Every finding on record at Warren Haven Rehab and Nursing Center

Complaint 2800212Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable temperature on 1 of 2 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 5/7/26 at 11:25 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Director (FSD).At 11:35 AM, the surveyor and FSD observed the food truck arrive on the 1st floor unit. The surveyor and FSD observed the first lunch tray being served at 11:36 AM. At that time a test tray of a regular diet and pureed consistency was identified by the surveyor and FSD, this tray was removed from the food truck and placed on top of the food cart by the FSD. After the last meal tray was delivered to a resident at 11:45 AM, the surveyor took the temperatures of the following items in the presence of FSD with calibrated thermometers and were as follows: Garlic chicken: 131.3 FSweet potato: 123.1 FBroccoli: 130.3 FMilk 42.8 FCoffee: 159 FApple juice: 43.2 F At 11:48 AM, following the food temperature recording, the FSD agreed that the garlic chicken, sweet potato and broccoli were not in range for serving temperature. The FSD further stated corrective action would be taken immediately. On 5/11/26 the [NAME] President of Operations (VPO) provided the surveyor with a facility policy titled, Food Temperature Policy, with a revised date of 2/2026. The procedure section of the policy revealed, 1. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135F. On 5/11/26 at 12:42 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing and VPO to review concerns found during the survey. The LNHA, DON and VPO acknowledged the food temperatures were under the 135F threshold. On 5/12/26 at 11:20 AM, the surveyor met with the LNHA, DON, VPO, Infection Preventionist (IP) and Human Resources (HR) for the exit conference. No further pertinent information was provided. NJAC 8:39-17.2(a) 2, (e)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to conduct annual performance evaluations for all Certified Nursing Assistants (CNAs). This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following:1. Review of the personnel file for CNA #1, with a date of hire of 5/1/2008, revealed no evidence of a completed annual performance evaluation. 2. Review of the personnel file for CNA #2, with a date of hire of 8/12/24, revealed no evidence of a completed annual performance evaluation. 3. Review of the personnel file for CNA #3, with a date of hire 4/6/18, revealed no evidence of a completed annual performance evaluation. 4. Review of the personnel file for CNA #4, with a date of hire 5/6/25, revealed no evidence of a completed annual performance evaluation. 5. Review of the personnel file for CNA #5, with a date of hire 12/20/21, revealed no evidence of a completed annual performance evaluation. On 5/12/26 at 9:00 AM, during an interview with the surveyor, the LNHA confirmed that the CNAs had not received annual performance evaluations. On 5/12/26 at 10:55 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that the CNAs had not received annual performance evaluations. The DON further stated that annual performance evaluations were important for identifying strengths and areas of weakness and for determining whether additional education or training was needed. On 5/12/26 at 11:10 AM, during an interview with the surveyor, the Director of Human Resources stated that she had not been involved in overseeing the annual performance evaluations. A review of the facility's Evaluation Process policy dated 3/2026 reflected.It is the policy of our facility to review the work performance of employees with a formal written evaluation annually.Original evaluation tools are to be forwarded to the Human Resource department to be processed and placed in the appropriate personnel file. On 5/12/26 at 11:30 AM, no further information was provided. NJAC 8:39-43.17 (b)

Repeat DeficiencyBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to have readily accessible physician progress notes (PPN). This deficient practice was identified for 7 of 8 residents reviewed, (Resident #8, #9, #10, #35, #50, #68, and #88) and was evidenced by the following:1. On 5/5/26 at 10:32 AM, the surveyor observed and interviewed Resident #10 in the dayroom. Resident #10 stated they were not sure when they had seen the facility primary physician (PP#1).On 5/5/26 at 11:28 AM, the surveyor reviewed Resident #10's hybrid medical record (HMR) a combination of electronic and paper medical record. A review of Resident #10's Face sheet (FS) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior,), urinary tract infection (an infection in any part of the urinary system) and type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels).A review of the Quarterly Medicare [NAME] Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 8/10/26, revealed that the resident had a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment.A review of Resident #10's HMR revealed no available PPN from PP#1, only progress notes written by the Advanced Practice Nurse (APN#1) were available. 2. On 5/5/26 at 10:43 AM, the surveyor interviewed Resident #9 in their room. Resident #9 could not recall when they had seen PP#1.On 5/5/26 at 12:30 PM, the surveyor reviewed Resident #9's HMR. A review of Resident #9's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to abnormalities of gait and mobility (unusual or impaired patterns of walking, and overall mobility), disorder of bone density and structure (condition in which bones become weaker, less dense, and more prone to fractures), and pulmonary fibrosis (a lung disease characterized by scarring and thickening of lung tissue, which makes it difficult for oxygen to pass into the bloodstream).A review of the Quarterly MDS, with an ARD of 3/10/26, revealed that the resident had a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive function. A review of Resident #9's HMR revealed no available PPN from PP#1, only progress notes written by APN#1 were available. 3. On 5/5/2026 at 10:43 AM, the surveyor interviewed Resident #8 at bedside. Resident #8 revealed, they were not sure who their PP was in the facility. On 5/5/26 at 10:43 AM, the surveyor reviewed Resident #8's HMR. A review of Resident #8's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to depression disorder (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems), bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes) and anxiety (a multisystem response to perceived threats, involving emotional, cognitive, and physiological changes,).A review of the admission MDS, with an ARD of 4/21/26, revealed that the resident had a score of 14 out of 15 on the BIMS, which indicated intact cognitive function. A review of Resident #8's HMR revealed no available PPN from PP#1, only progress notes written by APN#1 were available. 4. On 5/5/26 at 10:51 AM, the Surveyor interviewed Resident #68 in room. Resident #68 revealed they could not recall if they had been seen by PP#1.On 5/5/26 at 11:28 AM, the surveyor reviewed Resident #68's HMR. A review of Resident #68's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to vascular dementia (cognitive decline caused by reduced or blocked blood flow to the brain), chronic kidney disease (a long-term condition in which the kidneys are damaged and gradually lose their ability to filter blood and perform essential functions), and depression disorder. A review of the Quarterly MDS, with an ARD of 3/26/26, revealed that the resident had a score of 5 out of 15 on the BIMS, which indicated severe cognitive impairment. A review of Resident #68's HMR revealed no available PPN from PP#1, only progress notes written by APN#1 were available. 5. On 5/5/26 at 10:59 AM, the surveyor observed Resident #88 in bed with their eyes closed. On 5/5/26 at 11:33 AM, the surveyor reviewed Resident #88's HMRA review of Resident #88's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to acute and chronic respiratory failure with hypercapnia (when the lungs cannot effectively remove carbon dioxide) and acute and chronic respiratory failure with hypoxia (when the lungs cannot supply enough oxygen to the blood)A review of the Quarterly MDS with an ARD of 3/28/26, revealed that the resident had a score of 15 out of 15 on the BIMS, which indicated intact cognitive function. 6. On 5/5/26 at 11:03 AM, the surveyor interviewed Resident #35 at bedside. Resident #35 revealed they had not seen PP#1 in over a month.On 5/5/26 at 11:38 AM, the surveyor reviewed Resident #35's HMR. A review of Resident #35's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to dysphagia (difficulty swallowing), muscle wasting (the loss or thinning of skeletal muscle mass, leading to decreased strength and physical function), and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe). A review of the Quarterly MDS, with an ARD of 3/28/26, revealed that the resident had a score of 3 out of 15 on the BIMS, which indicated severe cognitive impairment. A review of Resident #35's HMR revealed no available PPN from PP#1, only progress notes written by APN#1 were available. 