mandated staffing ratio. The DON further stated that the facility determined staffing levels needed per day by the census and the total care of the residents. A review of the facility's Supporting Activities of Daily Living policy, reviewed/revised January 2024, included that appropriate care and services will be provided for residents who are unable to carry out ADLs independently including .c) elimination (toileting). 43308 2.) A review of the Nurse Staffing Report for the following weeks provided by the facility revealed the following: 1. For the week of Complaint staffing from 10/08/2023 to 10/14/2023, the facility was deficient in Certified Nurse Aide (CNA) staffing for residents on 7 of 7 day shifts as follows: -10/08/23 had 9 CNAs for 131 residents on the day shift, required at least 16 CNAs. -10/09/23 had 12 CNAs for 131 residents on the day shift, required at least 16 CNAs. -10/10/23 had 12 CNAs for 131 residents on the day shift, required at least 16 CNAs. -10/11/23 had 14 CNAs for 131 residents on the day shift, required at least 16 CNAs. -10/12/23 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -10/13/23 had 12 CNAs for 137 residents on the day shift, required at least 17 CNAs. -10/14/23 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. 2. For the week of Complaint staffing from 11/26/2023 to 12/02/2023, the facility was deficient in CNA staffing for residents on 4 of 7 day shifts and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -11/26/23 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -11/27/23 had 13 CNAs for 118 residents on the day shift, required at least 15 CNAs. -11/28/23 had 14 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/02/23 had 13 CNAs for 121 residents on the day shift, required at least 15 CNAs. -12/02/23 had 6.9 CNAs to 15.4 total staff on the evening shift, required at least 8 CNAs. 3. For the week of Complaint staffing from 06/02/2024 to 06/08/2024, the facility was deficient in CNA staffing for residents on 3 of 7 day shifts as follows: -06/03/24 had 15 CNAs for 135 residents on the day shift, required at least 17 CNAs. -06/07/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs. -06/08/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs. 4. For the 2 weeks of staffing prior to survey from 11/03/2024 to 11/16/2024, the facility was deficient in CNA staffing for residents on 5 of 14 day shifts and deficient in total staff for residents on 1 of 14 evening shifts as follows: -11/05/24 had 16 CNAs for 140 residents on the day shift, required at least 17 CNAs. -11/07/24 had 18 CNAs for 151 residents on the day shift, required at least 19 CNAs. -11/09/24 had 14.5 total staff for 151 residents on the evening shift, required at least 15 total staff. -11/10/24 had 18 CNAs for 150 residents on the day shift, required at least 19 CNAs. -11/12/24 had 17 CNAs for 148 residents on the day shift, required at least 18 CNAs. -11/16/24 had 19 CNAs for 157 residents on the day shift, required at least 20 CNAs. On 11/21/24 at 2:22 PM, the surveyor interviewed the Staffing Coordinator (SC) who stated the Director of Nursing (DON) and the Assistant DON (ADON) informed her of the staffing ratio requirements. She stated she scheduled according to the facility's census to ensure she met the requirements. On 11/22/24 at 9:58 AM, the surveyor interviewed the DON who stated the facility had an on-call rotation for staffing and they educated the staff on the expectations on arriving on time and calling out. The DON stated the facility did everything they could to handle call outs in real time. She stated that the staffing ratios had been okay and tried to ensure they were staffed according to the required staffing ratios. A review of the facility's Staffing policy revised December 2023, included, 1. Staffing levels: the facility will meet federal state, and local staffing requirements. 3. Staff to Resident Ratios: the facility will maintain a minimum staff-to-resident ratio of 1:8 during the day shifts, 1:10 during the evening shifts, and 1:14 during the night shifts. 4. Adjustments to staffing will be made based on: resident acuity levels; special care units; and fluctuations in resident census. 5. Staffing Assignments and Schedules: A staffing plan will be developed and reviewed regularly by the Director of Nursing, Scheduler, or designee to ensure appropriate allocation of resources. NJAC 8:39-5.1(a); 25.2(a,b); 27.1(a)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 5 of 5 pantries designated for resident food, and was evidenced by the following: On 11/88/24 from 9:16 AM to 10:26 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen and observed the following: In the Walk-in Freezer: 1. one box containing French toast inside a plastic bag that was not closed and the French toast was open to the air. 2.One 10-pound box of veggie burgers inside a plastic bag that was not closed, and the burgers were open to the air. At that time, the FSD stated that the French toast and the veggie burgers should be closed and wrapped. On 11/19/24 at 9:32 AM, the surveyor accompanied by the Licensed Practical Nurse (LPN #1) observed the following in the 200-unit pantry: a) the freezer did not contain a thermometer b) the freezer had dark dust like debris on the white plastic bottom shelf. LPN #1 stated the freezer should be clean. On 11/19/24 at 9:20 AM, the surveyor, accompanied by the Director of Nursing (DON), observed the following in the 100 Unit pantry: a) the freezer had dark dust like debris on the white plastic bottom shelf. b) the Microwave had dried food particles inside oven and on the inside of the door. The DON stated that housekeeping cleans the refrigerators and freezers. On 11/19/24 at 9:32 AM, the surveyor, accompanied by the Registered Nurse/Resource Nurse (RN/RSN #1), observed the following in the 300 Unit pantry: a) the freezer did not contain a thermometer b) the freezer had ice build up c) the freezer contained a pint of chocolate brownie ice cream, not dated, or labeled, with ice buildup on the container. RN/RSN #1 stated that the ice cream belonged to a resident and should have had a name and date on it. The surveyor observed a sign on the refrigerator that all temperature logs maintained in the kitchen. On 11/19/24 at 9:49 AM, the surveyor, accompanied by the Minimum Data Set (MDS) Coordinator, observed the following in the 400-unit locked pantry: a) a stainless-steel sink had dried food particles and dust like debris in the sink area. b) The water machine outside the locked pantry had white debris on the grate. The MDS Coordinator stated that she thought housekeeping was responsible to clean the pantry. On 11/19/24 at 9:58 AM, the surveyor, accompanied by the Registered Nurse/Resource Nurse (RN/RNS#2), observed the following in the 500-unit locked pantry: a) food particles outside the microwave. b) red and clear liquid on the bottom tray of the refrigerator. RN/RNS #2 stated that FSD comes into the pantry and cleans it, or housekeeping cleans the pantry. On 11/19/ 24 at 10:05 AM, the surveyor interviewed the housekeeper on the 500 unit (HSK #1) who stated that the floor technician was responsible and I think they are cleaned daily. On 11/19/24 at 9:36 AM, the surveyor interviewed HSK #2 who stated that the floor technician was responsible for cleaning the pantry. On 11/20/24 at 10:07 AM, the surveyor interviewed the Housekeeping Supervisor (HS) who stated that the floor technician was responsible to clean the floors, tables, sink and counter in the pantries and the dietary department was responsible for the refrigerator, freezer, and ice machine. The HS stated that the housekeeper should have cleaned the stainless sink and microwaves in the pantries. The HS further stated that there was a miscommunication of who cleans the stainless sinks in the locked pantries on the 400 and 500 units. On 11/21/24 at 10:38 AM, the surveyor interviewed the FSD who stated that dietary department was responsible for cleaning the refrigerator and freezers daily. The FSD stated the freezers would be de-iced once a week, on Fridays, when the refrigerators were scheduled for a deep clean. The deep clean would be completed by both the dietary and housekeeping departments.The FSD further stated that ice machines were cleaned monthly. The FSD stated that he removed the thermometers from the 200- and 300-unit freezers because they weren't working. On 11/21/24 at 12:44 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and survey team, stated that his expectation would be that the pantries would be kept clean, thermometers would be in the freezers, and the refrigerators and freezers would be clean. Review of the facility's Food receiving and Storage policy, reviewed/revised December 2023, included, All foods stored in the refrigerator or freezer will be covered, labeled, and dated. All food belonging to residents must be labeled with the resident's name, the item, and the date. