Every finding on record at The Elms Rehab and Healthcare Center of Cranbury

Complaint #: 2720895Based on interviews and review of pertinent facility documents on 1/27/26 and 1/29/26, it was determined that the facility failed to ensure that a resident (Resident #1) who had severely impaired cognition, behaviors, and underlying medical infection was free from physical restraints imposed for purposes of care convenience and not required to treat the resident's medical symptoms. On 01/16/26, around 6:30 PM, Resident #1's family member walked into the resident's room and found the resident alone in their room. The resident was seated in a wheelchair with dinner on the overbed tray table in front of them, and a white bed sheet wrapped around their waist and tied behind the resident's wheelchair. This deficient practice occurred for 1 of 4 sampled residents (Resident #1).The facility's failure to ensure a resident with severe impaired cognition, behaviors, and an underlying medical infection was free from physical restraints placed Resident #1 as well as other residents at risk for harm and injury. This resulted in an immediate jeopardy (IJ) situation. The IJ began on 1/16/26 at 5:30 PM when CNA #1 served dinner to the resident and put a sheet around the resident's lap to prevent the resident from removing their pants or tampering with their brief during mealtime.The facility's Administration was notified of the IJ on 1/29/26 at 1:30 PM. The facility submitted an acceptable Removal Plan (RP) on 2/4/26 at 2:38 PM. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 2/12/26. This deficient practice is evidence by: A review of the facility's policy on Use of Restraints, with a revision of date April 2017, included under Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Under Policy Interpretation and Implementation: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. A review of the Reportable Event Record/Report (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 01/17/26, included the date and time of event: 01/16/26 at 6:30 PM. The FRE further revealed under Narrative that on 01/16/26 at approximately 6:30 PM, the facility leadership was notified by Resident #1's family of a concern involving the resident being seated in their wheelchair with a sheet wrapped around their waist and tied behind the resident's wheelchair. The resident was immediately assessed with no injuries identified. A review of the facility's Investigative Summary Report (ISR) dated 01/17/26 revealed an allegation was reported by Resident #1's family who stated that upon entering the resident's room they observed the resident seated in their wheelchair with a sheet over their lap that was loosely secured behind their back. Upon notification, the nursing staff responded immediately and at that time, the resident was observed sitting upright in their wheelchair with a sheet over their lap and loosely secured behind their back. The nursing supervisor (NS) immediately removed the sheet. The ISR, under Statements and Interviews, revealed CNA #1 reported that a sheet was initially folded over the resident's lap to reduce exposure due to frequent disrobing behaviors; however, the sheet repeatedly fell to the floor. Due to concern that the resident, who ambulated impulsively, could trip or fall on the sheet, the CNA stated that the sheet was loosely tied to prevent it from falling. A review of the facility's ISR included statements from staff. According to CNA #1 they were given a report that the resident was on isolation precautions for C-diff [Clostridium difficile, an infection of the intestine causing loose bowel movements] and that the resident had behaviors of taking off their clothes and briefs. At about 5:30 PM, CNA #1 served Resident #1's dinner and put a sheet on the resident's lap to prevent the resident from tampering with their brief or removing their pants during mealtime. A review of the statement of the nurse on duty (NOD) revealed Resident #1's family member came in and questioned about a sheet around the resident's waist that was tied in the back. The family member wanted to talk to the supervisor. A review of the nursing supervisor (NS)'s statement revealed that on 1/16/26, at approximately dinner time, the NS was called upstairs to speak with Resident #1's family. The resident's family member was in the room and reported that upon entering they observed the resident seated in a wheelchair with a sheet over their waist that was loosely secured behind their back. The NS stated they untied the sheet and apologized. The surveyor reviewed the medical record for Resident #1.A review of the admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with diagnoses which included but were not limited to dementia, dysphagia [difficulty in swallowing], anxiety disorders, and osteoporosis. A review of the Minimum Data Set (MDS), an assessment tool dated 10/30/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which reflected the resident's cognition was severely impaired. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's care plan report (CP) included the following Foci [Problem areas/needs]: I have impaired cognitive function or impaired thought processes r/t [related to] dementia, initiated 7/24/25.I have behavior issues as evidenced by grabbing/pushing/putting small objects in my mouth, removing briefs and leaving them anywhere, removing ace bandage from LLE [left lower extremity], initiated 8/7/25.I am receiving antibiotics, initiated on 01/15/26.I have Clostridium Difficile (C-diff), with a revision date of 01/15/2026, which included interventions of; contact isolation: wear gowns and masks when changing contaminated linens, disinfect all equipment used before it leaves the room, educate resident/family/staff regarding preventive measures to contain the infection.I require contact precautions r/t C-Diff, initiated 01/15/2026, which included interventions/tasks of: dispose of all soiled products/garments per facility policy, place resident in a private room, remind/assist resident in changing positions periodically/frequently, and wash hands appropriately before/after caring for a resident, donning/removing gloves to prevent the spread of infection.On 1/27/26 at 1:18 PM, the surveyor interviewed CNA #2 who was Resident #1's assigned CNA for the day. CNA #2 stated the resident was on barrier precautions for loose bowel movements (BMs) from an infection [c-diff]. CNA #2 further stated the resident was confused, incontinent and walked around but stayed in their room when they were on barrier precautions. On 1/27/26 at 1:46 PM, the surveyor interviewed LPN #2. LPN #2 stated the resident was confused and did not stay in one place. The LPN further stated Resident #1 remained in their room due to their infection. On 1/27/26 at 3:40 PM, the surveyor interviewed the NS. The NS stated that close to 5:30 PM or 6 PM, she got a call from a CNA that a family member was upset about their family member (Resident #1) was on isolation. The NS went upstairs, reviewed the resident's chart and went to the resident's room. The NS stated that the resident's family member was clearly upset. The NS observed Resident #1 sitting in their wheelchair with their dinner tray table in front of them and the family member showed the NS how the resident had a sheet wrapped around their waist and tied behind the resident's wheelchair. The NS stated the resident was not in distress, was calm, and had food in their hand which the resident started eating. NS said there were no other staff in the room. The family member showed the NS a white sheet that went underneath the armrest and around the back of the wheelchair with the ends tied. In a 1/28/26 telephone interview at 10:00 AM, the resident's family member stated that on 1/16/26 at 6:30 PM, when they got to Resident #1's room they noted the door was closed. When the family member went in the room, she saw the resident was in the wheelchair with the tray table in front of them. The family member stated she looked in the hallway for staff but saw nobody. Upon returning to the room, they pulled away the tray table and saw the white bed sheet around the resident's waist and tied behind the wheelchair. On 1/29/26 at 10:55 AM and at 11:38 AM, telephone calls were placed to CNA #1, but the CNA did not return the calls. On 1/29/26 at 11:12 AM, the surveyor interviewed the Unit Manager (UM). The UM stated that on 1/16/26 the evening NS called around 7 PM to report Resident #1's family member walked in and found the resident in the wheelchair with a sheet wrapped around the resident's waist and that the DON had been notified. The UM further stated that Resident #1 was able to walk independently but stayed in their room due to being on contact precautions. The UM stated Resident #1 would remove their own brief. The UM further stated the resident, who would eat in their room, did not require feeding assistance but staff were to supervise the resident to ensure the resident ate. The UM said that they do not usually place sheets over the resident when they eat. On 1/29/26 at 11:49 AM, the surveyor interviewed CNA #2. CNA #2 stated on 01/16/26 that they were not assigned to Resident #1 but at around dinner time they saw Resident #1's door open. When CNA #2 looked inside they saw the resident's daughter was inside the room and Resident #1 was in a wheelchair with a sheet around them that was tied behind the wheelchair. On 1/29/26 at 12:25 PM, the surveyor interviewed the LNHA and the DON. The DON stated CNA #1 was terminated. The DON further stated that when the daughter called regarding the incident, she immediately went to the facility and checked on Resident #1. Resident #1 was in their room, in bed, and a skin check was done. The LNHA denied the facility restrains residents. The LNHA further stated that CNA #1 had no intention of harming the resident, but they immediately suspended and in-serviced CNA #1 and started staff education right away. An acceptable Removal Plan (RP) was submitted by the facility on 2/04/26 at 2:38 PM indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: On 01/16/26, Certified Nursing Assistant (CNA) #1 was immediately removed from resident care and suspended pending investigation; nursing staff conducted an immediate comprehensive head-to-toe physical, skin, and neurological assessment, with no injuries identified; the resident's primary medical provider was notified; responsible parties present in facility were notified; the NJDOH and Office of the Ombudsman were notified; ongoing monitoring orders were initiated for three (3) consecutive days; all residents with a Brief Interview for Mental Status (BIMS) score of 11 or less received precautionary skin checks; all residents with BIMS score of 12 or higher were interviewed and denied witnessing or experiencing any abuse or concerning behavior related to CNA #1's assignment; written statements were obtained from all staff involved; a full-house in-service training was initiated for all staff with emphasis on CMS F604 (Freedom from Abuse, Neglect, and Exploitation); education reinforced that no improvised devices, linens, or methods may be used in any manner that could be perceived as restrictive, regardless of intent; staff were re-educated on the requirement that only approved, care planned, and policy compliant interventions may be utilized at all times. The surveyor verified the implementation of the RP on-site on 2/12/26 and determined the immediacy was removed as of 1/19/26. NJAC 8:39-4.1(a)6

Complaint # 432327Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence and hygiene care was provided to residents who were dependent on staff for activities of daily living (ADL) care. The deficient practice occurred for 1 of 2 residents (Resident #100) reviewed for ADL's and was evidenced by the following: Complaint #On 9/23/25 at 10:30 AM, the surveyor interviewed the Lead Certified Nurse Aide (CNA) regarding where the care provided was documented. The CNA informed the surveyor that all CNAs where to document the care provided on the Electronic Medical Record. The CNA was able to show to the surveyor where the care provided was documented. The CNA informed the surveyor that licensed staff had access and could print the document if needed. On 9/23/25 at 10:30 AM, the surveyor requested the above document from the Director of Nursing (DON). Upon review of the document, it was noted that on multiple shifts care was not signed as being provided nor that Resident #100 had refused care during their stay on 2/16, 2/17 and 2/21/25.On 9/23/25 at 12:30 PM, the surveyor reviewed the resident's clinical record. The admission Face Sheet reflected that Resident #100 was admitted to the facility with diagnoses which included, unspecified Dementia, chronic obstructive pulmonary disease, and muscle weakness. The admission Minimum Data Set ( MDS), an assessment tool, used by the facility to prioritize care dated 2/16/25, revealed that Resident #100 was moderately cognitively impaired. Resident #100 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS).Section GG of the MDS which addressed Functional Status, revealed that Resident #100 was totally dependent on staff for care, including bathing and incontinence care. Resident #100 had an ADL Self Care Performance Deficit related to deconditioning due to recent hospitalization initiated 2/9/25. The Goal was I will accept staff assistance regarding the performance of ADLs with maximum self-participation as able through the review date, 7/10/25. The interventions for Resident #100 included to receive the assistance of one person for bathing and hygiene and was a two person assist for mobility and transfer.A review of the Order Recap Report dated 2/1/25 to 2/28/25, reflected the following orders: Resume Bath/ shower/ nail care twice a week, and document any refusals and to see the shower assignment and schedule accordingly; every day shift every Tuesday and Friday for hygiene. On 9/23/25 at 11:30 AM, the surveyor requested the above document from the Director of Nursing (DON). On 9/23/25 at 12:29 PM, the DON provided a document titled, Documentation Survey Report v2. Upon review of the document the surveyor observed the following: thatOn 2/16/25 incontinence care was not documented as being offered/ provided during the 3:00 PM-11:00 PM shift and 11:00 PM-7:00 AM shift. Bowel Management was not documented for the 11:00 PM- 7:00 AM shift. Personal Hygiene was not documented as being offered/provided for 3:00 PM-11:00 PM shift and the 11:00 PM- 7:00 AM shift.On 2/17/25 Incontinence care was not documented as being offered/provided for the 7:00 AM-3:00 PM shift. Personal Hygiene/ shower/bath were not documented as being offered/provided during the 7:00 AM-3:00 PM shift. Bowel Management was not documented also for the 3:00 PM-11:00 PM shift and the 11:00 PM-7:00 AM shift. On 2/21/25 incontinence care, hygiene care, shower/bath were not documented as being offered/ provided. On 9/23/25 the surveyor reviewed the Point of Care document provided by the facility and observed that staff failed to document that incontinence care, hygienic care, shower/bath were provided, on 2/16/25, 2/17/25 and 2/21/25 during the 7:00 AM -3:00 PM shift and 3:00 PM-11:00 PM shift. On 9/23/25 at 1:15 PM, a review of the nurse's progress notes from 2/16/25 to 2/17/25 revealed that the resident was at the facility and there was no rationale regarding why the care provided was not entered in the clinical record.On 9/24/25 at 12:30 PM, the surveyor reviewed the Documentation Survey Report for February 2025, with the DON. The DON confirmed that the care was not entered and could not be verified as having been provided. The surveyor then asked the DON if the facility had a system in place to review the care had been provided. The DON stated that staff would be educated, and that staff should notify their supervisors if they could not log-in to enter the data on the Point of Care.A review of the facility's policy titled, Activities of Daily Living (ADL), Supporting last revised April 2025, revealed the following:Policy Statement:Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility's policy titled, Charting and Documentation last revised July 2017, revealed the following:Policy Statement:All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial 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 8:39-27.2(f)(i).NJAC 8:39-35.2(d)16(g).

Based on interview, review of the medical record and other facility documentation, it was determined that the facility failed to maintain Hospice Communication Records for 1 of 2 residents (Resident #95) reviewed for Hospice Services. This deficient practice was evidenced by the following:failed to ensure all residents medical record were readily accessible and available for review by the survey team. This deficient practice was identified for Resident #95, 1 of 2 residents reviewed for Hospice Services and was evidenced by the following: On 9/19/25 at 10:21 AM, the surveyor reviewed Resident #95's electronic medical record. The admission Face sheet, an admission summary reflected that Resident #95 was admitted to the facility with diagnoses which included but were not limited to; malignant neoplasm of unspecified part of the bronchus or lung (lung cancer), holiday relief care, secondary malignant neoplasm of the brain (brain cancer) and malignant neoplasm of the bone (bone cancer).The Nursing admission Evaluation dated 5/15/25, reflected that Resident #95 was unable to participate with the admission process. The resident was severely cognitively impaired and was unable to report the correct day, month or year. The initial plan of care listed clinical considerations as hospice or respite. The admission Evaluation also reflected that Resident #95 was admitted for palliative care under hospices services. A review of the individualized person-centered care plan included a focus area for hospice services, initiated 5/15/2025. Th goal was for Resident #95 to remain comfortable. The interventions included: Administer all medications as ordered, initiated 5/16/25. Encourage verbalization of thoughts/feeling or condition, hospice CNA (certified nursing assistant) visit per my care plan, hospice nurse visit at least once per week, notify hospice with any change in condition, other hospice staff (SS/clergy) visit as often as necessary, provide adequate rest periods between activities, initiated 5/16/25.A review of the Order Recap Report (ORR) dated 5/15/25 to 5/21/25, included an order for Do Not Hospitalize every shift for hospice code status with an original date of 5/17/25. A review of a progress notes dated 5/17/25 timed 4:09 PM, indicated the following: Hospice Nurse came to evaluate Resident #95. Recommendations given to change Morphine back to 0.5 milligrams (mg) every hour as needed and to change the code status to DNH as per the Resident Representative request. Hospice nurse at bedside monitoring the resident condition. On 9/24/25 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who completed the admission evaluation. The surveyor inquired regarding the process for hospice services. The LPN/UM stated if a resident was admitted for hospice services or if the resident was already on hospice, the hospice nurse would evaluate and make recommendations as needed. These recommendations would be communicated to the physician. Once approved by the physician, the hospice nurse would come as scheduled and communicate daily with the facility regarding the resident's care. The hospice nurse will enter in the hospice book any recommendation regarding medications and change in condition. The surveyor then requested the hospice recommendations for Resident #95. The LPN/UM did not provide any. The LPN/UM stated she was unsure where the communication log was for Resident #95. The LPN added that Resident #95 was discharged , and the facility could not locate the log.On 9/25/25 at 12:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated when a resident was on hospice services the facility would provide a continuation of care. That's when the hospice service and the facility would get together and coordinate a plan of care for the resident. This would include a schedule for how frequently the nurses and aides would visit the resident. The DON acknowledged there was no documentation in the medical record that an interdisciplinary meeting had been held to discuss hospice services. She further acknowledged the facility staff was unable to locate any additional records on site. At that time the DON confirmed she did not have any of the hospice records. When asked how long the facility was required to maintain records at the facility, she stated five years. The DON acknowledged the hospice records should have been on the premises and available for review. A review of the Nursing Facility Services Agreement, effective 12/10/24 included.Hospice and Facility will jointly develop and agree upon a coordinated, interdisciplinary Plan of Care which is consist with the hospice philosophy and is responsive to the unique needs of the hospice patient and his or her expressed desire for hospice care. Hospice and the facility shall periodically conduct joint reviews of each plan of care as necessary to coordinate provision of facility services. The Plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care.A review of the Hospice Program policy with a revised date of July 2017 indicated.In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.NJAC 8:39-27.1(a) 35.2 (k)