7. On 5/5/26 at 11:31 AM, the surveyor observed Resident #50 in their wheelchair in their room. Resident #50 revealed they have saw PP#1 within the past two weeks.On 5/5/26 at 11:43 AM, the surveyor reviewed Resident #50's HMR. A review of Resident #50's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (an autoimmune disease that affects the central nervous system), chronic kidney disease, and dementiaA review of the Quarterly MDS, with an ARD of 3/28/26, revealed that the resident had a score of 6 out of 15 on the BIMS, which indicated severe cognitive impairment. A review of Resident #50's HMR revealed no available PPN from PP#1, only progress notes written by APN#1 were available. On 5/6/26 at 9:43 AM, the surveyor interviewed Licensed Practical Nurse (LPN#1), who revealed PP#1 completes their notes in a different charting system than the facility staff. LPN#1 unaware if PP#1's PPN were available to facility staff, but APN#1 is in the facility daily and their progress notes are available to facility staff.On 5/7/26 at 10:51 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who revealed PP#1 works for a consulting medical company. PP#1 dictates their PPN and the notes are transcribed into their company's system, those PPN should be sent to the facility and uploaded by Medical Records (MR) into the resident's electronic chart. The LNHA further revealed PP#1 had not been sending their PPN in a timely fashion.On 5/11/26 at 9:30 AM, the surveyor attempted to conduct a phone interview with PP#1 but was unable to get in contact with PP#1. On 5/11/26 at 9:40 AM, the [NAME] President of Operations provided the surveyor with a facility policy, Physician Progress Notes with a revised date of 2/2026. The policy interpretation and implementation revealed, 1. Physician progress notes are maintained for each resident residing in this facility.3. The resident's Attending Physician must write, sign, and date the physician progress notes upon each visit.On 5/11/26 at 12:42 PM, the surveyor met with the LNHA, Director of Nursing (DON) and VPO to review concerns found during the survey. The LNHA, DON and VPO acknowledged PP#1's PPN were not readily available in the HMR. On 5/12/26 at 11:20 AM, the surveyor met with the LNHA, DON, VPO, Infection Preventionist (IP) and Human Resources (HR) for the exit conference. No further pertinent information was provided. NJAC 8:39-35.2 (d)(5)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required and failed to include Dementia training for the CNAs. This deficient practice was identified for 5 of 5 CNA files reviewed for in-service training and was evidenced by the following:On 5/11/26 at 9:00 AM, the surveyor reviewed in-service education hours for five randomly selected CNAs files provided by the facility. The surveyor reviewed the following:CNA #1 was hired on 5/1/2008, had a total of 10.5 hours of in-service training, and this training did not include Dementia in-service training.CNA #2 was hired on 8/12/24, had a total of 10.5 hours of in-service training, and this training did not include Dementia in-service training.CNA #3 was hired on 4/6/18, had a total of 9 hours of in-service training, and this training did not include Dementia in-service training.CNA #4 was hired on 5/6/25, had a total of 10.5 hours of in-service training, and this training did not include Dementia in-service training.CNA #5 was hired on 12/20/21, had a total of 11 hours of in-service training, and this training did not include Dementia in-service training. On 5/12/26 at 9:00 AM, during an interview with the surveyor, the LNHA confirmed that the CNAs had not received their required 12 hours of education and had not received the mandatory Dementia in-service. On 5/12/26 at 10:55 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that the CNAs had not received their required 12 hours of mandatory in-services. A review of the facility's policy, Required Training, Certification and Continuing Education of Nurse Aides dated 4/2026 reflected .It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides .The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year .Minimum training will include Dementia management and care of the cognitively impaired . On 5/12/26 at 11:30 AM, no further information was provided. NJAC 8:39-43.17 (b)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed in 2 resident rooms on 2 of 2 nursing units (West Unit and Secured Unit) and was evidenced by the following:On 5/526, 5/6/26, and 5/7/26, the surveyor observed in room [ROOM NUMBER] on the west nursing unit a strong malodorous urine odor.On 05/5/26, 5/6/26, and 5/7/26, the surveyor observed in room [ROOM NUMBER] in the secured nursing unit a heavily soiled bathroom toilet and floor, and a strong malodorous urine odor. On 5/7/26 at 9:43 AM, during an interview with the surveyor, Housekeeper (HK #1) assigned to the west nursing unit acknowledged the strong urine odor present in room [ROOM NUMBER]. HK #1 stated that they had cleaned the room on the previously observed dates but indicated that the room always smells like that.On 5/7/26 at 9:46 AM, during an interview with the surveyor, the Director of HK(DHK) confirmed the presence of a strong urine odor in room [ROOM NUMBER]. The DHK stated that the room had been placed on high alert, meaning it was scheduled to be cleaned more than twice daily. The surveyor informed the DHK that a strong urine odor had been observed in the room for three consecutive days. The surveyor then asked whether they believed the room had been cleaned appropriately in accordance with the facility's high alert cleaning process. The DHK did not respond.On 5/7/26 at 9:53 AM, the surveyor and the DHK entered room [ROOM NUMBER]. During the observation, the DHK acknowledged that the strong urine odor and that the toilet and bathroom floor were soiled. The DHK confirmed that the room had not been cleaned properly and stated that its condition did not provide a clean, homelike environment for the resident.On 5/7/26 at 9:55 AM, during an interview with the surveyor, the HK assigned to the secured unit (HK #2) stated that room [ROOM NUMBER] had already been cleaned. The surveyor and DHK then showed HK#2 the concerns identified in the bathroom of room [ROOM NUMBER]. HK #2 stated, Maybe I just gave it a quick clean. The DHK confirmed that the bathroom had not been adequately cleaned and further acknowledged that the condition did not provide the resident with a clean, homelike environment.On 5/11/26 at 8:46 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator.A review of the facility's Safe and Homelike Environment policy dated 3/2026 reflected .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .Environment refers to any environment that is frequented by residents including (but not limited to) the resident's rooms, bathrooms, hallways, dining areas .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .On 5/12/26 at 11:30 AM, no further information was provided. NJAC 8:39-4.1(a)11. 31.4 (a), (b)

Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement a comprehensive person-centered care plans (CP) that included: pain medication and b. oxygen (O2). The deficient practice was identified for 2 of 3 residents (Resident #9 and #88) reviewed for care plans.1. On [DATE] at 10:43 AM, the surveyor interviewed Resident 9, who complained of constant back pain. Resident #9 furthered revealed they receive a daily pain patch, which helped with back discomfort.On [DATE] at 12:30 PM, the surveyor reviewed Resident #9's electronic medical record (e-MAR). A review of Resident #9's Face sheet (FS) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; abnormalities of gait and mobility (unusual or impaired patterns of walking or movement), disorder of bone density and structure (condition in which bones become weaker, less dense, and more prone to fractures), and pulmonary fibrosis (a lung disease characterized by scarring and thickening of lung tissue, which makes it difficult for oxygen to pass into the bloodstream).A review of the Quarterly Medicare [NAME] Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of [DATE], revealed that the resident had a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive function. A review of the [DATE] Physician Orders (PO) for Resident #9 revealed a PO dated [DATE], Lidocaine Patch 4 %, apply to lower back and left knee topically one time a day for pain. Apply patch to lower back in the AM and remove in the PM. For external use only and remove per schedule.A review of Resident #9 Care Plan Report (CPR) did not reveal a care plan for pain or use of pain medication.2. On [DATE] at 10:59 AM, the surveyor observed Resident #88 in bed with their eyes closed. Resident #88 was receiving O2 via nasal cannula ((NC) a medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 2 liter per minute (l/min). On [DATE] at 9:43 AM, the surveyor reviewed Resident #88's e-MAR. A review of Resident #88's FS revealed the resident was admitted to the facility with diagnoses that included but were not limited to; acute and chronic respiratory failure with hypercapnia (when the lungs cannot effectively remove carbon dioxide) and acute and chronic respiratory failure with hypoxia (when the lungs cannot supply enough oxygen to the blood).A review of the Quarterly MDS with an ARD of [DATE], revealed that the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive function. The MDS also revealed Resident #88 receives O2. A review of the [DATE] Physician Orders (PO) for Resident #88 revealed a PO dated [DATE], oxygen continuously at 2 liters per minute via nasal cannula. A review of Resident #88's CPR did not reveal a care plan for oxygen.On [DATE] at 11:30 AM, the [NAME] President of Operations (VPO) provided the surveyor with multiple facility policies. A review of the Pain Management Policy with a revised date of [DATE] revealed, 2. The interventions for pain management will be incorporated into components of the comprehensive care plan. A review of the Oxygen Administration Policy with a revised date of 3/2026 revealed, 4. The resident's care plan shall identify the interventions of oxygen therapy.On [DATE] at 12:42 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and VPO to review concerns found during the survey. The LNHA, DON and VPO acknowledged for a resident who received pain medication and oxygen therapy, a care plan should be initiated. On [DATE] at 11:20 AM, the surveyor met with the LNHA, DON, VPO, Infection Preventionist (IP) and Human Resources (HR) for the exit conference. No further pertinent information was provided. NJAC 8:39-11.2 (e)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress (a medical-grade mattress that uses continuous airflow to keep the skin dry, cool, and pressure-free, help that to prevent and treat pressure injuries) was accurately set and monitored according to the resident's weight for 1 of 6 residents (Resident #22). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 8:13 AM, the surveyor observed Resident #22 in bed, eyes closed, lying on an air mattress. Resident #22's air mattress was set to 260 pounds (lbs). The surveyor reviewed Resident #22's electronic medical record (e-MAR), which revealed the following: A review of the admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease (a brain disease that destroys memory) and diabetes mellitus (high blood sugar). A review of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #22 had a Brief Interview for Mental Status score of 3 out of 15 indicating severe cognitive impairment. The MDS further revealed, under section M, that Resident #22 was receiving a pressure-reducing device for the bed. A review of Resident #22's vital signs revealed that the resident's most recent weight was 179 lbs. on [DATE]. A review of the Care Plan Report (CPR) revealed that no plan of care was included for the use of a low-air-loss mattress. A review of the current Physician Order Summary Report (OSR) reflected there were no physician orders (PO) for a low-air -loss mattress. On [DATE] at 8:15 AM, the surveyor showed the Licensed Practical Nurse (LPN) who was assigned to resident #22, the gauge setting on the specialty mattress. The LPN acknowledged that the setting was 260 lbs. and stated that the air pump was supposed to be set to the Resident's weight. At that time, the LPN reviewed the weight in the eMAR, which was 179 lbs. on [DATE]. The LPN stated that the mattress was ordered to aid in healing or prevent wounds and that she should have ensured that it was set to the proper weight. The surveyor and LPN reviewed the POs and CPR. There were no PO or CP for the use of a low-air-loss mattress. On [DATE] at 8:42 AM, during an interview with the surveyor, the Registered Nurse supervisor confirmed that the specialty mattress gauge should be set to the resident's weight and that there should be a PO for the low air loss mattress. On [DATE] at 8:43 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator. A review of the facility's policy, Use of Support Surfaces, dated 4/2026, reflected .Support surfaces will be used in accordance with evidence-based practice for residents with or who are at risk for pressure injuries .For powered devices, or those requiring air, the licensed nurse will check each shift and when necessary for proper functioning and/or inflation .On [DATE] at 11:30 AM, the surveyor met with the administration team, and no further information was provided. NJAC 8:39-19.4(a); 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain intravenous (IV) administration tubing in accordance with infection prevention and professional standards of practice, and b) maintain an Individual Personalized Care Plan (IPCP) for new diagnosis, treatment plans and significant changes according to professional standards of practice for 1 of 18 residents reviewed. (Resident # 87).As evidenced by the following:On 5/5/26 at 10:17 AM, the surveyor observed Resident #87, with a left chest central venous catheter (CVC), (long, flexible tube inserted into a large vein (usually in the chest or neck), with a dressing dated 5/5/26. The infusion pole contained an empty bag of Zosyn (antibiotic) with undated IV administration tubing draped over the pole top with the IV administration tubing leur lock collar (allows a needle, syringe, or tubing (female Luer fitting) to be securely screwed onto the device) exposed and open to air and void of a protective cap. On 5/6/25 at 9:26 AM, the surveyor observed the left CVC, with a dressing dated 5/6/26. The infusion pole contained an empty antibiotic bag with undated IV administration tubing draped over the pole top with the IV administration tubing leur lock collar exposed and open to air and void of a protective cap. On 5/7/26 at 10:30 AM, the surveyor along with the infection preventionist (IP) and the unit manager licensed practical nurse (UM-LPN) observed the empty antibiotic bag on the infusion pole with tubing that was undated, uncapped and looped over the top of the infusion pole with the end of the administration tubing open to air. The IP and the UM-LPN acknowledged and agreed the tubing should be labeled with a date and nursing initials and the leur lock should be capped.On 5/6/26 at 10:04 AM, the surveyor reviewed the medical record for Resident #87.A review of the admission Record Sheet (an admission summary) revealed Resident #87 was admitted to the facility with medical diagnoses which included but was not limited to; metabolic encephalopathy (condition is caused by chemical imbalances in the body) and psoas muscle abscess (a collection of pus in the psoas muscle of the spine, located in the lower lumbar region of the spine).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 3/21/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Under section O, the MDS indicated Resident #87 had a left CVC access and the resident was receiving antibiotics.A review of the IPCP revealed a focus of renal and perinephric abscess (between the kidney capsule and Gerota's fascia (perirenal space)) and returned on antibiotic. date initiated on 9/5/25 and revised on 3/16/26. A further review of the IPCP revealed the facility did not update the IPCP with each readmission [DATE], 4/1/26, 4/8/26 and 4/16/26), CVC access and most recent diagnosis of Psoas abscess (within the psoas muscle (posterior retroperitoneum). and CVC in the left chest wall.A review of an Infectious Disease progress note, dated 5/6/26, revealed that the resident had a right psoas and renal abscesses with a plan to continue IV Antibiotics every 6 hours as ordered with no end date, repeat abdominal Magnetic Resonance Imaging (MRI) on 5/28/26, return to office in 2 weeks, resident will remain on antibiotics until abscesses are resolved completely on MRI.A review of the order summary report (OSR) revealed an initial order date of 4/7/26 for CVC dressing changes on day shift every Tuesday.A review of the OSR revealed an order date of 4/10/26 for CVC dressing change one time only. Must be changed on admission to facility. A review of the OSR revealed an active order date of 4/10/26 for CVC dressing changes on day shift every Friday.A review of the Medication Administration Record (MAR) dated 4/1/26- 4/30/26, revealed the following:Zosyn IV solution 3.0375 gram/50 milliliters, use 2.25 gram IV every 6 hours for infection, discontinued date 4/10/26Zosyn IV solution 3.0375 gram/50 milliliters, use 2.25 gram IV every 6 hours for infection, discontinued 4/14/26Zosyn IV solution 3.0375 gram/50 milliliters, use 2.25 gram IV every 6 hours for infection, discontinued date 4/29/26Zosyn IV solution 3.0375 gram/50 milliliters, use 2.25 gram IV every 6 hours for infection, until 5/28/26A review of the Treatment Administration Record (TAR) dated 4/1/26- 4/30/26, revealed the following:Left Chest Central Line dressing change use transparent dressing, change needless connector every Day shift on Tuesday, discontinuation 4/10/26. Left Chest Central Line dressing change use transparent dressing, change needless connector every Day shift on Friday, discontinuation 4/14/26.Left Chest Central Line dressing change use transparent dressing, change needless connector. cap the end with green cap at all times every Day shift on Saturday, discontinuation 5/5/26.On 5/6/26 at 12:06 PM, the surveyor interviewed the IP, who stated that all IV/CVC tubing should be labeled with the date opened. Once the dose is completed, it should be disconnected from the resident, and a cap should be placed on the leur lock collar in between doses within a 24-hour period. IV tubing for all intermittent medications should be changed every 24 hours according to facility policy. On 5/6/26 at 12:28 PM, the surveyor interviewed the Director of Nursing (DON), who stated that all IV/CVC tubing should be dated and the leur lock should be capped. This process would allow all staff to know exactly when it was changed and to prevent infection. All IV/CVC sites should be monitored and maintained according to nursing standards of practice and facility policy. The DON further stated that the IPCP should have been updated with a new Focus to include the new diagnosis and new infusion site. On 5/12/26 at 11:16 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), and DON, who both acknowledged and agreed the survey team concerns and no further information was provided.A review of the facility's policy titled, Infection Prevention and Control Program, updated 1/2026, indicated; educating staff and ensuring that they adhere to proper techniques and procedures.A review of the facility's undated policy titled, Infusion Therapy Manual, indicated; IV administration tubing for primary intermittent infusions shall be changed at every 24 hours per facility policy.label IV tubing indicating the date and time started and nurses' initials.no tubing shall have an open end when not in use. When tubing is disconnected from the patient, the nurse shall immediately attach sterile protective cap to end of tubing.the entire administration system, including the IV solution and tubing shall be changed immediately if sterility of system has been compromised. A review of the facility's policy titled, Care Plan revisions upon status change, reviewed 3/2026, indicated; the comprehensive care plan will be reviewed and revised as necessary.the care plan will be updated with the new or modified interventions.NJ 483.25(h)

