Every finding on record at Trenton Gardens Rehabilitation and Nursing Center

Complaint #2974086 Based on interviews, review of medical records, and review of other pertinent facility documents on 4/14/26, 4/16/26 and 4/17/26, it was determined that the facility failed to provide a safe environment and adequate supervision to prevent the elopement of a resident (Resident #3) who was identified as an elopement risk. Resident #3 eloped from the facility on 4/1/26, and was later found in the neighborhood near the facility by the local police. During the survey a finding that constituted an immediate Jeopardy (IJ) was identified under CFR 483.12(a) (1) for F689. The facility failed to implement interventions to maintain a safe environment with adequate supervision to prevent elopement.On 4/1/26, at approximately 3 PM, Resident #3's assigned nurse, Licensed Practical Nurse (LPN #1), observed the resident seated in a wheelchair in the main lobby, near the front door. LPN #1 stated during interview on 4/14/26, that she was aware that Resident #3 was an elopement risk, and that she did not approach the resident and and did not check for the resident's Safety Band (SB) on the resident's wheelchair. LPN #1 further stated that she left the facility and went home because it was the end of her shift. According to the Facility's Reportable Event (FRE) dated 4/2/26, on 4/1/26 at 3:15 PM during rounds, the 3-11 shift staff discovered that Resident #3 was not in their room and they initiated a search for the resident. The Director of Nursing (DON) and the police were notified of the missing resident (Resident #3) at approximately 3:20 PM. The Police located the resident on 4/1/26 at approximately 4 PM in the neighborhood near the facility and transported the resident to the hospital for evaluation.The facility's failure to provide a safe environment and adequate supervision to prevent Resident #3 from leaving the facility without staff knowledge, placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 4/1/26. The Licensed Nursing Home Administrator (LNHA) was informed of the F689 IJ and was provided with the IJ template on 4/16/26 at 5 PM. An acceptable Removal Plan (RP) was received on 4/17/26 at 11:36 AM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring.The surveyor verified the implementation of the RP during the continuation of the on-site survey on 4/17/26 and determined the immediacy was removed as of 4/2/26. The deficient practice was identified for 1 of 3 residents (Resident #3) reviewed and was evidenced by the following:The facility policy titled: Policy and Procedure Resident Elopement, with a reviewed date of June 2025, under Definitions, revealed that Elopement is defined as when a resident leaves the facility without their knowledge. The policy further revealed that after an elopement attempt, care plans would be updated and interventions that were established by the interdisciplinary team would be implemented. The facility policy titled: Policy and Procedure [Safety Band], with a revised date of June 2025, under Purpose, revealed that the placement of a Safety Band (SB) would aide in elopement prevention. The policy further revealed that the names of all residents at risk for elopement would be kept in a log, along with their picture, at the front desk. The policy also revealed that if a resident wearing a SB attempted to leave the facility, the alarm would be activated. A review of the Facility Reportable Event (FRE) dated 4/2/26, which the facility submitted to the New Jersey Department of Health (NJDOH), revealed that at approximately 3:15 PM on 4/1/26, the 3-11 shift staff determined that Resident #3 was not in their room. The facility then initiated a search for the resident and notified the local police department. The FRE further revealed that police officers (PO) arrived at the facility at 4:15 PM with Resident #3 and then transported the resident to the hospital for evaluation. A review of the document titled: Incident Summary Report (IRS) dated 4/1/26, provided by the Director of Nursing (DON), revealed that Resident #3 was last seen by staff in the first floor lobby at approximately 3 PM. The IRS further revealed that according to hospital staff interview, the resident's Safety Band (SB) was not on the resident's wheelchair when the resident arrived at the hospital; and that the facility believed that Resident #3 removed their SB before they exited the facility. Resident #3 was not at the facility at the time of the survey. A closed record review was conducted as follows: According to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paranoid schizophrenia (subtype of schizophrenia characterized primarily by delusions and auditory hallucinations), schizoaffective disorder (a mental health condition that includes symptoms of both schizophrenia and mood disorders) and anxiety disorder. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/15/26, Resident #3 had a BIMs score of 7 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #3's Elopement assessment dated [DATE] at 2:41 PM, indicated that Resident #3, .becomes impatient when waiting to be picked up by responsible party and will self-propel [themself] towards door, has exit seeking behavior at times. A review of Resident #3's Progress Notes (PN) revealed a nursing note dated 3/31/26 at 1:33 PM, written by Licensed Practical Nurse Unit Manager (LPN/UM), stated Resident observed to have potential to exit seek due to restlessness, poor impulse control, and impatience. Resident self-propelling towards door, resident expressing to go out front. [SB] placed on the back of resident's wheelchair, refused to have placed on wrist. A review of Resident #3's Order Summary Report revealed that an order was initiated on 3/31/26 for an SB to be placed on the back of the resident's wheelchair and that staff were to check for placement every shift. A review of Resident #3's Treatment Administration Record (TAR) for April 2026 revealed that Licensed Practical Nurse (LPN #1) signed that the SB was checked for placement on the back of the resident's wheelchair on the 4/1/26 day shift. A review of Resident #3's Care Plan (CP) revealed a focus initiated on 3/31/26, indicating that Resident #3 was an elopement risk, .related to impatience, and poor safety awareness, impulsive behavior, becomes impatient and has potential to self-propel [themself] in wheelchair out the door . The CP further revealed that Resident #3 had a SB placed on their wheelchair and that staff were to monitor the resident's whereabouts. An interview was conducted on 4/14/26 at 11:55 AM with Licensed Practical Nurse (LPN #1), who confirmed she was assigned to Resident #3 on the 4/1/26 on the 7 AM - 3 PM day shift. She stated that she was aware of Resident #3's elopement risk and that she checked the SB to be in place on the back of the resident's wheelchair on 4/1/26. LPN #1 further stated that interventions included monitoring and redirecting Resident #3 when exit seeking behaviors were observed. LPN #1 stated that when she observed Resident #3 in the lobby at 3 PM, she did not approach the resident and did not notify other staff members that the resident was in the lobby near the front door entrance. LPN #1 denied seeing the SB on the resident's wheelchair, and stated that the SB alarm system was not sounding when Resident #3 was in the lobby near the front entrance door. An interview was conducted on 4/14/26 at 12:39 PM with the Receptionist who stated that she worked at the Front Desk on 4/1/26 from 8 AM - 4 PM. She stated that she was trained on the Elopement Book (EB) and the SB system. The Receptionist stated that the EB had names and photos of all residents that were elopement risks. Receptionist further stated that she was to observe for wandering residents near the exits and report concerns immediately. She further stated that the purpose of the photos was to provide staff with a reference of which residents were at risk of eloping. Receptionist denied seeing Resident #3 in the lobby at 3 PM on 4/1/26, and stated she did not hear the SB alarm system sound. An interview was conducted on 4/14/26 at 2:09 PM with LPN/UM who stated that on 3/31/26, she assessed Resident #3 to be an elopement risk and placed an SB as preventative measure. LPN/UM stated when Resident #3 was located by the police and sent to the hospital for an evaluation, she contacted the hospital staff, and that when she inquired if Resident #3's SB was on the wheelchair, the hospital staff stated that there was no SB on the wheelchair. An interview was conducted on 4/14/26 at 2:51 PM with the Maintenance Director (MD). He stated that the SB system was tested weekly by his staff and that the last test prior to the elopement incident was done on 3/27/26 and there were no issues identified with the system. He further stated that a re-test was conducted on 4/1/26, after the elopement incident and no issues were identified with the SB system. An interview was conducted on 4/14/26 at 3:07 PM with the DON and the Licensed Nursing Home Administrator (LNHA). The LNHA stated that there was no camera footage available for review of the 4/1/26 incident. The DON stated that she was informed that Resident #3 was missing when she received a phone call from the Assistant Director of Nursing (ADON), and that by 4 PM she was informed that the resident was located by the police. The DON stated that a team meeting was held on the morning of 4/2/26 to review information provided to the team by the facility's staff which revealed that Resident #3's SB was not on the wheelchair when the resident arrived at the hospital. The DON stated that the team concluded that Resident #3's SB must have been removed prior to exiting the facility. An acceptable Removal Plan (RP) was received on 4/17/26 at 11:36 AM, indicating the action the facility would take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice, including:-Resident #3 had not returned to the facility.-On 4/1/26 the Maintenance Director tested exit doors that had SB antennas, including sensitivity ranges, and ensured that they were in proper working order.-On 4/2/26 the ADON conducted an audit of all residents wearing SB and confirmed that SB were in place and functional. The Staff Educator and the ADON initiated in-services to facility staff on SB and Elopement Policy and Procedures. Receptionists also received an in-service on Front Desk Responsibilities.-On 4/2/26, the DON implemented that going forward, to reduce the front door/lobby traffic, staff were now to use the side entrance to enter/exit the building. A sign was posted by the lobby door notifying all staff of the new entry/exit protocol. Staff Educator also initiated in-services for staff on the new side door entry/exit protocol.The surveyor verified the implementation of the Removal Plan on-site on 4/17/2026, and determined the immediacy was removed as of 4/2/26. NJAC 8:39-27.1 (a)

COMPLAINT #297096, 2971506, & 2980872 Based on interviews, review of medical records and other pertinent facility documentation on 4/15/26, 4/16/26, and 4/17/26, it was determined that the facility failed to maintain accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to: a) consistently document toileting and bowel & bladder elimination in the Documentation Survey Report v2 (DSR) (Resident #4 and Resident #9) and b) provide documentation that a resident's request for a specific roommate was addressed (Resident #6).This deficient practice was identified for 3 residents of 9 reviewed (Resident #4, Resident #6, & Resident #9) and was evidenced by the following:a). A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: osteoarthritis (a degenerative joint disease where joint tissues break down over time), morbid obesity, and rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood).Review of Resident #4's comprehensive Assessment Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 1/24/26, indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15; indicating that the resident's cognition was intact. Further review of the MDS revealed that the resident required, Substantial/Maximal assistance with toileting hygiene. The MDS also indicated that the resident was always incontinent of bowel and bladder.A review of Resident #4's care plan (CP) indicated that Resident #4 required four to six people assistance with bed mobility, and required use of a medical lift for all transfers. The CP stated that the resident was always incontinent of bowel and bladder.A review of Resident #4's Documentation Survey Report v2 (DSR) for April 2026 included care areas and times for staff to document on Resident #4's care. There was no evidence of documentation on the following dates and shifts:-Bowel and Bladder Elimination:4/4 Day, Evening, & Night4/5 Evening4/6 Evening4/7 Evening4/9 Day4/10 Day4/11 Evening -Toilet Transfer:4/4 Day, Evening, & Night4/5 Evening4/6 Evening4/7 Evening4/10 Day4/11 Evening -Toilet Hygiene:4/4 Day, Evening, & Night4/5 Evening4/6 Evening4/7 Evening4/9 Day4/10 Day4/11 Evening A review of the admission Record revealed that Resident #9 was admitted to the facility with diagnoses that included but were not limited to: heart failure, rheumatoid arthritis, cachexia (a wasting syndrome that leads to weakness, fatigue, and loss of skeletal muscle and fat).Review of Resident #9's comprehensive MDS an assessment tool used to facilitate the management of care, dated 2/16/26, indicated that Resident #9 had a BIMS score of 14 out of 15 indicating that the resident's cognition was intact. Further review of the MDS revealed that the resident required, partial/moderate assistance with toileting hygiene and transfer. The MDS also indicated that the resident was occasionally incontinent of bowel and frequently incontinent of bladder.A review of Resident #9's CP indicated that staff were to monitor and assist Resident #9 with transferring to the toilet and toilet hygiene.A review of Resident #9's DSR for April 2026 included that the following should be documented during each shift. There was no evidence of documentation on the following dates and shifts:-Bowel and Bladder Elimination:4/1 Day & Night4/2 Day & Night4/3 Day & Night4/4 Day & Night4/5 Day & Night4/6 Day & Night4/7 Day & Night4/8 Day -Toilet Transfer:4/1 Day & Night4/2 Day & Night4/3 Day & Night4/4 Day & Night4/5 Day & Night4/6 Day & Night4/7 Day & Night4/8 Day -Toilet Hygiene:4/1 Day & Night4/2 Day & Night4/3 Day & Night4/4 Day & Night4/5 Day & Night4/6 Day & Night4/7 Day & Night4/8 Day During an interview on 4/16/26 at 10:31 AM, Certified Nursing Assistant (CNA #1) stated that incontinent rounds were to be completed every two hours, and the purpose was to prevent skin breakdown. She stated CNAs were primarily responsible for providing the care and that all care provided was to be documented in the resident's electronic medical record (EMR), in order to keep all team members informed of the care provided. She stated that there should be no blanks but that there were times when care was provided and they forget to document. During an interview on 4/17/26 at 10:04 AM, Licensed Practical Nurse (LPN #2) stated that CNAs were responsible for providing and documenting all incontinent care in each resident's EMR. She stated that incontinent rounds were important to prevent skin breakdown. She further stated that all care should be documented because that is confirmation that care was provided. During a joint interview on 4/17/26 at 3 PM, with the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse Consultant (RNC), the RNC stated that CNAs were primarily responsible documenting incontinent care in the EMR. She stated that documentation was important because it confirmed that care was provided. In the presence of surveyor, they reviewed the aforementioned DSR forms for Resident #4 & Resident #9. The RNC stated that there should not be any blanks on the forms and that Unit Managers were primarily responsible for ensuring that CNAs were documenting as they should be. She stated she was not sure what happened in these cases. b). A review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to: chronic kidney disease, depressive disorder.Review of Resident #6's comprehensive MDS, dated [DATE], indicated that Resident #6 had a BIMS score of 14 out of 15 indicating that the resident's cognition was intact.A review of Resident #6's CP indicated that the resident had a special relationship with another resident that was initiated on 2/6/26.A review of Resident #6's EMR did not reveal any documentation related to a request to have a specific roommate.The facility reported that there were no grievances on file for this resident. During an interview on 4/16/26 at 11:13 AM, Resident #6 stated that they would feel more comfortable if they had the roommate of their choice (Resident #5) and not liking that they could not be together. When asked if Resident #6 had expressed this concern to facility staff, the resident could not recall specific names but stated that they had and they still were not roommates. During an interview on 4/17/26 at 10:19 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated that around the time of Resident #6's admission it came to her attention that Resident #5 and Resident #6 wanted to be roommates. She stated that all room change requests are referred to the social worker and that this is what she did in this case. She stated that she was aware that Resident #6's CP had been updated and that the residents spend time together regularly but that she was not sure why the rooms had not been changed. During an interview on 4/17/26 at 11:00 AM, the Director of Social Work (DSW) stated that she was familiar with Resident #6 expressing wanting to be roommates with Resident #5. She stated she was aware that Resident #6's cognition was intact and that the resident was able to make their own decisions. The DSW stated that the interdisciplinary team (IDT) met, developed a plan that they thought would ensure safety for both residents, and that Resident #6 had agreed with the plan. She stated that after the meeting, Resident #6's CP was updated to include the agreed upon interventions. When asked if there was any documentation that the resident agreed with the plan, the DSW stated that they did not document it but that they should have. During an interview on 4/17/26 at 1:40 PM, the LNHA stated being familiar with Resident #6's roommate request but that he was unsure of who told him. He stated that he, along with the DSW, participated in an individual meeting with Resident #6 to discuss the matter further. He further stated that after that meeting was held he participated in an IDT meeting and that they discussed that resident safety remained their primary goal. He stated that an an alternate plan was developed that included that the residents could spend time together. The LNHA stated that Resident #6 agreed with the plan that was developed and the care plan was updated and implemented. The surveyor requested evidence of documentation that the meeting occurred and that Resident #6 agreed with the plan and explained that none had been provided. The LNHA stated that the team meeting should have been documented so that everyone was aware that the request was addressed. A review of the facility's Policy and Procedure [Activities of Daily Living], dated December 2025, revealed that toileting and continent care were part of the facility's basic self-care tasks. It further revealed that CNAs were to document, in real time in the EMR and that documentation was to include the level of assistance the resident required the resident's response to the care, and/or if the resident refused. A review of the facility's P&P Resident Room Change policy, dated October 2025, revealed that the purpose of the policy was to, Ensure that all resident rights under law are adhered to. The policy further revealed that the social worker would address any resident requests for room changes. N.J.A.C. 8:39-27.1(a)

Based on observations, interviews, record review, and review of facility policy, it was determine that the facility failed to ensure standard food safety practices were put in place to prevent food borne illness by ensuring a.) the dish machine and the three-compartment sink were maintained in safe operating conditions in accordance with manufacturer's specifications; b.) adherence to sanitary requirements to ensure all dishware was properly sanitized to prevent potential foodborne illness or potential exposure to hazardous chemicals; and c.) a monitoring system was in place and staff were competent to record the temperature and the chemical concentrations of the sanitizing agent. This deficient practice had the potential to affect all 185 residents. On 2/5/26, the surveyor observed breakfast meal trays on two resident nursing units that contained disposable dishware, as well as trays with regular wash ware. Interviews with dietary staff revealed that since 1/28/26, the facility's dish machine had not been operating at the appropriate temperature, so the facility was serving on disposable dishware and trays. The Cook, who was the Acting Food Service Director (FSD), stated that the facility was using disposable dishware for most of the residents, and the facility sanitized the cookware including pots, pans, and utensils in the three-compartment sink (a manual sink used in commercial kitchens to wash, rinse, and sanitize dishes). The surveyor also observed a rack of insulated bowls and cups that the [NAME] confirmed was sanitized by the dish machine. The [NAME] was unable to provide evidence that the dish machine was being checked daily for function, and the last recorded entry on the daily log was 12/31/25. The surveyor observed the Dietary Staff (DS #1) washing pots in the three-compartment sink, who stated he did not check the sanitizer prior to washing pots and pans, and there was no log provided that the sanitizer levels were being checked daily in the three-compartment sink. Interview with the Dish Machine Vendor (DMV) on 2/5/26, revealed that the facility's high temperature's dish machine's booster (aided in increasing hot water temperature) was not functioning properly, and he modified the dish machine to a low temperature dish machine to sanitize with a chemical solution. The DMV was on-site on 2/5/26, and he informed the facility that the chemical solution in the dish machine was expired and not properly sanitizing dishware. The facility's failure to ensure a process was in place for residents' dishware and the cookware used to prepare and serve meals were being properly sanitized in accordance with manufacturer's specifications and standards of food safety practice placed all residents at risk for food borne illness. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 2/5/26, when it was observed dishware and cookware including pots, pans, and utensils were not being properly sanitized. The facility was notified of the IJ on 2/5/26 at 6:20 PM. The facility submitted an acceptable Removal Plan (RP) on 2/6/26 at 12:05 PM. The surveyors verified the implementation of the Removal Plan during the continuation of the on-site survey on 2/6/26. The evidence was as follows:A review of the facility's policy titled, Dishwasher Temperature dated 5/10/24, last revised 6/12/24, revealed: It is the policy of the facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures.Policy Explanation and Compliance Guidelines:All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize all items.Staff shall follow for machine washing and sanitizing instructions.For high temperature dishwashers (heat sanitization):The wash temperature shall be 150-165-degree Fahrenheit (F)The final rinse temperature shall be 180-degree F or above but not to exceed 194-degree F (165 degree F) for stationary rack, single temperature machine) Corrective actions shall be taken for final temperatures below the required final rinse temperatures.For low temperature dishwashers (chemical sanitization):The wash temperature shall be 120-degree FThe sanitizing solution shall be 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse. A review of the facility's policy titled, Dish machine Failure dated 6/22/24, revealed the following procedure: If dishwasher is out of service, the facility will utilize disposable products for meals until dishwasher is in proper working order. If temperature of dishwashing machine reads below 160 [degrees F] for wash/180 degrees [F] for rinse degrees restart the machine if then the temps are not sufficient notify your supervisor. The supervisor will notify Maintenance Department to address the problem.If Maintenance department cannot resolve the problem, Dietary Supervisor will notify the repair service.Until the dishwasher is repaired, meals will be served on disposable plates and plastic utensils/ paper cups plates will be covered with plastic wrap.Dietary Supervisor will notify each unit of the situation. There was no information in the policy regarding converting to a low temperature chemical sanitizer process if the heat booster failed. A review of the Safety Data Sheet for the Low temp Sanitizer that was attached to the dish machine and identified as the sanitizer solution, revealed the following:Signal Word: DangerHazard Statement: Causes eye and skin burns. It causes respiratory tract irritation. Harmful if swallowed.Acute Effects: Eyes: Corrosive to eyes. Causes burns. Inflammation of the eye is characterized by redness watering and itchingInhalation: may give off gas. Vapor or dust that is very irritating or corrosive to the respiratory system. Exposure can cause coughing, chest pain and difficulty in breathing.Ingestion: harmful if swallowed. May cause burns to mouth, throat and stomach. Ingestion may cause burns to mouth, throat and stomach. Ingestion may cause erosion of mucus membranes and perforation of the esophagus and stomach. A review of the Food Service Director Job Description revealed the following:The Food Service Director (FSD) will report to the Administrator.The FSD is responsible for planning, organizing, staffing, directing, coordinating reporting, budgeting, and physical management of the dietary department's employees and equipment in a way that the dietary services of the facility shall be maintained in accordance with established policies. The FSD is directly responsible to the Administrator.Inspect and supervise food preparation and service to ensure that infection control and the highest sanitation standards in all aspects of the dietary department are followed. On 2/5/26 at 8:10 AM, the surveyor toured the Second-floor nursing unit and observed that all the residents were being served their breakfast meal on disposable dishware with disposable utensils. During an interview with the nurse on the floor at that time, she stated that that she could not comment why residents were eating on disposable ware and that the surveyor would have to ask the kitchen staff. On 2/5/26 at 8:20 AM, the surveyor toured the Third-floor nursing unit and observed the residents' breakfast meals were also being served on disposable dishware and utensils. The surveyor also noticed that regular meal trays with washable ware were being utilized for some residents. The surveyor also observed a meal cart with residents' used meal trays located in the hallway near the nursing station. Some of the meal trays contained regular ceramic type dishware and utensils and others had disposable items. On 2/5/26 from 8:30 AM to 9:42 AM, the surveyor conducted an inspection of the kitchen and inquired why the residents were being served on disposable dishware. The observations and interviews revealed the following: The soap dispenser was not working, and a soap bottle was observed on top of the faucet. There were no paper towels nearby to dry hands after washing their hands. The [NAME] stated she was the Acting Food Service Director (FSD) while the FSD was out on leave. The [NAME] stated she had been made responsible for the operations of the kitchen as well as continuing to serve as the cook. The [NAME] stated that the dish machine had been out of service since last week due to the snowstorm, and that the dish machine did not meet the minimum temperature specification of 180 degrees F for the sanitizing agent. The [NAME] reported that the (heat) booster was not working. At that time, the surveyor observed a rack of insulated bowls and cups that had been washed in the dish machine, were located at the drying area of the dish machine. The [NAME] confirmed that the rack of dishware had been cleaned in the dish machine. The [NAME] stated that the Licensed Nursing Home Administrator (LNHA) had been aware of the malfunctioning dish machine. The surveyor asked if the temperature of the dish machine and the chemical concentration were being monitored and recorded. The [NAME] stated the temperature of the dish machine and the chemical concentration had not been recorded. When the surveyor asked the [NAME] to demonstrate how the dish machine chemical would be monitored to ensure if was at the appropriate level, the [NAME] was unable to demonstrate how to check the chemical concentration. When asked if there were any test strips that were used to check the chemical concentrations, the [NAME] was unable to provide a test strip or any method to check the chemical concentrations. The [NAME] stated the facility was using disposable dishware for most residents and continued to use regular dishware for two residents who refused to eat their meals on disposable dishware and used washable utensils. On 2/5/26 at 11:15 AM, the surveyor returned to the kitchen and further inquired about the documented temperature log and sanitizer concentrations for the dish machine and for the three-compartments sink. The [NAME] was unable to provide any documented evidence of temperature or chemical maintenance. The surveyor observed the shelf in the kitchen contained a clipboard with a temperature log for the dish machine. The last entry was dated 12/31/25. The [NAME] was unable to provide a log for the three-compartment sink to ensure that the chemical sanitizer concentration had been monitored and recorded. The [NAME] was unable to locate any test strips to check the sanitizer was at the appropriate concentration level to sanitize. The [NAME] could not elaborate on what the staff's responsibilities were and who was responsible for checking and recording the temperature of the dish machine prior to use on 2/5/26. On 2/5/26 at approximately 11:25 AM, the surveyor observed the Dietary Staff (DS #1) washing pans and pots in the three-compartment sink. The surveyor observed DS #1 washing the pots in the first compartment (wash) sink, then skipped the second compartment (rinse sink) and then submerged the pots and pans directly into the third compartments sink which contained the chemical sanitizer. DS #1 then exited the kitchen before he could be interviewed. A review of the manufacture's guidelines, the first compartment sink was to have soap and water to wash, the second compartment had clean water to rinse off the soap, and the third compartment contained the chemical sanitizing solution. DS #1 did not rinse the pots and pans prior to submerging them into the sanitizing solution. At that time, the surveyor discussed their observations with the Cook, who stated that DS #1 just returned to work and would be in-serviced. No further information was provided. On 2/5/26 at approximately 11:30 AM, during an interview with DS #2, she stated they had been having issues with the dish machine lately. Upon further inquiry, DS #2 stated that since the FSD left, things have been falling apart. DS #2 was also unable to locate the log for the dish machine, or the three-compartment sink. On 2/5/26 at 12:15 PM, the surveyor interviewed the LNHA, who stated the dish machine had been working, and the facility chose to use disposable dishware because of the influx of 40 residents who were evacuated from another facility to this facility on 2/3/26. The LNHA stated that facility decided to serve all residents on disposable dishware. When asked if the facility did not have enough dishware to serve all their current residents when the facility was licensed for 215 beds, the LNHA did not comment. On 2/5/26 at 12:30 PM, the surveyor asked the Cook, in the presence of the LNHA, to run the dish machine and requested that the chemical concentration and temperature be checked in the presence of the surveyor. The [NAME] was unable to operate the dish machine, and she could not locate the test strips to confirm that adequate chemical concentration. The surveyor then asked the [NAME] who was responsible for checking the chemical concentration and temperature prior to using the dish machine, and what mechanism was used. The [NAME] declined to comment. On 2/5/26 at 12:35 PM, the LNHA informed the surveyor that the dish machine temperature did not need to be checked and recorded. It is a low temperature machine. The LNHA did not comment that there were no test strips to check the temperature. The LNHA stated he could not recall the date he was made aware that the dish machine was not working, but he had called the vendor to service the dish machine at that time. The LNHA stated the vendor informed him and confirmed that the dish machine rinse temperature was not reaching the minimum required temperature for sanitation (180 degrees F), and that the dish machine could be utilized as a low temperature dish machine with chemical sanitizer. The LNHA stated that the dish machine had been running as a low temperature dish machine, however, he was unable to confirm when that occurred. The surveyor then asked the LNHA for the work invoice and the date that the work was completed by the vendor. According to the LNHA, the dish machine was operating at a low temperature and the staff were aware. The surveyor asked the LNHA if the New Jersey Department of Health (NJDOH) was made aware that the dish machine had not been working for a week, when they accepted 40 additional residents from an evacuated facility, and the LNHA stated that he did not have to inform the NJDOH since the dish machine had been running as a low temperature dish machine. The LNHA was not aware that the sanitizer also needed to be monitored with the low temperature setting, and neither the LNHA nor the dietary staff knew how to interpret the concentrations. The facility could not provide documentation that the sanitizer concentration had been checked and recorded on the log. The dietary staff were unable to demonstrate the procedure, set up the sanitizer solution, and measure the concentration. On 2/5/26 at 12:48 PM, the surveyor conducted an interview with the Director of Nursing (DON) regarding the dish machine. The DON informed the surveyor that she was informed on Friday night (1/30/26), that the dish machine was not functioning. The DON stated she purchased disposable dishware for the residents on Saturday morning and declined to comment further. The DON informed the surveyor that the LNHA was responsible for the kitchen, and she was not familiar with the operation of the dish machine. On 2/5/26 at 1:00 PM, the surveyor interviewed an unsampled resident who resided on the Third-Floor nursing unit. The unsampled resident informed the surveyor that last Sunday (2/1/26), the facility started using disposable ware. On 2/5/26 at 1:25 PM, the surveyor returned to the kitchen, and again interviewed the LNHA, who was also in the kitchen. The LNHA stated he was informed again at lunch time today, 2/5/26, that the dish machine was not working. The LNHA then informed the dietary staff to serve lunch on disposable dishware until the vendor could repair the dish machine. On 2/5/26 at 2:30 PM, the surveyor returned to the kitchen and observed DS #1 using the three-compartment sink. The surveyor asked DS #1 if he could demonstrate the process for using the three-compartment sink. DS #1 stated I don't check for anything. DS #1 was unable to explain the process and what the solution in each compartment should be. The surveyor then asked DS #1 to provide the log where the sanitizer concentration was recorded, and he could not provide the log and exited the kitchen. The surveyor then approached the [NAME] and inquired about the protocol for the three-compartment sink. The [NAME] could not locate the strips for the three-compartment sink to check the sanitizer concentration. There was no documented evidence that staff had been checking the sanitizer concentration. On 2/5/26 at approximately 2:40 PM, the surveyor contacted the Dish Machine Vendor (DMV) via telephone, who stated the hot water booster for the facility's dish machine was not working since the snowstorm. The DMV stated they could not resolve the issue with the (heat) booster, and he modified the dish machine to operate as a low temperature machine with the chemical sanitizer. The DMV stated he demonstrated and informed the staff at that time that the chemical needed to be checked daily. Upon inquiry, the DMV informed the surveyor the work on the dish machine was completed on 1/28/26, and he will forward the invoice today (2/5/26). A review of the dish machine service Invoice dated 1/28/26, and provided by the facility revealed, The Booster is not working. The Booster is down due to weather blocking the ventilation for the exhaust. The Booster works on gas. Set up the dishwasher on chemical until booster is fixed. On 2/5/26 at 4:30 PM, the surveyor observed the DMV in the kitchen. The invoice confirmed that he completed work on the dish machine on 1/28/26, eight days prior, and informed the staff that the sanitizer for the dish machine needed to be checked daily. A review of the DMV's Invoice dated 2/5/26, provided by the LNHA revealed the following: Description of issue: Low temp chemical not reading.Work performed: Cleaned the spray nozzle of final rinse arms and changed the chemical bottle. It was reading the chemical when I left. Recommended to delime (deliming-prevents Operational Failure as limescale buildup can damage heating elements, pumps, and sensors, leading to machine failure and results in dirty dishes). On 2/6/26 at 8:00 AM, the surveyor entered the kitchen and observed the breakfast meal tray preparation was in progress and all disposable dishware was utilized and placed on non-disposable meal trays. The surveyor also observed that the non-disposable trays were in the three-compartment sink submerged in the sanitizer. At that time, the [NAME] was interviewed regarding the status of the dish machine. The [NAME] stated the dish machine was not being used and confirmed that the DMV came yesterday. The [NAME] stated when the DMV looked at the sanitizer that had was attached to the dish machine, and he informed the [NAME] that it to be appeared expired due to the faded color of the product. The [NAME] continued that the sanitizer was a chlorine-based sanitizing agent so it would lose its potency over time. The [NAME] stated the (heat) booster was still broken which was related to something on the roof and that the dish machine still needed to be delimed. The [NAME] stated that the DMV checked the chemical potency with the test strips, and she stated, it was not registering and the chemical was no good. The [NAME] stated that the DMV did not have another chemical sanitizer to provide the facility at that time. The [NAME] stated at that time, the LNHA instructed the [NAME] to stop using the dish machine. On 2/6/26 at 8:35 AM, the surveyor asked the [NAME] about the meal trays submerged into the sanitizer compartment of the three-compartment sink that the basin of the sink was not filled to the level of the sanitizer per the sticker affixed to the outside of the sink. The surveyor asked her to check the sanitizer solution for appropriate concentration. The [NAME] brought over two chlorine test strip containers and placed a strip into the sanitizer compartment, counted to fifteen, and removed the strip. The strip did not change color when she compared the strip to the corresponding colors on the package. When asked how long the test strip should be submerged, she stated fifteen seconds. The surveyor observed the chlorine strip package had 1 second, and not fifteen. The [NAME] stated, it is not registering, it is no good, and the concentration should be 200 (PPM- parts per million), and she was not familiar with the chemicals. At that time, the surveyor observed a poster affixed to the wall above the three-compartment sink titled Pot & Pan Cleaning & Sanitizing Procedures. The poster was in English and Spanish and revealed: Step 1. fill wash sink with hot water and with the detergent cleaner; 2. Pre-scrape pots and pans and soak for at least five minutes; 3. Scrub all surfaces; 4. Submerge in hot water rinse (2nd sink); 5. Submerge in sanitizer sink for 1-2 minutes. The instructions were to check the sanitizer solution, which was a quaternary solution, per the manufacturer's label and required a different type of test strip to confirm appropriate concentration which was 200-400 PPM. The surveyor brought the poster to the Cook's attention and inquired about the procedures. The [NAME] went to the office and retrieved an unopened package of a quaternary test paper, ripped off a piece, and tested the sanitizer which turned the indicator color between 200 PPM and 400 PPM. There was no thermometer to test the water temperature observed. When asked how long the strip was to be in the solution, the [NAME] stated 10 seconds, not 1 second. The surveyor asked if the concentration has been documented, and the [NAME] stated, there was no log. When the [NAME] was asked what needed to be completed, she stated, we are going to have to Inservice. The surveyor requested any policies or procedures related to the three-compartment sink. The [NAME] stated that other than the poster, she was unaware of any other information related to the three-compartment sink. On 2/6/26 at 9:54 AM, the surveyor interviewed the LNHA regarding the dish machine. The LNHA stated that the machine was not yet delimed and the (heat) booster not functioning was related to a vent on the roof so the dish machine was not being used. The LNHA did not speak to the expired chemical. When asked if the staff had been educated on the process for the three-compartment sink, the LNHA stated that staff were instructed verbally, that they should dip it in (the strip) for 2-3 seconds and pull it out and the concentration should be documented on a log. The surveyor informed the LNHA of the observations above, and the affixed poster, and he said, he will check it out and he confirmed there were no competencies completed with the staff on 2/5/26. An acceptable Removal Plan (RP) was received on 2/6/26 at 12:05 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including; on 2/5/26, the LNHA contacted the DMV. On 2/6/26, the LNHA the [Cook], dietary cooks and dietary aides regarding kitchen sanitation, to ensure proper handling of pots, pans, cutlery, and dishware. The LNHA re-educated the dietary staff on how to properly use the dish machine and the three-compartment sink to ensure washing, rinsing, and sanitizing was correctly done, in the correct order, with proper temperatures and sanitizing. The LNHA re-educated the dietary staff on the importance of documenting sanitizer tests results on flow sheets with each use. On 2/6/26 at 10:00 AM, return demonstrations/ competencies were completed by the pot washers and observed by the LNHA and interim FSD (the Cook). All dietary staff will be re-educated and required to complete competencies and return demonstrations prior to working. The LNHA re-educated the [Cook] and dietary staff regarding the use of disposables of paper goods in the event the dishwasher is out of service. All necessary dishware was immediately re-sanitized, and signs in English and Spanish with instructions for sanitizer use was posted by the dish machine and three-compartment sink. The survey team verified the implementation of the Removal Plan on-site and determined the immediacy was removed as of 2/6/26 of 2:12 PM. NJAC 8:39-17.2 (g)

Based on observation, interview and document review, it was determined that the facility failed to ensure the dietary staff were competent to maintain the kitchen in a manner to ensure that appropriate sanitation measures were in place to prevent potential food borne illness or potential exposure from hazardous chemicals. This deficient practice had the potential to affect all residents and was evidenced by the following:On 2/5/26 at 8:10 AM, the surveyor toured the Second-floor nursing unit and observed that all the residents were being served their breakfast meal on disposable dishware with disposable utensils. During an interview with the Nurse on the floor at that time, she stated that that she could not comment why residents were eating on disposable ware and that the surveyor would have to ask the kitchen staff. On 2/5/26 at 8:20 AM, the surveyor toured the Third-floor nursing unit and observed the residents' breakfast meals were also being served on disposable dishware and utensils. The surveyor also noticed that regular meal trays with washable ware were being utilized for some residents. The surveyor also observed a meal cart with residents' used meal trays located in the hallway near the nursing station. Some of the meal trays contained regular ceramic type dishware and utensils and others had disposable items. On 2/5/26 between 8:30 AM and 9:42 AM, the surveyor toured the kitchen and inquired why the residents were being served on disposable dishware. The Cook, who was the Acting Food Service Director (FSD), informed the surveyor that the dish machine had not been functioning for one week and the facility had been using disposable dishware throughout the facility. The surveyor observed a rack which contained insulated burgundy colored bowls and cups. The [NAME] stated that those items were washed in the dish machine, although it was not functioning, but that the Licensed Nursing Home Administrator (LNHA) was aware. On 2/5/26 at 11:25 AM, the surveyor observed a Dietary Staff (DS #1) washing pans and pots in the three-compartment sink (a manual sink used in commercial kitchens to wash, rinse, and sanitize dishes). The surveyor observed DS #1 scraping off the food off the pots and pans, and then he washed the pots and pans in the first compartment sink, skipped the second compartment sink, and then submerged the pan and pots in the third compartment sink. DS #1 exited the kitchen before he could be interviewed. On 2/5/26 at 12:30 PM, the surveyor interviewed the LNHA and inquired if the New Jersey Department of Health (NJDOH) was informed that the dish machine had been out of service for one week. The LNHA stated, no he did not have to inform NJDOH as the dish machine was operating now as a low temperature dish machine. In the presence of the LNHA, the surveyor asked the [NAME] to run the dish machine. The [NAME] could not operate the dish machine. The LNHA could also not operate the dish machine. There were also no test strips to check that the chemical concentrations were adequate. The surveyor then asked for the log the facility used to monitor the function of the dish machine. The [NAME] could not locate the log. The [NAME] was unable to identify who checked the chemical sanitizer that morning. On 2/5/25 at 12:35 PM, the LNHA stated that the dish machine temperature did not need to be checked, and stated it is a low temperature machine. The surveyor asked him to check the chemical concentration, and the LNHA could not locate the test strips. The surveyor then observed a clipboard on a metal shelf in the kitchen. The surveyor reviewed the dish machine log, and the last entry was recorded on 12/31/25. On 2/5/26 at 2:30 PM, the surveyor returned to the kitchen and observed DS #1 operating the three-compartment sink again. The surveyor asked DS #1 to explain the process to operate the three-compartment sink. DS #1 stated, I do not have to check anything. The surveyor then asked him to check the sanitizer in the third compartment sink. DS #1 could not check the sanitizer, there were no test strips available, and he then exited the kitchen. On 2/5/26 at 2:35 PM, the surveyor approached the [NAME] and inquired about the protocol for the three-compartment sink. The [NAME] was unable to provide a log and there were no test strips to check the sanitizer concentration. On 2/5/26 at 2:40 PM, the surveyor called the Dish Machine Vendor (DMV) and inquired about the work order for the dish machine. The DMV informed the surveyor that he was at the facility on 1/28/26, to check the dish machine. The DMV stated that the dish machine could not reach the required temperature because of the problem with the roof exhaust system; and the heat booster was not working. The DMV stated that he then set the machine to operate at a low temperature and with a chemical sanitizer. The DMV stated that he recommended that staff checked the chemical sanitizer regularly to ensure adequate sanitation. On 2/5/26 at 4:30 PM, the surveyor observed the DMV in the kitchen. The invoice provided confirmed that he worked on the dish machine on 1/28/26, and advised the dietary staff to check the sanitizer daily. The facility was unable to provide documentation that the sanitizer had been checked. On 2/6/26 at 8:00 AM, the surveyor entered the kitchen and observed the breakfast meal tray preparation was in progress and all disposable dishware was utilized and placed on non-disposable meal trays. The surveyor also observed that the non-disposable trays were in the three-compartment sink submerged in the sanitizer. At that time, the [NAME] was interviewed regarding the status of the dish machine. The [NAME] stated the dish machine was not being used and confirmed that the DMV came yesterday. The [NAME] stated when the DMV looked at the sanitizer that had was attached to the dish machine, and he informed the [NAME] that it to be appeared expired due to the faded color of the product. The [NAME] continued that the sanitizer was a chlorine-based sanitizing agent so it would lose its potency over time. The [NAME] stated the (heat) booster was still broken which was related to something on the roof and that the dish machine still needed to be delimed. The [NAME] stated that the DMV checked the chemical potency with the test strips, and she stated, it was not registering and the chemical was no good. The [NAME] stated that the DMV did not have another chemical sanitizer to provide the facility at that time. The [NAME] stated at that time, the LNHA instructed the [NAME] to stop using the dish machine. On 2/6/26 at 8:35 AM, the surveyor asked the [NAME] about the meal trays submerged into the sanitizer compartment of the three-compartment sink that the basin of the sink was not filled to the level of the sanitizer per the sticker affixed to the outside of the sink. The surveyor asked her to check the sanitizer solution for appropriate concentration. The [NAME] brought over two chlorine test strip containers and placed a strip into the sanitizer compartment, counted to fifteen, and removed the strip. The strip did not change color when she compared the strip to the corresponding colors on the package. When asked how long the test strip should be submerged, she stated fifteen seconds. The surveyor observed the chlorine strip package had 1 second, and not fifteen. The [NAME] stated, it is not registering, it is no good, and the concentration should be 200 (PPM- parts per million), and she was not familiar with the chemicals. At that time, the surveyor observed a poster affixed to the wall above the three-compartment sink titled Pot & Pan Cleaning & Sanitizing Procedures. The poster was in English and Spanish and revealed: Step 1. fill wash sink with hot water and with the detergent cleaner; 2. Pre-scrape pots and pans and soak for at least five minutes; 3. Scrub all surfaces; 4. Submerge in hot water rinse (2nd sink); 5. Submerge in sanitizer sink for 1-2 minutes. The instructions were to check the sanitizer solution, which was a quaternary solution, per the manufacturer's label and required a different type of test strip to confirm appropriate concentration which was 200-400 PPM. The surveyor brought the poster to the Cook's attention and inquired about the procedures. The [NAME] went to the office and retrieved an unopened package of a quaternary test paper, ripped off a piece, and tested the sanitizer which turned the indicator color between 200 PPM and 400 PPM. There was no thermometer to test the water temperature observed. When asked how long the strip was to be in the solution, the [NAME] stated 10 seconds, not 1 second. The surveyor asked if the concentration has been documented, and the [NAME] stated, there was no log. When the [NAME] was asked what needed to be completed, she stated, we are going to have to Inservice. The surveyor requested any policies or procedures related to the three-compartment sink. The [NAME] stated that other than the poster, she was unaware of any other information related to the three-compartment sink. On 2/6/26 at 9:54 AM, the surveyor interviewed the LNHA regarding the dish machine. The LNHA stated that the machine was not yet delimed and the (heat) booster not functioning was related to a vent on the roof so the dish machine was not being used. The LNHA did not speak to the expired chemical. When asked if the staff had been educated on the process for the three-compartment sink, the LNHA stated that staff were instructed verbally, that they should dip it in (the strip) for 2-3 seconds and pull it out and the concentration should be documented on a log. The surveyor informed the LNHA of the observations above, and the affixed poster, and he said, he will check it out and he confirmed there were no competencies completed with the staff on 2/5/26. The facility was unable to provide documentation that the chemical sanitizer had been checked every shift prior to use the dish machine. There was no log for the three-compartment sink. A review of the facility's policy titled, Dishwasher Temperature dated 5/10/24, last revised 6/12/24, revealed: It is the policy of the facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures.Policy Explanation and Compliance Guidelines:All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize all items.Staff shall follow for machine washing and sanitizing instructions.For high temperature dishwashers (heat sanitization):The wash temperature shall be 150-165-degree Fahrenheit (F)The final rinse temperature shall be 180-degree F or above but not to exceed 194-degree F (165 degree F) for stationary rack, single temperature machine) Corrective actions shall be taken for final temperatures below the required final rinse temperatures.For low temperature dishwashers (chemical sanitization):The wash temperature shall be 120-degree FThe sanitizing solution shall be 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse. A review of the facility's policy titled, Dish machine Failure dated 6/22/24, revealed the following procedure: If dishwasher is out of service, the facility will utilize disposable products for meals until dishwasher is in proper working order. If temperature of dishwashing machine reads below 160 [degrees F] for wash/180 degrees [F] for rinse degrees restart the machine if then the temps are not sufficient notify your supervisor. The supervisor will notify Maintenance Department to address the problem.If Maintenance department cannot resolve the problem, Dietary Supervisor will notify the repair service.Until the dishwasher is repaired, meals will be served on disposable plates and plastic utensils/ paper cups plates will be covered with plastic wrap.Dietary Supervisor will notify each unit of the situation. There was no information in the policy regarding converting to a low temperature chemical sanitizer process if the heat booster failed. A review of the Safety Data Sheet for the Low temp Sanitizer that was attached to the dish machine and identified as the sanitizer solution, revealed the following:Signal Word: DangerHazard Statement: Causes eye and skin burns. It causes respiratory tract irritation. Harmful if swallowed.Acute Effects: Eyes: Corrosive to eyes. Causes burns. Inflammation of the eye is characterized by redness watering and itchingInhalation: may give off gas. Vapor or dust that is very irritating or corrosive to the respiratory system. Exposure can cause coughing, chest pain and difficulty in breathing.Ingestion: harmful if swallowed. May cause burns to mouth, throat and stomach. Ingestion may cause burns to mouth, throat and stomach. Ingestion may cause erosion of mucus membranes and perforation of the esophagus and stomach. A review of the Food Service Director Job Description revealed the following:The Food Service Director (FSD) will report to the Administrator.The FSD is responsible for planning, organizing, staffing, directing, coordinating reporting, budgeting, and physical management of the dietary department's employees and equipment in a way that the dietary services of the facility shall be maintained in accordance with established policies. The FSD is directly responsible to the Administrator.Inspect and supervise food preparation and service to ensure that infection control and the highest sanitation standards in all aspects of the dietary department are followed. NJAC 8:39-17.1 (a)