Complaint #: NJ00181255, NJ00181471 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/17/2024, it was determined that the facility failed to ensure resident safety by using portable space heaters in resident rooms when the boilers became non-operational. The Maintenance Director (MD) stated he received a call on 12/8/24 from a staff member that a resident was complaining about the temperature being cold in their room. The MD stated he went to the facility and noticed that the boilers were not operational and supplemental heat was needed in certain areas of the facility. The MD notified the Licensed Nursing Home Administrator (LNHA) that the boilers were not operational and supplemental heat was required. The MD purchased the portable space heaters and placed them in the resident's rooms. The two non-operational boilers were replaced on 12/10/24. The facility discontinued using the portable space heaters on 12/11/2024. There were 38 cognitively impaired residents in the facility on 12/8/24 and there were 10 residents on oxygen on 12/8/24. The facility had knowledge that portable space heaters were being used in resident's rooms where the residents were cognitively impaired, and oxygen was being utilized despite being a fire hazard. This placed all residents at risk for an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy was identified on 12/17/2024 at 6:06 PM and was reported to the LNHA and the Director of Nursing (DON). The LNHA and DON were presented with the IJ template that included information about the issue. The IJ began on 12/8/2024 and continued through 12/18/2024 when the facility submitted an acceptable Removal Plan. On 12/20/2024, the surveyors verified the implementation of the removal plan during an onsite revisit. The facility implemented the Removal Plan, which included education for the LNHA and MD on not using space heaters in the facility; education for all staff on not using the space heaters in the facility. The noncompliance remained on 12/20/24 as a level D based on that facility staff have been educated on not using space heaters in the facility. Audits that monitor compliance with space heaters not being used in the facility were conducted to ensure that they are being implemented. This deficient practice was identified for 48 of 48 residents and was evidenced by the following: A review of the facility's Facility Reported Event (FRE) records revealed: On Sunday 12/08/2024 at approximately 1 P.M., the Director of Maintenance notified the Administrator that both of the Water Source Heat Pump Boilers were not properly functioning and has caused an interruption of service for the heating units. The contracted boiler company was immediately contacted, and a representative was called on sight to inspect both boilers and begin working on the repairs. Ambient temperatures were still being maintained at this time in all resident living spaces. The entire Emergency Chain of Command was immediately notified including the contracted boiler repair company, corporate office, DOH (Department of Health), and NJLTCO (New Jersey Long Term Care Ombudsman). Two replacement boilers units were ordered and scheduled for delivery and install beginning 12/9/2024. During this time the Nursing Department and Maintenance Department are completing and maintain temperature check logs every two hours, and a Fire Watch is in effect with hourly monitoring. Substitute heat devices were in place where needed and extra blankets and comforters are being provided to all residents in need. Wellness checks are ongoing to ensure the comfort and safety of each resident. According to the Admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Pulmonary Fibrosis (scarring and thickening of the tissue around and between the air sacs in the lungs), and Chronic Respiratory Failure (a serious condition that occurs when the lungs cannot take in enough oxygen). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 09/10/2024, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired. The MDS further revealed that the resident was on oxygen therapy. A review of the facility's document titled Order Listing Report (OLR) revealed that Resident #6 had an order for 6 Liters of oxygen via nasal cannula at six liters per minute continuously. During a tour of the second-floor unit at 10:25 A.M., the surveyor observed Resident #6 wearing 6 Liters of oxygen via nasal cannula with an oxygen concentrator in his/her room. During an interview with the surveyor on 12/17/2024 at 10:25 A.M., Resident #6 stated he/she remembered there was a portable space heater in his/her room approximately a couple of weeks ago. Resident #6 stated the staff removed the portable space heater but was unsure of the date the heater was removed. According to the AR, Resident #4 was admitted to the facility with diagnoses which included but were not limited to: Iron Deficiency Anemia and Hypertension. According to the Quarterly MDS dated [DATE], Resident #4 had a BIMS score of 13 out of 15, which indicated the resident's cognition was intact. During an interview with the surveyor on 12/17/2024 at 10:27 A.M., Resident #4 stated approximately at the beginning of the month, the facility did not have heat because the boilers went down. Resident #4 stated staff brought a portable heater to his/her room. Resident #4 stated the heat did not operate for approximately four to five days. Resident #4 further stated I could not bear it, it was cold when the heat was not working. Resident #4 stated that the Maintenance staff removed the heaters, once the heat came back on but he/she was unsure of the exact date this had occurred. During an interview with the surveyor on 12/17/2024 at 10:34 A.M., the Licensed Practical Nurse Unit Manager (LPN/UM) stated that the boilers were not operating on the weekend of 12/08/2024. She stated that the residents were given portable space heaters and extra blankets. The LPN/UM stated that residents with oxygen were also provided with portable space heaters, but they were placed on the other end of the resident's room. According to the AR, Resident #5 was admitted to the facility with diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways usually from smoking or other irritants), and Peripheral Vascular Disease (a condition caused by narrowing, blockage, or spasms in the blood vessels). According to the Quarterly MDS dated [DATE], Resident #5 had a BIMS score of 10 out of 15, which indicated the resident's cognition was moderately impaired. The MDS further revealed that the resident was on oxygen therapy. A review of the facility's document titled Order Listing Report (OLR) revealed that Resident #5 had an order for 2 Liters of oxygen via nasal cannula at two liters per minute continuously. During a tour of the second-floor unit at 10:38 A.M., the surveyor observed Resident #5 wearing 2 Liters of oxygen via nasal cannula with an oxygen concentrator in his/her room. During an interview with the surveyor on 12/17/2024 at 10:38 A.M., Resident #5 stated he/she could not remember the date, but the heat was not working. Resident #5 stated the Maintenance staff brought a plug-in heater into his/her room. Resident #6 stated he/she told the staff they could not plug the heater in his/her room. Resident #5 stated the plug-in heater was left in the room even though he/she requested it be removed. Resident #5 stated the plug-in heater was eventually removed but he/she cannot remember when it was removed. Resident #5 stated that he/she did not use the plug-in heater. According to the AR, Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Aftercare Following Joint Replacement right knee, Type 2 Diabetes (chronic disease that occurs when the body has difficulty using insulin, a hormone that regulates blood sugar levels), Hyperlipidemia (a condition where there are too many lipids (fats) in the blood). According to the Quarterly MDS dated [DATE], Resident #1 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. During an interview with the surveyor on 12/17/2024 at 10:51 A.M., Resident #1 stated on 12/09/2024, he/she received a portable space heater in his/her room. Resident #1 stated the portable space heater operated for one night but was not connected to the red emergency outlet, which resulted in shutting off the lights in his/her room. Resident #1 stated the portable space heater was removed from his/her room on 12/10/2024. During an interview with the surveyors on 12/17/24 at 1:15 P.M., the MD stated when he went to the facility on [DATE] around 6 P.M., he noticed the common area was a little chilly. He checked the boilers and noticed that the temperature was 52 degrees. He stated the normal temperature should have been 80 degrees. The MD stated that one boiler was not functioning properly, and the other boiler did not have enough output to keep the facility warm. The MD stated that the appropriate temperature for the resident's room should be between 71-81 degrees. The MD stated he toured the facility to assess which of the resident's rooms needed supplemental heat. He stated that some of the heating consoles in some of the resident's rooms were providing appropriate temperatures and therefore did not require supplemental heat. The MD stated that he was aware of the issues with the one boiler not being operational and the other two boilers needed to be repaired. He was obtaining quotes to have them repaired. The MD stated that he was aware that the portable heaters were a fire hazard, but this was an emergent situation and felt this was the best option to keep the residents comfortable at the time. During an interview with the surveyors on 12/17/24 at 2:41 P.M., the LNHA stated that he was notified on 12/8/24 by the MD that the boilers were not working properly. The LNHA stated he was aware that it was against regulations to use the portable space heaters because it was a fire concern. The LNHA stated it was not acceptable to not follow regulations regarding space heaters for the best interest of the residents. He stated this was an emergent situation and that his focus was the best interest of the resident's health and safety and to keep the residents comfortable. The LNHA stated that he would have considered evacuation if the problem with the boilers and no heat was a persistent problem. During a tour of the Physical Therapy aquatics room on 12/17/2024 at 5:11 P.M., the surveyor observed multiple portable space heater boxes. The MD confirmed that there were 46 boxes present during the tour. Review of the facility's Emergency Preparedness Plan for Fire Prevention dated 08/19/2024 revealed under Policy Statement, It is the policy of the facility that all personnel participate in methods of fire prevention and to report any condition (s) that could result in a potential fire hazard. Revealed under Procedure, fire prevention is the responsibility of all personal, residents, visitors, and public alike. Should a fire hazard, or other conditions that could develop into a fire hazard be discovered, it shall be reported to the Maintenance Director immediately. Hazardous conditions must be corrected as soon as practical. Any hazardous condition requiring more that twenty-four (24) hours to correct must be reported to the Administrator outlining what corrections shall be made, methods of correction, and when the hazardous condition is expected to be corrected. NJAC 8:39-31.2 (e)

Complaint #: NJ00181255, NJ00181471 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/17/2024, it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure the resident safety by allowing the use of space heaters in resident rooms while the boilers were not operational. The Maintenance Director (MD) notified the LNHA that the boilers were not operational and supplemental heat was required. The MD purchased the portable space heaters and placed them in the resident's rooms. The two non-operational boilers were replaced on 12/10/24. The facility discontinued using the portable space heaters on 12/11/2024. There were 38 cognitively impaired residents in the facility on 12/8/24 and there were 10 residents prescribed oxygen on 12/8/24. The facility had knowledge that portable space heaters were being used in resident's rooms where the residents were cognitively impaired, and oxygen was being utilized despite being a fire hazard. This placed all residents at risk for an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy was identified on 12/17/2024 at 6:06 P.M. and was reported to the LNHA and the Director of Nursing (DON). The LNHA and DON were presented with the IJ template that included information about the issue. The IJ began on 12/8/2024 and continued through 12/18/2024 when the facility submitted an acceptable Removal Plan. On 12/20/2024, the surveyors verified the implementation of the removal plan during an onsite revisit. The facility implemented the Removal Plan, which included education for the LNHA and MD on not using space heaters in the facility; education for all staff on not using the space heaters in the facility. The noncompliance remained on 12/20/24 as a level D that is not an IJ based on that facility staff have been educated on not using space heaters in the facility. Audits that monitor compliance with space heaters not being used in the facility were conducted to ensure that they are being implemented. This deficient practice was identified for 48 of 48 residents and was evidenced by the following: A review of the facility's Facility Reported Event (FRE) records revealed: On Sunday 12/08/2024 at approximately 1 P.M., the Director of Maintenance notified the Administrator that both of the Water Source Heat Pump Boilers were not properly functioning and has caused an interruption of service for the heating units. The contracted boiler company was immediately contacted, and a representative was called on sight to inspect both boilers and begin working on the repairs. Ambient temperatures were still being maintained at this time in all resident living spaces. The entire Emergency Chain of Command was immediately notified including the contracted boiler repair company, corporate office, DOH (Department of Health), and NJLTCO (New Jersey Long Term Care Ombudsman). Two replacement boilers units were ordered and scheduled for delivery and install beginning 12/9/2024. During this time the Nursing Department and Maintenance Department are completing and maintain temperature check logs every two hours, and a Fire Watch is in effect with hourly monitoring. Substitute heat devices were in place where needed and extra blankets and comforters are being provided to all residents in need. Wellness checks are ongoing to ensure the comfort and safety of each resident. During an interview with the surveyors on 12/17/24 at 2:41 P.M., the LNHA stated that he was notified on 12/8/24 by the MD that the boilers were not working properly. The LNHA stated he was aware that it was against regulations to use the portable space heaters because it was a fire concern. The LNHA stated it was not okay to not follow regulations regarding space heaters for the best interest of the residents. He stated this was an emergent situation and that his focus was the best interest of the resident's health and safety and to keep the residents comfortable. The LNHA stated that he would have considered evacuation if the problem with the boilers and no heat was a persistent problem. During a tour of the Physical Therapy aquatics room on 12/17/2024 at 5:11 P.M., the surveyor observed multiple portable space heater boxes. The MD confirmed that there were 46 boxes present during the tour. Review of the facility's Emergency Preparedness Plan for Fire Prevention dated 08/19/2024 revealed under Policy Statement, It is the policy of the facility that all personnel participate in methods of fire prevention and to report any condition (s) that could result in a potential fire hazard. Revealed under Procedure, fire prevention is the responsibility of all personnel, residents, visitors, and public alike. Should a fire hazard, or other conditions that could develop into a fire hazard be discovered, it shall be reported to the Maintenance Director immediately. Hazardous conditions must be corrected as soon as practical. Any hazardous condition requiring more that twenty-four (24) hours to correct must be reported to the Administrator outlining what corrections shall be made, methods of correction, and when the hazardous condition is expected to be corrected. A review of the Administrator Job Description,dated May 2023 revealed under Major Duties and Responsibilities: 1. Plans, develops, organizes, and implements, evaluates and directs the overall operation of the facility as well as its program and activities, in accordance with current state and federal laws and regulations. 2. Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. 3. Follows appropriate safety and hygiene measures at all times to protect residents and themselves NJAC:8:39-9.2 (a) NJAC:8:39-27.1 (a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates were not 5% or greater. During the morning medication administration observation on 2/20/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 37 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 5.41%. This deficient practice was identified for one (1) of four (4) residents, Resident# 83, that was administered medications by one (1) of the two (2) nurses that were observed. The deficient practice was evidenced by the following: On 2/20/2024 from 9:23 AM to 9:40 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN) prepare and administer medications to Resident # 83 which included: (i) Icosapent Ethyl (a medication used along with a proper diet to help lower fats [triglycerides] in the blood.) oral capsule one (1) gram (GM) (ii) Darolutamide (an oral tablet for prostate cancer that has not spread to other parts of your body) oral tablet 300 milligrams (MG). The surveyor asked the LPN if the resident had breakfast and the LPN stated, the resident has not eaten yet. The LPN opened up resident's room door to show the surveyor that his/her breakfast tray was on the tray table, which was positioned away from the resident's bed and further stated, the resident is waiting for [his/her] wife to bring [him/her] breakfast from home. At 10:00 AM, the surveyor reviewed Resident #83's Electronic Medication Administration Records (eMARs), which included special directions for these medications: (i) Icosapent Ethyl- Give 1 capsule by mouth two times a day for HLD (hyperlipidemia [high lipids]). Give with meals. (ii) Darolutamide Oral tablet 300 MG- Give 2 tablet by mouth two times a day for prostate cancer. Please ensure given 12 hrs. (hours) apart and with food in the stomach and also with food. At 1:25 PM, the surveyor asked the LPN when the resident ate last and the LPN stated, the resident had food last night. At that time the surveyor requested the LPN to review the eMARs and read the directions for the above medications, Give with meals and Please ensure given 12 hrs. apart and with food in the stomach and also with food. After reviewing the directions, the LPN stated, I should've HOLD the medications. A review of facility's policy, Medication Administration, revised on 5/30/23, included the following: 14. Administration medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluids. A review of an undated policy titled PharmACCURATE Medication Pass, which was provided by the Director of Nursing on 2/23/24, included the following instructions under the subsection titles, Medication Timing: -Medication ordered with food may be administered up to 15 minutes after a meal or given with 4 ounces of milk and 2 graham crackers (or similar items). -Applesauce is not food. -Medication ordered with meals should be given with the meal (i.e., Metoprolol). -Milk and crackers do not constitute a meal. N.J.A.C 8:39-29.2 (d)