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. The facility did not provide a policy on the cleaning the pantry area. NJAC 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 11/18/14 at 10:06 AM, during initial kitchen tour with the Food Service Director (FSD), the surveyor observed the trash company at the dumpster area. The surveyor observed the debris, trash, leaves around the enclosed dumpster area. The dumpster area included four (4) blue dumpsters and one (1) black dumpster container for used oil. The surveyor observed five (5) black trash bags lying directly on the ground next to the first dumpster and one (1) black trash bag lying directly on ground next to third dumpster. At that time, the surveyor, in the presence of the FSD, interviewed the driver of the trash company who stated that he had just moved the (5) black trash bags that were lying in front of the dumpster directly on the ground to the side of the dumpster so he could get access the dumpster. The FSD stated that there should be no debris, trash, or trash bags outside or around the dumpster area. The FSD further stated that it was maintenance, housekeeping and dietary who was responsible for cleaning the dumpster area. The FSD stated it was important to keep the dumpster area clean to avoid pests or rodents to get in the area. On 11/20/24 at 9:45 AM, the surveyor interviewed the Facility Manager (FM) who stated that both maintenance and dietary were responsible to clean the dumpster area. The FM further stated that no debris, trash, or trash bags should be on the ground around the dumpsters to keep out rodents. On 11/21/24 at 12:44 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON) and the survey team, stated that it was unacceptable to leave bags of trash on the ground around the dumpsters. A review of facility's Disposal of garbage: policy, reviewed/revised March 2024, included: - containers and dumpsters shall be kept covered when not being loaded and the surrounding shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. -garbage should not accumulate or be left outside the dumpster. N.J.A.C. 8:39-19.3(c)

Based on observation, interview, medical record review and other facility documentation, it was determined that the facility failed to implement mitigation strategies to prevent the transmission of COVID-19 by not a.) appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI) for [MEDICAL CONDITION] and not implementing appropriate PPE according to Centers for Disease Guidelines (CDC) and b.) posting proper signage to identify residents exposed to Covid-19 as PUI and the type of isolation precautions necessary for that resident c.) educating staff on appropriate infection control measures upon discovery that residents were exposed to Covid-19. This deficient practice was identified on 1 of 5 units (200 unit) identified as a non-Covid-19 (well) unit and 2 of 5 units (400/500 unit) identified as Persons Under Investigation (PUI) unit during a focused infection control survey. On 11/10/2020, the facility became aware that one staff member, a Certified Nursing Assistant (CNA #1) was confirmed positive for Covid-19. CNA #1 worked on the Long-Term Care (LTC) 200 Unit and provided direct care to the residents that resided on that unit. On 11/17/2020, the facility discovered that 8 residents on the LTC 200 Unit tested positive for the Covid-19 virus after routine weekly testing was done. The facility moved these Covid-19 positive residents to the Covid-19 (Red) positive unit and moved their roommates to the Presumptive, Under Investigation Unit (PUI) that was located as a subpart of the LTC 200 Unit. The rest of the LTC 200 Unit continued to be identified by the facility as a 'well non-exposed unit. The surveyors reviewed the facility Line Listing on 11/30/2020. This review revealed that during the routine Covid-19 testing of the unidentified exposed residents on the LTC 200 unit conducted on 11/20/2020, 11/22/2020, 11/23/2020, 11/29/2020 and 11/30/2020 it was noted 23 additional residents were positive for Covid-19. The line list also indicated that during routine testing of employees for Covid-19 on 11/17/20, 11/22/2020, 11/23/2020, 11/24/2020, and 11/25/200, that 12 additional employees tested positive for Covid-19. The surveyor reviewed the facility line listing provided by the facility on 11/25/20. According to the line list, the facility became aware one nurse who worked on the 400/500 unit tested positive for Covid-19 on 11/10/2020. The 400/500 unit consists of new admissions/short stay unit/PUI Unit and non-ill residents. On 11/10/20, 2 residents on the 400 Unit tested positive for Covid-19. On 11/16/20, 2 nurses on the 400/500 Unit and one therapist who works throughout the facility tested positive for Covid-19. On 11/17/20, two residents on the 400 Unit tested positive for Covid-19. In addition, on 11/17/20, a resident who resided on the 400 Unit was sent to the hospital and tested positive for Covid-19 at the hospital. On 11/21/20, one nurse on the 500 Unit tested positive for Covid-19. The facility failed to identify that all residents residing on the LTC 200, 400, and 500 Units were exposed to Covid-19 and should have been considered as PUI with the accompanying Transmission Based Precautions (TBP) implemented to mitigate the continued spread of [MEDICAL CONDITION] with appropriate PPE as indicated by the CDC such as N95 mask, gown, gloves and goggles/faceshields. During the survey of 11/25/20, the surveyors staff on the LTC 200, 400, and 500 units wearing only face shields, N95 mask or only a surgical mask as the only personal protective equipment (PPE) because the residents on these units were not identified by the facility as exposed to Covid-19 and were not placed on transmission-based precautions. The facility's failure to adequately identify the Covid-19 exposed cohort resident group and institute appropriate TBP and PPE, appropriately identify the unit as a PUI unit and institute necessary TBP for those residents, and lack of education to staff as to appropriate TBP isolation precautions posed a serious and immediate threat to the safety and wellbeing of all non-ill residents residing in the facility. After consultation with the office it was determined that an Immediate Jeopardy (IJ) situation was identified on 11/25/2020 at 03:25 PM. The facility provided an acceptable Removal Plan on 11/27/2020 at 01:25 PM. The Removal Plan implementation was verified by the surveyor during an on-site visit on 11/30/2020. This deficient practice was evidenced by the following: According to the facility Administrator and the acting Director of Nursing Infection Preventionist (DON/IP) the facility followed the CDC guidelines for cohorting. Cohorting means any group of individuals affected by common diseases, environmental or temporal influences, treatments, or other traits whose progress is assessed in a research study should be house together. This cohorting guideline was as follows: a) Cohort 1 - COVID-19 Positive: This cohort consists of both symptomatic and asymptomatic patients/residents who test positive for COVID-19, including any new or re-admissions known to be positive, who have not met the discontinuation of Transmission-Based Precautions criteria. If feasible, care for COVID-19 positive patients/residents on a separate closed unit. Patients/residents who test positive for COVID-19 are known to [MEDICAL CONDITION], regardless of symptoms; therefore, all positive patients/residents would be placed in this positive cohort. b) Cohort 2 - COVID-19 Negative, Exposed: This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure, regardless of test results. All symptomatic patients/residents in this cohort should be evaluated for causes of their symptoms. Patients/residents who test negative for COVID-19 could be incubating and later test positive. To the best of their ability, long-term care facilities (LTCFs) should separate symptomatic and asymptomatic patients/residents, ideally having one group housed in private rooms. Even though symptomatic COVID-19 negative patients/residents might not be a threat to transmit COVID-19, they still may have another illness, such as influenza. Asymptomatic patients/residents should be closely monitored for symptom development. c) Cohort 3 - COVID-19 Negative, Not Exposed: This cohort consists of patients/residents who test negative for COVID-19 with no COVID-19 like symptoms and are thought to have no known exposures. The index of suspicion for an exposure should be low, as COVID-19 has been seen to rapidly spread throughout the post-acute care setting. In situations of widespread COVID-19, all negative persons in a facility would be considered exposed. Cohort 3 should only be created when the facility is relatively certain that patients/residents have been properly isolated from all COVID-19 positive and incubating patients/residents and HCP. Facilities may not be able to create this cohort. d) Cohort 4 - New or Re-admissions: This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted . This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be compatible with COVID-19. Testing at the end of this period could be considered to increase certainty that the person is not infected. COVID-19 positive persons who have not met the discontinuation of Transmission-Based Precautions should be placed in Cohort 1 - COVID-19 Positive. Individuals who have cleared Transmission-Based Precautions and it has been <3 months after the date of symptom onset or positive [MEDICAL CONDITION] test (for asymptomatic) of prior infection can go to cohort 3. On 11/25/2020 at 9:35 AM, Surveyor #1 interviewed the Administrator and acting Director of Nursing Infection Preventionist (DON/IP) who both described the different types of resident cohorting that was done in the facility and what PPE was to be worn in each cohort. The description was as follows: a.) Cohort 1- (Red Zone) comprised of Covid-19 positive residents. The required PPE on that zone were N95 mask, face shield, disposable isolation gown and gloves. The DON added that all staff were fit tested for the N95 mask and if the staff member failed the fit test they were provided with a PAPR mask (is a type of personal protective equipment used to safeguard workers against contaminated air. PAPRs consist of a respirator in the form of a hood. b.) Cohort 2 (Yellow Zone) was comprised of Covid-19 negative but exposed residents and was considered a PUI. The required PPE on that zone were N95 mask, face shield, disposable isolation gown and gloves. c.) Cohort 3 - (Green Zone) were comprised of Covid-19 negative, not exposed residents and the PPE required for this zone was a simple surgical mask and face shield. d.) Cohort 4- was comprised of new admissions and readmissions. The Administrator stated that this cohort was not considered a yellow zone or a PUI unit and stated that the residents were just quarantined for 14 days in their room to observe for signs of Covid-19 and that staff were only required to wear a N95 mask and a face shield. On 11/25/2020 at 10:00 AM, Surveyor #1 interviewed the DON/IP who stated that CNA #1 was asymptomatic, last had weekly routine facility testing done on 11/10/2020 and was determined to be positive for Covid-19. The employee was then quarantined to home. The employee worked on the LTC 200 Unit on 11/10/2020 and all residents on the 200 Unit were tested on [DATE] and were negative for Covid-19. The DON/IP then revealed that upon weekly routine resident testing, 8 residents tested positive for Covid-19 on the LTC 200 Unit on 11/17/2020. All 8 residents were asymptomatic. He added that based on contact tracing, he determined that CNA #1 could have exposed the residents to the Covid-19 virus when she worked on the LTC 200 Unit on 11/10/2020. After discovery of the 8 positive residents on the LTC 200 Unit, the DON/IP moved the positive residents to the Covid-19 positive unit and then moved their roommates to the PUI unit. He added that the remaining residents on the LTC 200 unit were not converted to a PUI (Yellow zone) and that there was no change in PPE requirement because he felt that there was no exposure to Covid-19. CNA #1 was wearing a face shield and mask when she provided direct care to residents on the LTC 200 Unit on 11/10/2020 so I did not think she exposed them. On 11/25/2020 at 12:30 PM, Surveyor #1 interviewed the acting DON/IP who did not have a response when questioned why residents on the LTC 200 Unit were not identified to be PUI after exposure to an employee who tested positive for Covid-19. Surveyor #2 was conducting a tour simultaneously while Surveyor #1 was conducting an entrance conference and interview with the acting DON/IP and Administrator. On 11/25/20 at 8:57 AM, Surveyor #2 interviewed the Administrator who stated that all employees were to wear a surgical mask and a face shield on all units except the Covid19 positive unit and the PUI Unit. On 11/25/20 at 9:16 AM, Surveyor #2 toured the LTC 200 Unit and observed a housekeeper #2, LPN #1, LPN#2, RN/UM wearing N-95 masks with a face shield in the hallways and in the resident's rooms. The surveyor did not observe any signs indicating the type of unit it was or what PPE the staff should wear on the LTC 200 unit. On 11/25/20 at 9:25 AM, during the tour of the LTC 200 Unit, Surveyor #2 interviewed the Registered Nurse Unit Manager (RN/UM) who stated she was the Unit Manager for the 500 Unit but was covering the LTC 200 Unit. The RN UM stated that the LTC 200 Unit consisted of 2 hallways of non-ill residents and one hallway of PUI residents. The PUI unit had a plastic sheet blocking the entrance to the hallway and the staff entered the PUI Unit using a separate door. The surveyor observed no signage indicating this hallway was a PUI Unit or signs indicating what PPE the staff was to wear on the unit either on the plastic sheet or on the doorway to the unit. The RN UM stated the PUI Unit consisted of the exposed roommates of the positive Covid-19 residents. The RN-UM added that the 500 Unit was dedicated for new admissions and re-admissions who were isolated for 14 days upon admission. These residents were encouraged to stay in their room and that the staff were to wear only a N-95 mask and face shield when caring for these residents. The RN UM confirmed that the staff were not to wear a gown or gloves upon entering a new admission's room on the 500 Unit even though the residents on that unit were presumptive positive for Covid-19. On 11/25/20 at 9:49 AM, Surveyor #2 toured the 400/500 Units (new admissions/short stay unit/PUI Unit and non-ill resident unit) which had a locked separate entrance for staff and residents. During the tour of the PUI 500 Unit, the surveyor observed an RN#1, CNA #2 and CNA wearing N-95 masks and face shields only. Staff did not wear a gown or gloves upon entering the residents' rooms on this unit. Surveyor #2 did not observe any signage posted to indicate what type of unit this was or what PPE the staff should be wearing on this unit or in the resident's rooms. On 11/25/20 at 9:55 AM, Surveyor #2 observed 2 resident rooms with a yellow colored bag of PPE hanging on the door. The surveyor interviewed RN #1 who stated that these residents were on isolation precautions which were not Covid-19 related and that the staff were to wear a gown and gloves upon entering the room. On 11/25/20 at 10:03 AM, Surveyor #2 observed a Certified Nursing Assistant (CNA #2) wearing only a N95 and a face shield who was interviewed at this time and stated that she was instructed to wear a N-95 mask and face shield only on this unit, and only donned full PPE (N95 mask, isolation gown, gloves, and face shield) upon entering a room housing a resident on isolation. Such a room would have a yellow bag of PPE hanging on the door. On 11/25/20 at 10:10 AM, Surveyor #2 toured the 400 Unit (new admissions/short stay unit/PUI Unit and non-ill resident unit) and observed a CNA#3, LPN UM and RN #3 wearing a N95 mask with a surgical mask covering the N-95 mask and a face shield only. The surveyor did not observe the CNA#3 and RN #3 donning gowns or gloves upon entering the resident rooms on this unit. The surveyor did not observe any signs to indicate what type of unit this was or what PPE the staff should wear upon entering the unit or residents' rooms. On 11/25/20 art 10:15 AM, Surveyor #2 observed CNA #3 wearing only a N95 mask and face shield who was interviewed at this time and stated that all the residents on the 400 Unit were admissions from the hospital and she only needed to wear a N-95 mask with a face shield in the hallway and in the resident's rooms. CNA #3 stated she was aware that 2 residents had tested positive for Covid-19 on this unit and had been transferred to the Covid-19 Unit. CNA #3 also stated that the 400 Unit had a PUI (Yellow Zone) hallway designated for residents that had been the roommates of the Covid-19 positive residents. She stated that the PUI unit had yellow bags of PPE hanging on the outside of each door and the staff was to wear full PPE upon entering those resident's room. On 11/25/20 at 10:40 AM, Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN UM) for the 400 Unit who stated the 400 Unit had a hallway for Enhanced Respiratory Isolation residents and the rest of the unit consisted of residents on quarantine from the hospital for 14 days but was not designated as a PUI Unit. She stated that Quarantine meant the residents were to stay in their room for 14 days after admission and the staff were only to wear a N-95 mask and a face shield in the hallways and in the resident's rooms. The only residents on this unit on isolation were those on Enhanced Respiration Isolation which included residents that had symptoms for Covid-19 and were waiting for Covid-19 testing results or residents that were exposed to Covid -19 by their positive roommate. When questioned how does the staff know what type of isolation