Every finding on record at The Fountains of Atco

Complaint #3041277 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement an effective water management plan in accordance with nationally accepted standards to mitigate the growth of Legionella bacteria in the facility's water system, b.) follow the recommended guidance from the New Jersey Department of Health's (NJDOH) Communicable Disease Service (CDS) including biweekly water testing and conducting a root cause analysis to identify and address any hazardous conditions, and c.) implement corrective actions for nine occupied resident rooms that tested positive for Legionella. This deficient practice had the potential to affect all 53 residents. A review of the facility provided water testing for Legionella dated 3/28/26, with a results date of 4/9/26, revealed 9 of 9 Long-Term Care (LTC) resident rooms tested positive for Legionella (bacteria found in the water that causes Legionnaire's disease, a severe pneumonia) in the water. The next test the facility conducted was on 5/20/26, with a results date of 5/29/26, which revealed 2 of the same 9 LTC resident rooms sampled tested positive for Legionella in the water. A review of the facility's census revealed all nine LTC resident rooms were occupied by residents. During interviews with the Licensed Nursing Home Administrator (LNHA) and the Maintenance Director (MD) on 6/4/26, revealed the NJDOH CDS recommended water testing every two weeks that was not being done and there was no determined root cause analysis. The MD stated that the facility's Pathogen Consultant had recommended flushing all water sources twice a week, and there was no evidence that was consistently being completed. Observation of four private resident bathrooms on 6/4/26, revealed four fixed shower heads that did not have filters and were operational. Out of those four occupied rooms, three had tested positive for Legionella. The facility's failure to implement an effective water management program including implementing recommendations to mitigate the growth of Legionella bacteria in the facility's water system posed the likelihood for serious harm or death from Legionnaire's disease. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/28/26, when the facility's LTC resident rooms tested positive for Legionella in the water. The Administration was notified of the IJ on 6/4/26 at 3:19 PM. The facility submitted an acceptable Removal Plan (RP) on 6/5/26 at 9:33 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/8/26. The evidence was as follows:Reference: ASHREA Guideline 12-2023, Table C-1 Performance Indicators for Water Management Program for Potable Water Systems, 1. Detection at or above 1 CFU/mL (colony forming units per milliliter) may indicate conditions that allow Legionella growth. An increasing trend over 10- to 100-fold indicates Legionella is poorly controlled. C5. Responses to Legionella Test Results If results from testing for Legionella indicate the water management program (Program) has not met the Legionella control objectives, then, based on the type of Legionella found (see section 4.2), the concentration, and the extent of colonization, implement the following as applicable:a. Review the sample collection, handling, and testing procedures to confirm that the results are not due to errors.b. Confirm that the system equipment is in good working order and functioning as intended.c. Review records to confirm that the Program was implemented as designed.d. Review assumptions about opening conditions, such as the physical and chemical characteristics of the water supplied to the building.e. Re-evaluate fundamental aspects of the Program, including the analysis of hazardous conditions, cleaning and maintenance procedures, chemical treatment, and other aspects of the Program that could affect results of Legionella testing.f. If review or re-evaluation of the Program indicates deficiencies, adjust the Program as necessary.g. After careful review, re-evaluation, and possible adjustment of the Program (see Sections C5[a] through C5[g]), consider whether remedial treatment is needed. In all cases, if the root causes of Legionella growth are not identified and controlled, growth of Legionella is likely to recur.h. Following any adjustments of the remedial treatments, and after waiting at least 48 hours to allow the system to restabilize, retest the collection of representative samples to confirm the effectiveness of the response, or remedial effort is recommended. A review of the facility's Water Management Plan, dated 7/19/25, included if a Legionella positive sample is found outside of control limits, more frequent samples may be required as part of the system of review of the system operation, in order to establish the source of contamination and determine when the system is back within control limits as specified in the WMP (Water Management Plan). Water Management Plan Procedures for Testing 1. Onsite staff receive Legionella water testing equipment at specified intervals by the WMP team.7. WMP Team and [testing vendor redacted] confer on action that needs to be taken or no action taken. 8. Documentation and/or remediation as required. On 6/4/26 at 9:11 AM, the surveyor interviewed the Director of Nursing (DON) and the MD regarding the facility's history of Legionella in the water. The MD stated that the facility had now contracted with a vendor for a monochloramine system (water disinfectant solutions that adds chlorine and ammonia to the water) that the vendor tested the system's functionality weekly at the facility. The MD stated that the facility had also put filters in all shower heads and were planning to put filters on the residents' sinks. The MD stated that the facility conducts sample water testing every two weeks, and that the water samples were to be sent to the lab tomorrow for evaluation. The MD stated that the facility was now maintaining their water storage tanks at 140 degrees Fahrenheit (F) to 150 degrees F as recommended by CDS. At that time, the DON stated that she had been at the facility for one month, and she was unaware of any residents who had respiratory symptoms. On 6/4/26 at 9:46 AM, the surveyor requested from the LNHA all Legionella water testing for the year. The LNHA stated that the facility had been lagging with the testing. When asked from what period the facility was lagging, the LNHA could not provide a timeframe. The LNHA stated that the facility had a recent lab report and received those results on Friday (5/29/26), and the facility was doing a campus water flush of all sinks and showers today. The LNHA stated that each sink was run for 30-40 minutes to flush the water. The LNHA stated that the facility had hired a Pathogen Consultant company for Legionella in February or March of this year and had been actively working with the Local Health Department (LHD) and CDS. The LNHA stated that the facility had discussed modifying their WMP, but it was a work in progress. The LNHA denied any LTC residents having Legionnaire's disease, but stated Resident #1 had a Caregiver who he was made aware of contracted Legionnaire's disease. The LNHA stated he was unsure if the Caregiver had visited Resident #1 while they were a LTC resident. At that time, the LNHA reiterated that the facility was testing their water every two weeks, but there was lagging between February and March for payment issues. The surveyor also requested documentation of all recommendations made to the facility by the LHD and CDS. A review of the facility provided water testing for Legionella dated 3/28/26, with a results date of 4/9/26, revealed 9 of 9 LTC resident rooms tested positive for the presence of Legionella in the water with results ranging from 2.75 CFU/mL to 325.00 CFU/mL. A review of the facility's follow-up testing dated 5/20/26, with a results date of 5/29/26, revealed that 2 of the 9 tested LTC resident rooms were positive for the presence of Legionella in their water. A review of the facility's Daily Census report dated 3/27/26, revealed that 8 of 9 of the resident rooms were occupied with Resident #1's room unoccupied at that time. A review of Resident #1's medical record revealed that they occupied the nineth affected room [room number redacted] from 4/7/26 through 6/1/26. Resident #1's room [room number redacted] tested positive again for Legionella on 5/20/26. A review of the Progress Note dated 5/12/26 at 3:23 PM, completed by the Licensed Practical Nurse/Charge Nurse (LPN/CN), included that the physician ordered a two-view chest x-ray and STAT (immediate) UACS PCR (urine analysis and protein/creatine ratio; a urine screening test) to rule out possible exposure to Legionella. A review of the Daily Census report dated 6/4/26, revealed resident room [number redacted] that tested positive for Legionella on 3/27/26 and 5/20/26, was still resident occupied. On 6/4/26 at 10:26 AM, the surveyor interviewed LPN #1, who stated Resident #1 had recently changed rooms. On 6/4/26 at 10:46 AM, the surveyor interviewed Resident #1, who stated that they had previously resided on another floor in the facility, but since residing on the LTC unit, their Caregiver had visited them once and they had not seen them since. Resident #1 stated that they used their sink to wash their face. On 6/4/26 at 11:11 AM, the LNHA provided the surveyor with the recommendations from the LHD and CDS, as well as the contract for the Pathogen Consultant and engineer report. The surveyor showed the LNHA the positive Legionella water test results provided and asked if there was any additional water testing since the facility received the positive test results on 4/9/26, until the next water testing on 5/20/26. The LNHA stated that he would have to check. On 6/4/26 at 11:32 AM, the LNHA informed the surveyor that there was no additional testing. A review of the emails provided from the LNHA, in correspondence with CDS, revealed on 10/8/25, the Research Scientist from CDS informed the LNHA, that, given that shock remediation was conducted in August of 2025, follow-up samples should be collected every 2 to 3 weeks. However, no more than 14 days should pass between receiving the laboratory results and conducting the next round of sampling. We remain flexible with the biweekly schedule because, following each sample event, the facility should work in coordination with its consultant to conduct a root cause analysis to identify and address any hazardous conditions that may be contributing to the continued presence of Legionella in the building water system when results indicate growth. It is important that any location where Legionella growth is detected be resampled and yield non-detect results in at least three consecutive follow-up sampling rounds.We also request that the findings of the root cause analysis and details of the implemented mitigation measures to control Legionella growth and spread be shared with the Health Department as soon as possible upon completion, along with scheduled date of the next follow-up sampling event. A review of the CDS Recommendations for Comprehensive Evaluation of potable Water System and Legionella Water Management Program, dated 12/18/25, addressed to the LNHA and provided to the surveyor by the LNHA, included the facility and its consultants have not demonstrated the ability to control Legionella, as the bacteria persist and rebound. This typically suggests that the underlying causes of Legionella growth have not been identified or addressed. To date, the facility has not shown that it has completed a comprehensive hazard analysis to determine effective control measures.It is concerning that a supplemental disinfection system is now being installed without first determining why Legionella is present, such as poor water flow, hydraulic imbalances, or other system risk factors. Supplemental disinfection is not considered an effective remediation method, and it will not resolve the underlying issues.The NJDOH and LHD recommend the following: 1. engage a state licensed engineer with expertise in potable water system design and building water management. The engineer should conduct an onsite comprehensive assessment and hazard analysis of the entire potable water system and provide a detailed report including but not limited to.clear, evidence-based recommendations tailored to the facility's specific conditions. 2. Retain a qualified, independent third-party environmental consultant to oversee and verify the work of the water chemical treatment vendor throughout the disease outbreak investigation. A review of the Pathogen Consultant Company's agreement, revealed the facility signed an agreement with the company for consulting on 1/21/26, and a Risk Assessment was completed on 3/24/26. A review of the Risk Assessment, included in the assessment survey and recommendations, that the available data suggest Legionella colonization is present in the facility, with evidence of a central system contribution to downstream positivity in higher-risk areas, particularly the LTC, as well as more localized and variable conditions in decentralized systems. The report also included, The facility has an existing water safety and management system program (WSMP) in place. The existing WSMP includes elements of a Legionella risk management program, including identification of building water systems, implementation of control measures, and routine monitoring activities. However, based on observations made during this assessment and review of available documentation, opportunities exist to further align the program with current system conditions and operational practices. Historical environmental sampling results indicate that Legionella has been detected within portions of the facility, including areas served by the central hot water system. These findings suggest that continued refinement of monitoring, control measures, and validation activities may be warranted to ensure affective management of Legionella risk across all systems. The facility should continue to implement routine monitoring, preventative maintenance, and validation activities identified in the WSMP and incorporate the recommendations of this assessment, as appropriate, to support ongoing Legionella risk management. On 6/4/26 at 12:12 PM, the surveyor reviewed the recommendations provided to the LNHA from CDS. The LNHA stated that in October 2025, it was recommended to conduct a root cause analysis, and the facility responded with a risk assessment completed by the Pathogen Consultant (dated 3/24/26), and the chemical engineer (completed 3/20/26). The LNHA stated that the LHD wanted us to do more. On 6/4/26 at 12:29 PM, the surveyor interviewed the MD, who stated that the Pathogen Consultant had recommended the facility test their water every two weeks and not once a month as previously doing. The MD stated that CDS requested a risk assessment be completed and water flushing two times a week. The MD stated the LPN/Charge Nurse (LPN/CN) and the previous DON were responsible for conducting the water flushes in the LTC unit. The MD stated flushes were conducted by running the hot water in every room and shower for thirty minutes and they kept a log on the unit. The MD stated he checked the logs monthly to ensure completion. When asked about the amount of water testing completed, the MD stated they collected a total of 33 samples throughout the entire building and continued collecting the same sampled rooms if they were positive until there were consecutive negative tests. On 6/4/26 at 12:38 PM, the surveyor conducted a telephone interview with the Pathogen Consultant, who stated he was contracted with the facility since February 2026, and had been physically on-site one time and he was in contact with the facility every couple of weeks. The Pathogen Consultant stated that they conducted an overview of the facility and a risk assessment, which was provided to the facility in March. The Pathogen Consultant stated that normal levels of Legionella were 0.50 CFU/mL to 20.00 CFU/mL, and levels higher than 100 CFU/mL was usually a sign of stagnant water. When asked what stagnant water was defined by, the Pathogen Consultant stated there was no clean definition, but commonly seen with a week of non-use and you would want to consider mitigating by flushing the water. The Pathogen Consultant stated that flushing was done by running the water for at least two minutes until stable, and conducting flushes more frequently was more beneficial than running the water longer than two minutes. When asked what a typical amount of water sampling gathered was, the Pathogen Consultant stated at least ten samples from each water source, and you sampled the same sources again if the results were positive. The Pathogen Consultant stated if the facility had positive results, the goal was to perform corrective action if the numbers were high, and you would test more areas if the numbers were super high. The Pathogen Consultant stated the testing frequency was guided by the Department of Health (DOH), and if the levels were super high, the facility should test twice a month. When asked if he reviewed the facility's water testing from March, the Pathogen Consultant stated that he did not recall making any recommendations, but he would advise to resample to ensure corrective actions worked. On 6/4/25 at 12:50 PM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated all the residents used the shower room except there were four private rooms that had their own showers. On 6/4/26 at 1:12 PM, the surveyor, accompanied by CNA #1, went into Resident room [ROOM NUMBER] that had a private shower. The surveyor observed a fixed shower head and a handheld shower wand with a separate shower head. CNA #1 stated that she did not use the fixed shower head even though it could be turned on and used, because the shower wand was handheld and easier to use. The fixed shower head was operational and contained no filter. On 6/4/26 at 1:17 PM, the surveyor interviewed Resident #7, who stated their room contained a private shower and they showered themselves. At that time, Resident #7 showed the surveyor their shower and stated that they normally used the handheld shower wand instead of the fixed shower head because it was easier, and they used their sink to wash their hands and brush their teeth. Resident #7 turned on the top fixed shower head to show that the shower head was operational, and the resident stated that when the fixed shower was in use, the handheld wand would not function. The fixed shower head was operational and contained no filter. On 6/4/26 at 1:19 AM, the surveyor went into room [number redacted], which was Resident #1's previous room that currently tested positive for Legionella. The fixed shower head was operational and contained no filter. On 6/4/26 at 1:21 PM, the surveyor observed the private shower in Resident room [ROOM NUMBER]. The shower contained a handheld shower wand and a fixed shower head. The fixed shower head was operational and did not contain a filter. Three of the four resident rooms that had operational fixed shower heads with no filters had tested positive for Legionella in the water. During a follow-up telephone interview with the Pathogen Consultant on 6/4/26 at 1:25 PM, the surveyor asked if there was a root cause analysis. The Pathogen Consultant stated that they completed a risk assessment, but the engineer identifies the root cause. The Pathogen Consultant stated the engineer was here once, but they needed to come back to determine a root cause. The Pathogen Consultant stated that ASHREA 188 was used for professional standards of guidance for control. The Pathogen Consultant stated it was important for shower heads to have filters because the spray contained Legionella bacteria. The Pathogen Consultant stated that there was a higher risk for susceptibility from Legionella for people who were immunocompromised and elderly. On 6/4/26 at 1:36 PM, the surveyor interviewed the LPN/CN, who stated that she conducted water flushes whenever the MD told her to do so and could not specify the frequency. The LPN/CN stated that she originally was running all the water sources for five minutes to flush but was then told thirty minutes. The LPN/CN stated she sent caregivers to every room to turn on the water, then signed off the flushes were completed on a log that was kept in a binder on the LTC unit. A review of the water flush log provided by the MD revealed that water flushes were conducted on the LTC unit on 12/31/25, but there was no documentation it was completed in all rooms. The next documented water flush was on 4/29/26, on the LTC unit, and there was no documentation it was completed in every room. The logs from 4/29/26 through present, did not include complete documentation that every LTC room was flushed twice a week with the water run start and end times, as well as the staff member's initials. On 6/4/26 at 2:43 PM, the surveyor in the presence of the LNHA and MD reviewed the water flush logs provided by the MD. The MD stated the frequency of the flushes was changed a couple of weeks ago by the Pathogen Consultant to two times a week. The MD reviewed the log and confirmed there were no other logs and that the logs were not consistently done or complete. The MD stated that the previous DON was responsible for the flushing. There was no documentation that the shower room was being flushed. A review of the facility's Water Management Plan, dated 7/15/25, included the following areas that specified to include the facility's plan were blank as follows: Program Confirmation/ASHREA 6.2.8 The Program Team shall determine whether testing for Legionella shall be performed and if so how the test results will be used to validate the Program. If the Program Team determines that testing is to be performed, the testing approach, including sample frequency, number of samples, locations, sampling methods, and test methods, shall be specified and documented.Program Team has decided to do the following procedures (if applicable): was blank. If the Program Team determines testing for Legionella shall be performed, please list when and where the tests shall be performed (if applicable): was blank. List the other actions the Program Team has determined to take to prevent exposure to contaminated water (if applicable): was blank. System Maintenance/ASHREA 7.1.2.13.E The Program Documents shall include procedures for Maintaining and storing component and equipment operating manuals. Manuals may be found here: was blank. Contingency Response Plan - Legionellosis suspected ASHREA 7.1.4, 7.2.8, 7.3.5.3, 7.4.5, 7.5.7 Program Team to list regional and local health department directives here: was blank. On 6/8/26 at 12:18 PM, the surveyor interviewed the LNHA, who stated there were no residents moved from the nine rooms that tested positive for Legionella that he could remember. The LNHA added there was no recommendation made for any residents to be moved from those rooms. The LNHA stated he had not received knowledge of who the resident was that had a visitor test positive until CDS came to the facility the day after Memorial Day. The LNHA added I found out by accident. The LNHA stated Resident #1 was moved from room [number redacted], that was a private room, on 6/1/26. An acceptable Removal Plan (RP) was received on 6/5/26 at 9:33 AM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including; on 6/4/26, the MD and LNHA flushed all the showers and sinks in all 30 LTC resident rooms and the DON and LNHA initiated respiratory assessments of all residents for signs and symptoms consistent with Legionella infection. On 6/4/26, the LNHA and DON initiated a facility wide education for all staff on Legionella policies and procedures including; peg-tube (percutaneous endoscopic gastrostomy; a surgically inserted feeding tube into the stomach) hydration with distilled water only, water testing every two weeks, and water flushes twice a week. The residents who resided in the two rooms that tested positive for Legionella on 5/20/26, were moved to a different room. On 6/4/26, the LNHA reviewed the WMP with the water management consultant and no changes were made. The Regional Administrator in-serviced the LNHA, MD, and the DON on the facility's Legionella policy and WMP. The overhead fixed primary shower heads in Resident room [ROOM NUMBER], #202, #301, and #302 were capped off on 6/5/26. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/8/26 at 11:54 AM. NJAC 8:39-19.4(a)NJAC 8:39-19.4(e)NJAC 8:39-19.4(f)NJAC 8:39-31.2(e)