Complaint NJ #161104 Based on record review, interviews and other facility documentation, it was determined that the facility failed to notify the Board of Nursing (BON) (evaluates license applications, issues licenses, renews licenses, and takes disciplinary action in response to professional misconduct) for a Licensed Practical Nurse/Supervisor (LPN/S #1) who was under investigation for misappropriation of Residents' narcotic medication. This deficient practice was identified for one of one investigation reviewed. This deficient practice was evidenced by the following: On 02/21/24 at 2:40 pm, the Director of Nursing (DON #1) provided the survey team with a file for an investigation dated 12/18/22. A review of the file revealed a Reportable event [Resident's name redacted] 12/18/22; Summary and Conclusion: On 12/18/22, the nurse assigned to [name redacted] went to administer his/her Oxycodone (an opioid pain medication-narcotic) around 9am. The nurse went to the declining inventory form (a record used to keep accurate count of controlled substances) for [name reacted] Oxycodone. The nurse observed three signatures timed 10a, 12p, and 2:20 p for 12/17/22. This nurse was also the nurse that worked this assignment on 12/17/22 7a-3p. The three signatures were not her signature. The nursing supervisor (LPN/S #2) notified the Director of Nursing (DON #2) and the Administrator. The signatures could not be identified. Further review of the investigation identified 2 other residents that had unidentified signatures on their declinining inventory sheets. Based upon the investigation and review of statements, the supervisor (LPN/S #1) who worked 3p-11p on 12/17/22 was the only nurse that had access to all three residents that had unidentifiable signatures on their declining inventory sheets .She was suspended pending investigation. Further review revealed that on 12/22/22, the Human Resource Director (HRD) reached out to the supervisor (LPN/S #1) to come in and meet with administration. A meeting was scheduled for 1/3/23. The supervisor (LPN/S #1) did not show up for the meeting. The HRD called her, but she did not answer. Further review of the investigation file revealed a certified letter dated 1/10/23 sent to the LPN/S #1, On Tuesday 01/03/23 at 1:30 pm you had a meeting scheduled at this facility with [name redacted] DON and me to discuss the outcome of an investigation. Since you did not attend this meeting, we are considering this a voluntary resignation. This letter was signed by the HRD. Additional review of the investigation file revealed that the police and the DEA (Drug Enforcement Administration) were notified. It did not reveal evidence that the Board of Nursing had been notified. On 02/22/24 at 8:45 AM, in the presence of the survey team, the Regional Director of Clinical Services (RDCS), confirmed that the facility did not report the LPN/S to the Board of Nursing because they did not have concrete proof she took the medications, but she (the LPN/S) was the only one who had access to all of the carts (medication carts). She then stated that the DEA and the police were notified. On 02/22/24 at 10:48 AM, the RDCS, the Regional Director of Operations (RDO), DON#1 and the Licensed Nursing Home Administrator (LNHA) met with the survey team to review the above-mentioned investigation. The RDCS, who confirmed at the time of the incident she was the DON #2, acknowledged that the investigation was completed and reported to the Department of Health, the police, and the DEA. She stated that it is fair to say yes we believe that [name redacted] (the LPN/S #1) was the common denominator, she had access to all the carts but I did not send a report to the BON. The RDCS stated that the purpose of reporting to the BON was so that they are aware of a situation, something that that nurse did, so they could investigate it. The administrative team all acknowledged that the incident should have been reported. On 02/23/224 at 10:22 AM, the DON provided the survey team with the incident report, dated 12/18/22 at 12:00 PM. Review of the report, revealed Agencies/People Notified: State Agency (DEA), Office of Ombudsman, Department of Health, and Physician. On 2/22/24 at 1:50 PM the LNHA provided the survey team with copy of a report that the above incident was submitted to the BON, dated 2/22/24. A review of the facility's policy Incident and Accidents revised 7/17/23, revealed: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements; Meeting regulatory requirements for analysis and reporting incidents and accidents. Compliance Guidelines: 4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse policy. 8. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. A review of the facility's policy Abuse, Neglect and Exploitation revised 7/2023, revealed: VII. Reporting/Response: A. the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, .all other required agencies. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. A review of the facility's policy Controlled Substance Administration & Accountability revised 5/20/23, revealed Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. 9. Discrepancy Resolution: e. Any discrepancies which cannot be resolved must be reported immediately as follows: iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities. NJAC 8:39-13.4(c)(2)(v)

Based on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to complete and submit a Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with the federal guidelines of the MDS 3.0 Resident Assessment Instrument (RAI) for 1(Resident #33) of 1 resident reviewed for hospitalization s. This deficient practice was evidenced by the following: On 02/14/24 at 11:30 AM, the surveyor observed Resident #33 in his/her room lying in bed. Resident #33 was alert and verbally responsive, the resident was observed wearing oxygen via nasal cannula (a medical device which provides supplemental oxygen therapy). The surveyor interviewed Resident #33, in reference to his/her hospitalization s. Resident #33 stated that he/she was admitted to [NAME] Medical Center three months ago, however he/she was unable to recall how many times or why he/she was admitted and readmitted from the hospital since admission to the facility. The surveyor reviewed the medical record of Resident #33. Review of the Admission Record (an admission summary) reflected that Resident #33 was admitted to the facility with diagnoses which included but are not limited to: chronic systolic heart failure (a chronic condition that occurs when the left ventricle cannot pump blood efficiently), acute and chronic respiratory failure with hypoxia (occurs when there is not enough oxygen in your blood), and chronic kidney disease stage 3 (mild to moderate damage, which they are less able to filter waste and fluid out of your blood). A review of the electronic medical record (EMR) under the section titled census, revealed that Resident #33 was admitted to the hospital on 10/18/23, readmitted to the facility on [DATE] and sent back to the hospital again on 11/24/23. A review of the MDS tracking records (a record which documented the resident's entry and discharge into and out of the facility) which revealed the following: 10/18 2023(Discharge Return Anticipated); 12/2/2023(Entry); 12/12/2023(Discharge Return Anticipated) and 12/19/2023(Entry). A review of the EMR progress notes revealed the following: 11/24/2023 14:2 Nursing Note Text: patient arrived from PMC ([NAME] Medical Center), respiratory distress noted VS (vital signs) 160/80 HR (heart rate)128, o2 (oxygen) 85% on 3L (liters), SOB (shortness of breath) using abd (abdominal) accessory muscles, MD notified, nebulizer treatment given, continue to monitor, call bell within reach. 11/24/2023 17:04 Nursing Note Text: oncoming nurse rounded on resident noticed he was in respiratory distress, reported to UM (unit manager), upon arrival to room resident noted to be SOB, utilizing accessory muscles, VS 145/58 HR 136, 97.7 Temp, 79% O2 on 3L, MD contacted order to send back to PMC for evaluation. 11/25/2023 08:37 Nursing Note Text: Resident was admitted to PMC with dx (diagnosis): chronic respiratory failure. On 02/20/24 at 10:16 AM, the surveyor interviewed the MDS Coordinator, who explained to the surveyor that she was informed of the facility admissions and discharges through morning meetings, utilization review meetings (review of subacute resident's discharge status), emails, and the discharge calendar. She stated that she completed the entry tracking and discharge records the day the resident was admitted , readmitted , or discharged if she was in the building or the next day. She further stated that if there was an admission, re-admission, or discharge on the weekend, that she completed the tracking assessment on Monday. The MDS coordinator reviewed Resident #33's MDS tracking record in the presence of the surveyor. The MDS Coordinator acknowledged that she did not see the entry and discharge tracking record for the date of 11/24/23. She stated, I will look into why the entry and discharge tracking were not completed for 11/24/23. On 02/20/24 at 11:08 AM, the MDS Coordinator acknowledged that the above mentioned MDS records were not completed for 11/24/23. She informed the surveyor that she completed and submitted the MDS entry/discharge tracking record after surveyor inquiry. A review of the facility policy titled MDS 3.0 Completion, date reviewed/revised 9/18/23 included the following: a. Entry Tracking i. Complete and submit with every entry into the facility no later than entry date + 7 calendar days. F. Discharge Assessment-completed using the discharge date as the Assessment Reference Date (ARD). Must be completed within 14 days of the discharge date /ARD. NJAC 8:39-11.2 (3)(i)

Complaint #: NJ159278, 159279, 159280 Based on interviews and record review, as well as review of pertinent facility documents on 12/20/22, 12/21/22, and 12/22/22 it was determined that the facility failed to report injury of unknown origin to the New Jersey Department of Health (NJDOH) and to follow the facility policy on Abuse Investigation and Reporting for 2 of 6 residents (Resident #1 and Resident #3). This deficient practice is evidenced by the following: 1. According to the ADMISSION RECORD (AR) form, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Dementia and Anxiety Disorder. The Minimum Data Set (MDS), an assessment tool dated 10/7/22, showed that Resident #1's cognition was severely impaired and required extensive assistance from staff in Activities of Daily Living (ADL). The care plan (CP), undated, revealed that Resident #1's cognition was impaired, forgetful, and had a diagnosis of Dementia. The facility's investigation report (IR) dated 10/17/22 at 10:22 am indicated that the facility investigated an incident involving Resident #1. The IR revealed that Certified Nursing Assistant (CNA #1) saw Resident #1's right shoulder, forearm, wrist, and hand were swollen during care and reported to the nurse on duty. The IR further revealed that the NP assessed Resident #1 and ordered an Xray of the shoulder, humerus, wrist, and hand and the Xray result was pending. The IR indicated the Resident was unable to explain what happened and there were no witnesses. On 12/18/22, the IR concluded by the Director of Nursing (DON) that there was no evidence of intentional mishandling. Included in the IR was a written statement from CNA #1 which indicated that she notified the nurse when she observed the swollen of right shoulder and wrist. Also included in the IR was a written statement for Registered Nurse (RN #1) verified she was notified by CNA #1 of the Resident's change in status. The RN indicated the Resident was confused and unable to express what happened. A Physician's progress note (PPN) dated 10/17/22 at 8:38 am, documented by the NP revealed that Resident #1 was evaluated for the right arm pain and edema and other medical problems. The PPN further showed that Resident's right arm was swollen, and the Resident was complaining of pain. Review of the Radiology Results Report (RRR) indicated that on 10/17/22 at 3:38 pm, X-ray was performed to Right Humerus, Right Wrist, Right Clavicle, Right Hand, and Right Shoulder to ruled out fracture. The PPN dated 10/18/22 indicated that it was unclear if Resident #1 had a fall and that the result of the X-ray was negative for fracture. Review of Resident #1's progress note (PN), on 10/17/22 at 5:36 pm, documented by RN #1 reflected the incident on the IR. The surveyor conducted an interview with CNA #1 on 12/21/22 at 1:53 pm. The CNA confirmed what she wrote on her aforementioned statement. She remembered the Resident was leaning on the right side, she assisted the Resident to the bathroom. When she removed the Resident's gown, she noticed the Resident's right shoulder was bigger than before, and that the Resident was complaining of pain. CNA #1 further stated that she was unable to explained how it happened and the Resident was unable to tell her what happened to the right shoulder. The surveyor conducted an interview with RN #1 on 12/22/22 at 1:53 pm. The RN confirmed what she wrote on her aforementioned statement. RN #1 stated that she immediately reported the incident on 10/17/22 to the Director of Nursing (DON) and did not report it to the NJDOH. During the post survey telephone interview with the NP on 12/28/22 at 2:08 pm, the NP stated that she received a report from one of the nurses stating that Resident #1's right shoulder and arm was swollen, Resident #1 was cooperative and was not agitated during the assessment, Resident #1 had pain when she/he lifted her/his arm. The NP further stated that an Xray was ordered to make sure that there was no fracture to Resident's right shoulder, she was unable to conclude what happened to the right shoulder without the Xray result. The surveyor conducted an interview with the DON on 12/21/22 at 3:51 pm. The DON confirmed the incident was not reported to the NJDOH because it was a known origin and the CNA was able to explain what happened. The DON further stated that the Resident acquired the injury from leaning on the right side. The DON confirmed that if a resident was unable to explain, the facility will report to the NJDOH within 2 hours. 2. According to the AR form, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Hemiplegia, Hemiparesis, and Amnesia, The MDS, dated [DATE], revealed that Resident #3's cognition was moderately impaired and required extensive assistance from staff in ADL. The CP, undated, indicated that the Resident was at risk for complications, injury related to anticoagulant therapy and behaviors. The CP further revealed that Resident #3 had impaired cognition and forgetful. The facility's IR dated 10/24/22 at 11:00 am, revealed that the facility investigated an incident involving Resident #3. The IR indicated that the Hospice CNA (CNA #3) reported a discoloration next to Resident's right eye. The investigation further indicated that Resident #3 was unable to explained what happened and there was no witness to explain how the discoloration next to the Resident's eye happened. The IR noted the incident was reported to the NJDOH on 10/27/22 at 1:11 pm which was not according to their policy. Additionally, the IR included a verbal statement from Licensed Practical Nurse (LPN #1) dated 10/24/22 signed and documented by the DON. The statement indicated that LPN #1 reported a discoloration to Resident #3's right eye. On 10/24/22 LPN #1 also stated that on 10/21/22 Resident #3 threw his/her breakfast tray on the floor, fluids flew in the air. The Resident was flailing his/her arms and bumped his/her face where the discolorations was located. A PN dated 10/21/22 at 3:23 pm, documented by LPN #1 indicated that CNA #4 (who was passing breakfast tray on 10/21/22) reported that Resident #3 threw breakfast tray on the floor and the Resident was agitated. LPN #1 walked into the room and asked Resident #3 what happened, the Resident did not say what happened and asked the LPN to leave the room. The PN had no documented evidence that the Resident was having behavior episode as indicated on the statement by DON on 10/24/22. The surveyor conducted an interview with the DON on 12/21/22 at 3:51 pm, the DON confirmed the aforementioned IR and verbal statement from LPN on 10/24/22. The DON stated that incident was not reported to the NJDOH because it was a known origin and added that LPN #1 was able to explain what happened on 10/21/22. The DON confirmed that if a resident was unable to explain how it happen, the facility will report the occurance to the NJDOH within 2 hours. During the post survey telephone interview with LPN #1 on 12/27/22 at 1:27 pm. The LPN stated that on 10/21/22 in the morning, when CNA #4 was passing tray, the CNA reported that the Resident became agitated, threw breakfast tray on the floor and all over the place. LPN #1 further stated that she did not witness that Resident threw the tray, when she walked into the room the tray was already on the floor, Resident #3 was calm and had asked the LPN to leave the room. The LPN confirmed what she documented on the PN dated 10/21/22 at 3:23 pm. During the post survey telephone interview with CNA #4 on 12/27/22 at 2:14 pm. The CNA stated that on 10/21/22, Resident #3 refused breakfast and reported to LPN #1. CNA #4 further added that the Resident was agitated, however, the Resident did not swing his/her hands and did not hit his/her face. The surveyor conducted an interview with the Administrator on 12/22/22 at 1:31 pm, who stated that injuries of unknown origin must be investigated according to policy and are to be reported within 2 hours to NJDOH. The facility's policy titled Accidents and Incidents - Investigating and Reporting, dated 7/2017 showed All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the administrator . The facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021 showed . residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restrain not required to treat the residents symptoms .8. identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within time frames required by federal requirements . NJAC 8:39-9.4(f)