Repeat Deficiency Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow Center for Disease Control recommendations and guidelines for Hand Hygiene and minimize the potential spread of infection to residents during meal service for 2 of 4 staff members (Licensed Practical Nurse (LPN)) and (Activity Assistant (AA)) observed in 1 of 2 dining rooms (West Unit). This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, and this should be done outside the water when rubbing your hands, then rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take approximately 20 seconds. On 05/05/2026 at 11:30 AM, the surveyor observed the lunch meal service in the west unit main dining.On 5/5/26 at 11:45 AM, the surveyor observed the Licensed Practical Nurse (LPN), wearing a surgical mask, perform hand hygiene. The LPN applied soap to her hands and immediately placed them under running water without first lathering. The surveyor further observed the LPN turn off the faucet with her bare hands. After completing hand hygiene, the LPN touched her surgical mask several times, and without performing hand hygiene again, assisted an unsampled resident with their meal.On 5/5/26 at 11:50 AM, the surveyor observed the LPN remove the lid from a garbage can, discard trash, replace the lid, and then assist a resident with their meal without performing hand hygiene. The surveyor observed the LPN hand a taco directly to a resident without prior hand hygiene. On 5/6/26 at 11:40 AM, the surveyor observed lunch meal service in the west unit main dining room.On 5/6/26 at 11:45 AM, the surveyor observed the LPN wearing a surgical mask. The surveyor observed that the LPN was serving and setting up residents, touching their silverware, then touching her mask between residents with no observed hand hygiene. On 5/6/26 at 11:50 AM, the surveyor, in the presence of another surveyor, interviewed the LPN and the Assistant Director of Nursing (ADON). The surveyor discussed the infection control (IC) breaches observed on 5/5/26 and 5/6/26. The ADON acknowledged observing the IC breaches on the previous day and stated that she had spoken with the LPN regarding the concerns. On 5/6/26 at 12:00 PM, the surveyor, in the presence of another surveyor, observed the Activity Assistant (AA) perform hand hygiene. The surveyor observed that the AA turned on the faucet, applied soap to their hands, and immediately placed them under running water without first lathering. The AA then turned off the faucet with her bare hands. At that time, the surveyor discussed IC concerns with the AA. The AA acknowledged that she should have lathered her hands with soap outside of running water and used a paper towel to turn off the faucet.On 5/11/26 at 8:43 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator. A review of the facility's Handwashing/Hand Hygiene policy reflected .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .Procedure:1. Wet hands first with water, then apply the amount of product recommended by the manufacturer to the hands.2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.3. Rinse hands with water and dry thoroughly with a disposable towel.4. Use a towel to turn off the faucet. On 5/12/26 at 11:30 AM, no further information was provided. NJAC 8:39-19.4 (a-c)(n); 27.1 (a)

Complaint: 2989444 Based on interviews, record review, and review of other pertinent facility documents on 04/24/2026, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) the fall with injury and the elopement of a cognitively impaired resident (Resident #1). This deficient practice was identified for 1 of 4 residents reviewed for accident and incidents and was evidenced by the following:According to the admission Record, Resident #1 was admitted to the facility with diagnoses including but not limited to: follicular lymphoma (slow-growing cancer of lymph nodes, bone marrow and other organs); schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves), auditory hallucinations (hearing sounds, voices, or noises that are not present in reality). Review of the brief interview for mental status (BIMS) assessment dated [DATE] revealed that Resident #1 had severely impaired cognition. Review of the Elopement/Wandering Risk Assessment dated 04/01/2026 revealed that Resident #1 was determined to be an elopement risk. Review of Resident #1's care plan (CP) initiated on 04/01/2026 revealed that the resident wandered and was an elopement risk related to the resident's impaired safety awareness. Interventions included provision of structured activities; walking inside and outside; and use of an elopement alarm. Further review of Resident #1's CP revealed that the resident was at risk for falls related to deconditioning, and gait and balance problems. Interventions included anticipating and meeting the resident's needs; and educating the resident, family, and caregivers about safety and what to do if a fall occurred. A review of a progress note (PN) written by the Director of Nursing (DON) dated 04/01/2026 at 10:28 PM revealed that Resident #1 had a fall and was transferred to the hospital. Review was conducted of a facility Resident Accident/Incident Report (RA/IR) with Resident #1's name; an event date of 04/01/2026; and time of incident of 7:45 PM at the top. Under Description and Facts of Event the document revealed that nursing staff noted that the resident was not in their room or the dayroom. This section of the document further revealed that nursing staff observed the resident's window screen was removed and their window was open. The resident was observed outside laying on the ground. Further review of the RA/IR revealed that the fall was documented as unwitnessed, the extent of the resident's injuries was unknown, and the resident was transferred to the hospital. Review was conducted of an Investigation Report (IR) from [NAME] Township Police Department dated 04/01/2026 at 7:49 PM. The IR revealed that Emergency Medical Services (EMS) suspected internal injuries and requested a helicopter to transport Resident #1 to the hospital due to suspected serious injuries. Further review of the IR revealed that the height from Resident #1's window to the ground outside was between 17 and 18 feet. An interview was conducted with Registered Nurse (RN) #1 on 04/24/2026 at 1:12 PM. RN #1 stated that she was working in the facility when Resident #1 exited through the window. RN #1 stated that on 04/01/2026 at 7:00 PM or 7:15 PM, she was doing rounds with the Assistant Director of Nursing (ADON), when Resident #1 was not seen. RN #1 and the ADON began to check other rooms for the resident and shortly afterward the ADON called out for RN #1 to call 911. RN #1 called 911, then went to Resident #1's room where she saw the window open and Resident #1 outside on the ground. RN #1 further stated that when she observed Resident #1 on the ground, one of the resident's legs appeared to be shorter than the other. RN #1 stated that this could be a sign that the resident's leg was broken. An interview was conducted with the Licensed Nursing Home Administrator (LNHA) on 04/24/2026 at 4:05 PM. The LNHA stated that falls with major injuries should be reported to NJDOH. The LNHA stated that Resident #1's fall was not reported because the facility was unable to get information from the hospital on the extent of the resident's injuries. During the same interview the LNHA stated that Resident #1's exit through the window was not reported to NJDOH as an elopement because the resident did not leave the facility grounds, so it was not considered an elopement. The facility policy Falls and Fall Risk Managing with an implementation date of May 2025 and a reviewed/revised date of April 2026 was reviewed. The facility policy revealed that a fall is when a resident unintentionally comes to rest on the ground, floor or other lower level. The policy revealed that unless there is evidence suggesting otherwise, when a resident was found on the floor it should be considered a fall. The facility policy Elopement and Wandering Residents with an implementation date of May 2025 and a reviewed/revised date of April 2026 was reviewed. The facility policy revealed that an elopement occurs when a resident leaves the premises or a safe area without authorization and/or the necessary supervision to do so. Under Procedure for Locating Missing Resident the facility policy revealed, g. Appropriate reporting requirements to the State Survey Agency shall be conducted. The facility policy Incidents and Accidents with an implementation date of May 2025 and a reviewed/revised date of April 2026 was reviewed. The facility policy revealed that it was the policy of the facility for staff to report, investigate, and review any accident or incident that involved a resident and occurred on facility property. Under Definitions: revealed, an Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident, and an incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operations of the organization. Under Policy Explanation the facility policy revealed that The purpose of incident reporting can include [.] Meeting regulatory requirements for analysis and reporting of incidents and accidents. Under Compliance Guidelines The facility policy further revealed, 4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. 