precautions the residents were on or what type of PPE was required for the resident because there weren't any signs posted on the resident's doors, the LPN UM stated that the staff were taught to not enter any room with a yellow bag of PPE hanging on the door but to ask the nurse first what PPE is needed before entering the rooms. On 11/25/2020 at 12:45 PM, Surveyor #1 and Surveyor #2 interviewed the contracted Director of Infection Prevention for the facility healthcare system (DOIP) and acting DON/IP. The DOIP stated that she came over from the hospital and offered consulting for the facility due to the outbreak. She added that she reviewed the facility line listing, toured the facility and determined that there was a breach in the PPE due to the outbreak of staff and residents. She stated that she recommended that the facility institute universal N95 mask wearing which was supposed to start on 11/30/2020. She revealed that there was a break in PPE, and it could have been from staff not wearing the PPE correctly. She stated that she did not think that by staff not wearing isolation gowns contributed to the outbreak. She also stated that when she worked in another location that if one resident or staff tested positive for Covid-19, that she would make the whole unit a PUI unit but didn't do that in New Jersey. On 11/25/20 at 3:30 PM, both Surveyor #1 and Surveyor #2 toured the Long-Term Care (LTC) 200 Unit and observed Housekeeper #1, LPN #1 and LPN #2 wearing N-95 masks and face shields. The surveyors did not observe any signs prior to entering the LTC 200 Unit or signage posted on the residents' doors to indicate what type of cohorting was in place or what PPE should be worn while in residents' rooms. On 11/25/2020 at 10:00 AM, Surveyor #1 interviewed the DON/IP who revealed that some staff and residents had tested positive for Covid-19 on this unit and had been moved to the Covid-19 Positive (Red) Unit. However, the residents that remained on the unit were not identified as PUI by the facility. On 11/25/20 at 3:30 pm, both surveyors interviewed Housekeeper #1 (HK#1) on LTC 200 Unit who stated she was told by the facility last week that some residents on the LTC 200 Unit tested positive for Covid-19 and that the staff were to wear only a N-95 mask while in the residents rooms. She further stated that if a resident was under investigation then the staff was to wear a gown and gloves before entering the room. She stated that she was not educated by the facility to wear a gown and gloves in residents' rooms on the LTC 200 Unit even though residents on that unit had been exposed to Covid-19. On 11/25/20 at 3:30 PM, the surveyors interviewed LPN #1 on LTC 200 unit who stated that if any resident showed signs or symptoms of Covid-19 then they would be moved to the PUI unit but until then staff were to wear only N-95 mask and face shield while caring for residents on the LTC 200 unit even though the residents on that unit were exposed to Covid-19. LPN #1 stated indicated that the facility did not tell her to wear PPE such as an isolation gown or gloves in residents' rooms. On 11/25/20 at 3:35 PM, Surveyor #1 interviewed LPN #2 on LTC 200 unit who was observed wearing a N95 mask and a face shield. LPN #3 stated that after residents and staff began contracting Covid-19 on LTC 200 unit that she thought that the entire unit was a Yellow Zone but was not sure. She thought that signs would have been posted on what PPE should have been worn, but since there was no signs, she did not think she needed to wear gown and gloves in resident's rooms. She stated I'm not sure. On 11/30/2020 at 01:35 PM, Surveyor #2 conducted a telephone interviewed with CNA #1 who stated that she had a routine Covid-19 test on 11/10/2020 and she worked throughout that day on the LTC 200 unit. She stated that she found out she was positive for Covid-19 on 11/11/2020. She added that when she cared for residents on 11/10/2020 she was wearing a N95 mask and a face shield. She said that she was not required to wear a gown or gloves when caring for residents on this unit because the unit was a Green Zone and the residents were non-ill. On 11/30/2020 at 02:10 PM, Surveyor #2 conducted a telephone interviewed with CNA #4 who had tested positive for Covid-19 on 11/18/2020. CNA #4 stated that she wore a N95 mask and a face shield when she cared for residents on 11/18/2020 on the LTC 200 unit. She stated that she was not educated that she should wear a gown or gloves in the resident's rooms even though residents and staff tested positive for Covid -19 on that unit. On 11/30/2020 at 02:20 PM, Surveyor #2 interviewed CNA #5 who worked on the LTC 200 unit on 11/14/2020 and tested positive for Covid-19 on 11/19/2020. CNA #5 stated that he was wearing only a surgical mask when he worked on the LTC 200 unit on 11/14/2020 and that he did not wear a face shield because his face shield was destroyed, and he forgot to get a new one. According to the facility's Covid-19 education dated October 2020: a.) Face Shields-were required when in the presence of patients. b.) N95 Mask and Surgical Mask- N95 mask were required during care of patients who were positive for Covid-19, PUI, or residents getting aerosol-generating procedures. N95 mask for asymptomatic patients are generally not recommended and surgical mask should be worn instead. This education curriculum did not include when disposable gowns or gloves should be utilized after outbreak was identified on 10/28/2020. According to the facility policy with revised date of 11/2020 and titled, Infectious Outbreaks indicated that in the event of an outbreak the facility would group residents into 3 categories: 1. Patients/residents who have tested positive for Covid-19. 2. Patients/residents who have been exposed to someone who has tested positive for Covid-19 or has shown symptoms of Covid-19. 3. Patients/residents who are not ill and have not been exposed. According to Communicable Disease Services (CDS) Testing Response to a Newley Identified Covid-19 cases in Long-Term Care Facilities dated 10/29/2020; Once a new case of Covid-19 was identified, there are critical actions facilities should take regardless of where the transmission event occurred. The following steps should take place: -Perform a risk assessment to determine any potential exposures and/or infection control breaches at the facility. -Determine any possible exposures the new case of Covid-19 (e.g., resident, Healthcare Provider, essential caregiver) may have had prior to [DIAGNOSES REDACTED]. -Alert the local Health Department. -Identify close contacts. Close contacts are identified as being within six feet of a Covid-19 case for a prolonged period of time, a cumulative total of 15 minutes and having direct contact with infectious secretions form and individual with Covid-19. -Quarantine close contacts for 14 days from last exposure and provide care using all Covid-19 recommended PPE. According to the CDC and referenced website (https://www.nj.gov/gov/health/cd/topics/covid2019healthcare.shtml) Covid-19 PPE is comprised of N95, gown, gloves and eye protection and full PPE is required for: -Covid-19 positive. -Suspected of having Covid-19. -New and Re-admission. -Close contact/exposed to Covid-19 positive person. -Unit (or facility) wide when transmission is suspected or identified. Full PPE can be discontinued according to the following criteria: -Covid-19 positive-Upon meeting the discontinued TBP criteria. -Suspected of having Covid-19-Upon meeting the discontinued TBP criteria or based on alternate diagnoses. -New and Re-admission-Upon completion of 14-day quarantine. -Close contact/exposed to Covid-19 positive person-Upon completion of 14-day quarantine. -Unit (or facility) wide when transmission is suspected or identified-Upon containment of outbreak or 2 incubation periods of no new cases-in conjunction with Local Health Department (LHD). NJAC 8:39-19.4 (a)(b)(c)(d)