C# NJ100159278, 159280 Based on interviews, medical record review, and review of other pertinent facility documents on 12/20/22, 12/21/22, and 12/22/22, it was determined that the facility staff failed to consistently document in the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. In addition, the facility staff failed to follow the facility's policy titled Guidelines for Charting and Documentation for 4 of 4 residents (Resident #1, #2, #3, and #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Dementia. The Minimum Data Set (MDS), an assessment tool, dated 10/7/22, revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated that the Resident's cognitive status was severely impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. The surveyor reviewed the Documentation Survey Report (DSR), an ADL record documented by the Certified Nursing Assistant (CNA) during their assigned shift for September 2022. The DSR revealed the following: The DSR forms had assigned ADL care tasks which included but were not limited to Bed Mobility, Behavior Symptoms, Dressing, Personal Hygiene, Skin Observation, Toilet Use, Transferring, Turning and Repositioning, and Eating and percentage of amount eaten. Review of Resident #1's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 9/1/22, 9/4/22, 9/11/22, 9/18/22, and 9/25/22. Evening shifts on 9/24/22. Night shifts on 9/2/22, 9/12/22, 9/16/22, 9/21/22, 9/26/22, and 9/30/22. Eating and percentage of amount eaten for breakfast and lunch on 9/1/22, 9/4/22, 9/11/22, and 9/25/22. Additionally for breakfast on 9/18/22, and dinner on 9/24/22. Review of Resident # 1's Progress Notes revealed no documentation of the aforementioned ADL care. 2. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Hypertension. The MDS dated [DATE], revealed a BIMS score of 15 which indicated that the Resident's cognitive status was intact. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #2's ADL record in the DSR form for October 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 10/25/22 to 10/28/22, and 10/31/22. Evening shifts on 10/14/22, 10/23/22, 10/24/22, 10/26/22, 10/28/22, and 10/31/22. Night shifts on 10/12/22, 10/17/22, 10/20/22, and 10/22/22. Eating and percentage of amount eaten for breakfast and lunch on 10/25/22 to 10/28/22, and 10/31/22. Additionally for dinner on 10/3/22, 10/23/22, 10/24/22, 10/26/22, 10/28/22, and 10/31/22. Review of Resident # 2's PN revealed no documentation of the aforementioned ADL care. 3. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction. The MDS dated [DATE], revealed a BIMS score of 12 which indicated that the Resident's cognitive status was moderately impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #3's ADL record in the DSR form for December 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 12/4/22, 12/7/22, 12/9/22, 12/13/22, and 12/16/22. Evening shifts on 12/4/22, 12/9/22, and 12/18/22. Night shifts on 12/3/22, 12/5/22, 12/10/22, 12/17/22 and 12/19/22. Eating and percentage of amount eaten for breakfast and lunch on 12/4/22, 12/7/22, 12/9/22, 12/13/22, and 12/16/22. Additionally for dinner on 12/4/22, 12/9/22. Review of Resident # 3's PN revealed no documentation of the aforementioned ADL care. 4. According to the AR, Resident #4 was admitted to the facility on [DATE] with diagnosis that included but was not limited to Alzheimer's Disease with Late Onset. The MDS dated [DATE], revealed that BIMS was zero and rarely understood which indicated that the Resident's cognitive status was severely impaired. The MDS also indicated that the Resident required extensive assistance from staff for ADLs. Review of Resident #4's ADL record in the DSR form for November 2022 revealed the following: There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shifts on 11/13/22 and 11/20/22. Evening shifts on 11/4/22, 11/9/22, 11/13/22, 11/14/22, 11/17/22, 11/20/22, 11/28/22, and 11/29/22. Night shifts on 11/1/22, 11/6/22, 11/7/22, 11/10/22, 11/14/22, 11/16/22, 11/19/22, 11/21/22, and 11/29/22. Eating and percentage of amount eaten for breakfast on 11/13/22 and 11/20/22, and for lunch on 11/4/22, 11/9/22, 11/13/22, 11/14/22, 11/17/22, 11/20/22, 11/28/22, and 11/29/22. Additionally for dinner on 11/1/22, 11/6/22, 11/7/22, 11/10/22, 11/14/22, 11/16/22, 11/19/22, 11/21/22, 11/21/22, and 11/29/22. Review of Resident # 4's PN revealed no documentation of the aforementioned ADL care. During an interview with the surveyor on 12/21/22 at 1:53 PM, CNA #1 stated that CNAs are responsible for entering the ADL care provided to residents in the POC kiosk and must be completed by the end of the shift. During an interview with the surveyor on 12/22/22 at 12:10 PM, CNA #2 stated that CNAs are responsible for documenting the ADL care into the kiosk. She further stated that all tasks must be answered as these reflected the resident's status and the ADL care provided. She could not explain why there were blanks in the sampled resident's ADL records but stated that they should have been completed. During a telephone interview with the surveyor on 12 /22/22 at 12:35 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that CNAs are expected to complete the ADL care in the kiosk at the end of their shift. She stated that it was her responsibility to ensure that the tasks are documented timely and accurately, however, she could not explain why there were blanks in the ADL records for the sampled residents. During a conference with the DON and Administrator on 12/21/22 at 4:00 PM, the DON stated that CNAs are expected to document the ADL care provided to the residents into the kiosk by the end of their shift. The DON could not explain why there were blanks in the sampled Resident's ADL records but stated that they should have been completed. Review of the Job Description titled Certified Nursing Assistant under Main Duties revealed Support the facility's philosophy of care .Carry out assignments for resident care including (but not limited to) a.) bathing b.) dressing .e.) feeding .Complete assignment .at the end of every shift. Review of the facility's policy titled Guidelines for Charting and Documentations indicated The purpose of charting and documentation is to provide: 1. A complete account of resident's care .the progress of the resident's care. 3. The facility a tool for measuring the quality of care provided to the resident. 5. Assistance in the development of a Plan of Care .under General Rules for Charting and Documentation indicated 6. Document assessments, interventions, treatments, etc 7. Chart all entries legibly. 8. All entries must reflect the date, the time, and the signature and title of the person recording the data. NJAC 8:39-35.2 (a)(g)1

Complaint Intake #NJ154751 Based on observation, interviews, record review, and facility policy review, it was determined the facility failed to maintain a medication error rate below 5% for 1 (Resident #8) of 4 residents observed during medication passes conducted by three licensed nurses. The medication error rate was 8%, based on a total of 25 opportunities observed and a total of two medication errors detected. Findings included: Review of an Order Summary Report, revealed Resident #8 had a physician's order dated 09/16/2022 for a multivitamin with minerals one tablet daily for supplement. Additionally, the resident had a physician's order dated 09/22/2022 for cyanocobalamin (Vitamin B12) 1000 mcg, one tablet daily for B12 deficiency. Observation on 09/25/2022 at 8:23 AM revealed Licensed Practical Nurse (LPN) #2 administering medication to Resident #8. The LPN administered cyanocobalamin 100 microgram (mcg) one tablet and a multivitamin tablet to the resident. During an interview on 09/25/2022 at 10:02 AM, LPN #2 acknowledged and agreed she had administered cyanocobalamin 100 mcg tablet and a multivitamin tablet. LPN #2 confirmed the resident should have received cyanocobalamin 1000 mcg tablet and a multivitamin with minerals tablet, which were available in the medication cart. During an interview on 09/25/2022 at 10:14 AM, the Regional Director of Nursing Services (RDNS) stated nurses should administer medications according to the physician's orders. Review of a facility policy titled, Administering Medications and Treatments, reviewed/revised 02/2020, revealed Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. New Jersey Administrative Code 8:39-29.2(d)

Based on observations, interview, record review and review of the pertinent facility documentation it was determined the facility failed to: a.) ensure that oxygen tubing was appropriately labeled and dated, b.) the nasal canula was stored in a way to prevent bacterial microbial growth, c.) the oxygen humidification bottle was checked to ensure the appropriate water level for humidification, and d.) the facility followed their Policy and Procedure for Oxygen Administration. This deficient practice was identified for three of four residents, (Resident #11, Resident #27, and Resident #50) reviewed for respiratory care and was evidenced by the following. 1. A review of Resident #11's Admission Record indicated Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/09/2021 at 10:15 AM, the surveyor observed Resident #11sitting in a wheelchair in the his/her room. Resident #11 did not speak to the surveyor. The oxygen concentrator machine was observed next to the wheelchair. The surveyor observed that the oxygen tubing was in direct contact with the floor. On 11/10/2021 at 9:01 AM, the surveyor observed the oxygen tubing and the nasal cannula in direct contact with the floor. On 11/15/21 at 10:07 AM, the surveyor observed the oxygen concentrator machine running and titrated at four liters per minute via nasal cannula. The surveyor further observed that the oxygen tubing was dated 11/14/2021 and was in direct contact with the floor in the resident's room. Additionally, the nasal cannula was not protected and was observed on the floor in the resident's room. On 11/16/21 at 9:34 AM, the surveyor observed Resident #11 seated in the wheelchair in his/her room. The oxygen tubing and nasal cannula were both observed on the floor and dated 11/14/2021. During an interview with the Licensed Practical Nurse (LPN) on 11/15/2021 at 10:30 AM, the LPN stated that Resident #11 was on hospice and very confused. The LPN further stated that Resident #11 removed the nasal cannula all the time. The surveyor observed the LPN enter the resident's room and place the oxygen tubing on the concentrator. A review of the resident's Care Plan revised 11/09/2021 reflected that the resident did not have a focus care area for the use of oxygen. 2. A review of Resident #27 Admission Record revealed that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS dated 11/2021 revealed an physicians order dated 09/13/2021 for oxygen to be administered at two liters via nasal cannula continuous every eight hours as needed. On 11/09/21 at 11:25 AM, the surveyor observed the oxygen tubing and the nasal cannula on the floor in the resident's room. The tubing was dated 11/04/2021. The surveyor further observed that there was no water in the humidifier bottle. On 11/15/21 at 10:07 AM, the surveyor observed the oxygen flowing at two liters per minute via nasal cannula. The Hospice Aide (HA) was observed in the room. The oxygen concentrator machine was on and running. The nasal cannula was observed on the floor mat. The HA stated that Resident #27 kept removing the nasal cannula. At that time, the surveyor observed the HA remove the nasal cannula from the floor mat and placed it on the resident's bed. The surveyor observed that the nasal cannual and humidification bottle were labeled and dated 11/15/2021. On 11/16/21 at 9:01 AM, the surveyor observed Resident #27 in bed. The oxygen concentrator was observed to be running. Resident #27 did not have the nasal cannula on. The nasal cannula was observed on the bed rail. Resident #27 did not have her/his socks on. Resident #27's feet were purplish in color. Resident #27 was calling out. The surveyor left the room, located the nurse and informed her that Resident #27 needed help and was calling out. At 9:09 AM, the surveyor observed the nurse enter the room and apply the nasal cannula that was on the bed rail. The surveyor observed Resident #27 in bed with the oxygen flowing two liters. The nasal cannula was dated 11/15/2021. During an interview with the LPN on 11/16/2021 at 12:30 PM, the LPN stated that regarding the oxygen tubing being on the bed rails revealed that Resident #27 was very confused. The LPN further stated that Resident #11 removed the nasal cannula all the time. The LPN stated that the 11:00 PM - 7:00 AM nurses were responsible for changing the nasal cannula and the humidifier bottle. On 11/17/21 at 12:05 PM, the surveyor requested the policy for respiratory care. The Director of Nursing (DON) told the surveyor she would look for the policy. The DON further stated, It was the facility's practice to store the nasal cannula in a plastic bag when not in use. This interview contradicted the surveyors observations. There was no plastic bag hung on the concentrator machine or in the room to store the nasal cannula when not in use. A review of the resident's undated Care Plan reflected a focus area that the resident had refused care and oxygen therapy. The goal of the resident's Care Plan reflected that the resident's behaviors would not interfer with his/her activities of daily living. The interventions in the resident's Care Plan included to allow the resident to express self, have consistency with caregivers, and reassure the resident. 3. A review of Resident #50 Admission Record revealed that Resident #50 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's November 2021 POS revealed an physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/09/2021 at 12:30 PM, the surveyor observed the oxygen on and flowing at two liters nasal cannula, there was no water in the humidifier bottle. The surveyor further observed that the oxygen tubing was not labeled and dated. On 11/10/2021 at 9:08 AM, the surveyor observed Resident #50 seated in a wheelchair, eating breakfast. The oxygen concentrator was running. The nasal cannula was observed on the bed rail. The oxygen tubing was observed on the floor. On 11/15/2021 at 8:20 AM, the surveyor observed Resident #50 in bed resting. The oxygen was running at two liters via nasal cannula. The surveyor observed that the oxygen tubing was not labeled or dated. On 11/15/21 at 11:45 AM, the surveyor observed Resident #50 sitting in his/her wheelchair leaning forward. The resident reported feeling lousy and wanted to go back to bed. The surveyor observed that the oxygen tubing was not labled or dated and the nasal cannula was observed placed on the oxygen concentrator.The surveyor further observed that there was no bag attached to the oxygen concentrator machine to store the nasal cannula. On 11/17/21 at 12:05 PM, the surveyor shared the above observations with the Director of Nursing (DON) and inquired about a policy for respiratory care treatment. The DON told the surveyor she would look for the policy. The DON also stated, It was the facility's practice to store the nasal cannula in a plastic bag when not in use. There was no plastic bag hung on the concentrator machine or in the room to store the nasal cannula when not in use during observations on the following dates: 11/09/2021, 11/10/2021,11/15/2021 and 11/16/2021. On 11/18/2021 the facility was asked to provide any in-services and further information regarding Oxygen therapy. No further information was provided during the conference meeting on 11/19/2021. The facility policy titled, Oxygen Administration revised October 2021, indicated that the purpose of this procedure is to provide guidelines for safe oxygen administration. The procedure contained 17 steps that staff were to follow with oxygen administration. Steps 8 of the procedure indicated the following: Be sure there is water in the humidifying bottle if needed and that the water level is high enough that the water bubbles as oxygen flows through. Steps 10 of the procedure read, Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Steps 11 Periodically re-check water level in humidifying jar, change tubing and supplies weekly. The Oxygen Administration Policy and Procedure did not include how the oxygen supplies would be stored when not in use. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility staff failed to: a) consistently follow a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) ensure that a resident's hearing aid used to facilitate communication was applied as ordered by the physician, and c.) accurately following a Physician's Order (PO) to hold a medication ([MEDICATION(S)]) according to blood pressure results. This deficient practice was identified for three of 25 resident's, (Resident #27, #50, and #93) reviewed for professional standards of nursing practice. 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. 1. According to the facility Admission Record, Resident #27 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 08/11/2021, revealed that the resident had impaired cognition and needed assistance with all activities of daily living (ADLs). The MDS indicated the resident was at risk for falls. Review of the Progress Notes revealed that Resident #27 sustained a fall at the facility on 09/12/2021. Review of the November 2021 Physician Order Sheet (POS) included a PO dated 09/01/2021 for Resident #27 to have a hip protector on at all times. The hip protector was to be removed during hygiene and checked for skin integrity. Review of the November 2021 Treatment Administration Record (TAR) confirmed the order and was plotted to be checked by all three shifts (7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM). During a tour of the 200 Unit on 11/10/2021 at 9:00 AM, the surveyor observed Resident #27 in bed. The resident attempted to get out of the bed unassisted with his/her feet on the floor mat. The surveyor alerted the staff who went in and assisted Resident #27 back to bed. On 11/10/2021 at 12:27 PM, the surveyor observed Resident #27 in bed. Resident #27 removed the bed covers and was calling for help. The surveyor observed that Resident #27 did not have the hip protector on. On 11/15/2021 at 8:51 AM, the surveyor observed the resident in bed, positioned on the left side, calling out for help, and no hip protector was in place. On 11/15/2021 at 10:07 AM, the surveyor observed Resident #27 in bed partly covered with blankets, the Certified Nursing Assistant (CNA) was at bedside and was assisting the resident with the breakfast meal. Resident #27 did not have a hip protector on. At that time the surveyor interviewed the CNA who stated that Resident #27 was totally dependent on staff for all care. The surveyor returned to the resident's room at 12:27 PM, and observed Resident #27 in bed dressed for the day. The surveyor inquired about the hip protector. The CNA went to the resident's room with the surveyor and verified that Resident #27 did not have a hip protector on. The CNA accompanied the surveyor to the linen room and showed the surveyor a bin with several hip protectors available for use. The CNA told the surveyor all residents on fall precautions were to have hip protectors on. An interview with the nurse at 11:37 AM, revealed that the CNAs were responsible to apply the hip protectors and the nurses would signed the TAR. The nurse acknowledged that she did not verify that the hip protector had been on before signing the TAR. The surveyor requested a copy of the 11/2021 TAR for review. Review of the TAR indicated that on the following dates, 11/09, 11/10, 11/15 and 11/16, the nurses had signed that the hip protector was on despite the surveyor observation and staff verification with that the hip protector was not on the resident. 2) On 11/10/2021 at 9:08 AM, the surveyor observed Resident #50 seated in his/her wheelchair eating breakfast, Resident #50 did not have his/her hearing aids on. According to the facility Admission Record, Resident #50 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #50's Physician Order Sheet (POS) dated 11/2021 reflected a PO dated 07/31/2021 for bilateral hearing aid to be applied every morning and evening shift. The order also indicated to remove bilateral hearing aids at bedtime. On 11/15/2021 at 11:45 AM, the surveyor observed the resident resting in bed and the resident's hearing aids were not on. The surveyor interviewed the resident's CNA who stated that Resident #50 was alert and could communicate his/her needs. On 11/17/2021 at 09:17 AM the surveyor observed Resident #50 sitting in the chair eating breakfast and the hearing aids were not on. On 11/17/2021 at 11:20 AM, the surveyor conducted an interview with the resident's representative who stated that the resident was very alert and able to communicate. The family member stated that he/she was very involved with the care and the resident required hearing aids on to be able to communicate. The resident representative expressed concerns over the staffs failure to ensure that the hearing aids were on. The resident representative indicated that during visits, the staff had to be reminded to apply the hearing aids in the morning. On 11/17/2021 at 11:56 AM, the surveyor again went to the room and observed the resident did not have his/her hearing aids in place. The surveyor interviewed the resident's primary nurse at 12:57 PM who stated that the hearing aids were applied when the resident was out of his/her room. The surveyor reviewed the November 2021 POS and the resident's PO for the hearing aides with the nurse and the order read, Apply hearing aid in the morning and removed at HS [Hour of sleep ]. The nurse did not have any comment. During a conference meeting on 11/18/2021, the facility was made aware of the above concerns. During a conference meeting on 11/19/2021 at 11:30 AM, the Director of Nursing (DON) indicated that staff should ensure that the hearing aids were in place before signing the TAR. 3. On 11/10/21 at 10:28 AM, the surveyor observed Resident #93 sitting in a chair in the hallway with a walker nearby. The surveyor attempted to interview the resident, but the resident was unable to understand the surveyor and spoke another language. The surveyor reviewed the medical record for Resident #93. A review of the resident's Transfer/Discharge Report revealed that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/21/21, reflected that the resident had a brief interview for mental status (BIMS) score of 12 out of 15, indicating that the resident had an intact cognition. A review of the October and November 2021 electronic Medication Administration Record (EMAR) for Resident #93 reflected the physician's order (PO) dated 10/14/21 for [MEDICATION(S)] (a medication used to treat high blood pressure) 0.2 milligrams, give one tablet by mouth every eight (8) hours for [CONDITION(S)]. Hold for systolic blood Pressure (SBP) (the maximum or top number of the blood pressure measurement) less than 160. In addition, the EMAR reflected the administration of the [MEDICATION(S)] on the following dates and times with the corresponding SBP results that were less than 160: on 10/17/21 at 2:00 PM for a SBP of 138. on 10/19/21 at 10 PM for a SBP of 134. on 10/20/21 at 2 PM for a SBP of 148. on 10/20/21 at 10 PM for a SBP of 118. on 10/29/21 at 2 PM for a SBP of 138. on 10/30/21 at 2 PM for a SBP of 140. on 11/7/21 at 10 PM for a SBP of 144. on 11/8/21 at 10 PM for a SBP of 132. on 11/10/21 at 2 PM for a SBP of 128. on 11/12/21 at 10 PM for a SBP of 145. On 11/16/21 at 8:49 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who reviewed the resident's EMAR and verified that a check mark indicated that the medication was administered. The UM/LPN added that if a medication was not administered there would be a code number documented on the EMAR to indicate that the medication was held and thought there may also be a progress note. Another review of the resident's EMAR revealed that all the dates listed above had a check mark and there was no code numbers entered that corresponded to the medication being held. A review of the electronic progress notes (EPN) on the above dates and times revealed that there was no EPN indicating that the [MEDICATION(S)] was held. On 11/15/21 at 11:26 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the resident spoke some English at times but was confused. The CNA added that there had been times that the resident would get upset and would not speak any English and would only speak in another language. The CNA added that there was several staff members that spoke the same language as the resident. On 11/15/21 at 12:46 PM, the surveyor interviewed the Housekeeper (HK) who stated that she spoke the same language as Resident #93 and was called at times to interpret when the resident became upset. The HK explained that the resident forgets why they had to come to the facility and that was what was causing distress. The HK stated that the resident does understand some English and can make needs known to the staff but speaks in another language. On 11/16/21 at 11:29 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who verified her initials on the EMAR for the administration of [MEDICATION(S)] on 10/19 at 10 PM, 10/20 at 10 PM and 11/10 at 2 PM listed above. The LPN stated that she thought that she had not administered the medication. The LPN added that the computer system was difficult to strike out or change that the medication was not administered. The LPN stated that she would have to review and was unable to speak to the EMAR documentation of the [MEDICATION(S)] being administered. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/16/21 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses were able to document in the electronic system if a medication was held or there was a change in a PO. The DON added that she would have to review the resident's EMAR for the [MEDICATION(S)] administration. On 11/17/21 at 8:39 AM, the surveyor, in the presence of the survey team, interviewed the physician (MD) who stated that he was very familiar with the resident and stated that the resident had fluctuating blood pressures (BP) and was asked to speak with the survey team. The MD added that the nurses frequently called him about the resident's BP and has instructed the nurses to administer the [MEDICATION(S)] even if the SBP was less than 160. The MD added that the resident was clinically assessed and had no concern with the [MEDICATION(S)] administration. The MD was unable to verify the specific dates or times that he gave permission for the [MEDICATION(S)] to be administered for a SBP less than 160. The MD also acknowledged that when the nurses called him, and he gave permission there should have been documentation in the resident's progress notes to indicate the discussion. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, there was no documentation of a change in the PO for [MEDICATION(S)] on the above dates and times to allow the [MEDICATION(S)] to be administered when the SBP was less than 160. On 11/17/21 at 9:30 AM, the surveyor interviewed the DON who stated that after reviewing the resident's EMAR for the [MEDICATION(S)] administration, she completed a Quality Assurance review with the nurses. The DON added that the nurses frequently called the physician but had not documented in the chart. On 11/17/21 at 12:20 PM, the surveyor interviewed the Registered Nurse (RN) who stated that she was familiar with Resident #93 because she administered medications to the resident. The RN added that she had to take a BP prior to administering the [MEDICATION(S)] and if the SBP was less than 160 then the medication should be held and documented in the EMAR. The RN acknowledged that she had signed the EMAR on 10/17 at 2 PM and 10/29 at 2 PM for the administration of [MEDICATION(S)] when the SBP was less than 160. The RN stated that she had made a mistake. The RN added that the physician was aware of the resident's fluctuating BP. On 11/18/21 at 1:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone. The CP acknowledged that the nurses were to follow a PO accordingly and to follow a hold order as instructed. The CP stated that the nurses frequently called the MD and would take a PO over the phone. The CP acknowledged that a PO would have had to be documented. The CP stated that the EMAR system allowed for documentation of medications being held and the nurses could also document in the EPN if there was a problem with medication administration. The CP also stated that he does review the EMAR for accurate medication administration according to a hold order. The CP added that if the documentation indicated that the medication was inaccurately being administered then he would notify nursing. On 11/19/21 at 12:01 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Regional Clinical Nurse, and a DON from a sister facility. There was no further information provided regarding not following the standard of practice for the administration of [MEDICATION(S)] for the above listed dates and times. A review of the facility policy dated as revised April 2021 for Administering Medications provided by the DON reflected that medications were to be administered as prescribed. The policy also reflected that if vital signs (important medical signs that indicate the status of the body's life sustaining functions such as BP) were necessary then the vital signs were to be checked/verified prior to administering medications. In addition, the policy reflected that if a medication was withheld, refused or given at another time other than the scheduled time then the electronic health record would be appropriately documented. NJAC 8:39- 11.2(b), 29.2(d)