5. The following incidents/accidents require an incident/accident report but are not limited to [ .] Elopement [ .] Falls. The facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation with an implementation date of May 2025 and a reviewed/revised date of April 2026 was reviewed. The facility policy revealed that it was the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment [ .] which are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Under Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: revealed When suspicion of abuse/neglect/exploitation [ .] occur, the following procedure will be initiated [ .] 2. The Administrator or designee will: a. Notify the appropriate agencies immediately; as soon as possible, but no later than 2 hours after discovery or forming the suspicion. NJAC 8:39 - 9.4(f)

Based on observation, interview, and record review, it was determined that the facility failed to have physician progress notes (PPN) readily accessible in the facility. This deficient practice was identified for 7 of 12 residents reviewed, (Resident #207, #5, #48, #16, #21, #6, #45) and was evidenced by the following. 1. On 12/17/24 at 10:42 AM, the surveyor observed Resident #207 in the dayroom watching television. The resident stated to the surveyor they have seen their primary physician (PP) a few times since their admission. A review of Resident #207's Face sheet (FS) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes, peripheral vascular disease, and heart failure. A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate care management dated 12/11/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:01 PM, the surveyor reviewed the hybrid medical records (HMR), (combination of the physical and electronic chart) and did not observe any PPN documentation. 2. On 12/17/24 at 11:20 AM, the surveyor observed Resident #5 in the dayroom watching television. The surveyor interviewed Resident #5 who stated they can't recall when they were seen by their PP. A review of Resident #5 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to generalized anxiety disorder, anemia, type 2 diabetes, and hyperlipidemia. A review of the Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate care management dated 11/8/24, indicated a BIMS score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:05 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 3. On 12/17/24 11:25 AM, the surveyor observed Resident #48 in the dayroom seated in the wheelchair with eyes closed. A review of Resident #48 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, Parkinson's disease, insomnia, and generalized anxiety. A review of the Q/MDS, an assessment tool used to facilitate care management dated 11/28/24, indicated a BIMS score of 15 out of 15 which indicated that resident was cognitively intact. On 12/18/24 at 12:10 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 4. On 12/17/24 at 12:00 PM, the surveyor observed Resident #16 in the dayroom seated in their wheelchair. A review of Resident #16 FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dementia cognitive communication deficit, protein-calorie malnutrition, and glaucoma. A review of the Q/MDS, an assessment tool used to facilitate care management dated 10/3/24, indicated a BIMS score of 00 out of 15 which indicated that resident had severely impaired cognition. On 12/18/24 at 12:20 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 46889 5. On 12/17/24 at 9:50 AM, the surveyor observed Resident #21 in bed watching television. Resident #21 was able to answer the surveyor's inquiry. On 12/18/24 at 11:42 AM, the surveyor reviewed the HMR of Resident #21, which revealed the following: A review of the FS revealed that Resident #21 was admitted with diagnoses that included but were not limited to dementia (loss of memory). A review of the Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 8 out of 15, which indicated that the resident had moderately impaired cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 6. On 12/17/24 at 10:10 AM, the surveyor observed Resident #6 seated in their wheelchair. On 12/19/24 at 12:03 PM, the surveyor reviewed the HMR of Resident #6, which revealed the following: A review of Resident #6's FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). A review of the Q/MDS, dated [DATE], reflected that the resident had a BIMS score of 6 out of 15 which indicated that the resident severely impaired cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. 7. On 12/17/24 at 9:40 AM, the surveyor observed Resident #45 awake and was seated in the wheelchair inside the dayroom. On 12/17/24 at 11:54 AM, the surveyor reviewed the HMR of Resident #45, which revealed the following: A review of Resident #45's FS revealed that the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus (high blood sugar). A review of the A/MDS, dated [DATE], reflected that Resident #45 had a BIMS score of 15 out of 15 which indicated that the resident had intact cognition. On 12/18/24 at 1:22 PM, the surveyor reviewed the HMR and did not observe any PPN documentation. On 12/18/24 at 12:41 PM, the surveyor interviewed the PP, who stated he is the PP for all the residents in the facility. The PP also stated that he would come in the facility every Wednesday and most weekends. The PP further stated the resident's PPN were not in the facility's electronic charting system, but were in a separate electronic system in which only the PP would have access to them. The PP acknowledged that the PPN's were not inside resident's physical chart. On 12/18/24 at 1:01 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) who confirmed that the facility including the nursing staff does not have access to the resident's PPN and there were no PPN's observed in the physical chart. On 12/18/24 at 1:15 PM, the Director or Nursing (DON) provided the surveyor with a facility policy titled, Physician Service policy and Procedure with a revised date of 7/24. Under the policy and implementation section it states, 3. Physician orders and progress notes shall be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. On 12/19/24 at 1:12 PM, the survey team met with the DON and Director of Operations (DOO) and reviewed the above concerns. The DON stated, they were aware of the concern. No further information was provided. NJAC 8:39-35.2 (d)(5)

Based on observation, interview, record reviews, it was determined that the facility failed to follow a.) appropriate infection control practices for handling and storing clean clothes observed in the laundry room and b.) the policy and procedure of the facility's Water Management Program to prevent the growth of Legionella (a waterborne pathogen). This deficient practice was evidenced by the following: 1. On 12/19/24 at 9:35 AM, the surveyor together with the facility's Infection Preventionist (IP) toured the laundry room. The surveyor observed a rack of hangers of clothes covered with a clean blanket touching the laundry room floor. The surveyor interviewed the Housekeeping Manager (HM) who stated those clothes clean. The HM also stated the clothes were washed and brought to the residents who would need them. The HM acknowledged to the surveyor that the clean clothes should not touch the floor. On 12/19/24 at 10:03 AM, the surveyor interviewed the IP regarding the above concern. The IP stated that the clothes should not touch the ground because they were clean already. On 12/19/24 at 10:45 AM, the Director of Nursing (DON) provided a policy titled The Laundry Process, but it did not address handling clean clothes after washing. On 12/19/24 at 1:13 PM, the survey team met with the DON and Director of Operations regarding the above concern. The DON stated that those clothes were unlabeled and once the owner was found, they would give the clothes back. The DON also stated the clothes have been on the rack for 30 days; and they were lost-and-found clothes. 2. On 12/17/24 at 10:15 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor requested the facility's water management program and evidence of monitoring. On 12/19/24 at 9:25 AM, the surveyor interviewed the IP. The surveyor asked if there had been a case of resident diagnosed with Legionella or other waterborne pathogen illness in the facility, the IP stated that there had not been any cases reported. On 12/20/24 at 12:56 PM, the surveyor interviewed the LNHA, who stated the facility hired an outside company for the well water (water from a well, which is a hole dug into the ground to access groundwater) system. The LNHA stated they couldn't find the last water testing from the previous company. On 12/23/24 at 1:20 PM, the survey team met with the LNHA to discuss the above concern. The LNHA stated they do not have records for their water management. The LNHA also stated that the facility had no water management plan. A review of the records provided by the Director of Maintenance (DM) titled Certificate of Analysis, dated December 5, 2024, and November 11, 2024, indicated the facility monitored the chlorine and coliform levels. There was no documented evidence for the monitoring of waterborne pathogens. A review of the facility's policy titled Water Management Plan, with a reviewed date of November 15, 2023, included the following: Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens . NJAC 8:39 - 19.4(i) NJAC 8:39-19.1