COMPLAINT # 2792802 and 2795965 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that facility staff members failed to a.) ensure control measures were implemented, maintained and monitored to prevent the growth of Legionella in accordance with the facility Water Management Program (WMP)(a risk management plan for the prevention and control of legionellosis associated with the building water systems) and in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guideline 12, when there was a positive Legionella report in December 2024 and February 2025, by maintaining and changing filters in the shower heads and ice machine; b.) including the Infection Preventionist (IP) in the control measures to minimize the risk of Legionella exposure to all residents; and c.) update the WMP to include current responsible identified program team members. The deficient practice had the potential to affect all residents and was evidenced by the following: Reference: CDC guidelines for Legionella Control dated March 15, 2024, indicates to follow a successful remediation procedure, clean and maintain water system components regularly in accordance with manufacturer recommendations and ice machines are cleaned regularly and replace filters per manufacturer recommendations. In addition, implement Legionella control measures for devices that use water per ASHRAE Guideline 12. On 03/05/2026 between 10:19 AM and 11:00 AM, the survey team, accompanied by the Campus Maintenance Director (CMD) and the New Jersey Department of Health (NJDOH) Communicable Disease Services (CDS) Research Scientist/Water Systems Analyst (Water Scientist), and a Local Health Department (LHD) representative, toured the skilled nursing section of the building and observed the following: On 03/05/2026 at 10:44 AM, the surveyor, in the presence of the CMD, observed three (3) shower heads in the shower room. The CMD stated two (2) of the three (3) shower heads were in use. The CMD acknowledged one of the two (2) shower heads had a filter. The CMD explained the Certified Nursing Aides (CNAs) may have removed the filter to get better flow. The CMD added that the filters were checked by the maintenance department every three (3) months. The CMD also added there would be a log indicating the filters were checked/replaced and would provide the log. On 03/05/2026 at 10:49 AM, the surveyor, in the presence of the CMD, observed an ice machine in the dining room/pantry area with an inspection sheet that indicated on 11/18/2025, the ice machine was cleaned and sanitized by the Heating, Ventilation and Air Conditioning Mechanic (HVACM). In addition, there was a filtration device attached to the wall connected to the water line for the ice machine with a date of 02/04/2025, handwritten on the device. The CMD stated 02/04/2025, may have been the date of installation and was unsure if the filter had been changed after that date. The CMD could not speak to the manufacturer's specifications as to when the filter device should have been changed. The CMD added he would provide a log when the ice machine filter was checked/replaced. On 03/05/2026 at 11:05 AM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA), who stated he became the LNHA in October 2025. The LNHA also stated he was aware the filters required to be checked and changed and would have to check with maintenance for the schedule. On 03/05/2026 at 11:10 AM, the surveyor interviewed the Director of Nursing (DON), who stated water for the residents was supplied from water coolers and no water for consumption was obtained from the faucets. The DON added that the ice machine was used on a regular basis for the residents and any filters were done by maintenance. In addition, the DON was unaware of any water pressure issues with the shower heads. The DON added the residents used the shower room and there were four (4) rooms with private showers. The DON provided a shower schedule for all residents. On 03/05/2026 at 11:27 AM, the surveyor interviewed the IP/Licensed Practical Nurse (IP/LPN), who stated she had been the IP for approximately a year. The IP/LPN stated she had no knowledge of any issue with Legionella and upper management, and maintenance were involved in handling Legionella. The IP/LPN added she was told to provide education regarding Legionella approximately a year ago to the staff as to what the disease was, how you get the disease and where it was found. The IP/LPN also added she was unaware of any issues currently with Legionella in the building. The IP/LPN stated the water for consumption for the residents was obtained from water coolers and ice was in the ice machine and used on a regular basis for meals, devices, and medications. The IP/LPN explained residents on nectar thick liquids could not receive ice and thought maintenance was responsible for the filter. The IP/LPN also stated the CNAs were responsible for following the shower schedule for all residents and remembered shower head filters being put in by the previous LNHA but was unable to remember when that was. The IP/LPN added she thought maintenance checked the filters. The IP/LPN also added there were no complaints by staff about low water pressure from the shower heads. On 03/05/2026 at 12:27 PM, the surveyor interviewed the LNHA, who stated the IP/LPN was responsible for educating the staff on Legionella but was currently not involved in remediation. The LNHA added he would involve the IP/LPN if there were any cases of Legionella. The LNHA confirmed the IP/LPN had not been included in any discussions since becoming LNHA regarding Legionella but had planned on including her. On 03/05/2026 at 12:35 PM, the surveyor observed LPN #1 at the medication cart with a water pitcher approximately three-fourths empty with water and ice melting. LPN #1 stated she filled the pitcher with water from the cooler and ice from the ice machine before going out to administer medications to the residents and the ice was melting but the water was still cold. LPN #1 added that was her usual procedure. On 03/05/2026 at 12:39 AM, the surveyor observed CNA #1 carrying a resident's meal tray. The surveyor interviewed CNA #1, who stated he was bringing a meal tray to a resident and used the water dispenser to fill the cup on the tray with water and ice from the ice machine in the dining room. On 03/05/2026 at 12:41 PM, the surveyor observed an unsampled resident with two (2) cups on their overbed table. The surveyor interviewed the unsampled resident who confirmed the two (2) cups contained water with ice and received showers in the shower room approximately twice a week. On 03/05/2026 at 12:45 PM, the surveyor observed CNA #2 in the dining room filling a cup with ice and pouring juice in the cup and placed the cup on a meal tray for a resident. The surveyor interviewed CNA #2, who stated that was her regular routine to fill the cups with ice and add juice or water from the cooler for the resident's meal tray. On 03/05/2026 at 12:46 PM, the surveyor interviewed CNA #3 and CNA #4, who stated neither had an issue with low pressure from the shower heads in the shower room. CNA #4 added he had given a resident a shower in their room that morning because they had a private shower in their room and had no issues with pressure. CNA #3 and CNA #4 both acknowledged their usual routine every day was to provide each resident with a cup of water from the cooler and ice from the ice machine in the morning and then whenever needed during their shift. On 03/05/2026 at 2:03 PM, the surveyor interviewed the HVACM in the dining room at the ice machine. The HVACM confirmed he signed the inspection record and explained on 11/18/2025, he disassembled, sanitized, soaked parts and re-installed all parts of the ice machine. The HVACM stated he normally would change the cartridge to the filter but in November 2025, there was a different filter device and had he not changed the filter device. The HVACM added the filter device should have been changed. The HVACM also stated he knew the device had a date of 02/04/2025, written on it because he was told by the CMD that morning and thought the date of 02/04/2025, was when the device was installed but he was unsure. The HVACM added he would be changing the filter device, but the device had to be ordered. The HVACM added he did not do the ordering and thought the Maintenance Supervisor (MS) was responsible for ordering the filter device, but the MS was terminated last month. On 03/05/2026 at 2:29 PM, the surveyor interviewed the CMD, who stated he could not provide logs of when the shower head filters, or ice machine filter was checked or changed. The CMD had no ordering schedule or receipt of order because vendors were changing frequently and there were too many hands involved. The CMD explained the MS was terminated for multiple reasons which included one of the reasons was audits not being completed and completed properly. The CMD provided a SNF Community Shower Room log which indicated 08/10/2025, was Date New Filter Was Installed. The CMD could not speak to what the log meant. The CMD added that it was the only record he had. On 03/05/2026 at 3:09 PM, the surveyor interviewed the LNHA, who stated he thought the audits for the shower heads and filters were being done. The LNHA added he was unaware the filters were not changed as per manufacturer's specifications. The LNHA explained the administrative team was new and there was a change in ownership. The LNHA also stated he was aware when he became the LNHA in October 2025, there was a history of a Legionella issue but was unaware of the magnitude and was unaware where in the process of mitigation the facility was. The LNHA then acknowledged he had been in contact with the NJDOH CDS regarding Legionella remediation since becoming the LNHA in 10/2025. The LNHA stated he thought he was following all recommendations made by the NJDOH CDS for remediation. The LNHA added he had a third-party consultant come in 02/19/2026, for sampling and received a preliminary report that there was one positive sample for Legionella and had not retained a mechanical engineer yet due to conflicting schedules. The LNHA confirmed the 02/19/2026, was the only sampling report completed and thought he was following the facility WMP. The LNHA was unable to provide documentation as to the NJDOH CDS recommendations that were completed before 02/19/2026. At that time, the LNHA reviewed the facility policies provided to the surveyors regarding Legionella Water Management Program and stated that was not the facility WMP and would provide the WMP. A review of the facility WMP titled Water Management Plan dated 07/15/2025, provided by the LNHA, revealed the program team members included the current CMD and an Executive Director and Administrator who no longer were employed at the facility. In addition, the WMP revealed ice machines, medical devices, shower heads and hoses were specific devices at risk for Legionella contamination. The WMP further explained ice machines required a control measure of regular cleaning and changing filters according to manufacturer's specifications and documented. In addition, the WMP included but not limited to instructions; showerheads and hoses required regular cleaning, replacing or dismantling, disinfecting, and eliminating all deposits of scale from shower heads, hoses, aerators or flow restrictors. The WMP indicated If Legionella-positive sample is found outside of the control limits, more frequent samples may be required as part of the review of the system operation, in order to establish the source of the contamination and determine when the system is back within control limits as specified in the WMP. A review of the facility policy titled Legionella Water Management Program with a revision date of 9/2022, provided by the DON, revealed the facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. In addition, the water management team consisted of at least the infection preventionist, administrator, medical director, director of maintenance and director of environmental services. NJAC 8:39-19.4 (b), 19.6(d)

Complaint #: 2792802 and 2795965 Based on observations, interviews, and review of pertinent facility documentation on 03/05/2026, in the presence of the facility's Campus Maintenance Director (CMD), it was determined that the facility failed to provide 0.2-micron biological point-of-use filters on resident showerheads and change water filters on ice machines to ensure control measures were implemented to mitigate the growth of legionella. This deficient practice had the potential to affect all residents and was evidenced by the following:A review of facility provided documentation from the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS) to the facility, dated 01/21/2025, included:Immediate Control Measures: 1. Immediately install 0.2-micro biological point-of-use filters on any shower heads intended for use or restrict showers and use sponge baths instead. Filters must comply with the requirements of ASTM F838.a. Access the facility for the potential installation of additional point-of-use filters at water fixtures where the risk of exposure to aerosolized water is elevated, such as salon sinks used for hair washing and other sinks accessed by residents at higher risk for Legionnaires disease. b. Understand point-of-use filters manufacturers recommendations regarding the temperature, pressure, chemical levels that filters can withstand, and suggested frequency for replacement.2. Provide bottled drinking water for residents who are at risk of aspiration (i.e., swallowing difficulties). Do not provide tap water to residents at risk of aspiration, including use of ice from the facility's ice machines in their beverages and use tap water used in dilution/hydration of meals for patients on a soft diet. Consider providing bottled water to other susceptible patients. On 03/05/2026 at 10:19 AM, the surveyor, accompanied by the CMD, the Research Scientist/Water Systems Analyst (Water Scientist) from the NJDOH CDS, and a Local Health Department (LHD) Representative observed the following: At approximately 10:45 AM, an inspection inside the Resident Shower Room revealed when the showerhead was opened, there was no evidence of a 0.2-micron biological point-of-use filter. At that time, the CMD told the surveyor that sometimes the Certified Nursing Aides (CNA) removed the filter if the water flow was low. The CMD added that the filters were checked by the maintenance department every three (3) months. The DM also added there would be a log indicating the filters were checked/replaced and would provide the log. At approximately 11:05 AM, an inspection of the ice machine in the service area adjacent to the resident dining area, revealed the filter was installed on 02/04/2025. The CMD stated 02/04/2025, may have been the date of installation and was unsure if the filter had been changed after that date. The CMD could not speak to the manufacturer's specifications as to when the filter device should have been changed. The CMM added he would provide a log when the ice machine filter was checked/replaced. At that time, the Water Scientist informed the CMD that those filters needed to be changed every six months. On 03/05/2026 at 11:05 AM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA), who stated he became the LNHA in October 2025. The LNHA also stated he was aware the filters required to be checked and changed and would have to check with maintenance for the schedule. On 3/5/26 at 2:03 PM, the surveyor interviewed the Heating Ventilation Air Conditioning Mechanic (HVACM) in the dining room at the ice machine. The HVACM confirmed he signed the inspection record and explained on 11/18/2025, he disassembled, sanitized, soaked parts and re-installed all parts of the ice machine. The HVACM stated he normally would change the cartridge to the filter but in November 2025, there was a different filter device and had he not changed the filter device. The HVACM added the filter device should have been changed. The HVACM also stated he knew the device had a date of 02/04/2025, written on it because he was told by the CMD that morning and thought the date of 02/04/2025, was when the device was installed but he was unsure. The HVACM added he would be changing the filter device, but the device had to be ordered. The HVACM added he did not do the ordering and thought the Maintenance Supervisor (MS) was responsible for ordering the filter device, but the MS was terminated last month. On 03/05/2026 at 2:29 PM, the surveyor interviewed the CMD, who stated he could not provide logs of when the shower head filters, or ice machine filter was checked or changed. The CMD had no ordering schedule or receipt of order because vendors were changing frequently and there were too many hands involved. The CMD explained the MS was terminated for multiple reasons which included one of the reasons was audits not being completed and completed properly. The CMD provided a SNF Community Shower Room log which indicated 08/10/2025, was Date New Filter Was Installed. The CMD could not speak to what the log meant. The CMD added that it was the only record he had. On 03/05/2026 at 3:09 PM, the surveyor interviewed the LNHA, who stated he thought the audits for the shower heads and filters were being done. The LNHA added he was unaware the filters were not changed as per manufacturer's specifications. The LNHA explained the administrative team was new and there was a change in ownership. The LNHA also stated he was aware when he became the LNHA in October 2025, there was a history of a Legionella issue but was unaware of the magnitude and was unaware where in the process of mitigation the facility was. The LNHA then acknowledged he had been in contact with the NJDOH CDS regarding Legionella remediation since becoming the LNHA in 10/2025. The LNHA stated he thought he was following all recommendations made by the NJDOH CDS for remediation. The LNHA added he had a third-party consultant come in 02/19/2026, for sampling and received a preliminary report that there was one positive sample for Legionella and had not retained a mechanical engineer yet due to conflicting schedules. The LNHA confirmed the 02/19/2026, was the only sampling report completed and thought he was following the facility WMP. The LNHA was unable to provide documentation as to the NJDOH CDS recommendations that were completed before 02/19/2026. No additional information was provided. A review of the facility's policy titled Water Management Plan (WMP) dated 07/15/2025, provided by the LNHA, revealed the program team members included the current CMD and an Executive Director and Administrator who no longer were employed at the facility. In addition, the WMP revealed ice machines, medical devices, shower heads and hoses were specific devices at risk for Legionella contamination. The WMP further explained ice machines required a control measure of regular cleaning and changing filters according to manufacturer's specifications and documented. In addition, the WMP included but not limited to instructions; showerheads and hoses required regular cleaning, replacing or dismantling, disinfecting, and eliminating all deposits of scale from shower heads, hoses, aerators or flow restrictors. The WMP indicated If Legionella-positive sample is found outside of the control limits, more frequent samples may be required as part of the review of the system operation, in order to establish the source of the contamination and determine when the system is back within control limits as specified in the WMP. NJAC 8:39-31.2(e)

