Every finding on record at The Pines at Medford

Complaint # 2794238 Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to implement their abuse policy to immediately conduct a thorough investigation to protect a resident (Resident #65) who alleged sexual abuse. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #65). A review of a Nurse Practitioner (NP) Progress Note dated 2/22/26 at 10:00 AM, revealed that Resident #65 alleged, I was raped. During an interview on 6/09/26, Resident #65 revealed that someone tried to force [themself on me, I thought [gender redacted] was a worker hired to care for me. On 6/10/26, the Director of Nursing (DON) stated that the NP informed the Nursing Supervisor (NS) of the allegation on 2/22/26, and the NS reported it to the Assistant Director of Nursing (ADON). The DON stated the ADON did not report the allegation to anyone, and on 2/24/26, the Medical Director (MD) had asked the DON for the outcome of the allegation. The Licensed Nursing Home Administrator (LNHA) and DON acknowledged that immediately after an allegation of abuse was made, the police should have been notified, an investigation should have been initiated, interviews with alert and oriented residents should have been done, and physical assessments of cognitively impaired residents should have been done. A review of the investigation for the allegation on 2/22/26, provided by the facility included no statements from any residents or for any staff members who had given care to Resident #65 prior to the allegation. A review of the Certified Nursing Aide (CNA) assignment sheet dated 2/21/26, revealed CNA #2 was the resident's assigned aide and the [gender redacted] that was alleged. The facility's failure to implement their abuse policy by immediately conducting a thorough investigation for an allegation of sexual abuse placed Resident #65, as well as all residents at risk for abuse. This posed the likelihood for serious physical or psychosocial harm, which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 2/22/26 at approximately 8:30 AM, when the NP reported the alleged sexual abuse to the NS and the facility did not immediately investigate it. The Administration was notified of the IJ on 6/11/26 at 2:42 PM. The facility submitted an acceptable Removal Plan (RP) on 6/15/26 at 12:39 PM. The survey team verified the implementation of the RP onsite during the continuation of the survey on 6/15/26. The evidence was as follows: A review of the facility's Abuse, Neglect policy dated effective 1/15/2020, included; under no circumstances does this facility allow and/or condone abuse, and as such, we are dedicated to assuring that each resident is kept from abuse.Sexual abuse includes but is not limited to sexual harassment, sexual coercion, and sexual assault. The facility will not condone resident abuse by anyone.All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made[.] to the administrator of the facility, the Department of Health and the Long Term Ombudsman (if appropriate). Any person witnessing or suspecting abuse or neglect, including injuries of an unknown source and misappropriation of resident property shall follow the following procedures:Immediate removal of resident or employee from a harmful environment and initiates medical treatment.Notify immediate supervisor/department head/ administrative/designees. The type of abuse that was committed.Upon receiving reports of physical abuse, the charge nurse/designee shall immediately examine the resident and report to their supervisor. Findings of the examination must be recorded in the resident's medical record. (Note: If sexual abuse is suspected, do not bathe the resident or wash the resident's clothing or linen. Call the police immediately.)The administrator or designee will notify the following persons or agencies of such incident.Ombudsman- upon allegation.Department of Health.Resident Representative.Law Enforcement Officials, as appropriate.When an incident of resident abuse is suspected or determined, such incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in the policy.The surveyor reviewed Resident #65's medical record.A review of the admission Record face sheet (an admission summary), revealed the resident was admitted with diagnoses which included but were not limited to; major depressive disorder, muscle wasting and atrophy, cognitive communication deficit, obesity, and unspecified psychosis not due to a substance abuse.A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/1/25, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment.A review of the Progress Notes included the following notes:A Late Entry Nursing Progress Note dated effective 2/22/26 at 12:20 PM, written by the NS, that the NP informed her that the resident stated they were raped last night. The resident refused to go to the hospital for fear of retaliation. The NP instructed the NS that the resident cannot have male CNAs. The NS checked on the resident who was unable to recall the conversation at that time. The resident had no visible injuries observed, they denied pain or discomfort, and the ADON was made aware.A Late Entry NP Progress Notes dated effective 2/22/26 at 5:11 PM, written by the NP, revealed that the resident was seen for a monthly recapitulation (recap) and was lying in bed with oxygen. The resident was noted upset and not [the resident's] usual self. When questioned [the resident] states, I was raped. [The resident] did not elaborate and could not provide a specific time or description of individual. [The resident] did not want to discuss any further. Recommend referral to ED [Emergency Department] and [the resident] declined.A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated initiated 2/24/26, for at risk for behavioral symptoms related to cognitive impairment and false accusations. The interventions included body assessment, obtain labs, psychiatry consult and follow up as needed (PRN), two-person approach during interactions with staff when available, and two-person approach during care when available. All the interventions were initiated on 2/24/26. On 6/09/26 at 12:45 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that Resident #65 was alert and able to make their needs known. The surveyor then inquired if Resident #65 expressed any behaviors or made any accusations, and LPN #1 stated that Resident #65 could be confused at times in the evening shift and had never made any false accusatory remarks toward staff.On 6/09/26 at 12:55 PM, the surveyor interviewed Resident #65, who stated someone tried to force [themself on me, I thought [gender redacted] was a worker hired to care for me. When asked if they recalled who the person was, they stated even if I saw them now, I would not be able to identify them. The surveyor then asked if they had reported the incident, and Resident #65 stated, I did, and someone came and talked to me. On 6/10/26 at 1:15 PM, the surveyor interviewed the DON, who stated that the facility had no knowledge of the alleged sexual abuse on 2/22/26. The surveyor requested from the DON all investigations for Resident #65.On 6/10/2026 at 1:20 PM, the surveyor conducted a telephone interview with the MD, who confirmed that the sexual abuse allegation was reported to the NS on 2/22/26.On 6/10/26 at 2:17 PM, the surveyor conducted a telephone interview with the NP, who confirmed that Resident #65 reported the alleged sexual abuse to her on 2/22/26, and that she informed the NS and the Medical Director (MD) that day (2/22/26). The NP denied being asked to provide a statement to the facility. The NP denied doing any physical assessment for the alleged rape and she was not contacted by the police department. The NP stated she notified the facility and documented the incident in the Progress Notes, and she would not comment on what the facility should have done at that time.On 6/10/26 at 2:30 PM, the surveyor interviewed the DON in the presence of the LNHA. The DON confirmed that the NS was aware of the alleged rape and that the NS reported the alleged sexual abuse to the ADON on 2/22/26, but the ADON failed to report the alleged sexual abuse until 2/24/26. The DON further stated that she was made aware on 2/24/26, when the MD called to inquire about the outcome of our investigation into the allegation. At that time, the LNHA stated that she reported the alleged sexual abuse to the New Jersey Department of Health (NJDOH) within two hours on 2/24/26, after she was made aware of the alleged sexual abuse by the MD. The LNHA stated that after she was made aware of the incident, the facility requested a psychiatry and a psychology consultation which did not reflect any psychosis. The LNHA stated a urine analysis was also ordered and it was negative for a urinary tract infection.On 6/10/26 at 2:45 PM, the surveyor conducted a telephone interview with Resident #65's Representative (RR), who stated that Resident #65 called them on 2/21/26, and reported to the RR that there was a man in their room who will be giving them a bath, and they felt uneasy about it. When asked if the RR contacted the facility, the RR stated that they did not inform the facility. The RR stated that they had received a call from the facility on Tuesday 2/24/26, and was informed that Resident #65 had been assaulted. The RR stated that Resident #65 had described the aggressor as a male with long dark hair with a ponytail, and that Resident #65 refused to go to the hospital for fear of retaliation.On 6/10/26 at 2:48 PM, the DON provided a summary of the incident, where she stated that Resident #65 reported the sexual allegation of abuse on 2/22/26, to the NP. The timeline provided by the DON reflected that the MD reported the alleged sexual abuse on 2/24/26 at 8:11 AM. The DON reported the incident to the LNHA on 2/24/26 at 8:17 AM. The LNHA reported the alleged sexual abuse to NJDOH on 2/24/26 at approximately 10:00 AM. The police department was called on 2/24/26. In summary, the DON stated that the facility was unable to substantiate any actual harm or abuse. There were no statements included in the investigation from potential witnesses including staff who cared for the resident prior to the allegation or from residents.On 6/11/26 at 9:13 AM, the surveyor re-interviewed the LNHA and DON. The DON confirmed the NP had reported the allegation of sexual abuse on 2/22/26, and that the ADON was aware of the allegation on 2/22/26. The LNHA confirmed that an allegation of rape was considered sexual abuse, and the immediate actions that should have been taken were that the nurse immediately assessed and documented a body check; the allegation was reported immediately to the NJDOH, police, MD, and RR; the nurse would follow any orders by the MD or NP to send to the ED; statements were collected going back twenty-four hours of staff who cared for the resident; the facility would interview the resident and all alert and oriented residents on the unit; and if a specific staff member was named as the perpetrator, they would be suspended pending the outcome of the investigation.On 6/11/26 at 9:27 AM, the surveyor asked the DON if Resident #65 ever made false allegations, and the DON responded, No, it was the first time, but Resident #65 did hallucinate bugs in the room and outside. The surveyor then asked the DON if she reviewed the NP's Progress Notes where the NP documented that Resident #65 was upset and was not their usual self, and the DON confirmed that the NP informed the NS of the alleged abuse on 2/22/26. On 6/11/26 at 9:37 AM, the surveyor interviewed the ADON about the allegation of sexual abuse on 2/22/26, and the ADON stated she was on call that day, but she was not physically at the facility. The ADON confirmed the NS made her aware of the allegation on 2/22/26, but she could not recall the time. The ADON stated, I failed to report it to my supervisor. The ADON reported that Resident #65 was touched, and she remembered asking the NS, Did it really happen? The ADON stated that she reported the incident on 2/24/26, and that she just returned from vacation, had jet lag, and was tired. The surveyor had requested the ADON provide a timeline for 2/22/26.On 6/11/26 at 10:40 AM, the ADON provided the following information; on 2/22/26, morning time, the NS called to inform her that Resident #65 notified the NP that they were allegedly sexually assaulted, the ADON instructed the NS to do a body check and to have the NP do a body check and offer to send to the ED. The ADON stated, the incident should have been reported in two hours, and the LNHA would initiate the process. I failed to generate the process.On 6/11/26 at 11:35 AM, the surveyor attempted to re-interview Resident #65, who stated there was a male CNA that had been working here and cared for them, he was a gentleman. Resident #65 further stated, now they have these workers from [out of state redacted] working at the facility. When asked to elaborate further, Resident #65 declined to comment. On 6/11/26 at 12:14 PM, the LNHA stated that the facility reported the incident on 2/24/26, and confirmed that the allegation of sexual abuse had not been investigated when Resident #65 reported the abuse to the NP on 2/22/26.On 6/11/26 at 12:15 PM, the surveyor interviewed CNA #1, who worked on the unit where Resident #65 resided. CNA #1 stated that for the last six months, he had not been assigned to Resident #65. Upon further inquiry, CNA #1 stated he was not on duty the day of the incident, and that a male Agency CNA (CNA #2) was assigned to Resident #65 that day. The CNA declined to comment further on the incident.A review of the assignment sheet dated 2/21/26, provided by the DON, revealed there were two male CNAs assigned to Resident #65's unit for the 7:00 AM to 3:00 PM (7-3) shift, and that CNA #2 had cared for the resident. The facility did not collect any statements from the staff assigned to the unit or from CNA #2.On 6/12/26 at 10:47 AM, the surveyor conducted a telephone interview with the NS, who stated on 2/22/26, she had reported the allegation of sexual abuse to both the ADON and the DON. The NS alleged that the DON stated it was serious and should be reported. On 6/12/26 at 11:30 AM, the surveyor reviewed the facility's abuse policy with the LNHA and asked the LNHA what was done on 2/24/26, after the MD called and inquired about the investigation. The LNHA confirmed that she did not collect any statements from staff, the facility did not interview or assess other residents on the unit for potential abuse.An acceptable Removal Plan (RP) was received on 6/15/26 at 12:39 PM, indicating the action the facility will implement to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including; on 2/22/26, at approximately 8:30 AM, the resident reported to the NP they were allegedly raped, the NP conducted a body check with no findings, the resident declined to be transferred to the ED, and the NS was notified who notified the ADON. On 2/24/26, the police were notified and came to the facility, the RR was notified, the ADON was re-educated on abuse, and psychology was consulted. On 6/11/26, the facility interviewed all cognitively intact residents and conducted body checks of cognitively impaired residents, the Abuse and Neglect Policy was reviewed and revised, and all staff were educated on the new policy. The facility implemented a Reportable Checklist.The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 6/15/26 at 3:11 PM. NJAC 8:39-4.1(5)NJAC 8:39-9.4(f)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure a) written policies and procedures were developed and implemented to thoroughly investigate, and maintain documentation of investigation, for all types of abuse b) written procedures were in place to ensure that all residents were protected from physical and psychosocial harm during and after the investigation, and c) ensure ensure that upon receipt of an allegation of abuse, a policy and procedure was followed to ensure when an allegation of resident abuse was reported that the required notification was made within 2-hours to the Department of Health and to other agencies, including law enforcement as indicated. This deficient practice was identified for 1 of 2 residents reviewed for abuse, and occurred when a resident (Resident #65) alleged they were raped and the facility became aware of the allegation on 2/22/26. This deficient practice affected all residents who resided at that facility and was evidenced by the following: Refer to 600J A review of the facility's Abuse, Neglect policy dated effective 1/15/2020, included; under no circumstances does this facility allow and/or condone abuse, and as such, we are dedicated to assuring that each resident is kept from abuse.Sexual abuse includes but is not limited to sexual harassment, sexual coercion, and sexual assault. The facility will not condone resident abuse by anyone.All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made[.] to the administrator of the facility, the Department of Health and the Long Term Ombudsman (if appropriate). Any person witnessing or suspecting abuse or neglect, including injuries of an unknown source and misappropriation of resident property shall follow the following procedures:Immediate removal of resident or employee from a harmful environment and initiates medical treatment.Notify immediate supervisor/department head/ administrative/designees. The type of abuse that was committed.Upon receiving reports of physical abuse, the charge nurse/designee shall immediately examine the resident and report to their supervisor. Findings of the examination must be recorded in the resident's medical record. (Note: If sexual abuse is suspected, do not bathe the resident or wash the resident's clothing or linen. Call the police immediately.)The administrator or designee will notify the following persons or agencies of such incident.Ombudsman- upon allegation.Department of Health.Resident Representative.Law Enforcement Officials, as appropriate.When an incident of resident abuse is suspected or determined, such incident must be reported to the charge nurse regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in the policy.The surveyor reviewed Resident #65's medical record and a review of the Progress Notes included the following notes:A Late Entry Nursing Progress Note dated effective 2/22/26 at 12:20 PM, written by the NS, that the NP informed her that the resident stated they were raped last night. The resident refused to go to the hospital for fear of retaliation. The NP instructed the NS that the resident cannot have male CNAs. The NS checked on the resident who was unable to recall the conversation at that time. The resident had no visible injuries observed, they denied pain or discomfort, and the ADON was made aware.On 6/09/26 at 12:55 PM, the surveyor interviewed Resident #65, who stated someone tried to force [themself on me, I thought [gender redacted] was a worker hired to care for me. When asked if they recalled who the person was, they stated even if I saw them now, I would not be able to identify them. The surveyor then asked if they had reported the incident, and Resident #65 stated, I did, and someone came and talked to me. On 6/10/26 at 1:15 PM, the surveyor interviewed the DON, who stated that the facility had no knowledge of the alleged sexual abuse on 2/22/26. The surveyor requested from the DON all investigations for Resident #65.On 06/10/26 at 1:20 PM, in the presence of the survey team, the surveyor conducted a telephone interview with the Medical Director (MD) regarding Resident #65's allegation of rape. The MD stated that the allegation of sexual abuse from Resident #65 on 2/22/26 was reported immediately to the Nursing Supervisor by his Nurse Practitioner (NP) as he was also immediately informed on 2/22/26.On 6/10/26 at 1:45 PM, the DON provided an incident report for Resident #65 which confirmed that the facility was made aware of the allegation of sexual abuse on 2/22/26 around 8:30 AM. A review of the incident report also reflected that on 2/22/26 at 8:30 AM, the NP reported the allegation of rape to the MD and the Nursing Supervisor on duty that day, on 2/22/26.On 6/10/26 at 2:17 PM, the surveyor conducted a telephone interview with the NP, who confirmed that Resident #65 reported the alleged sexual abuse to her on 2/22/26, and that she informed the NS and the Medical Director (MD) that day (2/22/26). The NP denied being asked to provide a statement to the facility. The NP denied doing any physical assessment for the alleged rape and she was not contacted by the police department. The NP stated she notified the facility and documented the incident in the Progress Notes, and she would not comment on what the facility should have done at that time.On 6/10/26 at 2:30 PM, the surveyor interviewed the DON in the presence of the LNHA. The DON confirmed that the NS was aware of the alleged rape and that the NS reported the alleged sexual abuse to the ADON on 2/22/26, but the ADON failed to report the alleged sexual abuse until 2/24/26. The DON further stated that she was made aware on 2/24/26, when the MD called to inquire about the outcome of our investigation into the allegation. At that time, the LNHA stated that she reported the alleged sexual abuse to the New Jersey Department of Health (NJDOH) within two hours on 2/24/26, after she was made aware of the alleged sexual abuse by the MD. The LNHA stated that after she was made aware of the incident, the facility requested a psychiatry and a psychology consultation which did not reflect any psychosis. The LNHA stated a urine analysis was also ordered and it was negative for a urinary tract infection.A review of a the facility provided documentation dated 2/24/26, confirmed the facility reported the alleged sexual abuse to the New Jersey Department of Health (NJDOH) on 2/24/26 at 10:00 AM (two days after the allegation of rape was received by the facility).On 6/11/2026 at 9:13 AM, in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA) the surveyor again interviewed the DON who confirmed that the allegation of rape was an allegation of sexual abuse and had been reported to the ADON on 2/22/26. The DON confirmed at that time the NP informed the facility of the alleged sexual abuse on 2/22/26. The surveyor then asked the LNHA what should happen when a resident reported an allegation of secual abuse. The LNHA stated the following would occur: -The nurse would immediately assess, and document a standard physical assessment and check for bruises, scratches, and confirmed that no overt signs of injury would not indicate anything except facts and it would be documented in the medical record.-The incident would be reported to the Department of Health, the Ombudsman, the police immediately, and the MD. Also the responsible party, and it would be documented in medical records.-The nurse will follow physician orders. When asked if a certain type of assessment should be completed for an allegation of sexual assault. The DON stated, if there were NP or MD orders to transfer the resident to the hospital, the resident would be sent to the hospital according to the DON. The DON stated, it was is based on what the physician stated it was ultimately it is a medical decision and did not reference a facility policy. The DON stated that the MD, the medical staff and the family were part of the decision making process and that it was a collaborative decision when an allegation of sexual abuse occurred. The surveyor then asked the LNHA what else should occur after the allegation was received. The LNHA stated that the facility would collect statements, and usually we would look back 24 hours. The facility would then interview all involved with the resident's care. The facility would ensure the safety of other residents, would interview other residents on the same unit or the same assignment to ensure their safety of alert and oriented residents on the same unit or assignment, and those who were not alert and oriented, the facility would conduct body checks. The LNHA stated if they had a staff member identified, we would suspend them pending investigation. When asked if there was another policy describing what she stated should occur, or related to an allegation of sexual abuse, she stated there was no specific policy for an allegation of sexual abuse and there were no additional policies for abuse other than what was provided to the survey team.There was no evidence provided by the facility of the above stated actions from the LNHA were implemented and documented.On 6/11/2026 at 10:40 AM, the surveyor interviewed the Registered Nurse/ Assistant Director of Nursing, ADON, who confirmed that the facility was aware of the alleged sexual abuse as of 2/22/26. The ADON stated, the incident should have been reported in two hours, and the LNHA would have initiated the process. I failed to generate the process.On 6/11/26 at 12:30 PM, the LNHA stated that the facility reported the incident to Department of Health on 2/24/26 and confirmed that the allegation of sexual abuse had not been investigated when Resident #65 reported the abuse to the NP on 2/22/26. The LNHA confirmed that the facility did not complete assessments of any other residents to rule out abuse, interview staff, or notify the Department of Health, and other state agencies in a timely manner. On 6/15/26 at 2:06 PM, during the exit conference held with the LNHA and DON, no additional information was provided. NJAC 8:39-13.4 (2)(i)(v).