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included anti-anxiety medication. This deficient practice was identified for 1 of 12 residents (Resident #6) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 12/17/24 at 10:10 AM, the surveyor observed Resident #6 seated in their wheelchair. On 12/19/24 at 12:03 PM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #6, which revealed the following: A review of the Admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory). A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 11/5/24, reflected that the resident had a Brief Interview for Mental Status score of 6 out of 15, indicating severely impaired cognition. A review of the December 2024 Order Summary Report for Resident #6 reflected a Physician Order (PO) dated 10/30/24 for Lorazepam Concentrate (an anti-anxiety medication) 2 mg (milligram)/ml. (milliliter) give 0.25 ml sublingually (administered under the tongue) every 4 hours as needed . A review of Resident #6's November and December 2024 electronic Medication Administration Record (eMAR) revealed the above PO were administered to the resident on 11/23/24 at 8:57 AM and 12/11/24 at 12:40 AM. A review of the progress notes dated 11/23/2024 at 10:12 AM revealed that Resident #6 was given Lorazepam according to the PO due to increased shortness of breath. A review of Resident #6's CP did not reflect a CP for the use of anti-anxiety medication. A review of the hospice records titled Interdisciplinary Group Meeting, dated 11/7/24 under current CP did not reflect any CP for the use of anti-anxiety medication. On 12/20/24 at 11:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the above concern. The LPN stated that if a resident was on an anti-anxiety medication, it must be addressed in the resident's CP. On 12/20/24 at 11:29 AM, the surveyor conducted a telephone interview with the Clinical Director/Registered Nurse (CD/RN) for the hospice company who did not provide any information regarding the CP for the use of anti-anxiety medication. On 12/23/24 at 1:10 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above concern. There was no additional information provided. A review of the policy titled Hospice Services with a reviewed date in May 2024 stated under Procedure: 14. Each resident's plan of care will include an integrate both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practical physical, mental, and psychological well-being. NJAC 8:39-11.2(e)(2)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of fourteen (14) residents reviewed, (Resident #40) for medication management and was evidenced by the following: On 12/18/24 at 11:45AM, the surveyor observed Resident #40 in the facility activity room. The resident was seated in a wheelchair and was observed coloring pictures. The surveyor reviewed Resident #40's medical records. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; gastrostomy status (refers to the presence of a surgical opening into the stomach, which allows for nutritional support of gastric decompression), neurocognitive disorder with Lewy bodies (type of dementia characterized by a decline in thinking abilities, including attention, visual perception, and executive function) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete painful blockage). A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 11/22/24, reflected that the resident's cognitive skills for daily decision-making score was 0 out of 15, which indicated that the resident's cognition was severely impaired. A review of the December 2024 Order Summary Report (physician's order sheet) (OSR) revealed a physician's order (PO) dated 10/11/24, for Donepezil tablet 10 mg (milligrams) by mouth at bedtime related to dementia in other diseases classified elsewhere. The December 2024 OSR also revealed a PO dated 5/12/23 for NPO (not by mouth) diet NPO texture, receives Bolus Feeding. A review of the November 2024 and the December 2024 electronic medication administration record (eMAR) revealed a PO dated 10/11/24, for Donepezil tablet 10 mg by mouth at bedtime related to dementia in other diseases classified elsewhere. Donepezil was scheduled to be administered every day at 20:00 (8:00 PM). A review of the CP's evaluation reports dated 11/1/24 and 12/3/24 indicated that the CP reviewed the medication regimen for Resident #40 with no new medication recommendations indicated. On 12/18/24 at 12:50 PM, the surveyor in the presence of the Registered Nurse (RN)/ Unit Manager (UM) reviewed Resident#40's PO. At that time, the RN/UM acknowledged that Donepezil medication was ordered by the physician to be given by mouth but also acknowledged that the resident received their medications via a g-tube (gastrostomy tube). The RN/UM further stated that the CP should have identified the discrepancy during their monthly medication review. On 12/19/24 at 1:00 PM, the surveyor met with the Licensed Nursing Home Administrator and Director of Nursing to discuss the above concerns. There was no additional information provided. On 12/20/24 at 12:15 PM, the surveyor conducted a telephone interview with the CP who acknowledged that she reviewed the residents' medication regimen monthly. The CP also acknowledged that part of her reviews was to ensure that the medications for the residents were being administered via the correct route. The CP further acknowledged that Resident #40 was NPO and received medications via a g-tube. The CP stated the facility should have been notified regarding the PO for Donepezil administration route discrepancy. A review of the facility's policy for Administrative Policy and Procedures dated 07/31/24, which was provided by the DON included the following: The Consultant Pharmacist shall identify, document, and report actual and potential irregularities for review and action to the Director of Nursing and or/designee, Administrator, Medical Director and physicians (where appropriate). The physician's recommendations will be communicated to the Director of Nursing and/or Designee for distribution and action by the attending physician via email, fax (or both). NJAC 8:39-29.3

Based on interview, record review and review of pertinent facility provided documents, it was determined that the facility failed to rule out abuse for an injury of unknown origin and an allegation of sexual abuse, for 1 of 2 residents reviewed for reportable events (Resident #29). Resident #29 had diagnoses which included but were not limited to; Dementia, major depressive disorder, anxiety, and paroxysmal atrial fibrillation (irregular heartbeat). A review of an Accident/Incident report, signed by a Licensed Practical Nurse (LPN), dated 01/26/23, revealed a right-hand bruise with no indication of the origin or if the bruise had been witnessed or unwitnessed. Further review of the Accident/Incident report revealed an attached Investigation/Witness Statement dated 01/24/23 at 6:45 PM, which included that the resident .was in bed [Resident #29] was screaming rape . A nurse progress note documented on 01/24/23 at 18:42 (6:42 PM), revealed .resident was screaming Rape at the top of [his/her] lungs for over an hour . On 09/19/23, the nurse was interviewed and acknowledged that the resident had been yelling Rape and that she did not report the allegation to a supervisor. A nurse progress note documented on 01/26/23 at 14:42 (2:42 PM), revealed at 1:30 PM, a bruise was noticed on right top hand . 2 [centimeter cm] x 1.5 [cm]. The facility's failure to protect the resident, to rule out abuse, and ensure the allegation of sexual abuse was investigated resulted in an Immediate Jeopardy (IJ) situation. The IJ situation began on 01/24/23 and was identified on 09/19/23 at 4:09 PM. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified of the IJ situation. An acceptable removal plan was received at 09/19/23 at 8:22 PM and was verified as implemented on 09/20/23 at 9:59 AM. The deficient practice was evidenced by the following: On 09/19/23 at 12:02 PM, the surveyor reviewed facility provided incident reports for injuries of unknown origin for Resident #29. The reports included a Resident Accident/Incident Report signed and dated 01/26/23, by a Licensed Practical Nurse (LPN). The Date of Accident/Incident was 01/26/23 at 1:30 PM. The Description and Facts of Event: revealed [right upper hand bruise purple in color]; What does the Resident state happened: revealed why, now nothing happed to my hand?; Injury: revealed bruise; Injury was left blank which included check off boxes for known, unknown, and occurred during care; Resident/Staff Allegations section was left blank which included check off boxes for Physical Abuse, Verbal Abuse, Sexual Abuse, Mental Abuse and Neglect; The Current BIMS (Brief Interview for Mental Status) score was 12/15 which indicated the resident was moderately impaired, alert, and oriented X 1 [self]. The Interventions Implemented to Prevent Future Occurrences: revealed 24 [hours], [statement] 01/24/23 staff, [rule out] infection, if negative, then [redacted physician service name], (recent increase of Zyprexa on 01/12/23 for stated depression). The Resident Accident/Incident Report failed to document a conclusive summary of findings of a bruise of unknown origin. One Investigation Witness Statement Form was attached and revealed the Date/Time of the Incident was 01/24/23, and was signed by Certified Nurse Aide (CNA #1) at 6:45 PM. The Witness Statement: revealed . While attempting to transfer Resident #29 to bed, resident grabbed my arm and dug [his/her] nails into my side after releasing grip, Resident #29 grabbed my side and started digging his/her nails into my side, after releasing his/her grip, Resident #29 grabbed another CNA's arm and dug his/her nails into the CNA's arm. While attempting to put the [Standing Mechanical Lift Machine] sling on Resident #29, the Resident began screaming at the top of lungs and was trying to rip the sling off. After Resident #29 had care completed and was in bed, Resident #29 was screaming Rape . An attached Investigation of Unknown Injury- 24 Hour Look Back revealed the Type of Occurrence: Bruise, 01/26/23 at 1:30 PM, and failed to address if the bruise of unknown origin was ruled out for abuse. The look back statements were documented by 3 CNAs and depicted the residents condition on 01/25/23. There was no Accident/Incident Report to address when Resident #29 screamed Rape on 01/24/23, and the Resident Accident/Incident Report also failed to document any additional staff statements, or 24 hour look back statements. A review of the Care Plan included a focus area initiated 01/24/21, diagnosis and history of dementia with behavioral disturbances. Interventions included but were not limited to; two staff for all care. Caregivers to provide opportunity for positive interaction. Continue to monitor for worsening mood and aggressive behavior. Consult for psychiatric and behavioral health services. Redirect using calm approaches and distraction. If resistant to care, assure he/she is safe and reapproach at a later time. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. The Care Plan did not include allegations of sexual abuse, or any history of abuse or trauma. The surveyor reviewed the Abuse Identification & Prevention Program policy effective September 2018. The policy revealed, C. 4. Nursing and social workers identify those residents whose personal histories render them at risk for becoming a victim of abuse from others. D. Clues to Help Identify Abuse included but was not limited to; 1. Physical Abuse: color of bruises - red, purple, or black indicated a one-day old bruise. E. Investigation: Upon receipt of information (verbally or in writing) related to observed abuse, overheard abuse, suspected abuse, injury of unknown origin, or misappropriation of resident's property, the director of nursing/designee will ensure an investigation (if one has not been initiated previously) is initiated. 1. The Director of Nursing notifies the administrator of the situation and that an investigation has started. 3. The Director of Nursing/designee will: Have an unusual occurrence/incident report completed, Collect and preserving physical and documentary evidence, Interview alleged victim/s and witness/es, Obtain statements from caregivers, others directly involved with the resident 48 hours prior to the alleged abuse and 24 hours after, Interview other residents to determine if they have been abused or mistreated, Interview staff who worked the same shift to determine if they have been abused or mistreated, Interview staff who worked previous shifts to determine if they were aware of an injury or incident, Obtain statements from caregivers and others directly involved with the resident for the forty-eight hours prior to the alleged abuse and up to twenty-four hours after, Involve other regulatory authorities who may assist, e.g. local law enforcement, elder abuse agency . The DON will maintain an investigative package which includes . a conclusive summary of findings which indicated why or if and how abuse has been ruled out. On 09/19/23 at 11:36 AM, the DON stated the above incident was not reported to the state [New Jersey Department of Health]. The DON stated that the facility would have to do an investigation and gather the facts. She stated Resident #29's bruise was unwitnessed and that if there was a significant injury and we suspect abuse, we call right away. The DON stated Resident #29 moves around a lot and we figured it was shear or friction and was not significant and did not suspect abuse. On 09/19/23 at 12:27 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The surveyor inquired if the abuse policy reviewed was the facility abuse policy and the LNHA confirmed that it was the abuse policy. The DON stated that the types of abuse included physical, emotional, financial, verbal, sexual, and neglect. The DON stated the abuse policy did not speak to the injury of unknown origin. The surveyor asked what would constitute an allegation of sexual abuse? The LNHA stated a resident saying someone touched them inappropriately, or an unusual injury and fear of certain people. The surveyor asked the LNHA if a resident verbalizing rape would also constitute an allegation of sexual abuse. The LNHA stated, of course. The surveyor asked the LNHA what the process would be if a resident alleged rape. The LNHA stated the facility would ensure the resident was safe, remove the abuser, interview the resident, and all the caregivers, anyone who had been around the resident, and not only the CNAs. The DON stated that if this happened in the evening, the nurse should contact her, and a head-to-toe physical assessment would be completed, witnessed by two people and the police would also be contacted. The surveyor asked the DON and LNHA about the statement completed on 01/24/23, regarding Resident #29 exclaiming Rape. The DON stated that the resident had a history of saying these things and that the family had informed her that the resident had been raped in the past. The surveyor asked what was the process that was completed after Resident #29 stated rape. The DON stated she would have to check as she could not recall. On 09/19/23 at 1:17 PM, the surveyor interviewed a Registered Nurse Unit Manager (RN UM) regarding the process if an allegation of abuse was made or suspected. The RN UM stated she would inform a supervisor, obtain witness statements, and investigate the allegation. On 09/19/23 at 1:30 PM, the surveyors interviewed the DON and asked when she was first made aware of the allegation that Resident #29 made on 01/24/23. The DON stated the incident report was brought to morning meeting on 01/27/23. The DON stated the nursing unit contacted her via telephone, and she could not recall who she had spoken with on 01/26/23 and that was about a bruise that occurred at 1:30 PM. The DON stated that a UM, she could not recall which one, informed her of the bruise that was identified on that the same day, 01/26/23, for Resident #29. The DON stated that the nurses knew how to complete an investigation and would also complete a 24- hour look back to obtain statements from all caregivers 24 hours prior to the discovery/when the allegation was made. The DON stated the nurses have been educated on how to complete the incident reports and obtain statements only from the staff who provided hands on care. The DON reviewed the investigation in the presence of the survey team and stated that there was a missing statement from one of the CNA's who was in the room with Resident #29 at the time of the allegation. The DON stated she only received a statement from CNA#1 and not from CNA #2. The DON stated she would have CNA #2 write a statement today, 09/19/23. The DON stated she brought the Incident Report to the morning report meeting held on 01/27/23, and at that time the incident report, and the 24 hours look back had not yet been completed and that nothing else had been provided for the investigation. The DON stated she was not provided CNA #1's statement on 01/27/23 regarding rape and could not recall when she was given that statement. The DON confirmed there were two CNAs in the room with Resident #29 and she just realized that she did not have CNA #2's statement. The DON stated, I know I read it quickly knowing what had happened and stated what happened was that resident was throwing food, digging nails, a horrible scene. The DON stated Resident #29 had a history of an abusive spouse. The