Complaint #: 2704937; 414412 Based on observation, interview, and record review, it was determined that the facility failed to ensure a) adequate supervision was provided to a cognitively impaired resident (Resident #7) identified as being at high risk for falls, impulsive, and required supervision. Resident #7 sustained 13 falls including three falls with injury that required transfer to the emergency room on 8/10/25, for a contusion and laceration to the left supraorbital and frontal scalp; on 10/28/25, for a large intramuscular hematoma to the right thigh, and on 11/14/25, for a closed head injury and laceration to the forehead which required sutures; b) ensure each fall was thoroughly investigated to prevent additional falls; and c.) consistently initiate and implement new fall prevention interventions in response to falls to prevent further falls. This deficient practice identified for 3 of 3 residents reviewed for falls (Resident #7, #27, and #70) and was evidenced by the following: A review of the facility's policy titled Managing Falls and Fall Risk, dated/revised 3/2018, included the staff would identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling.Under Resident-Centered Approaches to Managing Falls and Fall Risk included; that the staff with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather many at once). When a fall reoccurred despite initial interventions, the staff would implement additional or different interventions or indicate why the current approach remained relevant. If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until reduced or stopped, or until the reason for the continuation was identified as unavoidable. Under Monitoring of Subsequent Falls and Fall Risk included that the staff would monitor and document each resident's fall response to interventions intended to reduce falling or the risks of falling. For continued falls the staff would re-evaluate the situation and the appropriateness to continue or change current interventions and the attending physician would help the staff reconsider possible causes that may not have been identified. A review of the facility's Falls- Clinical Protocol Policy, revised September 2012, and the Falls Risk Assessment Policy, revised March 2018, were also reviewed. All three policies did not include supervision related to falls. 1. On 1/05/26 at 10:00 AM, the surveyor toured the nursing unit and observed Resident #7 seated in a wheelchair in the dayroom (room [ROOM NUMBER]). The resident had a peg board on the table and was trying to play with the board. The resident could not communicate with the surveyor. The resident appeared restless and confused and there was no staff in attendance. On 1/05/26 at 11:00 AM, the surveyor observed Resident #7 in the dayroom (room [ROOM NUMBER]) seated at a table alone, along with seven other residents. There was no staff observed in attendance. At 11:20 AM, the surveyor observed a staff member coming from the other room (staff identified it as the Purple Room), and the staff member identified herself as the Activity Aid (AA). The AA informed the surveyor she had to provide activities and monitor both rooms by herself, and she stated she didn't have any help. The AA informed the surveyor that the facility used two dayrooms where the Certified Nurse Aides (CNAs) brought the residents to after providing morning care, and the residents could attend activities in either room [ROOM NUMBER] or the Purple Room. According to the AA, the facility assigned only one staff member to cover both activity rooms. There was no staff observed in the first room to supervise the residents, while the AA had to monitor the residents in the Purple Room. On 1/06/26 at 11:15 AM, the surveyor observed Resident #7 seated alone at a table in room [ROOM NUMBER]. The resident appeared restless and was observed attempting to stand, moving back and forth in the wheelchair. The AA was in the Purple Room and there was no clear, unobstructed path to visualize what was happening in room [ROOM NUMBER]. The surveyor interviewed the AA and inquired who was responsible to supervise and provide activities to room [ROOM NUMBER] while she was attending to the residents in the Purple Room. The AA stated that currently she had no help, and at times she had to transport some of the residents to the hairdresser, so she had to ask the nursing staff to keep an eye on both rooms. The AA stated there were no staff physically assigned to monitor the activity area if she had to step out. The AA asked the surveyor what the ratio should be for activities as she was aware that she could not provide activities and supervise both rooms. The surveyor referred her to the Licensed Nursing Home Administrator (LNHA). The surveyor then asked the AA if she discussed her concerns with the Activity Director, and she stated, yes. On 1/06/26 at 11:35 AM, the surveyor interviewed the CNA who cared for Resident #7. The CNA stated that Resident #7 required extensive assistance with care, was very confused, and required supervision to prevent falls. The CNA further stated that the resident was usually transferred to the dayroom after care for activities. On 1/06/26 at 11:45 AM, the surveyor interviewed Resident #7's Charge Nurse regarding resident falls. The Charge Nurse stated that all the falls were reviewed during morning meetings and the Director of Nursing (DON) updated the care plan. On 1/06/26 at 11:55 AM, the surveyor requested all of Resident #7's fall investigations, their fall risk assessments, and a timeline of their falls from the DON. On 1/07/26 at 10:11 AM, the surveyor observed Resident #7 in room [ROOM NUMBER] with six other residents and there was no staff in attendance. Resident #7 was observed attempting to stand from the wheelchair and another resident (unsampled) asked the resident to sit down. There was no staff in attendance. The surveyor walked to the next room, the Purple Room, and observed the AA in the back of the Purple Room with her back facing the entrance door to the room, looking through papers. The AA was unable to visualize the residents in room [ROOM NUMBER] that was divided by a wall. At that time, the residents in room [ROOM NUMBER] were left unattended. At 10:18 AM, the surveyor was about to exit the door, when the AA came into the room and stated to the surveyor that she had to get something from the Purple Room. On 1/07/26 at 11:30 AM, the surveyor reviewed Resident #7's medical record which revealed the following: A review of the admission Face Sheet (an admission summary), reflected that Resident #7 was admitted to the facility with diagnoses which included but were not limited to; aphasia following cerebral infarction (loss or impairment of language ability due to brain injury following a stroke), muscle weakness, bipolar disorder, current episode hypomanic (elevated mood), repeated falls, traumatic subdural hemorrhage with loss of consciousness (blood collects under the brain's outer layer due to head injury), adult failure to thrive. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 11/12/25, reflected that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3 out 15, which indicated a severely impaired cognition. A review of Resident #7's Comprehensive Care Plan provided by the facility on 1/07/26, included a focus area initiated 4/11/25, that Resident #7 was at risk for falls. The goal was that Resident #7 will be free from falls related injuries through the next review date: 10/15/25, with a target date of 3/24/26. The interventions included:Keep items of importance within reach, initiated 4/14/25. The resident had a special scoop mattress to the bed to facilitate proper positioning and to deter them from rolling off the bed, initiated 4/14/25.The resident was impulsive and has poor safety awareness and requires prompt response to all requests for assistance, initiated 4/14/25.Maintain the bed in the lowest position, initiated 4/18/25.Evaluate the environment at the time of the resident's fall and identify any factors that may have contributed to the fall, initiated 4/22/25. Therapy to screen/evaluate and/or treat as indicated, initiated 4/22/25. The resident was to be in the common area when out of bed, and do not leave the resident alone in the room in the wheelchair, initiated 4/28/25. Staff to bring resident out of the room after morning care to participate in activities of their choice, initiated 4/28/25. The resident needs supervised activities that minimize the potential for falls while providing diversion and distraction, initiated 10/29/25. On 1/07/26 at 11:40 AM, the following Fall Risk Evaluations were provided by the DON: -Fall Risk Evaluation dated 1/16/25, reflected Resident #7 scored a 20, which indicated a high fall risk. (10 or above = high risk for falls).-Fall Risk Evaluation dated 4/16/25, reflected that the facility identified Resident #7 as a high fall risk. Resident #7 received a score of 24. -Fall Risk Evaluation dated 4/24/25, reflected that the facility identified Resident #7 as a high fall risk. Resident #7 received a score of 24. -Fall Risk Evaluation dated 7/23/25, reflected that the facility identified Resident #7 as a high fall risk. Resident #7 received a score of 21.-Fall Risk Evaluation dated 10/24/25, reflected that the facility identified Resident #7 as a high fall risk. Resident #7 scored a 22. The following incidents and Fall Evaluations were documented in the electronic Medical Record, and/or provided by the DON, and revealed the following:-On 11/11/24 at 1:03 PM, a Nursing Progress Note revealed Resident #7 was found on the floor by the housekeeping staff between the bathroom and the bed. There was no fall investigation provided by the facility. -On 11/27/24 at 12:30 PM, a Nursing Progress Note revealed that the writer was called to room by the CNA, and they observed the resident laying on the floor in the room, next to the wheelchair on their right side. The resident was incontinent, and Resident #7 was provided with incontinence care and taken to the common area. There was no fall investigation provided by the facility. -On 11/29/24 at 7:40 PM, a Nursing Progress Note revealed the resident fell in the room and sustained a skin tear. There was no fall investigation provided by the facility. -On 12/09/24 at 2:20 PM, a Nursing Progress Note revealed the resident found on the floor in the activity room. No investigation was provided for this fall. The facility did not identify who was responsible to monitor the resident in the dayroom. -On 12/14/24 at 8:06 PM, a Nursing Progress Note revealed that the resident was found on the floor in the doorway of the room and sustained a skin tear to the right elbow. There was no fall investigation provided by the facility. -On 3/31/25 at 7:00 PM, a Nursing Progress Note revealed that the resident was found on the floor in the room, and upon assessment, Resident #7 was noted with redness to the left arm. A review of the corresponding Unwitnessed Fall report dated 3/31/25, did not include a causal factor for the fall. The Interdisciplinary Care (IDC) team indicated that, The resident has been identified as high risk for falls. All current interventions remain appropriate and in place. Additional interventions are not appropriate at this time. The goal for the resident is to prevent injury from falls.- On 4/09/25 at 9:06 AM, a Nursing Progress Note revealed that the resident was found on the floor in the room, and that the CNA found the resident on the floor in the room, on their back leaning against the bed. The resident was assisted to bed with no injury noted. Neurological checks were initiated. The corresponding Unwitnessed Fall investigation dated 4/09/25, revealed the aide reported the resident on floor. 4/10/25, the IDC team reviewed the fall. The resident fell from bed, the resident was impulsive and does not recognize limits.No revised interventions added to the Care Plan.-On 4/17/25 at 10:15 PM, an Incident report dated 4/17/25, reflected that Resident #7 was found in the room between the bed and the bathroom's door. The recommendation was to maintain their bed in the lowest position. According to the staff, the resident was attempting to go the bathroom. The IDC team notes dated 4/18/25, documented the resident remains impulsive and with poor safety awareness. Bed in lowest position. -On 8/10/25 at 9:11 PM, an Incident Report revealed Resident #7 sustained a fall in the hallway during transfer. The progress notes revealed that the resident was observed lying on the floor in the hallway with swelling and blood dripping from left side of their head. The resident stated, I fell and hit my head. The CNA assisted the resident into the wheelchair and the resident fell forward. The resident was transferred to the Emergency Department (ED) and was diagnosed with soft tissue injury to left supraorbital and frontal scalp, contusion and laceration (skin tear and bruising in the area above the eye). The IDC team's recommendations were to educate staff on safely repositioning in the wheelchair. During the transfer to the room, there was no leg rest in use. According to the CNA's statement, the resident's legs got caught underneath, the resident fell and hit their head. -On 10/06/25 at 2:00 AM, an Incident Report revealed during rounds, a CNA found the resident on the floor. The bed was low, and the IDC team met on the same day to discuss the fall and there was no causal factor indicated for the fall per the resident's care plan intervention, and the care plan interventions were not reviewed or revised.-On 10/28/25 at 11:30 AM, an Incident Report revealed that a CNA alerted the nurse that Resident #7 was found on the floor in the activity room with the wheelchair behind them. On 10/29/25, the IDC team reviewed the fall, and it was determined that Resident #7 would stand and sit repetitively even when there would be a puzzle or activity in front of them. During the fall, Resident #7 stood up and went to sit down and missed the chair and sat on the floor. The resident needs supervised activities that minimize the potential for falls while providing diversion and distraction. - On 11/4/25 at 7:42 AM, following the fall of 10/28/25, the CNA reported to the nurse that Resident #7 had right leg bruising and was swollen and was warm to the touch. The resident was transferred to the ED for evaluation and treatment. A review of the hospital records revealed a history of fall and trauma. A computed tomography (CT) scan (diagnostic imaging that uses a combination of X-rays and computer technology to produce images of any part of the body) of the right lower extremity was performed on 11/04/25, which revealed a large intramuscular hematoma (bruise) to the right leg, measuring 28 centimeters (cm) by (x) 6.5 cm x 4.3 cm. Resident #7 remained at the hospital from [DATE] to 11/08/25. The resident was also diagnosed with bandemia (large amount of immature white blood cells (band cells) released by bone marrow to fight infection or inflammation. Common causes are severe pain or stress, tissue damage.) There was no acute fracture. -On 11/14/25 at 4:03 PM, a late entry Incident Note revealed that Activity Saff reported that the resident was found on the floor in the activity room. The resident was actively bleeding from the right side of their forehead with injury above their eyebrow with a 3-centimeter cut noted and discoloration on their nose bridge noted. The resident was transferred to the emergency room for facial/head injury. The resident sustained a laceration above the right eye, bruises to the bridge of nose, open area to the right side of the head. The resident was diagnosed with closed head injury and facial laceration (skin tear) that required sutures (stitches). The Incident Report dated 11/14/25, revealed that on 11/17/25, the IDC team reviewed the fall and determined that Resident #7 attempted to ambulate and fell and All current interventions remain appropriate and in place. Additional interventions are not appropriate at this time. The goal for the resident is to prevent injury from falls. The IDC team did not address the failure to supervise the resident after it was documented post fall on 10/28/25, that the resident required supervision while in activities. A review of the therapy Screen/Referral Form dated 9/30/25, revealed the following: After speaking with nursing staff and CNA, as well as observation of [the resident], [the resident] may at times demonstrate unsafe behavior (stands up with I to participate in [activities of daily living (ADLs)], however this is [the resident's] typical behavior. There has been no decline in ADLs or transfer. No [occupational therapy] indicated. The facility did not indicate what measures were put in place to address the unsafe behavior. On 1/08/26 at 9:53 AM, the surveyor interviewed the DON regarding Resident #7's multiple falls at the facility including the falls with injuries. The DON stated that the staff should have followed the care plan. When asked if Resident #7 had behaviors, the DON stated, No. The DON added that Resident #7 was easily redirected, and Resident #7 attempted to stand up all the time as this is their ritual, someone has to remind them to sit. On 1/09/26 at 11:39 AM, the surveyor interviewed and shared the above concerns with the Activity Director (AD) regarding staffing. The AD stated, the activity needs to be re-evaluated, currently staffing is lacking, and stated her expectations were to re-evaluate and provide a safe environment to all residents. When asked if her expectations were being met/considered, she stated that she was aware of the staffing issue, that the activity staff had to oversee residents in both rooms, and she did not have a plan yet to resolve the staffing issues and ensure the residents' needs were met. A review of the Activity Director Position Description revealed the following: The activity director is responsible for the development, implementation, and supervision of the full scope of the facility's recreation services. This includes providing an ongoing inclusive program that uses purposeful activities to improve and maintain the quality of life for residents. The Activity Director was to uphold and safeguard resident's rights, advocates for and on behalf of residents. 2. The surveyor reviewed the electronic medical record (EMR) which revealed a comprehensive Minimum Data Set (MDS), an assessment tool dated 8/05/24, which indicated Resident #70 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated an intact cognitive function. a further review of the MDS revealed Resident #70 required maximum assistance for transfers and had diagnoses that included but were not limited to; Alzheimer's disease, anxiety, and diabetes. A review of the individual comprehensive care plan (ICCP) included a focus area dated 7/29/24, for high risk for falls. The focus area was updated to include a fall with no injury on 8/03/24, a fall with no injury on 8/06/24, a fall with no injury on 8/11/24, a fall with no injury on 8/14/24, a fall with no injury on 8/30/24, and an actual fall with skin tear to their left hand and elbow on 10/18/24. Interventions dated 7/29/24, included to review information on past falls and attempt to determine cause of falls; record possible root causes; after remove any potential causes if possible; anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; the resident needs prompt response to all requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; ensure that the resident is wearing appropriate footwear; follow facility fall protocol; maintain bed in lowest position while in bed; offer and provide toileting assistance before and after meals, at bedtime and as needed. An intervention dated 8/06/24, was physical therapy (PT) and occupational therapy (OT) evaluate and treat as ordered or as needed (PRN). An Intervention dated 8/11/24, was to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Interventions dated 8/14/24, were to continue as risk plan and offer activities that minimize the potential for falls while providing diversion and distraction. An intervention dated 10/21/24, was the resident currently needs new glasses and will be seen by the optometrist on 10/23/24. Monitor closely at this time until new glasses are received. According to documentation reviewed, there were no new interventions for the falls that occurred on 8/30/24. A review of the facility provided Accident/Incident reports did not indicate when the resident was last seen or toileted, footwear at time of the incident, position of bed (if applicable), or if resident had participated in activities as per ICCP interventions. Effectiveness of interventions were not evaluated and a root cause of falls not identified. A review of the facility provided Fall Risk Evaluation dated 7/29/24, indicated that Resident #70 scored a 22 (above 10 indicates high risk for falls). No additional fall risk evaluations provided. On 1/09/26 at 10:55 AM, the survey team interviewed the Director of Nursing (DON), who stated that when there was a fall, the nurse on duty did the incident report. The DON continued that the Interdisciplinary care team (IDCT) met the next morning to look for the root cause of the fall, and interventions were put into place immediately, before investigation was complete. The DON stated as a team, the fall was reviewed to look at what happened, and the care plan was updated with intervention(s) to prevent further falls. The DON stated they contacted whoever was needed for the intervention (i.e. therapy if PT or OT was indicated). The DON stated when the investigation was complete, we changed the interventions if needed. A review of the facility provided policy Falls - Clinical Protocol, dated revised March 2018, which included:Assessment and Recognition .2. In addition, the nurse shall assess and document/report the following .h. Precipitating factors, details on how the fall occurred .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations, etc .Cause Identification: 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .2. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes .Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation . 3. On 1/05/25 at 10:44 AM, the surveyor observed Resident #27 in the activities room, seated in a high back wheelchair, well dressed, groomed, asleep and was not awakened by the surveyor's voice. The surveyor reviewed the medical record for Resident #27. According to the resident's admission Record, Resident #27 was admitted to the facility with diagnoses that included but not limited to; hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect arms, legs and facial muscles) following cerebral infarction (stroke due to disrupted blood flow to the brain) affecting left non-dominant side and epilepsy. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 2 out of 15, which indicated the resident had a severely impaired cognition. Section E -Behavior reflected the Resident #27 did not exhibit behaviors related to the rejection of care. Section GG, Functional Abilities, reflected Resident #27 was dependent (helper does all the effort) for upper and lower body dressing and toileting (adjust clothes before and after voiding or bowel movements). A further review of the MDS under Section J1800 Falls revealed the resident had a fall that resulted in an injury (skin tears, abrasion, laceration, superficial bruises, hematomas and sprain; or any fall -related injury that caused the resident to complain of pain). A review of the facility Risk Management Report (RMR) dated 8/12/25 at 6:45 PM, revealed Resident #27 had fallen while being turned on their right side, by the Certified Nursing Assistant (CNA). The report was prepared by the Licensed Practical Nurse (LPN) who was alerted by the CNA. The LPN also documented that the Resident #27's leg hit the floor while their body remained on the bed. The RMR did not include Resident #27's signed statement but was described as aware of who they were and the situation. Further review of the RMR reflected that on 8/13/25, the interdisciplinary (IDCP) team met to discuss Resident #27's fall and resulted in staff education of positioning the resident in the center of the bed before turning to one side or the other. A review if the individualized comprehensive care plan (CP) for Resident #27 under falls did not include the incident that occurred on 8/13/25, and the CP was not updated after that fall, including that the fall occurred and the intervention discussed of proper positioning Resident #27 required prior to being turned to one side or the other. On 1/09/26 at 10:15 AM, during an interview with the surveyor, the Licensed Practical Nurse/Charge Nurse stated that the Director of Nursing (DON) was responsible for updating the resident's CP. On 1/09/26 at 10:49 AM, during an interview with the surveyor, the DON stated that the Assistant Director of Nursing (ADON) was responsible for collecting the data for all incidents and accidents reported and that she as the DON reviewed the information the ADON collected. The DON stated that after a fall, the interdisciplinary team (included the DON, ADON, social services, rehabilitation services and activities) met as a team to review and placed interventions prior to the completion of investigation to prevent further falls. On 1/09/26 at 12:02 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concerns regarding Resident #27's CP was not updated to include the intervention discussed during the IDCP meeting on 8/13/25, to prevent falls. A review of the provided policy titled; Managing Falls and Fall Risk included that the staff would monitor and document each resident's response to interventions intended to reduce falling or risk of falling. No further information was provided. N.J.A.C. 8:39-27.1(a)

Based on interview and document review, it was determined that the facility failed to have a system in place to ensure a) prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which including dietary and housekeeping. The deficient practice was identified for 28 of 55 (50%) employee files reviewed that were provided by the facility (99 out of 154 employee files were not able to be provided by the facility).The evidence was as follows: A review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 included:Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: . 4.Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment or residents or misappropriation of resident property. On 1/5/26 at 9:40 AM, the surveyor requested a list of all employees, including contracted employees, that had been hired since 6/28/24 (last recertification survey date) and included employee name, date of hire, title, and date of separation (if applicable) from the Human Resources Director (HRD). On 1/6/26 at 7:55 AM, the HRD provided the list of 154 employee names with their status, title, department, date of hire and termination date (if applicable). The surveyor requested the HRD to provide all of the corresponding new hire documentation, including medical information, for the 154 employee names on the list. Thirty-five of the employees were listed as working for the Dietary and Housekeeping Department which was contracted with the facility. On 1/07/26 at 9:00 AM, the HRD provided the surveyor with 55 out of a total of 154 employee files requested. A review for employee files revealed the following:Employee # 2 was hired on 8/14/25, and a criminal background search was completed and dated 11/5/25 (22 days after employee #2 began working).Employee # 3 was hired on 9/4/25, and a criminal background search was completed and dated 11/4/25 (61 days after employee #3 began working).Employee # 7 was hired on 7/10/25, and there was no criminal background report report in the file. Employee # 8 was hired on 7/30/25, and a criminal background search was completed and dated 11/5/25 (98 days after employee #8 began working).Employee # 11 was hired on 5/29/25, and there was no criminal background report in the file. Employee # 12 was hired on 8/1/24, and a criminal background search was completed and dated 10/29/25 (89 days after employee #12 began working).Employee # 13 was hired on 6/5/25, and a criminal background search was completed and dated 10/30/25 (146 days after employee #13 began working).Employee # 14 was hired on 12/3/24, and a criminal background search was completed and dated 3/25/25 (112 days after employee #14 began working).Employee # 15 was hired on 9/5/25, and a criminal background search was completed and dated 10/29/25 (54 days after employee #15 began working).Employee # 17 was hired on 9/4/25, and a criminal background search was completed and dated 10/29/25 (55 days after employee #17 began working).Employee # 18 was hired on 7/17/25, and there was no criminal background report in the file. Employee # 19 was hired on 3/13/25, and a criminal background search was completed and dated 10/29/25 (230 days after employee #19 began working).Employee # 20 was hired on 8/28/25, and there was no criminal background report in the file. Employee # 22 was hired on 3/27/25, and a criminal background search was completed and dated 10/29/25 (216 days after employee #22 began working).Employee # 25 was hired on 1/7/25, and a criminal background search was completed and dated 10/29/25 (295 days after employee #25 began working).Employee # 28 was hired on 8/14/25, and a criminal background search was completed dated 10/30/25 (76 days after employee #28 began working).Employee # 31 was hired on 5/19/25, there was no criminal background report in the file. Employee # 32 was hired on 7/29/24, and a criminal background search was completed dated 10/30/25 (93 days after employee #32 began working).Employee # 37 was hired on 6/26/25, a criminal background search was completed and dated 11/4/25 (131 days after employee #37 began working).Employee # 38 was hired on 9/4/25 a criminal background search was completed and dated 11/4/25 (61 days after employee #38 began working).Employee # 39 was hired on 7/10/25, and there was no criminal background report in the file. Employee # 42 was hired on 8/21/25, a criminal background search was completed and dated 11/4/25 (76 days after employee #42 began working).Employee # 44 was hired on 2/7/25, a criminal background search was completed and dated 2/13/25 (Five days after employee #44 began working).Employee # 45 was hired on 7/31/25, a criminal background search was completed and dated 11/5/25 (36 days after employee #45 began working).Employee # 46 was hired on 7/24/25, a criminal background search was completed and dated 11/4/25 (88 days after employee #46 began working).Employee # 47 was hired on 9/1/25, a criminal background search was completed and dated 10/20/25 (50 days after employee #47 began working).Employee # 49 was hired on 9/6/24, a criminal background search was completed and dated 11/4/25 (59 days after employee #49 began working). Employee # 52 was hired on 5/22/25, a criminal background search was completed and dated 11/5/25 (162 days after employee #52 began working).Employee # 55 was hired on 9/11/24, a criminal background search was completed and dated 11/4/25 (54 days after employee #55 began working). On 1/07/26 at 12:27, PM, the HRD in the presence of the Licensed Nursing Home Administrator (LNHA), confirmed that they were unable to provide all requested employee files. The HRD stated we cannot find them. When asked how do you know that all the employees were not excluded to work based on a criminal back search, they were unable to answer.On 1/9/26 at 8:19 AM, the LNHA provided a copy of the Master Dining Service Agreement (Contractor) executed on 12/20/23 and commencing on January 1, 2024, the Contractor would provide the services identified on Exhibit B. Exhibit B which revealed: Management and Labor Responsibilities: Background checks for employees, at its cost, as required by, and in compliance with applicable federal and stated law. The Client Responsibilities section revealed: Vaccines, other physical and medical exams and tests, and drug screenings not required by the applicable state and federal authorities. On 1/9/26 at 9:30 AM, the Food Service Director provided a copy of an unsigned Dining Services Director/Account Manager Job Description which revealed under Job Function . Maintains personnel files in a locked cabinet. On 01/09/26 at 10:02 AM, the HRD confirmed that the background checks that were provided were what was available and confirmed that all background checks and references were not completed for all employees prior to date of hire. The HRD stated, I can't do references and background checks for employees that have been terminated. On 01/09/26 at 11:38 AM, the HRD confirmed that she had never received any of the 35 employee files requested from the Contractor and was unable to confirm if the required background checks were completed prior to hire. On 01/09/26 at12:01 PM, during and exit conference held with the LNHA and Director of Nursing, no further information was provided.NJAC 8:39-9.3(b)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure a) sufficient and competent staff were available to provide timely and appropriate incontinence care, showers, and feeding assistance for residents who were dependent on staff for Activities of Daily Living (ADL's) care, b) ensure staff were available to supervise residents identified as high fall risks, c) competent to reposition a resident in bed so the resident did not sustain a fall, and d) ensure minimum Certified Nurse Aide staffing requirements were consistently met. The deficient practice was evidenced for 5 of 5 residents who attended a resident council meeting, 4 of 4 residents reviewed for ADLs (Resident #9, Resident #22, Resident #73, Resident #74) and 2 of 2 residents reviewed for accidents (Resident #7 and Resident #27) and affected all residents who resident at the facility.The evidence was as follows: The deficient practice was as follows:Refer to F610, F677 & F689a) On 1/5/26 at 10:12 AM, during the initial tour of the facility, a strong odor of urine was permeated in the hallway. The surveyor continued the tour and entered Resident #22's room. A strong urine odor was noted in the room. The surveyor asked a Certified Nurse Aide (CNA) to assist with an incontinence tour. Resident #22 had 2 incontinence briefs on and was soiled with urine and feces. The CNA exited the room and returned 10 minutes later. The surveyor asked CNA #1 to check if the resident was incontinent. The surveyor observed Resident #22 wearing two incontinence briefs, the 1st brief was saturated with urine and soiled with feces. CNA #1 informed the surveyor that the 11:00 PM to 7:00 AM, staff provided care and left the two briefs on the resident. The surveyor then asked CNA #1 to ask the charge nurse to come to the room.On 1/5/26 at 10:30 AM, the surveyor summoned the Licensed Practical Nurse (LPN) Charge Nurse to the room and we both observed that the incontinent briefs were soiled with urine and feces. The LPN stated in the presence of CNA #1, that the resident should not have been wearing two incontinence briefs.On 1/6/26 at 8:30 AM, the surveyor observed the resident in the bathroom, CNA #2 was in the room making the bed. During an interview with CNA#2, she stated that the resident was aware of their incontinence needs, the resident required assistance with transfer from the bed to the bathroom.On 1/6/26 at 9:20 AM, the surveyor conducted an interview with Resident #22. The resident informed the surveyor that they did not request to wear two incontinence briefs. The resident stated that they were aware when they had to use the bathroom.On 01/07/2026 10:10 AM, the surveyor interviewed the Director of Nursing regarding incontinence care protocol. The DON stated incontinence care was to be provided every 2 hours and as needed. The DON also stated that no resident should have 2 incontinence briefs on, as the skin could be affected. The DON stated that she was made aware of the issue with the above resident, in-service education was done, she will provide the in-service education regarding incontinence care. On 01/07/2026 at 12:16 PM, the surveyor interviewed again CNA #1 who cared for Resident #22 on 1/5/26. The CNA admitted and contradicted the earlier statement provided to the surveyor and admitted that she placed the two briefs on the resident. CNA #1 stated again that the resident was a heavy wetter it is much easier for the resident and staff. The surveyor then asked CNA #1 what should be done for a resident that was frequently incontinent, CNA #1 stated, change them, or assist them to the bathroom.b. On 1/05/26 at 10:18 AM, the surveyor observed Resident #74 in bed. When asked about how their stay had been at the facility Resident #74 stated it's bad here and the resident stated, I am paralyzed. Resident #74 stated they wanted to be transferred to [another facility name] and the Social Worker (SSD) had been made aware. Resident #74 also reported that a couple weeks ago they called 911 because the staff did not feed me breakfast. Resident #74 stated they were worried because it was after 10:00 AM and the staff did not feed me, and Resident #74 stated that they were a diabetic and they started feeling unwell. Resident #74 also reported that they had not received a shower since they were admitted to the facility. The resident stated that every time the resident asked for a shower the staff stated the water was cold.On 1/06/26 at 9:22 AM the surveyor requested the Unit Manger (UM) provide documentation of the showers that were given to the residents. The surveyor reviewed the facilities shower binder for Skin Monitoring: Comprehensive CNA Shower Review Sheets (SRS) for December 2025 and January 2026. There were none found for resident #74. In addition, there were no skin assessments found in the medical record for resident #74. On 1/06/26 at 9:30 AM, the surveyor interviewed the Unit Manger (UM) regarding the Skin Monitoring: Comprehensive CNA SRS for Resident #74. In the presence of the surveyor, the UM reviewed the shower binder and was unable to find any shower sheets for Resident #74. The UM stated she would look for them. No further information was provided. On 1/06/26 at 12:15 PM Resident #74 stated I used to get a shower at the other facility. I would get out of bed for a shower oh yes! On 1/06/26 at 12:43 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that she had taken care of Resident #74. She stated that their shower days were Wednesday and Sunday 7 AM- 3 PM. The resident's CNA stated that she always offered Resident #74 a bed bath not a shower. CNA stated, they can't stand and don't like the shower bench and if they refused, I would document refused in the CNA documentation system. The surveyor then reviewed the CNA documentation system for December 2025 and January 2026 CNA task Bathing: Self Performance revealed Resident Refused column was left blank every day since Resident #74's admission date which was approximately one month prior. On 01/08/26 at 10:44 AM, the DON confirmed there were no SRS available for Resident #74. She stated I will look through the progress notes to see if they received the care. She further stated that the staff informed her that the Resident #74 refused a shower. c. On 1/5/26 at 10:28 AM, during the initial tour, the surveyor observed Resident #9 in bed, and the surveyor inquired about the care provided at the facility. Resident #9 stated there had been multiple times that they had been left unattended in wet incontinence briefs and linens for hours. Resident #9 also stated that one time they called 911 due to not being provided with incontinence care and the police responded to the facility. d. On 1/6/26 at 10:13 AM, two (2) surveyors interviewed Resident #27 regarding the care that they received. Resident #27 stated their name and was aware that they resided in a long-term care facility. Resident #27 also stated that they had anticipated a medical appointment related to follow-up brain surgery that was scheduled for 12/29/25, and Resident #27 shared that they were eager to see their physician because of the persistent deep pain they felt in their head. Resident #27 added that nobody from the facility came to get them dressed and ready for their appointment on the morning of 12/29/25. Upon request for incident reports the facility provided a Risk Management Report (RMR) dated 8/12/25 at 6:45 PM which revealed Resident #27 had fallen while being turned on their right side, by the Certified Nursing Assistant (CNA). The report was prepared by the Licensed Practical Nurse (LPN) who was alerted by the CNA. The LPN also documented that the Resident #27's leg hit the floor while their body remained on the bed. Further review of the RMR reflected that on 8/13/25, the interdisciplinary (IDCP) team met to discuss Resident #27's fall and resulted in staff education of positioning the resident in the center of the bed before turning to one side or the other.e. On 1/7/26 at 9:00 AM, during morning care, Resident #7 informed the Certified Nurse Aide (CNA) they would like to have a shower instead of being washed in the bed. The CNA did not provide a shower. The CNA informed the resident that their shower was scheduled for the 3:00 PM to 11:00 PM shift on Thursday. During an interview with the CNA she confirmed that Resident #73 had asked for a shower that morning, and she did not provide the shower as Resident #73 was scheduled to receive a shower on the 3:00 PM-11:00 PM shift. The CNA did not relay the request for a shower with the nurse. According to a review of the electronic medical record, Resident #73 had been hospitalized since 12/30/25. On 1/7/26 at 9:30 AM, Resident #73 asked the surveyor if they could arrange for them to have a shower. The resident reported that they had not had a shower since last week. The surveyor exited the room and went to the nursing station to inquire regarding Resident #73's shower day. During an interview with the Charge Nurse (CN), she stated that Resident #73 was scheduled to have a shower on Monday during the 3:00 PM-11:00 PM shift. The CN reviewed the shower log and the progress notes in the presence of the surveyor and was unable to locate any documentation regarding whether Resident #73 was offered or had refused a shower on 1/5/26 (scheduled shower day) during the 3:00 PM-11:00 PM shift.On 1/7/26 at 9:45 AM, the CNA confirmed that Resident #73 asked for a shower on 1/7/26 but did not provide the shower due to the resident shower being scheduled for the 3:00 PM-11:00 PM shift. f. On 1/6/6 at 10:30 AM, the surveyor conducted a resident council meeting with six alert residents and 6 of 6 residents reported the following concerns:A delay in answering the call lights during the 3:00 PM-11:00 PM and the 11:00 PM-7:00 AM shift. The residents reported concerns with care and staffing on the weekends, which were the worst regarding short staffing. One resident reported they had not had a shower since November 2025 and were only offered a bed bath, and 5 of 6 residents stated they would not be offered a shower on their scheduled shower day. The residents stated that staff would answer the lights and stated they would come back, and they never returned. Another resident stated they witnessed their roommate use the call bell and it took close to an hour for someone to respond. The surveyor discussed the above concerns with the Director of Nursing (DON) and no additional information was provided.g. On 1/5/26 at 12:30 PM, the facility provided a copy of the facility assessment (FA) which completed by the prior Licensed Nursing Home Administrator on 2/10/25 and revealed under Staff training/education and competencies 3.6 Describe the staff training/education and competencies that are necessary to provide the level and tapes of support and care needed for your resident population . It may be helpful to review specific references in the regulation regarding the facility assessment .Consider the following training topics (this is not an inclusive list) . A review of the Matrix for Provided (a required document that lists diagnoses for the resident population) that was provided by the Director of Nursing (DON) revealed facility residents had pressure ulcers, required nutritional support by a feeding tube, had falls, indwelling urinary catheters and one resident had a colostomy. On 01/09/26 at 8:43 AM, the surveyor asked the LNHA to review the FA and show the surveyor the competencies and training requirements identified for the staff based on the resident population. The LNHA stated, I can't say I see it. On 01/09/26 at 11:20 AM, the surveyor interviewed the Infection Preventionist (IP) /Staff Educator. The surveyor asked if the IP had a schedule on training that she completed for the staff. The IP stated that she did not have a schedule of training for the staff and confirmed that competencies were not completed. The IP provided a binder of education that was completed, and stated education was completed in relation to specific incidents that had occurred with residents. h. Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021:One Certified Nurse Aide (CNA) to every eight residents for the day shift.One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties.Staffing had been calculated for the following time frames and revealed the following: 1. For the 2 weeks of staffing prior to survey from 12/21/2025 to 01/03/2026, the facility was deficient in CNA staffing for residents on 3 of 14 day shifts as follows:-12/21/25 had 5 CNAs for 52 residents on the day shift, required at least 6 CNAs. -12/28/25 had 5 CNAs for 57 residents on the day shift, required at least 7 CNAs. -01/02/26 had 6 CNAs for 56 residents on the day shift, required at least 7 CNAs. On 1/9/26 at 12:02 PM, the above concerns regarding incontinence care and showers were presented to the Licensed Nursing Home Administrator and the Director of Nursing at the pre-exit conference and additional information was requested.01/09/26 at 8:43 AM, the surveyor asked the Licensed Nursing Home Administrator (LHNA) how the facility ensured that the staffing met the needs of the residents. The LNHA stated the staffing coordinator or nursing filled the positions when nursing staff had called out. When asked if the nursing department reported to the LNHA if staffing was adequate, he stated typically yes, but not all the time. The surveyor asked if the facility met the staffing requirements and he stated, we try to. On 1/9/26 at 1:30 PM, during the exit conference, no additional information was provided. no additional information was provided.A review of the facility's policy titled, Activities of Daily Living (ADLs) Supporting last revised 3/2018 revealed the following:Policy StatementResidents will be provided with care and services as appropriate to maintain or improve their ability carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate.A review of Resident Rights as documented in the facility admission Agreement revealed: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Self Determination: The resident has a right to be treated with respect and dignity, including, the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of the resident choice. The resident has a right to choose activities, schedules (including sleeping and waking times) NJAC 8:39-27.1 (a)2(g)(h); 8:39-4.1