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to have a system in place to ensure residents who were dependent on staff to provide Activities of Daily Living (ADLs- toileting, grooming, dressing, and bathing) were provided with appropriate incontinence and nail care care in a timely manner. This deficient practice was identified for five 5 of 5 residents reviewed (Resident #2, # 21, # 53, #84 and Resident # 92) for ADL care, on 2 of 3 Resident Units (Birch and Cedar), for 5 of 5 residents who attended a resident council meeting, and had the potential to affect all residents who resided at the facility. The evidence was as follows: A review of the Resident Census List dated 6/4/26 revealed there were 48 residents who resided on Birch; 48 Residents who resided on Cedar and 4 residents who resided on the Dogwood Unit which was the Subacute Unit. On 6/5/26 at 11:00 AM, a surveyor conducted a resident council meeting with five residents. All 5 of 5 residents reported agency staff was the worst, and on the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts were the worst, work doesn't get done, and the staff were on their cell phones. One resident stated they have laid in urine without being changed, and it has been brought up at resident council meetings.1.On 06/05/2026 at 10:00 AM, the surveyor observed Resident #92 in bed on the Birch Unit, and they reported not feeling well. The surveyor asked Resident #92 if they received incontinence care that morning and they stated that incontinence care was offered 5 hours earlier around 5:00 AM. The surveyor then asked the Registered Nurse (RN) if she could assist with an incontinent observation. The surveyor observed that Resident #92 was soaked with urine. The RN later identified herself as the Assistant Director of Nursing (ADON).On 06/09/26 at 11:45 AM, the surveyor reviewed Resident #92's medical record. The admission Face Sheet (an admission summary) reflected that Resident #92 was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, hypertension, muscle weakness and epilepsy.The Quarterly Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care reflected that Resident #92 had moderate cognitive impairment. Resident #92 scored 09 out of 15 on the Brief Interview for Mental Status (BIMS). The Comprehensive Care Plan had a focus for ADL Self care deficit initiated on 2/9/26 related to physical limitations and cognitive deficit. The goal was for Resident #92 to receive assistance with ADLs care. The interventions were to assist with care. 2. On 06/05/26 at 10:28 AM, the surveyor observed Resident #2 in bed on the Cedar Unit. Resident #2 was nonverbal and appeared contracted. Resident #2 had a feeding tube that was observed hanging on a pole. A strong urine odor permeated in the room. The surveyor asked a Certified Nurse Aide (CNA) who entered the room to assist with a care tour observation. The CNA then closed the door and proceeded to turn Resident #2 on the left side. The CNA pulled the blanket off, and we both observed that Resident #2 was heavily soiled with feces and urine. The bed sheet, the incontinence pad under the resident, the top sheet and the bottom sheet were all stained and saturated with urine. The incontinence brief was observed soiled with dark feces and urine. During an interview with the CNA at that time regarding the observation, she stated that the 11:00 PM- 7:00 AM, shift sometimes would not provide incontinence care during their shift and that is what the resident would look like.On 06/05/26 at 10:25 AM, the surveyor exited the room and observed the Director of Nursing (DON) and the Licensed Nursing Practical Nurse Licensed Practical Nurse Unit manager (LPN/UM) in the hallway. The surveyor accompanied both to the room where we all observed Resident #2 was in bed, and was heavily soiled and the DON confirmed that incontinence care had not been provided for a while. Another surveyor was called for another observation and we all observed that Resident #2 was heavily soiled with urine and feces and the linens were stained for urine. During a follow up interview on 06/05/26 at 12:30 PM, with the assigned CNA, she stated that 2 to 3 times weekly Resident #2 would be left soaked with urine and feces in the same manner as observed. On 6/5/26 at 12:30 PM, the surveyor reviewed Resident #2's medical record. The admission Face sheet reflected that Resident #2 had diagnoses which included but were not limited to, Alzheimer's disease with late onset, muscle wasting and atrophy and disorder of the bone.The quarterly Minimum Data Set (MDS) dated [DATE], reflected that Resident #2 had severe impaired cognition. Resident #2 received a score of 99. Section GG of the MDS which addressed Activities of Daily Living (ADLs) reflected that Resident #2 was totally dependent on staff for care.The Comprehensive Care Plan initiated 3/16/26 had a focus for ADL Self-care Deficit related to physical limitations and cognitive deficit. The goal was for Resident #2 to receive assistance necessary to meet ADL needs through next review. Target Date: 08/12/2026.The interventions included, to provide assistance with bed mobility and transfer, bathing and showering, incontinence care and personal hygiene. 3. On 06/09/26 at 6:48 AM, the surveyor conducted an incontinence care tour with the Certified Nursing Aide (CNA) who worked the 11:00 AM- 7:00 AM shift. Resident #53 who resided on the Cedar Unit, was wearing two intonince briefs which were both saturated with urine. During an interview with the CNA, she stated that she had 18 residents on her assignment and stated it is too much. The CNA further stated that the 3:00 PM-11:00 PM shift placed two incontinence briefs on Resident #53. Upon further inquiry, the CNA then stated that she checked Resident #53 on her first rounds at 11:00 PM, she put on their pants to prevent them from removing the incontinence briefs. Based on the information provided by the CNA, more than 8 hours had elapsed since Resident #53 had received incontinence care.On 06/09/2026 at 6:55 AM, the surveyor interviewed the Unit Manager (UM) regarding residents wearing two incontinent briefs, she stated no one should have two briefs on, to prevent skin breakdown.On 06/09/26 at 7:00 AM, the surveyor interviewed the Infection Control Nurse regarding residents wearing two incontinence briefs, he stated that residents should not have two briefs on to prevent skin breakdown and prevent Urinary Tract Infections (UTI). When inquired how the CNAs would know not to place two briefs on a resident, he stated that they learned that in school.On 6/10/26 at 10:30 AM, the surveyor reviewed Resident #53's medical record. The admission Face Sheet (an admission summary reflected that Resident #53 was admitted to the facility with diagnoses which included but were not limited to, obstructive and reflux uropathy, muscle weakness and need for assistance with personal care.The quarterly Minimum Data Set (MDS) dated [DATE] reflected that Resident #53 was severely cognitively impaired. Resident #53 received a score of 99 on the BIMS. Section GG of the MDS which addressed Functional Abilities, reflected that Resident #53 was totally dependent on staff for care. Resident #53 received a score of 01(dependent). The Comprehensive care plan initiated 02/12/2026, had a focus for ADL Self-care deficit related to physical limitations and cognitive deficit. The goal was that Resident #53 will receive assistance necessary to meet ADL needs, will be clean, well-groomed daily to promote dignity. The interventions were for staff to provide assistance with bathing, eating and personal hygiene. 4. On 06/09/2026 at 7:25 AM, the surveyor checked Resident #21 who resided on the Cedar Unit with a random CNA (CNA #2). Resident #21 also was wearing two briefs which were both saturated with urine. During an interview with CNA #2, she stated that she had 18 residents on her shif during last night, and stated it is hard. When inquired if she relayed her concerns to the administrative staff, she stated, they were aware of the workload. On 6/10/26 at 11:10 AM, the surveyor reviewed Resident #21's medical record. The admission Face Sheet (an admission summary) reflected that Resident #21 was admitted to the facility with diagnoses which included but were not limited to, difficulty in walking, muscle weakness, diabetes mellitus and hypertension.The quarterly Minimum Data Set (MDS) dated [DATE] reflected that Resident #21 was severely cognitively impaired. Resident #21 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe cognitive impairment. Resident #21 was totally dependent on staff for care. The Comprehensive care plan initiated 02/26/26, had a focus for ADL Self-care deficit related to physical limitations, cognitive deficit and history of cerebrovascular accident (stroke). The goal was that Resident #21 will receive assistance necessary to meet ADL needs, will be clean, dressed appropriately. The interventions were for staff to provide assistance with toileting and personal hygiene. During the care tour on 6/9/26, Resident #21 was wearing two incontinence briefs which were both saturated with urine. The CNA could not comment on the last time that she provided incontinence care to Resident #21. 5. On 06/05/2026 at 9:30 AM, the surveyor observed Resident #84, who resided on the Birch Unit in a recliner chair in the dayroom. Resident #84's hands were contracted. The nails were long, jagged and soiled.On 06/09/26 at 11:45 AM, the surveyor observed Resident #84 in the dayroom, the surveyor approached the resident, but they could not communicate clearly. The surveyor observed Resident #84's nails were long, jagged and soiled underneath all 10 fingernails as observed on 6/5/26 at 9:30 AM. The surveyor asked Resident #84 if they ate this morning. Resident #84 nodded and stated yes.On 06/09/26 at 11:52 AM, the surveyor asked the Licensed Practical Nurse/ Unit Manager (LPN/UM) if she could check Resident #84's hands. The LPN/ UM put on gloves and started to open Resident #84's hands. The surveyor observed large amount of white flaky material dropping from the resident's hands, nails were long jagged and soiled. The LPN/ UM confirmed that Resident #84's hands and nails should be cleaned and trimmedOn 06/09/26 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the unit. The LPN stated that residents' nails should be trimmed and cleaned, this is part of morning care. The LPN further stated, the CNAs should be looking at the resident's nails, the CNAs are my eyes and ears on the unit, and they should report to the nurses and UM any issues with care. The surveyor then inquired regarding agency staff. The LPN stated that all staff were trained in-house, they should know what to do as well as the facility staff. On 06/09/26 at 12:25 PM, the surveyor interviewed the Registered Regional Nurse regarding the above concerns. She stated that last week she made rounds and discussed ADLs care with the Unit Managers. When asked if she observed Resident #84's hands, she stated, yes, they are in the process of cleaning his/her nails and hands. On 06/09/26 at 1:06 PM, the surveyor interviewed the CNA assigned to Resident #84. The CNA revealed that Resident #84 was an early riser, the 11:00 PM-7:00 AM shift provided care and placed Resident #84 in the recliner chair.A review of Resident #84's medical record reflected that Resident #84 had diagnoses which included but were not limited to; muscle wasting and atrophy, generalized weakness and pressure ulcer of sacral region.The admission Minimum Data Set (MDS) dated [DATE] reflected that Resident #84 had severe cognitive impairment. The MDS reflected also that Resident #84 was dependent on staff for all activities of daily living. The Comprehensive Care Plan initiated 03/03/2026 had a focus for self-care deficit related to physical limitation, disease process and contractures. The goal was for Resident #84 to receive the assistance necessary to meet ADL needs through the next review. Initiated: 03/03/26. The intervention was that staff would provide assistance with bathing, showering, bed mobility and transfer. On 6/15/26 at 11:30 AM the above concerns were presented to the administrative staff during the pre-exit conference. The DON stated that her expectations were for staff to provide incontinence care every two hours and as needed. On 06/15/26 at 2:10 PM, during an interview with the LNHA, in the presence of the survey team,the surveyor discussed the staffing level with the LNHA. The surveyor asked if the facility had appropriate staffing, and was the LNHA aware that staff were using two incontinence briefs. The LNHA stated, I am very disappointed, and confirmed she was unaware that staff were using double incontinence briefs.A review of the facility's policy titled, Activities of Daily Living last revised 03/2025 revealed the following:The facility will ensure that ADLs are provided in accordance with accepted standards of practice, the residents' care plan, and the residents choices and preferences. The policy for Resident Nail Care last revised 3/2023 reflected the following: Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. During the exit conference on 6/15/26 at 3:18 PM, no additional 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 sufficient and competent staff were available to assure resident safety and to attain or maintain the highest practicable physical, menatal, and psychosocial well being of each resident by failing to a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADL's) care (Residents #2, #21, #53, and Resident #92), b) provide nail care for a resident who was dependent of staff for ADL's (Resident #84) and c) ensure staff were competent upon receipt of an allegation of sexual abuse to ensure a process was followed to ensure the safety of the victim, all facility residents and immediately initiate an investigations. The deficient practice had the potential to affect all residents who resided at the facility and was evidenced by the following: Refer to 600 J and 677 Fa. A Late Entry NP Progress Notes dated effective 2/22/26 at 5:11 PM, written by the NP, revealed that the resident was seen for a monthly recapitulation (recap) and was lying in bed with oxygen. The resident was noted upset and not [the resident's] usual self. When questioned [the resident] states, I was raped. [The resident] did not elaborate and could not provide a specific time or description of individual. [The resident] did not want to discuss any further. Recommend referral to ED [Emergency Department] and [the resident] declined.On 6/11/26 at 10:40 AM, the ADON provided the following information; on 2/22/26, morning time, the NS called to inform her that Resident #65 notified the NP that they were allegedly sexually assaulted, the ADON instructed the NS to do a body check and to have the NP do a body check and offer to send to the ED. The ADON stated, the incident should have been reported in two hours, and the LNHA would initiate the process. I failed to generate the process. b. On 06/05/2026 at 10:00 AM, the surveyor observed Resident #92 in bed on the Birch Unit, and they reported not feeling well. The surveyor asked Resident #92 if they received incontinence care that morning and they stated that incontinence care was offered 5 hours earlier around 5:00 AM. The surveyor then asked the Registered Nurse (RN) if she could assist with an incontinent observation. The surveyor observed that Resident #92 was soaked with urine. The RN later identified herself as the Assistant Director of Nursing (ADON).On 06/05/26 at 10:28 AM, the surveyor observed Resident #2 in bed on the Cedar Unit. Resident #2 was nonverbal and appeared contracted. Resident #2 had a feeding tube that was observed hanging on a pole. A strong urine odor permeated in the room. The surveyor asked a Certified Nurse Aide (CNA) who entered the room to assist with a care tour observation. The CNA then closed the door and proceeded to turn Resident #2 on the left side. The CNA pulled the blanket off, and we both observed that Resident #2 was heavily soiled with feces and urine. The bed sheet, the incontinence pad under the resident, the top sheet and the bottom sheet were all stained and saturated with urine. The incontinence brief was observed soiled with dark feces and urine. During an interview with the CNA at that time regarding the observation, she stated that the 11:00 PM- 7:00 AM, shift sometimes would not provide incontinence care during their shift and that is what the resident would look like.On 06/05/26 at 10:25 AM, the surveyor exited the room and observed the Director of Nursing (DON) and the Licensed Nursing Practical Nurse Licensed Practical Nurse Unit manager (LPN/UM) in the hallway. The surveyor accompanied both to the room where we all observed Resident #2 was in bed, and was heavily soiled and the DON confirmed that incontinence care had not been provided for a while. Another surveyor was called for another observation and we all observed that Resident #2 was heavily soiled with urine and feces and the linens were stained for urine.On 06/05/26 at 12:30 PM, during a follow up interviewith the assigned CNA, she stated that 2 to 3 times weekly Resident #2 would be left soaked with urine and feces in the same manner as observed. On 06/09/26 at 6:48 AM, four days later, the surveyor conducted an incontinence care tour with the Certified Nursing Aide (CNA) who worked the 11:00 AM- 7:00 AM shift. Resident #53 who resided on the Cedar Unit, was wearing two incontinence briefs which were both saturated with urine. During an interview with the CNA, she stated that she had 18 residents on her assignment and stated it is too much. The CNA further stated that the 3:00 PM-11:00 PM shift placed two incontinence briefs on Resident #53. Upon further inquiry, the CNA then stated that she checked Resident #53 on her first rounds at 11:00 PM, she put on their pants to prevent them from removing the incontinence briefs. Based on the information provided by the CNA, more than 8 hours had elapsed since Resident #53 had received incontinence care.On 06/09/2026 at 6:55 AM, the surveyor interviewed the Unit Manager (UM) regarding residents wearing two incontinent briefs, she stated no one should have two briefs on, to prevent skin breakdown.On 06/09/2026 at 7:25 AM, the surveyor checked Resident #21 who resided on the Cedar Unit with a random CNA (CNA #2). Resident #21 also was wearing two briefs which were both saturated with urine. During an interview with CNA #2, she stated that she had 18 residents on her shif during last night, and stated it is hard. When inquired if she relayed her concerns to the administrative staff, she stated, they were aware of the workload. c. On 06/05/26 at 9:30 AM, the surveyor observed Resident #84, who resided on the Birch Unit in a recliner chair in the dayroom. Resident #84's hands were contracted. The nails were long, jagged and soiled with debris under all of the fingernails.On 06/09/26 at 11:45 AM (4 days later), the surveyor again observed Resident #84 in the dayroom, the surveyor approached the resident, but they could not communicate clearly. The surveyor observed Resident #84's nails were long, jagged and soiled underneath all 10 fingernails as observed on 6/5/26 at 9:30 AM. The surveyor asked Resident #84 if they ate their meal this morning. Resident #84 nodded and stated yes. 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: andOne 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:For the week of Complaint staffing from 12/21/2025 to 12/27/2025, the facility was deficient in CNA staffing for residents on 7 of 7-day shifts as follows: -12/21/25 had 9 CNAs for 95 residents on the day shift, required at least 12 CNAs. -12/22/25 had 9 CNAs for 95 residents on the day shift, required at least 12 CNAs. -12/23/25 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/24/25 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/25/25 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/26/25 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAs. -12/27/25 had 9 CNAs for 96 residents on the day shift, required at least 12 CNAs. For the 2 weeks of staffing prior to survey from 05/17/2026 to 05/30/2026, the facility was deficient in CNA staffing for residents on 9 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -05/17/26 had 11 CNAs for 106 residents on the day shift, required at least 13 CNAs.-05/17/26 had 7 total staff for 106 residents on the overnight shift, required at least 8 total staff.-05/18/26 had 12 CNAs for 106 residents on the day shift, required at least 13 CNAs.-05/23/26 had 12 CNAs for 105 residents on the day shift, required at least 13 CNAs.-05/24/26 had 11 CNAs for 105 residents on the day shift, required at least 13 CNAs.-05/25/26 had 12 CNAs for 105 residents on the day shift, required at least 13 CNAs.-05/27/26 had 11 CNAs for 104 residents on the day shift, required at least 13 CNAs.-05/28/26 had 12 CNAs for 104 residents on the day shift, required at least 13 CNAs.-05/29/26 had 11 CNAs for 104 residents on the day shift, required at least 13 CNAs.-05/30/36 had 12 CNAs for 103 residents on the day shift, required at least 13 CNAs. On 06/10/2026 at 12:12 PM, the surveyor interviewed the staffing coordinator who stated she was aware of the NJ state requirements for CNA staff-to-resident ratios. She stated she spoke to the Director of Nursing (DON) and administrator if requirements were not met. She stated, I staff for those requirements but because of call outs or cancellations we do not always meet the requirements. On 06/15/26 at 2:10 PM, during an interview with the LNHA, in the presence of the survey team,the surveyor discussed the staffing level with the LNHA. The surveyor asked if the facility had appropriate staffing, and was the LNHA aware that staff were using two incontinence briefs. The LNHA stated, I am very disappointed, and confirmed she was unaware that staff were using double incontinence briefs. NJAC 8:39-25.2; 27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to ensure that the kitchen environment and equipment was maintained in a clean and sanitary manner to prevent potential contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: On 06/04/26 at 9:47 AM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed the following: -Hand washing sink #1 by the dining room door in the kitchen, soiled with food debris inside sink.-Hand washing sink #2 by the dry storage food in the kitchen, soiled with food debris inside sink. FSD stated the staff were straining food in the handwashing sink because they only had the 3 compartment sink and that sink was not always available. The staff had got used to using any sink that they had available. The food prep sinks have been broken since my beginning of time 2024. In addition, the FSD stated that food should not have been in there because it's dirty and washing your hands in a dirty sink defeats the purpose. -The metal can opener was affixed to the table and had black debris embedded on the blade, and the insert that held the can opener. FSD stated that the can opener was cleaned daily but it's an old one. -Microwave oven was splattered with food debris on all areas inside the microwave. FSD stated it's food splatter, I would have hoped the staff cleaned the microwave once a day. -Cutting boards white, yellow, green and red all had deep grooves. FSD stated they were old and beat up and she needed to order new cutting boards. On 06/09/26 at 11:37 AM, the surveyor along with the Infection Preventionist (IP) nurse observed handwashing sink #1 and handwashing sink #2 soiled with food debris inside the sink. The IP Nurse stated that the staff should not have been using the handwashing sinks for food prep because the sinks are contaminated. On 06/15/26 at 10:37 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing and Infection Preventionist and reviewed the above concern no additional information was provided. A review of the Kitchen Sanitation Policy effective date 2020 revealed Policy Statement: The food service area shall be maintained in a clean and sanitary manner. NJAC 8:39-27.1(g)