Based on interviews, record review, and review of pertinent facility documents on 2/5/26, in the presence of the Maintenance Assistant, it was determined that the facility failed to ensure that residents were provided with direct communication system in which residents' calls were received and answered by staff. This deficient practice was identified for 2 of 40 residents reviewed (Resident #1 and Resident #2), and was evidenced by the following: According to the admission Record (AR), Resident #1 was transferred to the facility on 2/3/26 with diagnoses which included but were not limited to: Sciatica left side, Depression, Parkinson's disease and peripheral vascular disease. Resident #1 was dependent on staff for care. Resident #2 was transferred also to the facility on 2/3/26 and had diagnoses of bipolar disorder, hyperkalemia and generalized anxiety disorder. According to the Resident they required minimum assistance with care. On 2/5/26 around 10:10 AM, during the facility tour, Resident #1 asked Surveyor #1 to call the nurse. The surveyor asked the resident to activate the call bell. At that time the surveyor observed that the resident did not have a functioning call bell.On 2/5/26 at 10:30 AM, Surveyor #1 shared the above concern with Surveyor #2.On 2/5/26 at 10:45 AM both surveyors returned to the room and observed that the residents did not have a functioning call bell.On 2/5/26 at 10:50 AM, Surveyor #2 interviewed Resident #1 who stated that they were transferred from another facility on 2/3/26 and had not had a call device since the transfer. When inquired how they would call the staff, Resident #1 stated that the roommate would go to the hallway and call for assistance. Resident #2 shared the room with Resident #1. During an interview with surveyor #2, Resident #2 stated that she was able to manage mostly without assistance from staff. Resident #2 further stated that Resident #1 could not get out of bed and needed staff assistance. Resident #2 confirmed that she had to get out of bed and shouted for the staff to assist Resident #1.On 2/5/26 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) regarding the residents not having a functional call device. The DON informed the surveyor that she was aware that the call device in the room (room [ROOM NUMBER]) was not functioning. She audited the room for items that were needed prior to transfer and asked the supervisor to provide the residents with a manual call device. She was made aware only this morning after the surveyor's tour that neither was provided with a manual call device. A review of the facility's policy, titled, Call bell Use Responsibility dated 12/25 revealed the following: PurposeTo ensure residents have timely access to assistance and that call bells are answered promptly to promote resident safety, dignity, and quality of care.Policy StatementAll residents will always have access to a functioning call bell system. Staff must respond to call bells without unreasonable delay and in accordance with resident's assessed needs. Failure to ensure access or timely response may place residents at risk. NJAC 8:39-31.2(e), 31.8(c)9

Based on observations and interviews on 2/5/26, in the presence of the facility's Licensed Nursing Home Administrator (LNHA), it was determined that the facility failed to provide privacy curtains in resident rooms to ensure each resident was afforded full visual privacy. This deficient practice had the potential to affect all eight residents who resided in the rooms (4 rooms). The deficient practice was evidenced by the following:On 2/5/26, between 9:00 AM to 10:45AM, the surveyor toured the 5th floor of the facility where eight out of 40 residents were transferred from another facility. In the presence of the Licensed Nursing Home Administrator (LNHA), the surveyor observed that there were no privacy curtains for residents in rooms 511A, 514A, 517A, and 519A.On 2/5/26 at 12:55 PM, the surveyor interviewed the LNHA and inquired why those residents did not have privacy curtains in their rooms. The LNHA stated the maintenance staff forgot to install privacy curtains in those rooms.The facility's Administrator was informed of the deficient practice at 3:28 PM during the Life Safety Code exit conference.A review of the policy titled Residents Rights provided by the LNHA revealed the following:Policy StatementEmployees should treat all residents with kindness and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility; these rights include the residents' right to privacy and confidentiality. NJAC 8:39-31.2(e), 31.8 (c) 5

Complaint # 2673152 Based on observation, interview, and record review, it was determined that the facility failed to ensure adequate supervision was provided to a cognitively impaired resident with a history of being restless and impulsive and a history of falls, who sustained a fracture during an unreported episode of restlessness. On 11/18/25, Resident #114 was grimacing in pain and guarding their left arm. An x-ray revealed an acute non-displaced fracture of the left clavicle (broken collarbone), and it was determined that the facility did not implement care plan interventions prior to the discovery of the fracture when the resident was restless. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #114). The evidence was as follows: A review of the facility's Policy and Protocol for Incident Reporting, last revised 11/2025, indicated the following: The facility is committed to keeping all resident's safe, maintain highest resident function and adhere to Federal and State regulations. An Accident and Incident report will be completed and investigated by the management team. The Interdisciplinary Team will discuss and attempt to determine the root cause and care plan interventions decided by the team will be implemented. Trending and tracking incidents will be done by the team and reported to the quality council to discover cause and/ or trends through this process.The Administrator and/ or Director of Nursing will process all Reportable Events to the advocacy agencies required by state and federal regulations.The Director of Nursing or the Licensed Nursing Home Administrator will review incidents with the Medical Director. On 12/02/25 at 11:44 AM, the surveyor toured the nursing unit and observed Resident #114 seated in a recliner chair in the hallway near the nursing station. Resident #114 was confused and could not be interviewed. On 12/04/25 at 9:20 AM, the surveyor observed Resident #114 seated in a recliner chair in the hallway by the nursing station with their eyes closed. The surveyor observed the resident with a sling (a flexible strap or belt used in the form of a loop to support or raise a weight) to their left arm. The resident had a tray table in front of the recliner chair, and staff were noted entering and leaving the nursing station and ambulating in the hallway. There was no staff in attendance at the nursing station, and three other residents were noted in the dayroom. On 12/05/25 at 12:38 PM, the surveyor observed Resident #114 in the hallway eating lunch. During a conversation with the resident, it was noted that the resident was very confused and could not answer questions appropriately. On 12/05/25 at 12:50 PM, the surveyor reviewed Resident #114's medical record. A review of the admission Record face sheet (an admission summary), reflected that Resident #114 was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity without behavioral disturbance, cognitive communication deficit, muscle weakness, unspecified abnormalities of gait and mobility, and displaced fracture of lateral end of left clavicle (onset 11/19/25). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/01/25, reflected that Resident #114 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. The facility used the Morse Fall Scale (Fall Risk Assessment) to assess Resident #114's risk of falling to implement preventive measures before a fall occurred. Resident #114 received a score of 75 on admission. According to the Fall Risk Assessment, 0-24 points were no risk; 25-50 points were low risk; and greater than (>) 50 points were high risk. A review of Resident #114's comprehensive care plan (CP) provided by the facility on 12/05/25, revealed a focus area initiated on 07/11/25, that [Resident #114] is at high risk for falls related to poor safety awareness, unsteady gait. The goal initiated on 07/11/25, was that Resident #114 will suffer no fall related injury. Another goal initiated on 08/12/25, was that Resident #114 will be safe. The interventions included Resident #114 will continue to receive rehabilitation for strengthening and energy conservation, initiated 07/23/25. Resident #114 had a floor mat in place when in bed for safety, initiated 07/11/25. Resident #114's bed to be kept in lower position, initiated 07/11/25. If Resident #114 has increased restlessness in bed at night, staff to get them out of bed in recliner chair in view of staff at the nursing station, initiated 07/14/25. An additional review of the CP included a focus area initiated 07/11/25, for altered mental status with declining in functional status and progressive dementia. [Resident #114] has period of restlessness and agitation. Confusion leads to agitation. The goal was for Resident #114 to have less episodes of agitation. The interventions were to anticipate Resident #114's needs; toileting needs, positioning, and pain. The following incidents were documented in the Progress Notes: The surveyor reviewed the medical record which revealed that Resident #114 had four falls from 07/10/25 through 10/25/25, that were documented in the Progress Notes. All four falls occurred in the resident's room between 4:43 PM and 12:38 AM. The most recent incidents were as follows: A nursing Progress Note dated 07/11/25 at 11:49 PM, revealed Resident #114 sustained a fall in their room. The resident was unable to provide any explanation regarding the fall. Resident #114 was transferred to bed with three-persons assistance, and the resident remained restless. A review of the nursing Progress Note dated 07/13/25 at 4:43 PM, revealed that Resident #114 was found on the floor of their room by a Certified Nursing Aide (CNA). The resident stated they were trying to get someone. Resident #114 reported back and hip pain, and an ordered x-ray was negative for fracture. A Post Fall Risk Assessment was completed, and the resident scored a 75 (high risk). After the fall on 7/13/25, the CP was revised, and the intervention to have Resident #114 out of bed and placed in the recliner chair at the nursing station during the night if the resident was restless was initiated on 07/14/25. A nursing Progress Note dated 07/20/25 at 12:38 AM, revealed Resident #114 sustained a fall in their room which resulted in a hematoma (collection of blood that gathers outside of blood vessels, forming a lump or mass) and abrasions to the back of their head. A Fall Risk Assessment was completed, and the resident scored a 75 (high risk). A nursing Progress Note dated 08/20/25 at 7:49 PM, that Resident #114 was found on the floor in the room in front of the television stand. The resident had blood on their clothes, and upon assessment, two skin tears were observed to their left elbow and one skin tear to their upper back. The resident denied discomfort or hitting their head. A Psychiatrist Consultation dated 08/22/25, after the fall, reflected the following: In light of [the resident's] current symptoms and behavioral profile, [the resident's] Ativan (anti-anxiety medication) regimen was adjusted from 2 [milligrams (mg)] at bedtime to 1 mg three times daily. The patient and family agreed with the plan, and the case was reviewed with nursing and unit leadership to support continued monitoring and structured care. A nursing Progress Note dated 10/25/25 at 11:00 PM, revealed Resident #114 was found on the floor in their room, and sustained two skin tears to the back. A Fall Risk Assessment was completed, and the resident scored a 65 (high risk). A nursing Progress Note indicated on 11/18/25, at approximately 8:00 AM, during morning care, Resident #114 was observed in bed guarding their left arm and grimacing upon touching their left arm. The physician was notified and ordered an x-ray of the left arm that was positive for an acute non-displaced left clavicle fracture. The recommendation was an orthopedic evaluation and transfer to the emergency room (ER) for further management and potential intervention. Resident #114 was transferred to the ER on [DATE] at 9:45 PM, and returned on 11/19/25 at 2:27 AM. Upon return, Resident #114 was complaining of pain and medicated with Ibuprofen 800 mg (non-steroid analgesic). A skin assessment was done upon return from the ER which revealed redness to left side of the resident's neck and shoulder. On 12/05/25 at 11:50 AM, the surveyor reviewed the facility investigation provided by the Director of Nursing (DON) dated 11/17/25, along with statements from all the caregivers who cared for the resident from 11/17/25 to 11/18/25. The investigation included a Reportable Event Record (RER) with a date of event 11/18/25 at 9:45 PM. The facility coded the incident as a Significant Event with an injury and the narrative revealed: during morning care, the aide noted the resident had discomfort in their left shoulder. The aide was able to wash and dress the resident, but the discomfort was a new finding by the nurse aide from the previous day. The aide reported it to the nurse and the clinical manager. The Registered Nurse assessed Resident #114 and there was no bruising or edema at site, but discomfort when touched. The physician was called and an order for Motrin (an anti-inflammatory) was ordered and provided. An x-ray was ordered, completed and reported as a fracture to the left clavicle non-displaced. The resident was sent to the emergency room and fracture was confirmed. The resident was returned to the facility with recommendations for a sling. Upon return an investigation was initiated. The statements attached to the investigation included the following: A statement from the Certified Nurse Aide (CNA #3) who worked the 11:00 PM-7:00 AM (11-7) shift on 11/17/25, documented that Resident #114 was restless for periods of time during my shift. I also seen them reaching and turning with their left arm. They were lying on their left arm for periods of time as well as also turns all ways in bed as they do in their chair. [Resident #114] did not yell or make any faces like they were in pain, and I confronted [Resident #114], and they eventually went to sleep. The Licensed Practical Nurse (LPN #1) who was assigned to Resident #114 during the 11-7 shift documented: Received [Resident #114] in bed, awake, talking out loud to self. No complaints of pain/discomfort observed or verbalized. Incontinence care rendered which consisted of resident having to be turned on right and left side. No issues reported or observed by CNA. Medication administered with no issues observed by this nurse. A telephone interview with LPN #2 that was documented by the Registered Nurse/Unit Manager (RN/UM) revealed that LPN #2 worked the 3:00 PM to 11:00 PM (3-11) shift on 11/17/25, and cared for Resident #114. LPN #2 stated resident was asleep at 10:00 PM. All medications were taken without difficulty. Very talkative and was in recliner chair in front of nursing station prior to bedtime. The Registered Nurse (RN #1) documented a statement dated the 11/18/25, incident that revealed the floor nurse informed her that Resident #114 was grimacing upon touching the left shoulder. Upon assessment, the resident verbalized pain upon touch. There was no redness, no bruise, no swelling. There was limited left upper extremity range of motion, and the resident was guarding their left shoulder. A STAT (immediate) x-ray was ordered by the physician. The Incident Summation Report revealed an Investigation and Conclusion: The 11/18/25, routine CNA reported a change to Resident #114, and it was determined that the injury occurred on the 11-7 shift on 11/17/25. CNA #3 reported that the resident had some periods of restlessness as also reported by the 3-11 shift while the resident was in the recliner, and although not new behavior, it did seem more pronounced. On 12/09/25 at 8:34 AM, the surveyor interviewed the RN/UM regarding Resident #114's care. The RN/UM stated that Resident #114 was confused, could stand and pivot, and always required assistance with care (extensive to dependent assistance). The RN/UM stated the resident was admitted to the facility with a diagnosis of dementia and could not execute any transfer without staff assistance. On 12/09/25 at 9:54 AM, the surveyor interviewed CNA #1, who was assigned to Resident #114 during the 7:00 AM to 3:00 PM (7-3) shift on 11/17/25. CNA #1 stated she provided care to the resident and brought the resident to the nursing station based on their plan of care. CNA #1 added that the resident was placed at the nursing station to prevent falls. On 12/09/25 at 10:15 AM, the surveyor conducted an interview with CNA #2, who was assigned to the resident during the 3-11 shift on 11/17/25. CNA #2 stated the resident was calm and did not display any signs of agitation during that shift. CNA #2 stated she transferred Resident #114 to bed with the 3-11 nurse at 9:00 PM, and she made her last rounds at 11:00 PM, and the resident was resting. On 12/09/25 at 10:35 AM, the surveyor interviewed CNA #3, who cared for Resident #114 during the 11:00 PM to 7:00 AM (11-7) shift on 11/17/25 (through 11/18/25). CNA #3 stated that Resident #114 was restless from the beginning of her shift (approximately 11:00 PM), when she made her first rounds, until 4:00 AM. The surveyor asked her how she handled the resident's behavior during the night, and CNA #3 stated that she kept going to the room to check on the resident. CNA #3 stated that she informed the night nurse of the behavior, and the behavior was entered on the plan of care. The surveyor then asked CNA #3 to provide the documentation on the plan of care where the behavior was documented, and she could not access or provide the documentation. On 12/09/25 at 11:05 AM, the surveyor then interviewed CNA #3 in the presence of the RN/UM, and CNA #3 restated that Resident #114 was restless from the beginning of the shift, (11:00 PM) until 4:00 AM, and that she reported it to the nurse. CNA #3 stated, any change in behavior must be documented. The RN/UM asked CNA #3 where she entered the documentation, and she stated in the plan of care. The RN/UM at that time stated that the behavior could not be documented in the plan of care. CNA # 3 changed her story and stated that the nurse documented the behavior. At that time, the surveyor reviewed the progress notes with the RN/UM, and they were unable to identify where the behavior was documented. The surveyor also reviewed the 24 hour report with the RN/UM and there was no documentation which reflected that Resident #114 was restless until 4:00 AM in the morning. The surveyor then asked CNA #3 if she was aware that the resident was to be transferred into the recliner chair and placed at the nursing station if they were restless at night. CNA #3 stated yes, but sometimes the resident refused to get out of the bed. In the presence of the RN/UM, the surveyor asked CNA #3 if Resident #114 refused to be transferred out of the bed into the recliner chair on 11/17/25, during the night shift when the resident displayed restless behaviors, and CNA #3 stated, No. On 12/09/25 at 3:56 PM, the surveyor interviewed LPN #1 who worked on 11/17/25, during the 11-7 shift. LPN #1 confirmed that the resident was awake during her first rounding at 11:00 PM, and did not report any pain. LPN #1 stated she medicated the resident at 6:00 AM, with Ativan 1 mg and Resident #114 was not in any distress. LPN #1 denied that CNA #3 informed her that the resident was restless all shift until 4:00 AM, as stated by CNA #3 twice. When asked what should have been done for the resident if they were restless during the night shift, LPN #1 stated there was an intervention on the care plan to transfer the resident into to the recliner chair and place them in staff's view at the nursing station. LPN #1 stated that Resident #114 was a high fall risk, and if she was made aware, she would have gone to the room, assessed the resident, attempted to calm them, and called the physician to request if the resident could be offered the 6:00 AM dose of Ativan earlier. On 12/10/2025 at 10:44 AM, the surveyor re-interviewed the RN/UM regarding the interviews conducted with both CNA #3 and LPN #1. The RN/UM stated that the 3-11 nurse (LPN #1) was very credible. The RN/UM stated if the resident was restless until 4:00 AM, CNA #3 should have transferred the resident into the recliner chair and placed the resident at the nursing station for supervision. The RN/UM added, When [Resident #114] was at the nursing station, they were much calmer, they loved to interact with the staff at the nursing station. On 12/10/25 at 11:35 AM, the surveyor discussed the above concerns with the DON and inquired about the investigation. The DON stated that she interviewed CNA #3, who stated that the resident was restless, and she was able to comfort the resident. The DON further stated that she was not aware that Resident #114 was restless until 4:00 AM. The DON stated that CNA #3 should have followed the care plan which was to transfer the resident into the recliner chair and place the resident at the nursing station where the resident could be closely monitored. A review of the summary of the investigation included the following: the Interdisciplinary team met and reviewed the incident. There was no evidence of abuse or mistreatment. The resident's diagnosis of anxiety which presented with restlessness on the 11-7 shift; and their protein deficiency and their history of osteoporosis all played a role in this injury. Ongoing staff education on how to observe and report signs of resident changes, how to approach and calm residents with anxiety and how to reposition residents was given. NJAC: 8:39-27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to ensure a system was in ensure annual competency evaluations were completed for Certified Nurse Aides (CNAs) and they were educated based on the outcome, and a system was in place to ensure CNAs were provided with at least 12 hours of education per their annual date of employment. The deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the amount of hourly training and/or performance evaluations for the requested CNAs. The DON could only provide checklists for the CNAs without any specifics related to the amount of training. On 12/11/25 at 10:15 AM, the surveyor interviewed the Assistant Director of Nursing who stated that she has seen the facility assessment book but has not gone through it. When asked if she was aware that there was education requirements in the facility assessment, the ADON responded, yes. The ADON further confirmed that there is not a person in the facility dedicated to check the competency of the staff providing care.On 12/11/25 at 11:55 AM, the survey team interviewed the Licensed Nursing Home Administrator, who acknowledged that the education in the building done was not being correctly and that there are no competencies being completed. A review of the facility's Policy and Procedure In-service Nursing Aid Training, dated December 2024, the policy revealed: [ ] methods used used to provide training may include in-person instruction, webinars, supervised practical training, computer based training, self-directed training, mentoring, and/or coaching. [.] Supervised practical setting training means training in a setting in which instruction and oversight are provided by a person who has relevant instruction education and/pr experience specific to the subject of the training being provided. NJAC 8:39-33.4

Based on interview, record review and review of pertinent facility documentation it was determined the facility failed to have a process in place to ensure that resident personal needs account (PNA) funds were available for distribution the same day as requested by the residents seven days per week. This deficient practice was identified for 3 of 3 residents (Resident #31, #40 and #130) who maintained PNA funds and attended a Resident Council (RC) group meeting.The deficient practice was evidenced by the following:Complaint #2595473On 12/04/25 at 11:04 AM, the surveyor conducted RC with four alert and oriented residents. During the RC meeting, three of three residents stated that they only had access to their money Monday through Friday, and every other weekend. All three residents confirmed there was only one staff member that had access to their PNA money, and she only worked every other weekend. During the weekdays the residents stated that the Activity Director (AD) distributed the PNA money when she was available. All three residents confirmed that there were no published hours when she was available, and she was hard to find.The surveyor reviewed the Electronic Medical Record (EMR) for Resident #31. A review of the resident's admission Record (AR) reflected that the resident was admitted to the facility with diagnoses which included but are not limited to Hypertension (HTN-high blood pressure) and Type 2 Diabetes Mellitus (DM-high blood sugar), Major depressive disorder and anxiety disorder.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 11/09/25, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident had intact cognition. The surveyor reviewed the EMR for Resident #40. A review of the resident's AR reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to; Hypertension (high blood pressure), Major depressive disorder (mental health condition), anxiety disorder (mental health condition) and Asthma (chronic condition that affects the airway).A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 13 out of 15, which indicated an intact cognition. The surveyor reviewed the EMR for Resident #130. A review of the resident's AR reflected that the resident was initially admitted to the facility with diagnoses which included but not limited to: Malignant neoplasm of the prostate (prostate cancer), and Hypertension. A review of the most recent admission MDS dated [DATE], reflected a BIMS score of 14 out of 15, which indicated an intact cognition. On 12/04/25 at 10:00 AM, the surveyor interviewed the AD, who stated she was responsible for distributing the PNA funds to the residents Monday through Friday. She stated that PNA money was available seven days a week and the receptionists distributed the PNA money on the weekends.On 12/04/25 at 12:33 PM, the surveyor interviewed the Receptionist (R #1). She stated that she worked every other weekend, and she distributed PNA money on the weekends that she worked. R #1 stated that she worked the prior weekend, 11/29/25 & 11/30/25. She stated the receptionist (R #2) who worked the opposite weekend did not distribute the PNA funds because she was not trained. On 12/09/25 at 1:00 PM, R #1 informed the surveyor that after surveyor inquiry, R #2, was now being trained to distribute the PNA funds to the residents on the weekends she worked.On 12/10/25 at 1:10 PM, the surveyor interviewed R #2. She stated that she worked the opposite weekend of R #1. R #2 stated that she started working at the facility one month ago, and confirmed that she has not been trained regarding distributing PNA funds to the residents. She further stated, hopefully I will be trained next week.On 12/11/25 at 1:21 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional DON and the survey team. The LNHA acknowledged that the PNA was not available seven days per week. No further information was provided. A review of the facility's PNA receipts revealed that there were no receipts available for any resident withdrawals for all weekends in June, July and September 2025. The receipts provided by the AD for August, October and November 2025 had receipts for every other weekend (the weekend that R #1 worked). The facility was unable to provide any documentation that resident PNA funds were available for residents seven days per week. NJAC 8:39-4.1(a)10

Based on interview and review of pertinent facility provided documents it was determined that the facility failed to a) ensure that within 30 days of a resident's death, the resident's funds, and a final accounting of those funds were conveyed to the resident's responsible party for 2 of 2 expired residents reviewed (Resident #163 and Resident # 164) Personal Needs Account (PNA) accounts; and b) ensure the resident or resident's responsible party was notified that the funds in their PNA account reached the $2,000 maximum Supplemental Security Income (SSI) or $200 less of the maximum which could jeopardize their eligibility for SSI or Medicaid. This was identified for 5 of 5 (Resident #59, Resident # 68, Resident # 69, Resident # 101, Resident #136 and Resident #165) PNA accounts reviewed. The deficient practice was evidenced by the following:On [DATE] at 10:23 AM, the surveyor reviewed the residents' Funds Listing Report (Personal Needs Account-PNA) as of [DATE] and electronic medical records which revealed the following: -Resident #163's PNA reflected a PNA balance of $2,049.16, this resident had expired at the facility in February 2024 (22 months prior). -Resident #164 PNA reflected a balance of $2,548.15, this resident had expired at the facility in [DATE] (8 months prior). A further review of the facility provided PNA account of Resident Funds Listing Report, revealed four of the balances were over the $2,000 SSI maximum and two of the balances were over the $1,800 which was $200.00 less than the $2,000 maximum. The account balances were as follows:Resident #59 had an account balance of $2,240.44.Resident #69 had an account balance of $2,198.00.Resident #68 had an account balance of $1,908.86.Resident #101 had an account balance of $1,920.41.Resident #136 had an account balance of $2,102.56.Resident #165 had an account balance of $2,599.40.On [DATE] at 10:40 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the remote business office Biller about the PNA statements for the two expired residents with remaining PNA balances. The Biller stated when a resident expired the account should have been closed, and the following should have occurred. 1. The money should have been taken back from the state, or 2. The facility should have written a check to the State. The Biller stated she did not know why the check was not sent back to the State. The Biller stated it was my error I should have emailed the office to cut a check, and I did not do that, I messed up on that one. On [DATE] at 11:11 AM, the surveyor again interviewed the Biller regarding the PNA account balances for the current residents and asked what was the process to ensure that residents did not exceed their maximum amount which could jeopardize their ability to continue to participate in the Medicaid program. The Biller stated that she emailed the facility a list of residents who were accumulating PNA money, sometimes I'll let the Social Worker (SW) know. She stated that she has not recently emailed the SW, but she would inform them. She could not provide any documentation or verification that there was any communication between the facility to the residents or resident's representative of the accounts which could potentially jeopardize the Medicaid eligibility.On [DATE] at 12:13 PM, the surveyor interviewed the Director of Social Work #1 (SW #1) and Social Worker (SW #2) in the presence of the survey team. SW #1 stated if a resident had a concern with PNA we followed up with the Business office. We were only involved with PNA funds with the prior ownership and those accounts were managed by the in house business office. SW #1 and SW #2 stated that they had not received any any correspondence or emails from the business office for the past 3 months regarding the need to spend down resident's PNA so they are not in jeopardy of losing their Medicaid funds. Both confirmed they were not aware that Resident #59 was over resources. Both then acknowledged that Resident #59 needed a spend down (purchasing items the resident needed). SW #2 stated that Resident #59 had a Care Conference scheduled the next day,[DATE], and was not informed the resident had PNA that needed to be spent down for their needs. SW #1 stated the residents will get kicked off of Medicaid if they go over funds. Both stated they were not aware of any process to manage PNA funds. A review of the facility's Personal Needs Accounts policy last reviewed 4/2024, included; if the amount in the account (plus the value of the resident's other non-exempt resources) reaches the SSI/Medicaid resource limit for one person, the resident may lose eligibility for Medicaid or SSI. No additional information was provided.NJAC 8:39-9.5

Complaint # NJ 2587050Based on observation, interview and document review, it was determined that the facility failed to maintain a clean, comfortable and homelike environment by failing to ensure a) resident rooms, including personal belongings and common areas were kept clean, sanitary, free of pests and ensuring soiled meal trays were removed in a timely manner, b) furniture and resident rooms and common areas were maintained in a clean and homelike manner, and c) resident excrement was cleaned up timely to limit odors. The deficient practice was identified for 4 of 4 residents who attended a resident council meeting and observed on 3 of 3 resident units (2nd, 3rd and 4th floor).The deficient practice was evidenced by the following:Based on observation, interview and document review it was determined On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:36 AM, the ice machine located in the dining room, had a plastic type ice shoot that was heavily soiled with white and black colored substances. The drain cover had a rust like build up. The molding around the ice machine was peeling and a hole was noted on the wall by the ice machine. The floor under the countertop where the ice machine rested was covered with black substances.At 7:49 AM, a food cart was adjacent to the nursing station. The food cart contained left over and uncovered food items from the prior evening meal.At 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. The bathroom floor was covered with various debris, which included used plastic bags, a broken toilet seat was also observed on the floor. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. The surveyor then asked the CNA's what the protocol was if staff observed cockroaches. The staff informed the surveyor that they would enter their observations into the pest control book which was located at the nurses' station and they would also notify the Maintenance Director (MD).At 8:15 AM, the surveyor reviewed the pest control book that was located at the nurses' station and reviewed the pest control book. According to the data entered in the book, there was documentation regarding staff observations and cockroaches on the 2nd floor, and in resident's rooms dating back to 7/17/25. At 8:18 AM, the surveyor entered room [ROOM NUMBER] and observed a pile of soiled linen on the floor. At 8:20 AM, Resident #100's room had food debris, including straws and a red substance that was splattered on the floor. A CNA stated the red substance was food debris. The surveyor also observed the wall in the room appeared to be bulging, and the ceiling area over the light appeared to have water stains. On 12/2/25 at 8:45 AM, Surveyor #2, conducted an initial tour of the facility on the third floor and observed the following:The ice machine located in the dining room had blackened areas inside the ice chute, the area also had blackened discolored areas where the ice chute attached to the machine and where a receptacle would be placed to catch the ice. The lower part of the ice machine also appeared soiled and stained in the drain area.Resident #3's nightstand had a triangular piece of the corner finish chipped off, the edge of the drawer and the sides of the nightstand also had chipped off finish and was not smooth.On 12/2/25 at 7:30 AM, Surveyor #3 conducted an initial tour of the facility on the fourth floor and observed the following:The ice machine located in the dining room had blackened areas inside the ice chute and where the ice would be collected in a receptacle. The drain area on the ice machine had embedded blackened and white areas, and various spatter type debris was located on the exterior of the ice machine. Room # 424: The surface coating of the bathroom countertop was cracked on the edge, had missing material with an exposed rough area by the sink area. An infusion pump on a pole was located next to the wall where the air conditioner unit was located. The lower portion of the wall had broken wall board and exposed the internal wall area. The molding was also missing.room [ROOM NUMBER]: The surface material around the sink in the bathroom was broken on the edges with sharpened type areas. The area behind the bed had a sunken-in wall area with many marked ripped areas. An interview with the Licensed Practical Nurse/ Unit Manager (LPN/UM) at that time revealed that the LPN/UM acknowledged the damage to the wall and countertop and stated it was in disrepair and should not look like that. On 12/04/25 at 9:49 AM, Surveyor #2 conducted a resident council meeting with four residents. Four of four residents stated that there were cockroaches in the facility and the residents stated they observed cockroaches in their bathroom, bedrooms, on the beds and 1 of 1 resident stated the cockroaches were inside of their closet. On 12/04/25 at 12:30 PM, Surveyor #2 and #4 observed Resident #31's room. Resident #31 allowed the surveyors to observe their closet for cockroaches. Upon opening the closet door, both surveyors observed swarming live cockroaches scatter, and many dead cockroaches were affixed to a white sticky trap. Personal belongings that included a blanket, computer and clothing were observed inside the closet with the swarming cockroaches. Upon interview, Resident #31 stated they were not offered to have their closet or clothing cleaned after the exterminator had placed the cockroach trap in the closet. On 12/04/25 at 12:47 PM, Surveyor #4 interviewed the Registered Nurse Unit Manager (RNUM) of the 3rd floor and asked if there were cockroaches observed on the 3rd floor. The RNUM stated, yes and showed the surveyor the pest log where sightings were documented. A review of the pest logs revealed cockroaches were documented as observed on the 3rd floor beginning 6/1/24. On 12/04/2025 at 12:54 PM, Surveyor #4 interviewed the Licensed Practical Nurse Unit Manager (LPNUM) for the 4th floor. When asked if there were cockroaches observed on the 4th floor, the LPNUM stated, yes and showed the surveyor the pest log. A review of the pest logs revealed cockroaches were documented as observed beginning 7/28/25.On 12/05/2025 at 7:00 AM, Surveyor #1 toured the 4th floor and a strong odor of feces permeated the hallway on the North side. The surveyor requested a CNA assist with an observation of care in the room where the odor was identified. The CNA informed the surveyor that Resident #21 was incontinent of bowel and bladder. Resident #53, the roommate was in bed and was wearing a surgical mask. Resident #53 informed the surveyor that they could not stand the smell, and when asked if they informed staff, Resident #53 stated they informed the night nurse of the horrible smell. Resident #53 stated that Resident #21 vomited into the garbage can in the middle of the night and there was feces left in the bedside commode. The CNA confirmed that there was still vomit in the garbage can and feces permeated the room. Surveyor #1 then interviewed the 11:00 PM to 7:00 AM Licensed Practical Nurse (LPN) regarding Resident #53's concerns. The LPN confirmed that the feces and vomit were due to Resident #21 being sick overnight and she had been aware of Resident #53's concerns. The LPN stated when Resident #53 informed her of the vomit and feces smell, she assessed Resident #21 and she thought the CNA cleaned the bedside commode. The LPN stated, the CNA knew better, she went to school. The LPN continued and stated that she was the only one on the floor, it is a lot. When asked if the odor of feces and vomit was still there, she confirmed that it was and stated, she didn't have the time to go back and check if it was cleaned and confirmed that the CNA did not clean it. On 12/05/2025 at 9:58 AM, Resident #31 informed Surveyor #2 that they had observed more cockroaches crawling on their floor during the night.On12/5/25 at 11:06 AM, Surveyor #5 conducted a building tour with the Licensed Nursing Home Administrator (LNHA) and observed cockroaches swarming on the hinged side of the bathroom door in room [ROOM NUMBER] and roach feces were observed on the door frame.On 12/05/25 at 12:25 PM, Surveyor #4 interviewed the LNHA regarding the cockroaches. The LNHA stated he started in the position on 8/26/25 and scheduled a meeting with the pest control company. Surveyor #4 asked the LNHA if he had observed cockroaches, and he stated yes, it is a problem. Surveyor #4 reviewed the observations with him regarding the swarming cockroaches in Resident # 31's closet, and on Resident #31's personal belongings and reviewed the additional observations that had occurred with Surveyor #5 with the LNHA during the building tour. The LNHA stated he has met with the pest control company and the plan was to do a few rooms at a time. On 12/09/25 at 7:22 AM, Surveyor #1 observed a cockroach crawling on the clean linen cart that was in the 2nd floor hallway. The surveyor alerted the staff and the Housekeeping Director (HD) then removed the linen cart from the floor. On 12/09/25 at 9:10 AM, Surveyor #4 met with the Supervisor from the Pest Management (SPM) Company and the LNHA, in the presence of the survey team. The SPM stated the cockroaches were the German cockroaches, and were the dirty roaches, the worst to get rid of. Surveyor #4 asked if the German cockroaches transmitted disease and the SPM stated, they can. The surveyor asked the LNHA if it would be okay if the cockroaches crawled on linens and on resident personal belongings and clothing? The LNHA stated that was not okay, nobody wants cockroaches. The surveyor asked what the follow-up had been with Resident #31's clothing and personal belongings after the surveyor informed him that the cockroaches were swarming in Resident #31's closet four days prior. The LNHA stated, it wasn't washed or anything. The SPM stated the clothes should be removed, bagged, and washed, because whatever is not treated, the bugs will come back. On 12/09/25 at 2:00 PM, Surveyor #4 in the presence of another surveyor, advised the LNHA of the above concerns regarding the environment and the need to extend the survey. On 12/09/25 at 4:12 PM, the Regional Director of Nursing (RDON), Director of Nursing (DON) and the LNHA met with the survey team. The RDON stated, we know that the pests are a problem, and we don't think what we have done has achieved the objective, even if we have to evacuate the building and we reached out to other vendors for another option. The LNHA stated we are going to take an aggressive approach. On 12/10/25 at 7:30 AM, Surveyor #2 observed the ice machine located in the 4th floor dining room had water surrounding it with a wet towel, and there was a box paper place mats saturated with water. There was ice cubes observed on the floor and on the counter. On 12/10/25 at 8:48 AM, Surveyor #2 interviewed an unsampled resident (UR) who resided on the third floor, The surveyor asked the resident if the resident observed cockroaches in the facility. The resident stated, I saw one yesterday, and when asked how they felt about the cockroaches, they stated it made them feel extremely angry, because if they are crawling on my face, then they are crawling on other people's faces. The resident stated they have seen cockroaches ever since they have been at the facility and stated they are a different kind of roach, much smaller. The resident further stated, I saw them coming up the wall, so I block my bed with towels to stop them from crawling on the wall onto my bed. The surveyor observed seven towels rolled up and placed on the long edge of the bed that was next to the wall. The resident stated, I do everything I can to keep them off of my face. On 12/10/25 at 10:32 AM, Surveyor #3 interviewed Resident #7 in their room while they were seated on the side of their bed. When asked if they had seen any pests like cockroaches in their room, they stated they see them and had been killing them. Resident #7 stated the facility had only treated certain rooms and not the whole floor. When asked how this made them feel Resident #7 stated terrible, and then stated, once, a while back my food was delivered and I took the top off, and a roach crawled out. Resident #7 stated the housekeepers don't clean very well and stated, I keep my room clean myself and showed the surveyor their personal broom and dustpan. The resident confirmed he had spoken to maintenance about the roach problem, but it didn't do any good, the problem had been going on for over a year. Resident #7 then stated a few weeks ago they had a roach crawling on him while in bed, and then they had to knock it off and then stepped on it. On 12/10/25 at 10:38 AM, Resident #12 was observed in their room seated on the side of his bed watching television. When asked if the resident had seen any pests like roaches in their room, they stated they had noticed roaches in their room. Resident #12 stated yesterday they saw a roach crawling on the wall behind their closet. Resident #12 stated they don't see them often but would feel better not seeing them at all. When asked how seeing cockroaches made them feel they stated it made them feel like I want to get up and smash them, but I can't get up. On 12/10/25 at 11:25 AM, Surveyor #1 was seated at the 2nd floor nurses' station, the surveyor observed a cockroach crawling on the wall next to the medication cart. The surveyor alerted the Licensed Practical Nurse who was nearby, who then used a cardboard piece to kill the cockroach. On 12/10/25 at 11:30 AM, during an interview with a CNA assigned to the 2nd floor, she informed Surveyor #1 that the cockroaches were all over the facility, staff had to keep their bags wrapped in plastic bag to prevent them from crawling on their belongings. The surveyor went to the 2nd floor staff lounge and observed all staff bags wrapped in plastic bag on the counter.On 12/10/25 at 11:40 AM, the surveyor interviewed four random residents on the 2nd floor and inquired if they had observed cockroaches in their rooms. Resident #1 stated that they observed cockroaches crawling on the wall most of the time. When inquired regarding how they feel about the cockroaches being in the room, they stated, they were scared. Resident #2 stated, I see them all the time on the walls and when I see them on the floor next to the bed, I step on them and kill them. Resident #2 added, it is disturbing when the facility had advertised itself as a 5-star facility. Resident #3 stated that the roaches would crawl on the wall, and from the bed they saw the roaches coming from the dresser in the room. Resident #3 stated, I cannot get to them, I am bedbound. On 12/11/25 at 1:17 PM, the survey team met with the Corporate Director of Nursing, the LNHA and DON to further review the above-mentioned findings regarding the cockroaches. When asked about the chipped dresser that was still in disrepair, the LNHA stated that was not prioritized, we know furniture in general was an issue, the ones that were jagged that could cause a skin tear were replaced. The surveyor asked if the lifting broken dresser top was homelike, and the LNHA stated no.On 12/11/2025 at 3:09 PM, the survey team met with the above facility representatives and no additional information was provided. NJAC 8:36-4.1(a)11; 27.3(c); 31.5(a)(1)(2); 31.8(e)