Based on interview and document review it was determined that the facility failed to ensure that annual performance reviews were completed for Certified Nurse Aides (CNAs) and ensure that education was provided based on the outcome of the review. The deficient practice was evidenced for 5 of 5 CNA records reviewed and was evidenced by the following: requested CNA files. A performance review had not been completed for all five of five CNAs: CNA #1, Date of Hire (DOH) 7/29/24CNA #2, DOH 7/30/2024CNA #3, DOH 8/08/2024CNA #4, DOH 9/06/2024CNA #5, DOH 11/07/2024On 01/07/26 at 12:30 PM, the Human Resources Director (HRD) confirmed that she did not have the performance reviews. On 01/09/26 at 10:02 AM, the HRD stated that performance evaluations were the responsibility of the department heads where the employee worked. The HRD stated sometimes the department heads provided copies and sometimes they did not. Performance evaluations are completed by the manager of the department where the employee works. Admin is responsible for department heads are responsible. Sometimes they give them to me and sometimes the manager keeps themOn 01/09/26 at 11:48 AM, the DON confirmed no competencies were completed for any CNAs and there was no training based on performance evaluations. NJAC 8:39-43.17(b)

Based on observation, interview and document review it was determined that the facility failed to have a system in place to ensure menus were prepared using standard meal planning guides, and recipes were utilized with portion sizes to ensure menus were nutritionally adequate. This deficient practice was evidenced by the following: On 1/5/26 at 10:00 AM, the Food Service Director provided a copy of the for week menu cycle and the surveyor requested the extensions/portion sized for all diets. On 01/06/26 at 12:03 PM, during the lunch preparation observation in the remote dining pantry, the surveyor observed staff utilize a 2- ounce scoop and prepared portions of cucumber salad that were placed in a plastic cup with a lid. When asked the staff how much the portion of the salad should be, she stated 4 ounces, and then showed the surveyor the blue handled ice cream type scoop which was a 2-ounce scoop. On 01/06/26 at 12:12 PM, the surveyor asked the Food Service Director (FSD) where the portion sizes were listed for staff to ensure that the proper portions were served? The FSD stated it should be on the meal ticket, and reviewed a meal ticket and confirmed there were no portion sized listed. The FSD confirmed the portion sizes were not listed on the menu either. Portion sizes or meal extensions/ portion sizes were not provided for the menus. On 01/06/26 at 12:36 PM, the surveyor interviewed the Executive Chef (EC) about the menus and asked to show the surveyor the recipes used for the menu items. The EC stated, we don't have them. When asked who reviewed the menus for nutritional adequacy? The EC stated that he and the FSD made the menus. When asked if the Registered Dietitian (RD)reviewed the menus also, he stated he hasn't seen her as the RD didn't work for the company. When asked about a nutritional analysis of the menus or a process used to develop the menus. He stated, I don't have that. When asked if that would be important to have, he responded, yes, for maintaining nutritional value of the menu. When asked how much cucumber salad was supposed to be served to the residents, he stated it should be at least a 4 ounce portion. The surveyor shared the observations of 2 ounce portion of the cucumber salad.On 01/06/26 at 1:18 PM, the surveyor interviewed the Registered Dietitian (RD) and asked if she worked with the kitchen on the menus? The RD stated she did not work with the kitchen and when asked if portion sizes, recipes and a nutritional analysis were important to have regarding the menus? The RD stated it was important to to ensure the residents were adequately served and the menus met the dietary guidelines. NJAC 8:39-17.2(b); 17.4(3)

Based on observation, interview, and document review, it was determined that the facility failed to ensure a) food was stored in a manner to ensure it was utilized by a safe use- by date, and b) the kitchen and remote service kitchen environment and equipment was maintained in a sanitary manner to prevent potential contamination from foreign substances and limit the potential for the development a food borne illness. This deficient practice was evidenced by the following:On 01/05/26 at 9:48 AM, the surveyor conducted an initial tour of the kitchen with the Executive Chef (EC) and Food Service Director (FSD) and observed the following:-The EC utilized a hair net on his face which did not cover all of his facial hair above lip and on sides. -Staff was observed using the dish-machine to clean dishware/food preparation equipment and while the dish machine was functioning the surveyor observed that the wash gauge did not register a temperature. The surveyor observed a hot water booster directly under the dish machine. The surveyor alerted the FSD to the observation and the FSD stated, we were not aware. When asked if the facility had a hot water booster, the FSD responded to the surveyor that he, didn't know. The surveyor observed the temperature log for the dish machine that was affixed to the wall which listed a wash temperature and 5 out of 13 entries, did not have staff initials documented next to the temperatures. The surveyor then interviewed the staff (FSW) that was observed doing the dishes and asked how was a temperature documented if the gauge did not function? The FSW stated that he just found out this morning and I did what I was told to do.Continued with EC and observed:-The fan in the walk in refrigerator unit was soiled with embedded dust like debris which was also affixed to the celling.-A partially sealed bag of scallions located on a shelf, had no use by date and the ends were shriveled.-A bin of celery, a box of carrots and a box of onions had no use by date. When asked the EC if there should be a use -by date, he stated yes.-An opened box of 4 ounce yogurts had no use by date, and the yogurts and box was stamped best by January 3rd, 2026 and the EC stated they expired on Saturday and removed the box. At 10:06 AM, a District Manager (DM) for the Management Company joined the tour.-The Dry storage area had food stored on metal racks which had visible debris affixed to the racks throughout the store room. The surveyor used a piece of paper to remove the debris and showed the EC. The surveyor asked when the racks were last cleaned and he stated he did not know and confirmed the surveyor's observations. -Visible dark and crumb like debris were observed behind the cooking area including the stoves and ovens. - English muffins were located in a reach in freezer without a use by date.- The large and small blender were both stored upright and were wet inside. The FSD stated nothing should be holding water.-The ceiling in the kitchen had visible splatters. -Underneath the metal shelf pass through by the food preparation area was heavily soiled with debris. On 1/5/26 at 10:29 AM, the surveyor observed the skilled nursing remote food service pantry with the FSD present, and observed the following:-One person was utilizing an under the counter dish machine to clean up the breakfast dishes. The same staff was removing clean dishes and placing dirty dishes into the machine without washing hands. When asked the FSD if one person was allowed to go from clean to dirty without washing hands, he stated, no.-The staff was observed with a rack of insulated bowls that were visibly wet and piled on top of one another, and the staff took each bowl and proceeded to wipe them with a rag on the inside. The surveyor asked if it was okay to use a rag to wipe the bowls and showed him the wet bowls piled up. The FSD stated the bowls should be air dried and stated only one staff was scheduled for dishes in the pantry.-The refrigerator in the pantry had an internal thermometer that did not register temperature and the FSD stated it was not working and needed to be removed.-The gaskets on the refrigerator were ripped in several areas and there was visible splatter and debris inside of the refrigerator. -The refrigerator contained 8 of the same 4-ounce expired yogurts that were observed in the main kitchen. The staff stated they brought the yogurts to the pantry from the main kitchen.On 1/5/26 at 2:14 PM, the surveyor received the requested report from the dish machine service company which detailed that all three temperature gauges for the dish machine and two fuses in the hot water booster were replaced due to broken temperature gauges. On 01/06/26 at 12:03 PM, the surveyor observed the meal service preparation in the pantry and observed a stack of 11 meal trays that staff confirmed were used to deliver meals to the rooms. The Food Preparation Policy, Revised 9/2017 revealed: 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services Staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical contamination. The Cold Foods Storage Policy, Revised 4/2018 revealed: 4. An accurate thermometer will be kept in each refrigerator . NJAC 8:39-17.2(g)

Based on observations, interviews, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. Prior to the survey, the surveyor accessed the facility website which listed the facility name as The Fountains at Atco at the address listed for the registered name Allegria at the Fountains. On [DATE] at 9:00 AM, upon arrival to the facility, the surveyors observed signage on the building which read The Fountains at Atco. That name did not correspond with the CMS licensed, approved name and provider registered name Allegria at the Fountains.On [DATE] at 9:05 AM, upon entering the facility, the surveyors observed signage on the wall which documented the License for 60 Long Term Care beds and was issued [DATE] from the New Jersey Department of Health, and Expired [DATE] which listed the facility name The Fountains of Atco, which differed from the exterior signage. The Centers for Medicare and Medicaid Services (CMS), Clinical Laboratory Improvement Amendments certificate, identified the facility name as Allegria at the Fountains. On [DATE] the surveyor requested from the Licensed Nursing Home Administrator (LNHA) any communication from CMS that confirms they have accepted the name change for the facility. The LNHA provided a copy of an approval from the New Jersey Department of Health, Certificate of Need and Licensing dated [DATE], that approved the transfer of ownership and name change to the Fountains of Atco. The LNHA did not provide information from CMS. No additional information regarding the facility's name change was provided to the survey team. NJAC 8:39-5.1 (a)

Based on interview, record review and document review it was determined that the facility failed to ensure the facility assessment addressed the skill sets, and competencies required by staff to provide care to the resident population. The deficient practice affected all residents and was evidenced by the following: On 1/5/26 at 12:30 PM, the facility provided a copy of the facility assessment (FA) which completed by the prior Licensed Nursing Home Administrator on 2/10/25 and revealed under Staff training/education and competencies 3.6 Describe the staff training/education and competencies that are necessary to provide the level and tapes of support and care needed for your resident population . It may be helpful to review specific references in the regulation regarding the facility assessment .Consider the following training topics (this is not an inclusive list) . A review of the Matrix for Provided (a required document that lists diagnoses for the resident population) that was provided by the Director of Nursing (DON) revealed facility residents had pressure ulcers, required nutritional support by a feeding tube, had falls, indwelling urinary catheters and one resident had a colostomy. On 01/09/26 at 8:39 AM, the surveyor interviewed the LNHA regarding what was the purpose of the FA. The LNHA stated it identified the care and services the facility offered and he stated it was completed prior to his arrival. When asked if he had reviewed it, he stated I did not. On 01/09/26 at 8:43 AM, the surveyor asked the LNHA to review the FA and show the surveyor the competencies and training requirements identified for the staff based on the resident population. The LNHA stated, I can't say I see it. NJAC 8:39-5.1(a)

Based on observation, interview and document review it was determined that the facility Quality Assurance and Performance Improvement (QAPI) committee failed to self-identify systems and processes that may negatively affect resident quality of care, quality of life and review significant events implement data driven QAPI program. The deficient practice affected all residents who resided at the facility and was evidenced by the following: Refer to 607F, 610E, 677E, 684E, 689H, 742DOn 1/5/26 at 10:12 AM, the surveyor observed Resident #22 lying in bed in their room. There was a strong urine odor in the room. The resident was alert and informed the surveyor that he/she was soiled. The surveyor left the room and informed the Certified Nursing Aide (CNA) if he could assist with an incontinence tour observation. The CNA exited the room and returned 10 minutes later. The surveyor asked CNA #1 to check if the resident was incontinent. The surveyor observed Resident #22 wearing two incontinent briefs which were saturated with urine and soiled with feces.On 1/05/26 at 10:18 AM, the surveyor observed Resident #74 in bed. When asked about how their stay had been at the facility Resident #74 stated it's bad here and the resident stated, I am a veteran. Resident #74 stated they wanted to be transferred to [another facility name]and the Social Worker (SW) had been made aware. Resident #74 also reported that a couple weeks ago they called 911 because the staff did not feed me breakfast. A review of Resident #74's electronic medical record revealed the resident had a history of Post Traumatic Stress Disorder (PTSD) that the facility had not identified.On 1/05/2026 at 10:28 AM, the surveyor observed Resident #9 lying in bed. Resident stated there have been multiple times that they have been left in wet brief and linens were also wet for hours. Resident #9 also stated that one time they called 911 was and the Police responded due to the staff not helping them.On 1/5/26 at 11:00 AM, the surveyor observed Resident #7 in the dayroom seated at a table alone, and seven other residents were in the room, and no staff observed in attendance. At 11:20 AM the surveyor observed a staff coming from the other room, the staff who identified herself as the activity aid, informed the surveyor she had to provide activity and monitor both rooms as she does not have any help. The facility had 2 dayrooms where the CNA placed the residents after care for activity, (room [ROOM NUMBER] and room [ROOM NUMBER]). According to the activity aid, the facility had one staff assigned to both activity rooms. There was no staff observed in the first room to supervise the residents while the activity aid had to monitor the residents in Room # 2 (the purple room).On 1/5/26 at 12:30 PM, the facility provided a copy of the facility assessment (FA) which completed by the prior Licensed Nursing Home Administrator on 2/10/25 and revealed under Staff training/education and competencies 3.6 Describe the staff training/education and competencies that are necessary to provide the level and tapes of support and care needed for your resident population . It may be helpful to review specific references in the regulation regarding the facility assessment .Consider the following training topics (this is not an inclusive list) . A review of the Matrix for Provided (a required document that lists diagnoses for the resident population) that was provided by the Director of Nursing (DON) revealed facility residents had pressure ulcers, required nutritional support by a feeding tube, had falls, indwelling urinary catheters and one resident had a colostomy. On 1/6/26 at 10:13 AM, during an interview with two (2) surveyors, Resident #27 stated their name and was aware that they resided in a long-term care facility. Resident #27 also stated that they had anticipated their appointment the night before 12/29/25 and was eager to see their physician because of the persistent deep pain they felt in their head. Resident #27 added that nobody came to get them dressed and ready for their appointment on the morning of 12/29/25 and did not refuse the appointment. The resident stated that they felt dizzy, had cramping pain and headache, the resident used their finger to indicate the pain was from the back base of their neck, radiated to the back of their head and removed their head scarf to show the pain radiated from their right hemi craniotomy (temporarily removing part of the skull to create space for a swollen brain). On 1/6/26 at 11:15 AM, the surveyor observed Resident #7 seated alone at a table. The resident attempted to stand and was moving back and forth in the wheelchair. Resident #7 appeared restless. The activity aid was in the next room and could not visualize what was going on in the first room. On 1/7/26 at 10:11 AM, the surveyor observed the resident in activity with 6 other residents, there was no staff in attendance. The resident attempted to stand; another resident had to ask the resident to sit down. The surveyor walked to the next room and observed the Activity staff in the back of the purple room, with her back facing the entrance door to the room, looking through some papers. She could not visualize the residents. At 10:18 AM, the surveyor was about to exit the door to get a staff at the nursing station to assist Resident #7, when the Activity staff came to the room and stated she had to get something in the next room. She was not aware that the surveyor had been in the first room, as the room is divided by a wall, and she was in the back of the purple room. A review of the electronic medical records for Resident #7, along with facility provided documents identified the resident as being at high risk for falls, was impulsive, required supervision, and sustained 13 falls including three falls with injury that required transfer to the emergency room on 8/10/25 for a contusion and laceration to the left supraorbital and frontal scalp; on 10/28/25 for a large intramuscular hematoma to the right thigh, and on 11/14/25 for a closed head injury and laceration to the forehead which required sutures.On 1/07/26 at 12:27, PM the Human Resources Director (HRD) with the LNHA present, confirmed that they were unable to provide all requested employee files, HRD stated we cannot find them.On 01/09/26 at 8:39 AM, the surveyor interviewed the LNHA regarding what was the purpose of the FA. The LNHA stated it identified the care and services the facility offered and he stated it was completed prior to his arrival. When asked if he had reviewed it, he stated I did not. On 01/09/26 at 8:43 AM, the surveyor asked the LNHA to review the Tacitly Assessment and show the surveyor the competencies and training requirements identified for the staff based on the resident population. The LNHA stated, I can't say I see it. The surveyor asked about the QAPI process and how would a QAPI plan be initiated? The LNHA stated when department heads identified and issue in the department, they would complete audits. The LNHA stated that the department head would bring the concern to the QAPI meeting they would discuss it at the QAPI meeting and develop audits to rectify the problem and the goal would be set at 100%. The LNHA stated the problem must be identified, the measures in place for review, data must be collected for each QAPI. The surveyor asked the LNHA what the current QAPI plans were and he stated per the most recent QAPI meeting, held on 10/9/25, the current QAPI plans were: 1. Residents with weight loss completed by the Registered Dietitian.2. Pharmacy consultant report. 3. Antibiotic Stewardship. 4. Rehabilitation from the former rehabilitation company.5. Number of grievances.6. Dietary (not related to sanitation).7. Radiology and Cardiology.8. Wheelchair cleaning.When asked if there was a review of significant events, including when 911 was called by two residents, the employee files that were not available, and there was no QAPI plans related to staffing, related to failure to identify residents with Post Traumatic Stress Disorder and for not having a system in place to ensure resident were sent to appropriate appointments, or appointment outside of the facility were rescheduled as needed. The LNHA stated he was unaware of how bad the employee files were and moving forward he would do more QAPI plans. NJAC 8:39-27.1(a)