Based on interview, record review, and review of pertinent documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure that all residents received care and to ensure the residents attained or maintained their highest practicable physical, mental and psychosocial well being by failing to ensure a) that written policies and procedures were developed and implemented to prevent and prohibit and thoroughly investigate all types of abuse, when on 2/22/26 Resident #65 alleged they were sexually assaulted and the LNHA did not become aware until 2/24/26, and b) ensure appropropriate levels of competent staff provided appropriate care and services to residents who depended on staff for care. The failure of the facility LNHA to self identify areas for improvement and implement measures to prevent potential resident harm, affected all residents who resided at the facility and was evidenced by the following: Refer to 607F, 610J A review of the Administrator's job description which was signed by the LNHA on 7/22/25 revealed the Purpose: to direct the day-to- day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulation that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times; Delegation of Authority: As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties; Duties and Responsibilities included: Develop and maintain written policies and procedures and professional standard of practice that govern the operation of the facility; Review the facility's policies and procedures at least annually and make changes as necessary to ensure continued compliance with current regulations and Interpret the facility's policies and procedures to employees, resident, family members, visitors, government agencies, etc . A review of the LNHA's resume revealed she has been an LNHA since 2003.A review of the Abuse and Neglect Policy Effective 1/15/2020 that was provided to the survey team during the Entrance Conference held on 6/4/26 at 12:00 PM revealed Procedures: Any person witnessing or suspecting abuse or neglect . shall follow the following procedures: 5. Upon receiving reports of physical or sexual abuse, the charge nurse/designee shall immediately examine the resident and report to supervisor. On 06/09/26 at 12:55 PM, the surveyor interviewed Resident #65 about any that they had regarding abuse and the resident stated that a worker that cared for them, tried to force themselves on them, and that I thought [they] were hired to care for me. When asked if the resident had reported the incident, they stated that they did and someone came to speak with them. On 06/10/26 at 12:52 PM, the surveyor asked the Director of Nursing when she became aware of the allegation of rape by Resident #65. The DON stated that the only reason she became aware of the allegation of rape was because the Medical Director (Resident #65's physician) wanted to know the outcome of what happened after the Nurse Practitioner informed the Nursing Supervisor of the allegation of rape by Resident #65 on 2/22/26. The DON stated the NP never informed the facility and the NP should have personally called the DON/Administrator immediately. When asked what should have happened, the DON stated the police should have been called, and the resident should have been transferred to the hospital. At that time, the facility still had not provided any investigation for the incident. On 06/10/26 at 2:17 PM, the surveyor interviewed the Nurse Practitioner (NP) who confirmed that on 2/22/26 Resident #65 informed her that they were raped and that she immediately informed the nursing supervisor on duty. When asked what should occur at the facility when a resident alleged, they were raped. The NP stated that she could not comment on what the facility should have implemented since she notified the nursing supervisor and the physician. When asked if she completed a specific physical assessment related to an allegation of rape, she stated she did not.On 6/10/26 at 2:30 PM, the surveyor again interviewed the DON, and now in the presence of the LNHA. The DON revised her prior statement and now confirmed that the NS was aware of the alleged rape and that the NS reported the alleged sexual abuse to the ADON on 2/22/26, but the ADON failed to report the alleged sexual abuse until 2/24/26. The DON further stated that she was made aware on 2/24/26, when the MD called to inquire about the outcome of our investigation into the allegation. At that time, the LNHA stated that she reported the alleged sexual abuse to the New Jersey Department of Health (NJDOH) within two hours on 2/24/26, after she was made aware of the alleged sexual abuse by the MD. The LNHA stated that after she was made aware of the incident, the facility requested a psychiatry and a psychology consultation which did not reflect any psychosis. The LNHA stated a urine analysis was also ordered and it was negative for a urinary tract infection.On 06/11/26 at 8:20 AM, the surveyor in the presence of the survey team interviewed the LNHA regarding Resident #65's allegation of rape. The LNHA confirmed that she only became aware of the allegation of rape, two days later (on 2/24/26) and as soon as she became aware it was reported to the Department of Health. On 06/11/26 at 9:13 AM, the surveyor conducted a subsequent interview with the Director of Nursing (DON) and LNHA, in the presence of the survey team. When asked was an allegation of rape considered sexual abuse and the LNHA stated, yes. The surveyor reviewed the Abuse and Neglect Policy at that time which did not indicate any specific procedures to protect any residents from abuse after an allegation of abuse was made by a resident. When asked how would you also protect any other residents to ensure everyone was safe. The LNHA stated the facility would interview alert and oriented residents on the same unit or assignment, and those who were not alert and oriented would conduct a body check. The LNHA also stated if a staff member was identified, they would be suspended pending investigation. The Procedure section of the Abuse and Neglect policy revealed any person witnessing or suspecting abuse or neglect including injuries of unknown source and misappropriation of resident property should follow the following procedures. The policy documented under # 1 the immediate removal of resident or employee from a harmful environment and did not document suspension of the employee.On 6/11/26 at 9:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), in the presence of the survey team, about the allegation of sexual abuse on 2/22/26, and the ADON stated she was on call that day, but she was not physically at the facility. The ADON confirmed the NS made her aware of the allegation on 2/22/26, but she could not recall the time. The ADON stated, I failed to report it to my supervisor. The ADON reported that Resident #65 was touched, and she remembered asking the NS, Did it really happen? The ADON stated that she reported the incident on 2/24/26, and that she just returned from vacation, had jet lag, and was tired. On 6/15/26 at 2:10 PM, the surveyor interviewed the LNHA, in the presence of the survey team, about the Quality Assurance and Performance Improvement (QAPI) program and asked what the purpose was. The LNHA stated to track and trend resident concerns and then they were reviewed at the QAPI meetings. When asked if the allegation of rape that occurred on 2/22/26 had been reviewed at the recent QAPI, which she confirmed was held on 4/2026. The LNHA stated I cannot recall, I don't have it documented that I discussed that specifically. The LNHA looked through her binder and stated, we would normally discuss incidents and accidents and I am not sure why I don't see it in there. When asked to review all of the QAPIs that were reviewed in 4/2026 the LNHA stated the following: 1. Environmental issues and related to capital. 2. Activities related to outdoor courtyards. 3. Laundry items getting lost. 4. Health files were identified as an issue in September/October 2025 and were ongoing with employee files.5.Marketing.6.Staffing-nurse recruitment since the facility utilized a lot of agencies. When asked if the facility met minimum requirements for staffing, the LNHA stated, yes, we have a group of people that monitor it. 7. Falls were reviewed; when asked for specifics, the LNHA did not have the data or any performance indicators.8. Infection Control regarding the flu shots.9. Asked about tracking and trending grievances and the LNHA stated she did not have that information. When asked the LNHA about meeting the staffing requirements, after the surveyor observed four resident observations on 6/5/26, Resident #92 was observed saturated with urine; Resident #2 was soiled with feces and urine, and on the same day and after the Director of Nursing was made aware of those observations, the surveyor subsequently observed on 6/9/26 (four days later) that Resident # 53 was wearing two incontinence briefs that were both saturated with urine, and Resident #21 was also observed wearing two incontinence briefs that were saturated with urine. The LNHA then responded that she was disappointed in the staff and no other information was provided. 8:39-9.2(a)

Based on observation and interview, it was determined that the facility failed to maintain the resident environment in a clean, sanitary, and homelike manner for 2 of 3 Resident Units (Birch and Cedar) observed, and the deficient practice was evidenced by the following: On 6/9/26 at 6:30 AM, Surveyor #1 observed the following on the Birch and Cedar units: Birch:-Upon approach to room [ROOM NUMBER], the surveyor observed a strong smell of urine. Upon entry, it was observed the room was a four bedded room and Resident #41 stated, it sinks and they thought it was the opposite bed (Unsampled Resident in bed 12B) that had smelled of urine because they peed the bed. At 6:55 AM, the Certified Nurse Aide (CNA) that was assigned to residents in room [ROOM NUMBER], confirmed that she had changed the #12 B bed linens and confirmed that the room still smelled of urine and she thought the urine smell was embedded in the resident's mattress who resided in bed 12B. Cedar:- room [ROOM NUMBER], the surveyor also observed a four bedded room, the ceiling area was soiled with debris and stained, the closet had four partitions with no closet door in place to cover resident belongings and bags of items were observed on the floor. The unsampled resident in A-bed confirmed they never had a closet door. - room [ROOM NUMBER], upon entry Resident #5 stated the room is a mess and the surveyor observed a bedsheet was being used as a window curtain and appeared thin and ragged. Resident #5 then stated it has been like that for a while. There was also dust like debris observed on the curtain that divided the resident areas which was confirmed by Resident #5. When asked if the curtains were ever washed, Resident #5 stated no. Resident #7 then stated that the sheets were hung up by the facility because there was too much sun coming into the room and the plastic type blinds did not keep the sun out. -room [ROOM NUMBER], the unsampled resident in A- bed, had two visibly soiled wheelchair cushions on the wheelchair next to their bed, the black bottom cushion and the beige cushion on top had debris on them. There was also a large square area behind their bed and by the lower molding with gray duct tape on the wall. The accordion door to the closet was visibly broken and had a jagged area. The bathroom sink area had ripped paint behind the sink. -room [ROOM NUMBER], there was no closet door to protect personal belongings. An unsampled resident was sleeping in A- bed and had a sheet covering them. The sheet had a hole in it. -room [ROOM NUMBER], the air conditioner unit had a broken piece under it and was soiled with debris. The door to the bathroom had a ripped area. On 6/10/26 at 10:40 AM, the surveyor conducted a follow-up observation room [ROOM NUMBER] on the Birch unit, with another surveyor present. The room again had an overwhelmingly powerful smell of urine that was observed prior to entering the room. There was a Licensed Practical Nurse (LPN) at a medication cart outside of the room. The surveyor asked if the LPN had smelled anything and the LPN stated, I don't usually work this unit, but today the urine smell is particularly strong. On 06/10/26 10:42 AM, the CNA stated that she was going to strip the unsampled Resident in B-bed's sheet, as she was working on the sheet for 12A at present. At that time, the surveyor observed that the CNA placed a stained sheet on # 12A's bed and asked the CNA if she observed the stain and the CNA stated that she did but the sheet was on the clean linen cart. Surveyor #2:On 6/10/26 at 11:10 AM, Surveyor #2 observed room [ROOM NUMBER] had bed sheets hanging over the windows and were being used as curtains.On 6/10/26 at 11:15 AM, Surveyor #2 interviewed Resident #7 at that time, who showed the surveyor that they needed to hang a bed sheet over the window to keep the sun from entering their room. The resident told the surveyor that the window blinds didn't keep the sunlight out of their room and the resident stated, that the sunlight was a real issue in the early afternoon. Resident #7 stated that they had spoken with the facility on multiple occasions about getting new blinds and the facility put the sheets up instead.On 6/12/26 at 10:00 AM, Surveyor #2 interviewed the facility Director of Maintenance (DOM) who stated that he was unaware that the resident had a sheet hanging over their window. The surveyor asked the DOM if a bed sheet was an appropriate window covering and he stated no and informed the surveyor that he put a temporary blind on the resident's window and would be replacing it with more permanent blind.On 06/12/26 at 1:30 PM, Surveyor #2 presented the findings to the Licensed Nursing Home Administrator (LNHA).On 06/15/26 at 10:46 AM, Surveyor #1 presented the observations from 6/9/26 and 6/10/26 to the Director of Nursing, Infection Preventionist Nurse and LNHA in the presence of the survey team. On 06/15/26 at 2:06 PM, the survey team met with the LNHA during the exit conference and no additional pertinent information was provided. NJAC 8:39-4.1(a)11; 31.4 (a)(b)(c)(f)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified for 1 (one) of 6 (six) residents (Resident #7) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.a). On 6/09/26 at 11:30 AM, the surveyor interviewed Resident#7 who was observed in his room. The resident stated that they did receive their Prazosin why they are taking for post-traumatic stress disorder. The resident also stated that they are not receiving their Oxycodone (pain medication) in a timely manner. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; post-traumatic stress disorder ( a psychiatric condition that can develop after experiencing or witnessing a life threatening or deeply traumatic event), chronic pain syndrome (a long-lasting pain condition persisting beyond 3 to 6 months, that triggers symptoms beyond physical discomfort), and bi-polar disorder (a lifelong mental health condition that causes extreme, cynical shifts in mood, energy, and activity levels).A review of a quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 05/04/26, reflected that the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident is cognitively intact. A review of the resident's June 2026 Order Summary Report (OSR) revealed that the resident had a physician's order ( PO) dated 6/10/26, for Prazosin oral capsule 5 mg, 1 capsule by mouth at bedtime for PTSD (Post-Traumatic Stress Disorder) hold for blood pressure (BP) less than 110. A further review into the OSR revealed a PO dated 05/27/26 that was discontinued on 6/8/26, for Prazosin oral capsule 1 mg, give 4 capsules by mouth at bedtime for PTSD.A review of the resident's June 2026 electronic medication administration record (e-MAR) revealed a PO dated 05/27/26, for Prazosin oral capsule 1 mg, give 4 capsules by mouth at bedtime for PTSD with a plotted time of 2100 (09:00 PM). A further review of the e-MAR revealed the following: On 6/5/26 and 6/7/26 a nurse documented NA on the e-MAR. On 06/06/26 a nurse documented that the medication was administered.A review of the resident's progress notes revealed no nursing notes from 6/5/26 and 6/7/26 that indicated why the resident's medication was not administered,On 6/10/26 at 10:20 AM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) who was the resident's medication nurse. LPN#1 stated that NA indicated that the medication was unavailable and when a nurse document that a medication was unavailable, they must put a note in the progress notes. LPN#1 reviewed the medical records in the presence of the surveyor, and she stated that they were no note in the progress notes indicating that the medication was not given. She further stated that the resident's Prazosin was changed to 5mg because the 1 mg was unavailable. LPN#1 was unable to tell the surveyor why a nurse documented that the resident's Prazosin was documented as being administered when the medication was unavailable. b). A review of the June 2026 OSR revealed the following PO:1.A PO dated 3/20/26 for Oxycodone oral tablet 10 mg, give 1 tablet by mouth every 4 hours for severe pain2.A PO dated 1/26/26 for Gabapentin oral capsule 400 mg, give 1 capsule by mouth four times daily for neuropathy3.A PO dated 5/29/26 for Benadryl allergy oral tablet 25 mg, give 2 tablets (50mg) by mouth three times a day for itching4.A PO dated 02/13/26 for guaifenesin ER (extended release) 600 mg tablet, give 1 tablet by mouth two times a day for cough and congestion.5.A PO dated 01/22/26, for Finasteride oral tablet 5 mg, give 1 tablet by mouth in the evening for urinary retention6.A PO dated 01/22/26, for Tamsulosin HCL oral capsule 0.4mg, give 1 capsule by mouth in the evening for benign prostatic hyperplasia (BPH)7.A PO dated 06/05/26, for Warfarin oral tablet 4 mg, give 1 tablet by mouth in the evening related to unspecified atrial fibrillation. A review of the June 2026 e-MAR and the June 2026 Medication Administration Audit Report revealed the following:1.A PO dated 3/20/26 for Oxycodone oral tablet 10 mg, give 1 tablet by mouth every 4 hours for severe pain. A plotted time of 0000(12:00AM), 0400 (4:00AM), 0800 (8:00 AM), 1200 (12:00PM), 1600 (4:00 PM) and 2000 (8:00 PM). The Medication Administration audit report revealed the following:- On 6/3/26 scheduled time for 12:00 PM medication was administered at 1:06PM.-On 6/5/26 scheduled time for 4:00 PM medication was administered at 5:53 PM-On 6/6/26 scheduled time for 12:00 PM medication was administered at 1:08 PM 2.A PO dated 1/26/26 for Gabapentin oral capsule 400 mg, give 1 capsule by mouth four times daily for neuropathy. A plotted time of 0800 (8:00 AM), 1200 (12:00 PM), 1600 (4:00 PM) and 2000 (8:00 PM).- On 6/3/26 scheduled time for 12:00 PM medication was administered at 1:06PM.-On 6/5/26 scheduled time for 4:00 PM medication was administered at 5:53 PM-On 6/6/26 scheduled time for 12:00 PM medication was administered at 1:08 PM 3.A PO dated 5/29/26 for Benadryl allergy oral tablet 25 mg, give 2 tablets (50mg) by mouth three times a day for itching. A plotted 0800 (8:00 AM), 1200 (12:00 PM) and 1600 (4:00 PM).- On 6/3/26 scheduled time for 12:00 PM medication was administered at 1:06PM.-On 6/5/26 scheduled time for 4:00 PM medication was administered at 5:53 PM-On 6/6/26 scheduled time for 12:00 PM medication was administered at 1:08 PM 4.A PO dated 02/13/26 for guaifenesin ER (extended release) 600 mg tablet, give 1 tablet by mouth two times a day for cough and congestion. A plotted time of 0600 (6:00 AM) and 1800 (6:00 PM)- On 6/3/26 scheduled time for 6:00 PM medication was administered at 7:09 PM.-On 6/7/26 scheduled time for 7:00 PM medication was administered at 8:27 PM5.A PO dated 01/22/26, for Finasteride oral tablet 5 mg, give 1 tablet by mouth in the evening for urinary retention. A plotted time of 1800 (6:00 PM)- On 6/3/26 scheduled time for 6:00 PM medication was administered at 7:09 PM.-On 6/7/26 scheduled time for 7:00 PM medication was administered at 8:27 PM6.A PO dated 01/22/26, for Tamsulosin HCL oral capsule 0.4mg, give 1 capsule by mouth in the evening for benign prostatic hyperplasia (BPH). A plotted time of 1800 (6:00 PM)- On 6/3/26 scheduled time for 6:00 PM medication was administered at 7:09 PM.-On 6/7/26 scheduled time for 7:00 PM medication was administered at 8:27 PM 7.A PO dated 06/05/26, for Warfarin oral tablet 4 mg, give 1 tablet by mouth in the evening related to unspecified atrial fibrillation. A plotted time of 1800 (6:00 PM)- On 6/3/26 scheduled time for 6:00 PM medication was administered at 7:09 PM.-On 6/7/26 scheduled time for 7:00 PM medication was administered at 8:27 PM On 6/12/26 at 11:35 AM, the surveyor interviewed LPN#2 via phone call. LPN#2 was unable to remember why Resident #7's medication was administered late on 6/5/26.On 6/12/26 at 11:45 AM, the surveyor left a message with LPN#3 regarding the late administration of Resident #7's medications on 6/7/26. On 6/12/26 at 1:30 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator.No further information provided A review of the facility's policy titled Administering Medications that was dated 03/2022 and was provided by the Director of Nursing indicated the following: If a drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication will utilize the correct code in the electronic medical record (EMR).NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview and record review it was determined that the facility failed to properly label, dispose of and store medications in 3 of 6 medication carts. The deficient practices were evidenced by the following:On 06/10/26 at 10:18 AM, the surveyor inspected Cedar medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an unopened bottle of Xalatan eye drops that was stored in the medication cart. The surveyor also observed one vial of Lantus insulin that did not contain a label with the resident's name. At that time, the surveyor interviewed LPN#1 who acknowledge that an unopened Xalatan eye drops should have been stored in the medication refrigerator. LPN#1 also stated that the Lantus Insulin vial should contained a pharmacy label with the resident's name on it.On 06/10/26 at 10:45 AM, the surveyor inspected the Cedar unit medication cart #2 in the presence of LPN #2. The surveyor observed an opened bottle of blood glucose test strips that were opened and not dated and a Lantus insulin vial that did not contain a pharmacy label with a resident's name on it. At that time, the surveyor interviewed LPN#2 who stated that an opened bottle of blood glucose test strips should have been dated. LPN#2 also stated that a Lantus insulin vial should have contained a pharmacy label with the resident's name on it.On 06/10/26 at 11:03 AM, the surveyor inspected the Birch medication cart#3 in the presence of LPN#3. The surveyor observed an opened bottle of Xalatan eye drops that were opened and contained no pharmacy label with the resident's name on it. The surveyor also observed an opened bottle of Xalatan eye drops with no opened date and a vial of Humalog insulin that contained no pharmacy label on it. At that time, the surveyor interviewed LPN#3 who stated that both the Humalog insulin vial and Xalatan eye drops should have had a pharmacy label with the resident's name on it. LPN#3 also stated that an opened Xalatan eye drops should have been dated.A review of the Manufacturer's Specifications revealed the following:Unopened bottle of Xalatan should be stored in the medication refrigerator.An opened bottle of Xalatan eye drops have a 42-day expiration date.An opened bottle of blood glucose test strips has a 90-day expiration date. On 06/12/26 at 1:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator. No additional information was provided. A review of the facility's policy titled Medication Storage dated 03/31/20 and was provided by the Director of Nursing, revealed the following: Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. NJAC 8:39-29.4(a)(h) and (d)

COMPLAINT #2718861 Based on interviews and review of pertinent facility documentation on 3/13/26 and 3/24/26, it was determined that the facility failed to provide a timely follow - up management and care of a resident's indwelling catheter to address urologist's recommended procedures. This deficient practice was identified for one of two residents (Resident #2) reviewed for catheter care and was evidenced by the following:A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: obstructive and reflux uropathy, congenital malformation of urinary system, and severe intellectual disabilities. Review of Resident #2's quarterly Assessment Minimum Data Set (MDS,) an assessment tool used to facilitate the management of care, dated 2/26/26, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview. Further review of the MDS revealed that the resident was dependent on staff for toileting. The MDS also indicated that the resident had an indwelling catheter. A review of Resident #2's care plan (CP) indicated that Resident #2 had an indwelling catheter; with intervention to observe and to report changes to the medical doctor. A review of Resident #2's progress notes (PN) revealed a nursing note dated 10/20/25 at 2:44 PM, indicated that the resident went for urology appointment. A nursing note dated 10/20/25 at 4:03 PM, stated that the resident returned from the urology appointment and that the doctor recommended, future [Operating Room] schedule. A review of the Resident #2's electronic medical record (EMR) revealed a visit summary from the urologist appointment dated 10/20/25, which indicated that the resident would be scheduled for the following procedures: cystoscopy, laser lithotripsy of bladder stone, and a Transurethral Resection of the Prostate.There was no documented evidence that the facility followed up with the urologist regarding the aforementioned procedures or that the facility contacted the resident's medical doctor regarding having issues scheduling appointment for the procedures. A Review of the EMR revealed that the resident was admitted to the hospital on [DATE] with an obstructed foley, bilateral hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder), and an acute kidney injury. Further review of the PNs revealed a nursing noted dated 1/11/26 at 5:11 PM that indicated that the resident had cloudy yellow urine, had not been eating, and was lethargic. The note further indicated that an order was obtained to send the resident out for further evaluation. During an interview on 3/13/26 at 4:06 PM, the Infection Preventionist (IP) stated that Resident #2 was last seen by urologist on 10/20/25 and that the urology office was expected to schedule an OR procedure. When asked if the facility had followed-up to contact the office to schedule, he stated that Central supply (CS) staff made attempts to call the urology office and that the office had not provided a date. When asked if the attempts to schedule the resident's appointment was documented; he stated that the Central supply staff did not document in the EMR. During an interview on 3/13/26 at 12:04 PM, Central supply (CS) staff stated that she was responsible for scheduling appointments for residents. During a follow-up interview on 3/13/26 at 4:56 PM, the CS stated that a residents' return from their medical appointments, she scheduled any upcoming appointments and scanned the documents into the computer to be uploaded into the resident's medical record. When asked about the follow-up form from Resident #2's 10/20/25 appointment, she stated that the resident did not have one because there was no follow-up appointment to schedule and that the urology office was to schedule Resident #2 for surgical procedures. The CS staff stated that she called the urology office weekly to set up appointments for all residents. She further stated that she does not have access to the EMR and that she keeps track of her attempts to schedule appointments on paper. When asked to provide the documented attempts for Resident #2, the CS stated stated that she did not save the paperwork. During a joint interview on 3/13/26 at 5:33 PM, with the Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON) both stated that the facility does not have a policy in place related to the scheduling of out-of-facility appointments for residents. The ADON stated that after an appointment, the Consult Sheet was reviewed by nursing and the CS to see when the resident was due for their next appointment. She stated that no form had been completed for Resident #2 because a follow-up appointment was not required, she stated that the urology office was to schedule the resident for surgery. They both stated that they were aware that the CS was calling regularly but that the office had not provided a date. LNHA and DON stated that the CS staff kept track of all of her attempts in her own personal log, and that this was the process that they had in place. When the surveyor informed them that the CS did not have a documented evidence of her attempts to schedule appointments, they provided no other information to the surveyor. The facility did not provide further information regarding action plans for when the CS staff is unable to schedule an appointment and no evidence of attempts to reach the urologist's office. A review of the facility's Charting Documentation policy effective 3/2020, indicated that, The medical record should facilitate communication between the interdisciplinary team . N.J.A.C. 8:39-27.1(a)