Based on observation, interview, review of medical records and review of facility documentation, it was determined the facility failed to document on the Care Plan (CP) a residents use and refusal of a hearing aid. This deficient practice was identified for 1 of 25 residents, (Resident #25) reviewed for CP. On 11/15/21 at 9:16 AM, the surveyor observed Resident #25 lying in bed, eyes closed. The resident did not respond to the surveyors greeting. On 11/16/21 at 9:59 AM, the surveyor observed the Certified Nursing Aide (CNA) enter the resident's room. The CNA spoke loudly to the resident. On 11/16/21 at 12:38 PM, the surveyor observed Resident #25 in their room sitting in a wheelchair. The surveyor did not observe any hearing aids in either of the resident's ears. On 11/17/21 at 11:55 AM, the surveyor observed the resident in bed and did not observe any hearing aids in either ear. On 11/17/21 at 12:40 PM, the surveyor observed the resident in bed with lunch next to the bed. The surveyor observed no hearing aids in either ear. On 11/18/21 at 8:42 AM, the surveyor observed the resident in bed with breakfast next to the bed. The surveyor observed no hearing aids in either ear. Resident #25 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the, Nursing Admission Screening/History, dated 8/27/21, revealed Resident #25 had a right hearing aid in use. Review of the Admission Minimum Data Set (MDS - an assessment tool), dated 7/16/21, revealed Section B, B0300 - that Resident #25 used a hearing aid or other hearing appliance; and that the resident required extensive assistance of a staff member for dressing and personal hygiene. The most recent Quarterly MDS, dated [DATE], revealed Section B, B0300 - that Resident #25 used a hearing aid or other hearing appliance; that the resident scored an 08 Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment; and that the resident required extensive assistance of a staff member for dressing and personal hygiene. Review of the facility provided 24 hour Report Sub-Acute Unit 1st Floor, revealed Resident #25's clinical needs which did not include hearing aids. Review of Resident #25's facility provided, Personal Effects Inventory, effective 7/10/21, revealed the resident had a hearing aid for Rt (right) ear in box. Review of Resident #25's facility provided, Personal Effects Inventory, effective 8/3/21, revealed the resident had a left hearing aid with batteries. Review of Resident #25's CP revealed a focus area of hard of hearing initiated 7/20/21 and revised on 7/20/21 with four interventions listed as follows: 1) speaker to adjust tone of voice, 2) speaker to face resident when speaking, 3) speaker to repeat as needed, and 4) speaker to talk to resident in quiet setting. Review of Resident #25's current CP provided by the facility, revealed a focus area of hard of hearing initiated 8/27/21 (after readmission to the facility) with interventions that included but were not limited to hearing aide to right ear initiated on 11/18/21. On 11/16/21 at 9:59 AM, the CNA caring for Resident #25 stated that the resident was hard of hearing so the staff would speak loudly. The CNA further stated the resident had glasses but she was not aware of any hearing aids. On 11/16/21 at 12:38 PM, Resident #25 stated she/he had hearing aids but was not sure where they were or why they were not at the facility. The CNA entered the room and was interviewed at that time. The CNA stated that if a resident had hearing aids, the nurses would keep them in the medication cart and put them in the residents ears. On 11/17/21 at 9:07 AM, Resident #25's family member was interviewed via telephone and stated that the resident had a right hearing aid at the facility but the staff never applied the hearing aid. The family member further stated that they never see the resident wearing the hearing aid but never remembered to ask staff why she/he was not wearing it. On 11/17/21 at 10:18 AM, the Registered Nurse (RN) caring for the resident stated that if a resident was able to put the hearing aids in themselves, they would keep their own hearing aids in the bedside table. The RN stated if the resident was unable, the nurses would keep the hearing aid in the medication cart and get an order to apply them. The RN stated the nurse would sign for the hearing aid on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21 at 10:24 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) of the resident's unit, stated alert residents keep their own hearing aids but residents who were not alert would have the hearing aids locked in the medication cart. The LPN/UM stated there was no log or accountability sheet kept for hearing aids and the hearing aids would not be documented unless the staff were to put them in the resident's ear. The LPN/UM stated if a resident was hard of hearing, the family would have to request an appointment to have that checked and that he was unaware of any resident on the unit with hearing aids. On 11/18/21 at 8:46 AM, the LPN MDS nurse stated she documented on the 11/4/21 MDS and would have obtained MDS information from the residents if able, the staff, the resident medical record and the Social Worker. The LPN MDS nurse stated Resident #25 was hard of hearing and that she was able to interview the resident. LPN MDS nurse documented the resident use of a hearing aid. On 11/18/21 at 8:49 AM, a second MDS nurse stated she documented on the admission MDS and that she would have obtained the information from the hospital records, staff and resident. The second MDS nurse stated Resident #25 had a right hearing aid. On 11/18/21 at 8:51 AM, the LPN MDS nurse stated the hearing aid should have triggered and been added to the CP. She further stated it would be the responsibility of the nurse, unit manager and MDS to enter the hearing aid on the CP. The LPN MDS nurse reviewed the initial CP and the most recent CP in the presence of the second MDS nurse and the surveyor and acknowledged that the hearing aids were never entered on the CP. The LPN MDS nurse added the intervention of the hearing aid at the time the surveyor brought it to her attention. On 11/18/21 at 8:55 AM, the LPN/UM stated the nursing staff should refer to the 24 hour report, the CP, and the MDS to know what type of care a resident needed. The LPN/UM, in the presence of the surveyor, reviewed Resident #25's admission and stated the staff should be encouraging the use of the hearing aid instead of just speaking loudly to the resident. The LPN/UM acknowledged the 24 hour report should have had the hearing aids on the clinical information but did not. The LPN/UM and the surveyor went to Resident #25's room to locate the hearing aids but the LPN/UM was unable to locate them. On 11/18/21 at 9:04 AM, the LPN/UM and surveyor approached the second RN who was caring for Resident #25 that day. The second RN showed the LPN/UM and surveyor the resident's hearing aids locked in the medication cart. The second RN stated the last time she tried to apply the resident's hearing aid was a few months ago and eventually the resident removed it. The second RN stated she had not tried again to put the hearing aid in. The second RN stated she was not sure if she had documented the resident refused the hearing aid at that time and stated she might have told someone but was unsure. The second RN stated the hearing aid should have been on the CP. On 11/19/21 at 11:19 AM, in the presence of the survey team, the facility regional nurse stated that the resident had a habit of taking out her/his hearing aids frequently. The facility was unable to provide documentation of the refusals by the resident. The surveyor asked if the residents refusal of the hearing aid should have been documented on the care plan? The Director of Nursing (DON) stated yes. On 11/19/21 at 11:23 AM, the Licensed Nursing Home Administrator stated that the hearing aides should have been documented on the care plan. Review of the facility provided, Care Plan-Baseline, policy revised 12/16, revealed the following: a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility provided, Care Plans, Comprehensive Person-Centered, revised 12/16, included but was not limited to the following. A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The interdisciplinary team, resident and family or legal representative, develops and implements a comprehensive, person-centered care plan. The care plan interventions are derived from a thorough analysis of the information gathered in the comprehensive assessment. The care planning process will facilitate resident and/or representative involvement; and include an assessment of the resident's strengths and needs. The comprehensive person-centered care plan will (included but was not limited to) the following: describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors; reflect the resident's expressed wishes regarding care and goals; identify the professional services that are responsible for each element of care; and aid in preventing or reducing decline in the resident's function level. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments are ongoing and care plans are revised as information about the residents and the residents' conditions change. The resident has the right to refuse to participate in medical and nursing treatments. Such refusals will be documents in the resident's clinical record in accordance with established policies. NJAC 8:39-11.2(d),(e)(1),(f),(g),