Based on observations, interviews, review of facility policies and review of pertinent facility documentation, it was determined that the facility failed to develop a system to prevent the spread of potential influenza (flu) by ensuring a process was in place to monitor employee flu vaccination to prevent potential transmission of influenza to residents. This deficient practice had the potential to affect all resident who resided at the facility and was evidenced by the following:Reference: Infection Prevention and Control Strategies for Seasonal Influenza in Healthcare Settings; Health Care Providers (HCP); April 28, 2025.On January 13, 2020, Governor [NAME] signed P.L. 2019 c. 330 (codified at N.J.S.A. 26:2H-18.79 and referred to hereafter as the Statute). The Statute requires certain healthcare facilities to establish and implement an annual influenza vaccination program. The New Jersey Department of Health (Department) is required by the Statute to promulgate rules and designate a medical exemption form to be distributed to the covered healthcare facilities. This memo and the attached form are intended to assist general or special hospitals, nursing homes (long-term care facilities licensed pursuant to N.J.A.C. 8:39), and home health care agencies, collectively referred to as facility or facilities, in understanding and meeting their obligations under the Statute, until the rules and the medical exemption form can be adopted through rulemaking.All facility employees are required to be vaccinated, including employees who are not responsible for direct patient care. Per diem and contract employees are to be considered facility employees and are required to be vaccinated.Facilities are required to review and confirm each medical exemption to ensure the exemption is consistent with standards enumerated by the Advisory Committee on Immunization Practices, which can be found at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html.Facilities must maintain a record or attestation, as applicable, of influenza vaccinations and medical exemptions for each employee. The Department will address through rulemaking proper procedures for submitting data to the Department.The facility must require any employee who does not receive an influenza vaccination to wear a surgical or procedural mask when in direct contact with patients and in common areas, as specified in facility policy, or to be removed from direct patient care responsibilities during influenza season. On 1/7/26 at 11:22 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the staff flu vaccine process, and she stated that there were many exemptions for the flu vaccine and those staff members must wear a mask during flu season.On 1/7/26 at 11:55 AM, the surveyor reviewed the facility provided documentation for staff flu vaccinations provided by the IP. The surveyor noted that 24 out of 75 employees (32%) were documented to have refused the flu vaccine for the current flu season. No medical documentation was found for these refusals. Many of the declination forms had no reason for refusal noted, other had various reasons including but not limited to will make me sick, I am satisfied that I possess sufficient/substantial antibodies, personal beliefs, I just do not want the vaccination at this time, religious reasons, I do not feel that it is effective in preventing the flu - there are many different strains and I am willing to take a chance, and my family never gets it. When I was 12 we stopped because I ended up getting it even though I got the shot.On 1/7/26 at 12:09 PM, the surveyor interviewed the Director of Nursing (DON), who stated she was unaware of employee flu vaccine refusals and would provide more information.On 1/08/2026 at 9:28 AM, the surveyor interviewed the IP who stated she was not aware of the current guidance for the flu vaccine including the New Jersey statute of 2020. She stated that she reminded managers to ensure their employees are wearing masks and wearing them properly. When asked if she does any audits regarding wearing masks and wearing them correctly, she stated she has no audits, and if I see a problem, I tell them. On 1/08/2026 at 9:53 AM, the surveyor interviewed the DON, who stated she was unaware any current guidance for the flu vaccine including the NJ state statute of 2020.No further information was provided by the facility.A review of facility provided policy Influenza Vaccine, not dated included:Policy StatementAll residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or resident' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Policy Interpretation and Implementation1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless vaccine is medically contraindicated, or the resident or employee has already been immunized.2. Employees hired or residents admitted between October 1st, and March 31st shall be offered the vaccine within 5 working days of the employee's job assignment or the resident's admission to the facility.3. Employees will be offered the influenza vaccine at no charge, at a location onsite.4. Prior to the vaccination, the resident or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record.5. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record.7. If an employee refuses the vaccine for reasons other than medical contraindication, this shall be documented on the employee informed consent for influenza vaccine.10. Residents and staff may obtain their influenza vaccines from their personal physicians. Documentation of pervious vaccination should be provided to the facility.11. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.N.J.A.C. 8:39-19.4(a)

Based on interview and document review, it was determined that the facility failed to develop and implement a staff training program and ensure staff were competent to provide care and services for the resident population as identified on the facility assessment. The deficient practice was evidenced by the following: On 1/5/26 at 12:30 PM, the facility provided a copy of the facility assessment (FA) which completed by the prior Licensed Nursing Home Administrator on 2/10/25 and revealed under Staff training/education and competencies 3.6 Describe the staff training/education and competencies that are necessary to provide the level and tapes of support and care needed for your resident population . It may be helpful to review specific references in the regulation regarding the facility assessment .Consider the following training topics (this is not an inclusive list) . A review of the Matrix for Provided (a required document that lists diagnoses for the resident population) that was provided by the Director of Nursing (DON) revealed facility residents had pressure ulcers, required nutritional support by a feeding tube, had falls, indwelling urinary catheters and one resident had a colostomy. On 01/09/26 at 8:43 AM, the surveyor asked the LNHA to review the FA and show the surveyor the competencies and training requirements identified for the staff based on the resident population. The LNHA stated, I can't say I see it. On 01/09/26 at 11:20 AM, the surveyor interviewed the Infection Preventionist (IP) /Staff Educator. The surveyor asked if the IP had a schedule on training that she completed for the staff. The IP stated that she did not have a schedule of training for the staff and confirmed that competencies were not completed. The IP provided a binder of education that was completed, and stated education was completed in relation to specific incidents that had occurred with residents. On 01/09/26 at 11:48 AM, the surveyor interviewed the Director of Nursing (DON) regarding any education or staff competencies that were completed for staff. The DON stated she was aware that the 12 hours of Certified Nurse Aide (CNA) education had been completed, and there was no additional staff education or competencies based on the CNAs performance evaluation.NJAC-8:39-33.4

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure investigations were initiated to determine if potential abuse and neglect had occurred when residents who were dependent on staff to provide care, contacted 911 due to the facility not providing incontinence care or assistance with meals. This deficient practice was identified for 2 of 2 residents (Resident #9 and Resident #74) reviewed for abuse and neglect and was evidenced by the following:a. On 1/5/2026 at 10:28 AM, during the initial tour, the surveyor observed Resident #9 in bed, and the surveyor inquired about the care provided at the facility. Resident #9 stated there had been multiple times that they had been left unattended in wet incontinence briefs and linens for hours. Resident #9 also stated that one time they called 911 due to not being provided incontinence care and the police responded to the facility. On 1/6/2026 at 8:58 AM, the surveyor interviewed Resident #9 again regarding the date the 911 call was made, and the resident was unable to recall.On 1/6/26 AT 11:10 am, the surveyor reviewed the electronic medical record (EMR) which revealed the following: A review of the admission Face Sheet (an admission summary) reflected that Resident #9 was admitted to the facility with a diagnosis which included but was not limited to, fracture of the left fibula (a bone in the lower leg).admission Minimum Data Set (MDS), an assessment tool, dated 12/4/25, which indicated Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive function and that the resident was occasionally incontinent of bowel and bladder.A review of the individual comprehensive care plan (ICCP) included a focus area dated 12/1/25, that the resident was continent of bowel and bladder with goals that the resident would remain continent of bowel and bladder. A focus area dated 12/1/25 for toileting was also noted with an intervention that the resident needs total assistance of one with toileting. There was no information related to calling 911 documented on the care plan. A review of the EMR from 11/30/25 through 1/6/26 did not reveal any progress notes or ICCP related to the resident making a call to 911.On 1/06/2026 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #9 called 911 about ten days ago. When asked if she would complete an investigation of any 911 calls made by residents? The DON stated, yes, they should be investigated.On 1/07/2026 at 2:37 PM, the survey team interviewed the DON who stated that a resident complaining of not receiving care that was so bad that resident called 911, could be allegation of neglect. She also stated that this should be investigated and that she would absolutely investigate what happened and if it was neglect she would definitely report it (to the Department of Health).b. On 1/05/26 at 10:18 AM, the surveyor observed Resident #74 in bed. When asked about how their stay had been at the facility Resident #74 stated it's bad here and the resident stated, I am paralyzed. Resident #74 stated they wanted to be transferred to a [another facility name] and the Social Worker (SSD) had been made aware. Resident #74 also reported that a couple weeks ago they called 911 because the staff did not feed me breakfast. Resident #74 stated they were worried because it was after 10:00 AM and the staff did not feed me, and Resident #74 stated that they were a diabetic and they started feeling unwell. On 1/06/2026, at 10:00 AM the surveyor reviewed the medical record for Resident #74 which revealed the following:According to the facility admission Record, an admission summary, reflected that Resident #74 was admitted to the facility with diagnoses that included, Quadriplegia (paralysis affecting all four limbs), C1-C4 complete (level of injury in the cervical (neck) spinal cord, Depression (mental health disorder), Type 1 Diabetes Mellitus (chronic autoimmune disease), Hypothyroidism (thyroid gland dysfunction), Gastro-Esophageal Reflux Disease (GERD) (digestive disorder) and Anemia (low red blood cells). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/08/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Section GG was left blank.A review of the individual comprehensive care plan (ICCP) included a Focus area dated 12/8/25, Eating; Goals included that the Dining needs will be met through the next review date. A Intervention revealed the resident needs total assistance of 1 with dining.A review of the Physician History and Physical note dated 12/21/25 revealed that Resident #74 was seen in bed talking to 911 and reporting not being fed breakfast.On 1/06/26 at 11:34 AM, the surveyor interviewed the DON regarding Resident #74's telephone call to 911. The DON stated if a resident had called 911 the incident should have been documented in the medical record and investigation should have been completed. The DON confirmed she was not aware that Resident #74 called 911 and had no investigation to provide. On 1/07/2026 at 12:46 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA), who stated he has been employed at this facility since October (2025).He stated that he was the Abuse coordinator and he has received training with in-services and videos during orientation. He stated that he tried to go to morning meeting and he did not keep any notes from meetings. He stated that he was notified if law enforcement entered the facility. The LNHA stated he is notified of 911 being called and if the police asked to speak with LNHA. On certain days the DON would be the next person responsible, and he stated, there was a list that include the Assistant Director of Nursing and other staff would be contacted to ensure someone was made aware that the law enforcement were in the facility. When asked, If resident was not being changed, or assisted with meals to the point that the resident contacted 911, could that be potential neglect per the facility abuse policy? The LNHA stated I would have to investigate and that he was not sure if it was potential neglect. He further stated that he was not aware of 911 being called and that law enforcement were contacted for either Resident #9 or Resident #74. When asked if he had been aware that resident complaints of not being assisted with meals, or not being changed, severe enough that the resident called 911, would that be investigated. The LNHA stated, yes. On 1/08/26, after surveyor inquiry, the DON provided the surveyor with a Grievance Report dated 1/07/26. A review of the Grievance Report revealed that Resident #74 reported that they became increasingly anxious when they had not received their breakfast on 12/21/25. Resident #74 stated that they had a panic attack and called 911. No further information was provided by the facility. A review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 included:Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriating of property by anyone including, but not necessarily limited to: 2. Develop and implement policies and protocols to prevent and identify a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.Review of facility provided policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, included:Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Policy Interpretation and ImplementationReporting Allegations to the Administrator and Authorities 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations:1. All allegations are thoroughly investigated. The administrator initiates investigations.7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s)reporting the incident. e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resdient during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to who the accuse employee provides care or services; k. reviews all events leading up to the alleged incident; and l documents the investigation completely and thoroughly 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. NJAC 8:39-9.4(f)

COMPLAINT #2704937 Based on observation, interview, and record review, it was determined that the facility failed to provide a communication device for a resident identified as having language barrier. This deficient practice was identified for one (1) of one (1) resident (Resident #27) reviewed for language and communication deficits and was evidenced by the following: Refer to 684EA review of the Complaint #2704937 reflected an alleged event date on 12/29/25 at 8:15 AM showed the family representative arrived at the hospital on that day at 8:00 AM that day, to meet the resident and was told that the facility cancelled the appointment. The family representative then arrived at the facility at 8:15 AM and spoke with Resident # 27 who spoke minimal English. On 1/5/26 at 10:44 AM, the Certified Nursing Assistant (CNA #1) assigned to the resident that day entered Resident #27's room with the surveyor. At that time, the CNA #1 could not locate a communication device and confirmed that a communication board was no communication board inside the resident's room. The surveyor reviewed the medical record for Resident #27. According to the resident's admission Record (AR; or face sheet; admission summary) reflected the resident was admitted to the facility with diagnoses that included but not limited to; hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect arms, legs and facial muscles) following cerebral infarction (stroke due to disrupted blood flow to the brain) affecting left non-dominant side and epilepsy. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/11/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated the resident had a severely impaired cognition. Section A1100. Language reflected Resident #27's preferred language was [dialect redacted] and needed an interpreter. A review of the individualized comprehensive care plan included a focus on communication that was initiated/revised on 8/22/25. The interventions were dated/ revised on 8/22/25, included that there were staff that spoke the same dialect and were able to translate. The family of Resident #27 was also available via phone to translate, and the resident had a communication board in their room. On 1/6/26 at 1:42 PM, during an interview with the surveyor, CNA #2 stated that the family arrived on 12/29/25 to go with the resident in the transport to help with translation, the resident doesn't speak English, you know. On 1/6/26 at 2:45 PM, during an interview with the surveyor, the Medical Doctor/ Director (MD) stated he could not speak the same language as Resident #27 and communicated with the resident by speaking slowly and by looking at the resident. The MD confirmed that he did not use a translation device or service, nor did the facility provide those services. On 1/7/26 at 11:03 AM, during an interview with the surveyor, the Licensed Practical Nurse/ Charge Nurse (LPN/CN) stated that they did not have a translation or ancillary communication device in the facility. On 1/7/26 at 11:07 AM, in the presence of the DON and the surveyor, the LPN/CN provided binders to the surveyor that had words with corresponding images. The LPN/CN informed the surveyor that she found the binders for translation was found underneath the bedside table. At that time, the surveyor discussed the concern with the communication device that the staff was not aware of and could not be located prior to surveyor inquiry. On 1/9/26 at 12:02 PM, during a meeting with the survey team the Licensed Nursing [NAME] Administrator and the Director of Nursing, the surveyor discussed the concern with the communication device that the staff was not aware of. A review of the provided facility policy titled; Translation Services dated/revised on 1/2020 included that the facility maintained a contracted relationship with a translation service for language and sign language. Family members and friends shall not be relied upon to provide interpretation services fir the resident unless explicitly requested by the resident. Family and friends used to interpret must have a written consent for disclosure of protected health information. No further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADLs) were provided with timely and appropriate incontinence care, showers, and feeding assistance The deficient practice was evidenced for 4 of 4 residents reviewed for ADLs (Resident #9, Resident #22, Resident #73, Resident #74) and was evidenced by the following:a) On 1/5/26 at 10:12 AM, during the initial tour of the facility, a strong odor of urine was permeated in the hallway. The surveyor continued the tour and entered Resident #22's room. A strong urine odor was noted in the room. The surveyor asked a Certified Nurse Aide (CNA) to assist with an incontinence tour. Resident #22 had 2 incontinence briefs on and was soiled with urine and feces. The CNA exited the room and returned 10 minutes later. The surveyor asked CNA #1 to check if the resident was incontinent. The surveyor observed Resident #22 wearing two incontinence briefs, the 1st brief was saturated with urine and soiled with feces. CNA #1 informed the surveyor that the 11:00 PM to 7:00 AM, staff provided care and left the two briefs on the resident. The surveyor then asked CNA #1 to ask the charge nurse to come to the room. On 1/5/26 at 10:30 AM, the surveyor summoned the Licensed Practical Nurse (LPN) Charge Nurse to the room and we both observed that the incontinent briefs were soiled with urine and feces. The LPN stated in the presence of CAN #1, that the resident should not have been wearing two incomitance briefs. On 1/6/26 at 8:30 AM, the surveyor observed the resident in the bathroom, CNA #2 was in the room making the bed. During an interview with CNA#2, she stated that the resident was aware of their incontinence needs, the resident required assistance with transfer from the bed to the bathroom. On 1/6/26 at 9:20 AM, the surveyor conducted an interview with Resident #22. The resident informed the surveyor that they did not request to wear two incontinence briefs. The resident stated that they were aware when they had to use the bathroom. On 01/07/2026 10:10 AM, the surveyor interviewed the Director of Nursing regarding incontinence care protocol. The DON stated incontinence care was to be provided every 2 hours and as needed. The DON also stated that no resident should have 2 incontinence briefs on, as the skin could be affected. The DON stated that she was made aware of the issue with the above resident, in-service education was done, she will provide the in-service education regarding incontinence care. On 01/07/2026 at 12:16 PM, the surveyor interviewed again CNA #1 who cared for Resident #22 on 1/5/26. The CNA admitted and contradicted the earlier statement provided to the surveyor and admitted that she placed the two briefs on the resident. CNA #1 stated again that the resident was a heavy wetter it is much easier for the resident and staff. The surveyor then asked CNA #1 what should be done for a resident that was frequently incontinent, CNA #1 stated, change them, or assist them to the bathroom. b. On 1/05/26 at 10:18 AM, the surveyor observed Resident #74 in bed. When asked about how their stay had been at the facility Resident #74 stated it's bad here and the resident stated, I am paralyzed. Resident #74 stated they wanted to be transferred to [another facility name] and the Social Worker (SSD) had been made aware. Resident #74 also reported that a couple weeks ago they called 911 because the staff did not feed me breakfast. Resident #74 stated they were worried because it was after 10:00 AM and the staff did not feed me, and Resident #74 stated that they were a diabetic and they started feeling unwell. Resident #74 also reported that they had not received a shower since they were admitted to the facility. The resident stated that every time the resident asked for a shower the staff stated the water was cold. On 1/06/26 at 9:22 AM the surveyor requested the Unit Manger (UM) provide documentation of the showers that were given to the residents. The surveyor reviewed the facilities shower binder for Skin Monitoring: Comprehensive CNA Shower Review Sheets (SRS) for December 2025 and January 2026. There were none found for resident #74. In addition, there were no skin assessments found in the medical record for resident #74. On 1/06/26 at 9:30 AM, the surveyor interviewed the Unit Manger (UM) regarding the Skin Monitoring: Comprehensive CNA SRS for Resident #74. In the presence of the surveyor, the UM reviewed the shower binder and was unable to find any shower sheets for Resident #74. The UM stated she would look for them. No further information was provided. On 1/06/26 at 12:15 PM Resident #74 stated I used to get a shower at the other facility. I would get out of bed for a shower oh yes! On 1/06/26 at 12:43 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that she had taken care of Resident #74. She stated that their shower days were Wednesday and Sunday 7 AM- 3 PM. The resident's CNA stated that she always offered Resident #74 a bed bath not a shower. CNA stated, they can't stand and don't like the shower bench and if they refused, I would document refused in the CNA documentation system. The surveyor then reviewed the CNA documentation system for December 2025 and January 2026 CNA task Bathing: Self Performance revealed Resident Refused column was left blank every day since Resident #74's admission date which was approximately one month prior. On 01/08/26 at 10:44 AM, the DON confirmed there were no SRS available for Resident #74. She stated I will look through the progress notes to see if they received the care. She further stated that the staff informed her that the Resident #74 refused a shower. c. On 1/5/26 at 10:28 AM, during the initial tour, the surveyor observed Resident #9 in bed, and the surveyor inquired about the care provided at the facility. Resident #9 stated there had been multiple times that they had been left unattended in wet incontinence briefs and linens for hours. Resident #9 also stated that one time they called 911 due to not being provided with incontinence care and the police responded to the facility. On 1/9/26 at 12:02 PM, the above concerns regarding incontinence care and showers were presented to the Licensed Nursing Home Administrator and the Director of Nursing at the pre-exit conference and additional information were requested. On 1/9/26 at 1:30 PM, during the exit conference, no additional information was provided. no additional information was provided. A review of the facility's policy titled, Activities of Daily Living (ADLs) Supporting last revised 3/2018 revealed the following: Policy Statement Residents will be provided with care and services as appropriate to maintain or improve their ability carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate NJAC 8:39-27.1 (a) 2 (g) (h)