Complaint #2604637Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered according to the physician's orders. This deficient practice was identified for 1 of 4 residents (Resident #2) reviewed for medication administration.This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 10/30/25 at 10:26 AM, the surveyor observed Resident #2 resting in bed with their eyes closed.On 10/30/25 at 11:21 AM, the surveyor reviewed the medical record for Resident #2.A review of the admission Record, an admission summary, reflected the resident was admitted to the facility with diagnoses which included, but were not limited to: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or paralysis of one side of the body), and an overactive bladder.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/7/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/2/2025, that the resident had a rash. Interventions included but were not limited to; administering anti-fungal cream as prescribed.A review of the Order Summary Report (OSR), dated as of 9/2/2025, included the following physician orders (PO):A PO, dated 9/1/2025, for nystatin powder, apply to the left abdominal fold, day and evening shift.A PO, dated 9/1/2025, for nystatin powder, apply to the pubic region in the morning and at bedtime.A review of the Medication Administration Record (MAR) for September 2025 revealed nystatin powder was not signed out as administered on the following dates:On 9/3/25, the evening dose of nystatin powder for the abdominal fold.On 9/14/25, the 9:00 AM dose of nystatin powder for the scrotum.On 9/16/25, the evening 9:00 PM dose of nystatin powder for the scrotum, and the evening dose for the abdominal fold. On 10/30/2025 at 1:50 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the physician's order should be followed. She further stated that the medication should be administered and then the nurse should sign off the medication as administered on the MAR. She also stated that if it was not signed off on the MAR, that would indicate that the medication was not administered.On 10/30/2025 at 1:59 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that medications should be administered according to the physician's orders. She further stated that the nurse should administer the medication and then sign the MAR to indicate that it was administered.On 10/30/2025 at 2:19 PM, the surveyor interviewed the Director of Nursing (DON), who also stated that the physician's orders should be followed. She further stated that if the medication was not signed off on the MAR, it meant that it was not given. A review of the facility's policy Administering Medications, revised 3/2019, included, Medications shall be administered in a safe and timely manner, and as prescribed.NJAC 8:39-27.1(a)

Refer to F561 Based on observation, interview and facility assignment sheet review, the facility failed to ensure sufficient number of staff were available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This deficient practice had the potential to affect all 82 residents and was evidenced by the following: On 12/7/24 at 8:30 AM, the surveyor interviewed the Manager on Duty/Infection Preventionist (MOD/IP) who stated there were eight staff call-outs because staff were not paid. The surveyor reviewed the staffing assignment sheet for the 7 AM - 3 PM shift. The facility census was 82 with three nurses and four Certified Nursing Assistants (CNAs). The MOD/IP stated she called the Director of Nursing (DON) regarding the call-outs but was told the DON resigned last night. The surveyor asked what the plan was regarding staffing and the MOD/IP stated they have been calling staff asking if they could come in today but so far no one has accepted. Last night's MOD stated she left messages with the facility's Consultant Administrator, Administrator and Executive Director early this morning but had not received a response. The MOD/IP stated the Assistant DON (ADON) was on her way to take over the manager duties so that she could act as a unit nurse. The surveyor met the identified ADON at 9:59 AM. When the surveyor asked if she was the ADON, the nurse stated no; I never officially took the title. The nurse continued that she had worked for the facility for [AGE] years and came in today to act as the Manager on Duty due to the short staffing. At 11 AM, Resident #1 requested to speak to the surveyor. Resident #1 stated that he wanted to get out of bed, but staff told him he would have to wait because the facility is short staffed. Resident #1 stated he was a hoyer lift (equipment to assist staff with transferring a resident) that required two people to operate. Resident #1 stated that he missed morning activities and coffee today. At 12:45 PM, the surveyor interviewed the acting MOD for an update regarding staffing. The acting MOD stated that department heads were coming in to help with non-nursing activities such as answering call bells and passing out meal trays. The acting MOD stated she would continue to call staff to come in but no one had accepted. At 2:42 PM, the surveyor interviewed Resident #2 in his room. Resident #2 stated staff were great and worked hard. The surveyor asked if anything was different with his care today. Resident #2 stated the call bell response was slower than usual as it normally would be answered within 5 minutes, but today it took about 30 minutes. At 3 PM, a consultant to the facility arrived and stated that he brought in food for the staff and was offering bonus' and gift cards for anyone who would pick up an extra shift. The surveyor, facility consultant and the 3 PM - 11 PM MOD reviewed the 3 PM - 11 PM staffing assignment sheet. According to the assignment sheet, 2 nurses and 4 CNAs called out.

Complaint # 181482 Based on observation and interview, the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis due to the DON resigning on 12/6/24. This deficient practice affected all 82 residents and was evidenced as follows: The facility's DON called the Department of Health Complaints' Hotline on 12/6/24 at 6:43 PM informing the Department that she resigned effective immediately. The surveyor entered the facility on 12/7/24 at 8:15 AM via a side entrance as the front door was locked and a handwritten sign was taped to the door instructing people to use the back entrance. At 8:50 AM, the surveyor spoke to the 7 AM - 3 PM shift Manager on Duty/Infection Preventionist (MOD/IP). The MOD/IP stated that the facility had eight employees call out due to not being paid. The surveyor asked if the Administrator or DON had been called. The MOD/IP stated she called the DON, but the DON told her that she resigned last night. The surveyor asked if the facility had an Assistant Director of Nursing (ADON). The MOD/IP stated yes, and that the nurse was on her way. The surveyor met the identified ADON at 9:59 AM. When the surveyor asked if she was the ADON, the nurse stated no; I never officially took the title. The nurse continued that she had worked for the facility for [AGE] years and came in today to help due to the short staffing. NJAC 8:39-25.1(a) NJAC 8:39-25.1(b)

Based on observation and interview, the facility failed to maintain the boiler to provide consistent hot water temperatures within 95 to 120 degrees Fahrenheit. This deficient practice had the potential to affect all 82 residents and was evidenced by the following: On 12/7/24 at 8:30 AM, the surveyor calibrated a thermometer and obtained the following hot water temperatures for the Dogwood Unit: Pantry: 122. At 9:35 AM it was rechecked and the hot water temperature was 101. Shower: 122. At 9:40 AM it was rechecked and the hot water temperature was 101. room [ROOM NUMBER]: 123. At 9:33 AM it was rechecked and the hot water temperature was 86. room [ROOM NUMBER]: 116. At 9:36 AM it was rechecked and the hot water temperature was 86. room [ROOM NUMBER]: 97. At 9:38 AM it was rechecked and the hot water temperature was 101. At 8:53 AM, hot water temperatures for the Birch Unit were obtained and were as followed: room [ROOM NUMBER]: 62. At 9:45 AM it was rechecked and the hot water temperature was 60. Bath 2: 90. room [ROOM NUMBER]: 88. At 9:15 AM, hot water temperatures for the Cedar Unit were obtained and were found to be within 95 to 120 degrees Fahrenheit. At 10:50 AM, the surveyor interviewed the maintenance staff (MS #1). MS #1 stated water temperatures were not consistent due to a small boiler that could not keep up with the demand. The surveyor visualized the boiler and holding tank and noted that both were used units. MS #1 also stated that the kitchen dish machine and laundry both pull off the same boiler as domestic. At 12 noon, the surveyor and MS #1 obtained hot water temperatures on all three units after calibrating their thermometers. The hot water temperature ranges were as followed: Dogwood Unit: 108-111. Birch Unit: 99-112 except for room [ROOM NUMBER] which remained at 60. Cedar Unit: 107-110. At 2:15 PM, the surveyor obtained hot water temperatures. The Dogwood and Cedar Units' hot water temperatures were within 95 to 120 degrees Fahrenheit. The Birch Unit hot water temperatures ranged from 80-110. rooms [ROOM NUMBERS] were 80 and the shower room was 90. NJAC 8:39-31.2(e)

Based on observation, interview and relevant facility record review, the facility failed to ensure that a resident (Resident #1) was assisted out of bed timely to participate in morning activities. This deficient practice was evidenced for one of two residents sampled for self-determination. On 12/7/24 at 8:30 AM, the surveyor interviewed the Manager on Duty/Infection Preventionist who stated that there were eight staff call-outs because they were not paid. The surveyor reviewed the staffing assignment sheet for the 7 AM - 3 PM shift. The facility census was 82 with three nurses and four Certified Nursing Assistants (CNAs). At 11 AM, Resident #1 requested to speak to the surveyor. Resident #1 stated that he wanted to get out of bed, but staff told him he would have to wait because the facility is short staffed. Resident #1 stated he was a hoyer lift (equipment to assist staff with transferring a resident) that required two people to operate. Resident #1 stated that he missed morning activities and coffee today. The surveyor observed the unit nurse was passing out medications and the CNA could not be found for interview. The surveyor reviewed the Staffing Assignment Sheet and Resident #1's unit census was 28, with one assigned nurse and one assigned CNA for the 7 AM - 3 PM shift. At 2:17 PM, the surveyor observed the resident in a motorized wheelchair in the hallway. Resident #1 stated he just left the afternoon activity in the Dining Room. Resident #1 stated staff got him out of bed at 2 PM. Resident #1 stated he feels bad and was mad that staff did not get him out of bed this morning and he missed morning activities and coffee. The surveyor observed the unit nurse was passing out medications and the CNA could not be found for interview. NJAC 8:39-4.1(a)(24)

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to protect the residents' right to be free from neglect by not addressing residents' complaints of cold water for bathing and showering. The deficient practice was identified on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 835L Interviews on 11/13/24, with both residents and staff, revealed the facility had no hot water for resident showering and bathing for months, and the facility was aware of the complaints. Temperatures obtained on 11/13/24, in both resident rooms and shower rooms on all the nursing units registered between 66.8 degrees Fahrenheit (F) and 82 degrees F. Interviews with the Maintenance Director (MD) confirmed water temperatures had been cold, that the water temperature should register at least 105 degrees F; residents and their families had complained; and the facility's boiler was underrated for the facility size. The facility's failure to protect all residents from neglect by addressing the residents' complaints of cold water when showered or bathed posed a likelihood of serious harm to the residents' care and ability to achieve their highest practicable level of wellbeing. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/13/24, when the survey team was made aware of the cold water. The facility Administration was notified of the IJ on 11/13/24 at 4:19 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: Reference: STATE OF NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF PUBLIC SAFETY AND OCCUPATIONAL SAFETY AND HEALTH BUREAU OF BOILER AND PRESSURE VESSEL COMPLIANCE included but was not limited to; boilers shall be inspected at 12-month intervals. A review of the facility provided Freedom from Abuse, Neglect and Exploitation policy dated effective October 2022, included: Purpose: To provide a proactive and systematic approach to the protection of the residents' rights and safeguarding residents from harm due to abuse, neglect and or misappropriation of property. This will be accomplished by incorporating the seven components of abuse prevention into the facility's procedural practices . Definitions: g. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. C. Prevention: Administration establishes a close rapport with residents and their representative at the time of admission. During this process, the residents and resident representatives are provided information regarding Resident's Rights, which includes discussion about who to speak to regarding any concerns, incidents, and grievances, without fear or retribution. A review of the facility provided Resident Rights policy, dated effective October 2021, included: Purpose: To inform, recognize, respect and safeguard the individual rights of all residents provided under law. Policy: The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, as described in the policy consistent with the principles of requirements of Federal, State and Local Laws and Regulation. b. Planning and implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: 5ii. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. d. Respect and Dignity. The resident has a right to be treated with respect and dignity, including: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. e. Self-Determination. The resident has the right to self-determination, including but not limited to the right to: 1. Choose activities, schedules (including sleeping and waking times), health car and providers of health care services consistent with his or her interests, assessments, and plan of care. i. ii. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment in accordance with 483.11(g), including but not limited to receiving treatment and supports for daily living safely. Surveyor #1: On 11/13/24 at 9:28 AM, Resident #43 stated to Surveyor #1 that they had a complaint and asked if it was okay to get washed by staff with cold water. On 11/13/24 at 10:04 AM, on the Birch Unit, Surveyor #1 interviewed a Certified Nurse Aide (CNA #1) about the water temperatures, and CNA #1 stated she was unable to shower residents because the water temperature was too cold and that the facility had been aware of the cold water problem. On 11/13/24 at 11:32 AM, Surveyor #1 interviewed the Housekeeping Director (HD) about the laundry process and the hot water temperatures. The HD stated that they needed to stop using the washing machines at 10:00 AM to preserve the hot water. Surveyor #1 then asked the HD if she had been aware that there was a problem with the hot water and she stated, yes, three months ago, and stated I never in my life worked in such a condition. Surveyor #2: On 11/13/24 at 11:12 AM, Surveyor #2 toured the Dogwood Unit, and in the presence of CNA #2 took the bathroom water temperature for room [ROOM NUMBER] (unoccupied resident room) which registered 68.1 degrees F. At that time, Surveyor #2 asked if that was the hot water knob and CNA #2 confirmed it was and that the facility had not had hot water in a while and they provided cold showers. On 11/13/24 at 11:22 AM, Surveyor #2 interviewed Resident #240, who stated that they could not take a shower, but their bed bath was also cold. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #23, who stated I won't shower with cold water and don't even ask me about washing my hair. It hasn't been pleasant. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #241, who stated they have not been at the facility long, but that the water was cold. Surveyor #3: On 11/13/24 at 11:19 AM, Surveyor #3 entered the Cedar Unit and in the presence of CNA #4, obtained the following water temperatures: Shower #1 the hot water from the sink and shower was 78 degrees F, and in Resident #72 and #74's room the bathroom sink was 78 degrees F. At the time of the observation, Surveyor #3 interviewed CNA #4, who stated that in the morning the water was hot when we gave their baths, it's usually around 10:30 AM and sometimes during the day that it got cold but not all the time. On 11/13/24 at 12:13 PM, Surveyor #3 interviewed Resident #79 about the water temperatures in the room, and the resident stated the water used to be hot but lately it's been cold; I don't take showers when the water was cold. [The facility] fixes it and it got cold again. The resident had reported that the issue had been going on in the last few days. On 11/13/24 at 12:17 PM, Surveyor #3 interviewed Resident #46 in their room who stated, I've been here for 4 1/2 years due to a blockage and had surgery for colostomy. I'm a quadriplegic. My major issue was there was no hot water for a year now. My last shower was two months ago, I took two showers that were ice cold. I got a bed bath but it's ice cold. I've told everyone, the nurses, Director of Nursing, Unit Managers, CNAs and Social Worker. Surveyor #4: On 11/13/24 at 11:13 AM, Surveyor #4, in the presence of CNA #5, entered Resident #82's room and tested the hot water in the resident's bathroom which registered at 80 degrees F. CNA #5 stated that residents complained of cold water all the time and CNA #5 stated he worked on all of the units. CNA #5 then accompanied Surveyor #4 to the shower room and held the shower head hose; the water felt cold and registered 69 degrees F. On 11/13/24 at 12:04 PM, Surveyor #4 entered the kitchen and observed the Kitchen Staff employee (KS #1) washing large stainless steel type pans in the three-compartment sink. The surveyor felt the wash water which felt cool and the wash temperature registered 92 degrees F, the sanitizer temperature registered 79 degrees F. Surveyor #4 asked KS #1 if there was hot water and he stated, depends if it was on and hot water was not always on. Surveyor #5: On 11/13/24 at 11:16 AM, Surveyor #5, in the presence of the Maintenance Director (MD), tested the hot water on the Birch Unit bathroom of room [ROOM NUMBER] (unoccupied resident room) which registered 66 degrees F. On 11/13/24 at 11:22 AM, Surveyor #5, in the presence of the MD, tested the hot water on the Birch Unit bathroom of room [ROOM NUMBER] (unoccupied resident room) which registered 66 degrees F. On 11/13/24 at 11:25 AM, Surveyor #5 interviewed the MD about the water temperatures in the boiler room. Surveyor #5 observed and counted that there were 12 boilers. There were six boiler certificates posted that indicated six boilers were inspected in 2023. The MD stated that the boilers observed were only used to heat the resident rooms and not for hot water. The MD stated that there were only six certificates because only six boilers were working. The MD stated that the hot water boiler was recently replaced. Surveyor #5 asked for the annual inspection certificate of the recently replaced hot water boiler and the MD stated that he was not sure if there was one because the boiler was changed prior to MD's date of hire. The MD stated that he believed that the boiler ran well but was undersized for the facility and he believed at one point the facility used to have two bigger boilers in use, telling from the empty space next to the smaller boiler. There were also two boiler venting pipes, one of them did not have a boiler hooked up to it, and the other pipe was connected to the current boiler. The other had the venting pipes reduced in size to accommodate the smaller boiler and appeared as though it was retrofitted per the MD, to accommodate a smaller boiler. Surveyor #5 then noticed old inspection stickers on the boiler and asked the MD if the unit was recently replaced, and why did it have an inspection sticker from January of 2016 on it? The MD stated that he was unsure since the boiler was already installed prior to his employment, and stated that the boiler could have been taken from somewhere else and then was installed at the facility. The MD stated, This was how it was when I got here, I inherited this. At that time the MD explained the facility boilers to Surveyor #5 which included the following: - (1) boiler that provided hot water for the entire building. Kitchen, laundry, and resident areas. - (12) boilers that were used for heating. Only (6) of those boilers were inspected because only (6) of them were working according to the MD, and the MD stated he got that information from the maintenance staff that worked there prior to his date of hire. On 11/13/24 at 12:31 PM, the survey team interviewed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the lack of hot water. The DON stated that she had only been at the facility for two months and had been told by the facility that they were working on it, and some units get it sometimes and some don't. The DON stated she didn't know what was happening, I do not know of anything and that the Executive Director (ED) had been aware of the problem. The ADON stated that she had worked at the facility for [AGE] years and occasionally the hot water doesn't work, and they (ED/LNHA) don't share with us. The ADON confirmed that residents and their families have complained about the lack of hot water. On 11/13/24 at 12:37 PM, the survey team interviewed the MD regarding the hot water temperature concerns, who stated he had worked at the building for five months. The MD continued that his staff informed him that there was an issue with the hot water. The MD stated the boiler was not fit for the property and the use, and was underrated for the facility size. The MD stated, the boiler only worked to produce enough hot water when the usage was low. The MD stated that the residents told him about the hot water not working and that not having hot water was unacceptable. The MD stated hot water should be available 24-7 (24 hours per day and seven days per week), and occasionally it doesn't work. The MD again confirmed that residents and their families have complained about the lack of hot water, and the ED and LNHA were aware. Surveyor #4 asked the MD if he had ever met the LNHA, and the MD stated, no, never saw him in the building. The MD stated, honest truth, I only spoke to him through her [ED] and stated he cannot call him. Surveyor #4 then asked about the discussion that occurred through the ED. The MD stated that his staff told him that the facility used to have a bigger system, and the MD stated that the hot water temperature needed to be at least 105 F. The MD stated, we only talked to him [the LNHA] through [the ED]. The MD stated about four months ago, he was on a conference phone call that the ED set-up between the ED and the LNHA (neither was present at the facility). The MD stated he informed the LNHA that the hot water system needed to be replaced sometime soon. The LNHA had no response regarding the MD's concerns, and nothing from the ED either, and he had not heard anything since. On 11/13/24 at 1:11 PM, Surveyor #4 interviewed the HD and asked if she had ever met the LNHA. She stated she had been there for six months and had never met him. The surveyor asked if the washing machine needed to be at a certain temperature to wash clothing and she stated, yes, 130 F. The surveyor asked how would you know, and she stated, I don't. The HD confirmed the facility did all linen and laundry in house. On 11/14/24 at 8:44 AM, the MD came to the conference room to show the survey team a cellular phone picture of a thermometer reading of 113 F. The surveyor asked the MD if the hot water was fixed and the water temperature was now consistent, and the MD confirmed that the hot water temperature was not consistent. On 11/14/24 at 10:14 AM, the LNHA met with the survey team to review the concerns with the lack of hot water and the IJ Situation that was presented to the facility on [DATE] at 4:19 PM. The LNHA stated that he looked at the IJs last night, but it was on his phone and he could not read them. The LNHA then stated I just got the printout this morning, and he now wanted to discuss how the facility was going to respond. The LNHA stated it [the hot water] was on and off these days, and if they [staff] adhered to the schedule they would get hot water, and yesterday they did not adhere to the schedule. The LNHA stated he knew there was an issue with the hot water and we implemented a schedule when they should be using the water and that the [residents] don't remember if they had a shower or not. Surveyor #1: On 11/14/24 at 12:39 PM, Survey #1 interviewed CNA #5, who stated the water was sometimes cold. CNA #5 stated that the resident showers could only be scheduled at 8:00 PM or after because that would be the only way they would have hot water. CNA #5 stated he could not give anyone a shower when they wanted it because of the cold water, and the nurses were aware of the hot water concerns. Surveyor #1 asked how CNA #5 knew the nurses were aware of it, and he stated because we reported it. On 11/14/24 at 12:45 PM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN #1) on the Birch unit, who stated that the concern with the hot water had been reported by staff and the staff had reported that during resident care the water being used was cold, and the water for hand hygiene was cold. LPN #1 stated that Management was already aware, and that they entered documentation regarding the water in the maintenance log. On 11/14/24 at 1:41 PM, Surveyor #1 interviewed a Maintenance Staff employee (MS #1), who stated he was aware of the issue with the hot water and that there was one pipe for the hot water that was smaller. On 11/14/24 at 2:24 PM, Surveyor #1 interviewed the 3:00-11:00 PM CNA (CNA #6), on the Birch unit, who stated they did not document the resident's refusal of a shower; they informed the nurse. On 11/15/24 at 10:55 AM, Surveyor #1 interviewed Resident #36 and Resident #8 in their room, and they both stated they had not received a shower for two months because of cold water. They both stated the DON and ADON were aware of the problem. Surveyor #1 asked how not receiving a shower made them feel and they both stated, very sad, and they do not know what was going on and they cannot shower because of cold water. On 11/14/24 at 2:28 PM, Surveyor #2 interviewed Resident #22, who stated that the showers were terrible. Resident #22 continued that this morning they got all stripped down and the staff used a [mechanical lift name] and went to shower at 9:30 AM and the water was so cold I didn't take one. We came back and I got a bed-bath with cold water. Resident #22 then stated they refused showers often because it was a struggle to get in because of the [mechanical lift] and the water was freezing. Resident #22 stated shower days were on Monday and Thursday but unfortunately they had to wait a week, and the wipes were cold. Resident #22 stated would like to take a warm shower but [expletive redacted]. On 11/14/24 at 12:45 PM, Surveyor #5 obtained water temperatures from room [ROOM NUMBER]'s (unoccupied resident room) sink which registered a hot water temperature of 98.6 degrees F. Surveyor #1: On 11/15/24 at 8:18 AM, Surveyor #1 checked the hot water with MS #1 on the Birch unit and the hot water temperature in the first shower registered 73.9 degrees F, and the sink registered 73.5 degrees F. On 11/15/24 at 8:35 AM, Surveyor #1 checked the hot water with the Maintenance Staff (MS #2) in the Birch unit second shower which registered 63.3 degrees F. On 11/15/24 at 8:37 AM, Surveyor #1 interviewed a Hospice Staff employee (HS #1), who revealed that she did not give showers because the water was cold, so she was only able to give sponge baths. On 11/15/24 at 8:39 AM, Surveyor #1 interviewed CNA #4, who stated she did not give showers because the water was cold. On 11/15/24 at 10:47 AM, Surveyor #1 interviewed MS #2, who revealed that residents could not be showered because of the cold water, and the ADON and DON had been informed. At that time, the shower log for Birch was reviewed and there was no documentation if residents received showers on their scheduled days. Surveyor #3: On 11/15/24 at 8:35 AM, Surveyor #3 observed Resident #46 lying in bed, who stated I've been refusing showers for about two months because it was cold; it made me feel [expletive redacted] because there was no substitute for a shower anymore. On 11/15/24 at 9:33 AM, Surveyor #3 interviewed CNA #5, who stated I gave Resident #46 a complete bed bath the other day. The CNA continued that the resident had not received a shower for some time because the water was cold. The CNA reported for the past three months, all the units had cold water; that the water was usually hot from 8:30 PM to about 7:00 AM. The CNA stated the water temperature was very inconsistent, and the residents wanted a hot shower. On 11/15/24, Surveyor #5 obtained the following hot water temperatures: At 9:59 AM, room [ROOM NUMBER] (unoccupied resident room) - 65.5 degrees F At 10:30 AM, Resident #21 and #47's room - 64 degrees F At 10:47 AM, Resident #2 and #42's room - 67 degrees F An acceptable Removal Plan (RP) was received on 12/4/24 at 12:24 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; a licensed plumber repaired the hot water system; a hot water management system was put in place to verify hot water was available; residents were offered a hot bath or shower two to three times a week; maintenance and nursing staff checked hot water temperatures twice on the day and evening shifts and once during the night shift to ensure acceptable temperatures; if water temperatures were not acceptable, the LNHA was notified to remedy the issue; and nursing staff utilized rinse free wipes for resident care if water was not within acceptable range and the resident requested care. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39- 4.1(a)(3)(5)(12); 5.1 (a); 27.1 (a); 27.2(i); 27.5e; 31.2(e); 31.6 (j), 31.7(h)