Complaint #s NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993Based on observation, interview and record review, it was determined that the facility failed to ensure that sufficient staff were available at all times to ensure residents maintained their highest practical physical and mental well-being by failing to ensure: a) residents were provided with timely incontinence care for 2 of 2 residents reviewed (Resident #81 and #135), b) medications were administered per standards of practice (Resident #121) , c) adequate staff were available to clean up resident excrement in a timely manner, and d) the mandatory New Jersey staffing requirements were consistently adhered to. The deficient practice had the potential to affect all residents who resided on 3 of 3 units and was evidenced by the following: a. Resident #81:On 12/02/25 at 8:02 AM, the surveyor observed Resident #81 in bed. During an interview with the resident, they informed the surveyor that they had not received incontinence care nor had been repositioned since 9:30 PM last night, which was 10.5 hours prior.On 12/02/25 at 8:34 AM, the surveyor interviewed the resident's 7:00 AM to 3:00 PM assigned Certified Nurse Aide (CNA) who stated that the resident informed him that they had not seen a CNA last night. They resident stated they were leaning against the siderail for the entire night and staff did not come to the room when they activated the call light.On 12/02/25 at 8:35 AM, the surveyor performed an incontinence observation with the CNA assigned to the resident. Resident #81 was saturated with urine, and the bedding, including the pad were soaked with urine and were yellow stained. The CNA assigned to Resident #81 for the morning shift stated that he was not aware that the resident had not been changed. The CNA further stated he did not receive report from the 11:00 PM - 7:00 AM shift, and he repositioned the resident this morning but did not provide incontinence care. Resident #81 had was observed with some redness on the buttocks and groin areas; the skin was not opened. The CNA stated that the night shift staff was supposed to check and change the residents, prior to leaving at the end of their shift.Resident #135:On 12/2/25 at 8:06 AM, the surveyor observed Resident #135 in bed, their extremities appeared contracted (muscles and tending shorten/stiffen and often from prolonged immobility). Resident # 135 was positioned on the right side; their eyes were opened but Resident #135 was nonverbal and unable to communicate with the surveyor.The surveyor asked a random CNA to assist with an incontinence care tour observation, and two CNAs performed incontinence care. The surveyor observed that Resident #135 was saturated with urine. Resident #135 had a wound dressing on the left hip area that was also saturated with urine and bloody drainage. The CNAs repositioned the resident to the right side, and we all observed Resident #135 was wearing two incontinence briefs which were both saturated with urine. One of the CNA informed the surveyor that Resident #135 was on her assignment, but she did not provide any care yet. The CNA declined to comment when inquired if it was the first time, that Resident #135 was clothed with two incontinence briefs.On 12/05/25 at 8:40 AM, the surveyor interviewed the CNA who assisted the surveyor with the incontinence observation. The CNA stated that when the CNAs reported to their units, the CNAs should be checking the residents to ensure that everyone was safe and that incontinent residents were clean and dry. The CNA further stated that incontinence care should be provided at least twice during each shift to ensure that the residents were not soiled or if they needed to be assisted to the toilet prior to finishing their shift. The CNA added, Incontinent residents should never be wearing multiple briefs because that create moisture and could cause skin issues.On 12/5/25 at 10:30 AM, the surveyor reviewed Resident #135's admission Record which reflected that the resident had diagnoses which included, but were not limited to; cognitive communication deficit, unspecified dementia, osteomyelitis of vertebra, muscle weakness, and bed confinement status.On 12/02/25 at 12:05 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that incontinence care was to be offered every two hours and as needed. The LPN/UM reviewed the schedule with the surveyor and stated that one CNA called out and there were only two CNAs for the floor, and each CNA had to care for 23 residents. The LPN/UM stated the Census was 47, and did not offer an option for other staff to assist if a CNA called outReview of the most recent quarterly MDS dated [DATE], indicated that Resident #135 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident had severe cognitive impairment. A further review of the resident's MDS, Section GG - Functional Status indicated that the resident was totally dependent on staff for care.On 12/09/25 at 11:34 AM, the surveyor interviewed the CNA who cared for the resident on 11:00 PM-7:00 AM shift. The CNA confirmed that she placed two briefs on the resident. She also stated she cared for the resident during the night, and the Resident had two incontinence briefs on at that time (3:00 PM to 11:00 PM shift). She stated she assumed that the resident needed two incontinence briefs. The CNA stated that she could not recall when Resident #135 was last changed during her shift. The CNA stated, usually incontinence care was provided every two hours, but one CNA called out last night and the workload was heavy.On 12/09/25 at 11:50 AM, the surveyor interviewed the LPN/UM #2 on the second floor. The LPN/UM #2 stated that the CNAs were responsible for providing incontinence care every two hours and as needed. On 12/09/25 at 1:22 PM, an interview with the Director of Nursing (DON) revealed that the CNAs were in-serviced regarding incontinence care. The DON further stated the facility's policy was to provide incontinence care at least every 2 hours during the shift and no resident should have to wear more than one brief. b. On 12/10/25 at 11:40 AM, a lingering odor of urine permeated in the hallway across Resident #121's room. At 11:43 AM, the surveyor entered Resident #121's room and observed the resident in bed with the sheet over their head. The surveyor observed a medication cup with 4 tablets inside the cup and a cup of water on the bedside table. The surveyor greeted the resident and attempted to engage with the resident. The resident was very drowsy and could not proceed with the conversation. The surveyor went to the hallway and observed one resident standing at the door in front of the resident's room and some ancillary staff in the hallway. At 11:48 AM, the Unit Manager (UM) entered the room and observed the medication cup with 4 tablets in the cup and a cup of water next to the medication cup. The UM removed the medications at the bedside and returned to the nursing station.On 12/10/25 at 11:55 AM, the surveyor interviewed the UM regarding the medication left unattended at the bedside. The UM stated that the nurses were not allowed to leave medications unattended at the bedside for safety reasons. The UM stated the nurses were to ensure that all residents swallowed their medications before initialed the Medication Administration Record. The surveyor asked the UM to print the Medication Administration Record (MAR).On 12//10/25 at 12:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the North Side where Resident #121 resided. The surveyor reviewed the Medication Administration Record with the LPN who identified the tablets in the medication cup as Lasix (a diuretic used to treat congestive heart failure) 40 milligrams (mg), Zyprexa oral tablet 5 milligrams, medication used to treat schizophrenia, Entresto (24-26 mg) a combination of Sacubitril-Valsartan) used to treat heart failure, and Pepcid 20 mg used for esophageal reflux. The nurse informed the surveyor she administered the medications and initialed the MAR at 8:41 AM (over three hours prior) and the medications were checked off as administered in the MAR. The LPN stated that possibly the resident spit the medications after they were administered. The surveyor and the UM observed the tablets in the cup. The tablets were dry, they were no residual substance which would indicate the resident spit the medications after they were administered. The surveyor then asked the LPN what the facility's protocol was for medication administration. The LPN stated, I should ensure that the resident swallowed the medications before initialed the MAR.On 12/10/25 at 1:35 PM, the surveyor returned to the 3rd floor and observed Resident #121 in bed, they were alert. The surveyor inquired regarding the medications observed on the bedside table at 11:43 AM this morning. The resident stated, It is my heart that is not right ma'am and they left the medication on the table and I did not have the strength to reach for the cup. When inquired if it was the first time that staff left medications at the bedside, Resident #121 did not answer.On 12/10/25 at 2:15 PM, the Director of Nursing approached the surveyor and stated that the UM called and reported the incident with the medications left unattended at the bedside. The DON provided the facility's medication administration which reflected under procedure the following: No medications will ever be left in a resident room or on the medication cart unattended. On 12/11/25 at 1:17 PM, during a pre-exit meeting held with the survey team and the administrative staff (DON, Regional Director of Nursing and the Licensed Nursing Home Administrator) the surveyor reviewed the concerns regarding Resident #121's medications left at the beside unattended and required additional information. On 12/11/25 at 3:09 PM, the facility administrative staff informed the survey team that they did not have any additional information to present.c. On 12/05/2025 at 7:00 AM, Surveyor #1 toured the 4th floor and a strong odor of feces permeated the hallway on the North side. The surveyor requested a CNA assist with an observation of care in the room where the odor was identified. The CNA informed the surveyor that Resident #21 was incontinent of bowel and bladder. Resident #53, the roommate was in bed and was wearing a surgical mask. Resident #53 informed the surveyor that they could not stand the smell, and when asked if they informed staff, Resident #53 stated they informed the night nurse of the horrible smell. Resident #53 stated that Resident #21 vomited into the garbage can in the middle of the night and there was feces left in the bedside commode. The CNA confirmed that there was still vomit in the garbage can and feces permeated the room. Surveyor #1 then interviewed the 11:00 PM to 7:00 AM Licensed Practical Nurse (LPN) regarding Resident #53's concerns. The LPN confirmed that the feces and vomit were due to Resident #21 being sick overnight and she had been aware of Resident #53's concerns. The LPN stated when Resident #53 informed her of the vomit and feces smell, she assessed Resident #21 and she thought the CNA cleaned the bedside commode. The LPN stated, the CNA knew better, she went to school. The LPN continued and stated that she was the only one on the floor, it is a lot. When asked if the odor of feces and vomit was still there, she confirmed that it was and stated, she didn't have the time to go back and check if it was cleaned and confirmed that the CNA did not clean it. d. 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. Direct care staff member means any registered professional nurse, licensed practical nurse, or certified nurse aide who is acting in accordance with that individual's authorized scope of practice and pursuant to documented employee time schedules. The following ratio(s) were effective on 02/01/2021:One 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.As per the Nursing Staffing Report completed by the facility as documented below:For the week of Complaint staffing from 02/09/2025 to 02/15/2025, the facility was deficient in CNA staffing for residents on 3 of 7 day shifts as follows:-02/09/25 had 15 CNAs for 171 residents on the day shift, required at least 21 CNAs.-02/10/25 had 19 CNAs for 170 residents on the day shift, required at least 21 CNAs.-02/15/25 had 20 CNAs for 170 residents on the day shift, required at least 21 CNAs.For the week of Complaint staffing from 07/20/2025 to 07/26/2025, the facility was deficient in CNA staffing for residents on 6 of 7 day shifts as follows:-07/20/25 had 18 CNAs for 168 residents on the day shift, required at least 21 CNAs.-07/21/25 had 19 CNAs for 168 residents on the day shift, required at least 21 CNAs.-07/23/25 had 20 CNAs for 166 residents on the day shift, required at least 21 CNAs.-07/24/25 had 19 CNAs for 166 residents on the day shift, required at least 21 CNAs.-07/25/25 had 19 CNAs for 166 residents on the day shift, required at least 21 CNAs.-07/26/25 had 14 CNAs for 166 residents on the day shift, required at least 21 CNAs.For the week of Complaint staffing from 08/03/2025 to 08/09/2025, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows:-08/03/25 had 17 CNAs for 174 residents on the day shift, required at least 22 CNAs.-08/04/25 had 19 CNAs for 174 residents on the day shift, required at least 22 CNAs.-08/05/25 had 20 CNAs for 173 residents on the day shift, required at least 22 CNAs.-08/06/25 had 20 CNAs for 173 residents on the day shift, required at least 22 CNAs.-08/07/25 had 18 CNAs for 173 residents on the day shift, required at least 22 CNAs.-08/08/25 had 17 CNAs for 173 residents on the day shift, required at least 22 CNAs.-08/09/25 had 17 CNAs for 173 residents on the day shift, required at least 22 CNAs.For the week of Complaint staffing from 09/28/2025 to 10/04/2025, the facility was deficient in CNA staffing for residents on 1 of 7 day shifts as follows:-10/04/25 had 19 CNAs for 161 residents on the day shift, required at least 20 CNAs.On 12/10/25 at 11:02 AM, the surveyor interviewed the Human Resources Director (HRD) who confirmed she oversaw the facility nurse staffing. She stated to the surveyor the facility was able to meet the minimum staffing requirements which were one CNA to every eight residents for the day shift, one direct care staff member to every 10 residents for the evening shift, and one direct care staff member to every 14 residents for the night shift. The HRD stated she followed a PAR established by the owners of the facility to make the weekly schedule. On 12/11/25 at 1:18 PM the surveyor interviewed the Director of Nursing (DON) who stated the minimum staffing requirements. The DON stated the facility did there best to meet the requirements but acknowledged they are not always able to meet the requirements, that on the night shift they had the hardest struggle. The DON stated the facility offered numerous incentives to staff to encourage attendance and for working additional shifts and also had plans for future recruitment for new staff.A review of the facility Policy and Procedure on Nurse Staffing Standards and Requirements undated included . Purpose: To provide adequate nursing coverage to meet the care and acuity of the facility's residents. To make efforts to meet the regulations set forth in the NJ Administrative Code, Title 8, Chapter 43E recognizing the challenges experienced by the national nursing shortage. PAR levels will be established to meet the ratio of nurse aides to facility census as set forth in the above NJ Administrative Code. Day Shift ratio 1 aide to every 8 residents, Evening shift ratio1 aide to every 10 residents and Night shift ratio 1 aide to every 14 residentsNJAC: 8:39-27.1 (a)

Based on observation, interview and document review it was determined the facility failed to develop and implement an infection prevention and control program (IPCP) to limit the potential transmission of bacteria during a facility wide infestation of cockroaches, ensuring clean linens were protected from pests, and ensure water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems were developed and implemented.The deficient practice affected all residents who resided on 3 of 3 resident units and was evidenced by the following: Reference: Guidelines for Environmental Infection Control in Health- Care Facilities; Recommendations of CDC (Centers for Disease Control) and the Healthcare Infection Control Practices Advisory Committee; 2003; Updated July 2019. Refer to F584 and F925Fa. On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:49 AM, a food cart was adjacent to the nursing station. The food cart contained left over and uncovered food items from the prior evening meal.At 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. The bathroom floor was covered with various debris, which included used plastic bags, a broken toilet seat was also observed on the floor. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches.At 8:15 AM, the surveyor reviewed the pest control book that was located at the nurses' station and reviewed the pest control book. According to the data entered in the book, there was documentation regarding staff observations and cockroaches on the 2nd floor, and in resident's rooms dating back to 7/17/25. At 8:18 AM, the surveyor entered room [ROOM NUMBER] and observed a pile of soiled linen on the floor. At 8:20 AM, Resident #100's room had food debris, including straws and a red substance that was splattered on the floor. A CNA stated the red substance was food debris.On 12/2/25 at 8:45 AM, Surveyor #2, conducted an initial tour of the facility on the third floor and observed the following:On 12/04/25 at 9:49 AM, Surveyor #2 conducted a resident council meeting with four residents. Four of four residents stated that there were cockroaches in the facility and the residents stated they observed cockroaches in their bathroom, bedrooms, on the beds and 1 of 1 resident stated the cockroaches were inside of their closet. On 12/04/25 at 12:30 PM, Surveyor #2 and #4 observed Resident #31's room. Resident #31 allowed the surveyors to observe their closet for cockroaches. Upon opening the closet door, both surveyors observed swarming live cockroaches scatter, and many dead cockroaches were affixed to a white sticky trap. Personal belongings that included a blanket, computer and clothing were observed inside the closet with the swarming cockroaches. Upon interview, Resident #31 stated they were not offered to have their closet or clothing cleaned after the exterminator had placed the cockroach trap in the closet. On 12/04/2025 at 12:47 PM, Surveyor #4 interviewed the Registered Nurse Unit Manager (RNUM) of the 3rd floor and asked if there were cockroaches observed on the 3rd floor. The RNUM stated, yes and showed the surveyor the pest log where sightings were documented. A review of the pest logs revealed cockroaches were documented as observed on the 3rd floor beginning 6/1/24.On 12/04/2025 at 12:54 PM, Surveyor #4 interviewed the Licensed Practical Nurse Unit Manager (LPNUM) for the 4th floor. When asked if there were cockroaches observed on the 4th floor, the LPNUM stated, yes and showed the surveyor the pest log. A review of the pest logs revealed cockroaches were documented as observed beginning 7/16/25.On 12/05/2025 at 9:58 AM, Resident #31 informed Surveyor #2 that they had observed more cockroaches crawling on their floor during the night.On 12/05/25 at 12:25 PM, Surveyor #4 interviewed the Licensed Nursing Home Administrator (LNHA) regarding the cockroaches. The LNHA stated he started in the position on 8/26/25 and scheduled a meeting with the pest control company. Surveyor #4 asked the LNHA if he had observed cockroaches, and he stated yes, it is a problem.On 12/09/25 at 7:22 AM, Surveyor #1 observed a cockroach crawling on the clean linen cart that was in the 2nd floor hallway. The surveyor alerted the staff and the Housekeeping Director (HD) then removed the linen cart from the floor. On 12/09/25 at 9:10 AM, Surveyor #4 met with the Supervisor from the Pest Management (SPM) Company and the LNHA, in the presence of the survey team. The SPM stated the cockroaches were the German cockroaches, and were the dirty roaches, the worst to get rid of. Surveyor #4 asked if the German cockroaches transmitted disease and the SPM stated, they can. The surveyor asked the LNHA if it would be okay if the cockroaches crawled on linens and on resident personal belongings and clothing? The LNHA stated that was not okay, nobody wants cockroaches. The surveyor asked what the follow-up had been with Resident #31's clothing and personal belongings after the surveyor informed him that the cockroaches were swarming in Resident #31's closet four days prior. The LNHA stated, it wasn't washed or anything. The SPM stated the clothes should be removed, bagged, and washed, because whatever is not treated, the bugs will come back. On 12/09/25 at 11:30 AM, the surveyor interviewed the Infection Control Preventionist regarding the above observation, she stated that she was made aware of the roach crawling inside the clean linen cart. When inquired if she was involved or if the facility had a plan to control the infestation, she stated, No. The IP added that the concern with the roaches was handled by the maintenance director. On 12/10/25 at 8:48 AM, Surveyor #2 interviewed an unsampled resident (UR) who resided on the third floor, The surveyor asked the resident if the resident observed cockroaches in the facility. The resident stated, I saw one yesterday, and when asked how they felt about the cockroaches, they stated it made them feel extremely angry, because if they are crawling on my face, then they are crawling on other people's faces. The resident stated they have seen cockroaches ever since they have been at the facility and stated they are a different kind of roach, much smaller. The resident further stated, I saw them coming up the wall, so I block my bed with towels to stop them from crawling on the wall onto my bed. The surveyor observed seven towels rolled up and placed on the long edge of the bed that was next to the wall. The resident stated, I do everything I can to keep them off of my face. On 12/10/25 at 10:32 AM, Surveyor #3 interviewed Resident #7 in their room while they were seated on the side of their bed. When asked if they had seen any pests like cockroaches in their room, they stated see them and had been killing them. Resident #7 stated the facility had only treated certain rooms and not the whole floor. When asked how this made them feel Resident #7 stated terrible, and then stated, once, a while back my food was delivered and I took the top off, and a roach crawled out. Resident #7 stated the housekeepers don't clean very well and stated, I keep my room clean myself and showed the surveyor their personal broom and dustpan. The resident confirmed he had spoken to maintenance about the roach problem, but it didn't do any good, the problem had been going on for over a year. Resident #7 then stated a few weeks ago they had a roach crawling on him while in bed, and then they had to knock it off and then stepped on it. On 12/10/2025 at 10:38 AM, Surveyor 3 observed Resident #12 in their room seated on the side of his bed watching television. When asked if the resident had seen any pests like roaches in their room, they stated they had noticed roaches in their room. Resident #12 stated yesterday they saw a roach crawling on the wall behind their closet. Resident #12 stated they don't see then often but would feel better not seeing them at all. When asked how seeing cockroaches made them feel they stated it made them feel like I want to get up and smash them, but I can't get up. Resident #12 stated they had never seen a cockroach in their bed and confirmed there were no roach traps in their room. On 12/10/2025 at 10:39 AM, Surveyor #4 interviewed the newly hired Maintenance Director (MD), who stated he was the former Maintenance Assistant and had worked at the facility for a few years. When asked about the cockroaches, the MD stated, it has been an ongoing problem here for years, and it is the worst I have ever seen them. The surveyor asked the MD if he ever read the Service Inspection Reports/Invoices (SIR)? The surveyor read one report dated 9/25/24 regarding treating room [ROOM NUMBER], #204, #205, #206, #207, #208 and #209 for roach activity . Under General Comments/Instructions: Recommend better sanitation, floors was really sticky and moderate food/trash in the rooms Asked if he recalled any follow-up regarding that recommendation, and stated he did remember that and maybe a word-of-mouth thing. A second SIR also dated 9/25/24 revealed Treated room [ROOM NUMBER] for roach activity, and Under General Comments/Instructions: Recommend better sanitation, observed moderate food and trash in rooms. On 12/10/25 at 11:25 AM, while seating at the nursing station, Surveyor #1 observed a cockroach crawling on the wall next to the medication cart. The surveyor alerted the staff, a Licensed Practical Nurse who was nearby used a cardboard to kill the roach.That same day at 11:30 AM, during an interview with a CNA assigned to the unit, she informed the surveyor that the roaches were all over the facility, staff had to keep their bags wrapped in plastic bag to prevent them from crawling on their belongings. The surveyor went to the 2nd floor staff lounge and observed all bags wrapped in plastic bag on the counter.On 12/10/25 at 11:40 AM, the surveyor interviewed four random residents on the 2nd floor and inquired if they had observed cockroaches in their rooms. Resident #1 stated that they observed cockroaches crawling on the wall most of the time. When inquired regarding how they felt about the cockroaches being in their room, they stated, they were scared. Resident #2 stated, I see them all the time on the walls and when I see them on the floor next to the bed, I step on them and kill them. Resident #2 added, it is disturbing when the facility had advertised itself as a 5-star facility. Resident #3 stated that the roaches would crawl on the wall, and from the bed they saw the roaches coming from the dresser in the room. Resident #3 stated, I cannot get to them, I am bedbound. On 12/11/25 at 9:31 AM, the surveyor interviewed the facility Infection Preventionist (IP), in the presence of the survey team. The surveyor asked if cockroaches were an infection control concern and the IP stated, yes, because they are bugs. When asked what her involvement related to infection control due to the cockroach infestation, the IP stated, I did rounds to make sure there was no improper food storage. When asked if there was anything in particular about the breed of cockroaches identified in the facility, the IP stated, I have not had any time to research these roaches, I am not a roach expert. When asked had she been informed of the type of cockroaches that have been in the facility, and she stated no. The surveyor asked if she had been made aware of cockroaches crawling on residents, or on residents' personal belongings, and she stated no. The surveyor asked the IP has spoken with the pest management company regarding the cockroach concerns and she stated, No, maintenance deals with it.On 12/11/25 at 11:02 AM, the surveyor conducted a telephone interview with the Medical Director (MDR) in the presence of the survey team. The surveyor asked the MDR if he was involved in infection control? The MDR stated, yes, he had been working on policies and reviewed antibiotic stewardship. The surveyor asked the MDR if he had been made aware of the facility had German cockroaches on all units. The MDR stated he was made are of the cockroaches a few weeks ago. The surveyor asked if he had been made aware that cockroaches crawled on residents and were on their personal belongings? The MDR stated that fecal matter from cockroaches, the droppings can cause ocular (eye) issues with the residents, and stated, I have to be updated. The surveyor asked the MDR if he had been updated by the IP regarding the cockroaches and he stated, the Director of Nursing told him there was a problem with cockroaches. When asked if he knew one of the residents used rolled up towels against the wall to prevent the cockroaches from crawling up the wall? The MDR stated he did not know the specifics and did not know that the cockroaches have been at the facility for over one year. The MDR stated, that is horrible, that is very serious and that is very disturbing. When asked if the MDR had been updated by the facility on the plan for the cockroaches, he stated no.' A review of the unsigned Infection control Preventionist Job Description, Updated January 2025 revealed: Job Summary: The purpose of this position is to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies, procedures, etc. Of the Infection Control Committee and to coordinate the systematic monitoring of causes, spread of infection, prevention. Main Duties: c. Establish specific policies and procedures for Infection Control as it relates to the following departments: a) nursing, b) maintenance, c) laundry, d) dietary, e) rehabilitation, f) ancillary services.b. On 12/5/25 at 11:30 AM, the surveyor interviewed the Maintenance Director (MD) regarding measures in place to prevent potential for Legionella at the facility. The surveyor requested the water management and the facility policy for Legionella prevention. The MD informed the surveyor that the Licensed Nursing Home Administrator had the binder in their office. The surveyor requested the log for any water testing and measures that have been implemented for Legionella prevention.On 12/09/25 at 1:10PM, the surveyor met with the MD and again requested all information regarding the facility measures that were in place to prevent Legionella. The MD stated that he informed the LNHA, and the LNHA will provide the binder.On 12/11/25 at 10:30 AM, the surveyor requested again the information for Legionella testing from the facility management, no information was provided. The facility did not provide the policy or any process that was in place to prevent Legionella. The MD stated if the LNHA did not provide it, we do not have it. On 12/11/25 at 2:55 PM, the DON confirmed there was no facility water management program. The facility was unable to provide any documentation that the water had been tested for Legionella.NJAC 8:39-31.5 (a)(1)(2)

Complaint # NJ 2587050Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure the ice machines were maintained in a clean and sanitary manner, and per manufacturers' instructions. The deficient practice was identified for 3 of 3 ice machines located on the 2nd, 3rd and 4th floor resident units, and was evidenced by the following: On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:36 AM, the ice machine located in the resident dining room, had a plastic type ice chute that was heavily soiled inside with white and black colored substances. The drain cover had a rust like build and the molding around the ice machine was peeling off.On 12/2/25 at 8:45 AM, Surveyor #2, conducted an initial tour of the facility on the third floor and observed the following:The ice machine located in the resident dining room had blackened areas inside the ice chute, and the area also had blackened discolored embedded areas where the ice chute attached to the machine and where a receptacle would be placed to catch the ice. The lower part of the ice machine also appeared soiled and stained in the drain area.On 12/2/25 at 7:30 AM, Surveyor #3 conducted an initial tour of the facility on the fourth floor and observed the following:The ice machine located in the dining room had blackened areas inside the ice chute and where the ice would be collected in a receptacle. The drain area on the ice machine had embedded blackened and white areas, and various spatter type debris was located on the exterior of the ice machine. On 12/2/25 at 1:30 PM, Surveyor #4 interviewed the Licensed Nursing Home Administrator (LNHA) and escorted the LNHA to observe the condition of the ice machines located in the 2nd, 3rd and 4th floor dining rooms. Surveyor #4 observed the finding as above in the presence of the LNHA. The LNHA confirmed the surveyor observations of all three ice machines and acknowledged the various debris observed inside the ice chutes and on the ice machines. The LNHA stated the ice machines would not be used due to the conditions of the machines and all three machines would be placed out of service until they are cleaned.On 12/5/25 at 8:46 AM, Surveyor #5 interviewed the Maintenance Director (MD) regarding the facility process for cleaning the ice machines located on the resident units, and asked how often the machines were cleaned? The MD responded that he did not know how often the ice machines were cleaned. Surveyor #5 asked the MD if there was a sticker, or document located at each ice machine to identify when it had been cleaned, and the MD stated he was not sure. The manual for the ice machines was also provided by the MD at that time. The MD was asked if he had cleaned the ice machines since he had been appointed the MD, and he responded he had not. Surveyor #5 asked the MD if he knew the steps for cleaning the ice machines and he responded, No, I think there are quite a few things that I do not know about here or know that they need to be completed. The MD stated, he will get it done.On 12/5/25 at 9:28 AM, the MD exited the tour and the LNHA continued the tour with Surveyor #5 and at that time Surveyor #5 observed the ice machine on the 2nd, 3rd and 4th floor were all turned off and placed out of service. Surveyor #5 observed a build up of a white substance at the ice chute area for all three ice machines. On 12/05/25 at 12:25 PM, Surveyor #4 interviewed the LNHA who stated he had been the LNHA since 8/26/25 and when asked the LNHA if he has seen cockroaches? The LNHA stated yes, it is a problem. The LNHA provided the Pest Management Service Inspection Report/Invoice book.The surveyor reviewed the Pest Management Service Inspection documents which revealed the following Service Inspection Report/Invoice dated 07/24/24. Under General Comments/Instructions: Check in with Maintenance. 2nd floor dining room and nurses' stations -roach activity 7/19 confirmed via phone. Treated second floor, nurses' station, pantry, and dining room area and kitchenette for roach activity . Observed minor activity near the ice machine. On 12/10/25 at 7:30 AM, Surveyor #2 toured the 4th floor and observed the ice machine in the dining room did not have an out of service sign on it. There was water on the countertop next to the machine, along with a wet towel in the water. The counter that the ice machine was located on had a box of paper place mats in a box, and the water was observed on the box of paper place mats. There were also ice cubes on the floor in front of the ice machine.On 12/10/25 at 10:39 AM, Surveyor #4 interviewed the MD who stated he was recently hired as MD, although has worked as Maintenance Assistant for a few years. When asked if he had ever been aware of cockroaches by the ice machine, he stated No. When asked if he had ever been instructed to clean the ice machines, he stated that after the surveyors brought the concerns with the soiled ice machines to the facility's attention, he cleaned them, and had to purchase the special chemicals to clean the ice machines since the chemicals were not available in the facility. When asked if the former MD, who he worked under, had educated him on the process to clean the ice machines, the MD stated, he never did and was unaware if the machines were cleaned. The MD stated when the new company took over the building, they did away with the service contracts for the ice machines, then stated the former company had the ice machines cleaned monthly and they looked clean. The MD stated there was a leak in the ice machine located in the 4th floor dining room, and when the company was called in for service for the leaking machine, the service company informed the facility that all the machines should be replaced due to wear and tear. The MD stated he could confirm that he changed the ice machine filters in August 2025, but that was the only maintenance that could be confirmed. A review of the facility provided manufacturer ice machine manual revealed: Section 4 Maintenance: Descaling and Sanitizing: Descale and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent descaling and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, and extremely dirty ice machine may be taken apart for descaling and sanitizing. Sanitizing for exterior, remedial, and detailed procedures can be performed independently and more frequently than descaling when needed. Using non [manufacturer's name redacted] may result in bodily harm and/or cause damage to the ice machine . Exterior cleaning: Weekly: remove grill from scrap ice tray and wipe splash panel, scrap ice tray and grill with sanitizer and water solution. Pour excess solution in scrap ice tray to clear drain. The ice machine has three separate cleaning procedures: Preventative Maintenance Descaling Procedure: Perform this procedure as required for your water conditions. Recommended monthly. Allows descaling the ice machine without removing all the ice from the bin. Descaling/Sanitizing Procedure: This procedure must be performed a minim of one every six months. All ice must be removed from the bin; The ice machine and bin must be disassembled descaled and sanitized; The ice machine produces ice with the descaler and sanitizer solutions.; All ice produced during the descaling and sanitizing procedure must be discarded. Heavily Scaled Descaling Procedure: Perform this procedure if you have some or all these symptoms: . The ice machine has not been on a regular maintenance schedule. Run a descaling procedure as described above after this procedure is complete. Note: A sanitizing procedure must be performed after all descaling procedures have been completed. Sanitizing Procedure: Ice machine sanitizer is used to remove algae or slime. It is not used to remove lime scale or other mineral deposits.NJAC 8:39-31.4(a)(b)(f)