COMPLAINT #: NJ 7 Based on interviews, review of Medical Records (MR), and review of other pertinent facility documents on [DATE] and [DATE], it was determined that the facility staff failed to consistently follow identified Care Plan (CP) interventions, for a mechanical lift transfer, to prevent accidents, as well as provide adequate supervision during a transfer to prevent injury for 1 of 3 sampled residents (Resident #1), when on [DATE], Resident #1 was improperly transferred out of bed (OOB) by stand and pivot method instead of Hoyer Lift with assistance of one staff member, which resulted in a [MEDICAL CONDITION] and fibula of the right leg. In addition, the facility staff also failed to follow the Facility Policy titled, Safe Patient Handling & Mobility Program/Policy This deficient practice was evidenced by the following: 1. According to the Face Sheet, Resident #1 was originally admitted to the Facility in 2010, and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool date [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,[DATE], indicating that Resident #1 had severe cognitive impairment. The MDS also indicated that this resident required extensive assistance for Activities of Daily Living (ADLs). Further review of the MDS an assessment tool date [DATE], revealed Resident #1 was Limited Assist for Locomotion on and off the unit while in her wheelchair. Review of Resident #1's Care Plan Activity Report (CP), with an effective date of [DATE], identified the resident as a Potential for Falls related to: .impaired function, he/she is total assist on transfer. Further review of the CP for Resident #1 under Interventions Resident is a total assist during transfer with the use of Hoyer Lift with 2 staff assistance. Active/Effective date of [DATE]. Further review of Resident #1's CP with an Active/Effective date of [DATE], under Focus Falls/Safety, indicated the resident was at risk related to the following: Poor Coordination, Decline in Functional Status, Impaired Balance, ROM (range of motion) Limitations, and Cognitive loss. Review of Resident #1's Progress Notes (PN) dated [DATE] at 7:00 a.m., indicated that the Nurse observed the following on Resident #1, during a Weekly Wound/Skin Evaluation Report: Bruising and swelling of the right shin. Pulse was palpable. Resident complained of pain however he/she was unable to state where. The site was the entire shin which was blue/purple in color. The nurse further documented: During last rounds the Aide made this nurse aware that the resident was c/o (complaining of) pain.an assessment of her body was done. The supervisor and the doctor were made aware. An x-ray was ordered of the leg. Review of the Facility's document titled Radiology Report of Resident #1's right lower leg x-ray, tibia/fibula dated [DATE] at 3:46 p.m., the radiologist reported the following: Results: Subtle fibula neck fracture without malalignment. Subtle distal tibial fracture. Conclusion: Age indeterminate fibula neck fracture. Old or healing distal tibial shaft fracture. Review of Resident #1's PN dated [DATE], at 4:50 p.m., the Licensed Practical Nurse (LPN#1) documented the following: Right lower leg swollen and bruised. X-ray results indicated an age indeterminate fibula neck fracture and an old or healing distal tibial shaft fracture. The Nurse Practitioner was notified and ordered to ace wrap and apply ice for the next 24 hours. According to the Facility's Accident/Incident Investigation Report completed by the Unit Manager (UM) on [DATE], the UM documented the following: On [DATE], I was notified by the CNA (Certified Nursing Assistance) that Resident #1 had swelling and bruising to her right lower leg. Assessment confirmed the bruising and swelling. The resident had no complaints of pain to the area at rest or on palpation and movement. The Physician Assistant (PA) was notified and ordered an x-ray to the site. The x-ray revealed that Resident #1 had a fracture to fibula neck and distal tibia, age indeterminate. The PA ordered an Ace wrap and apply ice for 24 hours. Further review of the Accident/Incident Investigation Report revealed documentation by the UM reporting: While requesting statements from Resident #1's recent caretakers, it was discovered that CNA #1 . transferred the resident from the bed to a Geri Chair without the use of a mechanical lift. Resident #1 was coded in the EMR (Electronic Medical Record) as requiring, a mechanical lift (Hoyer) and 2-person assistance for transfers. In addition, the UM documented While speaking on the phone with . (CNA#1) the Aide stated that she did not get a good report on her residents, and that she transferred Resident #1 via stand/pivot method. The CNA also stated that she had transferred the resident in the past in this way and had no issues and the resident did not complain of pain or otherwise. Review of the Facility document titled Report of Consultation dated [DATE], the Orthopedic revealed the following under Findings; Right lower extremity ecchymosis, proximal, tenderness to palpation. X-rays non-displaced proximal fibula/tibial plateau fracture. Under Diagnosis; Right proximal fibula fracture/tibial plateau fracture. Under Recommendations; Non weight bearing. Posterior splint. Daily skin checks at edges of splint. Follow up in 2 weeks. Review of the MDS dated [DATE], Type Significant Change revealed, the resident declined to total dependence or full staff performance for Locomotion on and off the unit. According to the Facility Reportable Event Record/Report (FRE) dated [DATE], with an Event date of [DATE], the Director of Nursing (DON) reported the following: During a routine skin check Resident #1 was found to have bruising and swelling to the right lower extremity. Resident did not complain of pain upon assessment. An investigation was initiated immediately by the Unit Manager. The investigation concluded that CNA #1 stated that the resident was transferred by stand and pivot. According to the plan of care the resident requires a 2-person transfer via mechanical lift. The FRE also indicated that the facility decided that CNA #1 is no longer permitted to work in the facility since the plan of care was not followed. Review of the Facility's IDC (Interdisciplinary conference) Summary notes dated [DATE], regarding Resident #1, revealed the following: Under Type of Review; Significant Change Under Narrative Resident has a tibial/fibula fracture with a right lower leg splint recommended by orthopedic. Secondary to the splint the resident now has right heel, knee, and right dorsal and lateral foot wounds. Resident was referred to palliative versus Hospice care. Pain management included [MEDICATION NAME] 37.5 mcg. (micrograms) and Tylenol every 8 hours. Weight continues to have a gradual decline. Family expressed interest in hospice but continued to be undecided. Review of the Hospice Assessment for Resident #1 showed she was admitted to Hospice on [DATE], with the Terminal [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#1 was on the following medication for pain management: [MEDICATION NAME] 37.5 micrograms per hour [MEDICATION NAME], Tylenol 650 milligrams by oral route every 8 hours, and [MEDICATION NAME] concentrate 5 milligrams every 6 hours as needed for pain. During an interview on [DATE] at 12:52 p.m., the DON stated that during the investigation CNA #1 reported she did not get much of a report on that day ([DATE]). Resident #1 had been a Hoyer Lift transfer for a longtime and CNA #1 had taken care of her before. She should have known how to transfer the resident. The resident was less than 100 pounds, but he/she was frail. I believe the CNA just figured she could do it alone. According to the Facility's progress notes Resident #1 died at the Facility on [DATE]. Review of the Facility's Policy titled Safe Patient Handling & Mobility Program/Policy with an Implementation date of (MONTH) 2010, and a last review and revised date of (MONTH) (YEAR), included under Purpose; To reduce injuries to staff and improve the quality of care and safety of patients through the establishment of a standard approach for patient lifting, transfer or repositioning. Under Compliance; Employees are responsible for taking ownership for their health and safety and that of their co-worker and patients during patient handling activities by adhering to this policy. Under Procedure section #2; The nurse will document in the CIS (Clinical Information System) (the electronic system that contains the patient record), the type of transfer device required by the patient, if any. NJAC 8:,[DATE].1(a)

Based on observation, interview and record review, it was determined that the facility failed to revise a care plan to address a slow, unplanned, significant weight loss of 10.4% for a resident receiving enteral feedings. There was no written goal, plan, or interventions in place to address the significant weight loss for 1 of 4 residents, Resident #6, reviewed for weight loss. This deficient practice was evidenced by the following: On 4/20/17 at 10:30 a.m., the unit manager (UM) told the surveyor Resident #6 was nonverbal, totally dependent on staff for all activities of daily living (ADL's), and was fed exclusively via an enteral feeding via pump. The UM did not mention any other concerns for Resident #6 at this time. The surveyor reviewed the admission record of Resident #6 on 4/21/17 at 10 a.m. The resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. The surveyor reviewed the 8/18/16 Annual Minimum Data Set (MDS, a comprehensive assessment tool). The MDS reflected that the resident's weight was 163 lbs. The surveyor reviewed the weight record in the electronic medical record (EMR). Weights documented were as follows: 9/12/16: 155.8 pounds (lbs); 10/10/16: 151.4 lbs; 11/10/16: 150.2 lbs; 12/5/16: 149.2 lbs; 1/4/17: 145.2 lbs; 2/5/17: 146.4 lbs; 3/4/17: 144.6 lbs; and 4/5/17: 141.6 lbs. From 8/18/16 through 4/5/17, 9 months, Resident #6 lost 21 lbs. while receiving an