Complaint # NJ 2704937Based on observation, interviews, and record review, it was determined that the facility failed to ensure that a system was developed and implemented that enabled residents to attend outside physician appointments in accordance with resident needs, goals for care, and professional stands of practice. This deficient practice was identified for one (1) of one (1) resident (Resident# 27) reviewed for Activities of Daily Living (ADL) and was evidenced by the following: On 1/5/26 at 10:51 AM, Resident #27 was observed asleep in the activities room and appeared well dressed and groomed. The surveyor reviewed the medical record for Resident #27. According to the resident's admission Record (AR; or face sheet; admission summary) reflected the resident was admitted to the facility with diagnoses that included but not limited to; hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect arms, legs and facial muscles) following cerebral infarction (stroke due to disrupted blood flow to the brain) affecting left non-dominant side and epilepsy. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/11/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated the resident had a severely impaired cognition. Section A1100. Language reflected Resident #27's preferred language was [dialect redacted] and needed an interpreter. Further review of the MDS under, Section E -Behavior reflected the Resident #27 did not exhibit behaviors such as rejection of care. Section GG Functional Abilities reflected Resident #27 was dependent (helper does all the effort) for upper and lower body dressing. A review of the physician's progress notes (PN) revealed two entries made by the provider in the resident's electronic medical record (eMR) which were on 9/8/24 and 11/25/24 and reflected the following:The Physician PN dated 9/24/24 was the comprehensive overview of Resident #27's heath status and indicated the resident underwent a right hemi craniotomy (temporarily removing part of the skull to create space for a swollen brain) after a stroke that caused swelling in one side of the brain.The Physician PN dated 11/25/24, included that the resident had left sided weakness and to follow-up with Neurology.No Physician PN were found for 2025 and 2026.On 1/6/26 at 10:13 AM, during an interview with two (2) surveyors, Resident #27 stated their name and was aware that they resided in a long-term care facility. Resident #27 also stated that they had anticipated their appointment the night before 12/29/25 and was eager to see their physician because of the persistent deep pain they felt in their head. Resident #27 added that nobody came to get them dressed and ready for their appointment on the morning of 12/29/25 and did not refuse the appointment. The resident stated that they felt dizzy, had cramping pain and headache, the resident used their finger to indicate the pain was from the back base of their neck, radiated to the back of their head and removed their head scarf to show the pain radiated from their right hemi craniotomy (temporarily removing part of the skull to create space for a swollen brain).On 1/6/26 at 2:45 PM, during a meeting with three surveyors, the Medical Director (MD) stated that he had his own eMR where he documented the resident's PN and transferred into the facility's eMR. The MD also stated that his office copied then pasted the information into the facility's eMR and that there must have been something that went wrong that occurred with transcribing the 2025 PNs. The MD stated he would look into the matter. At that time, the physician could not recall if he was informed by the facility of the missed appointment on 12/29/25. The MD also stated that the resident's headache could be related to the hemi craniotomy and could be related to the reason why he referred the resident to the Neurologist. The MD stated he would upload and forward the information to the surveyor. A review of the provided Physician PN that was uploaded into the facility's eMR reflected the following: On 4/15/25 at 3:39 PM, (late entry) the Physician PN included the resident had left sided weakness, recommended continuation of fall safety precautions, experienced headache, received Fioricet as needed (headache pain reliever) and recommended a follow-up with Neurosurgery/Neurology; On 8/12/25 at 3:25 PM, (late entry) the Physician PN included the resident had left sided weakness, recommended continuation of fall safety precautions, experienced headache, received Fioricet as needed (headache pain reliever) and recommended a follow-up with Neurosurgery/Neurology; On 1/6/25 at 4:01PM, (late entry) the Physician PN included that the resident was seen as a follow-up of the missed appointment [after surveyor inquiry]. Resident #27 complained of dizziness and the physician recommended a follow-up with Neurology. On 1/7/26 at 11:07 AM, during a meeting with the Director of Nursing (DON), the surveyor inquired if the DON was aware that there were no Physician PN on record prior to surveyor inquiry and discussed the concern that ancillary health care staff were not able to view the physician notes.On 1/7/26 at 2:07 PM, a follow up interview was held at the DON in which she confirmed that Resident #27 did not refuse to the physician appointment on 12/29/25.On 1/6/26 at 10:27 AM, during an interview with the surveyor, the Assistant Director of Nursing stated that appointments were scheduled and then documented in the resident's progress note.On 1/6/26 at 11:01 AM, during an interview with the surveyor, the Licensed Practical Nurse/Charge Nurse (LPN/CN) stated the unit clerk (UC) handled the scheduling and was not at work that day. The LPN/CN stated she also scheduled appointments for the residents and then it was written on the white bulletin board and in progress notes. According to the LPN/CN the December 2025 scheduled appointments were not kept for the record and had no additional information to provide. The LPN/CN stated that any appointments missed for any reason such as transportation, refusals or family member cancellation would be documented under the resident's progress notes. On 1/6/26 at 1:42 PM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated she learned from the Charge Nurse, or the Assistant Director of Nursing (ADON), or the Director of Nursing (DON) when a resident had an appointment so that she could get the resident ready for an appointment. The CNA recalled Resident #27 had missed an appointment last week and stated that she was not informed by anybody to get the resident ready for that appointment. The CNA also did not recall the resident's name being listed on the appointment/white board. On 1/6/26 at 1:56 PM, the surveyor and the ADON reviewed the Resident #27's PN together. At that time, the ADON confirmed that there were no documented notes made by facility staff that the resident refused to attend their appointment. The ADON also confirmed that the PN did not reflect the physician was made aware of the missed appointment, a rescheduled follow-up appointment with the Neurologist was not found prior to surveyor inquiry. On 1/9/26 at 12:02 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), and the DON, the surveyor discussed the concern regarding with Resident #27 who had communication deficits, was dependent on staff for upper and lower body dressing, was not assisted, and prepared by staff to attend their Neurosurgeon/Neurologist appointment that was recommended by the Medical Director since November 2024. Additionally, the surveyor discussed the concern that the facility failed to reschedule the appointment prior to surveyor inquiry and failed to inform the physician that the appointment he recommended was missed. A review of the facility provided policy titled; Charting and Documentation included the following information to be documented in the resident medical record: objective observation, treatment and services performed, events, incidents or accidents involving the resident.whether the resident refused the procedure/treatment, notification of family, physician, or other staff.The facility was unable to provide any policy regarding scheduling of resident appointments.NJAC 8:39-11.2(b); 27.1 (a)

Based on observation, interview, and record review, it was determined the facility failed to dispose of medications for one (1) of one (1) medication refrigerator and for one (1) of one (1) medication room inspected. The deficient practice was evidenced by the following:On 1/7/26 at 10:33 AM, in the presence of the Licensed Practical Nurse/Charge Nurse (LPN/CN), the surveyor inspected the medication refrigerator and observed the following: -Spikevax (Moderna COVID-19 Vaccine) the pharmacy label reflected, thawed on 10/10/25 and an expiration date of 12/10/25.-discharged Resident #78's one (1) box of Brovana (used for Chronic Obstructive Pulmonary Disease; COPD). Resident #78 was discharged on 11/29/25.-discharged Resident #79's one (1) box Cosentyx (biological medication used for chronic inflammatory condition. Resident #79 was discharged on 9/2/25.-discharged Resident #52's one box (1) of Wegovy (biological used to reduce excess body weight). Resident #52 was discharged on 12/31/25. At that time, the LPN/UM stated that the nurses on the 11:00 PM to 7:00 AM shift and the consultant pharmacist checked for expired medications, and both should have removed the discharged resident's medications from active inventory. On 1/7/26 at 10:59 AM, the surveyor observed 8 boxed of Santyl that belonged to Expired/Unsampled Resident #81 who expired on 7/24/25. At that time, the LPN/UM stated she would remove the items from active inventory A review of the most recent Consultant Pharmacist unit inspection dated 12/11/25 reflected that there was no expired medication in the storage area. The facility's compliance rate for December 2025 was 95.12%. On 1/7/26 at 11:03 AM, the surveyor discussed the concerns found during the inspection of the medication refrigerator and medication room. A review of the undated, provided facility policy titled; Medication Labeling and Storage included that the dispensing pharmacy is contacted for instruction regarding returning or destroying discontinued, outdated or deteriorated medications or biologicals. No further information was provided. NJAC 8:39- 29.4(a) (g)(h), 29.7(a)

Based on interview and record review, it was determined that the facility failed to provided rehabilitation services per physician order to ensure a resident reached their highest physical and practical level. The deficient practice was evidenced for 1 of 1 resident reviewed for rehabilitation services (Resident #74) and was evidenced by the following:On 01/05/26 at 10:18 AM, the surveyor observed Resident #74 in bed and when asked how things were going at the facility, Resident #74 stated, it's bad here, I am paralyzed. Resident #74 stated they wanted to be transferred to [another facility name]. Resident #74 also reported that a couple weeks ago they called 911 because the staff was not assisting them with eating breakfast and was worried because they were Diabetic (a condition where your body doesn't make enough insulin and may require insulin to utilize food as energy). The resident also reported that they had not received physical therapy since they were admitted because the facility was waiting for an authorization. On 1/6/25 at 11:00, the surveyor reviewed the medical record for Resident #74 which revealed the following:A hospital Discharge summary, dated [DATE], detailed Resident #74 was treated for acute tetraplegia secondary to spinal epidural abscess due to ESBL (extended spectrum beta-lactamase) E-coli (Escherichia) bacteremia (a sudden onset of paralysis affecting all four limbs due to a severe infection). Treatment prior to transfer and recommendations included: Upper extremity swelling stable, spinal cord injury, occupational therapy addressing upper extremity with splints and positioning; History of sacral wound resolved, continue with turning every two hours, [manufacture name pressure relieving] boots while in bed, specialty mattress .; Description of Further Services Needed: Aspiration Precautions: upright positioning during meals and for at least 30 minutes after. Slow rate, small bites, small/single sips, repeat swallows. Monitor for signs/symptoms aspiration. Discontinue food by mouth if any difficulty noted. Hand Splints: Please DON (put on bilateral resting hand splint on hands after dinner and remove in the AM before breakfast. The Physician Orders, active as of 12/1/26, were reviewed and an Occupational and Physical Therapy Evaluation and Treat as indicated was ordered on 12/8/25. There was no speech therapy evaluation although the resident had a percutaneous endoscopic gastrostomy tube (feeding tube) and aspiration precautions were identified as further services. There were no orders related to the hand splints. There was no therapy documentation or assessment completed per the physician orders on 12/8/25. On 01/06/26 at 11:34 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The surveyor asked about the therapy for Resident #74. The DON stated that she spoke with Resident #74 the previous day regarding the need for the facility to get an authorization prior to providing therapy services. The DON stated she asked for occupational therapy to show her how to stretch Resident #74's arms and legs so she could do it when she was there. The DON stated the resident doesn't want to get out of bed due to being uncomfortable. The DON confirmed Resident #74 has not received any therapy since they were admitted on [DATE] and the Social Worker needed to follow- up to obtain authorization.On 01/06/26 at 12:15 PM, the surveyor asked Resident #74 about receiving therapy services and they stated, I've been waiting for the therapy authorization and stated they used a motorized wheelchair at the prior facility but was unable to take it with them. Resident #74 stated that they got up two weeks ago via a mechanical lift. On 01/06/26 at 1:17 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) if the facility accepted an admission would the facility wait until they received payment authorization prior to providing therapy services, despite having an order for therapy? The LNHA stated that therapy should be performed and an evaluation and treatment for Resident #74 should have occurred regardless of payment source. The LNHA stated he was unaware that Resident #74 was not provided with therapy services. NJAC 8:39-27.1(a)

Complaint #: NJ161922, NJ169428 Based on interviews, medical record review, and review of other pertinent facility documentation on 12/5/2023 and 12/6/2023, it was determined that the facility failed to ensure that the process of receiving medications from an outside pharmacy vendor was followed by staff. It was determined on 3/4/2023 that a Security Guard (SG) working at the main lobby of the facility received a mailed package addressed to Resident #2 with his/her name and room number on the unopened package. The SG delivered the unopened package to Resident #2 . Resident #2 is cognitively impaired and SG failed to give this package to nursing staff , so the package could be opened by resident with staff present. After SG left package with Resident #2, a Certified Nursing Assistant (CNA) observed the resident with an opened bottle of Risperdal 2 milligrams (mg) (a medication used to treat to treat schizophrenia) which contained 30 tables was empty. The Registered Nurse/Supervisor (RN/Supervisor) was made aware, the empty bottle with the label Risperdal 2mg was retrieved along with other unopened bottles of medications that were in the delivered package to Resident #2's room. The Physician was made aware and emergency response number 911 was called by facility staff. Resident #2 was sent to the emergency room (ER) for evaluation and treated for overdose with no adverse effects noted. This deficient practice of failure to follow facility policy and proceedures for the delivery of packages of medications posed a safety hazard for residents with cognitive impairment to be accessible to encounter hazardous items that could cause injury, harm or death. The Immediate Jeopardy Past Non -Compliance began on 3/4/2023 and ended on 3/6/2023 after the facility educated all staff, residents and family members on the new mail delivery process and revised the delivery policy. The facility- initiated monitoring of all incoming mail with the resident's knowledge to ensure that this does not reoccur. The facility submitted the following document at the time of the survey that indicated the following: 1.Security will not be delivering packages to any residents. 2. Any items coming in from the outside that may cause any risk to the resident and the facility will be monitored, with the resident's knowledge, upon delivery to the resident. 3. On 3/6/2023 the facility in-serviced security, Nursing and all staff about the new mail delivery process. The Mail deliver policy was revised. 4. No other incident has occurred since the new system has been implemented. There is sufficient evidence that the facility corrected the non-compliance and is in substantial compliance at the time of this Complaint Survey for the specific F689 regulatory requirements. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for incidents and accidents. During a tour of the unit on 12/5/2023 at 9:00 A.M., the Surveyor did not observe any unopened packages in resident's rooms that could be a risk to the resident or facility. On 12/5/2023, a review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the Admission Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Post -traumatic stress disorder, and Unspecified Mood Disorder. According to the Minimum Data Set (MDS), an assessment tool dated 3/6/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7/15, which indicated the Resident was severely cognitively impaired. Review of the facility's form titled Incident/Accident report dated 3/4/23 and timed 4:00 p.m., under possible cause of incident Resident was confused and was given a bag of drugs and ingested 30 pills of 2mg of risperidone. Review of the facility's transfer form titled New Jersey Universal Transfer Form dated 03/04/2023 under reason for transfer reveal: Consumption of unknown amount of unknown substance. Review of Resident #2's Progress Notes (PN)dated 3/4/2023 and timed 6:01p.m., by the Social Worker Director (SWD) revealed the following: SWD working on nursing unit when CNA reported to LPN (Licensed Practical Nurse) that she had found the pt (Resident #2) with an opened package of medications and the pt (Resident #2) taking pill and having the pill bottle up to his/her mouth. Nursing immediately came to the pt's (Resident #2) room and asked him/her if they took the medication. The pt (resident #2) allegedly stated to nursing, 'I don't know. Nursing searched room for pills in sheets, pt (resident #2) clothing, on floor, in trash can, but no pills were found. Nursing alerted the doctor, the DON (Director of Nursing) and SWD alerted the LNHA and daughter of Resident #2. Vitals were taken and the pt (Resident #2) was given a 1:1 CNA (Certified Nursing Assistant) observer to report any unusual signs and symptoms of the drugs overdose which were researched from the medication alert paperwork that came with the drug. All other medications that had been delivered from the VA (Veterans Association) to the pt (Resident #2) were accounted for and the VA pharmacy was called, and verification given by VA pharmacist that signed dispense of the medication (quantity of 30) in the empty bottle was recorded. The doctor ordered the pt (Resident #2) sent to the ER (emergency room ) via 911 and the nursing Supervisor called in Nurse-to-Nurse report later and was informed that pt (resident #2) was stable and alert and aware and responsive with flat affect. The poison control center was contacted and recommended the pt (Resident #2) be sent 911 to the hospital ER. The pt (Resident #2) is presently at Virtua ER for continued evaluation. The administrator will complete the investigation. During an interview on 12/5/2023 at 11:32 a.m., the SG informed the Surveyor that he received packages from the mail on 3/4/2023 that were addressed to residents on the units. I took the packages that had the names and room numbers of residents on it and delivered to the residents. When asked by the Surveyor if he delivered a package to Resident #2's room, he stated yes, I did. During the same interview, the SG acknowledged that he didn't ask Resident #2 to open his/her package in his presence to ensure the package was safe for Resident #2 and the facility. The SG further stated that he was aware of Resident's Right to received unopened mails/packages but was not aware he could ask the residents permission to open his/her package in his presence. During a telephone interview on 12/5/2023 at 1:20 p.m., the CNA stated she saw a guy on the unit with a package and he asked for Resident #2's room, and she pointed him in the direction and went to provide care to another resident. She further stated, I didn't know who the guy was at the time. The CNA revealed that on her way back he observed Resident #2 sitting on his/her bed with an empty bottle pill bottle in his/her hand. I asked the resident (Resident #2) what he/she was doing, and they stated, I was going to drink my medicine. When asked by the Surveyor if there were any other opened bottles of pills or pills on the floor or bed, the CNA responded, No. The CNA stated she immediately went out to the nurse's station and notified the nurse of what she has seen. During a telephone phone interview on 12/5/2023 at 12:06 p.m., the RN/Supervisor stated she was notified by staff that probably Resident #2 had taken Risperdal, but they were not a 100% sure. I immediately told one of the nurses to call 911 and get the crash cart. Resident #2 was observed sitting on his/her bed, alert, awake, responsive and in no acute distress with no respiratory distress noted. Resident #2 was assessed, vitals were stable, poison control/doctor was notified, and an order obtained to transfer Resident #2 to the ER for further evaluation. The Risperdal 2mg bottle was empty, I don't remember a 100%, there was no pills on Resident #2's bed, room floor, pillow or anywhere. The RN/Supervisor acknowledged that the bottle of Risperdal was empty when she got it from Resident #2's room. I asked the staff how Resident #2 got a whole of the pills and was told, the SG delivered the package directly to Resident #2, instead of giving the package to the nursing. The RN/Supervisor revealed the rest of the unopened bottles of medications were retrieved from Resident #2's room and placed in the package and taken to the DON's office. During the same interview, when asked by the Surveyor what the process is for residents receiving mails/packages, she revealed normally all packages should be delivered to the nurse's station and we (Nurses) will take the package to the resident and ask their permission to open the package to ensure the resident is allowed to have what is in the package. When asked if the process was followed on 3/4/2023, the RN/Supervisor said, No. During an interview on 12/5/2023 at 10:07 a.m., the SWD stated the process for receiving medications from the VA pharmacy included the following steps: the medical doctor came into the facility and wrote the scripts, give them to the DON who in turn will give them to her. She would than fax the scripts over to the VA pharmacy and follow-up with a phone call for delivery time. She stated the medications were delivered in a white bag with the resident's name and room number on the bag. The bag also had the VA pharmacy address on it, and you can fill the bottles in the bag. The SWD stated on 3/4/2023, she was on the unit when the CNA notified nursing of what she observed with Resident #2. We all ran to the Resident's room. Once I got to the room, I saw the package opened with several other bottles of pills that were still intact and unopened. The Nurse had the opened bottle of Risperdal 2mg in her hand. Resident #2's daughter had ordered their medications through the VA pharmacy prior to their admission to the facility. The VA pharmacy was called to confirm all the numeric quantity of pills in each bottle that was dispensed. After the count, it was confirmed that all other medications were correct, and it was only the Risperdal 2mg bottle that was empty. When asked by the Surveyor if there was any Risperdal 2mg in the opened bottle, the SWD said, I don't remember if there was any Risperdal left in the bottle. During the same interview, the SDW said the expectation was if a package is delivered to the main lobby, the SG is expected to bring the package to the nurse's station and deliver to the nurse and advice he didn't know what was in the package. The receiving Nurse would then take the package to the resident and ask their permission to open the package in their presence to ensure it was safe for the resident to have the package. When asked if the process was followed on 3/4/2023, the SWD said, No. During an interview on 12/5/2023 at 2:06 p.m., with the DON in the presence of the Administrator, the Administrator informed the Surveyor that all packages go to the main lobby and is distributed to the various buildings. Packages of concerns go to Nursing who will than deliver to the residents, and with their permission open the package to ensure the resident's and facility's safety. He further stated, any package of possible danger or risk to the residents has to be opened in the presence of the nurse with the resident's permission. When asked if the process was followed on 3/4/2023, the Administrator said No, the package should not have been delivered directly to Resident #2. During the same interview, the DON stated, there was no policy in place on how resident's packages were delivered prior to the incident. After the incident on 3/4/2023, the facility implemented the following for the SG on monitoring packages: All mail for skilled unit must go to management to ensure it goes to the right person. Please do not deliver anything directly to the patient's room until inspected. N.J.A.C.: 8.39- 27.1 (a)