Based on observation, interview and document review it was determined that the facility failed to have an effective pest management program to irradicate an infestation of German cockroaches. The deficient practice occurred on 3 of 3 resident units and was evidenced by the following:Refer to 584F and 880F On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. The bathroom floor was covered with various debris, which included used plastic bags, a broken toilet seat was also observed on the floor. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. The surveyor then asked the CNA's what the protocol was if staff observed cockroaches. The staff informed the surveyor that they would enter their observations into the pest control book which was located at the nurses' station and they would also notify the Maintenance Director (MD).At 8:15 AM, the surveyor reviewed the pest control book that was located at the nurses' station and reviewed the pest control book. According to the data entered in the book, there was documentation regarding staff observations and cockroaches on the 2nd floor, and in resident's rooms dating back to 2/28/25. A further review of the Pest Management Logs (PML) for the 2nd floor revealed the following documented facility cockroach observations:- 2/28/25 Room #'s 214, 216, 213 Roaches- Bathroom/Room.- 4/16/25 Cockroach Room # 231B.- 4/21/25 Roaches spotted in room [ROOM NUMBER].- 4/22/25 Roaches in dayroom/bathroom.- 5/6/25 Ants and Roaches room [ROOM NUMBER] near air conditioner.- 5/14/25 Roaches room [ROOM NUMBER].- 6/10/25 Roaches 2nd floor medication room.- 6/13/25 Roaches 2nd floor medication room.- 7/16/25 Roaches.- 7/17/25 Roaches room [ROOM NUMBER].- 7/24/25 Please see rooms 208, 211, 215, 206, 209, 213, 226 and 230 for roaches please!!! Thank you, infested bad!! - 8/19/25 Roaches in Curtain room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER].- 8/25/25 Roaches room [ROOM NUMBER] and #207.- 8/27/25 Roaches in room [ROOM NUMBER] and #211 (Cracks in ceiling over mirror and baseboards).- 9/10/25 Complete infestation of roaches in room [ROOM NUMBER] and #215!!!, Roaches!!, Walls, floors, doors, bed!!! Sink!! Everywhere! Please Address ASAP, Infestation!!-11/13/25 Roaches 2nd Floor, #214.-10/14/25 Roaches, room [ROOM NUMBER], #208, #211, #213, and #230.-11/14/25 Roaches room [ROOM NUMBER].-11/18/25 Roaches room [ROOM NUMBER], #211(underneath sink), #214 and #227.On 12/04/2025 at 12:47 PM, Surveyor #4 interviewed the Registered Nurse Unit Manager (RNUM) of the 3rd floor and asked if there were cockroaches observed on the 3rd floor. The RNUM stated, yes and showed the surveyor the pest log where sightings were documented. A review of the pest logs revealed cockroaches were documented as observed on the 3rd floor beginning 6/1/24.A further review of the Pest Management Logs (PML) for the 3rd floor revealed the following documented facility cockroach observations:-6/1/24 Roaches in main dining room, back of nursing station.-7/2/24 Roaches in dining room.-7/16/25 Roaches in dayroom cabinets.-7/25/24 Resident found bug in bed, room [ROOM NUMBER]B.- 9/1/24 Main dining room roaches all around ice machine.-10/8/24 Roaches room [ROOM NUMBER].-11/18/24 Roaches room [ROOM NUMBER] Closet.-1/28/25 Infestation roaches under sink in bathroom.-2/19/25 Roaches Infested room [ROOM NUMBER], #307, #308, Under sinks and bathroom roaches, room [ROOM NUMBER], #327 and #330.-3/2/25 Roaches in bathroom.-3/5/25 Roaches all over in room [ROOM NUMBER].-4/23/25 Roaches 3rd floor all over the room [ROOM NUMBER].-5/30/25 Cockroaches on nurses stated.-6/13/25 Roaches room [ROOM NUMBER], #304, #305, #306, #308, #309.-7/2/25 Roaches 3rd Floor.-7/9/25 Roaches 3rd Floor.-7/28/25 Roaches room [ROOM NUMBER]B.-7/29/25 Roaches room [ROOM NUMBER]B.-8/8/25 Roaches room [ROOM NUMBER] and #328.-8/25/25 Roaches (multiple) room [ROOM NUMBER]B.-9/16/25 Roaches room [ROOM NUMBER]B.-10/12/25 Roaches, whole in wall room [ROOM NUMBER]B.-10/14/25 Roaches room [ROOM NUMBER]B.-10/21/25 Roaches (air con area and hallway) room [ROOM NUMBER]B.-10/29/25 Roaches at nursing station.-11/10/25 Roaches in drawers room [ROOM NUMBER]B.-11/14/25 Roaches room [ROOM NUMBER] and #302.-11/17/25 Roaches All over room [ROOM NUMBER] floor.-11/26.25 Roaches Room #s302 and #303.-11/30/25 Roaches Room #s301, 304, 302 (inside drawers and cabinets).-12/1/25 Roaches nurses station kitchen.-12/2/25 Roaches in dining room by refrigerator.-12/3/25 Roaches in room [ROOM NUMBER]A behind television and dresser. On 12/04/2025 at 12:54 PM, Surveyor #4 interviewed the Licensed Practical Nurse Unit Manager (LPNUM) for the 4th floor. When asked if there were cockroaches observed on the 4th floor, the LPNUM stated, yes and showed the surveyor the pest log. A review of the pest logs revealed cockroaches were documented as observed beginning 7/28/25.A further review of the Pest Management Logs (PML) for the 4th floor revealed the following documented facility cockroach observations:-7/28/25 Roaches in Room and bathroom [ROOM NUMBER].-7/30/25 Roaches in room [ROOM NUMBER].-7/30/25 Roaches in room [ROOM NUMBER].-11/5/25 Roaches in room [ROOM NUMBER].-11/14/25 Roaches in room [ROOM NUMBER].-11/18/25 Roaches in room [ROOM NUMBER].On 12/5/25 at 11:06 AM, Surveyor #5 conducted a building tour with the Licensed Nursing Home Administrator (LNHA) and observed cockroaches swarming on the hinged side of the bathroom door in room [ROOM NUMBER] and roach feces were on the door frame. During the tour of Resident #31's room, the resident stated that the cockroaches were in the room and closet and when asked if the facility had addressed the concerns, Resident #31 stated the pest control company was in their room on 11/25/25 and a monitoring station was observed under the sink counter which was located inside the room and had several dead cockroaches trapped in it. At that time, Surveyor #5 asked the LNHA if there was any ongoing pest management and he stated he began an aggressive pest management program with the existing pest company about three months ago as he was made aware of the cockroach problem after he arrived. During the tour complaints of roach sighting came from residents located in room [ROOM NUMBER]A, 327B, 417B and 419B with observations of monitoring stations with dead cockroaches trapped inside in each of the room monitoring stations. The LNHA stated the plan was to work each of the 5 floors separately, and empty 4-5 resident rooms of all the resident belongings on the day of treatment, then the pest control company would spray the room and the room would have to be kept empty to keep the resident safe from chemical exposure and the resident and belongings would then be moved back. The LNHA did not offer any plan related to the residents' belongings and personal items being exposed to cockroaches and excrement. The LNHA stated that the roaches would eat the bait and die in the chemically treated room, however, the cockroaches would be chased to the next rooms and would only die when all the rooms were treated. According to the LNHA the surviving cockroaches would continue to the next floor, and then the next until the entire building was treated. Surveyor #5 asked if the facility sanitation was being addressed as well in conjunction with the chemical management to kill the cockroaches, to ensure there was no sources to attract the cockroaches. At that time, the LNHA pointed to the hallway floors and stated they were recently cleaned and waxed, and he was working on having the same completed in the residents' rooms, however, he did not provide any specifics. On 12/05/2025 at 12:25 PM, Surveyor #4 interviewed the LNHA stated he had been the LNHA since 8/26/25 and he scheduled a meeting with the pest control company the first day. When asked the LNHA if he has seen cockroaches? The LNHA stated yes, it is a problem. When asked if the current pest management program was effective, he reiterated, he knows it is a problem. The surveyor informed the LNHA of the observations with the swarming cockroaches in Resident #31's closet and the LNHA provided the Pest Management Service Inspection Report/Invoice book.The surveyor reviewed the documents which revealed the following: -9/18/24 General Comments/Instructions: 203,204,205,206,207,208,209 Roach Treatment, unable to fully treat for service due to patients still in the room and rooms were not fully prepared. -9/25/24 General Comments/Instructions: Treated room [ROOM NUMBER] for roach activity. Treated baseboards, kitchen, bathroom, nurses' station, dining area, and common areas throughout facility . Recommend better sanitation, observed moderate food and trash in rooms.-9/25/24 General Comments/Instructions: Treated rooms 203, 204, 205, 206 207, 208 and 209 for roach activity .observed minor activity during service. Recommend better sanitation, floors were really sticky and moderate food/trash in the rooms.-12/18/24 General Comments/Instructions: Treated room [ROOM NUMBER] for roach activity .Minor activity seen during service. Recommend better sanitation throughout patient rooms.-4/9/25 General Comments/Instructions.Inspected and treated throughout kitchen and nurses' station on 4th floor. Observed live roach activity along the side of the countertop behind refrigerator, pulled out refrigerator and bated along countertop, inside fridge motor components and cabinets. Positive bait acceptance observed .-4/23/25 General Comments/Instructions: Treated rooms 203, 211, 213, 305, nurses' stations and pantry rooms on floors for control of roach activity. Observed live activity in room [ROOM NUMBER]. -4/23/25 General Comments/Instructions: ROOM [NAME] BE PREPARED 232 -roach treatment. Inspected and treated room [ROOM NUMBER] for roach activity . -5/1/25 General Comments/Instructions: Treat rooms 301 through 324 for roaches. Inspected and treated rooms 301-324 for roaches. Baited voids, nightstands, dressers and placed insect monitors throughout. Heavy roach activity observed throughout rooms; 301, 308, and 311. Roach activity was observed in all rooms on 301-316 side. Poor sanitation throughout the 3rd floor. Especially rooms 301-316. Spoke with Maintenance Director (MD) regarding observations and recommendations.-5/21/25 General Comments/Instructions: Service 5 rooms on the 3rd floor for roaches. Rooms must be prepared. Spoke with LNHA and head of maintenance. Rooms were not prepared. - 7/30/25 General Comments/Instructions: Spoke with MD and Dietary Manager. Inspected and treated throughout rooms 401, 408 and 420 for roach activity. Inspected and treated throughout rooms on 2nd floor .Inspected and treated throughout kitchen, dishwasher room, service hallway and break room. Observed roaches in kitchen oven areas and deep freezer areas.8/28/25 General Comments/Instructions: Met with new LNHA to discuss roaches and sanitation, along with the former MD. helpful with getting back on track with the roach program and the LNHA stated will have a meeting internally to discuss a few things with his staff members.On 12/09/25 at 9:10 AM, the surveyor interviewed the supervisor for the Pest Management Company (SPM) with the LNHA present. The SPM stated he oversees the facility pest management program and when asked about the cockroaches that per the pest logs were identified in June 2024. The SPM stated the facility did not ensure the rooms were appropriately prepared for pest management services and the rooms had to be cleaned and emptied. Reviewed a 5/1/25 Service Inspection Report regarding roach activity in all rooms on 301-316 side, and poor sanitation throughout the 3rd floor, and was reported to the MD, and asked if the SPM recommendations were followed, the LNHA stated he spoke with the staff regarding no food being left over from the residents and the food and meal trays were supposed to be cleaned up right away and he could not speak to May 2025. The surveyor asked the LNHA about the resident food that was observed left out on the units during survey, including on 12/2/25? The LNHA stated nothing should be left out; no meal trays should be left out. The surveyor asked what the specifics of the new cockroach program were. The SPM stated that residents must vacate their rooms and the facility must remove all resident items. Th SPM stated the German roaches could have 30 egg sacks per roach and the gel bait dust would not work unless the resident was out of the rooms. The SPM stated people can bring the roaches into the facility, they are dirty roaches and the worst to get rid of. When asked if the German cockroaches can transmit disease, the SPM stated, yes, they can. The surveyor asked what the facility was doing to eliminate the cockroaches and ensuring residents do not bring them to the facility. The LNHA stated there was nothing in place to ensure residents coming to the facility as new admissions were not bringing in cockroaches. The SPM stated 5-6 rooms need to be completed at each time. The surveyor requested the cockroach plan and any documentation related to the room treatment plan. The LNHA stated we give the company a list of 6-7 rooms to treat. The surveyor asked if cockroaches crawled on linens and clothes was that, okay? The LNHA stated, that was not okay, nobody wants roaches. Asked about Resident #31's clothing and personal belongings that were in the closet with swarming cockroaches? The LNHA stated, it wasn't washed or anything. The SPM stated, the clothes should be removed, bagged, washed, because whatever is not treated, the bugs will come back. The surveyor asked the LNHA did Resident #31 have their room emptied? The LNHA stated he didn't think the room was fumigated. On 12/09/25 at 9:40 AM, the surveyor asked the LNHA what is being done to ensure the cockroaches are irradicated after they are on personal belongings and clothing? The LNHA stated there is no process in place regarding the clothing and personal belongings. This was 5 days after the survey team notified the LNHA of the observations in Resident #31's closet and the resident's desire to have belongings washed and the closet cleaned out. On 12/09/2025 at 4:00 PM, advised the LNHA of concerns regarding the environment and need to extend the survey, in the presence of Surveyor #5.On 12/09/25 at 4:12 PM, the Regional Director of Nursing (RDON), Director of Nursing and LNHA addressed the survey team. The RDON stated, we know the pests are a problem and we don't think what we have done has achieved the objective, even if we have to evacuate the building, they will, we are going to take an aggressive approach. The LNHA stated the 6 to 7 rooms per what we are doing is probably not working. On 12/10/25 at 10:39 AM, the surveyor interviewed the Maintenance Director (MD), who stated he worked at the facility for a few years and was recently promoted to Director from Maintenance Assistant. The surveyor asked about his role related to the pest management and logs. The MD stated his role was to make sure that the pest logs matched the Invoices and they were not duplicated and then he would send the Invoices to accounts payable. The surveyor asked what else he did with the Invoice Reports? The MD stated, I just file them. The surveyor asked if he had ever read them regarding the recommendations, and he stated, I read quite a few of them. The surveyor reviewed a report dated 9/25/25 regarding needing better sanitation and asked what was done? The MD stated it was discussed with housekeeping and nursing per the former MD and that was documented in the morning meeting. When asked if there was documentation related to that he stated, no. When asked about a recommendation from a 10/9/24 Invoice to Recommend maintenance sealing up voids near vent area in room [ROOM NUMBER] and 323, did he recall that being completed? The MD stated, that was vague and didn't remember anything about that since he was not the MD at that time. When asked about the recommendations regarding sanitation, he stated maybe a word-of-mouth thing. When asked about rooms not being prepped for service he stated, it happened quite often, and that had to do with nursing. When asked if the cockroaches were a problem he stated, it has been an ongoing problem here for years, is it the worst now, the facility is not really assessing the problem when they see it. The MD confirmed there were no additional Invoice reports at that time. When asked about the 5/1/25 report regarding the poor sanitation, he recalled having a discussion with the former MD about coordinating the whole right side of the wing because the 5-room thing wasn't working, but it would have been a big effort and the resident would have to be removed for 48 hours to vent and fumigate. When asked what happened, he stated, he did not hear any follow up at all, it was passed on and went nowhere. When asked if he met with the pest company when the current LNHA came, he stated it was an internal meeting and nothing was funneled down to him as he was not involved.On 12/10/25 at 2:55 PM, the LNHA provided the surveyor with a copy of the undated pest management company plan for Roach Treatment which revealed: Description of service: Our roach control service will be performed in a systematic, room -by-room order, addressing five resident rooms per service visit to ensure thoroughness, safety, and minimal disruption. Resident Preparation Requirements: 1. Prior to service, the following must be completed for each room: 1. Remove all resident belongings from drawers, cabinets, and closets. a. clothing, personal items, papers, and other contents must be taken out and placed in sealed bags or bins provided by the facility. 2. Clear all items from floors. 2. No boxes, shoes, bags, or loose items may remain on the floor. 3. Thoroughly clean the room before treatment, including: a. Sweeping and mopping floors, b. Cleaning baseboards, c. Wiping down all furniture (inside and out) such as dressers, nightstands, and bedframes, d. Removing any food debris or spills, e. Ensuring trash is removed. 4. Move furniture slightly away from the walls where possible to allow proper access for treatment .Post-Service Requirements: After treatment: Residents must remain out of their rooms for 3-4 hours to allow products to dry and settle safely; Rooms must remain clean and clutter-free to maximize the effectiveness of treatment and prevent re-infestation. Facility Responsibilities: Ensure staff is available to prepare rooms ahead of the scheduled service; Coordinate temporary relocation of residents for the required out-of- room period; Maintain sanitation and housekeeping standards between services. On 12/10/25 at 11:25 AM, while seating at the nursing station on the 2nd floor, Surveyor #1observed a roach crawling on the wall next to the medication cart. The surveyor alerted the staff, a Licensed Practical Nurse who was nearby used a cardboard to kill the roach. On 12/11/25 at 10:15 AM, Surveyor #4 interviewed the Assistant Director of Nursing (ADN) and asked if she was aware of the cockroaches, and she stated, I know we have roach issues. When asked if she had been involved with the pest management company to appropriately prepare the resident rooms for service, she stated that we are informed what rooms need service would then inform the Charge Nurse. When asked who followed up to ensure the resident rooms were ready for treatments, she stated, no one. When asked if there were any other steps or areas that needed to be monitored to eradicate the cockroaches besides moving residents out of rooms, and asked specifically to ensure that facility sanitation was maintained, including making sure there were no resident food trays left out. The ADON stated, no, On 12/11/25 at 1:17 PM, the survey team met with the Corporate Director of Nursing, the LNHA and DON to further review the above-mentioned findings. On 12/11/2025 at 3:09 PM, the survey team met with the above facility representatives and no additional information was provided. NJAC 8:36-4.1(a)11; 27.3(c); 31.5(a)(1)(2); 31.8(e)

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training for 5 of 5 CNAs education reviewed. This deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the hourly training and/or performance evaluations for the requested CNAs. The DON and could only provide checklists for the CNAs.On 12/10/2025 at 1:15 PM, the surveyor interviewed the Human Resources Director (HRD) who confirmed there were no competencies for the staff, and for the CNA education, there was a trifold bulletin board used with no documentation regarding any hourly training provided to CNAs. The HRD confirmed that there was no proof of the hours trained and only had a checklist. On 12/11/25 at 10:15 AM, the surveyor interviewed the Assistant Director of Nursing who Nursing who confirmed that there was no system in place to document the hourly training and could only provide checklists for the CNAs.On 12/11/25 at 11:55 AM, the survey team interviewed the Licensed Nursing Home Administrator, who acknowledged that the education in the building was not being done correctly.A review of the facility's Policy and Procedure In-service Nursing Aid Training, dated December 2024, the policy revealed: [.] The facility completes a performance review of nurse aides at lease every 12 months [.]Annual in-service: ensure the continuing competence of the nurse aides; are no less that 12 hours per employment year; address areas of weakness as determined by the nurse aide performance reviews; address the special needs of the residents, as determined by the facility assessment; include the training that addresses the care of residents with cognitive impairment; and include training in dementia management and resident abuse prevention [.]N.J.A.C. 8:39-43.17(b)

Based on observation, interview and document review it was determined that the facility failed to ensure a comprehensive, data-driven Quality Assurance Program (QAPI) was implemented and sustained during leadership transition and focused on resident outcomes and quality of life to ensure for an ongoing infestation of cockroaches that was documented as observed on the 3rd floor beginning 6/1/24, and affected 3 of 3 resident units.The deficient practice was evidenced by the following:Refer to 584F, 925F, and 880F The surveyors observed cockroaches during the following observations:- On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. -On 12/04/25 at 12:30 PM, Surveyor #2 and #4 observed Resident #31's room. Resident #31 allowed the surveyors to observe their closet for cockroaches, and upon opening the closet door, both surveyors observed swarming live cockroaches scatter, and many dead cockroaches were affixed to a white sticky trap. Personal belongings that included a blanket, computer and clothing were observed inside the closet with the swarming cockroaches. Upon interview, Resident #31 stated they were not offered to have their closet or clothing cleaned after the exterminator had placed the cockroach trap in the closet. -On 12/5/25 at 11:06 AM, Surveyor #5 conducted a building tour with the Licensed Nursing Home Administrator (LNHA) and observed cockroaches swarming on the hinged side of the bathroom door in room [ROOM NUMBER] and roach feces were on the door frame.-On 12/05/2025 at 12:25 PM, Surveyor #4 interviewed the LNHA stated he had been the LNHA since 8/26/25 and he scheduled a meeting with the pest control company the first day. When asked the LNHA if he has seen cockroaches? The LNHA stated yes, it is a problem. When asked if the current pest management program was effective, he reiterated, he knows it is a problem. -On 12/09/25 at 7:22 AM, Surveyor #1 observed a cockroach crawling on the clean linen cart that was in the 2nd floor hallway. The surveyor alerted the staff and the Housekeeping Director (HD) then removed the linen cart from the floor. -On 12/10/25 at 11:25 AM, while seating at the nursing station, Surveyor #1 observed a cockroach crawling on the wall next to the medication cart. The surveyor alerted the staff, a Licensed Practical Nurse who was nearby used a cardboard to kill the roach. On 12/09/25 at 9:10 AM, the surveyor interviewed the supervisor for the Pest Management Company (SPM) with the LNHA present. The SPM stated he oversees the facility pest management program and when asked about the cockroaches that per the pest logs were identified in June 2024. The SPM stated the facility did not ensure the rooms were appropriately prepared for pest management services and the rooms had to be cleaned and emptied. The surveyor asked what the specifics of the new cockroach program were. The SPM stated that residents must vacate their rooms and the facility must remove all resident items. Th SPM stated the German roaches could have 30 egg sacks per roach and the gel bait dust would not work unless the resident was out of the rooms. The SPM stated people can bring the roaches into the facility, they are dirty roaches and the worst to get rid of. When asked if the German cockroaches can transmit disease, the SPM stated, yes, they can. The surveyor asked what the facility was doing to eliminate the cockroaches and ensuring residents do not bring them to the facility. The LNHA stated there was nothing in place to ensure residents coming to the facility as new admissions were not bringing in cockroaches. The surveyor asked if cockroaches crawled on linens and clothes was that, okay? The LNHA stated, that was not okay, nobody wants roaches. Asked about Resident #31's clothing and personal belongings that were in the closet with swarming cockroaches? The LNHA stated, it wasn't washed or anything. The SPM stated, the clothes should be removed, bagged, washed, because whatever is not treated, the bugs will come back. On 12/09/25 at 9:40 AM, the surveyor asked the LNHA what is being done to ensure the cockroaches are irradicated after they are on personal belongings and clothing? The LNHA stated there is no process in place regarding the clothing and personal belongings. This was 5 days after the survey team notified the LNHA of the observations in Resident #31's closet and the resident's desire to have belongings washed and the closet cleaned out. On 12/09/25 at 4:12 PM, the Regional Director of Nursing (RDON), Director of Nursing and LNHA addressed the survey team. The RDON stated, we know the pests are a problem and we don't think what we have done has achieved the objective, even if we have to evacuate the building, they will, we are going to take an aggressive approach. The LNHA stated the 6 to 7 rooms per what we are doing is probably not working. On 12/11/2025 at 11:55 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA confirmed he oversaw QAPI and if the facility identified concerns, they would add to QAPI and develop a performance improvement plan. The surveyor asked what QAPI's were in place. The LNNHA stated the facility reviewed falls, a QAPI related to splints, side rail use and consents. When asked if there was any QAPI transferred to him from the prior administration, and he confirmed there was none.The Quality Assessment and Performance Improvement Plan , undated revealed: The facility shall establish and maintain a QAPI Committee that oversees the identification and handling of the quality issues. This plan is under the guidance of the owners and administrator of Water's Edge. Goals of the Committee: To oversee facility systems and processes related to improving quality of care and services; To help identify negative outcomes relative to resident care and resolve them appropriately; To coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and service, and between facility staff, residents, and family members. NJAC 8:39-33.1

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 5 of 5 Certified Nurse Aides reviewed and the deficient practice was evidenced by following: A review of the facility-provided CNA annual performance evaluations revealed that 5 of the 5 CNAs did not have an annual performance evaluation for 2024.On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document performance evaluations for the requested CNAs. The DON and could only provide checklists for the CNAs.On 12/11/25 at 10:15 AM, the surveyor interviewed the Assistant Director of Nursing who Nursing who stated that there is not a person in the facility dedicated to check the competency of the staff providing care.On 12/11/25 at 11:55 AM, the survey team interviewed the Licensed Nursing Home Administrator, who acknowledged that the education in the building was not being done correctly and confirmed there are no staff competencies being completed.A review of the facility's Policy and Procedure In-service Nursing Aid Training, dated December 2024, the policy revealed: [.] The facility completes a performance review of nurse aides at lease every 12 months [.]Annual in-service: ensure the continuing competence of the nurse aides; are no less that 12 hours per employment year; address areas of weakness as determined by the nurse aide performance reviews; address the special needs of the residents, as determined by the facility assessment; include the training that addresses the care of residents with cognitive impairment; and include training in dementia management and resident abuse prevention .NJAC 8:39-43.17(b)

Based on interview and document review it was determined that the facility failed to ensure the Facility Assessment identified competencies and skill sets that were necessary to provide the level and types of care needed for the resident population. This deficient practice affected all residents who resided on 3 of 3 resident units and was evidenced by the following: On 12/2/25, during the entrance conference, the facility provided a copy of the Facility Assessment which revealed under Services and Care Provided: Other Special Care Needs: dialysis, chemotherapy, radiation, ostomy care, tracheostomy, ventilator care .On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the amount of hourly training and/or performance evaluations for the requested CNAs. The DON could only provide checklists for the CNAs without any specifics related to the amount of training. On 12/11/25 at 9:31 AM, the surveyor interviewed the facility Infection Preventionist (IP). When asked if the IP ever completed staff competencies? The IP stated besides handwashing, there were no other competencies provided.On 12/11/25 at 10:15 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding her role. The ADON stated she oversaw the nurses and completed audits. When asked if she physically observed nursing staff provide care, she stated, no, I don't physically observe care. The surveyor asked if she was involved with staff education? The ADON stated, I do education if there was a need. The ADON stated if there was an updated Care Plan for a resident. The surveyor asked if she completed annual competencies on the staff, or did the facility have an annual education schedule? The ADON, stated, no, I do not. When asked who was responsible for education, the ADON stated that sometimes the DON completed education. The ADON stated we used to have an online company and now the facility used another online company since the transition occurred with the new owners. The surveyor asked about dialysis residents, as they were listed on the Facility Assessment, and was it important to know how to care for a resident who required dialysis, including knowing how to check a dialysis catheter? The ADON stated, yes, but we don't have a person to do that. The surveyor asked how would you know if staff was competent, the ADON stated, they can ask me or a charge nurse. The surveyor asked was it important to know if staff could use mechanical lifts? The ADON again stated, yes, but they don't have a person for that. The surveyor asked how do you know your staff is competent, the ADON stated, they have been here a long time, but to actually know if staff have done something correctly, no, I don't have a person to do that. The surveyor asked if residents had tracheostomies (trach)? The ADON stated yes, and when asked how do you know that staff provide appropriate trach care? The ADON stated I can't tell you; they are seasoned nurses. When asked how do you know that the agency staff knows what to do, the ADON stated, I cannot tell you, I don't have an educator to demonstrate back. On 12/11/25 at 11:55 AM, the survey team interviewed the Licensed Nursing Home Administrator, who acknowledged that the education in the building is not being done correctly and that there are no competencies being completed.NJAC 8:39-43.17(b)

Complaint #s NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents who were dependent on staff for care were provided with a) routine and appropriate incontinence care and b) provided with care to maintain their fingernails in a clean manner. This deficient practice was identified for 3 of 4 residents reviewed for Activities of Daily Living (Resident #11, #81 and Resident #135. The deficient practice was evidenced by the following: 1. On 12/02/25 at 7:50 AM the surveyor observed Resident # 11 lying in bed, the resident was awake and alert and the surveyor further observed that the resident's fingernails were long and jagged with a black substance underneath all of the nails.On 12/04/25 at 8:25 AM, the surveyor again observed Resident #11's fingernails were not cleaned trimmed. During an interview with the surveyor, the resident stated, I would like them to be trimmed and cleaned.On 12/05/25 at 11:30 AM, the surveyor again observed Resident #11's fingernails and the resident's fingernails were not trimmed or cleaned after being assisted with morning care.On 12/05/25 at 11:40 AM, the surveyor interviewed the Unit Manager regarding what should be completed for resident nail care. The Unit Manger (UM) stated that residents nails were supposed to be trimmed and cleaned with the weekly skin assessment. The surveyor reviewed the shower log with the UM, and observed that Resident #11's shower schedule was every Wednesday. Resident #11 had a shower on Wednesday 12/3/25, and nail care was not completed.Review of the resident's December Physician Order Sheet (POS) did not reveal a Physician's Order (PO) for fingernail care. The POS included an order for skin assessment every Monday on the 3:00 PM-11:00 PM shift.On 12/5/25 at 12:15 PM, the surveyor reviewed Resident #11's admission Record which reflected that the resident had diagnoses which included, but was not limited to; difficulty in walking, contracture left foot, and adjustment disorder with mixed anxiety and depressed mood. The Quarterly Minimum Data Set (MDS) dated [DATE], coded Resident #114 as being of intact cognition. Resident #11 scored 15 out of 15 on the Brief Interview for Mental Status. (BIMS) Normal Score 15. Section GG of the MDS which addressed functional status reflected that Resident #11 required assistance with care. The interventions where staff will encourage the resident to perform tasks, they are physically capable of. Staff will assist with 2 staff members when appropriate. 2. On 12/02/25 at 8:02 AM, the surveyor observed Resident #81 in bed. During an interview with the resident, they informed the surveyor that they had not received incontinence care or had been repositioned since 9:30 PM last night.On 12/02/25 at 8:34 AM, the surveyor interviewed the resident's Certified Nurse Aide (CNA) who stated that the resident informed him that they had not seen a CNA last night. They resident stated they were leaning against the siderail for the night and staff did not come to the room when they activated the call light.On 12/02/25 at 8:35 AM, the surveyor performed an incontinence check with the CNA assigned to the resident. Resident #81 was saturated with urine, and the bedding, including the pad were soaked with urine and were yellow stained The CNA assigned to Resident #81 for the morning shift stated that he was not aware that the resident had not been changed. The CNA further stated he did not receive report from the 11:00 PM - 7:00 AM shift, and he repositioned the resident this morning but did not provide incontinence care. Resident #81 had was observed with some redness on the buttocks and groin areas and the skin was not opened. The CNA stated that the night shift staff were supposed to check and change the residents, prior to leaving, at the end of the shift.Resident # 81's admission Record reflected the resident had diagnoses which included, but were not limited to; multiple sclerosis, cognitive communication deficit, paraplegia (loss of motor and sensory function in the lower half of the body) major depressive disorder and anemia.Review of the most recent quarterly MDS, dated [DATE], indicated that Resident #81's cognitive skills for decision making were intact. Resident #81 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). A further review of the resident's MDS, Section GG - Functional Status indicated that the resident required one-person physical assist with personal hygiene.Review of the resident's Care Plan revised on 10/30/23, reflected a focus area that the resident had preferences and interventions to help maintain his/her quality of life and assist with daily choices. Initiated 10/30/2023. The goal of the resident's Care Plan was that the resident's preferences will be honored and updated as they changed. Initiated 10/30/2023 with a target date of 01/25/26. The interventions for the resident's ADL Care Plan included to provide care, Resident #81 was a total care, to assist with baths and showers and assist with incontinence care. On 12/02/25 at 12:05 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The LPNUM stated that incontinence care was to be offered every two hours and as needed. The LPNUM reviewed the schedule and stated one CNA called out and there were only two CNAs for the floor. Each CNA had to care for 23 residents. The Census was 47.3. On 12/2/25 at 8:06 AM, the surveyor continued the tour and entered Resident #135's room. The surveyor observed Resident #135 in bed, their extremities appeared contracted. Resident # 135 was positioned on the right side; their eyes were opened but Resident #135 was nonverbal. The surveyor asked a random CNA to assist with an incontinence care tour observation, 2 CNAs entered the room and proceeded to perform the incontinence check with the surveyor. The surveyor observed that Resident #135 was saturated with urine. Resident #135 had a dressing on the left hip area that was also saturated with urine and bloody drainage. The CNAs repositioned the resident to the right side, and we all observed Resident #135 was wearing two incontinence briefs which were both saturated with urine. One of the CNA informed the surveyor that Resident #135 was on her assignment, but she did not provide any care yet. The CNA declined to comment when inquired if it was the first time that Resident #135 had been wearing two incontinence briefs.On12/05/25 at 8:40 AM, the surveyor interviewed the CNA who assisted the surveyor with the incontinence observation. The CNA stated that when the CNAs reported to their units, the CNAs should be checking the residents to ensure that everyone was safe and that incontinent residents were clean and dry. The CNA further stated that incontinence care should be provided at least twice during each shift to ensure that the residents were not soiled or if they needed to be assisted to the toilet prior to exit the unit. The CNA added, Incontinent residents should never be wearing multiple briefs because that create moisture and could cause skin issues.On 12/5/25 at 10:30 AM, the surveyor reviewed Resident #135's admission Record which reflected that the resident had diagnoses which included, but were not limited to; cognitive communication deficit, unspecified dementia, osteomyelitis of vertebra, muscle weakness, and bed confinement status.Review of the most recent quarterly MDS dated [DATE], indicated that Resident #135 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident had severe cognitive impairment. A further review of the resident's MDS, Section GG - Functional Status indicated that the resident was totally dependent on staff for care.Review of the resident's Comprehensive Care Plan dated 10/06/25, revealed a focus area that the resident has preferences and interventions to help maintain his quality of life and assist with daily choices. The goal of the resident's CP was the resident's preferences will be honored and updated as they changed. The interventions for the resident's ADL Care Plan included, incontinence care, assistance with bathing and hygiene and bed mobility.On 12/09/25 at 11:34 AM, the surveyor interviewed the CNA who cared for the resident on 11:00 PM-7:00 AM shift. The CNA confirmed that she placed two briefs on the resident She stated she cared for the resident during the night, and the Resident had two incontinence briefs on at that time. She assumed that the resident needed two incontinence briefs. The CNA stated that she could not recall when Resident #135 was last changed during her shift. The CNA stated usually incontinence care was provided every 2 hours, but one CNA called out last night and the workload was heavyOn 12/09/25 at 11:50 AM, the surveyor interviewed the LPNUM on the second floor. The Unit Manager stated that the CNAs were responsible for providing incontinence care every 2 hours and as needed. On 12/09/25 at 1:22 PM, an interview with the Director of Nursing (DON) revealed that the CNAs were in-serviced regarding incontinence care. The DON further stated the facility's policy was to provide incontinence care at least every 2 hours during the shift and no resident should have to wear more than one brief.The facility policy titled, Resident ADL Care dated 11/11/25 indicated the following:Purpose: To ensure all residents receive person-centered, safe, and consistent assistance with Activities of Daily Living (ADLs) that promote dignity, independence, comfort, and overall quality of life.Policy: The facility is committed to providing individualized ADL care based on each resident's unique needs, abilities, preferences, and care plans. Assistance shall be provided in a manner that upholds residents' rights, dignity, privacy, and safety.NJAC: 8:39-27.1 (a)

COMPLAINT #2620207 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/07/2025, it was determined that the facility failed to ensure a resident (Resident #2) whose smoking privileges were revoked did not have cigarettes in their possession or smoke in the facility in the presence of oxygen to prevent accidental explosion and fire from unsafe smoking. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for accidents. During an interview with the Nursing Supervisor (NS) on 10/07/2025, she stated that while conducting her rounds on 09/16/2025, at approximately 8:00 P.M., she observed Resident #2 seated in a wheelchair, smoking a cigarette in Resident #1 and Resident #3's room. The NS stated that Resident #2 did not reside in that room; they were talking to Resident #3; and Resident #1, who was present, had oxygen in use. The NS stated that Resident #2 saw her entering the room and immediately tried to put out the cigarette on the wheelchair, and she stated, No, no, no. You're not supposed to have that in your possession and the resident handed it to her. The NS stated that a search of Resident #2's wheelchair revealed a pack of cigarettes and a bottle of vodka. During an interview with the Director of Nursing (DON) on 10/07/2025, she stated that Resident #2 had already had smoking privileges revoked for repeated violations of the smoking policy which included the sharing of cigarettes, attempting to smoke in areas outside of the designated smoking area, and not leaving cigarettes at the front desk. The facility's failure to ensure a resident, whose smoking privileges were revoked, did not have cigarettes in their possession or smoke in the facility in the presence of oxygen placed all residents at risk for serious harm, injury, or death from accidental explosion or fire from unsafe smoking. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 09/16/2025 at 8:00 P.M., after Resident #2 was observed smoking a cigarette in Resident #1's room while oxygen was in use. The facility was notified of the IJ on 10/07/2025 at 4:24 P.M. The facility submitted an acceptable Removal Plan (RP) on 10/12/2025 at 5:52 P.M. The surveyor verified the implementation of the RP during the on-site survey on 10/14/2025. The evidence was as follows:A review of the facility's Smoking Policy and Procedure dated revised 05/2025, included that the purpose of the policy was, To provide a safe environment for all. The Procedure/Protocol section included, . 3. Residents will only be allowed to smoke in the designated facility Smoking Area, 4. All tobacco products . will be kept at the Reception Desk, 5. No tobacco products or lighting materials will be allowed to be kept on the Resident's person or stored in their rooms [.] 16. E-Cigarette and Vape smoking will not be permitted within the building. A review of the Facility Reportable Event (FRE) sent to the New Jersey Department of Health (NJDOH), indicated that on 09/16/2025 at 8:00 P.M., while completing rounds, the NS observed Resident #2 smoking in Resident #1's room while oxygen was in use. The cigarette was immediately taken away and Resident #2 was escorted out of the room. The FRE indicated that Resident #2's, . smoking privileges were revoked prior to this event for other infarctions. The FRE also revealed that a search of Resident #2's room and wheelchair led to the discovery of cigarettes and alcohol and the resident was then placed on one-to-one (1:1) supervision. Further review of the FRE documentation that was provided by the facility on 10/07/2025, included the following:-Incident Summation Report.-Physical Assessment of Resident #2.-Incident Investigation Form.-Employee Statement from assigned nurse.-Statements from the DON who interviewed Resident #2 and the Assistant Director of Nursing (ADON). No documentation was provided regarding statements collected or assessments completed for Resident #1 or Resident #3 on the night of the incident. 1. On 10/07/2025 at 9:32 A.M., the surveyor observed Resident #1 lying in bed asleep. The surveyor was unable to interview the resident during the survey. A review of the resident's medical record was conducted. According to the admission Record face sheet, an admission summary, Resident #1 was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease, chronic respiratory failure, and dependence on supplemental oxygen. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool dated 08/07/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated that the resident's cognition was severely impaired. A further review of the MDS revealed that the resident required oxygen therapy. A review of Resident #1's Order Summary Report (OSR) revealed an active order for 5 liters per minute (lpm) of continuous oxygen via nasal cannula, that was initiated on 09/11/2025. A review of the resident's corresponding Medication Administration Record (MAR) for September 2025, revealed that on the evening shift of 09/16/2025, the box was signed indicating that the resident had oxygen in place. A further review of the medical record did not include documentation of a statement or an assessment related to the incident. 2. Resident #2 was not at the facility at the time of the survey. A closed medical record review was conducted. According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following a cerebral infarction, glaucoma, mood disorder, and anxiety disorder. A review of Resident #2's comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. A further review of the MDS revealed that the resident currently used tobacco. A review of Resident #2's care plan (CP) revealed that the resident had a focus related to smoking that was initiated on 07/10/2024. The focus included:-[Resident #2] is noncompliant with smoking policy. [They] violated policy.-[Out on pass] changed to not permitted to leave facility.-[Resident #2] was observed smoking in room.The focus area included a revision date of 09/26/2025, but did not indicate when each individual update was made to this goal. A further review of the resident's CP included interventions as follows:09/08/2025: [Resident #2's] smoking privileges were revoked. The resident was re-educated on the smoking policy and informed of the revocation.09/08/2025: The resident was re-educated on smoking cessation and options were offered.09/16/2025: [Out on pass] changed to not permitted to leave the facility.09/17/2025: 1:1 observation initiated.09/17/2025: Continued education with use of nicotine patch.09/17/2025: Room search and person was searched as well.09/17/2025: Staff were to continue to perform random room checks. A review of the Resident #2's Progress Notes (PN) from September 2025, revealed the following:-09/08/2025 at 10:50 A.M., the Social Worker (SW #1): Team met with the resident to discuss the resident's violation of the facility's smoking contract. The resident admitted to sharing a cigarette, and smoking privilege was revoked. The resident acknowledged understanding of the revocation.-09/08/2025 at 11:43 A.M., the ADON: Team discussed resident's revocation of smoking privileges with doctor, nicotine patch was ordered, and the CP was updated.-09/08/2025 at 1:29 P.M., the DON: Met with resident to discuss the resident's understanding of the smoking privilege revocation.-09/10/2025 at 5:32 P.M., SW #2: Team met with resident to discuss a vaping incident that occurred in the facility's day room.-09/12/2025 at 12:44 P.M., Licensed Practical Nurse (LPN #1): Resident is smoking [physician] made aware.-09/15/2025 at 5:45 P.M., SW #2: Team met with the resident to discuss that the resident was observed outside on the facility grounds smoking. Due to the incident, the resident's [Out of Facility] passes were revoked, and smoking privileges were suspended indefinitely due to repeated violations of sharing cigarettes, vaping in the facility, and bringing cigarettes on the unit. The resident continues with the nicotine patch.-09/17/2025 at 6:09 P.M. SW #2: Team met with resident to discuss incident related to Resident #2 smoking in a room with oxygen, and the police were called. The resident was informed that a 1:1 would continue, and they could be subject to person and room searches. Their smoking privilege continues to be revoked indefinitely. A review of Resident #2's medical record indicated that the resident was connected to a psychiatric provider prior to the incident, but there was no indication that the resident was seen after the incident occurred. A further review of the medical record revealed that Resident #2's most recent Smoking Assessment, dated 09/15/2025, indicated that the resident did not understand the facility's smoking policy. 3. On 10/07/2025 at 9:34 A.M., Resident #3 was observed lying in bed awake. When asked about the incident, the resident reported hearing about a resident smoking in the room but denied being in the room at the time of the incident. The resident further stated being educated about smoking around the use of oxygen was very dangerous and that no smoking supplies were to be kept in the room. According to the admission Record face sheet, Resident #3 was admitted to the facility with diagnoses that included but were not limited to: fracture of the sacrum (lower back), anxiety disorder, and hypertension (high blood pressure). A review of Resident #3's comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. During an interview with the Smoke Aide (SA) on 10/07/2025 at 10:05 A.M., he stated that no smoking was allowed in the building and that residents were to keep all cigarettes at the front desk. The SA explained that each resident had designated times when they were allowed to smoke, and when it was their turn, they were given one cigarette from the front desk staff and brought it directly to the designated smoking area where he would light it and provide the appropriate level of monitoring/assistance. The SA further stated that smoking near oxygen was especially dangerous because of the fire risk, and he denied knowledge of any resident being caught smoking inside of the building. During a telephone interview with the Certified Nurse Assistant (CNA #1) on 10/07/2025 at 11:18 A.M., she stated that no smoking was allowed in the building, only in the designated area, and that no residents were allowed to have smoking supplies on the units, and if either were observed, she had to report it immediately to the nurse. CNA #1 stated that she recalled catching Resident #2 with cigarettes and a vape prior to the incident, and that she reported each instance to the nurse after the resident was not compliant with turning them over to her. CNA #1 stated that in those instances, the nurse managed to get the resident to comply with turning them over, but that she was unsure what happened or what was documented after that. CNA #1 could not recall the specific date or time of these incidents. CNA #1 confirmed that she was assigned to Resident #2 on 09/16/2025, during the evening shift, and stated that she was not on the unit at the time of the incident. CNA #1 stated that she recalled seeing the resident that night but denied seeing the resident with any smoking supplies or else she would have reported it to the nurse. During an interview with the DON and the Consultant Licensed Nursing Home Administrator (Consult LNHA) on 10/07/2025 at 12:27 P.M., the DON stated that Resident #2's smoking privileges had previously been revoked due to the resident's repeated violations of the smoking policy including: the sharing of cigarettes, signing out on pass and smoking in outdoor areas on the property outside of the designated smoking area, and vaping on the unit. The DON stated that she was contacted on the night of 09/16/2025, by the NS, who informed her that Resident #2 was caught smoking a cigarette in another resident's room in the presence of continuous oxygen. The DON stated could not recall the exact time, and that the NS said she immediately removed the cigarette. The DON instructed the NS to place Resident #2 on 1:1 observation and that a search of Resident #2's wheelchair was immediately done, and a pack of cigarettes and a full bottle of alcohol were confiscated and disposed of. The DON further stated that neither of these were allowed on the unit, and the resident should not have been smoking around oxygen. The DON stated that none of the resident's prior incidents involved smoking in a room with oxygen. During a telephone interview with LPN #1, the surveyor asked her about a PN dated 09/12/2025 at 12:44 P.M. LPN #1 stated that she observed Resident #2 with a vape in their mouth while in a hallway on the unit, and she saw a puff of smoke and then the resident placed it in their pocket. LPN #1 stated that she immediately reported it to the doctor who discontinued the resident's nicotine patch. LPN #1 further stated that residents were not allowed to have vapes or any smoking supplies on the unit; they were to be kept at the front desk. When asked if she addressed the resident and/or reported the incident to anyone, she stated no and that, The resident was hard-headed. During an interview with the NS on 10/07/2025 at 3:06 P.M., she stated that while conducting her rounds on 09/16/2025, at approximately 8:00 PM, she observed Resident #2 seated in a wheelchair, smoking a cigarette in Resident #1's room, while Resident #1's oxygen was in use. The NS stated that Resident #2 did not reside in that room, but that she observed Resident #2 speaking with Resident #3 who also resided in that room. The NS stated that Resident #2 saw her entering the room and immediately tried to put out the cigarette on the wheelchair, and she stated, No, no, no. You're not supposed to have that in your possession, and the resident handed it to her. The NS stated that Resident #1 slept throughout the entire incident, and she observed that oxygen was on and functional. The NS stated that she then explained to Resident #2 that a search would have to be conducted, and the resident responded, Yeah, yeah, I know. The NS stated that the search of the wheelchair revealed a pack of cigarettes and a bottle of alcohol that she removed from the unit.The NS further stated that she conducted a search of both (Resident #2 and Resident #1 & #3's) rooms at that time, and no other smoking supplies were found. The NS stated that after the incident, she contacted the DON who initiated a 1:1 observation for Resident #2, and the resident remained at her side for the first hour until she was able to assign the task to another staff member. The NS stated that Resident #2 remained on 1:1 observation for the remainder of their stay at the facility. The NS reiterated that Resident #1 was not affected by the incident as the resident slept through the whole thing, and that she provided verbal education to Resident #3 regarding reporting this type of incident immediately in the future as smoking was not allowed on the unit especially around the use of oxygen as that would be a fire risk. During a follow-up interview with the DON on 10/07/2025 at 2:10 P.M., she stated that no residents should have access to cigarettes, lighters or matches on the unit, especially around oxygen tanks, which had the potential to start a fire. During the interview, the DON provided a list of residents highlighted on the Smoking Schedule and stated that on 10/01/2025, a search of all smokers, and their rooms, was conducted.At that time, the surveyor reviewed the list which identified ten residents that were in violation of the smoking contract due to having smoking supplies on their person and/or room. Additionally, the DON provided the surveyor with the initial Smoking Contracts signed by Resident #1, Resident #2, and Resident #3. The surveyor noted the signed contract for Resident #2 which indicated in section 10 that, I understand that my room and/or person can be searched at any time for smoking items. The surveyor then asked since the facility was aware of Resident #2's repeated violation of the smoking contract/policy, if searches had been done prior to the incident on 09/16/2025, and the DON stated that they may have but she would have to check. No additional documentation was provided to the surveyor. On 10/10/2025 at 11:48 A.M., the surveyor attempted to verify the implementation of the facility's Removal Plan (RP) submitted to the New Jersey Department of Health (NJDOH) on 10/09/2025 at 5:09 P.M. At that time, the DON informed the surveyor that the facility did not have the education in the building, that the Consultant DON had the documents and was not at the facility. The surveyor was unable to verify the RP, and the DON was informed that the immediacy continued. An acceptable Removal Plan (RP) was received on 10/12/2025 at 5:52 P.M., 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 to include: the NS immediately removed the cigarette from Resident #2; Resident #2 was searched, and a pack of cigarettes and a pint of vodka was confiscated and destroyed; and Resident #2 was placed on 1:1 assignment until their discharge from the facility on 09/26/2025. On 09/16/2025, the NS educated Resident #2 and Resident #3 that smoking was prohibited in a resident room. On 10/08/2025, nurse leaders began educating all residents who smoked on the facility's smoking policy and the dangers of smoking near oxygen, and their rooms and equipment were searched by the ADON for violation of the smoking policy. On 10/10/2025, the nurse leaders and Consultant Registered Nurse (RN) re-educated all staff on the smoking policy and the dangers of smoking near oxygen. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 10/14/2025 2:23 P.M. N.J.A.C. 8:39-27.1(a), 31.6(e)