Part A Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain hot water temperatures at a safe level to protect residents from third degree burns and serious injury on 3 of 3 units (Birch, Cedar, and Dogwood). Refer F 835L Hot water temperatures obtained on 11/16/24, in both residents' rooms on all three nursing units and in resident shower rooms on the Cedar and Dogwood units, registered between 117 degrees Fahrenheit (F) and 131.5 degrees F. Interviews with the Maintenance Director (MD) revealed that the facility's boiler system was undersized for the facility size; provided inconsistent hot water temperatures; and the residents' water used should be between 95 degrees F through 115 degrees F. The facility's failure to ensure the residents were protected from excessive hot water temperatures posed the likelihood of serious harm and injury from third degree burns. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/16/24 at 1:25 PM, when the survey team identified water temperatures on the resident units in excess of 120 degrees F. The facility Administration was notified of the IJ on 11/16/24 at 5:38 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: Reference: State Operation Manual; Guidance to Surveyors for Long Term Care Facilities; 483.25 (d)(1); Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Time and Temperature Relationship to Serious Burns Water Temperature and Time Required for Third degree Burn (Penetrate the entire thickness of the skin and permanently destroy tissue). Water temperature and time required for a third degree burn to occur: 148 F - 2 Seconds 140 F - 5 Seconds 133 F - 15 Seconds 127 F - 1 Minutes 124 F - 3 Minutes 120 F - 5 Minutes On 11/13/24 at 11:25 AM, Surveyor #5 interviewed the MD, who stated that the facility's boiler was undersized for the facility. The MD continued that the facility had one boiler that provided hot water for the entire building with six working boilers used for heating. On 11/14/24 at 8:44 AM, the MD came to the conference room to show the survey team a cellular phone picture of a thermometer reading of 113 degrees F. The surveyor asked the MD if the hot water was consistent, and the MD confirmed that the hot water temperature was not consistent. On 11/16/24 at 10:42 AM, Surveyor #6 interviewed the MD, who stated that the hot water temperatures were higher in the afternoon when laundry and the kitchen were not utilizing hot water. The MD continued that the boiler ran continuously so the water when not in use, was held in a holding tank where it increased in temperature until use. The MD stated the water the residents used should be within 95 degrees F to 115 degrees F for safety. On 11/16/24 at 12:02 PM, Surveyor #5 and Surveyor #6 interviewed the MD about the hot water readings. The MD stated that currently the hot water boiler could not be controlled and when no hot water was being utilized throughout the facility, it produced these hot temperatures. The MD continued and stated he had no control of the boiler and he did not know enough about the system to adjust it. On 11/16/24 beginning at 1:25 PM, the survey team in the presence of the MD obtained the following water temperatures on all three nursing units that registered over 120 degrees F: Dogwood Unit: Unoccupied Resident room [ROOM NUMBER] - 127.9 degrees F Unoccupied Resident room [ROOM NUMBER] - 128.8 degrees F Unoccupied Resident room [ROOM NUMBER] - 121.5 degrees F Unoccupied Resident room [ROOM NUMBER] - 129.7 degrees F Resident #239's Room - 131.5 degrees F Shower room [ROOM NUMBER] - 127 degrees F Pantry - 128.6 degrees F Bathroom by Dogwood Nurses' Station - 127 degrees F Cedar Unit: Unoccupied Resident room [ROOM NUMBER] - 124.1 degrees F Unoccupied Resident room [ROOM NUMBER] - 123.3 degrees F Resident #29's Room - 120.6 degrees F Resident #80's Room - 121.9 degrees F Shower room [ROOM NUMBER] - 122.7 degrees F Pantry - 121.3 degrees F Resident #24 and #35's Room - 121.2 degrees F Resident #79 and #84's Room - 120.2 degrees F Birch Unit: Unoccupied Resident room [ROOM NUMBER] - 120.2 degrees F Unoccupied Resident room [ROOM NUMBER] - 120.2 degrees F A review of the facility's Weekly Water [Temperature] Reading 2024 log provided by the MD, revealed that the last weekly temperature obtained was on 11/11/24. The log reflected that the water temperatures were within normal range, but the log did not include at what time the temperatures were obtained. An acceptable removal plan was received on 12/4/24, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; a plumber repaired the hot water system; the Licensed Nursing Home Administrator (LNHA) and maintenance department were educated on acceptable water temperatures, obtaining water temperatures several times a day, and notification to the LNHA of water temperatures outside parameters; maintenance and nursing staff monitored water temperatures daily; and if water temperature was not in acceptable range, nursing staff utilized rinse free body wipes for resident care. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39-31.7(h) Part B Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to protect the residents by ensuring the facility's smoking area was maintained to prevent accidental fire. The deficient practice was identified in the smoking courtyard and affected 3 of 3 units (Birch, Cedar, and Dogwood). Refer F 835 Observations and interview on 11/17/24, with both residents and staff, revealed that the facility did not have a system to ensure that a safe smoking environment for residents who smoked was maintained and to ensure there was a process for the safe storage of lighting materials. Observations and interviews also confirmed that the dried leaves that surrounded the courtyard contained extinguished cigarettes and the residents utilized open ashtrays and dumped their discarded cigarettes and ashes into four plastic lined garbage receptacles that were filled with combustibles. The residents also held onto their own lighting materials which included matches and lighters. The facility's failure to ensure that appropriate smoking receptacles were utilized and a process was followed to ensure the safe storage of lighting materials posed the likelihood of serious harm, injury, or death due to fire. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/17/24 at 10:52 AM, when the survey team identified extinguished cigarettes in the dried leaves. The facility Administration was notified of the IJ on 11/17/24 at 1:26 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: Reference: 11/17/24: The New Jersey Forest Fire Services: Advisory: STAGE 3 FIRE RESTRICTIONS IN EFFECT: In response to prolonged dry conditions and increased wildfire activity until further notice . Current Fire Danger (for facility county) RED: EXTREME. A review of the Smoking Policy for Residents dated effective October 2022, included the purpose: to verify that residents that choose to smoke will be properly assessed and be able to smoke outdoors in a safe environment. Policy: the organization is non-smoking facility and will permit residents to smoke in designated outside areas only. Procedure: 1. Any resident who is a smoker will be informed at the time of admission of the facility smoking policy. Residents admitted will be required to acknowledge the policy and adhere to it .4. Cigarettes may be kept by residents in their locked drawer. 5. Matches and lighters, will be kept in a locked box or in a locked drawer in the medication room/on each unit or in the medication cart. Lighters and/or matches may be taken out to the smoking area by residents but must be turned to staff upon the resident re-entering the facility. 6. Residents are strictly prohibited from having matches/lighters in their possession inside of the facility. Smoking is strictly prohibited inside the facility. 7. Cigarettes must be extinguished in the ashtrays provided in the smoking area. Butts cannot be retained by any resident and taken inside the facility . On 11/17/24 at 10:52 AM, Surveyor #2 and #4 entered the designated smoking courtyard and immediately upon entrance observed approximately one foot from the automatic door opener to the courtyard, multiple areas of ash and black marks directly on the red brick wall; spread on four bricks. There were multiple cigarette butts on the ground located in the rocks and mixed in the leaves in the same area of the black and ash marks. There were no observed covered ashtray receptacles located in that area. The landscaping beds were observed throughout the entire courtyard to be covered with dried leaves, pine needles, and other debris. At the time of the observation, Resident #71 greeted the surveyors and confirmed that they smoked and held onto their smoking materials and lighter and brought them into the facility. The surveyor asked about the condition of the courtyard including the debris and leaves, and Resident #71 stated that the landscapers had not been at the facility for months, that he [Licensed Nursing Home Administrator (LNHA)] isn't paying the bill. When asked how Resident #71 knew that the LNHA did not pay the bills, the resident stated, we know. On 11/17/24 at 10:55 AM, Surveyor #2 and #4 then observed Resident #34, #85, and #66 at a table outside with two black plastic-like open ashtrays in front of Resident #66 and Resident #34 while they were smoking. At that time, the surveyors observed no staff were present in the courtyard. The surveyor asked Resident #34 what was done with the ashes in the ashtrays when they were finished smoking? Resident #34 stated that they had to dump their own ashes. When asked if anyone ever helped them, all four residents stated there was never anyone out there to help them. On 11/17/24 at 10:59 AM, Resident #190 joined the other residents and stated that the facility never kept their cigarettes or lighters and did not provide a locked box. The resident continued that they stored their cigarettes and lighter in their jacket pocket which the resident left on their wheelchair. On 11/17/24 11:00 AM, Resident #66 pulled a lighter out of their pocket and lit the cigarette in front of the surveyors and stated, I don't have a locked box. The resident continued that staff were aware since they knew that the resident stored their cigarettes and lighter in a bag on the back of their wheelchair. When asked if it was accessible to other residents, Resident #66 stated anyone can take it (cigarettes and lighter). On 11/17/24 at 11:01 AM, Resident #67 stated their lighter was kept in an unlocked drawer in their room. On 11/17/24 at 11:06 AM, Resident #79 confirmed there was no locked box in their room. On 11/17/24 at 11:16 AM, Surveyor #5 and Surveyor #6 joined the observation. The surveyors observed that there were five cigarette butts in the ashtray with ashes in front of Resident #34. The surveyor asked Resident #34 where they discarded their used cigarettes and the ashes from the ashtray, Resident #34 stated, we dump them in the trash. At that time, all four surveyors observed four trash cans in the courtyard and lifted the lids which revealed plastic lined cans filled with debris including; cigarette packs, multiple cigarette butts, ashes, paper, a cardboard pizza box, and other combustible debris inside the plastic liners. There was one fire extinguisher in the opposite corner of the courtyard with a sticker attached that it was last inspected in June 2024. Two additional black plastic-like open ashtrays were observed on two other tables located in the smoking patio. On 11/17/24 at 2:00 PM, the Maintenance Director (MD) informed the survey team that he tried to contact the LNHA regarding the IJ, and the phone went to voicemail. The MD stated that he checked all four garbage cans in the smoking courtyard, and confirmed that he observed the cigarettes, papers, and ashes inside. The MD acknowledged he understood the concerns shared by the survey team and he discarded all the garbage in all four receptacles located in the courtyard. An acceptable removal plan was received on 12/4/24 at 12:24 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including leaves around or near resident smoking area were removed; lighters and matches were now held by the nursing staff; residents assessed as independent smokers were given their lighting material prior to smoking and were educated to return upon entrance into the building; maintenance inspected the smoking area a minimum of twice a day to remove any debris; housekeeping staff emptied ashtrays twice on the day shift and once on the evening shift; additional smoking post receptacles were purchased; and the smoking policy was reviewed with residents. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39-31.6(e) Part C Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was transferred in a safe manner to prevent potential injury. The deficient practice occurred for 1 of 5 residents reviewed for accidents (Resident #43) and was evidenced by the following: On 11/14/24 at 2:00 PM, the surveyor entered Resident #43's room. Upon entrance, the surveyor observed that the bed was in a high position with Resident #43 lifted by a mechanical lift dangling in the air over the resident's bed. The surveyor observed one Certified Nurse Aide (CNA #2) in the room operating the mechanical lift. The surveyor then exited the room, notified the Licensed Practical Nurse (LPN #1), and the surveyor and LPN #1 returned to the room. CNA #2 was in the process of completing the mechanical lift transfer when the LPN #1 informed the surveyor that the facility policy was to have two people assist when operating the mechanical lift. On 11/14/24 at 2:15 PM, during an interview with CNA #2, he stated, that I forgot, I usually asked another CNA to assist with the [mechanical lift]. On 11/14/24 at 2:50 PM, the surveyor re-interviewed CNA #2 about the mechanical lift transfer and how CNA #2 knew how Resident #43 needed to be transferred? CNA #2 provided the surveyor with a form titled Nursing Care Log initiated on 12/31/22, which indicated the following: transfer: mechanical lift, two-person assist. On 11/15/24 at 9:41 AM, the surveyor observed Resident #43 in bed and interviewed the resident regarding how they were usually transferred. The resident stated that usually there were two people who transferred them with the lift. The resident continued when female staff operated the lift, there were two people, but when a male CNA cared for them, they operated the lift by themselves. On 11/15/24 at 10:00 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #43 which revealed the following: A review of the Admission Record face sheet (an admission summary) reflected the resident had diagnoses which included but were not limited to; unspecified abnormality of gait and mobility, history of falling, supraventricular tachycardia (abnormally fast heart rhythm), obesity, and hypertension (high blood pressure). A review of the most recent quarterly Minimum Data Set, an assessment tool dated 10/10/24, indicated that the resident was totally dependent on a two-person assist with transfers. Resident #43 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15; which indicated the resident had a moderately impaired cognition. A review of the individualized comprehensive care plan (ICCP) dated 03/19/23, revealed that Resident #43 had a physical functioning deficit with mobility impairment. The interventions included: to provide the resident with a safe environment and bed in low position. On 11/20/24 at 1:03 PM, the surveyor interviewed the Director of Nursing (DON), who stated that she was aware of the incident of 11/14/24, and the Assistant Director of Nursing (ADON) was going to address the concern with the mechanical lift. On 11/21/24 at 10:55 AM, during an interview with the Nurse Educator, she revealed that she was informed on 11/20/24, that CNA #2 did not execute the transfer of Resident #43 properly while using the mechanical lift. The Nurse Educator stated that Resident #43 should have been transferred with two staff members assisting with the transfer. The surveyor then asked what the protocol was and the Nurse Educator stated, that a two-person assist at all times for transfer using the [mechanical lift]; that one person took care of the head and the other person directed the movement of the lower extremities. The Nurse Educator stated that if the resident grabbed the bar and the lift started tilting, we needed another person to prevent injury. On 11/20/24 at 12:50 PM, the DON provided Resident #43's statement which the resident confirmed that CNA #2 used the [mechanical lift] alone. On 11/20/24 at 1:00 PM, the DON provided CNA #2's statement dated 11/15/24, which the CNA indicated that they just forgot and lifted the resident with the mechanical lift by themselves. A review of the facility's Mechanical Lift and Stand Policy dated October 2023, included; policy: the mechanical lift or stand lift will be used for those residents who cannot be transferred comfortably and/or safely by other normal transfer technique. Procedure: all appropriative staff will receive training on hire and as needed for proper use of the mechanical lift. Prior to use of the mechanical lift/stand the employee will ensure that: there is a second person to assist with transfer . NJAC 8:39-27.1(a)