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the visiting Physician adhered to the facility policy and procedures put in place to prevent infection spread. This deficient practice was identified for 1 of 1 Physician visiting the facility as evidenced by the following: On 2/12/21 at 9:45 AM, the surveyors observed a temporary movable separation barrier at the end of the hallway. The surveyor noted the temporary barrier with signage that read, STOP Report to Nurse Before Entering. The surveyors were informed by the Facility Administrator that behind the barrier was the resident COVID unit. The Administrator added that all entry and exit from the COVID unit is accessed through a separate outside door by all staff. The separate outer door leads directly in and out of the COVID unit. The Administrator added that no one accesses the COVID unit through the temporary barrier separation. On 2/12/21 at 10:00 AM, the surveyor observed the facility Physician walk through the 14-day quarantine Observation Unit, move the temporary barrier separation, and access the COVID unit. On 2/12/21 at 10:15 AM, the surveyor observed the facility Physician leave the COVID unit via the barrier separation and stand at the Observation Nursing Station. On 2/12/21 at 10:30 AM, the surveyor interviewed the Infection Control Preventionist (Registered Nurse) (ICP), who stated that the Physician should not have accessed the COVID unit via the separation barrier. The ICP informed the surveyor that the Physician should access the COVID unit only through the outside door access. On 2/12/21 at 10:45 AM, the surveyor interviewed the Physician, who was wearing an N95 mask with a surgical mask on top. The Physician stated that he did access the COVID unit through the separation barrier to see a resident in the COVID Unit after doffing full PPE (Protective gown, gloves, N95, surgical mask, and face shield). The Physician could not explain why he accessed the COVID unit via the restricted barrier wall and then left the COVID area via the Observation Unit. The Physician informed the surveyor that he was exiting the building. On 2/12/21 at 1:30 PM, the surveyor received a COVID-19 Timeline dated 12/10/20, which documented information regarding the procedure for the COVID Unit Barrier has yellow stop sign; Designated entrance. No employees may cross the barrier! The facility supplied no additional information. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review of documentation provided by the facility, it was determined that the facility failed to implement an identified safety intervention by transferring the resident with one person instead of a two person assistance with the use of a sliding board (a piece of equipment that is used if a person cannot use their legs to complete a transfer between surfaces or if a standing transfer was not safe to perform. The board allows for a bridge between two surfaces that a person could slide across to transfer between them) when performing a transfer into bed for the resident. The resident sustained [REDACTED]. The resident also received increased pain medication. This deficient practice was noted for 1 of 6 residents (Resident #36) reviewed for falls and was evidenced by the following: On 11/17/19 at 10:10 AM, the surveyor observed Resident #36 in bed watching television. The surveyor interviewed the resident who informed the surveyor of an incident that occurred on the evening of 8/5/19, when the resident had been transferred to the bed with only one Certified Nursing Assistant (CNA #1) and without a sliding board. Resident #36 informed the surveyor that the incident occurred two days before a planned discharge home. On 11/19/19 at 10:32 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM) who gave her account of the 8/5/19 incident based on her interview with the resident and the subsequent investigation. The RNUM spoke to Resident #36 who stated that CNA #1 was getting the resident up from the wheelchair to put in bed and the resident's leg got caught under the bed. The RNUM added that the resident said that he/she screamed in pain. The RNUM further stated that the physician was notified and an x-ray was ordered that revealed a [MEDICAL CONDITION]. CNA #1 was taken off Resident #36's assignment indefinitely and was counseled and re-educated regarding safe transfers. The surveyor reviewed Resident #36's medical record and noted the following: According to the Admission Intake Form, Resident #36 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a knee immobilizer to the right knee. The resident was only able to put toe touch weight bearing to the right leg and was to progress to partial weight bearing with Physical Therapy. The [DIAGNOSES REDACTED]. A comminuted fracture is when the bone breaks into several fragments. The Admission Minimum Data Set (MDS) an assessment tool dated 6/18/19, indicated that the facility performed a Brief Interview for Mental Status (BIMS) for Resident #36. The resident scored 15 out of 15 which indicated the resident was cognitively intact. The facility also indicated that Resident #36 required two-person extensive assistance with all transfers from bed, wheelchair, chair and standing position. According to the Quarterly MDS dated [DATE], the facility performed a BIMS and Resident #36 scored 15 out of 15, which indicated that the resident remained cognitively intact. The (MONTH) 2019 Physician order [REDACTED]. The Comprehensive Care Plan (CP) initiated on 6/11/19 identified the resident as being at risk for falls . The CP was revised on 6/12/19 to include the intervention to use a sliding board with two person assist for all transfers. The care plan was revised on 7/4/19, 7/19/19, 8/11/19, 9/1/19, 10/11/19 and 11/11/19. Each time the care plan was revised the intervention for a sliding board with two persons assist for all transfers remained. According to the Report of Consultation dated 7/25/19, Resident #36 was seen by the Orthopedist who recommended to discontinue the immobilizer, continue physical therapy and the resident could put full weight bearing on the right leg. According to the Physical Therapy Treatment Encounter Note dated 8/5/19 at 4:41 PM, the afternoon prior to the incident, Resident #36 was standing with a rolling walker with the assistance of two persons. The Incident/Accident Report dated 8/5/19 revealed that CNA #1 reported to the RN (RN #1) on duty the evening of 8/5/19, that Resident #36 was complaining of pain. RN #1 documented that she immediately went to assess the resident. RN #1 documented that she assessed the right leg and there was no bleeding, no bruise and the resident was able to wiggle toes without difficulty. At that time, Resident #36 informed RN #1 that his/her right leg was injured during the transfer. The facility's investigation of Resident #36's injury included statements obtained from staff members. A statement from CNA #2 dated 8/6/19 documented that CNA #2 reported that CNA #1 requested her help in transferring Resident #36 after CNA #1 had already tried doing the transfer by herself. CNA #2 reported that the resident was complaining that his/her ankle hurt and requested that the nurse come in to look at it. A statement from RNUM dated 8/6/19 documented that Resident #36 reported to her that CNA #1 picked the resident up from the wheelchair to put the resident to bed and the resident's foot got caught under the bed. The RNUM documented that Resident #36 stated that he/she started screaming in pain. The resident stated he/she received pain medication at that time. A statement from the Licensed Practical Nurse (LPN #1) dated 8/6/19 documented that during morning rounds, Resident #36 complained of right lower leg pain and informed LPN #1 what occurred the evening before. Resident #36 stated that while he/she was being transferred his/ her ankle was caught under the bed and at that time the resident stated he/she seemed to hear a snap. A statement from CNA #1 dated 8/9/19 reported that CNA #1 documented that Resident #36 wanted to go to bed. CNA #1 documented that she looked at her census, a 24 Hour Report form to provide the staff with care instructions for each resident. This Report indicated Resident #36 needed a sliding board and two person assistance for transfers. CNA #1 documented that she looked in the closet and looked behind the resident's wheelchair and didn't see a board. She documented that the resident told her that she was going to need another person. CNA #1 asked CNA #2 for assistance and they both reached under the resident's arms and grabbed the back of the resident's pants to transfer the resident from the wheelchair into bed. CNA #1 also documented that the resident was okay, no yelling or complaining until a half hour after the resident was put to bed. CNA #1 documented that she told the nurse about the resident's pain. The x-ray report dated 8/6/19 contained under the Findings section the following; Acute comminuted and minimally displaced [MEDICAL CONDITION]. Under the Impression section of the report indicated the following; Fracture Mid Tibial Shaft ([MEDICAL CONDITION] of the lower leg bone). A physician's orders [REDACTED]. On 8/7/19 the physician ordered [MEDICATION NAME] 10 mg to be given to the resident one half hour prior therapy sessions for pain management. A Progress Note dated 8/6/19 at 2:09 PM indicated that the resident's physician informed the nurse to make the resident non-weight bearing to the right leg. Non-weight bearing means no weight can be placed on the affected leg, which means it's the most restrictive of all weight-bearing limitations. The (MONTH) 2019 Medication Administration Record [REDACTED]. The resident also had [MEDICATION NAME] 5 mg to be given every six hours as needed for severe pain and Tylenol 325 mg two tablets every four hours for mild pain. The resident complained of pain levels from four to nine out of a pain scale zero to 10 from 8/5/19 - 8/31/19. Pain scales are commonly used to rate a persons pain on a scale of 0 to 10. Zero meaning no pain and 10 being the worst possible pain. Specific pain mediation would be administered based on the persons expression numerically, which the numbers would then be grouped into mild to severe pain. The person would express numerically the level of pain they were experiencing. Mild pain would be expressed numerically as one to three, moderate pain could be expressed numerically from four to six and severe pain could be expressed numerically from seven to 10. The resident received [MEDICATION NAME] 5 mg 13 times from 8/5/19 - 8/20/19 for severe pain and Tylenol 325 mg two tablets 17 times from 8/6/19 - 8/30/19 for moderate pain. For the period immediately preceding the fracture, 8/1/19 to 8/4/19 the resident received only one dose of the as needed [MEDICATION NAME] and one dose of the as needed Tylenol. Additionally the on 8/7/19 the physician had ordered the resident be given [MEDICATION NAME] 10 mg one half hour before Physical Therapy sessions. On 11/20/19 at 11:42 AM, the surveyor interviewed the Physical Therapist (PT) who stated that Resident #36 had been using the sliding board with two persons assisting with transfers since admission because the resident had decreased mobility of the right lower extremity and both ankles and range of motion to the ankles was limited. On 11/20/19 at 12:05 PM, the surveyor discussed with the Administrator and Director of Nursing (DON) the incident that occurred on 8/5/19. The surveyor requested contact information for CNA #1, CNA #2, LPN #1 and RN #1 who wrote statements for the investigation. On 11/21/19 at 9:49 AM, the DON provided the surveyor with the contact information that the surveyor requested and the DON also provided a copy of the Personnel Warning Notice given to CNA #1 for failing to use proper transferring equipment (sliding board), as well as the failure to notify the supervisor of missing equipment which resulted in an injury to Resident #36. Attached to the Personnel Warning Notice was a statement from CNA #1, obtained by the RN Supervisor who counseled CNA #1 by telephone on 8/6/19 that revealed CNA #1 stated that she was about to transfer Resident #36 and she couldn't find the sliding board anywhere in the room. She realized the resident was so tiny and maybe she could do it herself. CNA #1 further stated that when she tried to transfer the resident, the resident started to complain of pain of the right leg. She put the resident back in the wheelchair and called for CNA #2 to help her. On 11/21/19 the following interviews were conducted by telephone and in the presence of the survey team: At 9:47 AM, the surveyor interviewed CNA #1 who stated that Resident #36 wanted to go to bed and that she thought she could transfer the resident by herself, but the resident insisted that she get another CN[NAME] She stated that the resident told her that she needed a sliding board with two people assisting, but she was not able to find a sliding board. CNA #1 stated that she did not have the resident's care plan with her and that she should have gone down to the therapy department to get a sliding board. CNA #1 stated that she started to put her arms around the resident to move the resident, however the resident stopped her and insisted that she get help. CNA #1 stated that she thought she could transfer resident by herself because the resident was so small. CNA #1 went to the hallway to ask CNA #2 to help transfer the resident to the bed. At 9:56 AM, the surveyor interviewed CNA #2 who stated she was walking down the hall and CNA #1 was in the hall and asked, Can you help me transfer the resident, I just tried to do it myself and I think I hurt (the resident's) ankle. When CNA #2 got into the room the resident was in a wheelchair next to the bed. We put our arms under the resident's arms and grabbed the pants and lifted the resident into bed. Once in bed the resident complained of pain in his/her ankle and asked that we notify the nurse. CNA #2 stated that she was not aware of any special equipment needed to transfer the resident. At 10:09 AM, the surveyor interviewed RN #1 who worked the 7 PM to 7 AM shift on the evening of 8/5/19. RN #1 stated that CNA #1 told her that Resident #36 was complaining of pain. RN #1 assessed the resident and did not see any bleeding or bruising and the resident was able to move their toes. She gave the resident pain medication. RN #1 stated the resident told her that when CNA #1 transferred him/her into bed the resident hurt his/her leg. At 10:30 AM, the surveyor interviewed LPN #1 that was assigned to Resident #36 the morning of 8/6/19. LPN #1 stated that she was doing her rounds and Resident #36 complained of pain and was crying. The resident told her that when the resident was put to bed the night before, the resident's ankle got caught under the bed and it got twisted. The resident stated that he/she heard a snap. LPN #1 was aware of the care plan that included the intervention to use a sliding board with two person assist for all transfers. A review of the facility's policy titled Safe Handling Lifting and Moving Residents Safely under Potential risk factors that may lead to injuries included: Lifting alone. Under Improper lifting and moving increases the risk for included: Broken bones. Under Preventative measure to incorporate into your work practices will minimize your risk for injury included: Follow the residents transfer status, have a census, get report from the nurse, discuss the transfer/lift with coworkers, agree on the count. Under Transfer board included: Position the sliding board under the resident's thigh and resting on the bed, have the resident place their hands on their chair and slide board to move across the board to the other surface. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to properly store, label and dispose of medications. This deficient practice was noted in 4 of 8 medication carts and 1 of 2 medication room refrigerators inspected and was evidenced by the following: On [DATE] at 11:02 AM, the surveyor inspected the Subacute Unit medication cart #4 in presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an open vial of Admelog Insulin and an open Admelog insulin pen that were not dated when opened. The surveyor interviewed LPN #1 who stated that the Admelog pen and vial should have been dated when opened. On [DATE] at 11:05 AM, the surveyor inspected the Subacute medication room refrigerator in the presence of a Registered Nurse (RN#1). The surveyor observed two opened vials of Influenza Vaccine that were not dated when opened. The surveyor interviewed RN #1 who stated the Influenza vaccine should have been dated when opened. On [DATE] at 11:10 AM, the surveyor inspected the Subacute Unit medication cart #2 in the presence of LPN #2. The surveyor observed one unopened bottle of [MEDICATION NAME] eye drops, one unopened Basaglar Insulin pen and one unopened Humalog Insulin pen that were not dated and were stored in the medication cart and not stored in the refrigerator. The surveyor also observed one Basaglar Insulin pen without a resident's name on it and one opened Basaglar insulin pen with an expiration date of [DATE] written on it. The surveyor interviewed LPN #2, who stated that an expired Basaglar insulin pen should have been removed from stock and discarded. Also that any medication without a resident's name should have been removed from active medication stock. LPN #2 also stated that the unopened bottle of [MEDICATION NAME], Basaglar Insulin pen and Humalog Insulin pen should have been stored in the refrigerator until opened. On [DATE] at 11:15 AM, the surveyor inspected the Subacute Unit medication cart #3 in the presence of RN #2. The surveyor observed an unopened Basaglar Insulin pen and an unopened Humalog Insulin pen that was not dated and and stored in the medication cart instead of the refrigerator. The surveyor interviewed RN #2, who stated that the unopened Basaglar and Humalog Insulin pens should have been stored in the refrigerator until opened. The surveyor also observed an opened Basaglar Insulin pen and an opened Admelog Insulin pen that were not labeled with residents names. RN #2 stated that the Basaglar and Admelog Insulin pens without a resident's name should have been removed from active medications. On [DATE] at 12:00 PM, the surveyor inspected the Pavilion Unit medication cart in the presence of LPN #3. The surveyor observed an opened bottle of UTI-STAT supplement that had an open date of [DATE] and was expired. The surveyor interviewed LPN #3, who stated that UTI-Stat supplement was expired and should have been removed from stock. A review of Manufacturer's Specifications for the above medication revealed the following: 1. Admelog Insulin vial once opened had a 28-day expiration date. 2. Admelog Insulin pen once opened had a 28-day expiration date. 3. Influenza Vaccine vial once opened had a 28-day expiration date. 4. Humalog Insulin pen once opened had a 28-day expiration date. 5. Basaglar Insulin pen once opened had a 28-day expiration date. 6. [MEDICATION NAME] eye drops once opened had a 42-day expiration date. 7. Unopened Basaglar Insulin pen should be stored in the refrigerator. 8. Unopened Humalog Insulin pen should be stored in the refrigerator. 9. Unopened [MEDICATION NAME] eye drops should be stored in the refrigerator. 10. UTI-Stat bottle once opened had a 90-day expiration date. On [DATE] at 10:40 AM, the facility Administrator told the surveyor that they have no facility policy for dating and labeling of medication. The Administrator stated that each medication cart contained information regarding insulin dating and storage. NJAC: 8:,[DATE].4 (a) (h) and (d)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) verification that recently hired non-certified Nursing Aides were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program, b.) validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, and c.) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified Nursing Aides. This deficient practice was identified for 3 of 3 non-certified NA's hired within the last 8 months (NA #1, #2, #3), who worked on 3 of 3 nursing units (First Floor, Second Floor and the Pavilion Unit) and were scheduled to work on an independent resident assignment during 3 of 3 shifts (day, evening and night shift). On 01/08/19 and 01/09/19, the surveyor reviewed the employee files for the three newly hired NA employees, and reviewed their orientation schedules, Timecard Reports, the unit assignment sheets and other facility documents. The documents revealed that there was no evidence the 3 of 3 Nursing Aides had completed Module 1 in their CNA Training Program(s) before they were given an independent resident assignment. NA #1 worked 18 shifts with an independent resident assignment. NA #2 worked 26 shifts on 3 of 3 resident care units with an independent resident assignment, and NA #3 worked 13 shifts with an independent resident assignment without evidence of enrollment in a CNA Training Program and and in addition, worked an additional shift on 01/08/19 without evidence of completion of Module 1 in the CNA Training Program. Interviews with facility staff reflected that certified and licensed staff responsible for directly overseeing resident care were not aware of the accurate certification status of the NA working on their shift, and there was no delineation between assignments for NA's and CNA's. According to interviews with facility Administration, NA's had an employee identification badge that inaccurately reflected a status of CNA, and the practices of the facility were that NA's were allowed to have an independent resident assignment for up to 90 days before being enrolled in a CNA Training Program. The Administration was unable to provide evidence of a job description for NA's, and a policy related to the staffing of NA's on resident care units. The facility's failure to ensure that non-certified Nurse Aide's were currently enrolled in a New Jersey (NJ) state-approved CNA Training Program prior to assigning them nurse aide responsibilities, and failure to ensure NA's had completed Module 1 before independently assigning them to care for residents, posed a serious and immediate threat to the safety and well-being of all residents in the facility. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/14/18 at 07:02 AM when NA #1 had an independent resident assignment and was identified by the survey team on 01/09/19 at 12:00 PM, and corrected on 01/09/19 at 03:01 PM, based on an acceptable Plan of Correction (POC) that was implemented by the facility and verified by the survey team. This deficient practice was evidenced by the following: On 01/02/19 at 10:53 AM, the surveyor conducted an entrance conference with the Administrator and Director of Nursing (DON) in the presence of a second surveyor. The surveyor inquired if the facility had any non-certified Nursing Aides, and the DON responded that all the nurse aides were certified. The DON then stated to the surveyors that she would confirm that. The surveyor requested a list of the NA's, if appropriate, and the CNA's with their corresponding hire dates. The list of Licensed Staff provided by the Administrator reflected that there were currently three employee names listed as CNA Trainee without a CNA certification number. NA #1 had a hire date of 11/19/18, NA #2 had a hire date of 11/30/18, and NA #3 had a hire date of 12/03/18. On 01/07/19 at 09:21 AM, the surveyor interviewed a CNA on the First Floor subacute rehab. The CNA stated that NA #1 worked mostly the 7 AM to 3 PM day shift, NA #2 worked mostly night shifts 11 PM to 7 AM, and NA #3 had worked this past weekend. The CNA stated that the NA's were all certified to her knowledge. On 01/08/19 at approximately 08:30 AM, the surveyor reviewed the CNA Daily Assignments sheet for the Subacute Shift 7:00 AM - 3:00 PM with (6 aides). The assignment sheet reflected for the First Floor, that NA #3 had an independent assignment with seven (7) residents at that time. The surveyor requested to interview NA #3. The surveyor observed on the NA #3 employee identification badge under her name, the title CNA. The surveyor inquired about her title, and the NA #3 stated that she was a Certified Nursing Aide. On the same day on 01/08/19 at 09:17 AM, a second surveyor observed NA #3 independently assisting Resident #35 with activities of daily living (ADL) and morning care, including surface-to-surface transfers, oral care and incontinence care. The surveyor also observed the employee identification badge for NA #3 to reflect CNA under her name. At approximately 10:00 AM, the surveyor interviewed NA #3 who told the surveyor she was a CNA by title. The surveyor asked NA #3 how long she had been a CNA, and she stated that she finished school on the 26th. The surveyor asked for clarification as to what month she finished school, asking if it was December 26th. The NA #3 then admitted to the surveyor that she had not graduated yet, and that she was currently enrolled in a CNA Training Program and graduation was later this month. On 01/08/19 at 10:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #35, and the six other residents under the care of the NA #3 that day. The LPN stated that NA #3 floated to different floors and that she mostly worked on the Second Floor, and not the First Floor. She stated that she believed NA #3 was certified as a CNA. The surveyor asked how one would know if a nurse aide was certified or not, and the LPN stated if they are in training, she would be assigned to an aide .you would see a slash next to their name on the resident assignment sheet. The LPN stated that because there was no slash next to the name of NA #3 with another CNA's name next to it, it meant she was out of orientation and has her own assignment. The LPN could not speak to if there was a difference in training and resident assignments for NA's and CNA's and/or how responsibilities would differ for NA's and CNA's. At 10:20 AM, the surveyor interviewed the Registered Nurse (RN) assigned to the desk. The surveyor inquired if NA #3 was a Certified Nursing Aide. The RN stated that NA #3 is certified, I believe adding that she thought NA's have to finish school first before having their own assignment. She confirmed NA #3 had her own assignment that day. The RN stated that she doesn't assign nursing assistants to residents for the day shift and that the night supervisors usually handle that. On 01/08/19 at 11:02 AM, the surveyor interviewed the CNA Trainer/CNA. The CNA Trainer who stated she was also a CNA told the surveyor that each unit had a Head CNA who would be available to assist the CNA's as needed, and they also assist in the making the resident assignments on the unit. The CNA Trainer stated that she was a last resort in making CNA staff assignments on the floor. The CNA Trainer stated NA #3 was still in class and not certified. The surveyor inquired about the process of hiring, orientation, training, and scheduling of NA's that were not yet certified. The CNA Trainer stated that the facility hired non-certified NA's, and when they are in school, we orient them for two weeks .if they are still having trouble, we re-orient them reviewing weaknesses . The CNA Trainer added, We all keep an eye, mostly me, unit managers or supervisors on the floor, and the nurse on that side. The CNA Trainer stated that the facility did not have a buddy system for NA's. She added that some reasons that the facility would keep a NA or CNA on orientation was if there were lots of complaints, not good with residents, not nice to coworkers or residents and/or if the aide did not not listen, the facility would keep that person on orientation. The CNA Trainer stated that the other girls on the floor orient them and determine if the NA or CNA needs more training or time orienting. She further stated that she and others on floor watch how care was performed to see if they are doing tasks correctly. The CNA Trainer stated that she and the Staff Educator/LPN review handwashing competencies with the nurse aides and nursing staff. At 11:21 AM, the surveyor interviewed the Head CNA on the First Floor who stated that she believed NA #3 was certified as a nurse aide. The Head CNA stated that all newly hired staff get two weeks of in-servicing and then they get put on their own, But we help everyone out; all hands on deck. The Head CNA stated that the night nurse supervisor does the CNA assignment for the next shift because it was too hectic in the morning to change assignments. The surveyor inquired if NA's get a different resident-assignment load based on competencies they had been evaluated on, and the Head CNA confirmed there was no special assignment for NA's who are not certified, they just get a full assignment like everyone else. The surveyor inquired if there was a time that an NA would not be given a resident with special care needs such as a resident who was nothing by mouth (NPO) with a gastric tube feeding (surgically placed tube through the abdominal wall into the stomach typically placed for nutritional/supplemental feedings). The Head CNA responded to the surveyor that it doesn't happen and that the NA's get an assignment like everyone else. The Head CNA confirmed that when making assignments, the special care needs of a resident was not a consideration, as all residents required a form of specialized care, and that everyone worked together. At 12:20 PM, the surveyor interviewed the Staff Educator/LPN who stated that she had been in the role as staff educator for approximately one year. The Staff Educator/LPN stated that she assisted in educating newly hired staff during their orientation period. She stated that they have a general orientation covering a comprehensive list of topics, and that newly hired staff should have a knowledge on everything on the [orientation] check list. She stated that the orientation checklist was not a competency evaluation. The Staff Educator/LPN stated that all newly hired staff get approximately 10 shifts or more, if needed. The surveyor inquired if this was the same procedure for newly hired non-certified Nursing Aides, and the Staff Educator/LPN confirmed that the hiring, orientation to the facility, and assignments did not differ between NA's and CNA's. She stated that after the 10 shifts the NA would be evaluated, and if deemed competent through the orientation period by the CNA and nurses, they would be given an independent assignment, and they know staff would be available to assist as needed. On 01/08/19, the surveyor began the process of reviewing the employee files for the three newly hired NA's, which included the following: NA #1 had a hire date of 11/19/18. A review of the Application for Employment reflected an interview date of 11/13/18 and that NA #1 was in CNA school-will finish in January and would like to start CNA work now. A review of an undated letter with a school letterhead, reflected that NA #1 will be attending our school for CNA program for a period of Two months, with a start date of 11/02/18 and an end date of 01/21/19. In the file included a financial invoice dated 10/21/18. (There was no evidence of additional correspondence with the school, a course schedule, or documented evidence in the file that NA #3 had completed Module 1 in the CNA Training Program). NA #2 had a hire date of 11/30/18. A review of the Application for Employment reflected an interview date of 11/27/18, the primary position desired was CNA, and that NA #2 goes to school Monday and Thursday from 4-9 PM.A review of an undated letter with a school letterhead, reflected that NA #2 will be attending our school for CNA program for a period of Three months, with a start date of 10/22/18 and end date of 01/21/19. In the file included a financial invoice dated 10/21/18. (There was no evidence of additional correspondence with the school, a course schedule, or documented evidence in the file that NA #3 had completed Module 1 in the CNA Training Program). NA #3 had a hire date of 12/03/18. A review of the Application for Employment reflected an interview date of 11/27/18, the primary position desired was CNA. The Application did not address the certification status of NA #3. A review of the New Hire Checklist dated 11/30/18 and signed by the Department Head on 12/04/18 reflected a handwritten comment: In CNA school, tuition-eligible. (There was no evidence of proof of enrollment in the CNA Training Program, correspondence with the school, a course schedule and/or documented evidence of completion of Module 1). On 01/08/19 at 12:44 PM, a surveyor interviewed the Human Resources (HR) Director, who stated that she was involved in the hiring process, which included the hiring of non-certified NA's. She stated that her responsibility was to make sure NA's are enrolled within 60 days of hire in a school. The HR Director added that some NA's will become employed at the facility while not in a school, and we will find a school for them. She stated that the NA's can be hired before being enrolled in school, and based on their orientation and how well they do with the residents and the resident assignments, the facility would assess if the NA was ready to enroll in a school. She stated that they are still trying to obtain proof of enrollment in the CNA Training Program for NA #3. The surveyor inquired who issued the employee identification badges with the staff titles identified, and the HR Director stated that she was responsible for that. She confirmed that the three NA's had the title CNA under their name on their employee identification badge, stating that they were hired for that title and never gave it a second thought .they were going to school to become a CNA, so they will get that title. She confirmed the 3 NA's had not yet received their certifications. At 12:55 PM, the surveyor interviewed the NA #3 a second time in the presence of the survey team. NA #3 stated that she had started school sometime in November 2018. She stated that she had interviewed with the HR Director the first day as well facility Administration and was hired for CNA. She added that she didn't have proof of enrollment at the school except for a financial receipt she gave to the Director of Nursing yesterday. She added that the facility provided her with two weeks of training both on the First and Second Floors. NA #3 added that she had had many years of experience working in homecare and that the care was very similar. On 01/08/19 at 01:24 PM, the surveyor interviewed the Director of Nursing (DON) and Administrator in the presence of the survey team. The DON stated that the facility had three non-certified Nursing Aides, and they get trained like the CNA's on the floors, adding that if they need more or request more, we give them more training. She stated that the facility had a standardized list of competencies that all CNA's and NA's do and that there was no delineation between the training and orientation practices of NA's versus CNA's. She stated that the facility had 120 days to get the NA's certified. The DON stated that she had a financial receipt from the school where NA #3 attended the CNA Training Program. At 01:44 PM, the survey team requested evidence from the Administrator and DON of any forms of verification from the school(s) and any policy and facility program(s) pertaining to the hiring, orientation, assignments for non-certified Nursing Aides. At 02:12 PM, the DON provided the surveyor with two policies which included a policy for CNA Training Reimbursement effective 12/01/15 which included a reimbursement procedure for tuition; A policy on Staff Qualifications and Competency Policy effective November 2007, included every position within the organization shall have a written, clearly defined job description .shall have in place a system to ensure that the licensure, registration and certification required for resident care staff is continually maintained .Comprehensive staffing plans that take into account the scope and complexity of care, treatment and service, needed by residents, shall be developed for each unit and department of the organization. Neither policy provided addressed the hiring practices or procedures involved with the employment of non-certified Nursing Aides. At 03:05 PM, the DON provided the surveyor a copy of a handwritten Receipt dated 01/07/19 with the school's identification stamp. The receipt identified NA #3 by name and an amount paid, but there was no evidence what the financial receipt was for. There was no specification that the payment was associated with the current enrollment in a CNA Training Program. In addition, the DON provided the surveyor a copy of an email with correspondence with the school. The email was dated 01/04/19 at 10:58 PM with a request from the facility Staffing Coordinator requesting receipt indicating that [NA #3] is current a student and her status of full time. The email requested a call back as soon as possible. The copy of the email indicated that the school did not reply until 01/07/19 at 10:42 AM, indicating that As soon [sic] I received the outstanding balance from her, I will email you her receipt for your reference. The email did not contain evidence that NA #3 was currently enrolled in the CNA Training Program as a full time CNA at that time. At that time, the DON told the survey team that they were still working on getting proof of enrollment, and should have it by the next day because NA #3 was going there that night. The DON could not speak to why there was no policy provided that addressed the use of NA's in the facility. She stated that they were still working on getting that. She acknowledged it was not readily accessible. At 03:42 PM, in the presence of two surveyors, the Administrator stated that she understood what the surveyors were requesting regarding the policy/program for the hiring and employment of non-certified NA's. She stated that she did not have any written policy/procedure on that topic, and acknowledged the surveyors waited two hours for the policy and that it was not readily accessible. On 01/09/19 at 08:50 AM, the surveyor conducted a phone interview with the Director of the CNA Training Program. The Director stated that she was was on vacation for two weeks, and had just returned home last night on 01/08/19, and that she had someone cover for her. The Director further stated that NA #3 had started the CNA Training Program on 11/02/18 and was expected to graduate on 01/14/19. She added that NA #3 was provided with proof of school enrollment yesterday, and that that information was provided to the facility on [DATE] as well. On 01/09/19 at 09:29 AM, the surveyor interviewed the HR Director and the DON in the presence of the survey team regarding the hiring practices and assignments of non-certified Nursing Aides. The DON began by stating the general procedures, that a prospective employee will come in, and be interviewed by one of three people: her, the Administrator, or the Executive Director/Owner, and on rare occasions the Assistant Director of Nursing (ADON) would do an interview in the past. After an interview, HR would take over, references are checked; and if it looked like a good fit, the facility would hire the individual and a physical health exam/immunizations confirmed and the employee paper work would get processed. The DON stated that she will typically do reference checks or ask HR to do it, and that was specific to the hiring of staff in the nursing department. She added that an orientation calendar would be generated, and that she would assist in setting up a schedule to meet with the Staff Educator/LPN for general orientation, which includes a comprehensive list of skills that the employee should be familiar with. The DON further stated that they determine how much orientation was needed for that staff member, and everyone signs a copy of the orientation calendar, and it goes to the Staffing Coordinator. The DON stated that she checks in with the new employee, follows up and watches the staff member give care. The DON stated that she will also talk to the other nurses, peers of the new employee to determine if they need more orientation and that they give it to them. At that time, the surveyor inquired if that hiring process differed for the hiring of non-certified Nursing Aides. The DON stated that a CNA with past experience will only have one week of orientation, and non-certified NA's will have at least two weeks. When interviewing the NA's, the DON stated that they ask specific questions regarding past experience in healthcare. The DON stated that they will ask if they are enrolled in a CNA Training Program, and the HR Director would start the process to verify enrollment. The DON further added that she had asked for the enrollment verification receipt from NA #3 and was unable to get a copy of it. The DON stated we had no reason to believe she was not in school as they had verbal confirmation from NA #3. The HR Director then stated to the survey team that she believed that NA #3 was enrolled in a CNA Training Program because that's what NA #3 stated, so she had no reason to doubt otherwise. She stated that she never contacted the school in December to verify enrollment. The HR Director confirmed she did not have proof of enrollment until 01/08/19, because the Director of the CNA Training Program at the school was on vacation. The HR Director added that, on the rare occasion that they are not enrolled in school, we will follow up with them and get them in school as soon as we can, usually within 30-60 days. The DON added, that the facility really had 90 days to get them enrolled in school, because the NA would only have 120 days to get certified as a nurse aide, and 90 days post-hire was the latest that enrollment could take place to still comply within the 120 days. She further stated that if the 90-day period came and the NA was not enrolled in school she would need to ask the NA about enrollment status. The DON addressed that the hiring and orientation policy was the same for everyone including non-certified Nursing Aides, CNA's, and licensed nurses. The DON stated the facility did not have a NJ State-Approved Training Program accreditation. She added that the NA's get off orientation and have their own resident assignment just like any other CNA. The surveyor inquired how the facility evaluated competency levels with NA staff before giving them an assignment. The DON stated that they did not have 100 different competencies but that the Staff Educator/LPN used books from one of the CNA Training Programs that was used in the past, and takes information from those to review and evaluate competency levels with the NA's. The surveyor asked the DON if they receive information regarding skills completion and/or course completion from their CNA Training Program, and the DON replied, No. The DON stated that NA #3 was nervous and probably stated that she was a CNA, and what she meant was that she was certified to provide homecare. The DON stated that no NA's were on the schedule to work that day on 01/09/19. The DON provided the surveyor a copy of a letter with the school's CNA Training Program letter head, with a scanned date of 01/09/19 for NA #3. The letter indicated that NA #3 will be attending the school for a period of 3 months. The Program start date was 11/02/18 and a Program end date was 01/14/19 and The Skill Test on 01/25/19. On 01/09/19, the surveyor reviewed the surveyor reviewed the following documents for NA #1: A review of the December 2018 Employee Schedule Template reflected that NA #1 was a float with a circled position of CNA for the 7 AM-3 PM shift. Handwritten under the orientation schedule reflected 14 days and the calendar indicated an orientation for 14 days from 11/19/18 through 12/06/18. A review of the December 2018 new hire orientation calendar for NA #1 reflected that NA #1 had started an independent resident assignment on 12/14/18 during the 7 AM-3 PM shift. The Timecard Report reflected that NA #1 clocked in on 12/14/18 at 07:02 AM and a review of the CNA Daily Assignments sheet for the 7 AM-3 PM shift on Second Floor reflected that NA #1 had her own resident assignment with nine residents. Further review of the NA #1's Timecard Report and Unit Assignment sheets reflected that the NA worked a total of 18 shifts with an independent resident assignment on both the First Floor (Subacute Rehab) and the Second Floor (Long Term Care), without evidence of completion of Module 1 in their CNA Training Program. The surveyor reviewed the following for NA #2: A review of the December 2018 Employee Schedule Template reflected that NA #2 was a float with a circled position for Full Time CNA for all shifts. Handwritten under the orientation schedule reflected Experienced CNA in nursing school and the template calendar indicated an orientation for six days from 11/30/18 through 12/04/18. A review of the December 2018 new hire orientation calendar and the CNA Daily Assignments sheets reflected that NA #2 had started an independent resident assignment on 12/19/18 during the 3 PM- 11 PM shift. The Timecard Report reflected that NA #2 clocked in on 12/19/18 at 02:52 PM and a review of the CNA Daily Assignments sheet for the evening shift on Second Floor reflected that NA #2 had her own resident assignment with nine residents that day. The documents reflected that the NA #2 worked on all 3 shifts on 3 of 3 nursing units with an independent resident assignment. A review of the Timecard Report for NA #2 reflected that the NA worked 20 shifts off of the orientation from 12/19/18 through 01/08/19, without evidence of completion of Module 1 in their corresponding CNA Training Program. The surveyor reviewed the following for NA #3: A review of the December 2018 Employee Schedule Template reflected that NA #3 was a float with a circled position for Full Time CNA for the 7 AM to 3 PM shift. Handwritten under the orientation schedule reflected New CNA and the template calendar resembled an orientation for eleven shifts from 12/03/18 through 12/18/18. A review of the December 2018 new hire orientation calendar and the CNA Daily Assignments sheets for December 2018 reflected that NA #3 had started an independent resident assignment on 12/22/18 during the 7 AM to 3 PM shift. The Timecard Report reflected that NA #3 clocked in on 12/22/18 at 07:17 AM and a review of the CNA Daily Assignments sheet for that shift on the Second Floor reflected that NA #3 had her own resident assignment with 10 residents. The documents reflected that the NA #3 worked on all three shifts on 2 of 3 nursing units on the First Floor and the Second Floor with an independent resident assignment. Further review of the CNA Daily Assignments sheets for December 2018 reflected that NA #3 worked with a CNA on a resident assignment on 12/15/18, 12/17/18, 12/18/18, and 12/19/18 without documented evidence of proof of enrollment in a CNA Training Program, and had an independent resident assignment for 14 shifts from 12/22/18 through 1/05/18, without evidence of proof of enrollment in a CNA Training Program. In addition, NA #3 worked an additional shift on 01/08/19 with an independent resident assignment without evidence of completion of Module 1 in the CNA Training Program. A review of the New Hire Policy revised 03/2018 and provided by the DON on 01/09/19 at 10:27 AM, included, Staff that provide resident care, treatment, and services shall possess a license, certification or registration as required by law and/or regulation. Professional licensure and certifications shall be verified during the new hire process with the appropriate licensing board. The policy further included that Educational preparation and experience appropriate to the level of the applicant's job responsibilities shall be verified prior to employment. Nursing Assistants enrolled in an approved training program must complete their certification within 120 days. Employees will receive an orientation program between 1 week and 10 days, based upon performance and prior level of experience. The Department Head will monitor the employee's progress during orientation by speaking with the staff assigned to train the new employee and schedule additional training as necessary: Experience shall be verified by contacting the individual's previous employer. Educational preparation is understood to have been accomplished at the level required by the individual's license and/or certification requirements or as required by law or regulation. The policy also included that information obtained from the professional licensure and certification verification, as well as the education verification, shall be used in making decisions regarding new hire job responsibilities. At 10:27 AM, the DON stated that the facility did not have a job description for the non-certified Nursing Aides. She provided the surveyor a copy of the job description for CNA's. The DON also provided the surveyor a copy of the New Hire Process which she sent out in an email to four facility staff involved in the hiring process and scheduling of staff on 09/27/18 at 05:09 PM, which included that the Staff Educator/LPN would do orientation schedule 5 days experienced, and 10 days no experience generally but if floating units and shifts may need 6 days orientation. The New Hire Process in the email did not address verification of enrollment in a CNA Training Program, verification of completion of Module 1 in the Training Program. On 01/09/19 at 11:55 AM, the survey team met with the Administrator and DON who confirmed they had no additional information or documents to provide the survey team regarding the hiring practices of NA's and verifying proof of enrollment as a full time student in a NJ state-approved CNA Training Program, and completion of Module 1 before functioning as a nurse aide with an independent resident assignment. The Administrator and DON confirmed the facility did not have proof of completion of Module 1 for the 3 of 3 Nurse Aides reviewed. The Administrator stated at that time that she'd rather hire staff with less experience and willing to learn than someone with more experience that had an attitude. At 12:00 PM, the facility Administration was advised that the failure to verify student enrollment in a NJ State-Approved CNA Training Program, have documented evidence that the NA completed Module 1 in their CNA Training Program prior to giving the NA an independent resident assignment,and the hiring practices of allowing NA's to work for up to 90 days with a resident assignment without enrollment in a NJ State-Approved CNA Training Program, placed the residents on 3 of 3 nursing units in an immediate jeopardy (IJ) situation. At 12:13 PM, the Executive Director/Owner confirmed her role in the interviewing and hiring of NA's. She was unable to provide documented evidence for the completion of Module 1 for the three NA's reviewed. The Administrator was made aware of the IJ situation on 01/09/19 at 12:00 PM. The IJ was corrected and verified on 01/09/19 at 03:01 PM based on an acceptable Plan of Correction (POC), which included the following: 1. The non-certified nursing aides will be removed from the schedule