Complaint #: 2562900 Based on interviews, medical record reviews, and review of pertinent facility documentation on 7/22/25 and 7/23/25, it was determined that the facility failed to ensure the safety of a resident (Resident #3) with a known history of illicit drug use with multiple overdoses in the facility who overdosed in the facility on 7/11/25, by: A) monitoring and supervising the resident to ensure illicit drugs were not obtained or used and B.) developing and/or implementing care plan interventions to protect the resident from obtaining illicit drugs and preventing overdoses. This deficient practice was identified for 1 of 14 residents reviewed (Resident #14). On 7/11/25 at approximately 4:30 PM, the Registered Nurse (RN) Supervisor was called to main lobby regarding Resident #3 being found unresponsive with pinpoint pupils by the main elevator. Emergency services (911) were called, and the resident was administered Narcan (a medication to reverse opioid overdose). The resident was transported to the hospital for evaluation and the facility was notified that the resident received Narcan in the emergency room (ER) and was now stable. Interviews with staff on 7/22/25, confirmed that the resident had overdosed on illicit drugs in the facility. A review of the medical record revealed this was the resident's seventh overdose in the facility since November of 2024. The facility's failure to monitor and supervise Resident #3 who had a known history and six previous illicit drug overdoses in the facility placed Resident #3 and all other residents at risk for accidental drug overdoses. This posed the likelihood for serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 7/11/25 at 4:30 PM, when Resident #3 was found unresponsive in the main lobby and administered Narcan. The facility's Administration was notified of the IJ on 7/23/25 at 5:37 PM. An acceptable Removal Plan was received on 7/25/25 at 10:26 AM. The Removal Plan was verified on-site by the surveyor on 7/29/25. The deficient practice was evidenced by the following:A review of the facility's undated policy titled Policy on Illegal Drug Use included the facility complies with all laws, regulations, and other requirements related to substance abuse. Policy Interpretations and Implementation: 1. All residents admitted to the facility will be asked to sign a contract showing they understand that illegal drugs use (possession, taking of drugs or possession with intent to sell) is not allowed in the facility [.] 2. All residents may be subject to random room searches to ensure illegal substances are not being held within the facility. Any items found during the search will be removed, logged and locked in a designated area until the police are able to collect the items found.4. Residents identified as high risk for illegal drug use by the nursing department will be subject to be searched/have their bags searched by Security or Nursing upon return from authorized Out on Pass Visit. Security is to inform the Nurse in charge/ Director of Nursing (DON) immediately if any resident is found with illegal substances and police will be called. 5. In the event illegal drugs are found on a resident the following procedure must occur: [.] Incident report to be completed-Investigate how the resident received the illegal drugs and put interventions in place to prevent reoccurrence. The surveyor reviewed the medical record for Resident #3. According to the admission Record face sheet (admission summary), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: opioid dependence, hypertension (high blood pressure), and muscle weakness. According to the Minimum Data Set (MDS), an assessment tool dated 7/13/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. A review of the Progress Notes (PN) revealed the resident had overdosed from illicit drugs in the facility on 11/1/24, 11/28/24, 1/18/25, 1/28/25, 3/7/25, 3/30/25, and 7/11/25. A review of the PN dated 7/11/25 at 5:51 PM, completed by the Registered Nurse (RN), revealed that at approximately 4:30 PM, she was called to the main lobby regarding a resident's current status. Upon assessment, the resident was found unresponsive by main elevator. The resident was brought to the unit and sternal rub (rubbing the flat bone (sternum) of the chest) was performed and emergency services (911) was called. The resident's vital signs were obtained, and their pupils were pinpoint. Upon Emergency Medical Services' (EMS) arrival, the resident was placed on a non-rebreather (a mask that provides high amounts of oxygen in an emergency situation) and put on a stretcher and sent to the hospital for evaluation. A review of the PN dated 7/11/25 at 5:57 PM, indicated that a call was placed to the hospital at 5:40 PM, to obtain the resident's status. The resident was given Narcan in the emergency room (ER) and was now stable. A review of Resident #3's Care Plan (CP) included a focus area dated 10/17/24, and revised 6/12/25, that the resident had a history of opioid dependence, chronic back pain, on 5/9/25, had a history and potential risk for illicit drug abuse and overdose. The goal initiated on 10/17/24, with a target date of 7/15/25, was to verbalize relief of pain. Interventions included to encourage repositioning in bed to relieve pain; if confirmed diagnosis of overdose, facility will consider revoking out on pass and or may issue a thirty day discharge notice; reinforce facility support groups, virtual [name redacted alcohol and drug support groups] meetings can be arranged; educate the risks of overdose and/or possible death with use of illegal substances; if receiving methadone, methadone clinic also offers meetings; monitor for signs and symptoms of constipation which may be related to pain medication; and provide resident with pain medication as ordered by physician. The CP included an additional focus area dated 10/17/24 and revised 7/14/25, that the resident came from [previous facility's name redacted], has a history of opioid dependence; has a history and potential risk for illicit drug use abuse and overdose dated 7/11/25, and the resident was sent to the ER on [DATE], due to unresponsiveness and returned with diagnosis of opioid overdose. The goal initiated 10/17/24, with a target date of 7/15/25, was the resident will be safe. Interventions prior to the resident's overdose on 7/11/25, were all dated 10/17/24, and included: answer resident's questions honestly and factually to promote trust; assist in relaxation techniques, visualizations, and diversions; discuss consequences of continued substance abuse; encourage and support the resident's ability to take responsibility for their recovery; encourage resident to verbalize fears, feelings, and anxiety; increased staff supervision as needed; and Narcan as ordered. The following interventions were put in place on 7/14/25, current interventions reviewed and remain appropriate; care plan revised and updated; and Administration discussed consideration of thirty-day letter discharge. The Care Plan did not address how a resident with a history of six overdoses in the facility would be supervised and monitored to ensure their safety prior to their seventh overdose in the facility on 7/11/25. A review of the Order Summary Report dated active orders as of 7/1/25, included a physician's order (PO) dated 10/11/24, for Narcan nasal liquid 4 milligrams per 0.1 milliliter (4 mg/0.1 mL); to spray in nostril every twenty-four hours as needed for overdose. An additional PO dated 3/11/25, revealed that the resident was able to Leave the Facility independently even though the resident had multiple drug overdoses at the facility. The PO did not include an order for methadone or methadone clinic as the CP indicated if goes to methadone clinic, they hold meetings. A review of the Facility Reportable Event (FRE) for the illicit drug overdose dated 7/11/25, revealed that on 7/11/25, the resident was found unresponsive in the lobby and emergency services were called. The resident was administered Narcan and brought to the emergency room (ER). Per the ER nurse, the resident received Narcan there too. Included in the investigation and conclusion, Resident #3 indicated that they understood the reason they would be given a thirty-day discharge notice if they violated the drug policy again and the resident promised that [they] would not do this again. On 7/22/25 at 11:45 AM, the surveyor interviewed Resident #3, who stated that they did not recall the date or the exact time of their overdose but stated that they overdosed around smoke time. The resident stated they received what they assumed was a cigarette from another resident, and they smoked it. The resident further stated that after a few minutes, whatever it was took effect and they started to feel dizzy. The resident did not remember anything more except for waking up in the hospital. Resident #3 was unable to provide the surveyor with a name or a description of the resident they received the drugs from. On 7/22/25 at 12:58 PM, the surveyor interviewed the RN Supervisor, who stated that during her evening shift on 7/11/25, she observed Resident #3 went out to the smoking section on the patio to smoke around 3:00 PM. The RN Supervisor stated around 4:30 PM, she received a call from the Receptionist that Resident #3 had passed out, and when she responded to the call, Resident #3 was unresponsive. The RN Supervisor stated they brought the resident to the 3rd floor and provided oxygen and was instructed to administer a dose of Narcan by the DON, and the resident was still unresponsive. The RN Supervisor stated when EMS arrived, an additional dose of Narcan was administered, and Resident #3 remained unresponsive. The EMS placed a non-rebreather mask on the resident and transported them to the hospital. On 7/22/25 at 1:22 PM, the surveyor interviewed the DON, who stated that Resident #3 was given a thirty-day discharge notice after their overdose because they refused to tell the facility what they took or where they got it from. The DON stated the resident would only say they smoked something. The DON stated on the day of the incident, she saw the resident prior to their overdose and that the resident was fine. The DON stated that it had been a been a long time since the resident's last overdose. The DON stated the facility was not actively looking to place the resident in another facility at that time because the Licensed Nursing Home Administrator (LNHA) said the thirty-day notice could be lifted. On 7/22/25 at 1:42 PM, the surveyor interviewed the Social Worker (SW #1), who stated for residents with a history of drug use, they reviewed the drug policy with them, and that they had support groups there that the activities department could set up. SW #1 stated that the facility also posted signs about the groups. SW #1 stated if a resident violated the drug policy, she spoke to them and re-educated them on the drug policy and informed them that their out on pass could be affected or a thirty-day discharge notice could be given. On 7/22/25 at 2:00 PM, the surveyor interviewed SW #2, who stated when residents were first admitted to the facility, she went over the drug policy and had them sign it and informed the resident of the support offered. SW #2 stated if someone violated the drug policy, she met with the resident to re-educate them on the policy and reminded them that they had signed it. SW #2 stated that the DON and LNHA were responsible for revoking the resident's out on pass privileges or issuing a thirty-day discharge notice. On 7/23/25 at 3:07 PM the surveyors interviewed Assistant Director of Nursing (ADON), who stated that drug overdoses were discussed in the meetings, and they reviewed their care plans and interventions. The ADON further stated that if the current interventions in the care plan were appropriate, they add in documentation in the care plan indicating care plan was reviewed, and current interventions are appropriate. The ADON stated that all the care plans for individuals who had a history of drug overdose were reviewed and the interventions were updated. The surveyor inquired if the interventions in the care plan for Resident #3 were appropriate for Resident #3's drug abuse and overdose history. The ADON stated that she felt that Resident #3's current interventions were appropriate. The facility submitted an acceptable Removal Plan on 7/25/25 at 10:25 AM, 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 which included: the care plan for Resident #3 was reviewed and updated; daily behavioral monitoring was implemented; random room checks, room checks after going out on pass, and room checks after visitors leaved were implemented. Resident #3 was re-educated by the LNHA and the SW on the policy to prevent illicit drugs from entering the facility, which includes suspension of pass and potential 30-day discharge. The SW re-educated Resident #3 on the availability of counseling/cessation support/ and invited Resident #3 to weekly support groups to ensure safety. The care plans for Resident #3 and residents with history of having overdosed and who have overdosed at the facility were reviewed and updated to include daily behavior monitoring, random room checks, and checks made after visitors leave, in addition to reoffering of cessation support/invitation to support groups/counseling as appropriate. Signage on units to announce support group and advertise available support services. The staff caring for Resident #3 and residents with history of having overdosed and who have overdosed in the facility were re-educated on the prevention of illicit drug abuse and new care plan interventions. The surveyor verified the implementation of the Removal Plan on-site on 7/29/25. NJAC 8:39-27.1 (a)

Complaint #: NJ185458 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) and the administrative staff failed to ensure resident safety and well-being by failing to A) prevent illicit drugs from entering the facility and drug overdose incidents from occurring, B) ensure a thorough investigation was completed for a staff to resident sexual abuse allegation involving Resident #3 and multiple drug overdoses that occurred in the facility involving Resident #6, and C) ensure that the police and the New Jersey Department of Health (NJDOH) were notified of any drug overdoses that occurred in the facility. The facility's administrative staff failed to develop safety measures to ensure illicit drugs were not used by its residents and ensure that thorough investigations were completed for a staff to resident sexual abuse allegation and multiple drug overdoses that occurred, which placed all facility residents in an Immediate Jeopardy (IJ) situation. The IJ began on 2/21/25 and was identified on 5/8/25 at 6:00 PM and was reported to the LNHA. The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The Corporate Officer re-educated the LNHA and the Director of Nursing (DON) on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts on illicit drugs at the facility. Signage was posted in the front of the building that no alcohol or drugs were allowed in the facility. The DON or designee educated all the facility staff on elimination of illicit drug use in the facility and to report any illicit drug use to the DOH and the police. The LNHA and the DON audited all incidents and accidents from January 2025 to ensure there were no additional unresolved allegations of abuse, neglect, and illicit drug use identified. The LNHA and the DON implemented an audit process that occurred during the morning daily clinical meeting to assess potential abuse and any illicit drug activity and ensure these concerns were addressed per the facility policy. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F835 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. The deficient practice was evidenced by the following: A review of the facility's undated job description titled Administrator revealed under Purpose of Your Job Description, The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standard guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Under Administrative Functions, Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. A review of the facility's undated job description titled Director of Nursing revealed under Essential Duties and Responsibilities, Direct, develop, implement, review and revise nursing service goals and objectives. Establish and maintain standards of quality nursing practice. Maintain and enforce department and facility procedures and safety standards aimed at accident prevention . 1. According to the AR, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Hypertension, and Bipolar Disorder. According to the Quarterly MDS, an assessment tool dated 4/6/25, Resident #6 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #6's PN dated 2/21/25 completed by the IP revealed the IP was called into the resident's room at 6:30 PM by staff. The resident was slumped in his/her wheelchair with loud breathing. The resident's fingertips, lips, and lower half of face were cyanotic(blue). Sternal rub (used to assess a person's level of consciousness) was not effective. Narcan was administered at 6:43 PM with positive effect at 6:46 PM. The resident was transferred to the hospital. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 2/21/25 revealed under Diagnosis from Today's Visit, Opiate or related narcotic overdose. A review of the PN dated 4/1/25 completed by the Licensed Practical Nurse (LPN) revealed that Resident #6 was found sitting in his/her wheelchair and unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent out 911. The resident returned from the hospital and was treated for an overdose. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 4/1/25 revealed under Diagnosis from Today's Visit, Opioid overdose. A review of the PN dated 5/6/25 completed by the IP revealed that during rounds Resident #6 was noted to be slumped in his/her wheelchair. Twitching was noted to the resident's bilateral upper extremities. The doctor was notified, and a new order given to send to hospital for change in mental status. 911 was called and the resident was sent to the emergency room (ER). A review of Resident #6's EDD with a visit date of 5/6/25 revealed under Diagnosis from Today's Visit, Overdose opiate. A review of Resident #6's CP revealed a Focus revised on 4/29/25, that Resident #6 had a history of opioid and fentanyl use. admitted to using fentanyl 2 days prior to ER visit to deal with his/her pain. Urine Drug screen (UDS) positive for opioids. Resident #6 had an incident here where he/she was sent to the ER due to AMS (altered mental status) possibly due to use of illegal substance. On 5/8/25 at 1:44 PM, the surveyors interviewed the LNHA in the presence of the DON. The LNHA stated I can't say for a fact that the residents are bringing in drugs. We can't search them. The LNHA further stated We understand we are in a drug infested neighborhood. We are doing the best we can to prevent the drug problem, but we can't infringe on the resident's rights. On 5/8/25 at 2:35 PM, the surveyors interviewed the DON who stated she did not investigate Resident #6's multiple drug overdoses that occurred at the facility. The DON stated that she thought that the drug overdose that occurred on 4/1/25 was from the resident's prescribed medication and that was why an investigation was not conducted. The DON indicated that at that time, the facility changed the resident's plan of care by discontinuing his/her prescribed opioid medications. The DON stated that after the drug overdose that occurred in February, she had a discussion with the resident about his/her actions. The DON indicated No, I did not do an investigation. He/she was allowed outside and was not forthcoming about using drugs. The DON stated I have not reported drug overdoses to the DOH because I have not seen that in the regulations. The DON confirmed she did not notify the police regarding Resident #6's multiple drug overdoses that occurred in the facility. The DON stated that she was made aware by staff but could not remember who Resident #6 visited at the end of the facility's property recently and were suspicious that the resident was getting drugs. The DON further stated, I have not investigated this matter so far because I didn't have proof it happened. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Anxiety Disorder, Persistent Mood Disorder, and Hypertension. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/14/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. According to the AR, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Anoxic Brain Damage (a brain injury that occurs when the brain is completely deprived of oxygen), Tracheostomy (an opening of the trachea to facilitate breathing), and Epilepsy (seizures). According to the Quarterly MDS, and assessment tool dated 3/19/25, Resident #3 had a BIMS score of 99 which indicated the assessment could not be completed. The MDS further revealed the resident was non-verbal and dependent on staff with all activities of daily living (ADLs). On 5/7/25 at 10:17 AM, the surveyor interviewed Resident #2, who stated he/she went into the hallway at 3:00 AM and observed the medication cart in front of Resident #3's room. Resident #2 could not provide the surveyor with the exact date the alleged incident occurred. Resident #2 stated he/she waited about half an hour for LPN #1 to come out Resident #3's room. Resident #2 then went back to his/her room for a brief period and then returned to the hallway. Resident #2 stated he/she still observed the medication cart in front of Resident #3's room. Resident #2 stated he pushed the medication cart and went into Resident #3's room and observed LPN #1 pull the privacy curtain and jump off Resident #3's bed while fixing her shirt and pants. Resident #2 stated he observed Resident #3 with an erection. Resident #2 further indicated he/she asked LPN #1 what she was doing. The resident stated that the LPN told him/her that she was giving medical attention to Resident #3. Resident #2 indicated he/she reported the alleged incident the next day to the Ombudsman and the supervisor but was unsure of the supervisor's name. On 5/7/25 at 2:30 PM, the surveyor interviewed the DON who indicated she conducted a physical assessment on Resident #3 and interviewed Resident #2, LPN #1, the Assistant Director of Nursing (ADON), Infection Preventionist (IP), and the clinical manager (CM). The DON stated No, I did not speak to any residents she (LPN #1) cared for. No, I did not speak to any other staff members. I felt the people I spoke with gave me an honest report. The DON indicated that in the past she had collected resident and staff statements but denied collecting them for this incident. The DON further stated If I feel it is warranted, I would interview the residents. I did not feel it was warranted because I did not have a time frame of when the incident happened. On 5/8/25 at 4:29 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that a thorough investigation should be conducted for all abuse allegations. The LNHA further indicated All residents on a staff member's assignment for an abuse allegation should be interviewed. The LNHA stated that the staff should have been interviewed as well. The LNHA acknowledged that the facility's policy was not followed regarding conducting a thorough investigation. NJAC 8:39-9.2 (a)

Complaint #: NJ182907, NJ186028 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to complete thorough investigations when A) Resident #15 was observed to have bruising, swelling and a scratch to her/his face. B) when a resident reported witnessing an alleged sexual abuse between another resident (Resident #3) and the Licensed Practical Nurse (LPN #1). The facility also failed to ensure its policy titled Abuse, Resident Behavior and Facility Practice was implemented for the alleged physical abuse and alleged sexual abuse allegations. 1. On 10/12/24 at approximately 8:30 P.M, the Unit Manager (UM) was notified by LPN #6 that Resident #15 had a scratch on his/her face. LPN #6 reported that Resident #8 left the room that he/she shared with Resident #15 cursing and stating he/she had punched the resident (Resident #15). The DON failed to conduct a thorough investigation. The DON stated that Resident #15 was alert and oriented and denied being hit by their roommate (Resident #8). The DON also said, I spoke with both of them (Resident #8 and Resident #15) but they both denied that Resident #15 was hit. No follow-up investigation was conducted outside of the grievance filed for Resident #15. The facility failed to follow its policy titled, Abuse, Resident Behavior and Facility Practice and protect facility residents when the DON failed to immediately implement the abuse policy for the alleged physical abuse and to conduct a thorough investigation for the alleged physical abuse. This placed Resident #15 and all residents in an Immediate Jeopardy (IJ) situation. The IJ began on 10/12/24, was identified on 5/9/25 at 5:04 P.M. At this time, the IJ Template was presented to the DON. An acceptable removal plan was electronically emailed to the surveyor on 5/13/25 at 4:24 P.M., indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. All the facility staff were educated on the facility's policy abuse- prevention, recognition of and types of abuse, reporting urgency and reporting to the regulatory agencies. The LNHA and DON audited all incidents and accidents from 1/25 to 5/25, to assure there were no additional unresolved allegations of abuse identified. On 5/12/2025, the LNHA implemented an auditing process to assess potential abuse and ensure concerns are addressed through the policy. Auditing of all incidents/accidents will occur Monday through Friday, with weekend (Saturday and Sunday) incidents/accidents included in the Monday audit. 2. On 4/25/25, Resident #2 told LPN #1 that he/she was going to report her for raping Resident #3. LPN #1 reported this immediately to the Director of Nursing (DON) and LPN #1 was suspended. The DON stated that Resident #2 informed her on 4/25/25 that the alleged sexual abuse with LPN #1 and Resident #3 had occurred three weeks prior and then later stated the incident occurred six weeks ago. The DON stated she conducted an investigation and suspended LPN #1 immediately after the sexual abuse allegation was reported to her. The DON stated she did not conduct interviews or assessments for residents on LPN #1's assignment and did not obtain witness statements from other staff that worked on the unit when the sexual abuse allegation was made. The facility failed to follow its policies and procedures and protect the facility residents by not conducting a thorough investigation into whether other residents or staff members had any reports of abuse allegations involving LPN #1. This placed the residents being cared for by this staff member in an immediate jeopardy (IJ) situation. The IJ began on 4/25/25, was identified on 5/8/25 at 6:00 P.M., and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. On 5/8/25, the residents that were on LPN #1's schedule were interviewed and assessed for any complaints of inappropriate behaviors requested or witnessed by LPN #1. On 5/9/25, the DON and the LNHA educated the social workers (SW) and administrative nursing staff on the facility's policy on reporting of abuse and conducting a thorough investigation. The LNHA and the DON conducted an investigation into incidents and accidents from January 2025. On 5/12/2025, the LNHA implemented an auditing process to assess potential abuse and ensure concerns are addressed through the policy. Auditing of all incidents/accidents will occur Monday through Friday, with weekend (Saturday and Sunday) incidents/accidents included in the Monday audit. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F610 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 4 of 18 residents (Resident #2, Resident #3, Resident #8, and Resident #15) reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of unknown and a today's date of 4/25/2025 revealed that Resident #2 came up to LPN #1 and told her that he/she was going to report her for having sex with Resident #3. LPN #1 informed the DON and was suspended immediately pending an investigation. A review of the medical records for Resident #2 and #3 indicated the following: Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Anxiety Disorder, Persistent Mood Disorder, and Hypertension. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/14/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Anoxic Brain Damage, Tracheostomy, and Epilepsy. According to the Quarterly MDS, and assessment tool dated 3/19/25, Resident #3 had a BIMS score of 99 which indicated the assessment could not be completed. The MDS further revealed the resident was non-verbal and dependent on staff with all activities of daily living (ADLs). On 5/7/25 at 10:17 AM, the surveyor interviewed Resident #2, who stated he/she went into the hallway at 3:00 AM and observed the medication cart in front of Resident #3's room. Resident #2 could not provide the surveyor with the exact date the alleged incident occurred. Resident #2 stated he/she waited about half an hour for LPN #1 to come out Resident #3's room. Resident #2 then went back to his/her room for a brief period and then returned to the hallway. Resident #2 stated he/she still observed the medication cart in front of Resident #3's room. Resident #2 stated he/she pushed the medication cart and went into Resident #3's room and observed LPN #1 pull the privacy curtain and jump off Resident #3's bed while fixing her shirt and pants. Resident #2 stated he/she observed Resident #3 with an erection. Resident #2 further indicated he/she asked LPN #1 what she was doing. The resident stated that the LPN #1 told him/her that she was giving medical attention to Resident #3. Resident #2 indicated he/she reported the alleged incident the next day to the Ombudsman and the supervisor but was unsure of the supervisor's name. On 5/7/25 at 2:30 PM, the surveyor interviewed the DON who stated that on 4/25/25, LPN #1 reported to the supervisor that Resident #2 had alleged that she raped Resident #3. The DON stated she immediately suspended LPN #1 pending an investigation. The DON stated she spoke with Resident #2, and he/she stated that LPN #1 had sex with Resident #3. She further stated she asked him/her when the incident occurred, and Resident #2 stated three weeks ago and then changed it to six weeks ago. The DON indicated she conducted a physical assessment on Resident #3 and interviewed Resident #2, LPN #1, the Assistant Director of Nursing (ADON), Infection Preventionist (IP), and the clinical manager (CM). The DON stated No, I did not speak to any residents she (LPN #1) cared for. No, I did not speak to any other staff members. I felt the people I spoke with gave me an honest report. The DON indicated that in the past she had collected resident and staff statements but denied collecting them for this incident. The DON further stated If I feel it is warranted, I would interview the residents. I did not feel it was warranted because I did not have a time frame of when the allegation occurred. I didn't interview other staff because I did not have a timeframe of when the incident happened. On 5/8/25 at 4:29 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that a thorough investigation should be conducted for all abuse allegations. The LNHA further indicated All residents on a staff member's assignment for an abuse allegation should be interviewed. The LNHA stated that the staff working when the sexual abuse allegation occurred should have been interviewed as well. On 5/8/25 at 4:42 PM, the surveyor conducted a follow-up interview with the DON. The DON stated there has never been an abuse allegation in past involving LPN #1. The surveyor left a voicemail message for LPN #1 on 5/8/2025 and LPN #1 did not return the surveyor's phone call. A review of the medical records for Resident #8 and #15 indicated the following: Resident #8 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Depression, and Anemia. According to the Annual MDS, dated [DATE], Resident #8 had a BIMS score of 15 which indicated the resident's cognition was intact. Resident #15 was admitted to the facility with diagnoses which included but were not limited to: Cerebrovascular disease, Hypertension, Aphasia. According to the Quarterly MDS, an assessment tool dated 3/2/25, Resident #15 had a BIMS score of 14, which indicated the resident's cognition was intact. On 5/9/25 at 12:02 P.M, during an interview with the DON and the LNHA, the DON stated, I spoke with Resident #8 on the day I found out about the incident. I thought I wrote that on the incident report, but I guess I didn't. When the surveyor asked if an investigation was conducted, the DON said, I spoke with both of them (Resident #8 and Resident #15) but they both denied that Resident #15 was hit. No follow up investigation was conducted outside of the grievance filed for Resident #15. When the surveyor asked the DON if she spoke to witnesses, she stated, I spoke to staff but I didn't document. Nobody had witnessed any altercation. Speaking with staff I should have documented and collected witness statements. Our policy was not followed. The LNHA and DON both acknowledged a thorough investigation was not completed for the physical abuse and their policy was not followed. A review of the facility's policy titled Abuse, Resident Behavior and Facility Practice with a revised date of 5/24 revealed under Purpose, To ensure timely and thorough investigation of abuse, neglect, and/or mistreatment of residents. Under Investigation, 3. The DON/designee: a. Review the accident/incident report; b. Obtains written statements of staff assigned to the Resident for: i. the shift during which the allegation is noted; ii, a minimum of 16 hours prior to the incident if indicated or appropriate; c. Interview witnesses, in any; d. Reviews the Resident's record; e. Reviews staff assignments and staff performance; f. Corrective action is taken including but not limited to progressive counseling, education, increased supervision, up to and including termination as appropriate; g. Polices are re-evaluated and revisited if necessary to prevent recurrences; h. Reports findings to the Administrator. NJAC 8:39-9.3 (a)

Complaint #: NJ185458 Based on interviews, medical record reviews, and review of pertinent facility documentation on 5/8/25 and 5/9/25, it was determined that the facility failed to: A) ensure the residents' safety by failing to implement interventions to prevent drugs from entering the facility and overdose incidents from occurring while in the facility, B) conduct a thorough investigation into a resident's (Resident #6) drug overdoses, and C) notify the police and the New Jersey Department of Health (NJDOH) of the residents' drug overdoses. 1. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. On 2/22/25, Resident #6 returned to the facility from the hospital with a diagnosis of an opiate overdose. 2. On 4/1/25, Resident #6 was found sitting in his/her wheelchair unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent to the hospital via 911. Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. 3. On 5/6/25, Resident #6 was found slumped in his/her wheelchair during rounds. The resident was noted to have twitching in his/her bilateral upper extremities. The doctor was notified, and the resident was sent to the hospital. The Registered Nurse Unit Manager (RN/UM) stated that the Paramedics gave Resident #6 Narcan. According to the hospital emergency room (ER) documentation dated 5/6/25, the resident's diagnosis for the visit was opioid overdose. The facility had knowledge that Resident #6 had a history of opioid dependence and failed to implement interventions that ensured the residents safety and prevent illicit drugs from entering the facility. This resulted in Resident #6 having multiple drug overdoses while in the facility and being sent to the hospital for treatment of their symptoms. The facility failed to report Resident #6's multiple drug overdoses that occurred while in the facility to the NJDOH and the local police. The facility's failure to protect Resident #6 from drug overdoses placed all residents with a history of opioid dependence in an Immediate Jeopardy (IJ) situation. The IJ began on 8/24/24, was identified on 5/8/25 at 6:00 PM, and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. The Social Worker (SW) provided education to all residents with a history of drug overdose on the medical risks with illegal drug use, police involvement, possible discharge from the facility, and revoking of facility leave privileges. Education was provided to the residents on cessation programs and psychiatric consultations. Signage was placed at the entrance of the facility stating that drugs and alcohol were not allowed in the facility. Facility staff were educated that any drug overdose is to be reported to the appropriate regulatory agencies immediately. The facility staff were educated on the new interventions implemented to help prevent illegal drug use. These new interventions included education to the residents on the risks of a drug overdose, room searches, police involvement, possible discharge from the facility and revoking of facility leave privileges. The LNHA and the DON implemented an audit process that occurred during the morning daily clinical meeting that will identify the residents with a new history of opioid use and any drug overdoses that occur in the facility and that the police were called, and the appropriate regulatory agencies were notified. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F689 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. The deficient practice was evidenced by the following: According to the AR, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Hypertension, and Bipolar Disorder. According to the Quarterly MDS, an assessment tool dated 4/6/25, Resident #6 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #6's PN dated 2/21/25 completed by the IP revealed the IP was called into the resident's room at 6:30 PM by staff. The resident was slumped in his/her wheelchair with loud breathing. The resident's fingertips, lips, and lower half of face were cyanotic (blue). A sternal rub was not effective (used to assess a person's level of consciousness) Narcan was administered at 6:43 PM with positive effect at 6:46 PM. The resident was transferred to the hospital. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 2/21/25 revealed under Diagnosis from Today's Visit, Opiate or related narcotic overdose. A review of the PN dated 4/1/25 completed by the Licensed Practical Nurse (LPN) revealed that Resident #6 was found sitting in his/her wheelchair and unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent out 911. The resident returned from the hospital and was treated for an overdose. A review of Resident #6's EDD with a visit date of 4/1/25 revealed under Diagnosis from Today's Visit, Opioid overdose. A review of the PN dated 5/6/25 completed by the IP revealed that during rounds Resident #6 was noted to be slumped in his/her wheelchair. Twitching was noted to the resident's bilateral upper extremities. The doctor was notified, and a new order given to send to hospital for change in mental status. 911 was called and the resident was sent to the emergency room (ER). A review of Resident #6's EDD with a visit date of 5/6/25 revealed under Diagnosis from Today's Visit, Overdose opiate. A review of Resident #6's CP revealed a Focus revised on 4/29/25, that Resident #6 had a history of opioid and fentanyl use. admitted to using fentanyl 2 days prior to ER visit to deal with his/her pain. Urine Drug screen (UDS) positive for opioids. Resident #6 had an incident here where he/she was sent to the ER due to AMS (altered mental status) possibly due to use of illegal substance. On 5/8/25 at 9:24 AM, the surveyors interviewed Resident #7 who stated he/she was the facility's resident council President. Resident #7 stated that he/she had seen the nurses, and the Paramedics give Narcan to Resident #6 who had overdosed on Tuesday 5/6/25. On 5/8/25 at 10:33 AM, the surveyors interviewed the RN/UM who stated, Yes, he/she went to the hospital because he/she appeared high. The RN/UM stated she was unaware if the resident had taken any illegal drugs. The RN/UM further stated Resident #6 went to the Methadone Clinic on 5/5/25 for an initial dose. The RN/UM stated Yes, he/she signs himself/herself out on pass. He/she is alert and oriented and is his/her own responsible party. On 5/8/25 at 11:55 AM, the surveyors interviewed Resident #6 who stated that he/she was at the end of the facility's driveway on 5/6/25, when the staff reported that he/she was nodding out. The resident stated that he/she received Narcan. Resident #6 further stated I refused to go to the hospital, and they said I had to go. Resident #6 stated I smoked some weed that day. I bought it from a friend of mine. My friend was coming by, and I asked him to get it for me. Resident #6 further stated Between the blunt and the other meds, I nod out. Resident #6 indicated that he/she had received Narcan in the facility before. The resident stated Last time, it was a couple months. I didn't take anything, but they said I did and they Narcan me. On 5/8/25 at 1:21 PM, the surveyors interviewed the IP who stated Resident #6 was hypertensive, lethargic, and had twitching while sitting outside of his/her room on 5/6/25. The IP stated she immediately called 911. The IP indicated I am not sure if he/she received Narcan. The IP stated that on 2/21/25 she administered Narcan to Resident #6. The IP further stated the resident's fingers were cyanotic (blue) and was noted to had snored breathing. The resident wasn't completely unresponsive, but he/she was moaning. Resident #6 responded to the Narcan. I had my stopwatch on and literally three minutes later, he/she woke up. The IP stated she completed an incident report for the overdose that occurred on 2/21/25. The IP further indicated that she did not complete an incident report for the drug overdose that occurred on 5/6/25 because she wasn't sure if Resident #6 had overdosed at that time. On 5/8/25 at 1:44 PM, the surveyors interviewed the DON in the presence of the LNHA. The DON stated that Resident #6 went to the hospital on 5/6/25 because the resident had high blood pressure and twitching. The DON further stated she would have to review Resident #6's medical record to find out further information. The DON stated, Any resident with a BIMs score 12 or above can go out of the facility to drink and do drugs. She further stated, This was made clear to me by the Ombudsman. The DON stated that the facility worked with Resident #6 to get him/her to go to the Methadone Clinic and that the resident agreed to go within the last week. On 5/8/25 at 1:44 PM, the surveyors interviewed the LNHA in the presence of the DON. The LNHA stated I can't say for a fact that the residents are bringing in drugs. We can't search them. The LNHA further stated We understand we are in a drug infested neighborhood. We are doing the best we can to prevent the drug problem, but we can't infringe on the resident's rights. On 5/8/25 at 2:35 PM, the surveyors conducted a follow-up interview with the DON who reviewed Resident #6's PNs in the presence of the surveyors. The DON stated she did not investigate Resident #6's multiple drug overdoses that occurred at the facility. The DON stated that she thought that drug overdose that occurred on 4/1/25 was from the resident's prescribed medication and that was why an investigation was not conducted. The DON indicated that at that time, the facility changed the resident's plan of care by discontinuing his/her prescribed opioid medications. The DON stated that after the drug overdose that occurred in February, she had a discussion with the resident about his/her actions. The DON indicated No, I did not do an investigation. He/she was allowed outside and was not forthcoming about using drugs. The DON stated I have not reported drug overdoses to the DOH because I have not seen that in the regulations. The DON further indicated I would call the police if I suspected someone was selling drugs. The DON stated that she was made aware by staff but could not remember who Resident #6 visited at the end of the facility's property recently and were suspicious that the resident was getting drugs. The DON further stated, I have not investigated this matter so far because I didn't have proof it happened. A review of the facility's policy titled Illegal Drug Use dated 6/2024 revealed The facility recognizes that we have an increase in admission of residents with a history or recent active drug use. If drug use is suspected, resident assessment and follow up treatment, if warranted is provided. A review of the facility's policy titled Policy and Protocol for Incident Reporting with a revised date of 9/2024 revealed The Administrator and/or Director of Nursing will process all Reportable Events to the advocacy agencies required by state and federal regulations. NJAC 8:39-27.1 (a)

Complaint #: NJ185458 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #6) who had multiple drug overdose incidents while at the facility and b.) follow the facility's policy titled Policy on Resident Care Planning. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. On 2/22/25, Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. On 4/1/25, the resident was found sitting in his/her wheelchair unable to be aroused. Multiple attempts were made to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent to the hospital via 911. Resident #6 returned to the facility from the hospital with a diagnosis of opiate overdose. On 5/6/25, the resident was found slumped in his/her wheelchair during rounds. The resident was noted to have twitching in his/her bilateral upper extremities. The doctor was notified, and the resident was sent to the hospital. The Registered Nurse Manager (RNM) stated that the Paramedics gave Resident #6 Narcan. According to the hospital emergency room (ER) documentation dated 5/6/25, the resident's diagnosis for the visit was opioid overdose. The facility did not update Resident #6's CPs to manage the resident's substance abuse after the resident overdosed on 2/21/25, 4/1/25, and 5/6/25. The facility's failure to update the CP with interventions for Resident #6 to prevent further drug usage and overdoses placed all residents in an Immediate Jeopardy (IJ) situation. The IJ began on 2/21/25, was identified on 5/8/25 at 6:00 PM., and was reported to the Licensed Nursing Home Administrator (LNHA). The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 5/13/25 at 4:23 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. On 5/8/25, Resident #6's care plan was updated. On 5/9/25, the DON, Assistant Director of Nursing (ADON), and IP educated the administrative nursing staff and social workers (SW) were educated on updating and implementing care plans when incidents occur. The DON implemented a process to occur during daily morning clinical meeting to ensure that care plans were updated when incidents occur. The surveyor verified the removal plan on site on 5/15/25 and determined the IJ for F657 was removed as of 5/15/25. After the IJ removal plan, the non-compliance continued from 5/15/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and evidenced by the following: According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Opioid Abuse, Hypertension, and Bipolar Disorder. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 4/6/25, Resident #6 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 Resident #6's PN dated 2/21/25 revealed the IP was called into the resident's room at 6:30 PM by staff. The resident was slumped in his/her wheelchair with loud breathing. The resident's fingertips, lips, and lower half of face were cyanotic(blue). Sternal rub was not effective. Narcan was administered at 6:43 PM with positive effect at 6:46 PM. The resident was transferred to the hospital. A review of Resident #6's Emergency Department Documentation (EDD) with a visit date of 2/21/25 revealed under Diagnosis from Today's Visit, Opiate or related narcotic overdose. A review of the PN dated 4/1/25 revealed that Resident #6 was found sitting in his/her wheelchair and unable to be aroused. Multiple attempts were done to arouse the resident, and he/she remained unresponsive. The doctor was notified, and the resident was sent out 911. The resident returned from the hospital and was treated for an overdose. A review of Resident #6's EDD with a visit date of 4/1/25 revealed under Diagnosis from Today's Visit, Opioid overdose. A review of the PN dated 5/6/25 completed by the IP revealed that during rounds Resident #6 was noted to be slumped in his/her wheelchair. Twitching was noted to the resident's bilateral upper extremities. The doctor was notified, and a new order given to send to hospital for change in mental status. 911 was called and the resident was sent to the emergency room (ER). A review of Resident #6's EDD with a visit date of 5/6/25 revealed under Diagnosis from Today's Visit, Overdose opiate. A review of Resident #6's CP revealed a Focus revised on 4/29/25, that Resident #6 had a history of opioid and fentanyl use. admitted to using fentanyl 2 days prior to ER visit to deal with his/her pain. Urine Drug screen (UDS) positive for opioids. Resident #6 had an incident here where he/she was sent to the ER due to AMS (altered mental status) possibly due to use of illegal substance. Resident #6's CP revealed no updated CP interventions after the resident overdosed on 2/21/25, 4/1/25, and 5/6/25. On 5/8/25 at 10:33 AM, the Registered Nurse Unit Manager (RN/UM) stated that the care plans were updated after an incident occurred such as falls, drug overdoses, or any unusual change occurred. The RN/UM stated that she thought that Resident #6's care plans had been updated but she would have to check into it. On 5/8/25 at 2:35 PM, the surveyor interviewed the Director of Nursing (DON) who acknowledged that Resident #6's care plan interventions were not updated after the resident's multiple drug overdoses. The DON stated that the care plan interventions that were already in place for the resident were appropriate for his/her multiple drug overdoses and did not need to be updated after the drug overdoses occurred. The DON further stated Obviously, the interventions didn't work if he/she had another overdose. The DON indicated that the care plans were updated when there is a change in condition or a significant event. The DON stated Yes, the care plan should have been updated. The DON further indicated that it was important to update the care plans because it gives an accurate picture of the resident. On 5/8/25 at 4:16 PM, the surveyor conducted a follow-up interview with the DON. The DON stated that the expectation was that the care plans should be updated the first business day after an incident occurred. The DON indicated that the Nurse Manager or Assistant Director of Nursing were responsible for updating the resident care plans. The DON further indicated I think it wasn't updated because we as a team felt he/she had everything in place. A review of the facility's policy titled Policy on Resident Care Planning dated June 2024 revealed under Purpose, The main purpose of the Care Plan is the resident's quality of life and safety and updated with any changes in diagnosis or condition. Under Procedure, 2. The care plan will be reviewed and updated by the unit manager and other departments as changes in the resident occur. 3. The Care Plan is updated as warranted by the resident's changes and preferences. NJAC 8:39-11.2 (e) (1) (2)