Based on interviews, record review, and facility policy review, it was determined that the facility failed to perform cardiopulmonary resuscitation (CPR) in an effort to prevent death when a resident was found without a pulse or respirations. Resident #2 was a full code, as directed by the resident's POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired. This affected 1 of 14 residents (Resident #2) reviewed for code status. The facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, §483.24(a)(3) (Quality of Life) at a scope and severity of J. On [DATE] at 12:06 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed the survey team was calling Immediate Jeopardy (IJ) for failure to perform CPR in an attempt to prevent death when a resident (a full code) was found without a pulse or respirations. On [DATE] at 4:30 PM, the immediacy was removed after onsite verification that the Removal Plan had been implemented. Findings include: 1. A review of the medical record indicated Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had severe cognitive impairment. Resident #2 required set up assistance for eating and limited to extensive assistance of one person for all other activities of daily living (ADLs). Resident #2 had no care plan indicating code status. Resident #2's medical record contained a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The form was not signed by the power of attorney; however, it indicated verbal consent was received from the resident's power of attorney and was dated [DATE]. The form was signed by a facility nurse and physician. A nurse's progress note dated [DATE] at 6:35 PM, written by Registered Nurse (RN) #11, noted in part, Resident ceased to breathe at approximately 1600 [4:00 PM]. No breath or pulse present. MD [physician] made aware. On [DATE] at 3:00 PM, Licensed Practical Nurse (LPN) #1 (the unit manager) was interviewed. LPN #1 reviewed the clinical record and identified that Resident #2's POLST form called for a full code status, stating, It does not appear as though CPR was performed. LPN #1 recalled placing a call to the resident's power of attorney on [DATE] and received verbal consent for the POLST order for full code status. LPN #1 stated when Resident #2 returned from a previous hospital stay, LPN #1 should have called the power of attorney to determine if full code measures were to remain the same for Resident #2. LPN #1 confirmed that no such call occurred and confirmed the clinical record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, no clinical record audits had been completed. LPN #1 indicated the code status issue may have been caught if someone had been auditing the clinical records. On [DATE] at 4:35 PM, the Director of Nursing (DON) was interviewed. At 4:52 PM, the DON reviewed the clinical record for Resident #2. The DON stated the progress note on [DATE] at 6:35 PM indicated the resident expired, but staff failed to initiate code interventions. The DON acknowledged that both the POLST form and a physician's note, dated [DATE], identified Resident #2's desire for full code status. The DON stated the expectation was for code status to be determined prior to admission or upon admission. On [DATE] at 1:10 PM, the Medical Director (MD) was interviewed. The MD was unable to recall if Resident #2 was a full code or a DNR. The MD stated the standard of practice was to start CPR if a resident was a full code and unresponsive. The MD was unable to state why nursing staff failed to initiate CPR for Resident #2. On [DATE] at 4:06 PM, LPN #12 was interviewed. LPN #12 was unaware if Resident #2 desired full code status. LPN #12 worked on [DATE] when the resident stopped breathing and confirmed CPR was never started on Resident #2. On [DATE] at 9:13 PM, RN #11 was interviewed. RN #11 explained a certified nursing assistant (CNA) approached her between 3:15 PM-3:30 PM to say Resident #2 had a skin tear. RN #11 recalled asking the CNA if the skin tear was bleeding or if there was an urgent need for her to go to the room. The CNA indicated the situation was not urgent. Thus, RN #11 said she did not hurry to the resident's room. RN #11 entered the resident's room about ,d+[DATE] minutes later and found Resident #2 unresponsive and not breathing. RN #11 asked LPN #12 to assist. LPN #12 confirmed the absence of vital signs. RN #11 had no memory of performing CPR on Resident #2. RN #11 stated Resident #2's code status was likely checked but was unable to recall if the resident was a full code or a DNR. On [DATE] at 9:10 AM, CNA #13 was interviewed. CNA #13 recalled coming onto her shift at 3:00 PM and initiating rounds. Around 3:30 PM, CNA #13 recalled Resident #2 was up in a wheelchair beside the bed. CNA #2 planned to transfer Resident #2 to bed to rest before dinner when a skin tear was observed on the resident's left forearm. CNA #13 left Resident #2 in the wheelchair so RN #11 could assess the skin tear. CNA #13 immediately informed RN #11 about the skin tear and informed the nurse that Resident #2 was not in any distress. CNA #13 stated Resident #2 was quiet and alert at the time. CNA #13 stated, I know [Resident #2] was up in a wheelchair and I know [Resident #2] was alive. After informing RN #11 about Resident #2's skin tear, CNA #13 moved on to assist other residents in preparation for dinner. CNA #13 stated it was not until after dinner that RN #11 informed her Resident #2 had passed away and asked for assistance in preparing the body for the family to visit. CNA #13 denied any knowledge of Resident #2's passing until speaking with RN #11 after the dinner service. A review of a facility policy and procedure, titled, Emergency Procedure - Cardiopulmonary Resuscitation (copywrite 2001 MED-PASS, Inc. Revised February 2018), indicated: Section titled - General Guidelines: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [basic life support] shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis) If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Section titled - Emergency Procedure - Cardiopulmonary Resuscitation (in part): If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automated external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. A review of a facility policy, undated, titled, Advanced Directives, indicated: Policy - Advanced Directives will be respected in accordance with state law and facility policy. Policy and Interpretation and Implementation (in part): The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. The facility, as required, developed a removal of jeopardy plan as follows: The facility charge nurse (LPN #1) and the skilled nursing coordinator (LPN #5) reviewed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Five residents had code statuses that were updated with an accurate physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was verified by the state surveyor on [DATE]. All clinical and non-clinical staff (activities, housekeeping, dining services, maintenance, security) who worked on the skilled nursing unit were educated by the DON, LPN #5, and/or the 3:00 PM to 11:00 PM RN Supervisor regarding proper procedures to follow when a resident was found unresponsive. Education was to take place prior to or at the beginning of each shift to ensure all staff had been reached with a completion date of [DATE]. On [DATE], random employee interviews revealed some employees had not received the training. On [DATE] at 4:30 PM, the facility provided updated proof of education and random employee interviews indicated training had occurred. The immediacy was removed at 4:30 PM. The facility's plan to prevent a reoccurrence included: 1. The Charge Nurse (LPN #1) and Skilled Nursing Coordinator (LPN #5) were to conduct weekly audits for four weeks to check for proper code statuses. After four weeks, code statuses would be reviewed with residents and/or legal representatives during quarterly care conferences to ensure wishes had not changed. 2. Education regarding proper procedure to follow when a resident was found to be unresponsive was to be included in the facility orientation program for all new staff during new hire orientation. Ongoing education was to be incorporated into the facility's annual education program. The clinical management team was slated to review deaths of full code residents for the next three months. The necessity of ongoing reviews was to be determined based on those results. A completion date was set for [DATE].New Jersey Administrative Code § 8:,d+[DATE].1(a)

Based on interviews, record reviews, and facility policy reviews, it was determined the facility failed to: 1. Perform cardiopulmonary resuscitation (CPR) in an effort to prevent death when a resident that was a full code was found without a pulse or respirations for one resident (Resident #2 out of 14 residents reviewed for code status; and 2. Consistently follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. A review of the medical record indicated Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had severe cognitive impairment. Resident #2 required set up assistance for eating and limited to extensive assistance of one person for all other activities of daily living (ADLs). Resident #2 had no care plan indicating code status. Resident #2's medical record contained a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The form was not signed by the power of attorney; however, it indicated verbal consent was received from the resident's power of attorney and was dated [DATE]. The form was signed by a facility nurse and physician. A nurse's progress note dated [DATE] at 6:35 PM, written by Registered Nurse (RN) #11, noted in part, Resident ceased to breathe at approximately 1600 [4:00 PM]. No breath or pulse present. MD [physician] made aware. On [DATE] at 3:00 PM, Licensed Practical Nurse (LPN) #1 (the unit manager) was interviewed. LPN #1 reviewed the clinical record and identified that Resident #2's POLST form called for a full code status, stating, It does not appear as though CPR was performed. LPN #1 recalled placing a call to the resident's power of attorney on [DATE] and received verbal consent for the POLST order for full code status. LPN #1 stated when Resident #2 returned from a previous hospital stay, LPN #1 should have called the power of attorney to determine if full code measures were to remain the same for Resident #2. LPN #1 confirmed that no such call occurred and confirmed the clinical record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, no clinical record audits had been completed. LPN #1 indicated the code status issue may have been caught if someone had been auditing the clinical records. On [DATE] at 4:35 PM, the Director of Nursing (DON) was interviewed. At 4:52 PM, the DON reviewed the clinical record for Resident #2. The DON stated the progress note on [DATE] at 6:35 PM indicated the resident expired, but staff failed to initiate code interventions. The DON acknowledged that both the POLST form and a physician's note, dated [DATE], identified Resident #2's desire for full code status. The DON stated the expectation was for code status to be determined prior to admission or upon admission. On [DATE] at 1:10 PM, the Medical Director (MD) was interviewed. The MD was unable to recall if Resident #2 was a full code or a DNR. The MD stated the standard of practice was to start CPR if a resident was a full code and unresponsive. The MD was unable to state why nursing staff failed to initiate CPR for Resident #2. On [DATE] at 4:06 PM, LPN #12 was interviewed. LPN #12 was unaware if Resident #2 desired full code status. LPN #12 worked on [DATE] when the resident stopped breathing and confirmed CPR was never started on Resident #2. On [DATE] at 9:13 PM, RN #11 was interviewed. RN #11 explained a certified nursing assistant (CNA) approached her between 3:15 PM-3:30 PM to say Resident #2 had a skin tear. RN #11 recalled asking the CNA if the skin tear was bleeding or if there was an urgent need for her to go to the room. The CNA indicated the situation was not urgent. Thus, RN #11 said she did not hurry to the resident's room. RN #11 entered the resident's room about ,d+[DATE] minutes later and found Resident #2 unresponsive and not breathing. RN #11 asked LPN #12 to assist. LPN #12 confirmed the absence of vital signs. RN #11 had no memory of performing CPR on Resident #2. RN #11 stated Resident #2's code status was likely checked but was unable to recall if the resident was a full code or a DNR. On [DATE] at 9:10 AM, CNA #13 was interviewed. CNA #13 recalled coming onto her shift at 3:00 PM and initiating rounds. Around 3:30 PM, CNA #13 recalled Resident #2 was up in a wheelchair beside the bed. CNA #2 planned to transfer Resident #2 to bed to rest before dinner when a skin tear was observed on the resident's left forearm. CNA #13 left Resident #2 in the wheelchair so RN #11 could assess the skin tear. CNA #13 immediately informed RN #11 about the skin tear and informed the nurse that Resident #2 was not in any distress. CNA #13 stated Resident #2 was quiet and alert at the time. CNA #13 stated, I know [Resident #2] was up in a wheelchair and I know [Resident #2] was alive. After informing RN #11 about Resident #2's skin tear, CNA #13 moved on to assist other residents in preparation for dinner. CNA #13 stated it was not until after dinner that RN #11 informed her Resident #2 had passed away and asked for assistance in preparing the body for the family to visit. CNA #13 denied any knowledge of Resident #2's passing until speaking with RN #11 after the dinner service. A review of a facility policy and procedure, titled, Emergency Procedure - Cardiopulmonary Resuscitation (copywrite 2001 MED-PASS, Inc. Revised February 2018), indicated: Section titled - General Guidelines: If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [basic life support] shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis) If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Section titled - Emergency Procedure - Cardiopulmonary Resuscitation (in part): If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automated external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. A review of a facility policy, undated, titled, Advanced Directives, indicated: Policy - Advanced Directives will be respected in accordance with state law and facility policy. Policy and Interpretation and Implementation (in part): The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The updated care plan, on [DATE], revealed Resident #3 had a care plan for a significant weight change. The goals and interventions were appropriate for the care of Resident #3. A review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #3's cognition was severely impaired. The resident required total dependence on staff for bed mobility, transfer, toilet use, personal hygiene, and bathing. The resident required extensive assistance for dressing and eating. Resident #3 was discharged to the hospital on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #3's February 2021 MAR revealed the following medications/supplements were not documented as given on the following days: [DATE] - [MEDICATION(S)] 3 mg (milligrams) 2 tablets at bedtime, [MEDICATION(S)] 7.5 mg daily at 8 PM and [MEDICATION(S)] 10 mg at bedtime (9 PM); [DATE] - Glucerna 8 oz (ounce) (6 PM), tamsulosin HCL 0.4 capsule daily and [MEDICATION(S)] 5 mg daily at (6 PM); and [DATE] - Glucerna 8 oz (10 AM and 2 PM). A review of Resident #3's [DATE] MAR revealed the following supplement was not documented as given on the following days: [DATE] - Glucerna 8 oz (10 AM and 2 PM); and [DATE] - Glucerna 8 oz (10 AM and 2 PM). A review of Resident #3's [DATE] MAR revealed the following supplement was not documented as given on the following days: [DATE] - Glucerna 8 oz (ounce) (6 PM); [DATE] - Glucerna 8 oz (6PM); and [DATE] - Glucerna 8 oz (2 PM). During an interview on [DATE] at 10:45 AM, Licensed Practical Nurse (LPN) #2 indicated she was taught in nursing school that if it is not documented, it was not done. During an interview on [DATE] at 11:01 AM, the Administrator indicated that he expected the facility staff to follow the MAR as written. The Administrator further indicated that if a resident refuses medication, that it would be documented appropriately. During an interview on [DATE] at 1:02 PM, the Director of Nursing (DON) indicated that if it was not documented, it was not done. During an interview on [DATE] at 1:06 PM, LPN #16 indicated that if the nurses did not document and initial the MAR, it was not done. She further indicated that sometimes the computer was slow, and she would have to click several times before her initials show up. LPN #16 indicated that she had not reported this issue. During an interview on [DATE] at 1:10 PM, LPN #1 indicated that if it was not documented, it was not done. New Jersey Administrative Code § 8:,d+[DATE].1(a)

Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) implement appropriate infection control practices related to hand hygiene and the use of Personal Protective Equipment (PPE); b.) post appropriate transmission-based precaution signage; and, c.) provide the appropriate bins for PPE storage and disposal in a manner to prevent the transmission of COVID-19 in accordance with the Center for Disease Control and Prevention (CDC) and New Jersey Department of Health (NJ DOH) guidelines. This deficient practice was identified for 1 of 3 units (200 Unit) during the Recertification survey conducted 05/03/21. The 200 Unit was the designated unit for Persons Under Investigations (PUI) for COVID-19. A review of the resident roster of the PUI unit revealed 2 of 10 residents (Residents #243 and #244) were not fully vaccinated. The facility's failure on the PUI unit to implement the use of N95 masks, eye protection, gowns, and gloves while caring for residents, post appropriate transmission-based precaution signage designating the required PPE for staff to utilize when entering a resident's room, provide PPE bins with available PPE outside of the resident rooms and provide bins to discard the used PPE inside of the rooms exposed residents to COVID-19 infection and posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for COVID-19). The facility was notified of the Immediate Jeopardy situation on 04/28/21 at 4:15 PM. On 04/29/21, the facility submitted an acceptable removal plan to the NJ DOH. On 04/29/21, while the recertification survey was in progress, the surveyors verified the implementation of the Removal Plan and determined that the Immediacy of the Jeopardy could be removed effective 04/29/21. The deficient practice was evidenced by the following: On 04/27/21 at 8:30 AM, the surveyors entered the facility and interviewed the Infection Preventionist (IP). The IP stated that the required PPE on all units (100, 200, and 300 units) was a surgical mask and that the facility was currently not in an outbreak. The IP explained that the 200 Unit was the observation or PUI unit where the residents were quarantined for 14 days upon admission or readmission to the facility. On 04/27/21 at 10:30 AM, the surveyor observed a dry erase board, displayed on an easel, at the entrance of the 200 Unit, with a hand-written notification, Please Do Not Pass this point * Thank You. The surveyor questioned LPN #1 about the signage, and she stated, Don't worry about that. LPN #1 did not inform the surveyor that the 200 Unit was the PUI unit or the required PPE to be utilized while on the unit. While on the PUI unit, the surveyor observed that all nursing staff wore only surgical masks. The surveyor did not observe transmission-based precaution signage posted to indicate the required PPE for staff to utilize when entering a room, readily available PPE supplies (masks, gown, gloves, and eye protection), or bins located inside of each room to discard the used PPE. During an interview with the surveyor on 04/28/21 at 09:08 AM, the Director of Nursing (DON) stated that the facility was comprised of three units. The 100 and 300 Units housed long-term care residents, and the required PPE for those units were surgical masks. The 200 Unit (observation/PUI unit) housed newly admitted and readmitted residents, and the required PPE were surgical masks and gloves. The DON further stated that the facility followed the recommendations of an independent Infection Control Consultant (IC Consultant), who came to the facility sometime in February or March 2021 to complete an infection control survey. At that time, the surveyor requested a copy of the consultant's recommendations, and the facility failed to provide the surveyors with a copy. During a follow-up interview with the surveyor on 04/28/21 at 9:28 AM, the DON confirmed that the new admissions/readmissions residents on the PUI unit were quarantined for 14 days and required a negative COVID-19 test prior to admission. During an interview with the surveyor on 04/28/21 at 10:12 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility required a negative COVID-19 test prior to admitting a resident from the community as well as to quarantine the resident for 14 days upon admission. The LNHA stated that their process was based on what they had been doing and that the facility had an independent infection control survey with a private IC Consultant in February or March 2021. The LNHA stated that there should be signage on the residents' doors reflecting the required PPE and indicated that it was common knowledge with the staff and the therapists. The LNHA further stated, They know the required PPE to wear. At that time, the surveyor reviewed with the LNHA the NJ DOH Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities guidance dated March 25, 2021. The LNHA stated, I believe this is the guidance that we're following, not sure if it's the updated guidance. The surveyor inquired if new admissions/readmission residents were assessed for COVID-19 exposure prior to the resident being admitted . The LNHA stated that all residents were tested before entering the facility and required a negative COVID-19 test prior to admission. The LNHA further stated, I don't know if we ask about COVID exposure prior to the resident being admitted . At that time, the surveyor requested copies of the facility's COVID-19 policies, the IC Consultant's report, and the facility's guidance for the PUI unit. The facility failed to provide the requested documents. On 04/28/21 at 8:36 AM, while on the PUI unit, the surveyor observed Resident #246 in a wheelchair at the doorway of his/her room without pants asking the Certified Nursing Assistant (CNA) #1 for pants. CNA #1 wheeled Resident #246 back into the resident's room wearing only a surgical mask. CNA#1's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care to Resident #246. The surveyor further observed CNA #1 enter the following rooms to pass out breakfast trays: room [ROOM NUMBER] beds A and B; room [ROOM NUMBER] bed A; room [ROOM NUMBER] bed B; room [ROOM NUMBER] bed B; room [ROOM NUMBER] beds A and B; room [ROOM NUMBER] beds A and B; and room [ROOM NUMBER] bed A. At that time, the surveyor observed that CNA #1's PPE consisted of only a surgical mask. CNA #1's PPE did not include an N95 mask, gown, gloves, or eye protection while delivering breakfast trays to the aforementioned residents. On 04/28/21 at 9:15 AM, while on the PUI unit, the surveyor observed two staff members providing direct therapy care for Resident #246. Both therapists were observed wearing a surgical mask over a KN95 mask, a face shield (eye protection), and gloves but not a gown. When interviewed at that time, the Occupational Therapist stated that the PPE required on the PUI unit was a mask with a face shield and only gloves when touching the resident but not a gown. On 04/28/21 at 9:07 AM, while on the PUI unit, the surveyor observed CNA #1 feeding two residents (Residents #21 and #341) in the same room. CNA #1's PPE consisted of only a surgical mask that was positioned below the nose. When interviewed at that time, CNA #1 stated the mask should cover the nose. CNA #1's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care (feeding) to Residents #21 and #341. On 04/28/21 at 9:30 AM, while on the PUI unit, the surveyor observed CNA #2 removing breakfast trays from several resident rooms on the PUI unit wearing only a surgical mask positioned below the nose. CNA #2 was not wearing an N95 mask, gown, gloves, or eye protection. When interviewed at that time, CNA #2 stated that the PUI unit housed residents with admissions and readmissions from the hospital, the community, long-term care, and assisted living. CNA #2 further said that the staff needed to wear only a surgical mask on the PUI Unit. On 04/28/21 at 11:22 AM, while on the PUI unit, the surveyor observed Resident #246's spouse visiting in the room without wearing a mask. The surveyor further observed the mask was lying on the bed. When interviewed at that time, Resident #246's spouse stated, Ooh, and donned the mask lying on the bed. On 04/28/21 at 11:24 AM, while on the PUI unit, the surveyor observed LPN #2 at the medication cart gathering supplies to obtain a resident's blood glucose level. LPN #2 enter Resident #342's room without performing hand hygiene or donning gloves, obtained the resident's blood glucose level, and exited the room without performing hand hygiene. At that time, the surveyor observed that LPN #2's PPE consisted of only a surgical mask. LPN #2's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care to Resident #342. When interviewed at that time, LPN #2 stated, I was educated on hand hygiene but don't work here that much. Also, at that time, during an interview with the surveyor, LPN #3 stated that hand hygiene should be performed when entering and exiting the resident's room. LPN #3 further noted that hand hygiene should be performed before obtaining a blood glucose level on a resident, gloves should be worn during the procedure, and hand hygiene should be performed after finishing the procedure. During a follow-up interview with the surveyor on 04/28/21 at 11:34 AM, the DON stated that anyone going into a PUI room was required to wear gloves. A surgical mask and hand hygiene should be performed when entering and exiting resident's rooms. The DON further stated that an independent IC Consultant advised that a surgical mask was the only PPE required on the PUI unit. At that time, the surveyor requested a copy of the IC Consultant's report, and the facility failed to provide the requested report. On 04/28/21 at 12:43 PM, the IP provided the name of the IC Consultant but was unable to provide the IC Consultant's report. The IP stated that she was not present on the date the IC Consultant was in the facility but stated that the IC Consultant did not recommend that gowns were to be worn on the PUI Unit. The surveyor requested a copy of the COVID-19 guidance that the facility followed for the PUI unit; The facility failed to provide the guidance. On 05/03/21 at 11:55 AM, the survey team interviewed the LNHA, DON, and IP. The IP stated that the facility followed the guidance from the NJ DOH if they needed to cohort residents. The IP further noted that the facility followed COVID-19 infection control guidelines from the CDC, but they usually followed the NJ DOH guidelines because they were more stringent. The IP further stated that the facility discussed all updated guidance concerning COVID-19 infection control during morning and weekly meetings, which included all upper management staff, and stated, We make decisions as a group. The IP further stated that the Admissions Nurse Liaison ensures that all admissions had a negative COVID-19 test 72 hours prior to admission and were housed under observation for 14 days on the PUI unit. The IP then stated that on the PUI unit, the staff were to don gowns, gloves, surgical mask, and face shield before entering a resident's room and remove the PPE upon exiting the room, disposing of the PPE in a trash can located inside the resident's room. The IP stated that staff were to wear a surgical mask and face shield in the hallway of the PUI Unit. During the same interview, the DON stated that all new admissions and readmissions were placed on the 200 Unit on droplet precautions (precaution used to prevent the spread of respiratory illnesses) for 14 days. The IP stated that she was unsure if the Admissions Nurse Liaison addressed COVID-19 exposure prior to a resident's admission. During an interview with the survey team on 05/03/21 at 12:15 PM, the Admissions Nurse Liaison stated that all residents required a negative COVID-19 test within 72 hours prior to admission. The Admissions Nurse Liaison further noted that all residents were assessed for COVID-19 exposure by reviewing and discussing the medical record with the clinical team at the hospital. The Admissions Nurse Liaison added that if a resident had any potential exposure to COVID-19, the facility would not admit the resident to the facility. On 05/03/21 at approximately 1:30 PM, the LNHA provided the surveyors with a copy of the IC Consultant's report. The LNHA stated that the report was dated 03/25/21. The LNHA provided pages 4, 5, and 6 of the IP Consultant's report to the surveyors. He stated that pages 1, 2, and 3 contained an internal quality report for a different area of the facility. At that time, the facility was unable to provide the surveyors with the COVID-19 guidance they were following. The surveyor reviewed pages 4, 5, and 6 of the IC Consultant's report dated 03/25/21, which revealed the following recommendations: - Institute a formal hand hygiene surveillance program. - Re-educate staff on the appropriate use of gloves for standard precautions and transmission-based precautions. - Create a policy for face shield use, cleaning and disinfection, and storage if reused. Staff members should wear eye protection when residents can't comply with source control mask-wearing, such as those within their dementia unit. - Ensure that all staff is wearing appropriate masks. - Identify exposed individuals, test, and quarantine appropriately. The IC Consultant's report further revealed, Recommendations include but are not limited to full enforcement of source control masking, proper use of PPE, social distancing, appropriately isolating symptomatic residents, and education regarding cleaning and disinfection. During an interview with the survey team on 05/03/21 at 02:00 PM, the IP stated that she reviewed the 03/25/21 IC Consultant's report and that the facility was following the IC Consultant's recommendations. The IP further noted that, this correlated with the guidance we were following. A review of the facility's undated Outbreak Response Plan under the heading Isolation and Cohorting Isolation revealed that when the facility is in an outbreak, Anyone entering the room will don appropriate PPE before entering, in accordance with the current guidelines from the NJDOH, CDC or CMS. Most commonly, this would be face mask, gloves, gowns, and eye protection. A review of the facility's Isolation- Initiating Transmission Based Precautions policy, reviewed 04/01/21, revealed that When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): a) Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used; . d) Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions: (1) The signage informs staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instructions to see a nurse before entering the room. e) Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; . g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. 4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met. e. Restrict or ban admissions . A review of the facility's Isolation - Categories of Transmission-Based Precautions policy, reviewed 04/01/21, revealed under the heading Droplet Precautions 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 7. Signs - The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. A review of the NJ DOH/CDS Guidelines dated 03/24/21 titled Updates on Covid-19 Infection Prevention & Control Recommendations revealed Appropriate PPE - UNCHANGED All recommended COVID-19 PPE should be worn during care of residents under quarantine, which includes the use of: - N-95 or higher-level respirator (or well-fitting facemask if a respirator is not available) - Eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) - Gloves - Gown A review of the facility's Handwashing/Hand Hygiene policy, reviewed 04/1/21, revealed to Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: - Before and after direct contact with residents - After contact with blood and bodily fluids - After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident - Before and after entering isolation precaution settings - Before and after assisting a resident with meals The facility continues to remain out of compliance for F880 but at a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy. NJAC 8:39-19.4