Part A Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented including consistently providing hot water for all residents' bathing and care needs. This deficient practice affected all residents who resided on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 600L, F 689L Interviews on 11/13/24, with both residents and staff, revealed that the facility neglected residents' complaints of no hot water for showering and bathing for months, and that the LNHA had not been present at the facility in six months was aware. Temperatures obtained on 11/13/24, in both resident rooms and shower rooms on all three nursing units registered between 66.8 degrees Fahrenheit (F) and 82 degrees F. Interviews with the Maintenance Director (MD) confirmed water temperatures had been cold, that hot water should be at least 105 degrees F; residents' and their families had complained; and the facility's boiler was underrated for the facility size. The facility's failure to ensure the LNHA was present at the facility to implement all facility policies including the residents' rights to hot water for bathing and personal care needs posed a likelihood of serious harm to the residents' care and ability to achieve their highest practicable level of wellbeing. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/13/24, when the survey team entered the facility and became aware that the LNHA had not been present at the facility for six months and that the LNHA had neglected the residents' complaints including water temperatures. The facility Administration was notified of the IJ on 11/13/24 at 4:19 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: A review of the Administrator Job Description, signed as the Employee and Supervisor on 03/15/24, by the Licensed Nursing Home Administrator (LNHA) revealed: The Administrator is responsible for planning and directing the overall operation of the facility; budgetary development; expense control; supervisory oversight; and ensuring federal and state licensure requirements are met. Job responsibilities: 1. Assists Department Managers in the development and use of facility policies and procedures . 2. Overseeing all department facility operations. 3. Maintaining and meeting federal and state regulations governing nursing facility operations. 4. Plans, submits and reviews financial data and develops budget for operations, revenue and expenses for all departments . 6. Reasonable for facilitating positive resident outcomes and addressing and grievance or concerns in a timely manner following regulatory and organizational policy. 8. Actively participates in facility committees' and community programs. 9. Conducts thorough investigation of occurrences. Participated in and/or conducts Root Cause Analysis (RCA) for precursor/serious safety events. Tracks, analyzes, reports, and oversees plan of correction for occurrences in compliance with organizational policies and procedures. Reports results to the Quality Assurance Performance Improvement (QAPI) Committee. 12. Completes payroll in an accurate and timely manner. 13. Promotes the professional growth and development of all employees. Monitors plans for educational needs of the employees and ensuring compliance for mandatory education as governed by state, federal and accrediting agencies. j) Grievances: 1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances to the facility without discrimination or reprisal. Such grievances include those with respect to care and discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished. 2. The resident has the right to prompt efforts by the facility to resolve grievances in accordance with 483.11 (h). A review of the facility's Resident Rights policy dated effective October 2021, included the resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. The facility must protect and promote rights of each resident, as described in the policy consistent with the principles of requirements of Federal, State and Local Laws and Regulation . On 11/13/24 at 8:10 AM, the survey team entered the facility and the surveyor asked the Receptionist if the LNHA was available. The Receptionist stated, he [the LNHA] worked up north [northern New Jersey]; that he [the LNHA] was the owner and was not in the building. The surveyor then asked the Receptionist if he was expected at the facility, and the Receptionist stated he did not physically work in the facility. The surveyor observed the LNHA's framed New Jersey Department of Health (NJDOH) LNHA license hanging behind the Receptionist on the wall. The Receptionist again stated to the survey team that he works up north, and she did not know where, and informed the survey team that the Executive Director (ED) was in charge. The survey team then observed, affixed to the wall opposite of the reception desk, a plastic holder that contained copies of a document titled: [Facility Name] Below is a list of the Department Heads at Our Facility, Please Feel Free To Call If You Have Any Questions of Concerns Regarding Yourself or a Family Member; listed as the administrator was the ED's name and telephone number, which did not correspond with the facility's NJDOH LNHA license on file. On 11/13/24 at 8:15 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who confirmed that the LNHA was the person with the license hanging on the wall, but he was up north [northern New Jersey]. On 11/13/24 at 8:39 AM, the Director of Nursing (DON) greeted the survey team, and when the survey team inquired about the LNHA, and asked if he would be expected at the facility for the survey, the DON stated, he doesn't work here, and she had no idea where he works. The DON stated she was employed by the facility as the DON for two months, and she never met or communicated with the LNHA. The DON continued that the person she reported to, and who hired her was the ED. The DON stated the ED was not available and was not coming to the facility today. The surveyor then inquired if the ED was a LNHA, and the DON stated she was not, and the surveyor then requested a business card for the DON and ED. On 11/13/24 at 9:00 AM, the DON provided a business card for the ED. The card revealed the (ED's name), listed as a registered nurse (RN) with the title Chief Nursing Officer for the [name redacted] Management Company in [town redacted], New Jersey. The surveyor conducted an Internet search for the company location which revealed it was located 96 miles north of the facility. Surveyor #1: On 11/13/24 at 9:28 AM, Resident #43 stated to Surveyor #1 that they had a complaint and asked if it was okay to get washed by staff with cold water. On 11/13/24 at 10:04 AM, on the Birch Unit, Surveyor #1 interviewed a Certified Nurse Aide (CNA #1) about the water temperatures, and CNA #1 who stated she was unable to shower residents because the water temperature was too cold and that the facility had been aware of the cold-water problem. On 11/13/24 at 11:32 AM, Surveyor #1 interviewed the Housekeeping Director (HD) about the laundry process and the hot water temperatures. The HD stated that they needed to stop using the washing machines at 10:00 AM to preserve the hot water. Surveyor #1 then asked the HD if she had been aware that there was a problem with the hot water and she stated, yes, three months ago, and stated I never in my life worked in such a condition. Surveyor #2: On 11/13/24 at 11:12 AM, Surveyor #2 toured the Dogwood Unit, and in the presence of a CNA #2 took the bathroom water temperature for room [ROOM NUMBER] (unoccupied resident room) which registered 68.1 degrees F. At that time, Surveyor #2 asked if that was the hot water knob and CNA #2 confirmed it was and that the facility had not had hot water in a while and they provided cold showers. On 11/13/24 at 11:22 AM, Surveyor #2 interviewed Resident #240, who stated that they could not take a shower, but their bed bath was also cold. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #23, who stated I won't shower with cold water and don't even ask me about washing my hair. It hasn't been pleasant. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #241, who stated that they had not been at the facility long but that the water was cold. Surveyor #3: On 11/13/24 at 11:19 AM, Surveyor #3 entered the Cedar Unit, in the presence of CNA #4, obtained the following water temperatures: Shower #1 the hot water from the sink and shower was 78 degrees F, and in Resident #72 and #74's room bathroom sink was 78 degrees F. At the time of the observation, Surveyor #3 interviewed CNA #4, who stated this morning the water was hot when we gave their baths, it's usually around 10:30 AM and sometimes during the day that it gets cold but not all the time. On 11/13/24 at 12:13 PM, Surveyor #3 interviewed Resident #79 about the water temperatures in the room and the resident continued, the water used to be hot but lately it's been cold; I don't take showers when the water was cold. [The facility] fixes it and it got cold again. The resident had reported that the issue had been going on in the last few days. On 11/13/24 at 12:17 PM, Surveyor #3 interviewed Resident #46 in their room, who stated I've been here for 4 1/2 years due to a blockage and had surgery for colostomy. I'm a quadriplegic. My major issue was there was no hot water for a year now. My last shower was two months ago, I took two showers that were ice cold. I got a bed bath but it's ice cold. I've told everyone, the nurses, Director of Nursing, Unit Managers, CNAs and Social Worker. Surveyor #4: On 11/13/24 at 11:13 AM, Surveyor #4, in the presence of CNA #5, entered Resident #82's room and tested the hot water in the resident's bathroom which registered at 80 degrees F. CNA #5 stated that residents complained of cold water all the time and CNA #5 stated he worked on all of the units. CNA #5 then accompanied Surveyor #4 to the shower room and held the shower head hose; the water felt cold and registered 69 degrees F. On 11/13/24 at 12:04 PM, Surveyor #4 entered the kitchen and observed the Kitchen Staff employee (KS #1) washing large stainless steel type pans in the three-compartment sink. The surveyor felt the wash water which felt cool and the wash temperature registered 92 degrees F, the sanitizer temperature registered 79 degrees F. Surveyor #4 asked KS #1 if there was hot water and he stated, depends if it was on and hot water was not always on. Surveyor #5: On 11/13/24 at 11:16 AM, Surveyor #5, in the presence of the Maintenance Director (MD), tested the hot water on the Birch Unit bathroom in room [ROOM NUMBER] (unoccupied resident room), which registered 66 degrees F. On 11/13/24 at 11:22 AM, Surveyor #5, in the presence of the MD, tested the hot water on the Birch Unit bathroom in room [ROOM NUMBER] (unoccupied resident room), which registered 66 degrees F. On 11/13/24 at 11:25 AM, Surveyor #5 interviewed the MD about the water temperatures in the boiler room. Surveyor #5 observed and counted that there were 12 boilers. There were six boiler certificates posted that indicated six boilers were inspected in 2023. The MD stated that the boilers observed were only used to heat the resident rooms and not for hot water. The MD stated that there were only six certificates because only six boilers were working. The MD stated that the hot water boiler was recently replaced. Surveyor #5 asked for the annual inspection certificate of the recently replaced hot water boiler and the MD stated that he was not sure if there was one because the boiler was changed prior to MD's date of hire. The MD stated that he believed that the boiler ran well but was undersized for the facility and he believed at one point the facility used to have two bigger boilers in use, telling from the empty space next to the smaller boiler. There were also two boiler venting pipes, one of them did not have a boiler hooked up to it. The other had the venting pipes reduced in size to accommodate the smaller boiler. Surveyor #5 then noticed old inspection stickers on the boiler and asked the MD if the unit was recently replaced, and why did it have an inspection sticker from January of 2016 on it? The MD stated that he was unsure since the boiler was already installed prior to his employment, and stated that the boiler may have been taken from somewhere else, and then was installed at the facility. The MD stated, This was how it was when I got here, I inherited this. On 11/13/24 at 12:31 PM, the survey team interviewed the DON and ADON regarding the lack of hot water. The DON stated that she had only been at the facility for two months and had been told by the facility that they were working on it, and some units [nursing units] get it sometimes and some don't. The DON stated she didn't know what was happening, I do not know of anything and that the ED had been aware of the problem. The ADON stated that she had worked at the facility for [AGE] years and occasionally the hot water doesn't work, and they (ED/LNHA) don't share with us. The ADON confirmed that residents and their families had complained about the lack of hot water. On 11/13/24 at 12:37 PM, the survey team interviewed the MD regarding the hot water temperature concerns. The MD stated he had worked at the building for five months and stated that his staff informed him that there was an issue with the hot water. The MD stated the boiler was not fit for the property and the use, and was underrated for the facility size. The MD stated, the boiler only works to produce enough hot water when the usage was low. The MD stated that the residents tell him about the hot water not working and that not having hot water was unacceptable. The MD stated hot water should be available 24-7 (24 hours per day and seven days per week), and occasionally it doesn't work. The MD again confirmed that residents and their families complained about the lack of hot water, and the LNHA and ED were aware. Surveyor #4 asked the MD if he had ever met the LNHA, and the MD stated, no, never saw him in the building. The MD stated, honest truth, I only spoke to him through her [ED] and stated he cannot call him. Surveyor #4 then asked about the discussion that was had through the ED. The MD stated that his staff told him that the facility used to have a bigger system and the MD then stated the hot water temperature needed to be at least 105 degrees F. The MD stated, we only talk to him [the LNHA] through [the ED]. The MD stated about four months ago he was on a conference phone call that the ED set up with her and the LNHA (neither was present at the facility). The MD stated he informed the LNHA that the hot water system needed to be replaced sometime soon. The LNHA had no response regarding the MD's concerns, and nothing from the ED either, and he had not heard anything since. On 11/13/24 at 1:11 PM, Surveyor #4 interviewed the HD and asked if she had ever met the LNHA. She stated she had been there for six months and had never met him. The surveyor asked if the washing machine needed to be at a certain temperature to wash clothing and she stated yes, 130 degrees F. The surveyor asked how would you know, and she stated, I don't. The HD confirmed the facility did all linen and laundry in house. On 11/13/24 at 1:48 PM, Surveyor #4 interviewed the Payroll Staff employee (PS) who provided the LNHA's job description. The LNHA's job description was signed and dated as Employee and Supervisor on 3/15/24. Surveyor #4 asked the PS about the date, and she stated that was when the other LNHA left and he took over. Surveyor #4 asked the PS where the LNHA was since he was not at the facility, and the PS stated he was up north (northern New Jersey) in the corporate office. Surveyor #4 asked when the last time you physically saw the LNHA at the facility and she stated, six months ago. On 11/14/24 at 7:55 AM, the DON informed the survey team that she forwarded the IJ templates to the ED yesterday when they were presented to her. On 11/14/24 at 8:16 AM, the surveyor team observed through the opened door to the conference room, a male who introduced himself as the facility LNHA to the DON, and the LNHA then immediately entered the conference room. Upon entrance, the LNHA introduced himself as the LNHA and stated to the survey team that he had not yet read the IJ templates (provided to the DON more than 12 hours prior). The surveyor informed the LNHA that the IJ templates were sent to the ED per the DON, and then asked the LNHA if the ED was a licensed nursing home administrator? The LNHA confirmed that the ED was not a a licensed nursing home administrator. The surveyor then informed the LNHA of the observation regarding the introduction that he made to the DON, and asked if he had met or interacted with her. The LNHA stated, he spoke with her before. On 11/14/24 at 8:44 AM, the MD came to the conference room to show the survey team a cellular phone picture of a thermometer reading of 113 degrees F. The surveyor asked the MD if the hot water was fixed and the hot water temperature was now consistent, and the MD confirmed that the hot water temperature was not consistent. On 11/14/24 at 10:14 AM, the LNHA met with the survey team to review the concerns with the lack of hot water and the two IJ Situations that were presented to the facility on [DATE] at 4:19 PM. The LNHA stated he looked at the IJs last night, but it was on his phone and he could not read them. The LNHA then stated I just got the printout this morning, and he now wanted to discuss how the facility was going to respond. The LNHA stated it [the hot water] was on and off these days, and if they [staff] adhered to the schedule they would get hot water, and yesterday they did not adhere to the schedule. The LNHA stated to the survey team, I do not communicate with everyone, I am explaining that I communicate through the ED. The LNHA then stated the ED would not be at the facility. The LNHA provided a business card to the survey team that identified him as the President of the same company as the ED and in the same location (the business card did not identify him as the facility LNHA). The LNHA stated he knew there was an issue with the hot water and we implemented a schedule when they should be using the water and that the [residents] don't remember if they had a shower or not. An acceptable removal plan was received on 12/4/24 at 12:24 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; a licensed plumber repaired the hot water system; the LNHA was on-site fulltime; the facility maintained a log to track the LNHA at the facility; the Consultant (Consult) LNHA in-serviced the LNHA on facility policies and procedures and the importance of implementing them; a hot water management system was put in place to verify hot water was available; and the LNHA audited daily temperature logs and immediately addressed any temperatures outside parameters. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39-9.2(a)(2) Part B Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) implemented all facility policies and procedures to function in a manner that ensures the resources were available for residents to attain or maintain their highest practicable level by ensuring: a) a system was in place to ensure consistent food and supplements were regularly purchased to coincide with the resident menu and therapeutic needs; b) residents were provided with an operational telephone system; c) a QAPI (Quality Assurance and Performance Improvement) program existed and involved facility staff and the Medical Director; d) waste services were consistently provided to ensure recycling was not stored in the facility due to lack of dumpster space; and e) residents' Personal Needs Account (PNA) funds were protected by having a current surety bond that was in full force and effect. The deficient practice affected all residents who resided on 3 of 3 resident units (Birch, Cedar, and Dogwood) and was evidenced by the following: A review of the Administrator Job Description, signed as the Employee and Supervisor on 03/15/24, by the Licensed Nursing Home Administrator (LNHA) revealed: The Administrator is responsible for planning and directing the overall operation of the facility; budgetary development; expense control; supervisory oversight; and ensuring federal and state licensure requirements are met. Job responsibilities: 1. Assists Department Managers in the development and use of facility policies and procedures . 2. Overseeing all department facility operations. 3. Maintaining and meeting federal and state regulations governing nursing facility operations. 4. Plans, submits and reviews financial data and develops budget for operations, revenue and expenses for all departments . 6. Reasonable for facilitating positive resident outcomes and addressing and grievance or concerns in a timely manner following regulatory and organizational policy. 8. Actively participates in facility committees' and community programs. 9. Conducts thorough investigation of occurrences. Participated in and/or conducts Root Cause Analysis (RCA) for precursor/serious safety events. Tracks, analyzes, reports, and oversees plan of correction for occurrences in compliance with organizational policies and procedures. Reports results to the Quality Assurance Performance Improvement (QAPI) Committee. 12. Completes payroll in an accurate and timely manner. 13. Promotes the professional growth and development of all employees. Monitors plans for educational needs of the employees and ensuring compliance for mandatory education as governed by state, federal and accrediting agencies. j) Grievances: 1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances to the facility without discrimination or reprisal. Such grievances include those with respect to care and discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished. 2. The resident has the right to prompt efforts by the facility to resolve grievances in accordance with 483.11 (h). A) On 11/13/24 at 9:08 AM, upon entrance to the kitchen, the surveyor asked the FSD if there have been any concerns regarding the ability to purchase food. The FSD stated that the representative from the food purveyor sent her a text last week, within one hour of submitting order. The order was submitted 11/05/24, for delivery on 11/06/24, and the text informed her that food order was on hold, and she stated that was the order, that was never delivered last week. When the surveyor asked why that happened, the FSD stated, no one (facility or purveyor) said any reason why and maybe the business office person would know. The FSD stated, it was not the first time it happened and the former FSD told her that happened before. The surveyor asked how the lack of ability to order food was affecting the foods served to the residents, and the FSD stated not fully; that she tried to stock up on items and usually made the main menu items but has had to substitute vegetables. The FSD confirmed that she has had no communication with the LNHA regarding the reason why the food order was canceled. The surveyor requested substitution logs that were provided by the FSD at that time. A review of the substitution log revealed the following: Date: 11/13/24, for lunch revealed original item: green beans and substitute (sub) given asparagus; Reason for Substitution: Vendor did not deliver. Date: 11/13/24, for lunch revealed original item: stuffing and sub given mashed potato; Reason for Substitution: Vendor did not deliver. On 11/13/24 at 3:00 PM, the FSD provided the surveyor a copy of the food order that she stated was the ordered items that were submitted on 11/5/24, and was never delivered. The FSD stated the order would not be saved in the system if it was not delivered, and that was why the order was dated 10/22/24, and she would have to re-enter the entire food order. The food order listed 90 items. The surveyor asked the FSD if she was now able to order food, she stated that she may be able to. On 11/14/24 at 9:28 AM, the surveyor interviewed the FSD regarding if the facility was able to order food. The FSD stated that she was told by the payroll person that she could order food today for tomorrow, and the facility would scan a check to the food vendor after the food order was submitted. On 11/14/24 at 1:12 PM, the surveyor interviewed the Registered Dietitian (RD) regarding her role at the facility. The RD stated she reported to the Executive Director (ED) who was not a LNHA. The RD stated, this was the first time that she saw the LNHA since she had been back at the facility since March 2024. The surveyor asked the RD if she had ever had an issue with getting paid. The RD stated that she heard it had been an issue, but that she was directed by other department heads including the Business Office, to cash her paycheck quickly and deposit the cash into her account and to not directly deposit the paycheck. The surveyor asked the RD if there were problems with the facility being able to order food. The RD stated that she was aware that to order food, the facility had to scan checks first to pre-pay the vendor. The RD stated that there were times they needed to personally go to the grocery store to purchase food items, including not having coffee for the residents and food for a resident who required a gluten free diet and they were unable to get the food. The RD stated, the food order was usually delayed, and the residents were confused at times, because they ordered food and were getting substitutes. The RD stated that they did not have the magic cup [fortified ice cream for extra calories and nutrition] and seven residents received it. On 11/15/24 at 8:52 AM, the surveyor interviewed the FSD regarding the food order, and the FSD stated a new order is supposed to be in today. The surveyor asked if magic cups were available for the residents? The FSD stated, we do not have magic cups because the food order from last week, was not approved and the facility has not had them since lunch yesterday (two meals were missed). On 11/15/24/ at 11:00 AM, the surveyor observed the emergency food storage closet with the FSD, and the 3 Day Menu was posted on the wall. The FSD stated the supply was not full because when the food orders were not able to be ordered, she took food items from the emergency supply and used them for the regular menu which depleted the emergency supply. The FSD stated she did not have enough emergency water also and has not replenished either. On 11/15/24 at 12:21 PM, the surveyor interviewed the Business Office Manager (BOM) regarding why food cannot be delivered at times. The BOM stated there were times that Accounts Payable staff (AP) had to prepay for food before the food would be sent, and stated, we are making payments as the facility was over 60 days on payments for the food vendor. B) On 11/14/24 at 11:06 AM, Surveyor #3 conducted the Resident Council meeting with seven awake and alert residents. During the meeting, seven of seven residents informed the surveyor that the phones had not been working. On 11/20/24 at 8:33 AM, Resident #61 informed Surveyor #3 that their phone had not been working. Resident #61 stated that the maintenance staff could not fix the phone. They informed the nurse and the issue had not been addressed. Resident #61 stated, I feel like a motherless child, I feel horrible. On 11/20/24 at 8:59 AM, Surveyor #3 interviewed the Certified Nursing Aides (CNA #2) regarding the issue with the phone. CNA #2 stated, It makes the residents really upset when the communication system is not working. The residents cannot communicate with their families and they do not have a cell phone. C) On 11/13/24 at 10:27 AM, during the entrance conference that was held with the facility administration, the surveyor requested: the QAPI plan, the QAPI program, the quality assessment and assurance (QAA) committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. On 11/14/24 at 12:28 PM, the surveyor requested from the LNHA the QAPI plan, the QAPI program, the QAA committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. The LNHA stated, I don't know where it is, but I will look for it. On 11/15/24 at 10:36 AM, the surveyor again, requested from the LNHA the QAPI plan, the QAPI program, the QAA committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. On 11/15/24 at 12:38 PM, the surveyor reminded the LNHA that the QAPI documentation was requested on 11/13/24, during entrance conference. The LNHA confirmed that the documentation should have been readily available to the facility administration, but again stated he did not know where it was. The surveyor then stated to the LNHA that he may have additional time to provide the documentation, and the LNHA stated, don't bother, I won't have it. The LNHA stated the Executive Director (ED- not a Licensed Nursing Home Administrator) was in charge of the QAPI binder. On 11/15/24 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team, regarding any involvement she had with QAPI. The DON stated, not here, but was aware of what QAPI was. The DON stated that upon being hired, she requested the QAPI documentation from the ED since that was her supervisor, but was not provided anything. When asked if the facility's Medical Director (MD) was a required attendee of the QAPI meetings, the DON confirmed that the MD was required to attend. On 11/15/24 at 1:37 PM, the surveyor conducted a telephone interview with the acting MD. The MD stated he had been the full-time MD for the facility for seven years. The MD stated that he was involved in monthly QAPI meetings held by the facility until approximately six to nine months ago when the QAPI meetings stopped. The MD stated that the last QAPI meeting he was aware of was held in March 2024. The MD stated that the LNHA was responsible to ensure QAPI meetings were scheduled and held with all required attendees. The MD stated when the former LNHA resigned, there were no more QAPI meetings and he confirmed that he was not there, because it wasn't scheduled. The MD stated that things changed, [not for the good], and he had since resigned his position as the MD. The MD stated he was presently helping the new medical director transition into the role. The MD stated, the old LNHA scheduled QAPI meetings, like clockwork, and he knew to attend the last Wednesday of the month. D) On 11/13/24 at 9:08 AM, upon entrance to the kitchen, and in the presence of the Food Service Director (FSD) it was observed that cardboard boxes were piled up