Complaint Intake #NJ162088 Based on observations, interviews, record reviews, document review, and facility policy review, it was determined the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 5 sampled residents reviewed for elopement. The lack of an effective audible alarm on an exit door and lack of adequate supervision resulted in Resident #1 eloping from the facility and being found deceased on a local highway on [DATE]. The facility door alarmed when the resident exited; however, facility staff did not hear the alarm, allowing the resident to exit the facility without staff's knowledge. At the time of the survey, there were 3 residents identified as at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d)(2) Accidents/Supervision at a scope and severity of J. The IJ was determined to have existed on [DATE], when Resident #1 exited the building without staff knowledge and was found by law enforcement outside the facility, deceased . The facility developed and implemented a corrective action plan, and the IJ was determined to have been removed and the noncompliance corrected on [DATE], prior to the survey entrance date. On [DATE] at 5:38 PM, the Administrator, Director of Nursing (DON), Corporate Consultant #2, Administration Consultant, and Social Service Consultant were informed of the Past Noncompliance Immediate Jeopardy situation. Findings included: Review of a facility policy titled, Door Check, revised ,d+[DATE], revealed, Purpose: To ensure the security of facility residents and personnel and door closure integrity. Policy: Facility exit stairwell doors will be monitored monthly with door code changes by the Maintenance Department. Procedure: A. Maintenance personnel shall perform rounds of facility to evaluate the integrity/security of exit doors and stairwells on a monthly basis, or more often as necessary. B. Monthly rounds shall be documented on a log form with date and result. Comments will be added as necessary. Any problems must be reported on the log form and immediately reported to the Director of Maintenance and Administrator. Review of an Admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses that included dementia without behavioral disturbance and Alzheimer's disease. Review of an Elopement Assessment, dated [DATE], revealed Resident #1 could follow instructions, was ambulatory, could communicate, had a history of wandering, and had a diagnosis of dementia/cognitive impairment. Review of the Standard Assessments screen in the resident's electronic medical record indicated Resident #1 scored 8 on this elopement assessment. The scoring tool on the assessment indicated a score of 0 to 8 indicated a low risk for elopement. Review of Progress Notes, dated [DATE] at 4:58 PM, revealed Resident #1 was oriented to person, extremely confused, wandered, and walked frequently inside and outside of their room. Review of a Care Plan, dated as initiated [DATE], revealed Resident #1 had memory loss. Interventions directed staff to cue, reorient, and supervise or assist the resident as needed and to continue to anticipate Resident #1's needs. Review of Progress Notes, dated [DATE] at 4:14 PM, revealed Resident #1 was alert with some confusion and wandered around the floor at times. Review of Progress Notes, dated [DATE] at 4:33 PM, revealed Resident #1 was alert and able to make their needs known. The resident was in their room most of day watching television, and would sometimes go into a relative's room. Review of Progress Notes, dated [DATE] at 3:19 PM, revealed Resident #1 was alert with some confusion, walked around for a while, and stayed in their own room most of the shift. Review of Progress Notes, dated [DATE] at 2:30 PM, revealed Resident #1 was alert, confused, and visited a relative's room often. Review of a facility-reported incident report, dated [DATE], revealed Resident #1 eloped from the facility on [DATE] and was hit by a car and expired. Review of Progress Notes, dated [DATE] at 11:00 PM, revealed an entry written by Registered Nurse (RN) #1 that indicated Resident #1 was received in the resident's room watching television. The resident was oriented to self and confused. Resident #1 walked back and forth from their room and a relative's room. Around 8:00 PM, Resident #1 was sitting in a chair watching television with a relative. RN #1's note indicated the medication nurse provided information that Resident #1 was sitting in a chair watching television with their relative when the medication nurse provided a supplement to the resident's relative around 9:00 PM, and Resident #1 had shown pictures to a nursing assistant around the same time. The note revealed two law enforcement officers arrived at around 9:45 PM and informed RN #1 of Resident #1's unfortunate passing. Review of the evening shift staffing schedule, dated [DATE], revealed Licensed Practical Nurse (LPN) #8, LPN #9, Certified Nurse Aide (CNA) #11, CNA #12, and RN #1 were on duty during the shift when Resident #1 eloped from the facility. During an interview on [DATE] at 3:16 PM, LPN #8 stated Resident #1 was confused at times. The resident stayed in their room or their relative's room and watched television. LPN #8 stated there had been no issues with Resident #1 attempting to leave the floor or go out the exit doors to the stairwells. When asked the last time the LPN had observed Resident #1, she stated it was between 9:00 PM and 9:15 PM, and the resident was in a recliner in their relative's room. The LPN stated she then went to another floor to get some medication and did not hear an alarm when she returned to the floor. LPN #8 stated she was shocked when RN #1 told her what happened. During an interview on [DATE] at 4:00 PM, RN #1 stated she was the supervising nurse the night Resident #1 left the floor by going down the stairs. The RN stated the resident suffered from dementia and stayed in the resident's room or their relative's room, and on occasion would come as far as the nurses' station. The RN stated she supervised all floors and was not on the floor when the resident left the facility. RN #1 stated the guard at the front did not see anyone go out the front door. The RN stated the alarm worked but she could not hear it from the nurses' station when she came back onto the floor. During an interview on [DATE] at 4:22 PM, LPN #9 stated she was the charge nurse the night Resident #1 got out of the building. The LPN stated Resident #1 would wander from the resident's room to their relative's room, and to the nurses' station. The LPN stated Resident #1 was at the nurses' station between 9:00 and 9:15 PM before the incident. LPN #9 stated Resident #1 was in their relative's room when medications were provided to the relative about 9:30 PM by LPN #8. LPN #9 stated she could not hear the alarm when Resident #1 opened the door. LPN #9 indicated she talked with the two aides working on the hall, and they were providing care in other resident' rooms and did not hear the alarm. LPN #9 revealed she could not hear the door alarm from the nurses' station because the doors were too far away. During an interview on [DATE] at 9:36 AM, CNA #11 stated she was working the night Resident #1 left the building. The CNA stated she last saw Resident #1 between 9:00 PM and 9:15 PM watching television in their relative's room. CNA #11 stated she and CNA #12 were in another resident's room providing care and did not hear the alarm on the door sounding. The CNA stated they were in the other room [ROOM NUMBER] to 15 minutes and did not hear the alarm sound. CNA #11 stated she received training on elopement and residents who wandered upon being hired. The CNA stated when asked by the Administrator, she did let him know the CNAs could not hear the alarm sounding. During an interview on [DATE] at 9:55 AM, CNA #12 stated she worked on the 3:00 PM to 11:00 PM shift with Resident #1 on [DATE]. The CNA stated the last time she saw Resident #1 was between 8:00 PM and 8:30 PM in the resident's relative's room watching television. CNA #12 stated she was in another resident's room providing care with CNA #11 between 9:30 PM and 10:00 PM. CNA #12 stated when they had completed care, LPN #8 was crying and told them what happened. The CNA stated she never heard the alarm sounding on [DATE]. On [DATE] at 3:40 PM, the egress doors where Resident #1 exited the facility were observed with the Administrator present. The Administrator stated the resident had gone down the stairwell, out the egress doors, and through the unlocked gate. The Administrator stated the resident went along the building and through another fenced area where the dumpster and compactor were located. The Administrator pointed to the street to indicate the area where the incident with Resident #1 happened. During an interview on [DATE] at 4:40 PM, the Maintenance Director stated before the incident involving Resident #1, he would check the doors but did not document those checks anywhere. He stated the alarms were not loud enough to be heard at the end of the hallways with all the noise in the facility. During an interview on [DATE] at 4:55 PM, the Administrator stated he arrived at the facility at approximately 10:30 PM on [DATE], and the alarm was still sounding. The Administrator stated he entered the floor near the nurses' station and could not hear the alarm until he was right next to the door. He stated the staff could not hear the alarm when going into and out of rooms to provide resident care. During an interview on [DATE] at 7:05 PM, the Administrator stated the back patio was for barbecues and activities during the warm months. The Administrator stated he did not know if a lock had been in place on the gate in the past or if it was ever checked. On [DATE] at 8:45 AM, the area outside the compactor was observed. The area was approximately 50 feet from Highway 29. There was a sidewalk from the compactor area that led to the street. During an interview on [DATE] at 9:25 AM, the Assistant Director of Nursing (ADON) stated the interdisciplinary team discussed the elopement risk for Resident #1 on admission and determined the resident wandered to and from their relative's room and had no exit-seeking behaviors. On [DATE] at 10:24 AM, the Maintenance Director clarified the facility's old policy for checking alarm doors. He stated the old policy was to check the doors once a month to make sure they sounded and change the code to open the door. The Maintenance Director stated the alarms all sounded the same, but he never went down the hall to see if it could be heard. On [DATE] at 11:00 AM, the compactor area was observed with the Administrator and the Maintenance Director. The Administrator stated the gate must have been ajar because the approximate six-inch gap the gate had when closed would not be wide enough for the resident to get through. The Administrator confirmed the speed limit on Highway 29 where the incident occurred was 40 miles per hour. On [DATE] at 2:40 PM, the video surveillance footage from [DATE] was viewed with Corporate Consultant #2. The video showed Resident #1 walking across the concrete patio located on the south side of the building at 9:28 PM and 38 seconds. The resident left the camera view at 9:29 and 16 seconds. At 9:33 PM, the resident was observed on the inside of the gated area where the dumpster and compactor were located. Resident #1 stepped sideways and was outside the gated area. The resident turned left and walked toward Highway 29. Resident #1 was observed walking down the sidewalk towards Highway 29, reaching the road, and crossing the road at 9:34 PM. Resident #1 turned right, headed north on the median, and went out of camera view. Resident #1 entered the camera view heading south on the median at 9:44 PM, attempted to cross the street again at 9:46 PM, and was struck by an oncoming car. Resident #1 was pushed approximately thirty feet, landing on the road. Resident #1 was then struck by two additional cars. On [DATE] at 6:20 PM, the facility provided a copy of a corrective action plan that was developed and implemented beginning on [DATE] after Resident #1 got out of the facility. Review of the plan revealed the following: [NAME] police notified facility in person at approximately 9:50 p.m. [PM] to speak with nursing supervisor [RN #1]- [DATE] [[DATE]]. Nursing supervisor, [RN #1] contacted DON. DON notified Administrator. [DATE] Full house resident census head count completed on all units. [DATE] DON on site to commence investigation and conducted resident unit check, interview staff and obtain statements. [DATE] DON met with [local] Police Office answering questions related to demographics. [DATE] DON rounds with staff on all units. [DATE] Increased supervision and monitoring of second floor unit by nursing staff and supervisors until door checks completed. started [DATE] Administrator on site [DATE] around 10:30 pm [PM]. Third party door alarm vendor contacted at 11:45 p.m. on [DATE]. NJDOH [New Jersey Department of Health] notified approximately 11:50 p.m. on [DATE] via phone call. Family notification by administrator approximately 12:15 a.m. on [DATE] [[DATE]]. Voice message notification left for MD [medical doctor] approximately between ,d+[DATE]am [12:00 - 1:00 AM] on [DATE]. Maintenance Director called in to facility to perform door checks 12:18 am [AM] [DATE], arrived at facility around 12:30 am. Third party alarm company arrived to facility around 3:30 am on [DATE] conducts full house audit of all unit, stairwell and door alarms and found all other door alarms to be sufficient volume. Maintenance Director conducted full house audit/check of all unit stairwell, door alarms and locking mechanism on [DATE]. Secondary alarm installed on second floor unit north and south unit stairwell at around 4 am on [DATE]. Initiation of exit door, stairwell alarm and door lock checks twice daily by maintenance started on [DATE]. Nurse practitioner contacted by DON approximately ,d+[DATE] am on [DATE]. DON contacted medical director at approximately 7:30 am on [DATE]. [DATE] starting at 6 am: Review of the following policies and procedures: elopement policy and procedure, exit door egress alarm policy and procedure, elopement risk assessment policy and procedure, elopement risk assessment on all in house residents, facility education on response to alarms policy and procedures for elopement, purposeful rounding, dementia, wandering behaviors. Whole house elopement risk assessment completed on [DATE]. Ad hoc QAPI [Quality Assurance and Performance Improvement] meeting completed on [DATE]. Care plans for those residents deemed at risk for elopement reviewed and revised as necessary on [DATE]. Reportable event form submitted to NJDOH via email at 3:47 pm on [DATE]. Outdoor rounds completed on [DATE] and [DATE]. Lock installed on patio gate on [DATE]. Audits to commence: New Admissions Elopement Risk Audit commenced on [DATE]. Additional audits to be started included: Staff Knowledge of Elopement Prevention and Management, Staff Knowledge to response to egress door alarms, Audit to monitor proper function for all egress doors and alarms. Care plan agenda checklist reviewed and revised to include the quarterly elopement risk assessment. One elopement drill per shift per month. The surveyor conducted onsite verification on [DATE] to confirm the facility had implemented all components of the corrective action plan. After conducting the following interviews and record/document reviews, it was determined the facility implemented all components of the action plan and the deficient practice was corrected on [DATE] prior to the survey entrance. Review of statements from RN #1, LPN #9, CNA #11, CNA #12, LPN #8, dated [DATE] and [DATE], revealed each staff member working on Resident #1's floor on the evening of [DATE] provided a witness statement and signed it. The DON signed each statement. Review of a third-party alarm company invoice dated [DATE], indicated the company made an emergency service call at the facility and tested all the doors to ensure they were functioning properly. Review of an email to the Administrator, dated [DATE] at 6:47 AM, indicated a third-party alarm company arrived at the facility at 3:30 AM and performed a site inspection to make sure all the doors were working properly with the delayed egress and alarms. Further review of the email indicated all doors were tested and working as they should with proper equipment on them as of 6:45 AM. Review of a document titled, Simulated Elopement drill done on [DATE] with Nursing staff revealed between 1:30 AM and 5:00 AM, the facility reviewed the elopement policy with staff present in the facility, and the staff gave verbal feedback on what to do when a resident was missing and the importance of alarm response and rounding. Review of in-service documents titled, Elopement Risk Prevention: Dementia, wandering restless behaviors, and purposeful rounding, dated ,d+[DATE], revealed staff received education on identifying elopement, wandering, and unsafe wandering. Staff members were given examples of elopement and elopement prevention interventions and educated on practices that would promote resident safety and prevent elopement. Facility staff members signed attendance forms indicating they attended the in-service. During an interview on [DATE] at 3:16 PM, LPN #8 stated after the incident with Resident #1, the facility provided in-services on elopement and knowing where the at-risk residents were located. The LPN further stated they were to go and check on an alarming door and go into the stairwell to check and make sure no residents had exited. On [DATE] from 3:24 PM through 3:31 PM, egress doors were observed with LPN #13. All three stairwell alarms were activated on the second floor, resulting in a loud audible alert. A red light also flashed when the doors were opened. Staff came to the door promptly to check the alarm. On [DATE] at 3:40 PM, the egress doors where Resident #1 exited the facility were observed with the Administrator present. Outside the doors, there was a fence around a concrete platform. There was a locked gate on the left side of the patio. During an interview on [DATE] at 4:00 PM, RN #1 stated there had been training on elopement and checking the doors when they alarmed since the incident with Resident #1. The RN stated a louder alarm was added to the doors so it could be heard throughout the unit. During an interview on [DATE] at 4:22 PM, LPN #9 stated the facility provided training on elopement after the incident and what to do if the alarm went off. The LPN stated they must not only check the door but go into the stairway to check for residents. LPN #9 stated the alarms on the doors were now very loud. During an interview on [DATE] at 4:40 PM, the Maintenance Director stated louder alarms were installed on Monday, [DATE], so the alarms could be heard throughout the unit. During an interview on [DATE] at 7:05 PM, the Administrator stated a new lock was put on the patio gate. During an interview on [DATE] at 9:25 AM, the Assistant Director of Nursing (ADON) stated new elopement assessments were completed on all residents on [DATE] because of the incident with Resident #1. During an interview on [DATE] at 9:36 AM, CNA #11 stated she received training on elopement and residents who wandered after the incident with Resident #1. During an interview on [DATE] at 9:55 AM, CNA #12 stated she had received training on elopement and door alarms sounding since the incident. On [DATE] at 10:24 AM, the Maintenance Director stated since the incident occurred with Resident #1, the facility's new policy for checking doors alarms was to check the alarms twice a day, document the findings, and make sure the alarms could be heard down the hall. The Maintenance Director stated the doors had booster alarms put in, so they were a lot louder. When asked about the open gate, he stated the gate had never been locked in the past, and they had placed a lock on it after the incident with Resident #1. Review of the facility's new policy titled, Exit Doors, Stairwell, and Egress Passageway Checks, dated ,d+[DATE], indicated, Policy: Facility exit and stairwell doors and egress passageways will be monitored on a daily basis by maintenance personnel to ensure that the doors are effectively secured and locking mechanisms and/or alarms in place and active. The policy also indicated, Maintenance will document their findings on a daily log and any discrepancies, corrections, needed remediation will be documented in the comment section. Procedure: A. Maintenance personnel shall perform rounds of the facility to evaluate the security of the exit doors and stairwells daily and document their findings on the attached log. B. Rounds shall be documented daily to ensure that all door alarms and locks are in proper function, proper door locking release signage is present, and stairwell doors are secure on the forms entitled 'Exit Doors, Stairwells, Egress Passageways - Daily Log' & 'Door Alarm Daily Log/Egress Passageway Check'. The date and time of rounds will be entered by Maintenance Personnel, and a check mark placed in each box to indicate the door is secure and the door alarm/electronic maglock is in proper function. Any problems must be reported to the Director of Maintenance immediately for immediate follow up and repair/resolution and forwarded it to the administrator. Additionally, the policy indicated, C. Any unsecured or obstructed egress area shall immediately be reported to the Director of Facilities for immediate resolution and the surrounding area searched for Residents or any potential unauthorized persons (i.e. [that is] if a door is found to be breached and or [an] alarm is sounding). The Nursing Supervisor must be notified to account for all residents in the event of any discrepancies. Review of the Door Alarm Daily Log/Egress Passageway Check, forms indicated all floors were checked on each shift on [DATE] through [DATE] to ensure doors were armed, the alarms modules were secure, the alarms would go off when the doors were opened, and the alarms would reset. Review of the forms indicated all problems were immediately addressed. Review of the facility's QA [Quality Assurance] Minutes, dated [DATE] revealed a QA meeting was held and the committee examined the elopement and conducted a root cause analysis. New Jersey Administrative Code S 8:,d+[DATE].1(a)

Complaint # NJ Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently provide adequate/appropriate supervision for residents with known history of falls for 1 of 3 sampled residents, (Resident #2). The facility failed to consistently provide identified safety interventions, 1:1 observation, for Resident #2, who had an unwitnessed fall on 5/2/14, resulting in an acute Vertebrae Compression Fracture at Lumbar #2. This deficient practice was evidenced by: Medical records and facility documents were reviewed and interviews were conducted on 7/11/14. 1. According to the medical record, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 4/24/14, reflected a score of 9/15 on the Basic Interview for Mental Status (BIMS), which indicated moderate impairment of cognition. The MDS also indicated that Resident #2 required limited assistance for transfers and ambulation. The results of multiple "Falls Risk Assessment" (FRA) (total score of 10 or higher represents high risk) were as follows; FRA dated 4/29/14, reflected a score of 20, FRA dated 5/7/14, reflected a score of 22 and FRA dated 5/9/14, reflected a score of 22. These FRA scores all indicated that Resident #2 was a high risk for falls. The Care Plan for Resident #2 dated 4/27/14, indicated falls on the following dates; 4/27/14, 4/29/14, 4/30/14, 5/1/14, 5/2/14, and 5/9/14. Interventions included but were not limited to; 1 on 1 observation, encouraging the resident to call for assistance, encouraging the resident to use non-skid socks, assistance with toileting, encouraging the resident to call staff for assistance and Physical Therapy (PT) and Occupational Therapy (OT) evaluations for wheelchair positioning. The "Interdisciplinary Progress Note" (IPN) dated 4/30/14, no time specified, indicated that Resident #2 informed the 7 am-3pm nurse that she had fallen the night before and had not alerted any staff member. The IPN dated 4/30/14 at 9 am indicated that Resident #2 was medicated for pain in the left shoulder and that X-rays were ordered by the physician. The X-rays were negative for fracture and dislocation. According to the "1:1 Rotation" assignment schedule dated 4/30/14, 1:1 observation was documented as being in place for Resident #2. However, the IPN dated 4/30/14, at 10:00 a.m. indicated that Resident #2 had an unwitnessed fall and was found awake, crying, in a sitting position on the floor. The IPN also indicated that the resident lost her balance and fell . A subsequent IPN note dated 4/30/14, no time specified, indicated that a Certified Nursing Assistant (CNA) walked into Resident #2's room and observed the resident standing, lost her balance and fell . An "Incident/Accident Report" dated 5/1/14, at 11:00 a.m. indicated that Resident #2 fell in the Rehabilitation Gym. According to the "Fall Report Investigation" dated 5/1/14, Resident #2 attempted to stand independently and fell , hitting her head and right shoulder on a bedside table. The same report indicated that the chair alarm was in place, however did not sound at the time of the fall. Listed under "Immediate interventions to prevent reoccurrence" was a "self releasing seat belt alarm." However, there was no evidence provided that indicated a self releasing seat belt alarm was implemented. An interview was conducted by the surveyor with a Physical Therapy Assistant (PTA) on 7/11/14, at 1:20 p.m. The PTA stated that she witnessed Resident #2's fall on 5/1/14, in the therapy department. The PTA stated that the resident was a high risk for falls and was constantly trying to get up out of her wheelchair. "The resident was supposed to be on 1:1 observation, but CNA #1 left the room." An interview was conducted by the surveyor on 7/11/14, at 2:20 p.m. with CNA #1 who was assigned to Resident #2 on 5/1/14, during the 7 am-3pm. shift. CNA #1 stated that when she took Resident #2 to the rehab gym on 5/1/14, the therapist told her she could leave the resident there. CNA #1 went back to her assigned unit and left Resident #2 in the rehabilitation gym without 1:1 supervision. An "Interdisciplinary Care Plan Note" untimed, dated 5/1/14, reflected that Resident #2 has a history of multiple falls at home, 3 falls since admission and was on 1:1 supervision while in the facility. An IPN dated 5/2/14, at 6:15 a.m. indicated that Resident #2 had an unwitnessed fall and was found on the floor. Resident #2 complained of pain in her lower back. The same IPN note indicated that after the unwitnessed fall, 1:1 observation was resumed. According to Resident #2's care plan revised on 5/1/14, 1:1 staff observation would have been in place at the time of the fall. There is no documentation indicating that 1:1 observation was in place at the time of the fall. Subsequently, Resident #2 went to the hospital and was admitted with the [DIAGNOSES REDACTED].#2. An interview was conducted by the surveyor on 7/11/14, at 2:20 p.m. with CNA #2 who according to the "1:1 Rotation" sheet was assigned to Resident #2 on 5/2/14, at the time of the fall. The CNA stated that she was not in the room with the resident at the time of the fall. The CNA also stated "1:1 observation means someone is to be with her at all times." According to the IPN note dated 5/7/14, at 8:00 p.m. Resident #2 was readmitted back into the facility with the [DIAGNOSES REDACTED].#2 and was to wear a brace when out of bed. A "Pain Assessment" dated 5/9/14, indicated that Resident # 2 had "significant pain with movement and ambulation due to Acute Lumbar #2 compression fracture." The pain assessment reflected a level of "8" which indicated severe pain in the lower back. The physician's orders [REDACTED]. The "PRN Pain Flow Sheet" reflected that Resident #2 had to be medicated with pain medication and that Percocet 5/325 mg was administered as ordered by the physician, from 5/9/14 to 5/17/14 for back pain. The surveyor conducted an interview with the Assistant Director of Nursing (ADON) on 7/11/14, at 1:40 p.m. The ADON stated that when a resident is on 1:1 observation the resident should not be left alone. " I educated all the staff on 5/6/14, about the definition of 1:1 observation. The definition of 1:1 observation means that you have to stay with the resident at all times no matter what. I did the education as a result of Resident #2 falling on 5/2/14. I don't believe we have a policy on 1:1 observation." The revised policy dated 4/02, titled "Fall/Risk Assessment Reduction" indicated..., "Appropriate interventions will be implemented to reduce and minimum the potential for falls." A post survey review of Resident #2's hospital medical records dated 5/2/14, indicated that the resident "had a fall at the nursing home, and following this, she complained of severe back pain." The hospital medical records also indicated that Resident #2 was admitted with "an acute fracture at L2." NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that all residents were safe from resident's careless smoking in unauthorized areas of the facility. Residents #19, #27 and #31 were found on several occasions to be smoking in their rooms, bathrooms, and other unsafe, areas unsupervised by facility staff and were assessed as not requiring supervision while smoking. Staff noted smoke smell, smoke itself in the resident's room and bathroom, ashes on the floor and smoke paraphernalia on the resident's persons. The remedial measures were consistent with monitoring the resident, checking the resident and the resident rooms for smoking paraphernalia and re-educating them of the dangers. There was no evidence that a remedial plan was developed and/or that measures were consistently followed for the repeated episodes. There was no consistent knowledge of staff as to the interventions and no change in interventions in response to the resident's non-compliance. In addition, the monitoring log documentation was inconsistent. The deficient practice was identified for 3 of 3 residents identified as being non-compliant with the smoking policy and was evidenced by the following: The immediate jeopardy was identified on 1/28/14 at 1:30 p.m. and corrected on 1/28/14 at 3:30 p.m., based upon an acceptable plan of correction for immediacy and a revised plan of correction on 1/30/14 at 11:18 a.m. which was verified by the survey team. The deficient practice for the Immediate Jeopardy situation was evidenced by the following: 1. On 1/21/14 at 10:30 a.m. during the initial tour of the facility the nurse informed the surveyor that Resident #27 had a known behavior of smoking in the room. On 1/28/14 at 12:30 p.m. the surveyor reviewed Resident #27's medical record. The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment dated [DATE], indicated the resident had a moderate cognitive impairment, was assessed to have no long term memory impairment, and ambulated independently. A Social Service Reassessment dated [DATE] indicated the resident was alert to person, place, and time. A review of a smoking assessment completed on 11/16/13 revealed Resident #27 was assessed to physically be able to smoke safely. This assessment was based on the resident being able to safely light smoking materials and ability to verbalize the location of the smoking areas. The smoking assessment did not indicate if the policy was explained to the resident and/or if the resident agreed to the policy. According to an IPN dated 11/20/13 at 6 a.m., the nurse documented she smelled smoke in the resident's bathroom. The nursing supervisor was notified and upon entry into the room also smelled smoke. A lighter was observed next to the resident in bed. An IPN dated 11/21/13 at 6:00 a.m., revealed that the nurse was called to the room by the charge nurse with a report that cigarette smoke was smelled inside Resident #27's room. The resident was in bed with a lighter next to his/her right arm and denied smoking at that time. The resident was counseled and advised to smoke only in authorized areas designated for smoking. Documented incidents included but were not limited to; ashes found at bedside, fumes coming out of the resident's room, the smell of smoke, and a lighter found in bed with the resident. A review of Resident #27's Interdisciplinary Resident Care Plan (IDCP) dated 11/21/13, indicated the resident was "suspected" of smoking in room. The goal was the resident will not smoke in room and interventions included; check person every shift as the resident returned to the unit from the smoking area. The front desk was to give resident one cigarette at a time and have the resident's family leave cigarettes and lighter at the front desk. According to an Interdisciplinary Progress Note (IPN) dated 12/17/13 during the 11:00 p.m. to 7:00 a.m. shift, the nurse "observed the smell of smoke coming from resident's room." The nurse entered the room and observed ashes on the floor in front of the resident's bed and the Unit Manager (UM) was notified. An IPN dated 12/19/13 during the 3:00 p.m. to 11:00 p.m. shift reflected "smoke fume of cigarette in room, resident denies smoking in room. Will continue to monitor." A subsequent Smoking assessment dated [DATE] after the aforementioned incidents, revealed the resident could smoke without supervision. The smoking evaluation further revealed that the resident "does not abide all of the time to smoking policy." However, the assessment revealed the resident was approved to smoke without supervision. A review of a log initiated on 12/20/13, reflected that staff should check Resident #27's room, closet, and drawers for lighting materials (matches and lighters) every shift. For 14 times from 12/20/13 through 1/27/14 the log was not signed by staff to indicate that this was completed. There was no documentation from 11/21/13 through 12/19/13 that reflected the staff were monitoring the resident for smoking materials in the room. A review of a log initiated on 12/23/13 indicated staff were to check Resident #27 for lighting materials (matches and lighters) upon returning to the unit. There was no documentation from 11/20/13 through 12/22/13 to reflect that this was being completed. An IPN dated 1/7/14 during the 3:00 p.m. to 11:00 p.m. shift revealed the Certified Nursing Assistant (CNA) reported Resident #27 was smoking in the resident's room. The writer searched the room and did not find cigarettes. However, the room still "smelled like smoke." The surveyor interviewed the Unit Manger (UM) on 1/28/14 at 12:30 p.m., who stated that the resident was never caught smoking in the room. The surveyor showed the IPN entries to the UM. The UM did not have any comment. On 1/28/14 at 12:50 p.m., the Director of Nursing (DON) revealed the above incidents were "alleged" incidents. The DON further stated no further investigation was conducted to determine the source of the cigarettes/odor and no additional interventions were implemented. On 1/29/14 at 6:50 a.m. the surveyor interviewed the night shift CNA who stated in the presence of the night shift supervisor, that shortly after being admitted to the facility the resident was observed smoking in the room. The CNA further stated when the nurse called her to the room the resident proceeded to extinguish the cigarettes butts on the floor. During an interview with the night shift supervisor on 1/29/14 at 7:30 a.m., it was stated that staff did not observe the resident smoking in the room. The surveyor reviewed the IPN entries with the night supervisor and no comment/explanation was offered. On 1/29/14 at 8:30 a.m., the surveyor interviewed the Social Worker who revealed that she was unaware of the resident's unsafe smoking activities in unauthorized areas. On 1/29/14 at 9:30 a.m., the surveyor interviewed the CNA who cared for the resident during the day. The CNA revealed she was not aware that the resident needed to be monitored for any smoking activities in the room and was unaware to check the resident's room and person upon return from smoking. During an interview with the day shift Nursing Supervisor on 1/29/14 at 11:00 a.m., she revealed that she was aware of the concerns regarding Resident #27 smoking in unauthorized areas. She stated that she met with the UM of the second and third floors to discuss the concerns. She stated she developed an auditing tool to ensure safety and prevent smoking in the room. The UM's were to in-service the staff prior to implementation of the auditing tool. The auditing tool went into effect on 12/20/13. The day shift Nursing Supervisor provided the surveyor with the in-service document that showed it was completed on the second floor. However, there was no in-service completed for the third floor where Resident #27 resided. According to the auditing tool, staff were to check the resident each time upon return from smoking. The resident's room and jacket were to be checked for smoking materials. During a tour of the facility on 1/28/14 at 2:15 p.m., the surveyor noted that Resident #33 shared a room with Resident #27. The surveyor observed that Resident #33 was in bed. The CNA who was in the room at the time stated the resident was blind and used a wheel chair for locomotion. The surveyor interviewed Resident #27 on 1/29/14 at 11:10 a.m. The resident stated that the staff had not conducted any search of the their room or person. During an interview with two Licensed Practical Nurse's (LPN) on 1/28/14 at 1:35 p.m., one LPN revealed that they are responsible for signing the monitoring logs and checking the resident's pockets, drawers and "the rest." The LPN stated it was hard to keep up with the resident when the resident ambulated. The other LPN confirmed that she checks the resident's pockets, room and closet "..if we see the resident when they return to the unit." They further added that they don't always see Resident #27. 2. During the initial tour of the facility on 1/21/14 at 10:00 a.m., the nurse informed the surveyor that Resident #19 had behavior of smoking in the room. The resident's smoking materials were kept at the nurse's station. The surveyor reviewed Resident #19's medical record on 1/28/14. According to the Admission Face Sheet the resident had [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had no cognitive deficits and ambulated independently. The resident's IDCP initiated on 11/24/13 reflected the resident had a history of [REDACTED]. Interventions included, frequently check resident for matches, one to one education, check resident upon return to unit and "as often as possible." In addition, check room closets, and drawers for lighting material. On 1/21/14 at 10:30 a.m. during the initial tour of the facility the nurse told the surveyor that Resident #19 had a behavior of smoking in the room. On 1/28/14 at 12:30 p.m. the surveyor reviewed the resident record. According to the Admission Face Sheet, Resident #19 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated the resident had no cognitive deficits and ambulated independently. A review of an IPN dated 4/14/13 during the 3:00 p.m. to 11:00 p.m. shift, revealed that Resident #19 sat in the lobby and lit a cigarette. The cigarettes were taken by the nurse and given to the secretary. A review of Resident #19's "Smoking Assessment" dated 8/14/13 and 11/5/13, both reflected the resident was assessed as able to smoke without supervision and can "safely handle/hold smoking materials." In addition, the facility's smoking policy was reviewed with the resident and the resident agreed to abide by the policy. An IPN dated 11/24/13 at 10:00 p.m. revealed Resident #19 "was observed smoking in the room." Two cigarette butts were found still partly lit, "smoke still coming out." The IPN further reflected the resident tried to put out the cigarette when the nurse came in. Intervention at that time was 1:1 education. A review of Resident #19's "Smoking Assessment" dated 11/26/13 again reflected the resident was assessed as able to to smoke without supervision and can "safely handle/hold smoking materials." In addition, reflected the facility's smoking policy was reviewed with Resident #19 and the resident agreed to abide by the policy. An IPN dated 12/19/13 at 8:30 a.m. indicated Resident #19 was "caught smoking" by the Administrator while in the elevator. The resident was re-educated and reminded to keep cigarette and lighting materials away. The resident verbalized understanding. A review of Resident #19's "Smoking Assessment" dated 12/19/13 again reflected the resident was assessed as able to smoke without supervision and can "safely handle/hold smoking materials." In addition, the facility's smoking policy was again reviewed with the resident and the resident again agreed to abide by the policy. There was no documentation after each of the aforementioned smoking assessments that reflected the facility had identified that Resident #19 did not abide by the facility's smoking policy. The IDCP was updated on 1/21/14, however there was no documentation that indicated what new interventions were put in place. A review of a log initiated on 12/20/13 reflected that staff were to check the resident for lighting materials (matches and lighters) and cigarettes upon return to the unit. There was no documentation that reflected the facility was monitoring Resident #19's smoking behavior from 11/24/13 through 12/20/13. On 1/28/14 at 2:20 p.m., the surveyor interviewed Resident #19. The resident stated that sometimes they smoked outside. The resident denied smoking or having smoking paraphernalia in unauthorized areas of the facility. The resident also revealed that the facility staff had not been checking their room or person for smoking paraphernalia materials upon return from smoking. During an interview with the DON on 1/28/14 at 10:30 a.m., regarding Resident #19's unsafe smoking behavior, the DON informed the surveyor that she was not aware of any incidents of the resident smoking in the room. The DON further stated that if the staff had reported and/or documented such an incident an investigation should be completed. The DON indicated that the resident was never caught smoking in the room. 3. On 1/29/13 the surveyor reviewed Resident #31's medical record. According to the Admission Face Sheet the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident had no cognitive deficit and used a wheel chair for locomotion. On 1/29/14 at 9:15 a.m., the surveyor observed the resident seated in the designated smoking area smoking a cigarette. On 1/29/14 at 9:00 a.m., the survey team requested a list of resident's who resided in the facility that smoke but are not allowed to have lighters. According to a list provided by the facility on 1/29/14 at 9:30 a.m., Resident #31 was allowed to smoke unsupervised but could not have a lighter. On 1/29/14 at 11:10 a.m., the surveyor observed Resident #31 seated in their room. The surveyor approached the resident to validate the plan of correction provide by the facility after notification of the jeopardy situation. The resident informed the surveyor that they were a smoker. The resident then showed the surveyor cigarettes, a lighter and two boxes of matches located in the resident's coat pocket. The resident informed the surveyor the matches were provided by the facility staff on the ground level floor. Resident #31 informed the surveyor that there was a flood at the facility three weeks ago and the elevators were not working. The resident revealed that they were told by the staff that they could smoke in the room. The resident admitted to smoking in the bathroom on that day. The resident further stated that the morning shift staff did not approve of the smoking in the room and confiscated the lighter. The resident was counseled and advised not to smoke in the room. On 1/29/14 at 11:45 a.m., the surveyor accompanied the Administrator to the second floor. Resident #31 was seated in the room. The resident confirmed the aforementioned incident that the resident told the surveyor. The resident showed the Administrator the lighter that was in the resident's coat pocket. A review of Resident#31's Smoking assessment dated [DATE] and 1/9/14 reflected the resident could smoke without supervision. A review of a Resident #31's IDCP last updated on 12/17/13, reflected the resident was "caught smoking (questionable) in room" and complained of being cold outside. Interventions included; encourage to give up lighting materials, educate about smoking policy, encourage to wear warm clothes to smoke outside and provide hat for extra warmth. There was no documentation that assessment of the current plan was conducted or that a change in interventions were attempted. A review of Resident #31's IDPN dated 1/9/14 (untimed), indicated that during the 11:00 p.m., to 7:00 a.m. shift the Nursing Supervisor and Nurse reported the smell of cigarette smoke in the room. The resident relinquished the lighter to the supervisor. A review of a written summary dated 1/29/14 reflected that the DON was made aware that Resident #31 was smoking in the room that morning. The resident denied smoking and gave up the lighter. A statement dated 1/9/14, obtained during the course of the investigation revealed "during round I smell cigarette smoke" in Resident #31's room. On 1/29/13 at 12:30 p.m., the Administrator provided a summary of the interview with the resident that reflected the Administrator spoke to Resident #31 about smoking and holding own personal items. The resident stated that they did have matches or a lighter. I asked where the resident obtained the items and the resident stated the staff at the reception desk. The resident was not able to verify any specific individual. The Administrator then proceeded to ask the resident about the evening of the 1/8/14. The resident stated that on that evening the elevators were not working. Resident #31 did have" 2 puffs of cigarettes in the room." The statement reflected the Administrator removed the items that the resident had on their person. A review of the facility's Smoking Assessment policy implemented 12/30/2004, indicated that the facility will permit resident's to smoke in designated areas only. In addition, if the facility is jeopardized by a resident's disregard for the smoking policy, or if there is willful disregard of the safety of others, the resident will be counseled. Such action will be recorded in the resident's medical record, and may result in discharge from the facility. A review of the facility's policy "Resident Smoking" revised 12/30/2004, reflected the facility prohibits smoking in the enclosed areas of the nursing home. In addition, resident's who have been deemed not responsible may smoke only under direct supervision. The immediacy of the Jeopardy situation was corrected on 1/28/14 at 3:30 p.m. and verified by the survey team. An expanded plan of correction was implemented on 1/30/14 at 11:18 a.m. and verified by the survey team. The plan included the following: 1. One to One observation was implemented for Residents #19, 26 and 31. 2. The resident's care plans were reviewed and updated smoking assessments were performed by the Unit Manager, Social Services, and Nursing Administration for all residents in question. 3. Complete room inspections were conducted by the DON, Nursing Supervisor, and Social Worker for all 3 residents. 4. A Smoking Agreement was developed by Nursing Administration and Social Services and discussed with all residents and family regarding compliance. 5. Staff inservicing was initiated regarding smoking policy and procedure and resident smoking agreements. 6. The residents' attending physicians were notified by the nursing supervisor and Assistant Director of Nursing (ADON) for possible psychiatric consults and/or assistance with smoking cessation if possible. 7. All residents listed as smokers were screened, updated smoking assessments were completed, room checks of those identified as smokers that might be at risk for safety were completed. Discussions, counseling, updated agreements done for all. 8. Documentation tools were implemented. 9. Corrective actions will be presented to CQI (Quality Improvement) committee for one quarter then quarterly. N.J.A.C. 8:39-4.1(a)11