Based on observation, interview and record review, it was determined that the facility failed to ensure the activities of daily living/morning care was provided in a dignified manner. This deficient practice was identified for 1 of 28 residents reviewed (Resident #35), and was evidenced by the following: The surveyor reviewed the medical record for Resident #35. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, recurrent major depressive disorder, and muscle weakness. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/09/18, reflected that the resident had a short and long term memory problem with a moderately-impaired decision-making capacity. A review of the resident's individualized Comprehensive Care Plan dated 11/02/18 reflected that the resident had impaired cognition/forgetfulness due to a diagnosis of dementia. Interventions included provide consistency with caregivers/routine, reorient as needed and to offer praise and encouragement. On 01/08/19 at 09:17 AM, the surveyor knocked and entered the private room of Resident #35. At that time, the surveyor observed Resident #35 sitting on the edge of the bed, wearing a pair of pants. The elastic waist of the pants was positioned on the resident's mid thighs, exposing an incontinent brief. A non-certified Nursing Aide (NA) was in the resident's bathroom independently, and stated that she was assisting the resident with morning care at that time. The surveyor spoke to the resident, and the resident indicated to the surveyor that he/she was agreeable for the surveyor to observe the morning care provided by the NA. The surveyor observed that the resident was picking at the waist of the pants around the thigh. The surveyor then observed the NA explain to Resident #35 that she was going to transfer him/her from the bed to the wheelchair. The NA assisted the resident to stand up and pivot to the locked wheelchair. As she assisted the resident to the wheelchair, she did not adjust the resident's pants, and the waist of the pants remained around the resident's thighs exposing the incontinent brief. The NA then applied the wheelchair leg rests to the wheelchair and placed the resident's legs onto each leg rest in a 45-degree elevated position, and the NA propelled him/her to the bathroom. The NA brought the resident to the sink. At that time, the NA stated to the resident that it was time for mouth care and asked the resident if he/she wanted to do mouth care independently or if they wished to have the NA do it. The resident replied, I don't know. At that time, Resident #35 looked down at his/her pants with the waist positioned around the mid-thigh, and the resident began grabbing the pants again stating, I want you to fix this. The resident's incontinent brief was still fully exposed. The NA told the resident while standing behind the resident's wheelchair and out of the residents visual field that, Everything will get done. The NA then applied toothpaste to the resident's toothbrush and began brushing the resident's teeth for him/her. The NA then handed the resident a towel and had the resident try and spit into the sink. The resident leaned forward from the wheelchair as far as he/she could and was unable to reach the bowl of the sink to spit, and the resident tried to projectile spit into the sink, causing the spit to mostly get onto the [NAME] cloth towel in the resident's hand. The NA did not offer a basin or spit tray to the resident. She then had the resident rinse with a cup of water and had the resident spit twice more, using the towel to catch the spit that could not make it into the bowl of the sink. At 09:42 AM, the NA brought the resident to the bedside to change the resident's incontinence brief while in the bed. At that time, Resident #35 looked at the sheets and stated to the NA, Are you putting me on those sheets? The surveyor observed that the sheets had multiple areas of pilling and loose debris on them. The NA stated that the sheets get changed on shower days and as needed, and that although today wasn't a day for them to be changed, she would change the sheets that day. The NA then transferred the resident onto the bed, and had the resident sit at the foot of the bed, and assisted the him/her to lay down. The resident's pants were still around the thighs at this time. The resident was low on the bed that he/she had to keep the knees curled up, so as to not hit the foot board. The resident's back was facing the door. The NA did not ask for assistance to reposition the resident in bed, and provided pericare/incontinence care to the resident while he/she remained in the curled-up position low in the bed. At 10:03 AM, after the NA exited the room on two separate occasions to get additional supplies that were not available in the room, the resident remained in the bed with the knees curled, and pants still down. The resident's back was still facing the door. The NA did not cover the resident with a blanket or towel when he/she exited the room while the incontinent brief was exposed. On 01/08/19 at 11:02 AM, the surveyor interviewed the CNA Trainer/CNA. The CNA Trainer stated that she was a CNA who provided basic in-house training to NA's and CNA's. She stated that when NA's are in school, We orient them for two weeks, and if they are still having trouble, we add on time to their orientation schedule and evaluate for strengths and weaknesses. The CNA Trainer stated that when caring for resident's with Dementia, staff should try and get at eye level when communicating as much as possible. She added that the facility also had a Staff Educator who was a Licensed Practical Nurse (LPN) who provided training's on sensitivity and Dementia care. On 01/08/19 at 12:20 PM, the surveyor interviewed the LPN/Staff Educator who stated that she provided education to staff which included topics on privacy, Alzheimer's/Dementia care, cognitive impairment, behaviors and the aging process and customer service. She added that those topics are also covered under the general orientation for all new hires. 01/08/19 at 01:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated if NA's or CNA's need more orientation or request more we give them more training, we do standard competencies for all CNA's and any concerns we address them. The surveyor went over the findings with the Administrator and DON at this time. On 01/09/19 at 08:50 AM, the DON stated to the surveyor team that the NA only needed 10 shifts of orientation before she had independent assignments. The DON indicated that the NA was likely nervous with a surveyor observing care with her. A review of the facility's undated The Rights of the Residents handout sheet that was provided to the surveyor upon entrance on 01/02/19, included, You have the right to: Be treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals . NJAC 8:39-4.1(a)1; 9.5(a); 27.3