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to serve meals in a dignified, home-like manner by using disposable containers to serve food and beverages for residents who resided on 3 of 3 resident units (Birch, Cedar and Dogwood). The deficient practice was evidenced by the following: On 11/17/24 at 9:06 AM, Surveyor #2 and #4 observed the breakfast meal on the Cedar unit and observed that all hot cereal was served in a 1/4 pound plastic disposable container with a lid, and all the beverages were served in Styrofoam cups. On 11/17/24 at 10:10 AM, the surveyor observed the kitchen with the Food Service Director (FSD), who was preparing a fruit cup and pudding for meal service. The fruit cups were being placed into plastic drinking type disposable cups. The FSD stated that the facility had been using disposable diningware and confirmed that she did not have lids for any of the washable insulated bowls. On 11/21/24 at 9:09 AM, the survey team informed the Licensed Nursing Home Administrator (LNHA), in the presence of a Consultant LNHA, the concerns that the residents regularly received food and beverages in non-insulated, disposable cups and bowls. The LNHA stated, was there some regulation that says they can't use Styrofoam? A review of The Resident Rights Policy dated effective October 2021, included; Policy: The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, as described in the policy consistent with the principles of requirements of Federal, State and Local Laws and Regulation . NJAC 8:39-17.2 (e)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that the telephones located in resident rooms were functional and residents were provided an alternate means of communication to accommodate their needs and ensure their well-being was maintained. This deficient practice was identified for 7 of 7 residents who attended a resident council meeting and on 2 of 3 nursing units (Cedar and Birch units). The evidence was as follows: 1. On 11/14/24 at 11:06 AM, Surveyor #3 conducted the Resident Council meeting with seven resident who were alert and oriented. During the meeting, seven of seven residents informed the surveyor that the phones had not been working. On 11/20/24 at 8:33 AM, Resident #61 informed Surveyor #3 that their phone had not been working. Resident #61 stated that the maintenance staff were unable to fix the phone. Resident #61 informed the nurse and the issue had not been resolved. Resident #61 stated, I feel like a motherless child, I feel horrible. On 11/20/24 at 8:59 AM, Surveyor #3 interviewed CNA #2 regarding the issue with the phone. CNA #2 stated, It makes the residents really upset when the communication system was not working. The residents cannot communicate with their families and they do not have a cell phone. On 11/21/24 at 2:15 PM, Surveyor #3 informed facility administration of the concerns with the phone in the residents' rooms. On 11/22/24 at 8:30 AM, the DON provided an in-service education form dated 11/21/24, that staff would inform residents to use the phone at the nurse's station to call their families. 27193 Surveyor #1: 2. On 11/14/24 at 9:15 AM, Surveyor #1 toured the Birch unit of the facility. Resident #43 informed the surveyor that their phone in their room had not been working for the last two months, and stated they were unable to speak with their family. The surveyor observed a telephone located on the bedside table. The surveyor attempted to use the phone by lifting the receiver, and verified there was no dial-tone. Resident #43 further added that they informed the facility that the phone had not been working. On 11/14/24 at 10:30 AM, Surveyor #1 reviewed the maintenance log for the Birch unit which did not include any reported concerns related to the telephone that had not been working. On 11/15/24 at 9:30 AM, during an interview with a Certified Nursing Aide (CNA #3) on the Birch unit regarding the residents' phone system, CNA #3 stated that there were some issues with the telephone and the facility was aware. CNA #3 also stated that sometimes the telephone at the nurse's station did not work. On 11/15/24 at 12:30 PM, Surveyor #1 reviewed the electronic medical record (EMR) for Resident #13 which contained a document dated 11/03/24 at 6:20 PM. The document was an email sent by the Executive Director (ED-not a Licensed Nursing Home Administrator) that revealed the facility was experiencing intermittent phone outages; and that the phone lines may be intermittently unavailable. The facility provided an emergency number if needed. On 11/15/24 at 1:30 PM, the surveyor reviewed Resident #13's EMR which contained a document dated 11/7/24 at 6:20 PM. The document was an email sent by the ED that revealed the facility was experiencing intermittent phone outages; and that the phone line may be intermittently unavailable. The facility provided an emergency number if needed. On 11/20/24 at 10:00 AM, Resident #36 approached Surveyor #1 in the hallway and reported that their phone had not been working for the last two months. The resident reported that they were not happy with the telephone issue. On 11/20/24 at 10:29 AM, Resident #8 informed Surveyor #1 that their phone had been out of service for at least two months. Resident #8 stated it was upsetting and sometimes they had to ask the CNA to use their cell phone. On 11/20/24 at 11:15 AM, the Licensed Practical Nurse (LPN # 1) assigned to the Birch unit, confirmed that the phones had not been working. On 11/20/24 at 12:30 PM, the surveyor interviewed a Maintenance Staff employee (MS #1), who confirmed that the issues with the phone were ongoing. When asked if the residents were provided with any other form of communication, he declined to comment. On 11/21/24 at 8:52 AM, Surveyor #1 interviewed the Maintenance Director (MD), who stated that he was aware the phones had not been working; staff verbally informed him. When inquired if an alternative form of communication was provided to the residents, he stated, No. A review of the facility's Telephone Service and Access policy dated last reviewed October 2024, included; Policy: All new admissions will be informed and given the opportunity to receive telephone services for while at the facility. Procedures: All residents will be informed of availability of phone service and cost involved. All residents may have a private telephone in their room at their own expense . NJAC 8:39-4.1(a)20

Complaint # NJ173186, NJ175516 Based on interviews, medical record review, and review of other pertinent facility documents on 10/09/2024 and 10/10/2024, it was determined that the facility a.) failed to follow Care Plan (CP) interventions for a resident which resulted in the resident sustaining an injury and b.) failed to update the CP and interventions after a resident-to-resident altercation occurred. The facility also failed to follow its policy titled Care Management Policy. This deficient practice was identified for 3 of 3 residents (Resident #1, Resident #11, and Resident #12) reviewed for care plans. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to, Unspecified Quadriplegia (a condition that causes paralysis that affects all a person's limbs), Chronic Pain Syndrome (persistent pain that last weeks to years), and Anxiety Disorder. A review of Resident #1's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/01/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of Resident #1's Progress Notes (PNs) dated 02/12/2024 revealed that Resident #1 reported a fall while in the shower room. The PNs further revealed that Resident #1's legs to knees were hanging down from the shower stetcher, but resident's entire upper body remained on the shower stretcher. The PNs revealed that Resident #1 complained of pain to the right side of resident's body. The physician was made aware, and an order was given for an x-ray of Resident #1's right shoulder, right hip, and right knee to rule out a fracture. A review of Resident #1's radiology results report with an examination date of 02/12/2024 and a reported date of 02/13/2024 revealed under findings a fracture involving the right distal femur. A review of Resident #1's CP revealed under Focus, The resident was verbally aggressive towards staff with an initiated date of 11/03/2023 and a revision date of 02/19/2024. Under Interventions revealed an intervention to provide paired care with an initiated date of 01/04/2024. During an interview with the surveyor on 10/09/2024 at 10:53 AM, Resident #1 stated remembering the incident that occurred in the shower room. Resident #1 stated Certified Nursing Assistant (CNA #1) did not put up the siderails on the shower stretcher while in the shower room. Resident #1 further stated that when CNA #1 rolled the resident over, the resident's lower body fell off the shower stretcher. Resident #1 stated only CNA #1 was in the shower room with resident at time of the incident. Resident #1 stated having pain to the right leg after the incident occurred. Resident #1 stated he/she went to the hospital and was told the right leg was broken and a brace was placed on the right leg. During an interview with the surveyor on 10/10/2024 at 2:01 PM, the DON stated that paired care meant that two people were present for all aspects of a resident's care. The DON stated that the expectation was that staff should follow the care plan. During a telephone interview with the surveyor on 10/10/2024 at 2:35 PM, the Licensed Practical Nurse (LPN #1) stated she remembered being called into the shower room on the date of the incident. LPN #1 stated she observed Resident #1 laying on his/her abdomen on the shower stretcher with resident's lower body off the shower stretcher. LPN #1 stated I don't remember how the resident got positioned on his/her abdomen on the shower stretcher. LPN #1 further stated there was only CNA #1 and the resident in the shower room at that time. LPN#1 stated she had to get more staff to help reposition Resident #1 back onto the shower stretcher. The surveyor was unable to reach CNA #1 for a telephone interview. According to the AR, Resident #11 was admitted to the facility with diagnoses which included but were not limited to, Unspecified Cerebral Infarction (stroke), Diabetes, Hyperlipidemia (high cholesterol). A review of Resident #11's most recent Quarterly MDS, an assessment tool dated 08/05/2024 revealed that the resident had a BIMS score of 5 out of 15, which indicated the resident's cognition was severely impaired. According to the AR, Resident #12 was admitted to the facility with diagnoses which included but were not limited to, Unspecified Dementia (a group of symptoms affecting memory, thinking, and social abilities), Anemia, and Insomnia (disorder characterized by difficulty falling asleep). A review of Resident #12's most recent Quarterly MDS, an assessment tool dated 08/10/2024 revealed that the resident had a BIMS score of 99, which indicated the resident was unable to complete the interview. According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents on 04/22/2024, with an event date of 04/21/2024 and a time of event date of 8:17 PM, Resident #11 was observed standing next to Resident #12's wheelchair with his/her hand on Resident #12's right arm. Resident #11 stated that Resident #12 swung right arm and hit Resident #11. Resident #11 took hold of Resident #12's arm to stop resident from hitting Resident #11. A review of Resident #11's CP revealed that the CP was not updated to reflect the resident-to-resident altercation. No interventions were implemented on the CP after the incident occurred. A review of Resident #12's CP revealed that the CP was not updated to reflect the resident-to-resident altercation. No interventions were implemented on the CP after the incident occurred. During an interview with the surveyor on 10/10/2024 at 2:01 PM, the Director of Nursing (DON) stated that care plans were updated quarterly and when a change of condition occurred. The DON stated that anything new in a resident's care could be considered a change of condition. The DON stated the care plans should be updated when resident to resident incidents occurred. The DON stated that it was important that care plans were updated so that staff knew how to properly care for the residents. The DON confirmed there were no updated interventions for Resident #11 and Resident #12 on their care plans. The DON stated that paired care on Resident #1's care plan meant that two people were present for all aspects of a resident's care. The DON stated that the expectation was that staff should follow the care plan. The DON further stated the Unit Manager (UM) and nurses were responsible for updating the care plan. The DON stated she could not speak to why the care plans were not updated. Review of the facility policy titled Care Management Policy with last reviewed date of 10/2024 revealed under Procedure, 9. All staff who provide care shall be knowledgeable of, and have access to, the plan of care. 10. The plan of care is continually updated to reflect current needs at all times. It can be modified without a formal interdisciplinary meeting by each discipline noting directly on Care Plan. 11. The nurse is responsible for coordinating and updating the plan of care. NJAC 8:39-11.2 (e) (2)

Complaint #: NJ00175516 Based on interviews, medical record review, and review of other pertinent facility documents on 10/09/2024 and 10/10/2024, it was determined that the facility failed to ensure that an avoidable accident was prevented because care plan interventions for providing paired care were not followed for Resident #1, and resident sustained a fracture. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for incidents and accidents. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to, Unspecified Quadriplegia (a condition that causes paralysis that affects all a person's limbs), Chronic Pain Syndrome (persistent pain that last weeks to years), and Anxiety Disorder. A review of Resident #1's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/01/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of Resident #1's Progress Notes (PNs) dated 02/12/2024 revealed that Resident #1 reported having a fall while in the shower room. The PNs further revealed that Resident #1's legs to knees were hanging down from the shower stretcher, but resident's entire upper body remained on the shower stretcher. PNs revealed that Resident #1 complained of pain to the right side of body. The physician was made aware, and an order was given for an x-ray of Resident #1's right shoulder, right hip, and right knee to rule out a fracture. A review of the facility's incident report for Resident #1 dated 02/12/2024 at 20:14 revealed that Resident #1 was helped back in to position on the shower stretcher by staff members. A review of Resident #1's radiology results report with an examination date of 02/12/2024 and a reported date of 02/13/2024 revealed under findings a fracture involving the right distal femur. A review of Resident #1's Care Plans (CP) revealed under Focus, The resident was verbally aggressive towards staff with an initiated date of 11/03/2023 and a revision date of 02/19/2024. Under Interventions revealed an intervention to provide paired care with an initiated date of 01/04/2024. During an interview with the surveyor on 10/09/2024 at 10:53 AM, Resident #1 stated remembering fall that occurred in the shower room. Resident #1 stated the Certified Nursing Assistant (CNA #1) did not put up the siderails on the shower stretcher while in the shower room. Resident #1 further stated that when CNA #1 rolled resident over, the resident's lower body fell off the shower stretcher. Resident #1 stated only CNA #1 was in the shower room with resident at the time of the incident. Resident #1 stated having pain to right leg after the incident occurred. Resident #1 stated went to the hospital and was told right leg was broken and a brace was placed on the right leg. During an interview with the surveyor on 10/09/2024 at 3:19 PM, the Director of Nursing (DON) stated she had no recollection of any information related to Resident #1's fall in February. The DON stated she was not working at the facility at the time of Resident #1's fall. During an interview with the surveyor on 10/10/2024 at 2:01PM, the DON stated that paired care meant that two people were present for all aspects of a resident's care. The DON stated that the expectation was that staff should follow the care plan. During a telephone interview with the surveyor on 10/10/2024 at 2:35 PM, the Licensed Practical Nurse (LPN #1) stated she remembered being called into the shower room on the date of the incident. LPN #1 stated she observed Resident #1 laying on his abdomen on the shower stretcher with resident's lower body off the shower stretcher. LPN #1 stated I don't remember how resident got positioned on his/her abdomen on the shower stretcher. LPN #1 further stated there was only CNA #1 and the resident in the shower room at that time. LPN#1 stated she had to get more staff to help reposition Resident #1 back onto the shower stretcher. LPN #1 stated I do not know how the incident was avoidable, the CNAs know how to do their job everyday. LPN #1 further stated They know the resident's care. The surveyor was unable to reach CNA #1 for a telephone interview. Review of the facility policy titled Care Management Policy with last reviewed date of 10/2024 revealed under Procedure, 9. All staff who provide care shall be knowledgeable of, and have access to, the plan of care. NJAC 8:39-27.1 (a)

COMPLAINT: #NJ165110 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 6/28/2023 and 7/3/2023, it was determined that the facility failed to thoroughly investigate an alleged Staff to Resident physical abuse between a Certified Nursing Assistant (CNA) and a Resident (Resident #2). The date of this alleged incident could not be determined. Resident #2 reported to his/her family on 6/17/2023 that when the CNA was taking the Resident to the shower, he/she was holding onto the doorway because he/she did not want to move. The CNA hit the Resident on the left wrist, and the Resident hit her back. The family reported it to the Social Worker (SW) that same day. The CNA was sent to the lounge area while the SW spoke with the Resident. The CNA resumed working on the next shift on a different floor that same day, 6/17/2023, to provide unsupervised care to residents on the next shift [3:00 p.m. -11:00 p.m.] The facility also failed to follow its policy titled Freedom From Abuse, Neglect, and Exploitation. There was no documented evidence of a thorough investigation. The CNA was allowed to continue to provide unsupervised care to residents on another floor for the next shift, 3:00 p.m. -11:00 p.m., working until 11:02 p.m. that night. The facility also failed to follow its policy titled Freedom From Abuse, Neglect and Exploitation. The facility's failure to thoroughly investigate and follow its policies and procedures for abuse and allowing the alleged CNA to continue caring for other residents placed other residents being cared for by this staff member in an immediate jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) on 6/28/2023 at 6:15 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 6/17/2023 and continued through 6/28/2023 when the facility started in-services on Abuse, Reporting, Investigating and Dealing with Difficult Residents. On 7/3/2023, the Surveyor verified the Removal Plan was implemented. The facility was educating all staff on the Policy Freedom From Abuse, Neglect and Exploitation, the Reporting and Investigation protocols, Supervisor's Responsibilities, and Dealing with Difficult Residents. So, the noncompliance remained on 6/28/2023 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents on 6/21/2023, with an event date of 6/17/2023 and a time of event of 11:00 a.m. On 6/17/2023, at approximately 11:00 a.m., Resident #2's family alerted the Social Worker (SW) that the Resident reported that 2 weeks ago [ .] a certified nursing assistant (CNA), hit him/her on the arm. The family stated they had not previously heard of this from the Resident but wanted to alert staff. The Resident did not report this incident to the facility at any time. The SW interviewed Resident #2, and she stated about two weeks ago, the CNA was pushing the Resident out [of] the room to be showered. The Resident did not want to go and was trying to hold onto the doorway. The CNA tried to move his/her arm, and he/she stated that the CNA hit him/her on the wrist, and the Resident hit her back. The Resident did not report it because she is a good CNA and has not had any further issues with her. The Resident stated that the CNA had her today, and she had not [had] other issues with the CNA. He/She identified the CNA. The CNA was interviewed and stated that she was trying to take the Resident out of the room, and the Resident became combative. She denies hitting [Resident #2] and only asked the Resident to let go of the door so that he/she did not get hurt. The CNA was immediately removed from the assignment. According to the Admission Record (AR), Resident #2 was admitted on [DATE] with diagnoses which included but were not limited to Hypertensive Heart Disease Without Heart Failure, Localized Edema, and Unspecified Schizophrenia. According to the Minimum Data Set (MDS), an assessment tool dated 5/2/2023, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated the Resident had moderate cognition. The MDS also showed Resident #2 needed extensive assistance and one-person physical assistance with most Activities of Daily Living (ADLs) and total dependence with locomotion on and off the unit. A review of the Resident's Care Plan (CP) initiated on 06/28/2023 revealed under Focus: that Resident #2 is resistive to care r/t (related/to) Anxiety. Under Goal, indicated, The Resident will cooperate with care through the next review date; the resident will participate in care by performing ADLS, as functionality allows, through [the] next review date. Under Interventions, included: Allow the Resident to make decisions about treatment regime, to provide a sense of control, Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, Encourage as much participation/ interaction by the Resident as possible during care activities, Give [a] clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for ADLs so that the Resident participates in the decision-making process. Return at the agreed upon time; if Resident resists with ADLs, reassure Resident, leave and return 5-10 minutes later and try again. Praise the Resident when behavior is appropriate, Provide consistency in care to promote comfort with ADLs. Maintain consistency in the timing of ADLs, caregivers, and routine, as much as possible; provide Resident with opportunities for choice during care provision. A review of Resident '#2's Progress Notes (PNs) dated 6/19/2023 at 10:09 a.m. written by the Unit Manager/Registered Nurse (UM/RN) revealed Patient was interviewed by write[r] and stated someone pushed his/her hand while he/she was coming from the bathroom. Spoke with an aide. Aide stated Patient opened his/her arms while being pushed out of the bathroom; the Patient's chest touched her chest. It was not intentional. Assessed Patient no visual injury noted. A review of the CNA's Timecard & Pay Records with Comments, dated 6/17/2023, revealed she worked from 7:05a (a.m.) to 11:02p (p.m.). During an interview on 6/28/2023 at 8:55 a.m., the Administrator, in the presence of the Director of Nursing (DON), stated, Resident #2 told his/her family on 6/17/2023 that a few weeks ago, the aide was taking care of him/her. [The] Resident was fighting with her. The CNA was taking [the Resident] out of the room. Resident #2 was holding onto the door frame, [and] the aide moved his/her arm and put the arm on the wheelchair. Then, the Resident said the aide hit him/her on the wrist and said, Don't do that! and the Resident hit the CNA back. I got a call from the Social Worker at 2:15 p.m. on 6/17/2023, and I took [the] aide off the assignment right away, so then the SW interviewed the Resident, and the Resident said the same CNA is his/her aide today. The exact day of the incident is not known. I took the aide off the Resident's assignment, but [the] aide still works on the floor. The Administrator further stated, the SW interviewed other residents on the CNA's assignment, and she did not provide me with any documentation on the interviews. During an interview on 6/28/2023 at 9:27 a.m., when the Surveyor asked what the CNA should do if a resident refuses care or a shower, the DON replied, I have not really spoken to the CNA myself, [the] SW Director did the interview. She continued to say, If a resident refuses any ADL, the aide should tell [the] charge nurse, Unit Manager or Supervisor so we can investigate further .If [a] resident is combative, we provide in-service education on behavior to staff. I don't know if the aide had behavior training done . During an interview on 6/28/2023 at 10:26 a.m., the Administrator stated, We haven't done any Behavior Training in-services and Abuse Training since the incident [was reported] on 6/17/2023. During an interview on 6/28/2023 at 11:08 a.m., Resident #2 stated when he/she was going out of the room, he/she held onto the doorway, and the CNA said, I'm not putting up with this! and the aide hit my left arm wrist with her fist, and I hit her back. There was no one else in the room. I was in a state of shock. The Resident continued, When I hit her, she removed her hand and brought me back to my room. It only happened that one time with the aide, and she doesn't care for me anymore. During an interview on 6/28/2023 at 11:49 a.m., the CNA stated Resident #2 was in the dayroom for an activity, he/she needed to use the bathroom, so I took him/her[,] and when we were leaving the room to return to the dayroom, the Resident put his/her arms out against the doorway to stop from leaving the room, I took his/her right hand and put it down to his/her side as the Resident sat in the wheelchair (w/c) then I took him/her out to the dayroom, but I don't remember what day it was. It had nothing to do with a shower [that day]. In the same interview, the CNA stated, I was behind him/her pushing him/her in the w/c, I reached from behind, grabbed his/her hand and said, put it down to make him/her let go of the wall and the Resident did not say anything to me. In the same interview, when the Surveyor asked the CNA, what do you do if a resident is combative, the CNA replied, If a resident is combative or refuses to go out, I'd tell the nurse, but no, for some reason, I did not tell the nurse that day, and I don't remember who the nurse was that day either. I haven't cared for Resident #2 since 6/17/2023. During an interview on 6/28/2023 at 1:00 p.m., the Unit Manager/Registered Nurse (UM/RN) stated I spoke to the Resident and the CNA on 6/19/2023 when I returned. The Resident said he/she did not want to come out of the room, so he/she opened his/her arms against the doorway, but the exact date was not known, and Resident #2 didn't say any words were exchanged, but the Resident requested the aide be removed from his/her care. Then, I assessed him/her with no injuries noted. In the same interview, the UM/RN stated the CNA tried to remove the Resident from the doorway, and their chests touched, but not intentionally [[NAME]]; there was no mention of touching his/her hand or any words spoken. In a second interview on 6/28/2023 at 2:04 p.m., the CNA stated, the Resident didn't hit me, [the] Resident had a high back wheelchair (w/c), and when I pushed him/her out of the doorway, my chest touched his/her chest [back], it was a quick reaction, and the Resident didn't say anything to me. During an interview on 6/28/2023 at 2:35 p.m., the Administrator stated the CNA was removed from the unit and placed on a different unit on 6/17/2023 then the CNA worked on Monday, 6/19/2023 on Resident #2's unit, but a different assignment. During a second interview on 6/28/2023 at 3:14 p.m., when the Surveyor asked the Administrator if she followed the facility policy titled Freedom From Abuse, Neglect, and Exploitation under Investigation, it reads, If the person implicated is a staff, the staff will be suspended, pending an investigation ., the Administrator stated depends, the aide was caring for the Resident [for] 2 weeks prior with no issues, so I don't know it happened. I never had an issue like this before. The SW told me that the aide grabbed or tapped his/her arm, and the Resident hit the aide back. The Resident said [the] aide tried to take him/her to a shower, but he/she didn't want to go, so the Resident held onto the doorframe, and the aide moved his/her arm onto [his/her] lap. [The] CNA said at no point did she hit him/her. The Resident said it was 2 weeks ago. Resident #2 was mad because he/she didn't want to go to a shower. If [the] Resident doesn't want to do things, he/she says things to get out of it . I didn't feel a need to suspend .This was a unique occurrence .Policy is there, but there are anomalies to things .SW said Resident #2 was fine with [the] aide, no reason to suspend. When the Surveyor asked if she usually suspends the staff if abuse is alleged, the Administrator replied, Totally, usually every other time if abuse is alleged, I'd suspend [the] employee, this was [a] different situation. I removed her from the assignment. [The] Resident said [the] aide hit him/her, but [the] aide said she didn't. The Administrator stated, There is no documentation that [the] aide was in [the] lounge area, [the] SW removed her [is what] was told to me. While the investigation was done, the aide was not in the Resident care area, but [there's] no documentation. During an interview on 7/3/2023 at 9:27 a.m., the SW stated it was on 6/17/2023; I was the Administrator on duty. The family of Resident #2 informed me that the Resident had an issue with an aide, the aide taking care of me today, the one with [the] curly hair. The SW said per the Resident, about 2 weeks ago, on the way to the shower, the Resident was fighting with the aide that he/she didn't want to go, so the Resident had his/her hands up on the doorway, the aide removed his/her left arm, hit him/her on the wrist, said I'm not going to take this today and placed his/her wrist on his/her lap to go through the door. The Resident hit the CNA back. The SW continued to say she asked the Resident why he/she did not say anything [earlier]; Resident #2 stated, I took care of it; I've had no issues since this one time, leaving it up to God, didn't want anyone to lose their job, since my family was visiting, I wanted someone to know . The SW stated she spoke with the aide (CNA); the Resident was combative that day; the aide was trying to protect him/her, she didn't want the Resident to get hurt, and the aide did not hit the Resident. The SW stated she verbally educated the aide in her conversation on what to do if a resident has combative behavior, but there is no documentation of the education. The family didn't say [a] shower issue, just said there was an issue with an aide, no specifics given, nor date known. [The] family just wanted to let someone know. The Surveyor asked the SW about the investigation; the SW stated the investigation lasted about a half hour; she only interviewed and got statements from the Resident and the CNA, spoke to the other residents on the assignment, and the Nurse Supervisor (NS). The aide was sent to the lounge area. After speaking to the Administrator, the Administrator and I concluded we couldn't substantiate it, and the aide could resume working on the next shift, a double, on a different floor that same day, 6/17/2023. When the Surveyor asked her about the policy concerning staff being suspended during an investigation, the SW replied, Yes, in the past we [facility] suspended, but it depends on the situation. I informed [the] Administrator, and she didn't alert me to do anything further. I did my investigation, and the NS worked a double [shift], and she was aware of the incident. I can't say if the aide was monitored [while] caring for other residents, but the NS was aware. NS is the Supervisor for the whole building. I did what I thought I should do. I wouldn't think the aide would be monitored because my investigation was concluded, and the NS was aware. During a telephone interview on 7/3/2023 at 10:38 a.m., the NS stated, The Resident said it happened 2 weeks ago, the SW talked to me, and I brought the CNA to the SW, so the 3 of us talked about what the Resident/family reported. [The] CNA had no idea what happened, [the] aide said she didn't hit the Resident, [the] Resident was in the bathroom, the aide said she was trying to move the Resident's hand from the doorway is all I remember. All [the] information I got came from the SW. I didn't talk to the Resident. I didn't give a statement, but the CNA gave a statement, and I left the conversation. After speaking to the Administrator, the SW and I moved the CNA to a different unit for the remainder of the day. I was there the rest of the day with the CNA. I wasn't next to the CNA, but I did rounds throughout my shift. I didn't monitor her. [The] CNA did Resident care, and I was aware there were no Resident care issues with [the] CNA. Review of the facility policy titled Freedom From Abuse, Neglect and Exploitation revealed the following: Under Policy: included The organization will protect the resident/patient right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, misappropriation of property and involuntary seclusion. Resident must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants or volunteers, visitors, staff of other agencies family members or legal guardians, friends or other individuals. This policy will be accomplished through the seven components of abuse prevention: 1. Screening of potential staff 2. Training of staff, through orientation and on-going sessions 3. Prevention information and grievance procedure for resident, representatives and staff 4. Identification of possible incidents or allegations which need investigation 5. Investigation of all incidents and allegations by qualified and trained individuals 6. Protection of resident during investigations 7. Reporting of abuse incidents, investigation and facility response Under Purpose: included To provide a proactive and systematic approach to the protection of the resident's rights and safeguarding resident from harm due to abuse, neglect and or misappropriation of property. This will be accomplished by incorporating the seven components of abuse prevention into the facility's procedural practices. All incidents of resident abuse or suspected resident abuse will be investigated thoroughly and appropriately addressed. Under Definitions included: a) Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse physical abuse, and mental abuse f) Physical abuse is defined as hitting, slapping, pinching, kicking etc . Under Procedure: included 1. The organization will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, resident representative, legal guardians, power of attorney, sponsors, friends, or other individuals. 2. The organization considers seven components with the development of this policy: .e) Investigation: The Administrator and/or Director of Nursing will be notified and review the investigation of any incident initiated by the Supervisor, Nurse Manager or Charge Nurse at the time the situation occurs .If the person implicated is a staff, the staff will be suspended pending a full investigation . N.J.A.C.:8.39-4.1 (a) (5)