A. Based on observation, interview and record review, it was determined that the facility failed to develop and/or implement interventions for resident's who perform careless smoking (Residents #'s 19, #27 and #31) and who smoked in unauthorized areas of the facility. Resident #19, #27 and #31 were consistently assessed by nursing staff to not require supervision while smoking even after several occasions staff noted smoke smell, smoke itself in the resident's room and bathroom, ashes on the floor, and smoke paraphernalia on the resident's persons. The remedial measures were consistent with monitoring the residents, checking the resident and the resident rooms for smoking paraphernalia, and re-educating the residents of the dangers. There was no evidence of a development plan or that these measures were consistently followed. The staff exhibited no consistent knowledge as to the interventions specific and no change in interventions in response to the resident's non-compliance. In addition, the smoking monitoring log documentation was inconsistent. The immediate jeopardy was identified on 1/28/14 at 1:30 p.m. and corrected on 1/28/14 at 3:30 p.m., based upon an acceptable plan of correction for immediacy. A revised plan of correction was provided on 1/30/14 at 11:18 a.m. to incorporate all facility action. The deficient practice for the Immediate Jeopardy situation was identified for 3 of 3 residents reviewed as being non-compliant with the smoking policy and was evidenced by the following: 1. On 1/21/14 at 10:30 a.m. during the initial tour of the facility the nurse informed the surveyor that Resident #27 had behaviors related to smoking in the room. On 1/28/14 at 12:30 p.m. the surveyor reviewed Resident #27's medical record. The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment dated [DATE], indicated the resident had a moderate cognitive impairment. The resident was assessed to have no long term memory impairment. In addition, reflected the resident ambulated independently. A Social Service Reassessment dated [DATE] indicated the resident was alert to person, place and time. A review of a smoking assessment completed on 11/16/13 revealed Resident #27 was assessed to be physically able to smoke safely since the resident was able to safely light smoking materials and could verbalize the location of the smoking areas. The smoking assessment did not reflect if the facility's Smoking Policy was explained to the resident and/or if the resident agreed to them. According to an IPN dated 11/20/14 at 6 a.m., the nurse documented the nurse smelled smoke in the resident's bathroom. The nursing supervisor was notified and also went into the room and smelled smoke. A lighter was observed next to the resident in bed. An IPN dated 11/21/14 at 6:00 a.m., reflected the nurse was called to the room by the charge nurse with a report that cigarette smoke was smelled inside Resident #27's room. The resident was in bed with a lighter next to his/her right arm. The resident denied smoking at that time and was counseled and advised to only smoke in authorized areas designated for smoking. Documented incidents included but were not limited to; ashes found at bedside, fumes coming out of resident room, smell of smoke, and resident found in bed with lighter. A review of Resident #27's Interdisciplinary Resident Care Plan (IDCP) dated 11/21/13 reflected the resident was "suspected" of smoking in room. The goal documented on the care plan was that the resident will not smoke in the room. The interventions included to check the resident's person every shift as the resident returns to the unit from smoking. The front desk was to give resident one cigarette at a time and have the resident's family leave cigarettes and lighter at the front desk. According to an Interdisciplinary Progress Note (IPN) dated 12/17/13 during the 11:00 p.m. to 7:00 a.m. shift, the nurse "observed the smell of smoke coming from resident's room." The nurse entered the room and observed ashes on the floor in front of the resident's bed. The Unit Manager (UM) was notified. An IPN dated 12/19/13 during the 3:00 p.m. to 11:00 p.m. shift reflected "smoke fume of cigarette in room, resident denies smoking in room. Will continue to monitor." A subsequent Smoking assessment dated [DATE] after the aforementioned incidents, revealed the resident could smoke without supervision. The smoking evaluation further revealed that although the resident "does not abide all of the time to smoking policy," he/she was assessed to smoke without supervision. A review of a log initiated on 12/20/13 reflected that staff should check Resident #27's room, closet and drawers for lighting materials (matches and lighters) every shift. For 14 times from 12/20/13 through 1/27/14 the log was not signed by staff to indicate that this was completed. There was no documentation from 11/21/13 through 12/19/13 that reflected the staff were monitoring the resident for smoking materials in the room. A review of a log initiated on 12/23/13 indicated staff were to check Resident #27 for lighting materials (matches and lighters) upon returning to the unit. There was no documentation from 11/20/12 through 12/22/13 to reflect that this was being completed. An IPN dated 1/7/14 during the 3:00 p.m. to 11:00 p.m. shift revealed the Certified Nursing Assistant (CNA) reported Resident #27 was smoking in their room. The writer searched the room and did not find cigarettes. However, the room still "smelled like smoke." The surveyor interviewed the Unit Manger (UM) on 1/28/14 at 12:30 p.m., who stated that the resident was never caught smoking in the room. The surveyor showed the IPN notes to the UM. The UM did not have any comment. On 1/28/14 at 12:50 p.m., the Director of Nursing (DON) revealed the above incidents were "alleged" incidents. The DON further stated no further investigation was conducted to determine the source of the cigarettes and no additional interventions were implemented. On 1/29/14 at 6:50 a.m. the surveyor interviewed the night shift CNA who revealed, in the presence of the night shift supervisor, that shortly after being admitted to the facility the resident was observed smoking in the room. The CNA further stated when the nurse called her to the room the resident proceeded to extinguish the cigarettes butts on the floor. During an interview with the night shift supervisor on 1/29/14 at 7:30 a.m., she revealed that staff did not observe the resident smoking in the room. The surveyor reviewed the IPN notes with the night supervisor. He did not have any comment. On 1/29/14 at 8:30 a.m., the surveyor interviewed the Social Worker who revealed that she was unaware of the resident's unsafe smoking activities in unauthorized areas. On 1/29/14 at 9:30 a.m., the surveyor interviewed the CNA who cared for the resident during the day, the CNA revealed she was not aware that the resident needed to be monitored for any smoking activities in the room and was unaware to check the resident's room and person upon return from smoking. During an interview with the day shift Nursing Supervisor on 1/29/14 at 11:00 a.m., she revealed that she was aware of the concerns regarding Resident #27 smoking in unauthorized areas. She stated that she met with the UM of the second and third floors to discuss the concerns. She stated she developed an auditing tool to ensure safety and prevent smoking in the room. The UM's were to in-service the staff prior to implementation of the auditing tool. The auditing tool went into effect on 12/20/13. The day shift Nursing Supervisor provided the surveyor documentation that showed in-services were completed on the second floor. However, there was no in-service completed for the third floor where Resident #27 resided. According to the auditing tool, staff were to check the resident each time upon return from smoking. The resident's room and jacket were to be checked for smoking materials. A review of Resident #27's IDCP interventions revealed there were no specifics as to how to provide close supervision and how routine checks would be performed. The aforementioned IPN repeatedly showed that the resident was able to secure smoking paraphernalia materials and used them in the room. The care plan was not revised to include directives to the direct care staff. The care plan lacked specific interventions to address the unsafe behavior of smoking in the room. 2. During the initial tour of the facility on 1/21/14 at 10:00 a.m., the nurse informed the surveyor that Resident #19 had the behavior of smoking in the room. The resident's smoking materials were kept at the nurse's station. The surveyor reviewed Resident #19's medical record on 1/28/14. According to the Admission Face Sheet the resident had [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had no cognitive deficits and ambulated independently. The resident's IDCP initiated on 11/24/13 reflected the resident had a history of [REDACTED]. Interventions included to frequently check resident for matches, one to one education, and to check resident upon return to unit and "as often as possible." In addition, staff were to check room closets and drawers for lighting material. On 1/28/14 at 12:30 p.m. the surveyor reviewed the resident record. According to the Admission Face Sheet, Resident #19 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated the resident had no cognitive deficits and ambulated independently. A review of an IPN dated 4/14/13 during the 3:00 p.m. to 11:00 p.m. shift, revealed Resident #19 sat in the lobby and lit a cigarette. The cigarettes were taken by the nurse and given to the secretary. A review of Resident #19's "Smoking Assessment" dated 8/14/13 and 11/5/13, both reflected the resident was assessed as able to smoke without supervision and can "safely handle/hold smoking materials." In addition, the facility's smoking policy was reviewed with the resident and the resident agreed to abide by the policy. An IPN dated 11/24/13 at 10:00 p.m. revealed Resident #19 "was observed smoking in the room." Two cigarette butts were found still partly lit, "smoke still coming out." The IPN further reflected the resident tried to put out the cigarette when the nurse came in. Intervention at that time was 1:1 education. A review of Resident #19's "Smoking Assessment" dated 11/26/13 again reflected the resident was assessed as able to to smoke without supervision and can "safely handle/hold smoking materials." In addition, the facility's smoking policy was reviewed with the resident and the resident agreed to abide by the policy. An IPN dated 12/19/13 at 8:30 a.m. indicated Resident #19 was "caught smoking" by the Administrator while in the elevator. The resident was re-educated and reminded to keep cigarette and lighting materials away. The resident verbalized understanding. A review of Resident #19's "Smoking Assessment" dated 12/19/13 again reflected the resident was assessed as able to smoke without supervision and can "safely handle/hold smoking materials." Again, the facility's smoking policy was reviewed with the resident and the resident agreed to abide by the policy. There was no documentation after each of the aforementioned smoking assessments that reflected the facility identified that Resident #19 did not abide by the facility's smoking policy. A review of a log initiated on 12/20/13 reflected that staff were to check the resident for lighting materials (matches and lighters) and cigarettes upon return to the unit. There was no documentation that reflected the facility was monitoring the Resident #19's smoking behavior from 11/24/13 through 12/20/13. On 1/28/14 at 2:20 p.m., the surveyor interviewed Resident #19 who revealed that sometimes the resident smoked outside. The resident denied smoking or having smoking paraphernalia in unauthorized areas of the facility. The resident also revealed that the facility staff had not been checking the resident's room or person for smoking paraphernalia materials upon return from smoking. The IDCP did not address the unsafe smoking behavior until 11/24/13. The IDCP was updated on 1/21/14, however there was no documentation that reflected what new interventions were put in place. Interventions were not specific as to how to provide close supervision and daily monitoring. Documentation in the Interdisciplinary Care Plan (IDCP) Notes repeatedly indicated that the resident continued to smoke in unauthorized areas of the facility. The care plan lacked interventions to address the behavior of unsafe smoking in the room and in common areas of the facility. The care plan failed to specify who would be responsible to monitor the resident to prevent recurrence of the behavior. The facility did not address the unsafe smoking behavior in the care plan until the third occurrence. 3. On 1/29/13 the surveyor reviewed Resident #31's medical record. According to the Admission Face Sheet the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident had no cognitive deficit and used a wheel chair for locomotion. The resident's IDCP initiated on 7/9/13 addressed the problems of non compliance with care, weight loss, skin integrity, and falls. On 1/29/14 at 9:15 a.m., the surveyor observed the resident seated in the designated smoking area smoking a cigarette. On 1/29/14 at 9:00 a.m., the survey team requested a list of resident's who resided in the facility that smoke but are not allowed to have lighters. According to a list provided by the facility on 1/29/14 at 9:30 a.m., Resident #31 was allowed to smoke unsupervised, but could not have a lighter. On 1/29/14 at 11:10 a.m., the surveyor observed Resident #31 seated in the resident's room. The surveyor approached the resident to validate the plan of correction provide by the facility. The resident informed the surveyor that they were a smoker. The resident then showed the surveyor cigarettes, a lighter and two boxes of matches located in the resident's coat pocket. The resident informed the surveyor the matches were provided by the facility staff on the ground level floor. Resident #31 informed the surveyor that there was a flood at the facility three weeks ago and the elevators were not working. The resident revealed that they were told by the staff that they could smoke in the room. The resident admitted to smoking in the bathroom on that day. The resident further stated that the morning shift staff did not approve of the smoking in the room and confiscated the lighter. The resident was counseled and advised not to smoke in the room. On 1/29/14 at 11:45 a.m., the surveyor accompanied the Administrator to the second floor. Resident #31 was seated in the room. The resident confirmed the aforementioned incident that the resident told the surveyor. The resident then showed to the Administrator the lighter that was in the resident's coat pocket. A review of Resident#31's Smoking assessment dated [DATE] and 1/9/14 reflected the resident could smoke without supervision. A review of a Resident #31's IDCP last updated on 12/17/13 reflected the resident was "caught smoking (questionable) in room" complained of being cold outside. Interventions included; encourage to give up lighting materials, educate about smoking policy, encourage to wear warm clothes to smoke outside and provide hat for extra warmth. There was no documentation that an effective plan was implemented. A review of Resident #31's Interdisciplinary Progress Note (IDPN) dated 1/9/14 not timed, reflected that during the 11:00 p.m., to 7:00 a.m. shift on 1/8/14, the Nursing Supervisor and Nurse reported the smell of cigarette smoke in room. The resident relinquished the lighter to the supervisor. A review of a written summary dated 1/29/14 reflected that the DON was made aware that Resident #31 was smoking in the room that morning. The resident denied smoking and gave up the lighter. A statement dated 1/9/14, obtained during the course of the investigation "during round I smell cigarette smoke" in Resident #31's room. On 1/29/13 at 12:30 p.m., the Administrator provided a summary of the interview with the resident that reflected the Administrator spoke to Resident #31 about smoking and holding their own personal items. The resident stated that he/she did have matches or a lighter. I asked where the items were obtained and the resident stated "the staff at the reception desk." The resident was not able to verify any specific individual. The Administrator then proceeded to ask the resident about the evening of the 1/8/14. The resident stated that on that evening the elevators were not working. Resident #31 did have" 2 puffs of cigarettes in the room." The statement reflected the Administrator removed the items that the resident had on their person. The care plan was not revised to address the behavior of unsafe smoking in the room. In addition, the CNA care plan was not updated to provide directives to direct care staff on how to manage the behavior. Staff was not made aware to check the resident upon return on unit for any paraphernalia materials. A smoking assessment dated [DATE] even after the incident indicated that the resident could smoke without supervision. The immediacy of the Jeopardy situation was corrected on 1/28/14 at 3:30 p.m. and verified by the survey team. An expanded plan of correction was implemented on 1/30/14 at 11:18 a.m. and verified by the survey team. The plan included the following: 1. One to One observation was implemented for Resident #'s 19, 26 and 31. 2. The resident's care plans were reviewed and updated smoking assessments were performed by the Unit Manager, Social Services, and Nursing Administration for all residents in question. 3. Complete room inspections were conducted by the DON, Nursing Supervisor, and Social Worker for all three residents. 4. A Smoking Agreement was developed by Nursing Administration and Social Services and discussed with all residents and families regarding compliance. 5. Staff in servicing was initiated regarding the smoking policy and procedure and resident smoking agreements. 6. The residents attending physicians were notified by the nursing supervisor and Assistant Director of Nursing (ADON) for possible psychiatric consults and/or assistance with smoking cessation if possible. 7. All residents listed as smokers were screened, updated smoking assessments were completed, room checks of those identified as smokers that might be at risk for safety were completed. Discussions, counseling, updated agreements were done for all. 8. Documentation tools were implemented. 9. Corrective actions will be presented to CQI (Quality Improvement) committee for one quarter then quarterly. N.J.A.C. 8:39-4.1(a)11 The deficiency continues at a lower scope and severity level of E as indicated in Part B. B. Based on observation, interview, and record review it was determined that the facility failed to consistently implement and/or initiate identified care plan interventions for 4 of 29 residents reviewed (Resident #11, 26, 8 and 12). The deficient practice was evidenced by: 1. The surveyor reviewed Resident #11's medical record on 1/24/14. The Admission Record reflected the resident was admitted to the facility with a medical [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident had a moderate cognitive impairment and utilized a limb restraint daily. The resident's January 2014 physician's orders [REDACTED]. The resident's care plan initiated on 5/3/10 and revised on 1/22/14 indicated Resident #11 was at risk for skin breakdown due to scratching. Interventions included but were not limited to "keep fingernails short and clean." The care plan did not include an intervention to apply hand mitts. The surveyor observed Resident #11 on 1/21/14 at 10:30 a.m. in bed wearing white hand mitts during a tour of the nursing unit with the UM. The UM indicated the resident utilized hand mitts due to pulling on the gastrostomy tube and their scratching bilateral upper extremities and chest area. The surveyor returned to Resident #11's room on 1/23/14 at 10:20 a.m. The resident was awake and alert and able to remove the hand mitts when requested by the surveyor. The surveyor observed that the resident's nails were untrimmed and extended beyond the nail bed on both hands. The surveyor interviewed the resident's regular CNA on 1/23/14 at 1:10 p.m. The CNA stated the resident wears mitts because of scratching. She further stated the resident's fingernails must be kept short. The CNA stated she didn't get a chance to cut them and would do so right away. The surveyor returned to the resident's room on 1/23/14 at 1:20 p.m. with the LPN. The LPN confirmed that the resident's nails were untrimmed and not kept short. The LPN further stated that the resident's CNA would be asked to cut the nails as soon as possible. 2. During the initial tour conducted on 1/21/14, the UM stated that Resident #26 was alert and oriented, and was able to make their needs known to staff. The UM also stated that Resident #26 was a high risk for falls. In addition, the resident had a "near" fall a few weeks ago. The UM also revealed that the fall occurred when the resident was transferred from the bed into a wheel chair. The UM stated Resident #26 informed her that their "legs gave out" and that the CNA had lowered the resident to the floor. At this time, Resident #26 was observed seated in a wheel chair at a table inside the 5th floor dining room. A review of the record revealed that Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] revealed that Resident #26 had long and short term memory problems. The MDS also revealed that Resident #26 required extensive two person assistance when turning from side to side while in bed, and for moving from the bed and into a wheel chair. During an interview conducted by the surveyor on 1/27/14 at 1:45 p.m., Resident #26 stated that they were admitted to the facility after having had a "stroke" and did not have any feeling on the left side. The resident revealed that a female CNA had made an attempt to transfer the resident into the wheelchair alone. The resident stated that they had told the CNA to get some help, but the CNA stated that she could do it alone. The resident stated my "legs gave out" and they fell to the floor. Resident #26 told the surveyor there was no injury from the fall. A review of the plan of care for Resident #26 dated 1/17/2014 in the presence of the UM revealed that Resident #26 had a history of [REDACTED]. The interventions identified on the care plan indicated that Resident #26 only required staff assistance for transfers. The care plan lack any information as to the number of staff members that were needed to perform this activity. A review of the CNA's care plan for Resident #26 lacked documentation as to how the CNA's were to transfer the resident from the bed into the chair or the number staff members required to perform this activity. This section of the care plan was blank. When interviewed on 1/28/14 at 9:20 a.m., the UM stated that Resident #26 required a two person transfer. The UM also stated the CNA's had their own care plan book for the residents. The UM revealed that this book was kept at the nurses station on the unit. The UM added that the other care plans were kept either on the resident's record or on the computer. The UM stated that only the Unit Managers and the MDS coordinator had access to the care plans on the computer. During this same interview, the UM stated that she was responsible for revising and printing the care plans and also for the documentation on the CNA's care plans. She could not offer an explanation as to why both of the care plans for Resident #26 lacked this information. When interviewed further, the UM stated that the fall could have been prevented if there had been two staff members transfering the resident instead of only one. 3. During the initial tour of the facility, the nurse told the surveyor that Resident #12 was confused, had behavior of being combative with care. On 1/23/14 at 9:30 a.m., the surveyor observed the resident in bed, and a strong urine odor was noted in the south hallway and in the room. On 1/24/14 at 8:00 a.m., the surveyor observed the resident in bed. The door was partly closed. A strong urine odor was permeated in the south hallway and in the resident's room. On 1/ 24/14 at 8:30 a.m. the surveyor approached the resident but the resident refused to answer any questions. During an interview with the CNA who cared for Resident #12 on 1/24/14 at 8:45 a.m., revealed that the resident required total assistance with care, can ambulate short distances, used the wheelchair mostly for ambulation and transfer. The CNA revealed that every morning the resident was soaked with urine and the bed had to be washed daily. The CNA further stated that every morning the resident's bedding including the pillow case was soaked with urine. An interview by the surveyor with a housekeeper that same day at 10:15 a.m. confirmed the aforementioned. On 1/24/14 at 9:30 a.m., the surveyor reviewed the resident's care plan dated 4/13/13. The care plan lacked specific interventions to address the resident's incontinence. The CNA care plan did not address and was not updated to provide interventions to the 11:00 p.m. to 7:00 a.m. staff on ways to manage the resident's urinary incontinence. During an interview with the UM on 1/24/14 at 12:10 p.m., the UM revealed that the resident was non-compliant with care but would be cooperative with certain staff and can re-directed with food items. None of these identified interventions was added to the care plan for the staff to follow during the 11:00 p.m. to 7:00 a.m. shift. 4. A review of Resident #8's Admission Face Sheet revealed Resident #8 had [DIAGNOSES REDACTED]. The MDS dated [DATE] reflected Resident #8 had a severe cognitive impairment and was totally dependent on staff for bed mobility and transfer. The surveyor reviewed the resident's medical record on 1/24/14 at 10:10 a.m. which revealed a Physician order [REDACTED]. An IDCP initiated 12/2/13 revealed that the resident was to wear geri sleeves to prevent further skin tears. The resident was observed without the compression stockings and without the geri sleeves on the following days during the survey: 1/21/14, 1/23/14 and 1/24/14 from 9 am to 1:30 p.m. On 1/24/14 at 12:40 p.m., the surveyor interviewed the CNA who cared for the resident. The CNA told the surveyor she cared for the resident daily and stated the resident did not have an order for [REDACTED]. A review of the CNA care plan did not include any provision for geri sleeve and compression stockings. There were no compression stockings or geri sleeves in the room. The surveyor reviewed the resident's care plan with the UM who stated he was not aware of the order for the geri sleeves and the compression stockings. A review of the Treatment Administration Record revealed the nurses had initialed the TAR to indicate the compression stockings were placed on the resident on 1/21/14, 1/23/14 and 1/24/14, although the surveyor observed the resident not to have them on. NJAC 8:39-27.1 (a) NJAC 8:39 - 11.2 N.J.A.C. 8:39-4.1(a)11

Based on observation, interview and record review, it was determined that the facility failed to protect female residents from sexual abuse and psychosocial harm by a confused, wandering resident, Resident #11, with known unpredictable and inappropriate sexual behaviors. This resulted in an immediate jeopardy situation for 2 cognitively impaired residents, Residents #20 and #22, as well as other female residents on the unit. Resident #11 had a history of [REDACTED].# 11 groped a female resident (Resident #20) and attempted to undress a female resident while in bed (Resident #22). Resident #11 also had a behavior of masturbating and ejaculating in areas frequented by other residents. The Administrator and Director of Nursing (DON) confirmed and acknowledged the incidents of sexual abusive behaviors to cognitively impaired female residents. The Immediate Jeopardy was identified on 2/28/13 at 3 p.m., and the immediacy was abated on 2/28/13 at 4 p.m., upon receipt of an acceptable plan of correction, which included 1:1 supervision of Resident #11. The deficient practice continued at a lower scope and severity of "E" until 3/7/13, when all staff received appropriate inservicing. The deficient practice was evidenced by the following: 1. On 2/26/13 at 10:15 a.m. the surveyor toured the unit with the Unit Manager (UM). The surveyor observed Resident #11 ambulating in the hallway unattended. The UM spoke to Resident #11 in Spanish to redirect the resident and stated that the resident also understood English. The UM stated the resident was ambulatory, wandered into other resident rooms and could be aggressive with staff and other residents. Resident #11's medical record was reviewed by the surveyor on 2/27/13 at 9:30 a.m. The cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 12/1/12, indicated the resident was severely cognitively impaired, wandered and had behaviors directed toward others. The surveyor reviewed the Interdisciplinary Plan of Care (IPC) dated 2/25/13, which revealed "problem/need": Aggressive Behavior; Sexually Inapp. (Inappropriate) and Physically Abusive Behavior; and Masturbates in Public. The surveyor reviewed the medical record and observed the following: A Nurses Progress Note dated 6/24/12, revealed "awake at 12 a.m. pacing hallway, into other occupied rooms." A Social Service Progress Note (SSPN) dated 7/20/12 indicated that Resident #11 was observed ejaculating on a medication cart. An SSPN dated 10/3/12, reflected "Contacted S-Cope (Statewide Clinical Outreach Program for the Elderly) re: referral (secondary) to inappropriate touching of female co-residents." The (S-Cope) Clinical Consultation dated 10/4/12, revealed the Presenting Problem as: " Client has been exhibiting sexually inappropriate behaviors. Client has touched two women's breasts and has ejaculated in public areas." The Clinical Impression from the consult stated "Client's sexual preoccupation and other behavioral disturbances have increased recently." On 10/8/12, S-COPE made the following recommendations: 1. A change in medication: "[MEDICATION NAME] and Ambien, individually and in combination, could be causing increase in sexual preoccupation and inappropriate sexual behaviors. Please consult with client's prescribing doctor about possibly discontinuing these medications." and 2. "It may be necessary to also change the floor client resides on if medication change does not decrease the problem behaviors." A review of the Psychiatrist follow-up consultation dated 10/9/12, reflected "(Resident #11) remains irritable, impulsive, will sometimes curse and try to hit people who interfere with his activities." The resident "has developed a romantic interest in a female peer whose responsible party gets upset at (resident's) attentions. The resident "can sometimes be hard to redirect from this woman." The SSPN from 10/18/12 responded to the S-COPE recommendations of 10/8/12 and indicated that [MEDICATION NAME] had been discontinued but [MEDICATION NAME] not discontinued due to the resident's "wakefuleness." The note continued: "Declined recc.(recommendation) for transfer to another floor." There was no further explanation or documentation in the medical record for not following the recommendation. The Interdisciplinary Care Plan Notes (ICPN) dated 12/10/12, revealed Resident #11 had physically and sexually inappropriate behavior. The ICPN dated 2/25/13, documentation revealed Resident #11 was more aggressive. The SSPN dated 1/3/13 stated that, per the nursing report on 1/2/13, at 11:20 p.m. Resident #11 was sexually inappropriate with female co-resident (Resident #22). The S-Cope Clinical Consultation, dated 1/3/13, stated: "Client (Resident #11) represented with sexually aggressive/inappropriate behavior involving a female resident whose room is opposite clients." The 1/3/13 Interdisciplinary Progress Note at 11 p.m. indicated "resident redirected for attempting to undress a female resident." On 2/27/13 at 2 p.m., the surveyor interviewed the Certified Nursing Assistant (CNA) responsible for the care of Resident #11. The CNA stated "they never told me to watch out for anything about behaviors" of the resident. The resident "walks around and I find him coming out of other people's rooms." On 2/27/13 at 10:30 a.m., the surveyor interviewed the UM regarding the monitoring of Resident #11. The UM stated that Resident #11 was monitored visually when the UM was at the nursing desk. The UM stated that they kept "an eye" on the resident. The UM stated if the resident walked into other residents rooms, staff would follow the resident. The UM further stated the resident's IPC indicated "to watch" the resident. A review of Resident #11's IPC dated 2/25/13 for sexually inappropriate behavior did not reflect interventions for inappropriate sexual behavior monitoring. Nor were there interventions to protect female residents from Resident #11's sexual advances. On 2/28/13, the surveyor requested that the UM provide all investigations regarding inappropriate behaviors. The investigations provided by the UM did not include any investigations for inappropriate sexual behavior. On 2/28/13 at 12:15 p.m. two surveyors interviewed the Director of Nursing (DON) regarding the investigations for the inappropriate undressing by Resident #11 on 1/2/13 towards Resident #22. The DON stated she was aware of the incident that occurred between Resident #11 and #22, however, was unable to provide an investigation for the incident. The DON stated that Resident #11 was found in the bed of Resident #22. The DON also stated, Resident #22 still resided at the facility on the same floor with Resident #11. The DON said "we keep an eye on him" but stated Resident #11 needed a detailed behavioral care plan and acknowledged that the current care plan was vague. The DON stated she was unaware of the breast-touching incident by Resident #11 toward Resident #20 that occurred in October 2012. The DON said they would have completed an investigation if they had known about the incident. The surveyor interviewed the social worker on 2/28/13 at 12:45 p.m. and inquired about the October incident. She informed the surveyor that she was "verbally notified" of the incident by the staff nurse on the unit but that she could not recall the name of the staff member. On 2/28/13 at 2:30 p.m., the surveyor interviewed the facility's DON and the Administrator and inquired about the 10/3/12 incident with Resident #11 towards Resident #20. The Administrator confirmed he was made aware of the above incident in October 2012, and that the resident who was inappropriately touched by Resident #11 was Resident #20. When the surveyor asked for the investigation of the incident, the DON indicated that no investigation was initiated. Resident #20's medical record was reviewed by the surveyor on 3/4/12. A review of Resident #20's admission face sheet reflected the resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #20 was severely cognitively impaired. The current IPC for Resident #20 reflected a care plan was in place for the [DIAGNOSES REDACTED]. There were no interventions to protect the resident from Resident #11's sexual behaviors. A review of Resident #20's IPN's reflected the following nursing notations: a. On, 10/4/12 at 7:00 a.m. to 3:00 p.m., a male resident (Resident #11) was "seen standing over" Resident #20 and was re-directed. b. On 10/5/12 at 7:00 a.m. -3:00 p.m., stated "observed male resident standing over resident while in dining room sitting next to resident, will continue to monitor." c. On 10/5/12 at 6:20 p.m., stated Resident #11 was observed standing over Resident #20 and talking and was re-directed "will continue to monitor." d. On 10/6/12 at 7:00 a.m. -3:00 p.m., stated "continued to stand over" Resident #20 and was re-directed 3 times. e. On 10/7/12 at 7:00 a.m. to 3:00 p.m. stated "sitting and standing by resident (Resident #20) easily redirected multiple attempt made to interact with resident." f. On 10/16/12 at 7:00- 3:00 p.m. stated "observed" Resident #11 "stand by resident (Resident #20) side, resident was redirected." g. On 10/18/12 at 7:00 - 3:00 p.m. stated "observed male resident (Resident #11) standing over resident and touching resident shoulder. Redirect male resident." Although there was documentation that indicated Resident #11 was redirected on the aforementioned dates and times during the month of October 2012, there was no documentation that reflected a monitoring plan was consistently in place to prevent further inappropriate touching by Resident #11 towards Resident #20 from 10/3/12 until 11/8/12 when Resident #20 was moved to another floor. A subsequent SSPN for Resident #20, dated 9/28/12 (not timed) reflected UM stated to Social Worker (SW) Resident #11 had "befriended" Resident #20 and would need to be re-directed by staff. The responsible party acknowledged that Resident #11 would remain around resident while the spouse was visiting with Resident #20. The SW directed Resident #20's spouse to "continue to request" that Resident #11 be re-directed to another area away from Resident #20. In addition the SW stated, if Resident #11"persists in not moving away from resident (Resident #20) then (the spouse) will go to staff member in order to intervene with (Resident #11). Resident #20's spouse is in agreement with this." A SSPN dated 11/8/12 (not timed) indicated that Resident #20's spouse requested that Resident #20 be transferred to another floor. During an interview on 3/5/13 at 2:50 p.m., Resident #20's spouse informed the surveyor that a male resident (Resident #11) was "stalking" Resident #20. The male resident was "consistently after (the resident)" and it "got on my nerves." The spouse further stated Resident #11 would stand hovering in front of both of them when he was visiting. The responsible party stated he requested Resident #20 be moved before "anything happened." 2. On 2/28/13 at 10:30 a.m. the surveyor reviewed the medical record for Resident #22. According to the cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool 12/1/12, indicated that the resident was severely cognitively impaired. The surveyor reviewed the Interdisciplinary Progress Notes (IPN) for Resident #22 for 1/2 and 1/3/13. The notes did not include the incident of sexually inappropriate behavior that was written in Resident #11's IPN on 1/3/13: "resident redirected for attempting to undress a female resident." The surveyor reviewed the Psychiatrist's follow-up consultation for Resident #11, dated 1/8/13, that stated, "Staff requested an early follow-up - again reporting sexual inappropriateness. Last week (Resident #11) was sexually forward with a female peer - groping, going into her room. (Resident #11) impulse control is poor and his insight and judgment are very poor." On 2/28/13 at 12:45 p.m. two surveyors interviewed the Social Worker (SW) regarding the incidents of inappropriate touching of Resident #20's breast and undressing Resident #22 while in bed by Resident #11. The SW stated regarding the incident in October 2012, when Resident #11 touched one resident's breast (Resident #20) and attempted to touch another (unidentified by facility), S-COPE was called for an evaluation. The SW also stated that she did not complete an investigation, however, the information went to the DON and it was also noted on the 24 hour report. In addition, the SW stated after the January 2013 incident had occurred with Resident #11 and nursing had informed her that the resident needed to be physically removed from the room of Resident #22, the SW began the process of obtaining authorization to transfer Resident #11 out of the facility. This was approximately three months after the first documented occurrence of sexual abuse by Resident #11. The surveyor reviewed the IPN documentation for 10/3/12 for Resident #20. There was no documentation regarding the breast touching incident by Resident #11 in the nursing notes. On 2/28/13 at 2:20 p.m. two surveyors interviewed the Administrator with the DON present. The Administrator stated that he was aware of the inappropriate touching of Resident #20 by Resident #11 that occurred in October 2012. He continued to state Resident #20 was moved to another floor on 11/8/12. This was more than one month after the incident of sexual abuse occurred. The Administrator then stated he was unaware that an investigation was not completed for the incident that occurred in October 2012. The Administrator stated he was aware of the January 2013 incident when Resident #11 got into bed with and began undressing Resident #22 and acknowledged that the investigation was not completed. The Administrator stated both instances were not reported to the State agency because there was no physical evidence of abuse. The surveyor reviewed the facility's "Abuse, Resident Behavior and Facility Practice" Policy. The Policy stated that "The resident has the right to be free from verbal, sexual, physical,or mental abuse..." and "This facility has policies and procedures for...protection of residents and for the prevention, identification, investigation, and reporting of abuse..." The immediacy of the sexual abuse was corrected on 2/28/13 at 4 p.m. based on an acceptable plan of correction which including the following: "1. Resident #11 was immediately placed on 1:1 observation and staff on all 3 shifts will observe behaviors and redirect the resident if required. 2. Resident #11 will be on consistent 24 hour reporting documentation by staff each shift to document behaviors witnessed. 3. Resident #11's Psychiatrist was made aware of the resident to resident inappropriate touching. 4. Staff was educated regarding abuse including resident to resident abuse, inappropriate sexual behavior, and all other forms of abuse. Inservicing on Abuse to be completed by 3/7/13 for entire facility staff. 5. Immediate inservices/education for all shifts by Psychiatrist and Administrative staff regarding geriatric sexual behavior to be completed by 3/7/13. 6. The facility will continue process of guardianship in order to place resident in behavioral setting that is needed. 7. Facility will provide inservices by a State clinical out reach program as recommended by consultation. 8. Continued follow ups by Psychiatrist to address new behaviors witnessed. 9. Nursing staff have received re-education regarding the facility's incident reporting/investigation and follow up. 10. A weekly meeting with nursing and administration to discuss new onset behaviors with all residents to determine corrective actions and care plan updates. and 11. Interdisciplinary team re-education on resident specific care planning for resident behaviors. " The deficient practice continued at an E level until March 4, 2013 when all facility staff completed the mandated inservices. NJAC 8:39-27.1 (a) NJAC 8:39-4.1 (a) 5

A. Based on observation, interview and record review, it was determined that the facility failed to a.) develop and implement a behavioral plan of care for a confused wandering resident, Resident #11, with known unpredictable and inappropriate sexual behavior and b.) failed to protect female residents, Resident #20 and #22, from sexual abuse and psychosocial harm by Resident #11. This deficient practice was identified for 3 of 31 residents reviewed, (Resident #11, #20 and #22). This resulted in an immediate jeopardy situation for cognitively impaired residents, Residents #20 and #22, as well as other female residents on the unit. Resident #11 had a history of [REDACTED]. Statements from the Administrator and Director of Nursing acknowledged the incidents of sexual behaviors toward cognitively impaired female residents. The Immediate Jeopardy was identified on 2/28/13 at 3 p.m., and the immediacy was abated on 2/28/13 at 4 p.m., upon receipt of an acceptable plan of correction. The deficient practice was evidenced by the following: 1. On 2/26/13 at 10:15 a.m. the surveyor toured the unit with the Unit Manager (UM). The surveyor observed Resident #11 ambulating in the hallway unattended. The UM spoke to Resident #11 in Spanish for redirection and stated that the resident also understood English. The UM stated the resident was ambulatory, wandered into other resident rooms and could be aggressive with staff and other residents. On 2/27/13 at 9:30 a.m. the surveyor reviewed the medical record of Resident #11. The cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 12/1/12, indicated the resident was severely cognitively impaired, wandered and had behaviors directed toward others. The Interdisciplinary Plan of Care (IPC) (care plan) dated 2/25/13, revealed as problems/needs: Aggressive Behavior; Sexually Inapp. (Inappropriate) and Physically Abusive Behavior; and Masturbates in Public. The interventions included but were not limited to: redirect resident if attempts to leave unit; psychiatric medications as needed; and psychiatric consult as needed. There was no documentation that reflected specific interventions were in place to address the resident's sexually inappropriate behavior. For the masturbation problem, the facility included the following interventions: Staff would take resident to his own room; remove from area; and psychological consults and medications as needed. There were no specific interventions to protect other residents from this behavior. A review of the Social Service Progress Notes (SSPN) revealed on 10/3/12, "Contacted (Statewide Clinical Outreach Program for the Elderly) re: referral (secondary) to inappropriate touching of female co-residents." The surveyor reviewed the Statewide Clinical Outreach Program for the Elderly (S-COPE) Clinical Consultation, dated 10/4/12, which revealed; Presenting Problem: "Client has been exhibiting sexually inappropriate behaviors. Client has touched two women's breasts and has ejaculated in public areas." A review of Resident #11's Psychiatrist consultation follow-up dated 10/9/12, revealed that the resident; "..remains irritable, impulsive, will sometimes curse and try to hit people who interfere with his activities." The resident "..has developed a romantic interest in a female peer..." The note further indicated that the responsible party gets upset at the attention. The resident "can sometimes be hard to redirect..." There was no documentation that indicated the resident's care plan was updated to reflect new interventions to prevent further sexually inappropriate touching. An IPN for Resident #11, dated 1/3/13 at 11 p.m. revealed that the resident was redirected for attempting to undress a female resident close supervision. Resident #11 was returned to bed. The Supervisor was made aware. A subsequent IPN dated 1/3/13 (not timed) reflected the resident's physician was notified of Resident #11's behaviors and prescribed [MEDICATION NAME] 25 mgs in the morning and would follow-up the next week. An IPN dated 1/3/13 (3:00 p.m. to 11:00 p.m.), reflected Resident #11 was placed on "1/2 hour watch this shift...." The surveyor reviewed the S- COPE Clinical Consultation dated 1/3/13, which revealed as the presenting problem: "Client represented with sexually aggressive/inappropriate behavior involving a female resident.." The recommendations from the State Clinical Outreach Program included: "Create an "ABC" chart (a behavior monitoring chart) for behaviors" and provide staff inservice training on geriatric sexuality. A review of Resident #11's Psychiatrist consultation follow-up dated 1/8/13, revealed "Staff requested an early follow-up-again reporting sexual inappropriateness. Last week (Resident #11) was sexually forward with a female peer-groping going into (resident) room." The Interdisciplinary Plan of Care (IPC) dated 2/25/13, revealed a Problem: Sexually (Inappropriate) with a Goal: Will be redirected as needed and will have less episodes of (negative) behavior with a target Date of 5/13. The Interventions: Offer job to do such as wipe down nursing station dining room tables (as previously preferred to do in the past), Psych meds as ordered, Follow up with psychiatrist as needed. The dates and specifics of the sexual abuse incidents were not noted on the careplan, nor did it reflect interventions to prevent reoccurrence, monitor behavior and protect other residents. The recommendations from the Statewide Clinical Outreach Program for the Elderly were not included in the plan of care. The DON was interviewed on 2/28/13 at 2:20 p.m. and the DON was unaware of the recommendations of the Statewide Clinical Outreach Program for the Elderly. On 2/27/13 at 10:30 a.m., the surveyor interviewed the UM regarding the monitoring of Resident #11. The UM stated that the resident was monitored visually when UM was at the nursing desk. We keep "an eye" on him if he walks in other residents rooms and the other staff will do the same. "It is in his care plan to watch him." There was no formal monitoring system for inappropriate behaviors and continued monitoring or interventions for behavior monitoring. 2. During the review of Resident #11's medical record on 2/28/13, the surveyor noted a Social Worker's note dated 10/3/12, which revealed Resident #11 was referred to a statewide Clinical Outreach Program for the Elderly (S-COPE), secondary to inappropriate sexual touching of female co-residents. On 3/4/13, the surveyor reviewed S-COPE's documentation which revealed that Resident #11 had been exhibiting sexually inappropriate behaviors - "has touched 2 women's breasts." At 2:30 p.m., the same day, the surveyor interviewed the facility's DON and the Administrator and inquired about the 10/3/12 incident. The administrator confirmed that he was made aware of the above incident in October 2012, and that the resident who was inappropriately touched was Resident #20. The surveyor reviewed Resident #20's medical record on 3/5/13 at 10 a.m. The medical record face sheet reflected the resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 12/31/12, indicated Resident #20 was severely cognitively impaired. A review of Resident #20's IPN's reflected the following nursing notations: 1. On 10/4/12 at 7:00 a.m. to 3:00 p.m., a male resident was seen standing over Resident #20 was re-directed. 2. On 10/5/12 at 7:00 a.m. -3:00 p.m., it was noted that a male resident was observed standing over Resident #20 while in the dining room and sitting next to the resident. Staff will continue to monitor. 3. On 10/5/12 at 6:20 p.m., reflected Resident #11 was observed standing over Resident #20 and talking and was re-directed "..will continue to monitor." 4. On 10/6/12 at 7:00 a.m. -3:00 p.m., reflected "continued to stand over" Resident #20 and was re-directed 3 times. 5. On 10/7/12 at 7:00 a.m. to 3:00 p.m. reflected Resident #11 was sitting and standing by Resident #20 and attempted multiple times to interact but was easily redirected. 6. On 10/16/12 at 7:00- 3:00 p.m., Resident #11 was observed standing by resident Resident #20 and was redirected. 7. On 10/18/12 at 7:00 - 3:00 p.m., Resident #11 was observed standing over Resident #20 and touching her shoulder. Resident #20 was redirected. Resident #20's current careplan was reviewed by the surveyor on 3/5/13 which did not contain a written care plan to address the episodes inappropriate sexual behaviors directed towards this resident or safety. 3. On 2/26/13 at 10:15 a.m. the surveyor toured the unit with the Unit Manager (UM). The UM stated Resident #22 had a history of [REDACTED]. On 2/28/13 at 10:30 a.m. the surveyor reviewed the medical record for Resident #22. According to the cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool 12/1/12, indicated that the resident was severely cognitively impaired. A review of Resident #22's Social Service notes dated 1/3/13 (not timed), documented the responsible party had inquired about the recent behavior incident on the evening of 1/2/13. There was no other documentation in Resident #22's medical record regarding the sexually inappropriate behavior on 1/3/12. The surveyor reviewed the careplan for Resident #22 dated 2/18/13. It did not include interventions to protect and prevent sexual abuse after the incident occurred on 1/2/13 by Resident #11. Resident #22 continued to reside directly across the hall from Resident #11. The immediate jeopardy was corrected on 2/28/13 at 4:00 p.m. based on an acceptable plan of correction which included the following: 1. The resident care plan was immediately re-written to reflect and address all areas of resident behaviors for the safety of the resident and other residents. 2. Resident was placed on continual 24 hour reporting documentation to assure all changes in behaviors are recognized and care plan is updated accordingly. 3. Immediate interventions regarding resident behavior was put into place including staff in-servicing on abuse reporting/investigation to be completed by 3/7/13 and consistent 1:1 observation for the resident in question. 4. All staff ID team members will be re-inserviced on proper care planning for resident specific issues. 5. A weekly meeting will occur with nursing and administrative staff to discuss new onset behaviors with all residents to determine corrective actions and IPC updates. 6. All residents who display inappropriate sexual behavior will have a 1:1 assigned to monitor behaviors until M.D. is informed and psychiatrist is able to evaluate resident for further management. 7. Continue the process of guardianship for the resident in question to place resident in a behavioral setting that is appropriate and needed. While the Immediate Jeopardy was abated for Resident #11, #20 and Resident #22, this deficient practice continued at F 279 at a lower scope and severity (E) level as follows: B. Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to update resident care plans to reflect new interventions for Residents #1, #18, #2, and #17, 4 of 31 residents' reviewed for care plan developement. The facility failed to a.) update Resident #1's care plan to reflect new interventions to prevent further skin tears, b.) failed to initiate a care plan for Resident #18 for use of a left hand roll to prevent further contractures, c.) failed to develop a care plan for Resident #2 for transfer from bed to chair while in the room, and d.) failed to initiate a care plan for Resident #17 who was at risk for pain. This deficient practice is evidenced by: 4. The medical record was reviewed by the surveyor on 3/4/13. According to the medical record admission sheet, Resident #1 was admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 2/18/13 indicated the resident had a severe cognitive deficit, was non-ambulatory and required 2 person Hoyer Lift for transfers. The Interdisciplinary Plan of Care (IPC) updated on 2/13/13 and 2/27/13, reflected Resident #1 was at risk for skin breakdown second degree to incontinence and limited mobility. A review of Interdisciplinary Progress Notes (IPN) dated 2/3/13 (3:00 p.m. to 11:00 p.m.), reflected Resident #1 had an "opened area noted to right lower leg." The physician was contacted and an order obtained to cleanse the right lower leg with normal saline solution (NSS), pat dry, apply [MEDICATION NAME] ointment and cover with border gauze daily. A Wound Care/Tube Feeding Alert Sheet dated 2/3/13, reflected Resident #1 had an open area to the right lower leg that measured 4 cm (centimeter) by 1 cm. There was no documentation that indicated the resident's Interdisciplinary Plan of Care was updated to reflect the resident's skin integrity or new interventions to prevent further skin tears. A review of Resident #1's Interdisciplinary Care Plan Notes dated 2/13/13, indicated the resident was readmitted to the facility on [DATE] and had a treatment in place for right lower lateral leg trauma. There was no documentation that indicated Resident #1's IPC was updated to reflect new interventions to prevent further skin tears. A Wound Care/Tube Feeding Alert Sheet dated 2/22/13 reflected the wound to Resident #1's right lateral leg had resolved. A subsequent IPN dated 2/26/13 (3:00 p.m. to 11:00 p.m.) indicated to cleanse the opened area right lateral leg with NSS, apply [MEDICATION NAME] ointment cover with border gauze daily until healed. A Wound Care/Tube Feeding Alert Sheet dated 2/26/13, reflected Resident #1 had a wound to the right lateral leg which measured 7 cm by 3 cm. A review of Resident #1's Interdisciplinary Plan of Care (IPC) not dated, reflected right lateral lower leg trauma healed on 2/22/13, interventions included treatment to right lateral lower leg. There was no documentation that reflected the IPC was updated to reflect new interventions to prevent further injury. On 3/4/13 at 11:35 a.m., the surveyor reviewed Resident #1's IPC with the Unit Manager (UM). The UM stated Resident #1's original injury to the right lower leg occurred on 2/3/13 and the second injury occurred on 2/26/13 and revealed she believed occurred as a result of Resident #1's leg was "banged" on the wheel chair rest causing both injuries. The UM confirmed that after injuries of unknown origin and skin tears the IPC should be updated to reflect new interventions to prevent further injury. The UM confirmed Resident #1's IPC was not updated to reflect new interventions to prevent further injury. 5. The surveyor reviewed Resident #18's medical record on 3/4/13. The nurse documented in the 2/1/13 interdisciplinary progress note that the resident was admitted to the facility with a left hand contracture. The surveyor reviewed the resident's 3/2013 physician's orders [REDACTED]." The surveyor reviewed the resident's current care plans. The 2/27/13 care plan developed for compromised nutritional status referenced a deficit in left arm mobility. The facility did not develop a care plan for hand contracture management. A care plan from a previous facility dated 5/25/10, noted the use of a left hand splint. 6. On 3/4/13 the surveyor reviewed Resident #2's medical record and fall investigations. The nurse documented in the 1/23/13 incident/accident report that the resident fell while transferring from the bed to chair while assisted by one caregiver. The surveyor reviewed the MDS assessments of 6/16/12, 9/3/12, and 11/21/12. The resident was assessed to require extensive assistance of two or more people for transfer. A review of the resident's 1/22/13 fall prevention care plan (revised 3/1/13) did not specify how many staff persons were needed to transfer the resident between surfaces in the room. Specific instructions were given for shower room transfers to utilize two person assistance. 7. On 2/26/13 at 10:30 a.m. the surveyor toured the unit with the Unit Manager (UM). The UM stated Resident #17 was total care, had a [DIAGNOSES REDACTED]. On 2/27/13 at 8:30 a.m. the surveyor observed resident #17 in bed and appeared severely contracted. The surveyor asked the resident about pain and the resident responded in a whispery voice "little bit" and asked how often, responded "usually". The surveyor interviewed the nurse responsible for the care of Resident #17 at 8:45 a.m. The nurse stated sometimes I ask him if he is in pain, I usually go by his face. The resident doesn't have anything ordered regularly for pain. The surveyor interviewed the Certified Nursing Assistant (CNA)responsible for the care of resident #17 at 12:00 p.m. regarding expression of pain by the resident during care. The CNA stated the resident makes noises when I turn him/her over. The CNA was unsure if that was related to pain. On 2/27/13 at 12:30 p.m. the surveyor reviewed the medical record for Resident #17. The cumulative [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 11/15/12, indicated the resident had severe cognitive impairment. The Pain Screen dated 6/18/12 was reviewed and revealed that the resident indicated they had pain, felt it should be treated, and rates it a 5 on a scale of 1 to 10. The Interdisciplinary Plan of Care (IPC) dated 2/11/13 was reviewed which revealed a Problem: Contracture Management and did not include interventions for pain monitoring. NJAC 8:39-11.2(e)2.