enteral feeding. The surveyor then reviewed the electronic Dietary note dated 2/14/17 at 11:19 a.m. The Dietitian documented 10.4% weight loss x 180 days. Weight loss at 180 days is significant, weight is being monitored monthly. IBW (ideal body weight) 132-161 lbs. Resident remains within IBW. Further review of the 2/14/17 Quarterly Nutrition Assessment/Monthly Weight Note revealed the following Nutrition Intervention: Vital 1.5 at 65 ml/hour x 13 hours, Free water flush 72 ml/hr x 13 hours, and Continue to monitor weight monthly, will document on weight status as needed. Review of the Monitor/Evaluate section revealed the following: Tolerate to enteral nutrition, Maintain weight +/- 5% x 30 days, +/- 10% x 180 days, Skin Integrity, Labs as ordered. On 4/24/17 at 9:30 a.m., the surveyor reviewed Resident #6's care plan initiated on 2/18/15, which did not reveal any additional nutritional interventions since 8/18/15. There was no documentation that indicated that new dietary interventions were implemented. On 4/25/17 at 9:15 a.m., the surveyor spoke to the dietitian. She stated that Resident #6 was still within his/her ideal body weight for his/her age and height, so I didn't feel the need to increase the feedings. On 4/26/17 at 12:20 p.m., in the presence of the survey team, the Assistant Director of Nursing (ADON) stated Resident #6 had not exceeded a 5 percent weight loss from month to month and therefore there were no new nutritional interventions implemented from the dietitian. The ADON further stated that the resident was easier to take care of at his/her current weight. The surveyor reviewed the facility's nutritional policy which did not identify a specific procedure regarding nutritional steps to take when there was a 5% weight loss in 30 days and/or 10% weight loss in 180 days. Refer to F325 NJAC 8:39-11.2(1)

Based on observation, interview and record review, it was determined that the facility failed to address a slow, unplanned, significant weight loss of 10.4% for a resident receiving enteral feedings. There was no written goal, plan, or interventions in place to address the significant weight loss for 1 of 4 residents, Resident #6, reviewed for weight loss. This deficient practice was evidenced by the following: 1. On 4/20/17 at 10:30 a.m., the unit manager (UM) told the surveyor Resident #6 was nonverbal, totally dependent on staff for all activities of daily living (ADL's), and was fed exclusively via an enteral feeding via pump. The UM did not mention any other concerns for Resident #6 at this time. On 4/21/17 at 9:30 a.m., the surveyor observed Resident #6 asleep in bed. The enteral feeding (Vital 1.5 cal) was infusing at 65 ml/hr via pump. At this time 762 ml of enteral feeding had infused. The surveyor reviewed the electronic medical record (EMR) of Resident #6 on 4/21/17 at 10 a.m. The resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. The surveyor reviewed the Annual Minimum Data Set (MDS), a comprehensive assessment tool dated 8/18/16. At that time the resident's weight was documented as 163 lbs. The MDS reflected that Resident #6 was not identified to be on a physician-prescribed weight-loss regimen. The surveyor reviewed the weight record in the electronic medical record (EMR). Weights documented were as follows: 8/18/16: 163.4 pounds (lbs) 9/12/16: 155.8 lbs; 10/10/16: 151.4 lbs; 11/10/16: 150.2 lbs; 12/5/16: 149.2 lbs; 1/4/17: 145.2 lbs; 2/5/17: 146.4 lbs; (16.6 lb weight loss in 6 months) 3/4/17: 144.6 lbs; and 4/5/17: 141.6 lbs. (21.8 lb weight loss in 8 months) Review of the Annual Nutrition assessment dated [DATE] at 2:48 p.m. documented the estimated kcal (caloric) needs of the resident was 1530-1912 kcal. The dietitian documented Resident total nutritional intake from Vital and Prosource 1388 kcal and 87 g protein .Current EN (enteral nutrition) appears to meet 90% kcal needs, 100% protein needs, and 100% hydration needs. There was no rationale documented for the decreased caloric intake. The surveyor reviewed the Quarterly Nutrition assessment dated [DATE] at 3:34 p.m. This assessment noted Resident with a 13.2 lbs weight loss or 8% this past quarter .resident still within goal weight. There was no new nutritional interventions implemented nor was there a plan in place to address the resident's significant weight loss within the quarter. The dietitian did not recalculate the resident's kcal needs in order to address the significant weight loss within the quarter. Nor was there documentation to reflect what the goal weight was for Resident #6. The dietitian documented to monitor weights monthly to determine need for increase in total volume of enteral nutrition. The surveyor reviewed the Quarterly Nutrition Assessment/Monthly Weight Note dated 2/14/17 at 11:19 a.m. The dietitian documented 10.4% weight loss x (times) 180 days. Weight loss at 180 days is significant, weight is being monitored monthly. IBW (ideal body weight) 132-161 lbs. Resident remains within IBW. There were no new dietary interventions implemented. Review of the Nutrition Intervention revealed the following: Vital 1.5 at 65 ml/hour x 13 hours, Free water flush 72 ml/hr x 13 hours, and Continue to monitor weight monthly, will document on weight status as needed. Review of the Monitor/Evaluate section revealed the following: Tolerate to enteral nutrition, Maintain weight +/- 5% x 30 days, +/- 10% x 180 days, Skin Integrity, Labs as ordered. Further review of the EMR revealed that the last laboratory results obtained were from 5/13/15 (two years ago). The dietitian did not address the resident's 10.4 % significant weight loss. There was no goal and/or plan by the dietitian in place to prevent further weight loss. Nor was there a nutritional/weight goal documented in the medical record. The surveyor reviewed Resident #6's care plan on 4/24/17 at 9:30 a.m. The care plan interventions dated 2/18/15 were not revised and/or updated to address the significant weight lost in 60 days and at 180 days. On 4/25/17 at 9:15 a.m., the surveyor spoke to the dietitian. She stated that Resident #6 was still within his/her ideal body weight for his/her age and height, so I didn't feel the need to increase the feedings. On 4/26/17 at 12:20 p.m., in the presence of the survey team, the Assistant Director of Nursing (ADON) stated Resident #6 had not exceeded a 5 percent weight loss from month to month and therefore there were no new nutritional interventions implemented from the dietitian. The ADON further stated that the resident was easier to take care of at his/her current weight. On 4/27/17 at 9 a.m., in the presence of the survey team, the dietitian stated that the nutritional plan was to maintain the resident's weight between 150 lbs and 155 lbs. According to the Dietitian's 11/16/16 note, the resident's weight was 150.2 lbs. The dietitian did not address the resident's weight nor did she have a documented plan in place in order to address further weight loss. The resident's weight on 12/5/16 was 149.2 lbs which was below the dietitian's stated nutritional plan and was not addressed by the dietitian. On 4/27/17 at 12:00 p.m., the surveyor reviewed the facility's Screening for Nutritional Risk which reflected the screening tools include the MDS, hospital records, interviews with resident/patient and/or family, and the nutrition assessment form. These are not all-inclusive and other tools may be used. The surveyor reviewed the facility's nutritional policy which reflected Nutrition assessment is an ongoing process that includes not only an initial assessment but also continual reassessment. Nutrition [DIAGNOSES REDACTED]. It involves the identification and labeling of an existing nutrition problem that the Registered Dietitian is responsible for treating independently. Data from the nutrition assessment is clustered to reveal a diagnostic category from which to formulate a specific nutrition diagnostic statement. The facility's nutritional policy did not identify a specific procedure regarding nutritional steps to take when there was a 5% weight loss in 30 days and/or 10% weight loss in 180 days. The 5% and/or 10% weight loss is considered a significant weight loss that the facility must assess according to the federally mandated Resident Assessment Instrument (RAI). NJAC 8:39-11.2(e), 17.1(c), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to prepare, store and cool potentially hazardous foods (PHF) within a safe temperature zone and time frame in a manner that would prevent food-borne illness. This deficient practice would potentially affect all residents who resided in the facility that were prescribed a diet to be consumed by mouth and prepared in the facility's kitchen. This resulted in an Immediate Jeopardy situation for substandard food preparation and improper cooling of roast turkey breasts which was identified on 5/5/16 at 3:45 p.m. Facility administration was notified of the Immediate Jeopardy at 3:45 p.m. on 5/5/16. The Immediate