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a resident-to-resident physical altercation was reported to the New Jersey Department of Health (NJDOH) within two hours after the alleged incident occurred. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #67). The evidence was as follows: On 01/03/19 at 11:27 AM, the surveyor observed Resident #67 sitting at a table with other residents in the sensory dining room adjacent to the large picture window in the hallway and nurses station. The surveyor attempted to interview the resident who stated his/her name to the surveyor, but did not respond appropriately to follow-up questions. The surveyor reviewed the medical record for Resident #67. A review of the Admission Record face sheet (an admission summary), reflected that the resident was readmitted to the facility on [DATE] and had diagnoses which included dementia with behavioral disturbance, late onset Alzheimer's Disease, and anxiety disorder. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/18/18 reflected that the resident had a brief interview for mental status (BIMS) score of 09 out of 15, indicating a moderately impaired cognition level. The assessment further reflected that the resident had behaviors of physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others one to three days out of the last seven days. A review of an electronic Behavior Note dated 11/07/18 at 16:25 (4:25 PM) reflected another resident reported that Resident #67 hit him/her. The note indicated that the Licensed Social Worker (LSW) confronted Resident #67 to inquire if he/she hit another resident, and Resident #67 began swearing at the LSW. The note reflected that the two residents were separated and that the family representative and the Administration was informed of the alleged incident. A review of the Incident/Accident Report dated 11/07/18 reflected that the time of the incident/accident was 09:50 AM in the dining hall. The description included that Resident #67 had a verbal exchange with another resident, and Resident #67 hit him/her, and the other resident hit him/her back. The residents were separated and talked to, and no further issues were noted during the shift. There was no physical injury to either resident and the seating arrangement was changed. The Incident/Accident Report reflected that the facility reported the incident to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman using the Reportable Event Record/Report (AAS-45 form). The Facsimile Transmittal Sheet reflected a fax receipt date and time of 11/07/18 at 18:32 (06:32 PM), over eight hours after the alleged physical altercation between the two residents. The AAS-45 form had the Administrator's name listed as the individual faxing the Reportable Event Record/Report to the NJDOH/Office of the Ombudsman. On 01/08/19 at 01:18 PM, the surveyor interviewed the Administrator who acknowledged she submitted the reportable event to the NJDOH and the Office of the Ombudsman. The surveyor requested additional information regarding when the incident was reported. On 01/10/19 at 10:13 AM, the Administrator stated to the survey team, that their phone system did not provide a phone history when the facility dials 1-800 numbers, and therefore they could provide documented evidence of when they made a call to the NJDOH. The surveyor inquired when the call was made, and the Administrator stated I don't know, I didn't call it in within two hours . She acknowledged the only date and time they had to confirm receipt of reporting to the NJDOH was on the Facsimile Transmittal Sheet dated 11/07/18 at 18:32 (6:32 PM). On 01/10/19 at approximately 11:50 AM, the facility Administrator provided the surveyor a copy of a letter from the Office of the Long Term Care Ombudsman dated 12/15/17. The Administrator stated the letter was from the Complaints department, and that it reflected that because the residents had no bodily injury, they had 24-hours to report the incident to to the NJDOH. A review of the facility's Policy on Elder Abuse Reporting revised 10/2016, included, .the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .(including to the State Survey Agency .). NJAC 8:39-9.4(f); Appx. B