COMPLAINT # NJ 3 Based on observations, interviews, review of the Medical Records (MR), and review of other pertinent facility documentation on 7/9/2020, it was determined that the facility failed to ensure a resident with severe cognitive impairment, who was at risk for elopement, and had a known history of wandering and exit seeking behavior, was appropriately monitored and supervised to prevent elopement or exiting the building. The facility also failed to follow their Elopement Policy and their Incident and Accident Policy. The facility also failed to secure the front door for safety to prevent elopement, for 1 of 3 residents (Resident #2) sampled for elopement. On 7/1/2020 at 9:45 p.m., Resident #2 was able to exit the facility unattended when the Nursing Supervisor deactivated the front door alarm, unlocked the front door and Resident #2 then exited the building. When the Supervisor reentered the facility, she failed to reactivate the alarm and lock the door, or have a staff member monitor the exit while the alarm was shut off. On 7/1/2020 at 9:45 p.m., Resident #2 was able to exit the building by the unsecured front door without the knowledge of the staff and was able to wander down the driveway and was observed by a motorist near a main road with a speed limit of 45 mph (miles per hour). The police were alerted and notified the facility that the cognitively impaired resident was outside of the building. The resident was transported to the emergency room (ER) via ambulance and evaluated for possible injuries. This deficient practice placed Resident #2 and all other residents with cognitive impairment who were at risk or who had a known history of wandering and/or elopement in an Immediate Jeopardy (IJ) situation. The IJ was identified on 7/9/2020 at 5:01 p.m., when the Facility's Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ and were provided the IJ template. The IJ ran from 7/1/2020 through 7/9/2020 at 6:09 p.m., and was lifted when the facility provided an acceptable Removal Plan. This deficient practice was further evidenced by the following: 1. According to the Face Sheet (FS), Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 5/22/2020, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00/15, indicating the resident had severe cognitive impairment. This MDS also indicated under section E900 Behavior, that Resident #2 had a behavior of wandering which occurred daily. Review of the Care Plan (CP) dated 4/9/2020, revealed Resident #2 had Dementia with behaviors, verbalizes wanting to go home, and had a history of [REDACTED]. Interventions on the CP included but were not limited to: a wanderguard (WG) alarm bracelet in place to the left ankle, and the resident's picture was posted at the nursing station and the front receptionist desk for safety. Goals included: The resident will not exit the building and will remain safe in their environment. Review of Resident #2's Physician order for [REDACTED]. Review of the Facility's Elopement Risk Assessment (ERA) dated 4/5/2020, revealed Resident #2 was at risk for elopement secondary to: A past history of wandering or exiting the home or facility without the needed supervision, verbalizing the desire to leave, cognitive impairment, problems with decision making, and responsible party voicing concerns that would indicate that the resident may try to leave or wander. Interventions included but were not limited to: Identification bracelet in place, use of a WG alarm bracelet, a photo on the elopement list, music, exercise, personalization of room with familiar objects and photos, and diversion activities. Review of the Psychiatric Consultation for Resident #2 dated 1/20/2020, indicated the Nurse Practitioner documented the following: Under Chief Complaint/Interval History, Facility requested a follow-up on resident due to agitation, irritability, wandering behavior, [MEDICAL CONDITION], appetite is undisturbed. The recommendations included; decreasing the residents [MEDICATION NAME] for 3 days then discontinuing the medication and starting [MEDICATION NAME] 125 mg (milligrams) 2 times a day. Review of the Incident/Accident Report dated 7/1/2020, revealed the following documentation by the nurse: Resident #2 eloped and had a fall on 7/1/2020, at 10:15 p.m., found in front drive at parking lot entrance, resident absconded from a facility door other than on Cedar Wing. Description of incident by resident: I want to go home. Under contributing factors, the following areas were marked by the nurse: Cognitive impairment, decreased balance/weakness, restlessness/agitation, and non-compliant patient. Under Possible causes of incident: the nurse documented, Resident wandered off of the unit and out one of the doors. Further review of the Incident/Accident Report dated 7/1/2020, revealed the following statement documented by the Admin: At approximately 10:00 p.m., the nurse on the unit noted Resident #2 was not in her room. The resident was seen approximately 15 minutes prior. A search was immediately initiated on the unit. The Nursing Supervisor was informed. During the search Nursing Supervisor #1 received a call from a nurse on another unit reporting that the police were in the driveway. Nursing Supervisor #1 was informed by the police that a passerby saw the resident sitting on the curb in the driveway and notified the police. The resident was assessed for injuries and vital signs were checked, there were no apparent injuries and the vital signs were stable. The resident was transported to the hospital for an evaluation and returned to the facility on [DATE] at 12:45 a.m., no injuries were found. Upon return to the facility the nurse checked the WG alarm bracelet and found it to be operational. Upon further investigation by the Admin, Nursing Supervisor #1 stated, that she unalarmed and unlocked the front door to check the back-entrance door to ensure they were secure, during which time the resident wandered to the front of the building and exited the doors. The Admin concluded the following on the Incident/Accident Report: The resident wandered to the front of the building and exited the front door while it was not alarmed and unlocked. Resident's WG alarm bracelet was on and under the resident's sock and clothing, possibly caused the WG alarm to not trigger. Review of the Facility's Progress note for Resident #2 dated 7/2/2020, with a Note time of 1:59 a.m., Nursing Supervisor #1 reported, she received a call from another staff member at 9:45 p.m., reporting the police responded to a passerby who observed a resident sitting on the ground in the driveway of the facility and an ambulance had been called. The resident was in usual alert and confused state of mind sitting on ground. Vital signs were assessed and within normal limits. The resident was sent to the emergency room (ER) for an evaluation. The facility nurse received a call from the ER nurse who reported the resident will be returning to the facility. No apparent injuries noted. During an interview on 7/9/2020 at 10:53 a.m., the Admin reported Resident #2 eloped from the Facility on 7/1/2020, through the front door. The staff were notified by the police that the resident was outside. Between 10:00 p.m. and 10:15 p.m., someone called the police when they saw the resident sitting in the driveway. The Admin further reported that routinely the front door is locked at 6:30 p.m. by the nursing supervisor when the receptionist leaves for the night. On 7/1/2020 around 10:00 p.m., Nursing Supervisor #1 unlocked and deactivated the alarm to the front door then went outside to check that the back door had been locked. If she went out the back door she would have been locked out of the building. The resident must have exited out the front door after the Supervisor. Nursing Supervisor #1 then came back in and reactivated the alarm not realizing Resident #2 was outside. The resident was wearing a WG alarm bracelet on the left ankle and the WG alarm sensor is located at the front door, the alarm should have sounded when he/she exited, however, the alarm did not sound. The Admin stated the resident had pants and socks on which could have prevented the alarm from triggering when the resident opened the door. During an interview on 7/9/2020 at 11:14 a.m., the Certified Nursing Assistant (CNA) reported Resident #2 was on her assignment on 7/1/2020, and she provided evening care to the resident between 9:10 and 9:30 p.m., and then assisted him/her to bed. She stated the residents WG alarm bracelet was on the ankle and the placement and function of the WG is checked by the nurse. The CNA reported that Resident #2 had a history wandering since the resident was admitted and that is why he/she had a WG alarm bracelet in place. In addition, the CNA stated that on 7/1/2020, Resident #2 was asking for his/her spouse and reported missing them, but never verbalized leaving the facility, however, the resident had a history of [REDACTED]. The CNA further stated that on 7/1/2020, when Resident #2 eloped from the facility she never heard any alarm sound. During an interview on 7/9/2020 at 11:37 a.m., the DON reported, that the Elopement Risk Assessments (ERA) for wander-guards are only done if the resident's are at risk for elopement. The staff looks at their behaviors, like wandering, saying they want to go home or leave, and the history the family gives us. The DON also reported, the nursing staff is responsible for checking the WG alarm bracelets for function and placement every shift so that if the resident gets near the front door the WG alarm will sound. The WG alarm and the front door alarm are 2 separate alarms. The front door alarm sounds when someone attempts to leave and pushes open the front door. During an interview on 7/9/2020 at 11:56 a.m., Nursing Supervisor #1 reported, her responsibility is to lock the front door when the front desk receptionist leaves for the evening, which is usually around 6:30 or 7:00 p.m. When she leaves, I lock both doors with a key. Nursing Supervisor #1 then reported that on 7/1/2020 around 9:30 or 10:00 p.m. she went out the front door with Nursing Supervisor #2 to show her the employee entrance door, which is located on the side of the building. It is the nursing supervisors job to check the door is locked or secured. Nursing Supervisor #1 stated she unlocked the front door and deactivated the door alarm, then walked around the building with Nursing Supervisor #2. Nursing Supervisor#1 stated I had the keys with me so people could get out when that door is locked but no one could get in. The employee door is locked, from 6:30 or 7:00 p.m. until 5:30 or 6:00 a.m., this prevents employee's from coming in that door, they need to come in the front door to get screened for Covid and temperatures taken before starting their shifts. In addition, the Nursing Supervisor #1 reported that they did not come back in the building through the front door, but entered the building by the employee entrance and as they were heading back to lock the front door she received a call from a nurse who reported the Police were outside with a resident. Nursing Supervisor #1 stated a passerby called the Police to say a resident was in the driveway outside. I guess he/she followed me outside. I never saw him/her exit the building It was my mistake that I left the door unlocked. I deactivated the alarm I thought the second door would alarm but it didn't. The doors don't lock just an alarm goes off. Nursing Supervisor #1 further stated, the first time she knew the resident was missing was when the Police were outside. It was within seconds. He/she must have followed us and exited the building right after us because it was within seconds the Police were here. During an interview on 7/9/2020 at 12:34 p.m., the Maintenance Director (MD) reported, he was never called in to check the door alarm or wander-guard alarm after the elopement of the resident on 7/1/2020, however, he routinely checks the alarms each morning. He also reported, that the WG alarm and the front door alarm are 2 different alarms. The WG alarm will sound when the resident gets within a few feet of the alarm. The front door alarm will sound when someone opens the inside door to exit the building. The outer door is locked so no one can enter the building, however, if the door alarm is deactivated residents or staff can exit the building without the alarm sounding. Once the front door alarm sounds, a key is needed to reset the alarm. If the wander-guard alarm sounds a code is needed to reset the alarm. During an alarm test observation on 7/9/2020 at 12:50 p.m., the MD activated the front door alarm using the key. When the MD attempted to exit the inner front door the alarm sounded. The MD reported the alarm should be heard throughout the facility. On 7/9/2020 at 12:59 p.m., Resident #2's wander-guard alarm bracelet was tested with the Admin and MD present. The resident was observed with a WG alarm bracelet to the left ankle. The WG check was done 2 times. When the resident attempted to exit the inner front doors the WG alarm sounded both times. On 7/9/2020 at 2:50 p.m., the Security Video footage for 7/1/2020, was reviewed with the Admin and revealed the following timeline: 6:49 p.m. the receptionist exits the building and Nursing Supervisor #1 locked the outer door then alarms the inner doors. 6:53 p.m. Nursing Supervisor #1 unlocked the door to let a resident back in the building then locked the doors and alarmed the front doors. 7:24 p.m. Nursing Supervisor #1 goes outside and looks around, comes back in and locked the doors and alarmed the front door. 7:26 p.m. Nursing Supervisor #1 puts 2 chairs near the front door. 7:30 p.m. to 8:30 p.m. No activity at the front entrance. 8:47 p.m. Nursing Supervisor #1 and #2 are observed at the front entrance. Nursing Supervisor #1 reaches up to the inner right door then the inner left door, deactivated the alarms, moved the chairs, and then they go outside. 8:58 p.m., The two Supervisors returned to the front lobby through the Service Corridor/employee entrance. They are not observed near the front doors either relocking or reactivating the alarms. 9:44 p.m. Resident #2 enters the front lobby alone, then exits through the left side of the inner front door, then out the outer door. 10:02 p.m. Strobe lights observed outside. (Police on scene) 10:07 p.m. A CNA and another staff member exit through the front door. 10:10 p.m. Nurse (RN #1) observed exiting through the front door without stopping to shut off or reset any alarms. 10:11 p.m. RN #1 reenters the building then exits with a wheelchair. 10:13 p.m. Supervisor #1 and Supervisor #2 exit building through front doors. During an interview on 7/9/2020 at 5:07 p.m., RN #1 reported; that the Police called to report a resident had eloped from the facility. RN #1 then called Nursing Supervisor #1 to inform the Supervisor the police were on site. RN #1 further stated he observed Resident #2 sitting on the curb in the driveway. He assessed the resident for injuries, no apparent injuries were noted, then he went inside to get a wheelchair for the resident. Shortly after the Emergency Medical Technicians (EMTs) arrived, they assessed the resident and checked the vital signs. Nursing Supervisor #1 and Nursing Supervisor #2 then came outside so RN #1 reported he went back to his unit. RN #1 stated he did not reset any alarms before exiting the building to assess Resident #2 because they were not sounding. Review of the Police Report dated 7/1/2020 at 9:55 p.m., indicated the Police were dispatched to the Facility to conduct a well-being check on a person observed seated on the curb in front of the location. Upon observing an ankle monitor on the person the officer was led to believe the person had eloped from the nursing facility. The officer contacted the nursing supervisor who confirmed that the person was a resident of the facility and the facility was unaware that he/she was not on the unit. The officer reported that the resident was highly confused and unable to specifically identify where he/she was or how they got there. The EMTs were requested to the location due to the resident's mental status, a complaint of knee pain, and an alleged fall, however, the officer reported no visible injuries were noted. Upon speaking to the facility staff, the officer reported that an employee stated that the resident likely walked out of a normal exit rather that the service area because the alarms to alert the staff were inaudible beyond the front of the building. The staff also reported the resident's mental status was normal for his/her known baseline and that the resident was known to wander away from the unit. The staff was unable to identify how long the resident was missing from the facility or when he/she was last accounted for by the staff. In addition, the resident was evaluated by the EMTs and asked to go to the hospital. However, the staff indicated that the resident likely did not need to be hospitalized and attempted to return the resident to the facility and the nursing supervisor stated that she would sign a Refusal of Medical Attention (RMA) on the resident's behalf, however, the staff indicated that the resident's spouse was the POA. Since the POA could not be reached the resident was transported to the hospital. The Police report further indicated that the officer was able to reach another family member who was listed as an emergency contact. The family member reported that this was not the first occasion in which he/she had successfully eloped from the facility without the knowledge of the staff and was known to wander. The family member also stated that they did not believe that he/she was placed appropriately within a secured unit in the facility given the prior history and that the staff repeatedly failed to ensure the safety by failing to monitor the whereabouts and protect him/her from eloping from the facility. Review of the facility policy titled Elopement Policy, with a revised date of 1/2017, and a reviewed date of 1/2020, revealed the following under Purpose: To maintain the safety and well-being of all residents within the facility. Under Procedure: section 8. Upon locating the resident, the facility will attempt to determine how the resident got out of the facility (if this is the case), and to develop a plan of care to insure the future safety and security of the resident, such as: In-service must take place for all three shifts regarding facility policies on wandering residents and what to do in case of an elopement of a resident. These in-services must include all Department Heads and facility receptionist. According to the Facility's Policy titled Incident and Accident Policy implemented on 9/1999, and last reviewed 01/2020, indicated the following under Policy: Accidents or incidents occurring in the facility or on facility property are to be reported. An incident is any occurrence not consistent with the normal care of the residents or any happening involving visitors or employees. Under Procedure section 10. Notification of the following as determined: a) Ombudsman b) Department of Health Resident #2 was able to exit the building by the unsecured front door without the knowledge of the staff and was able to wander down the driveway and was observed by a motorist near a main road with a speed limit of 45 mph (miles per hour). The police were alerted and notified the facility that the cognitively impaired resident was outside of the building. The resident was transported to the emergency room (ER) via ambulance and evaluated for possible injuries. This deficient practice placed Resident #2 and all other residents with cognitive impairment who were at risk or who had a known history of wandering and/or elopement in an Immediate Jeopardy (IJ) situation. The IJ was identified on 7/9/2020 at 5:01 p.m., when the Facility's Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ and were provided the IJ template. The IJ ran from 7/1/2020 through 7/9/2020 at 6:09 p.m., and was lifted when the facility provided an acceptable Removal Plan. A revisit to verify the Removal Plan occurred on 7/16/2020. N.J.A.C. 8:39-4.1(a)11