Jeopardy was removed on 5/5/16 at 4:30 p.m. after the facility submitted and implemented an acceptable plan of correction. This deficient practice was evidenced by the following sequence of events: On 5/5/16 at 1:50 p.m., the surveyor, in the presence of the Facility Manager, observed four large pieces of roast turkey in a pan on top of a 2-tiered cart in front of a food preparation table in the kitchen. The surveyor observed that no food service staff were working with the roast turkey. On 5/5/16 at 2:25 p.m., the surveyor observed a Cook standing in front of the meat slicer. The surveyor observed that two of the four large roast turkey breasts were no longer in the pan. The pan contained two large pieces of roast turkey breasts with dried on and wet meat drippings. The surveyor also observed a cutting board on which there were pieces of turkey and turkey drippings, one full pan of sliced roast turkey, one pan partially filled with sliced roast turkey and a small pan of ground roast turkey. The meat slicer and the commercial food processor both contained pieces of turkey. During an interview by the surveyor on 5/5/16 at 2:25 p.m., the Cook, who was standing in front of the meat slicer, stated he was preparing the roast turkey for the supper meal service that evening. The surveyor observed that the Cook was in the process of slicing and chopping the roast turkey breasts. The Cook stated these turkey breasts had been roasted earlier that morning and he had taken the roast turkey breasts out of the oven at 10:30 a.m. that morning. The Cook stated after he had removed the roast turkey breasts from the oven, he cut them in half, and placed the four halves of the roast turkey breasts back into the pan in which they had been roasted. The Cook stated he then placed the pan with the four roast turkey breast halves into the freezer to cool. During this same interview, the Cook stated he had monitored the cooling temperatures of the roast turkeys. The surveyor asked the Cook to see the roast turkey breasts cooling temperatures were logged. The cook and surveyor walked over to the table where the surveyor observed the Cooling Temperature Log. According to documentation on the Cooling Temperature Log, on 5/5/16, the Start Time for turkey breast was documented as 8:30 a.m. and was 179 degrees Fahrenheit. The surveyor observed that no cooling temperatures of the roast turkey breasts had been documented. When interviewed at that time, the Cook stated he had not written the cooling temperatures down. On 5/5/16 at 2:29 p.m., the surveyor asked the Cook to take a temperature of one of the roast turkey breast halves which was in the pan in which it had been roasted. The Cook placed his facility thermometer into one of the roast turkey breasts. The thermometer registered 94.6 degrees Fahrenheit. When interviewed at that time, the Cook stated during the cooling process, the temperature of the roast turkey breasts should have dropped to 70 degrees Fahrenheit after two hours and 41 degrees Fahrenheit or below in 6 hours. When asked by the surveyor what he would do with these roast turkey breasts, the cook stated that he could reheat the roast turkey breasts to 165 degrees and begin the cooling process again. The Cook then stated he took the roast turkey breasts out of the oven at 11:30 a.m., one hour earlier than he had stated in a previous interview that same day. On 5/5/16 at 2:30 p.m., the surveyor asked the DFN and the Executive Chef (EC) to come to the food preparation area where the roast turkey breasts were located. The calibration of the Cook's thermometer was verified in an ice bath in the presence of the DFN. When interviewed by the surveyor at that time, the DFN and EC had no documentation of the roast turkey cooling temperatures. On 5/5/16 at 2:35 p.m., the surveyor, in the presence of the DFN and Executive Chef (EC), observed the Cook's thermometer register 104.3 degrees Fahrenheit in the other turkey breast half. When interviewed at that time, the EC stated the roast turkey breasts had not been cooled properly. The DFN and EC both stated the roast turkey breasts were not safe to serve to residents and would be discarded. During an interview on 5/5/16 at 3:10 p.m., the EC stated the cooling temperatures of the roast turkey breasts were supposed to be logged on the Cooling Temperature Logs. The EC stated the Start Time indicated the time the cooling process was started. The Cooling Temperature Log directions indicated that hot food should be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit or below within 2 hours and then from 70 degrees Fahrenheit to 41 degrees Fahrenheit during the next 4 hours. On 5/5/16 at 3:15 p.m., the EC stated that the whole process for cooling of foods had broken down. When reviewed by the surveyor, the facility cycle menu revealed Roast Turkey was the entree for the residents' supper meal on 5/5/16. According to the facility Cooling policy, the cooling procedure was to cool hot foods from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, then from 70 degrees Fahrenheit to 41 degrees within an additional 4 hours. The maximum total cooling time was 6 hours. Documentation on the facility Cooling Temperature Log indicated documentation of cooling temperatures was required at 2 hours and at 6 hours on the Cooling Temperature Logs. During an interview by the surveyor on 5/5/16 at 3:30 p.m., the DFN stated that he had not seen the roasted turkey breasts on 5/5/16 until the surveyor inquired about them. The DFN stated that both he and the Cook had current certification that indicating that they were certified food protection managers. The DFN stated this certification was obtained through an accredited certifying program for food safety. The surveyor verified current certifications for both the DFN and the Cooks. On 5/5/16 at 4:30 p.m., the facility submitted and implemented an acceptable plan of correction. The plan of correction indicated the following: 1.) There were no residents found to be affected by this deficient practice. The turkey was discarded before consumption. If it had not been discarded, there was a potential for widespread foodborne illness. 2.) The facility acknowledged that all residents have the potential of being affected by this deficient practice. 3.) That 100 % of the dietary staff on duty was in-serviced on 5/5/16 on the topic of rapid cooling. Any staff member not here at the time of this in-service will receive the in-service before being allowed onto the floor. Food Service Manager is responsible for the accuracy and completion of the cooling log. 4.) Cooling logs will be audited on a daily basis for a period of 2 weeks by the Food Service Manager. Cooling log audits will be audited by the Food Service Manager on a weekly basis. Results for the entire month will be reviewed by the PI team on a monthly basis. The survey team continued to monitor the situation throughout the remainder of the survey. NJAC 8:39-17.2(g)

C# Based on interview and record review, it was determined that the facility failed to implement a care plan intervention regarding safe transfers for a resident (Resident #5) who was identified as being at risk for falls/accidents. This resident who suffered a fractured tibia and fibula, was transferred to the hospital and required casting and treatment. This deficient practice was identified for Resident #5, 1 of 24 residents whose care plans were reviewed. This resident was identified as being at risk for falls/accidents. This deficient practice was evidenced by the following: According to the medical record, Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident #5's care plan titled, "Falls, Potential for" that was "effective" as of 8/02/11, indicated that the resident was at risk for falls "due to decreased mobility; left sided flaccidity" and that this resident required maximum assistance of two staff and the use of a Hoyer lift for transferring the resident. This care plan also indicated that the staff should implement safety precautions including a hoyer lift for transfers. A review of a written statement obtained from CNA #2 dated 10/16/2014 (un-timed) revealed that CNA #2 manually transferred Resident #5 from the recliner into a shower chair, and later transferred the resident from the shower chair into the bed. CNA #2 documented that he asked Resident #5 to "grab" onto his shoulders while he was standing in front of the resident. CNA #2 documented that he used a "bear hug" technique to move the resident from the recliner to the shower chair. CNA #2 wrote that Resident #5 was "taller" than he was and that resident's feet remained on the floor during the transfers. CNA #2 documented that at 1:45 p.m. that same day, he returned to the shower room. CNA #2 wrote that when he raised the leg rest to the shower chair, Resident #5 made a noise that he described as the resident saying "ouch". CNA #2 wrote that they wheeled Resident #5 to his/her room and used the "bear hug" technique to transfer Resident #5 from the shower chair and into the bed. CNA #2 documented that the resident's feet were on the floor during this transfer. When interviewed by the surveyor on 3/13/15 at 1:30 p.m., CNA #2 stated that he knew Resident #5 was suppose to be transferred by the use of a Hoyer lift. CNA #2 stated that CNA #1 had requested assistance with transfer for Resident #5. CNA #2 stated that Resident #5's feet were on the floor during both transfers Resident #5 was taller than CNA #2. CNA #2 stated that he heard Resident #5 said "ouch" and did not think anything of it because the resident always complained of pain. CNA #2 stated he was just trying to help out his co-worker and did the wrong thing by not using the Hoyer lift to transfer Resident #5. (Refer to F323, example 1) NJAC 8:39-11.2(e) 2