Based on interview and record review, it was determined that the facility failed to fully and promptly address significant changes to a resident's health status. This deficient practice was identified for Resident #7, 1 of 5 residents reviewed for falls, who experienced a significant increase in pain and a significant decline in ambulation, posture/ability to sit, and transfer ability. The facility also failed to administer medications and failed to notify the physician regarding unavailable medications for Resident #3 and #10, 2 of 13 residents reviewed for quality of care. This deficient practice was evidenced by the following: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed the 3/6/15 and 6/17/15 Minimum Data Set (MDS), an assessment tool, which showed that the resident was severely cognitively impaired. A review of the Restorative (ambulation) Log dated from March 2015 to June 2015 showed that Resident #7 was on the Restorative Nursing Program (RNP) and was able to walk with the assistance of one person 200 to 400 feet daily. It also showed that the RNP was discontinued for the resident on 6/26/15. A Progress Note (PN) dated 6/24/15 at 10:08 a.m., and written by the Restorative Nurse Aide (RNA) showed that Resident #7 was a maximum assist of two for transfers and that the resident complained of pain all over. The RNA documented that she told a nurse about this complaint and would refer the resident to Physical Therapy. The surveyor reviewed a Physical Therapy Referral Form dated 6/24/15, in which the Therapist wrote that Resident #7 was unable to stand, complained of pain all over, was now max assist of two, and that the resident was recently ambulatory up to 200 ft. The surveyor reviewed a 6/25/15 Physical Therapy note dated 6/25/15 which indicated that the wheelchair was no longer safe for the resident because the resident was sliding out and was unable to keep their feet on the footrests due to pain. The note also indicated that the Director of Nursing (DON) and Assistant DON were notified of the concerns. The surveyor reviewed the June 2015 Medication Administration Record [REDACTED].) Resident #7 did not require the medication until 6/20, 6/21 and 6/26/15, when the resident's pain was rated as 6/10 (out of 10) on the rating scale. According to the pain rating scale being used by the facility, 6/10 pain rating was not defined as mild pain but rather moderate pain. The MAR indicated [REDACTED]. There was no evidence that the physician was notified that Resident #7 had a sudden onset of pain. The surveyor noted a verbal telephone order dated 6/21/15 at 10:27 p.m., for the muscle relaxant Orphenadtine [MEDICATION NAME] 100 mg every twelve hours to treat muscle spasm. A review of the MAR indicated [REDACTED]. There was no documentation as to why this medication was ordered. The surveyor reviewed the medical record and observed that nursing discovered a bruise on 6/26. The facility ordered an x-ray which showed that the resident had a fractured right hip. (Resident #7 had a fall that occurred on 6/18/15.) The resident was sent out to the hospital on [DATE], where he/she had surgery and received 32 staples to repair the [MEDICAL CONDITION]. There was no evidence that the facility provided a full evaluation of Resident #7 ' s increase in pain that was first identified on 6/20/15 when Resident #7 related to nursing a pain scale of 6/10; again related pain of 6/10 on 6/21/15 requiring medication; and progress notes from the RNP and the Physical Therapists regarding all over pain and decline in activities of daily living. A review of the facility's pain assessment policy showed that staff should systematically assess and document resident's pain when warranted by changes in a resident's condition. Refer to F226 2. During the initial tour on 8/24/15 at 10:30 a.m. the Charge Nurse/Registered Nurse (CN/RN) stated that Resident #3 was alert and oriented, blind and could perform the majority of their ADL's (activities of daily living) independently. The surveyor interviewed Resident #3 on 8/24/15 at 1:15 p.m. Resident #3 stated s/he had no major complaints about the facility. The surveyor reviewed Resident #3 's August 2015 electronic Medication Administration Record [REDACTED]. The eMAR had unsigned blank spaces for 8/9, 8/10 and 8/14. The eMAR also coded a 9 for 8/8 and 8/13. According to the Chart Codes on the eMAR, a 9 meant other/See Progress Notes. The surveyor reviewed the Progress Notes (PN) for 8/8/15 and 8/13/15. Staff documented that [MEDICATION NAME] was not given because the medication was unavailable and that the pharmacy was contacted. There was no documentation that Resident #3's physician was notified about the unavailable medication. The surveyor then reviewed the past eMARs and physician orders [REDACTED]. According to the February 2015 physician's orders [REDACTED]. A TSH ([MEDICAL CONDITION] stimulating hormone) laboratory value, done on 10/3/14, was within normal limits. A TSH was done via a blood draw to determine how the [MEDICAL CONDITION] was functioning. Based on the TSH value, the dosage of [MEDICATION NAME] could be adjusted if needed. The surveyor found no concerns with the eMAR's for [MEDICATION NAME] until March 2015. The eMAR had unsigned blank spaces with no corresponding documentation for 3/1 and 3/12. A 9 was coded for the 14th, 17th, 21st, 23rd and 24th with documentation that the medication was unavailable and the pharmacy was contacted and the facility was awaiting delivery. There was no documentation that the physician was notified. The surveyor then reviewed the April 2015 eMAR up to 4/6/15 and all spaces were documented that [MEDICATION NAME] was given. A TSH level was drawn on 4/6/15 and noted to be abnormally high. No documentation was found that the physician was notified. Resident #3 continued to receive the 137 mcg dose until the physician visited on 4/16/15 and increased the dose to 150 mcg. The surveyor reviewed the May 2015 eMAR. All spaces were signed as administered for [MEDICATION NAME]. The June 2015 eMAR spaces were signed as administered up until the 13th. A 9 was documented on the 14th with the corresponding PN awaiting pharmacy delivery. A TSH level was drawn on 6/15/15 and noted to be abnormally low. No documentation was found that the physician was notified. Resident #3 continued on the same dose of 150 mcg. After June 13, 2015, the eMAR had a unsigned blank space for the 29th with no further documentation and had a 9 documented for the 23rd, 24th, 25th and 27th with the following PN that the facility was awaiting pharmacy delivery. No documentation was found that the physician was notified that the doses were not given. A review of the July 2015 eMAR noted a 9 was documented for the 2nd, 3rd, and 7th with a corresponding PN that the medication was unavailable and pharmacy contacted. An unsigned blank space was noted for the 12th. No documentation was found that the physician was notified. A TSH level was drawn on 7/17/15 and was noted to be abnormally high. The physician ordered to give [MEDICATION NAME] 150 mcg daily and give an additional 75 mcg dose on Sunday only. 3. During the initial tour on 8/24/15 at 10:30 a.m. the nurse stated that Resident #10 was at the facility for rehabilitation. At 12:50 p.m. Resident #10 approached the surveyor requesting an interview. Resident #10 had multiple minor complaints. The surveyor reviewed Resident #10 's medical record on 8/25/15 at 12:45 p.m. Resident #10 had [DIAGNOSES REDACTED]. Since admission in April of 2015, Resident #10 received the anti-[MEDICAL CONDITION] medication Levetiracetam twice a day. The surveyor reviewed the July 2015 eMAR. From 7/1 to 7/26, Resident #10 received Levetiracetam 750 mg (milligrams) every 12 hours in tablet form. The order was changed by Resident #10 's neurologist on 7/27/15 to give the liquid form of Levetiracetam, 5 ml (milliliters) that was equivalent to 500 mg every 12 hours, to be given at 8 a.m. and 8 p.m. According to the eMAR, a 9 was documented for 7/27 at 8 p.m., 7/28 at 8 a.m., 7/29 at 8 a.m. and 7/30 at 8 a.m. The p.m. doses were signed as given. The corresponding PN for the 9 documented that the medication was unavailable and the facility was awaiting pharmacy delivery. No documentation was found that the physician was notified. Resident #10 did not suffer any [MEDICAL CONDITION] during this time. The surveyor interviewed the CN/RN and a Licensed Practical Nurse (LPN) on 8/26/15 at 9:15 a.m. Both nurses stated that the pharmacy delivers three times a day at 6 a.m., 2 p.m. and 11:30 p.m. as well as emergency deliveries. Both nurses stated that medications are ordered via the computer and if a medication was unavailable the physician should be notified and documented in the medical record. The surveyor discussed the issue with the Director of Nurses (DON) and Administrator on 8/27/15 at 10:25 a.m. The DON stated that the facility used multiple resources to obtain medications including using a local community pharmacy if a medication was not available. The DON also stated that the physician must be called if a medication was not given/unavailable. N.J.A.C. 8:39-27.1(a)

Complaint #NJ 091 Based on observation, interview and record review, it was determined that the facility failed to protect a resident from abuse. The resident received "rough handling" during care from a Certified Nursing Assistant and was left in soiled garments. In addition, the facility failed to ensure that all allegations of abuse were reported immediately. An incident of "probable abuse" occurred with a resident on 5/29/14 but was not reported until 5/30/14. This deficient practice was identified for Resident #2, 1 of 1 residents reviewed for an allegation of abuse, and was evidenced by the following: The surveyor reviewed a "Reportable Event Record/Report" (RER) sent to the Department of Health that indicated an incident of staff to resident alleged abuse occurred to Resident #2. Documentation on the RER stated two Certified Nursing Assistants (CNA) had transferred Resident #2 on 5/29/14 and the incident had occurred during that transfer. The RER stated the resident had [DIAGNOSES REDACTED]. The resident also had a [DIAGNOSES REDACTED]. The RER stated the following day, 5/30/14, a bruise was noted on the resident's right bicep. That day, a day after the incident had occurred, a CNA reported the "rough handling (probable abuse)" by a CNA during a transfer the previous day. The surveyor observed Resident #2 either sitting in a wheelchair or lying in bed during the survey. When in the wheelchair, the surveyor observed the resident feeding self at lunch and attending activities. When interviewed, the resident would answer simple questions. On 10/6/14 at 12:40 p.m. the surveyor observed the resident feeding self dessert in the small dining room. The resident was teary and when asked what was wrong, the resident said "I miss my mom and dad" and then complained that his/her left knee was hurting. The 8/20/14 Resident Assessment Instrument identified the resident as severely cognitively impaired and requiring extensive staff assistance with transfers, dressing and hygiene. The weight record identified the resident as weighing 281 lbs. Upon review of the medical record the surveyor observed a nurse's note written on 5/30/14 and timed 19:41 (military time for 7:41 p.m.) that stated "this nurse called to room by CNA and was shown a bruise on the upper, inner right arm. Bruise was large in size and purple in color." The surveyor requested the facility's investigation and was provided with a folder containing several documents which included the following: 1. The 5/30/14 incident report; 2. "Witness Statement" forms with written statements from the accused CNA (CNA #1), the witnessing CNA (CNA#2), the nurse whom CNA #2 reported the incident to on 5/30/14 and 2 CNAs who had worked on 5/28/14 (the day before the incident); 3. Inservice records that identified CNA #1 and CNA #2 had attended an inservice on "Elder Abuse and Neglect;" and 4. The facility's "Summary of Reportable Event." The surveyor reviewed the incident report written on 5/30/14 at 4:30 p.m. which identified the "incident type" as a bruise. The incident report also included "Description of incident by resident:" and next to this was written "(he/she) stated "it started with the girl with the ponytail last night" and "she threw me in bed." The surveyor then reviewed the written statements. The only written statements from caregivers other than those directly involved with the incident were from a CNA who wrote about transferring the resident on 5/28/14 "around 8:30 to 9 pm, the resident was cooperative, stood with assistance." The other non-involved CNA wrote about transferring the resident on 5/28/14 (no time given) "transferred without a problem, no bruise noticed." When interviewed on 10/8/14 at 1 p.m., the Director of Nursing (DON) said no witness statements had been taken from the 11 p.m. to 7 a.m. shift or 7 a.m. to 3 p.m. shift immediately following the 5/28/14 incident. CNA #1 wrote "during 2 person transfer with (CNA #2) resident was lifted under L & R (left and right) arm. (CNA #1 identified that she had been on the right side.) Resident was lifted and did (not?) want to stand she pulled back during transfer and sat on edge of mattress. (CNA#2) and I had to relift resident several times to get (resident) to the top of bed. Resident continued to not cooperate and pull back as we tried to stand (resident). Once resident was at top of bed, still not in middle, (CNA#2) assisted me with pull up and pm care. Residents legs were placed in bed." CNA #1 wrote that she had gone out to tell the nurse (identifying the nurse by name) how difficult the transfer had been. CNA#2 wrote "on May 29th 2014, I went to (resident's room number) to assist (CNA#1) with transferring (resident). (Resident) stood up, pivoted and then he/she sat on the bed. (CNA#1) gripped (resident's) arm as an attempt to stand her back up and get her higher up in the bed. (Resident) did not cooperate at that time so (CNA#1) started pulling at her arm violently. After (resident) was high enough in bed (CNA#1) then jerked her head forward and ripped off her day shirt. (CNA#1) then threw (resident's) legs up on the bed and left her there soiled." CNA#2 ended her statement with "at the time of the incident I felt uncomfortable to tell the nurse because (CNA#1) kept following me to make sure I wouldn't tell the nurse what had happen. So on 5/30/14 I reported the abuse to the nurse when we were both alone." The nurse wrote that on May 30, 2014 "this nurse was called to (resident's room number) by CNA. She proceded to show me a large bruise on the inner, upper arm. The bruise was purple in color. I asked the resident what happened and (resident) stated 'it started last night with that girl with the pony tail, she threw me in bed', (resident) stated discomfort but refused medication for pain." The nurse also wrote "prior to incident, on previous night 5/29, resident was sitting in wheelchair in common area very upset and crying for (his/her) legrests for wheelchair. I went to (his/her) room to find them. The aide on 3-11 stated she took them off because they were wet from urine, the resident was giving her a hard time about standing and the aide stated she was waiting for help to clean (him/her) up. Within 10 minutes I witnessed the assigned aide and helper aide take him/her to room to be cleaned and put to bed." The nurse also wrote an addendum statement saying that CNA#1 had never come to her on 5/29/14 about the resident being difficult to transfer. The surveyor reviewed the inservice training on "Patient Rights" and "Elder Abuse & Neglect" that had been given on 3/13/14. Both CNA#1 and CNA#2 had signed their names as attending. The inservice included "what is abuse and neglect" and included "some forms of physical abuse are rushing an elder and roughly assisting a senior." It also included guidelines for what to do if abuse or neglect was suspected which included "intervene immediately, take immediate steps." The surveyor reviewed the file of CNA#2 which included a CNA job description form, signed by CNA#2, that included "reports suspected abuse immediately." On 10/7/14 at 10:45 a.m. the surveyor interviewed the resident about the incident. The resident said he/she did not remember it. On 10/8/14 at 1:10 p.m. the surveyor interviewed the nurse who had been involved with the event. The nurse said CNA#2 had come to her on 5/30/14 and said something had happened the night before and took her to the resident's room to show her the bruise. The nurse said she did not know about the bruise until CNA#2 had shown it to her when the CNA came on duty at 3 p.m. that day. The nurse had been working 7 a.m. to 7 p.m. that day but no one had reported the bruise prior to CNA#2 reporting it when she got to work at 3 p.m. On 10/8/14 at 2:45 p.m. the surveyor interviewed CNA#2 about the event. CNA#2 told the surveyor that CNA#1 had asked her to help with the transfer (of Resident #2). CNA#2 said the resident got upset because (CNA#1) was yelling "no, you're standing up" and was pulling on her. "(Resident) got scared and half sat on the bed, (CNA#1) got (resident) to stand and we got him/her in bed." CNA#2 said the resident was afraid to stand because of a knee injury. The surveyor asked CNA#2 about a statement she had made on the "Witness Statement" form regarding CNA#1 "jerked (resident's) head forward and ripped off (resident's) day shirt" and "left (resident) there soiled." CNA#2 told the surveyor that CNA#1 had pulled the resident's head forward and "yanked" off the resident's shirt but left the resident in the pants and incontinence brief which were soiled. CNA#2 told the surveyor that CNA#1 said "(he/she) can wait" and left the room. CNA#2 said the resident "didn't get cleaned up until next rounds." When asked about the resident, CNA#2 said "for about a week after it happened (resident) kept saying "I'm scared" and "the girl with black hair put her hands on me." When asked why she didn't report the incident that night, CNA#2 said she was afraid of CNA#1. CNA#2 said "What I did was wrong, I should have told someone." The surveyor reviewed the facility's summary of the incident which stated the resident's description of the "girl with the pony tail last night who threw me in bed" matched that of CNA#1. CNA#2's statement regarding the incident corroborated what the resident had said. After the facility reviewed the entire incident, it pointed to CNA#1 being abusive to Resident #2. CNA#1 was contacted and told to report to the DON's office on her next day back to work. CNA#1 was terminated and reported to the Department of Health. When interviewed on 10/9/14 at 3 p.m., the Administrator said "we couldn't prove that (CNA#1) didn't do it." NJAC 8:39 - 4.1 (a) 5