A. Based on observation, interview and record review, it was determined that the facility failed to investigate allegations of sexual abuse by a confused, wandering resident, Resident #11, with known inappropriate sexual behavior. This deficient practice was identified for 2 of 28 residents reviewed for abuse, Resident #20 and #22. This resulted in an immediate jeopardy situation for cognitively impaired residents, Residents #20 and #22, as well as other residents on the unit. Resident #11 had a history of [REDACTED]. The Administrator and Director of Nursing (DON) confirmed and acknowledged the incidents of sexual abusive behaviors to cognitively impaired female residents. In addition, the facility failed to report the aforementioned incidents to the New Jersey Department Health. The Immediate Jeopardy was identified on 2/28/13 at 3 p.m., and the immediacy was abated on 2/28/13 at 4 p.m., upon receipt of an acceptable plan of correction. The deficient practice continued at a lower scope and severity of an E level until 3/4/13 when all staff received an inservice on the facility's reporting policy and procedure. The deficient practice was evidenced by the following: 1. On 2/26/13 at 10:15 a.m. the surveyor toured the unit with the Unit Manager (UM). The surveyor observed Resident #11 ambulating in the hallway unattended. The UM spoke to Resident #11 in Spanish to redirect the resident and stated that the resident also understood English. The UM stated the resident was ambulatory, wandered into other resident rooms and could be aggressive with staff and other residents. The Interdisciplinary Plan of Care (IPC) dated 2/25/13, was reviewed which revealed "problem/need": Aggressive Behavior, Sexually Inapp. (Inappropriate) and Physically Abusive Behavior, Masturbates in Public. The surveyor reviewed the Social Service Progress Notes (SSPN), which revealed on 10/3/12, "Contacted S-COPE (Statewide Clinical Outreach Program for the Elderly) re: referral (secondary) to inappropriate touching of female co-residents." The (S-COPE) Clinical Consultation dated 10/4/12, stated the Presenting Problem as: "Client has been exhibiting sexually inappropriate behaviors. Client has touched two women's breasts." The surveyor reviewed the 12/10/12 Interdisciplinary Care Plan Notes (ICPN) for Resident #11 which revealed the resident had physically and sexually inappropriate behavior. The 2/25/13 ICPN documentation revealed that the resident was more aggressive. The SSPN dated 1/3/13, revealed per nursing report on 1/2/13 at 11:20 p.m. Resident #11 was sexually inappropriate with female co-resident (Resident #22). The S-COPE Clinical Consultation dated 1/3/13, reflected as the presenting problem: Client represented with sexually aggressive/inappropriate behavior involving a female resident whose room is opposite clients. The 1/3/13 Interdisciplinary Progress Note at 11 p.m. indicated "resident redirected for attempting to undress a female resident." A review of the Psychiatrist follow-up consultation dated 1/8/13 revealed, "Staff requested an early follow-up- again reporting sexual inappropriateness. Last week (Resident #11) was sexually forward with a female peer-groping, going into her room. (Resident #11) impulse control is poor and (Resident's) his insight and judgment are very poor." During the review of Resident #11's medical record on 2/28/13, the surveyor noted a Social worker's documentation dated 10/3/12 which revealed that Resident #11 was referred to a statewide Clinical Outreach Program for the Elderly (S-COPE), secondary to inappropriate sexual touching of female co-residents. The surveyor interviewed the social worker on 2/28/13 at 12:45 p.m. and inquired about the October incident. She told the surveyor that she was notified of the incident by the MDS Coordinator Nurse. 2. Resident #20's medical record was reviewed by the surveyor on 3/4/12. A review of Resident #20's admission face sheet reflected the resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #20 was severely cognitively impaired. The surveyor reviewed Resident #20's IPN's dated 10/2 and 10/3/12. There was no documentation that Resident #11 inappropriately touched Resident #20's breasts. On 2/28/13 at 12:45 p.m. two surveyors interviewed the Social Worker (SW) regarding the incidents of sexual abuse by Resident #11. The SW stated regarding the incident in October 2012, when Resident #11 touched one resident's breast (Resident #20) she confirmed she did not complete an investigation, however, the information went to the DON and it was also noted on the 24 hour report. On 2/28/12 at 2:30 p.m., the surveyor interviewed the facility's Director of Nursing (DON) and the Administrator and inquired about the 10/3/12 incident. The administrator confirmed that he was made aware of the above incident in October 2012, and that the resident who was inappropriately touched was Resident #20. When the surveyor requested for the investigations on the incident, the DON indicated that they did not have any investigations on the incident. 3. On 2/28/13 at 10:30 a.m. the surveyor reviewed the medical record for Resident #22. According to the cumulative [DIAGNOSES REDACTED]. The surveyor reviewed the Interdisciplinary Progress Notes (IPN) for Resident #22 for 1/2/13. The records did not include the incident of sexually inappropriate behavior. On 2/28/13 at 12:15 p.m. two surveyors interviewed the DON regarding the investigations for the inappropriate undressing by Resident #11 towards Resident #22 on 1/2/13. The DON stated she was aware of the incident that occurred between Resident #11 and #22, however, was unable to provide an investigation for the incidents. The DON stated she was aware that Resident #11 was found in the bed of Resident #22. The DON was unable to provide an investigation regarding the aforementioned incident. On 2/28/13 at 2:20 P.M. two surveyors interviewed the Administrator with the DON present. The Administrator stated that he was aware of the inappropriate sexual touching of Resident #20 by Resident #11 that occurred in October 2012. The Administrator then stated he was unaware that an investigation was not completed for the incident that occurred in October 2012. The Administrator also stated he was aware of the January 2013 incident of sexual abuse by Resident #11 toward Resident #22 which occurred in January 2013 and acknowledged that the investigation was not completed. The Administrator stated both instances were not reported to the State because there was no physical evidence of abuse. On 3/5/12 at 1:00 p.m. the surveyor reviewed the Abuse, Resident Behavior and Facility Practice Policy which revealed: Procedure 7: "This facility ensures that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator/Designee of the facility, who will: a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and to take all necessary corrective actions depending on the results of the investigation; and c. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrence. The Abuse, Resident Reporting/Investigation Policy was reviewed which revealed: Procedure 5: " The person(s) observing an incident of resident abuse or suspected resident abuse must immediately report such incidents to the charge nurse. The following information should be reported to the charge nurse: a. The name of the resident b. The date and time the incident occurred c. Where the incident took place d. The name(s) of the persons (s) committing the incident, if known e. The name(s) of any witnesses to the incident f. The type of abuse that was committed (i.e. verbal, physical, sexual, etc. g. Other information that may be requested by the charge nurse 6. Upon receiving reports of alleged abuse the charge nurse shall immediately examine the resident. Findings will be recorded in the Resident Abuse Investigation Form. 7. The charge nurse must initiate a Resident Abuse Investigation Form and obtain written, signed, and dated statement from the person reporting the incident. Resident Abuse Investigation procedures will be followed. 8. The Resident Abuse Investigation Form and written statement from witnesses, if any, will be provided to the Director of Nursing and Administrator within twenty four (24) hours of the occurrence of such incidents. 9. The Office of the Ombudsman for the Institutionalized Elderly and the Department of Health and Senior Services need to be notified if abuse/neglect is witnessed, suspected, and/or family alleges. The internal investigation does not need to be completed prior to calling the Office of the Ombudsman for the Institutionalized Elderly and/or the Department of Health and Senior Services. The Trenton Police Department will be called if indicated. 10. 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 procedure should be followed as outlined in this policy. 11. Upon receiving information concerning a report of abuse, Social Worker will monitor the resident's reaction to any involvement in the investigation. 14. Unless otherwise requested by the resident, the Social Worker will provide the Administrator and the Director of Nursing Services with a written report of his/her findings." The immediate jeopardy was corrected on 2/28/13 at 4 p.m. based on an acceptable plan of correction which including the following: 1. Resident #11 was immediately placed on 1:1 observation and staff on all 3 shifts will observe behaviors and redirect the resident if required. 2. Resident #11 will be on consistent 24 hour reporting documentation by staff each shift to document behaviors witnessed. 3. Resident #11's Psychiatrist was made aware of the resident to resident inappropriate touching. 4. Staff was educated regarding abuse including resident to resident abuse, inappropriate sexual behavior, and all other forms of abuse. Inservicing on Abuse to be completed by 3/7/13 for entire facility staff. 5. Immediate inservices/education for all shifts by Psychiatrist and Administrative staff regarding geriatric sexual behavior to be completed by 3/7/13. 6. The facility will continue process of guardianship in order to place resident in behavioral setting that is needed. 7. Facility will provide inservices by a State clinical out reach program as recommended by consultation. 8. Continued follow ups by Psychiatrist to address new behaviors witnessed. 9. Nursing staff have received re-education regarding the facility's incident reporting/investigation and follow up. 10. A weekly meeting with nursing and administration to discuss new onset behaviors with all residents to determine corrective actions and care plan updates. 11. Interdisciplinary team re-education on resident specific care planning for resident behaviors. While the Immediate Jeopardy was abated for Resident #20 & Resident #22, this deficient practice continued at F 226 at a lower scope and severity (D) level as follows: B. Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to consistently investigate injuries of unknown origin (skin tears) for 1 of 7 reviewed for investigations (Resident # 1) . This deficient practice was evidenced by: The surveyor reviewed the medical record on 3/4/13. According to the medical record admission sheet, Resident #1 was admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 2/18/13 indicated the resident had a severe cognitive deficit, was non-ambulatory and required a 2 person Hoyer Lift for transfers. The Interdisciplinary Plan of Care (IPC) updated on 2/13/13 and 2/27/13, reflected Resident #1 was at risk for skin breakdown second degree to incontinence and limited mobility. The surveyor reviewed Interdisciplinary Progress Notes (IPN) dated 2/3/13 (3:00 p.m. to 11:00 p.m.) that reflected Resident #1 had an "opened area noted to right lower leg." The resident's physician was contacted and ordered a treatment to the right lower leg. A Wound Care/Tube Feeding Alert Sheet dated 2/3/13, indicated Resident #1 had an open area to the right lower leg that measured 4 cm (centimeter) by 1 cm. There was no evidence that an incident report and/or an investigation was completed as to the cause of the skin tear. In addition, there was no documentation that indicated the resident's Interdisciplinary Plan of Care was updated to reflect new interventions to prevent further skin tears. A review of Resident #1's Interdisciplinary Care Plan Notes dated 2/13/13, indicated the resident was readmitted to the facility on [DATE] and had a treatment in place for right lower lateral leg trauma. There was no documentation that indicated Resident #1's IPC was updated to reflect new interventions to prevent further skin tears. A Wound Care/Tube Feeding Alert Sheet dated 2/22/13 reflected the wound to Resident #1's right lateral leg had resolved. A subsequent IPN dated 2/26/13 (3:00 p.m. to 11:00 p.m.) indicated a treatment was ordered for the right lateral leg until healed. A Wound Care/Tube Feeding Alert Sheet dated 2/26/13, revealed Resident #1 had a wound to the right lateral leg which measured 7 cm by 3 cm. There was no evidence that an incident report and/or investigation was completed. On 3/4/13 at 11:35 a.m., the surveyor reviewed Resident #1's IPC with the Unit Manager (UM). The UM stated Resident #1's original injury to the right lower leg occurred on 2/3/13 and the second injury occurred on 2/26/13. The UM stated she believed the injury occurred as a result of Resident #1's leg was "banged" on the wheel chair rest causing both injuries. In addition, she stated an incident report and investigation should be completed. During an interview on 3/4/13 at 12:45 p.m., the Administrator confirmed that incident reports and/or investigations were not completed for resident #1's skin tears on 2/3 and 2/26/13. In addition he stated the nurses should have completed an incident report and conducted an investigation. Refer to F223 and F279 NJAC 8:39 13.4 (c) 2.i;v NJAC 8:39-27.1 (a)

C#NJ Based on observation, staff interview, medical record review, and review of other facility documentation, it was determined that the facility failed to consistently implement safety interventions to prevent injury to at-risk residents. The deficient practice was cited for 4 (Residents 13, 2, 25, 19) of 7 residents reviewed for accidents/hazards. Resident #13 was left unattended by staff in the shower, fell and sustained a fractured hip requiring surgical intervention and pain management. The deficient practice was evidenced by; 1. The surveyor spoke with Resident #13 on 3/5/13 at 8:15 a.m. The resident told the surveyor that the Certified Nursing Assistant (CNA) left the resident alone in the shower room and the resident fell to the floor resulting in a fractured hip. The resident stated that it was customary for the CNA to stand outside the shower room while the resident showered. The resident revealed to the surveyor that the resident no longer showered in the shower room, but preferred to have bed baths because of a "fear of falling." The surveyor reviewed the medical record on 3/5/13. The attending physician documented in the admission history and physical, 12/2010, that the resident had a history of [REDACTED]." The psychiatrist documented on 12/18/12 the resident agreed that the resident was "fearful of falling." The psychiatrist documented on 1/22/13 the resident was "fearful of falling." The surveyor reviewed a 12/28/12 fall investigation provided by the facility. The investigation indicated Resident #19 was left in the shower room alone. The CNA initially left the room to retrieve supplies and then went on to assist another CNA with care for another resident. When the CNA for Resident #13 returned to the shower room, the resident had fallen out of the shower chair and onto the floor. The facility provided the surveyor with an undated document on 3/4/13 which indicated that nursing staff was inserviced after the 12/28/12 incident. Staff were re-educated not to leave a resident alone in the shower. A review of Resident #13's interdisciplinary progress note (IPN) dated 12/28/12 at 8:25 a.m. indicated that the resident was transported to the hospital. An IPN dated 12/28/12 at 1 p.m. related the resident was diagnosed with [REDACTED].#13 was readmitted to the facility and had required an Open Reduction Internal Fixation (surgical procedure) of the left hip. A review of Resident #13's January, 2013 Medication Administration Record (MAR) and Controlled Drug Administration Tablet Record indicated Resident #13 was medicated with a standing daily order of Percocet 5-325 mg (a narcotic analgesic), one tablet at 8:00 a.m. prior to therapy. In addition, the resident was medicated at least 16 additional times with Percocet 5-325 mg one tablet every 6 hours as needed for severe pain to the left hip during the month of 1/2013. The surveyor reviewed the 9/23/12, 12/12/12, and 1/10/13 Minimum Data Set (MDS), an assessment tool. The 2 assessments prior to the hip fracture indicated that the resident did not have pain. The 1/10/13 assessment, completed after the hip fracture, indicated the resident had frequent pain of a severity of 8 on a scale of 1 to 10, where "0" indicated no pain and "10" indicated the worst pain. The surveyor interviewed 2 unit CNAs individually on 3/5/13 at 12 noon. Both staff persons told the surveyor that residents are never to be left alone in the shower room. The surveyor discussed the fall and fracture with the administrator on 3/5/13. The administrator did not offer any additional information to the survey team regarding the incident. 2. The surveyor observed Resident #2 in a wheelchair in the resident's room during the 2/26/13 unit tour at 11:05 a.m. The unit manager told the surveyor the resident had fallen at the facility and sustained a fracture. The surveyor requested to examine fall investigations for the resident. On 3/4/13 the facility provided the surveyor with 2 fall investigations. In the first, the resident was noted to have fallen during a transfer in the shower room on 1/22/13 at 6:45 p.m. in the presence of 2 CNAs. The resident was quoted to have said "I just got tired of holding on to the rail." The resident fell again the following day, 1/23/13, at 10:40 a.m. while transferring from the bed to the wheelchair. The resident was assisted by 1 CNA when the resident tripped and fell to the floor. The resident complained of left leg pain. The resident was transferred to the hospital for evaluation (1/23/13 IPN). The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The left ankle was splinted (1/24/13 IPN). During a follow-up orthopedic consult on 2/25/13, the orthopedist documented that the injury was a "moderately severe left ankle sprain." The surveyor reviewed the MDS assessments of 6/16/12, 9/3/12, and 11/21/12. The resident was assessed to require extensive assistance of 2 or more people for transfer prior to the 2 falls. The 2/8/13 assessment indicated the resident was completely dependent upon 2 or more staff for transfer following the falls and ankle injury. The surveyor reviewed the resident's fall prevention care plan which was initiated 1/22/13 and revised on 3/1/13. Four interventions were listed as follows: "2 person for shower days (Txfrs) (transfers); Bed to lowest position; Encourage to allow with assistance by staff; Hoyer lift for transfer when non compliant and non participating." On 3/5/13 at 1:30 p.m. the surveyor spoke with the administrator regarding concerns that the fall prevention care plan did not give specific instructions to nursing staff on the requirements for safely transferring a dependent resident from the bed to the wheelchair. The facility responded on 3/6/13 at 11:15 a.m., however, no rationale was offered as to why the resident was not clearly care planned for safe bed to chair transfers. 3. The surveyor observed Resident #25 on 3/5/13 at 1:25 p.m. seated in a wheelchair unattended in the third floor shower room. The resident was touching the top of a sharps container which was on the floor. Disposable plastic razors were visible in the container 2 - 3 inches from the top opening. The resident appeared to be trying to put an object on the top of the container, however, there was nothing in the resident's hands. The maintenance director summoned nursing staff to assist the resident out of the shower room to a supervised area. The surveyor reviewed the resident's medical record on 3/6/13. According to a 10/27/11 hospital transfer sheet, the resident had been admitted to the facility after losing consciousness at home and sustaining a nasal fracture. Hospital transfer forms dated 6/4/12 and 6/10/12 noted the resident experienced episodes of syncope and unresponsiveness. The resident's current care plans addressed (but were not limited to) a history of falls from home and actual falls in the facility, dementia with delusions, and occasional aggressive behavior toward other residents. Interventions included - engage in activity program, frequent room checks, and place in view of staff when out of bed. On 11/13/12 the psychiatrist noted that the resident exhibited behavior of "wandering around benignly." A review of interdisciplinary progress (IDP) notes revealed that on 12/12/12 at 7 p.m. the resident self propelled into the bedroom without supervision and fell to the floor. Staff was instructed to continue to monitor the resident. A 2/6/13 IDP note indicated the resident was found on the floor at the bedside during the 3 p.m. - 11 p.m. shift. A 2/11/13 quarterly IDP note referred to the resident's signs and symptoms of active psychosis, auditory hallucinations, pre-occupation, and distress. A 2/14/13 IDP progress note indicated the resident was observed after lunch appearing to be sleeping in a wheelchair, but was found to be unresponsive. The surveyor spoke with the administrator on 3/6/13 at 11 a.m. and described the observation of Resident #25 unattended in the shower room touching the sharps container. The administrator did not offer any additional information regarding the incident. 4. The medical record for Resident #19 was reviewed by the surveyor on 3/5/13. According the admission sheet, Resident #19 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #19 had a moderate cognitive deficit, and required assistance with transfers. A review of the resident's current Interdisciplinary Plan of Care reflected the resident was at risk for falls due to poor safety awareness and impulsiveness/non-complaint with safety needs, second degree to cognitive impairment. A Fall Risk assessment dated [DATE] indicated the resident had a history of [REDACTED]. During a tour of the facility on 3/5/13 at 9:28 a.m., Resident #19 was not in the room and was noted to be attending dialysis. An over sized wheel chair was observed in the resident's private room, with a chair alarm present and anti-tip rollers to the back of the wheel chair. A bed alarm was noted to the resident's bed. A review of an Interdisciplinary Progress Note (IPN) dated 12/31/12 (11 p.m. to 7 a.m.), and an Incident/Accident Report dated 12/31/12 at 12 a.m. indicated the nurse was called to Resident #19's room by a CNA. The resident was observed on the floor beside the bed in a sitting position. The resident was assessed by the nurse and no injury was noted. The nurse re-educated the resident "regarding the importance of using call bell." There was no documentation that reflected a bed alarm was in place and/or sounding. A review of Resident #19's Fall Investigation Report, dated 12/31/12 at 12 a.m. did not reflect a bed alarm was in place and/or if the alarm was sounding. The area on the report asked "Was Alarm in use ? yes/no Alarm sounding yes/no" was not completed by staff. On 3/6/13 at 9:50 a.m. the Administrator stated he would need to contact staff who completed the IPN and Incident Report to determine if a bed alarm was present and/or sounding. No additional information was received from the facility. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide a safe transfer for a resident, identified as requiring a 2 person assist with transfer, resulting in a fall and fracture. Resident #14, who was identified by the facility to require a 2 person assist with transfers, was accompanied out of the facility to a physician office by 1 Certified Nurse Aide (CNA). The CNA was not familiar with the resident and was not informed of the resident's care needs. The CNA transferred the resident alone while at the physician's office resulting in a fall and fracture of the left tibia. This deficient practice was noted for 1, Resident #14, of 6 residents reviewed for falls and was evidenced by the following: During the initial tour on 2/28/11 at 10 a.m., the surveyor observed Resident #14 lying in bed with a brace and sling on the upper left arm and a hard cast on the lower left leg. The Unit Nurse Manager (UNM) told the surveyor that the resident fell in November 2010 while independently transferring himself to the bathroom. That fall resulted in a fracture of the left humerus. According to the UNM the resident had a second fall at a physician's office while accompanied by a facility CNA. That fall resulted in a fractured left tibia. The UNM further stated that the resident was confused, had left sided weakness and was dependent on staff for care. Currently the resident was being medicated for pain related to the fractures and now required a mechanical lift for transfers. The surveyor reviewed Resident #14's medical record on 3/1/11. Prior to the fall and fracture of the left humerus, which occurred on 11/5/10, the resident had a care plan which included the fact that a 1 person assist with transfers was required. After the fall the resident had a Quarterly Minimum Data Set completed on 11/29/10, which was coded to indicate that the resident now required the "extensive" assistance of 2 persons for transfers. On 3/7/11 at 8:15 a.m. the surveyor interviewed the CNA who regularly provided care to this resident. The CNA stated that after the fall and fracture in November, the resident needed 2 people for transfers. At 8:50 a.m. the unit nurse confirmed that after the fractured humerus in 11/10 the resident required total assistance with care and 2 person assistance for transfers. The resident's care plan was not updated after the 11/5 fall to include the need for 2 person assistance with transfers. According to the facility "Fall Report Investigation", on 2/2/11 the resident was transported to a Cardiologist office accompanied by a facility CNA. While at the physician's office the CNA was attempting to transfer the resident from the wheelchair to the bathroom commode when the resident fell . The CNA needed assistance from the staff at the physician's office to help get the resident off of the floor and into the wheelchair. When the resident returned to the facility he did not complain of pain and was assessed by the facility staff to have no injury from the fall. On 2/4/11 at 9 a.m. the resident complained of pain to the left ankle; the ankle was noted to be swollen and an X-ray was ordered. The X-ray results confirmed that the resident had a fracture of the distal left tibia. The resident was sent to the hospital emergency room and returned with a cast to the lower left leg. The fall investigation included a statement from the CNA who was with the resident at the time of the fall. The CNA stated in this investigation that she knew "nothing about the resident at all." She further stated that the resident told her that he could stand and that while attempting to stand him in front of the commode he "lost his balance" and she "slid him down to the floor." On 3/2/11 at 10:15 a.m., the surveyor interviewed the Director of Nurses (DON) who confirmed that the CNA who accompanied the resident was "unfamiliar" with him and was not given a report of the resident's care needs. The DON concluded on the Fall Report Investigation that the resident fell while being assisted to the bathroom by 1 person. The report further included that in the future staff members accompanying residents out of the facility would be given a full report of the resident's needs, both "physical and mental." This information was not provided to the CNA who accompanied Resident #14 to the physician's office, resulting in a fall and fracture. NJAC 8:39-27.1(a)

Complaint # NJ- 354 Based on observation, interview and record review, it was determined that the facility failed to provide medical justification for not implementing the consultant psychiatrist's treatment suggestion intended to relieve a resident's extreme discomfort from unrelieved itch. Nor did the facility obtain a dermatology consult in a timely manner to treat the condition that had been ongoing over the past six months. Resident #2, endured extreme discomfort from unrelieved itch. This deficient practice occurred for Resident #2, 1 of 27 reviewed and who currently resided the facility. The facility also failed to respond to signs and symptoms of a medical emergency in a timely manner causing a delay in medical interventions for 1 of 1 residents reviewed who experienced a medical emergency, Resident #1. The facility also failed to re-order a [MEDICAL CONDITION] medication for a resident after readmission causing the resident to experience an increase in emotional disturbances. This was noted for 1 of 8 residents reviewed for the use of [MEDICAL CONDITION] medications, Resident #21. These deficient practices were evidenced by the following: 1. Resident #2 was first admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During the initial tour on 3/1/11, the nurse told the surveyor that Resident #2 was off the premises at [MEDICAL TREATMENT]. The nurse also told the surveyor that the resident wore a mitten on each hand due to "arm [MEDICAL CONDITION]." Later on the same day, the surveyor observed Resident #2 at 9:10 a.m., having returned from [MEDICAL TREATMENT], in bed wearing bilateral hand and arm splints. On 3/2/11 at 9 a.m. the surveyor reviewed the medical record for Resident #2. The record documented that the resident was coded on the Minimum Data Set assessment tool dated 1/21/11 as "usually understood" and "usually understands" and with no upper body contractures. On 3/2/11 at 9:30 a.m. the surveyor observed that both the resident's arms were covered with beige splints and puffy hand mitts were in place on both hands. At 9:30 a.m., the surveyor observed a nurse remove the left mitt and immediately Resident #2 reached to her right chest and scratched. When the surveyor asked the resident "does your skin itch?", the resident responded "yes." An Occupational Therapy Screen dated 9/13/10 indicated that Resident #2 had no range of motion dysfunction to either the left or right shoulders and elbows. The facility's "Rehabilitation Resident Quarterly Screen" dated 11/4/10 indicated the need for "Bilateral elbow splints to prevent self-inflicted injury and bilateral hand mitts." There was no documentation that the splints and mitts were being used for any other condition. On 3/2/11 at 10 a.m. The Unit Manager told the surveyor that the reason for the bilateral hand mitts and the bilateral splints was that they prevented the resident from bending at the elbows "because she will scratch at her skin until it bleeds." On 3/2/11 the surveyor reviewed the thinned portion of the Resident #2's medical record including nurses' notes that dated back to 8/20/10. From 8/20/10 through 10/19/10 the notes included the following: 8/20: Observed scratching chest area. 8/29: Dr. ordered [MEDICATION NAME] (anti-itch medication) every 12 hours for one week. 9/3: Constantly needed to be redirected from scratching self. 9/4: [MEDICATION NAME] (anti-[MEDICAL CONDITION]) ordered. 9/5: Continues to scratch even with mitts on. Rubs. Continues to scratch, opening up blister, bleeding, pus noted. [MEDICATION NAME] and [MEDICATION NAME] in use. New mittens put on. 9/6: Culture [MEDICAL CONDITION]. Hand mittens in place. 9/11: [MEDICATION NAME] antibiotic started, mitts in place. [MEDICAL CONDITION] (Methcillin Resistant Staph Aureus.) 10/4: Continues to itch. 10/6: Re-direction from scratching self even with mittens. Mitts in place but resident continues to rub persistently. 10/8: MD updated about continued itching. [MEDICATION NAME] 25 mg. ongoing. 10/18: Observed scratching, mittens to bilateral hands visibly soiled. Many areas of broken skin resulting from frequent scratching. 10/19: Intense itching. Bilateral hand mitten on body due to itching. The attending physician wrote a progress note dated 10/17/10 in which her "A" (assessment) was "intense pruritis and her "P" (plan) was "cause itch?? Continue [MEDICATION NAME] for now. [MEDICATION NAME] in tapering dose." On 10/19/2010 the consulting Psychiatrist noted that the staff requested an early follow-up appointment due to concerns about excessive and compulsive scratching of skin and that the current treatment of [REDACTED]. The psychiatrist documented in his consult that Resident #2 admitted to chronic itching. The Psychiatrist wrote "I have had some success in patients with neuro-[MEDICAL CONDITION] by using [MEDICATION NAME]." There was no response from the attending physician except for "please avoid [MEDICATION NAME]" dated 10/24/10. There was no documented rationale as to why [MEDICATION NAME] should be avoided for this resident. The record included that on 10/17/10 [MEDICATION NAME] 25 mg. was again ordered for two weeks for "intense pruritis." The order continued that after the initial two weeks the dose should be decreased to every 8 hours "as needed" for itching. On 10/24/10 during the 7 a.m. - 3 p.m. shift, [MEDICATION NAME] 10 mg. once daily for itching and [MEDICATION NAME] 0.5 mg. twice daily were ordered for anxiety, restlessness and agitation. Also, a tapering dose of [MEDICATION NAME] was ordered again for one month. On 10/24 through 10/28 the nurses' notes documented continued scratching and bleeding. The elbow splints had to be replaced twice as the resident "removes them with teeth." The Psychiatrist was consulted again on 1/25/11 and wrote that the staff reported "continued and significant problems with itching, she wears mitts almost all of the time." He noted "(Resident) was clearly uncomfortable. Under recommendations, he wrote:" There is little more to do for her psychiatrically. If we have exhausted dermatolological approaches, I would still recommend a trial of [MEDICATION NAME], if only for her comfort. I have seen good results with a number of neuro-[MEDICAL CONDITION] patients." A nurses' noted dated 3/2/11 and timed 1:00 a.m. reflected "resident gets restless, agitated, crying, try's to remove mitts, [MEDICATION NAME] given." On 3/3/11 at 9:30 a.m., the surveyor observed Resident #2 in bed with both hand mitts and elbow splints on and rubbing the upper torso back and forth against the mattress. On 3/3/11 at 2 p.m. the survey team was told by the Administrator that a call was placed to Resident #2's attending physician and she was asked about the Psychiatrist's written recommendations regarding "dermatological approaches" and/or the use of [MEDICATION NAME]. The administrator stated that the attending physician said that she does not look at what the psychiatrist writes and "go ahead and order a consult with a Dermatologist if you want." 2. Following review of a complaint investigation NJ- 354 dated 1/18/11, the surveyor reviewed Resident #1's medical record. Resident #1 had a [DIAGNOSES REDACTED]. The medical record included documentation that Resident #1 was transferred to the hospital on [DATE] after returning to the facility from [MEDICAL TREATMENT] for the following symptoms: shortness of breath, cyanotic lips and a pulse oximeter reading of 86%. On 2/28/11 during the initial tour the nurse told the surveyor that Resident #1 received [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The nurse further stated Resident #1 would leave the facility at 7:00 a.m., and returned around 12:30 p.m. On 2/28/11 at 1:30 p.m., the surveyor attempted to interview Resident #1 regarding the transfer but she was unable to answer any questions. On 3/2/11 at 9:50 a.m., the surveyor interviewed one of Resident #1's family member regarding the concerns with the hospital transfer of 1/15/11. The family member told the surveyor that when Resident #1 returned from [MEDICAL TREATMENT] on 1/15/11, she did "not look good" according to a family member that was present at the facility on 1/15/11. She also told the surveyor that it was her understanding that the nurse refused to send Resident #1 out for evaluation despite Resident #1's presented symptoms of shortness of breath and cyanotic mucus membranes. On 3/2/11 at 9:30 a.m., the surveyor reviewed the Interdisciplinary Progress Notes dated 1/15/11 and noted the following entries: "Daughter present in room when resident returned from [MEDICAL TREATMENT], indicated Resident #1 is not well, demand to call 911... cyanosis to mucus membranes noted, pulse oximeter 86% (normal 94-100%) on room air. Upon assessment (Resident #1) responding to verbal stimuli, opens eyes when name is being called, respiration rate 22, blood pressure 116/87." On 3/2/11 the surveyor reviewed the [MEDICAL TREATMENT] communication record which noted "Treatment ended 20 minutes earlier due to deep heavy breathing and patient not following commands. Rapid response team (RRT) called ....oxygen increased saturation 94%, patient condition improved, report to nurse." According to the Medi-Transport form, Resident #1 returned to the facility at 1:07 p.m. On 3/3/11 the surveyor interviewed the nurse who cared for Resident #1 that day. The nurse confirmed that Resident #1's lips were cyanotic and the pulse oximeter reading was 86% on room air. The nurse stated she was not familiar with Resident #1 and could not determine if these symptoms were Resident #1's baseline or usual condition after undergoing [MEDICAL TREATMENT]. The nurse indicated she assessed the patient and attempted to call the primary physician but she was unsuccessful because Resident #1 was re-assigned to another physician and the change was not made on the chart. The nurse stated she called the Director of Nursing (DON) and the DON instructed her to call another physician who gave her the order to transfer Resident #1 to the hospital for evaluation and treatment. The nurse told the surveyor that time had elapsed before sending Resident #1 to the hospital due to not being able to contact the primary physician and due to taking time to communicate with Resident #1's family member that were calling even from out of state. On 3/7/11 the surveyor reviewed the emergency medical system transport sheet and noted that the ambulance received the call at 3:25 p.m., arrived at the facility at 3:37 p.m., the ambulance left the facility at 3:47 p.m., and arrived at the hospital at 3:52 p.m. A review of all the documents revealed more than 2 hours had elapsed before the nurse called the medi-transport, causing a delay in medical interventions. Resident #1 was admitted in ICU and released after 5 days. A review of the consultation record from the hospital dated 1/16/11 noted that Resident #1 was brought to the emergency room after being found unresponsive and hypotensive with lethargy and cyanosis. 3. Resident #21 had a [DIAGNOSES REDACTED]. According to the record review conducted by the surveyor on 3/3/11, Resident #21 was hospitalized in July, and upon return while the [MEDICATION NAME] was reordered the [MEDICATION NAME] was not. On 3/3/11 the surveyor observed Resident #21 seated in the dining room. His behavior was calm and he was independent with eating. Later that day, the surveyor reviewed Resident #21's record and noted a psychiatric consult dated 7/20/10 which indicated Resident #21 showed a gradual decline both medically and cognitively. The psychiatrist further documented that "his medication is helpful and well tolerated." Another psychiatric consult dated 9/7/10 indicated Resident #21 was getting more confused and more disorganized. On 9/10/10 his [MEDICATION NAME] - an antipsychotic medication - was increased from 1 mg to 2 mg twice a day. An entry dated 9/14/10 noted that "Staff requested an early follow-up describing an acute exacerbation of his paranoid [MEDICAL CONDITION] over the last week. At least 2 or 3 days, (Resident #21) was acutely angry... refusing care believing he was a prisoner." Another psychiatric entry on 10/21/10 read, "(Resident #21) was withdrawn, he clearly voiced an increase in depressive ideation -dwelling on losses and loneliness. He expressed hopelessness...." The psychiatrist further stated, " I did not realize until today that (Resident #21) has been without [MEDICATION NAME] 1 milligram (mg) twice a day since July." The psychiatrist further noted, "(Resident #21) is more depressed, negative, irritable and hopeless; he has a long complicated history requiring a complex medication regimen for his psychiatric illness. His current decline is likely due to being without his [MEDICATION NAME]." The psychiatrist reordered the [MEDICATION NAME] at 1 mg at bedtime. The psychiatrist's following notes indicated that Resident #21 was doing much better on his current medication. An entry dated 11/2/10 stated, "He looks a little bit better back on some [MEDICATION NAME]." On 3/2/11 the surveyor reviewed the medical record with the charge nurse and confirmed that Resident #21's [MEDICATION NAME] was not re-ordered following his hospitalization of July. There was no documented evidence regarding the reason the [MEDICATION NAME] was omitted. On 3/7/11 during a pre-exit conference with the administrative staff, the administrator said the omission of the [MEDICATION NAME] was a transcription error. NJAC 8:39-27.1(a)