C# Based on observation, interview and record review, it was determined that the facility failed to use the appropriate technique multiple times while transferring a resident. This deficient practice was identified for 1 of 9 residents reviewed (Resident #5) for accidents/falls. This resident who required the use of a Hoyer lift, sustained a fracture of the tibia and fibula. The deficient practice was evidenced by the following: On 3/11/2015 at 10:00 a.m., the surveyor toured the 100 unit. The Unit Manager (UM) stated that Resident #5 was alert but confused and required assistance for all activities of daily living. The UM also stated that Resident #5 had sustained a fractured "ankle" a few months ago. On 3/13/15 at 12:00 p.m., the surveyor observed Resident #5 seated in the dining room before a Certified Nursing Assistant (CNA) pushed the resident to his/her room in a wheelchair. Once the CNA left the room, the surveyor interviewed the resident regarding his/her fractured ankle. Resident #5 response was incoherent. According to the medical record, Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Resident Assessment Instrument (RAI) dated 7/24/14 indicated that Resident #5 had long and short term memory deficits and required the extensive assistance of two staff members for bed mobility. The RAI also revealed that Resident #5 required the use of a Hoyer lift (a mechanical lift) for transfers and that the resident had a decrease range of motion (ROM) to his/her left arm. A review of Resident #5's care plan titled, "Falls, Potential for" that was "effective" as of 8/02/11, indicated that the resident was at risk for falls "due to decreased mobility; left sided flaccidity" and that this resident required maximum assistance of two staff and the use of a Hoyer lift for transferring the resident. This care plan also indicated that the staff should implement safety precautions including a hoyer lift for transfers. Review of a Nurses Note dated 10/14/2014 at 1:20 a.m. revealed that on 10/13/14 at 8:00 p.m., Resident #5 complained to a CNA of having severe left ankle pain This CNA, who had been providing care at the time, reported Resident #5's complaints of pain to a nurse. The nurse came into Resident #5's room and performed a physical assessment. During the physical assessment, Resident #5 complained of having severe left ankle pain, had facial grimacing, was guarding his/her left ankle. The nurses note also revealed that Resident #5's ankle was slightly swollen and was painful when touched. The nurse documented that she did was not aware of Resident #5 having had any traumatic injuries. The medical record indicated that the nurse notified Resident #5's doctor and a portable X-ray of the resident's left ankle. In the interim, Resident #5 was medicated for pain and ice was applied to the ankle. A review of a Nurses Note dated 10/14/2014 at 2:33 p.m. revealed that Resident #5 continued to complain of pain and the portable X-ray could not be performed. The nurse notified the doctor who ordered that the resident be sent to the emergency room (ER) to have the X-Ray done. The X-ray could not be performed while Resident #5 was at the ER and a Computed Tomography (CT) scan of his/her left ankle was performed. A review of the CT scan report dated 10/14/14 revealed that Resident #5 had a transverse fracture of the distal Tibia and an oblique fracture of the distal fibula of the left ankle. Resident #5 returned to the facility on [DATE] at 1:24 a.m. wearing a fiberglass splint to his/her left leg. A review of the incident report provided by the facility revealed that on 10/12/14 CNA #1 noticed that Resident #5 had an episode of incontinence. CNA#1 decided to give Resident #5 a shower and had asked for the assistance of another CNA, (CNA#2) in transferring Resident #5 to the shower chair. Resident #5 was transferred by CNA #2 holding him/her as CNA #1 held the chair in place. Resident #5 feet touched the floor during the transfer. After the shower, the leg rest was raised on the shower chair to transport Resident #5 back to the room. When the leg rest were raised Resident #5 stated "ouch." The CNAs interpreted Resident #5's reaction to the raising of the leg rest as an expression of mild pain due to bending of the knee/leg as Resident #5 had a history of [REDACTED]. The incident report also revealed that based on employee statements and Administration's viewing of the facility video, it was discovered that the Hoyer lift was not used on 10/12/14 when transferring Resident #5. Review of a written statement dated 10/16/14 (untimed) that the facility obtained from CNA #1 revealed that on 10/12/14 at 11:20 a.m., CNA #1 was preparing the residents for their lunch meal. At this time, CNA #1 noticed that Resident #5 had an episode of incontinence. The CNA #1 decided to give Resident #5 a shower and asked CNA #2 to assist her. Both CNAs took Resident #5 into the shower room. CNA #2 lifted Resident #5 from a "floral recliner" and lifted the resident manually into the shower chair. After the shower was completed, CNA #2 then transferred Resident #5 manually from the shower chair into the bed. CNA #1 documented that they did not use a Hoyer lift to transfer Resident #5. A review of a written statement obtained from CNA #2 dated 10/16/2014 (un-timed) revealed that CNA #2 manually transferred Resident #5 from the recliner and into a shower chair, and later transferred the resident from the shower chair and into the bed. CNA #2 documented that he asked Resident #5 to "grab" onto his shoulders while he was standing in front of the resident. CNA #2 documented that he used a "bear hug" technique to move the resident from the recliner to the shower chair. CNA #2 wrote that Resident #5 was "taller" than he was and that resident's feet remained on the floor during the transfers. CNA #2 documented that at 1:45 p.m. that same day, he returned to the shower room. CNA #2 wrote that when he raised the leg rest to the shower chair, Resident #5 made a noise that he described as the resident saying "ouch". CNA #2 wrote that they wheeled Resident #5 to his/her room and used the "bear hug" technique to transfer Resident #5 from the shower chair and into the bed. CNA #2 documented that the resident's feet were on the floor during this transfer. When interviewed by the surveyor on 3/12/15 at 1:55 p.m., CNA #1 stated that Resident #5 had soiled his/her clothes. CNA #1 stated that she thought that instead of giving a bed bath, "a shower would be better." CNA #1 stated that she asked CNA #2 for assistance to transfer Resident #5 into a shower chair. CNA #1 stated that they took Resident #5 to the shower room and CNA #2 lifted Resident #5 from the recliner alone, and transferred the resident into the shower chair. CNA #1 stated they did not use a Hoyer lift and that she could not offer any reason as to why she did not use the Hoyer lift. CNA #1 also stated that the Hoyer lift machines were available on the unit for use and they were not short of staff that day. CNA #1 stated that Resident #5 did make some sort of noise but she thought that the resident was complaining of his/her usual pain. CNA #1 stated that she used poor judgment that day. When interviewed by the surveyor on 3/12/15 at 11:40 a.m., the UM stated that the transfer of Resident #5 was done improperly by not using the Hoyer lift. When interviewed by the surveyor on 3/13/15 at 1:30 p.m., CNA #2 stated that he knew Resident #5 was suppose to be transferred by the use of a Hoyer lift. CNA #2 stated that CNA #1 had requested assistance with transfer for Resident #5. CNA #2 stated that Resident #5's feet were on the floor during both transfers and that Resident #5 was taller than CNA #2. CNA #2 stated that he heard Resident #5 say "ouch" and did not think anything of it because the resident always complained of pain. CNA #2 stated he was just trying to help out his co-worker and did the wrong thing by not using the Hoyer lift to transfer Resident #5. When interviewed by the surveyor on 3/18/15 at 9:30 a.m., the Administrator (LNHA) stated that both CNAs performed an improper transfer on Resident #5. NJAC 8:39-27.1(a)