DON stated the expectation was to have received all the statements and that it was ultimately my [DON] responsibility. The DON stated that on 01/27/23, the Accident/Incident report had been signed as reviewed but was not complete and stated the LNHA who also signed the report was no longer at the facility. The DON acknowledged she may have known about the allegation of rape, but it was the resident's normal behavior. The DON stated that the expectation would have been for the nurse to do a head-to-toe assessment, document any behaviors, and report the allegation. The DON stated that the investigation should have been completed within 24 hours and that it had not been reported to the Department of Health (DOH) or the police. The DON further stated that the facility did not have a written policy and procedure on sexual abuse, but the staff should have known what to do because they had been educated. The Licensed Nursing Home Administrator (LNHA) stated she was not working at the facility at that time, but that she would expect the staff to act on an allegation of rape, perform an assessment, and report it [to DOH]. The LNHA acknowledged there were no other files or documents regarding the allegation of rape by Resident #29. On 09/19/23 at 2:14 PM, during another interview with the surveyor, the RN UM stated she was responsible to initiate the questions on the back page of the Accident/Investigation report, but that the floor nurse would complete the front-page information. The RN UM stated that she would ask the staff to write statements. The RN UM further stated that Resident #29 has expressed behaviors however, had never made allegations of rape. On 09/19/23 at 2:22 PM, CNA #2 was interviewed by the survey team. CNA #2 stated she had never been educated on what to do if a resident yelled rape. On 09/19/23 at 3:02 PM, the LPN who cared for Resident #29 on 01/24/23, was interviewed by the survey team. The LPN stated she had cared for Resident #29 and knew the resident had been combative and would also yell at people. The LPN stated the resident required two- staff assistance to provide care. The LPN's progress note was read to the LPN, and the LPN acknowledged she documented the note, and also recalled the documentation regarding the resident yelling rape. The LPN further stated the resident screamed anything, but she had not documented before that the resident had screamed rape. The LPN stated she had not reported that the resident had yelled rape because it had not happened on my watch, and that it was a normal behavior for the resident to yell things for hours. The LPN further stated, I guess looking back that was something I should have reported. I just did not because the resident would say crazy things. The LPN stated, well I guess I wouldn't know if something had happened earlier in the day to Resident #29. A review of the facility provided, Abuse Identification & Prevention Program dated September 2018, included but was not limited to; C. Prevention 4. nursing and social workers identify those residents whose personal histories render them at risk for . becoming a victim of abuse. D. Identification of Signs and Symptoms of Abuse - clues to help identify abuse 1. physical abuse clues: color of bruises red, purple, or black indicate a bruise one day old. Note: Intentional or unintentional abuses necessitate an immediate investigation. During the investigation, the resident must be protected. E. Investigation 3. obtain statements from the caregivers and others directly involved with the resident 48 hours prior and 24 hours after. Interview other residents to determine if they had been abused or mistreated. Ensure the investigation is completed with three working days of the alleged abuse. The DON will maintain an investigative package with the copy of the incident report, all statements obtained and a conclusive summary of finding which indicated why or if and how abuse has been ruled out. A review of the facility provided, Abuse and Neglect Policy and Procedure undated, included but was not limited to; prohibiting mistreatment, neglect, and abuse of residents . Such steps include .monitoring and investigation of incident and accidents. Procedure included but was not limited to; 1. when the abuse is detected remove the resident from the harmful situation; 2. Physically assess the resident for injuries; 3. Get the facts; 4. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation are reported immediately to the DON, LNHA, attending physician, and resident's family/responsible party. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the incident is under investigation. NJAC 8:39-4.1(a)5; 27.1 38079

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 2 residents, (Resident #49, Resident #50) reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: 1. On 09/06/23 at 10:22 AM, the surveyor toured the East Unit of the facility and observed Resident #49 in bed. A strong foul urine odor permeated as the surveyor approached the resident's bed. On 09/06/23 at 10:35 AM, the surveyor exited the room and while in the hallway heard an alarm sounding. The surveyor returned to the room and observed the resident was now out of the bed and was wearing a blue incontinent brief that was observed bulging in the rear. At 10:36 AM, a Certified Nurse Aide (CNA) emerged from the bathroom door inside of the resident room and observed Resident #49 was out of the bed. The CNA then escorted the resident back to bed and told the resident to wait until she had completed care for the resident next door. The CNA informed the surveyor that Resident #49 would try to get out of the bed whenever if he/she was soiled. On 09/08/23 at 08:43 AM, the surveyor interviewed the 7:00 AM -3:00 PM Certified Nursing Aide (CNA) #1 on the East Unit. The CNA stated that she currently had 12 residents on her assignment and was the only CNA on the floor. Upon inquiry regarding the workload, the CNA stated, I tried to find time and I usually finished my assignment by 12:00 PM or 1:00 PM. The CNA added, Not all of the residents would be out of bed due to staffing. The residents at risk for falls would be out of the bed almost daily. When inquired regarding if administrative staff were aware, she stated, They make the schedule they knew about it. On 09/08/23 at 11:30 AM, the surveyor interviewed the 7:00 AM - 3:00 PM CNA #2 on the East Unit who stated that she had been working at the facility for several years and currently had 13 residents on her assignment. CNA #2 stated that she only worked the 7:00 AM - 3:00 PM shift and would usually have 12 to 14 residents on her assignment on the weekends. CNA #2 further stated that the number of residents on her assignment depended upon how many staff were working. On 09/15/23 at 8:37 AM, the surveyor observed incontinence rounds in the presence of CNA #2 along with the Infection Control Preventionist (IP) on the East Unit. The surveyor observed that Resident #49 was wearing two incontinent briefs which were saturated with urine. CNA #2 stated that in the morning she made rounds to ensure that the residents were safe and in bed, however, did not check for incontinence. She further added that she had not yet provided care to Resident #49. When inquired about Resident #49 wearing two adult incontinent briefs, she stated that was not the protocol but occasionally she would observe residents wearing two incontinent briefs and would report it to the Registered Nurse/Unit Manager (RN/UM). On 09/15/23 at 11:11 AM, the surveyor interviewed the IP who assisted with incontinent care that morning. The IP confirmed that occasionally she would observe other residents wearing two incontinent briefs during incontinence care. She stated that she discussed the issue with the RN/UM and could not comment on/or if any in-service education had been completed to address the above issue. She added that the staff had to be careful because wearing two incontinent briefs could damage the skin and could be very uncomfortable. On 09/21/23 at 08:30 AM, during an interview with CNA #3 who cared for Resident #49 on 09/15/23 during the 11:00 PM-07:00 AM shift, she revealed that she began her last rounds at 4:00 AM, she provided incontinence care to Resident #49 and applied one brief. CNA #3 stated that she had some residents that were, heavy wetters on her assignment and she would change them as needed. CNA #3 added that she would place several blue bed pads on the bed, otherwise she would have to strip the whole bed in the morning. According to CNA #3's interview, approximately four hours had passed since Resident #49's incontinence brief had been changed. The surveyor reviewed the medical record for Resident #49. The Admission Face Sheet (an admission summary) reflected that Resident #49 was admitted to the facility with diagnoses which included but were not limited to: Syncope and collapse, repeated falls, unspecified Dementia. The Admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 08/02/23, reflected that Resident #49 had a BIMS (Brief Interview for Mental Status) of 09/15, indicative of moderate cognitive impairment. A further review of the resident's MDS, Section G - Functional Status indicated the resident required extensive assistance of one-person physical assist for personal hygiene. A review of the resident's Care Plan (CP) with revised date of 07/26/23, reflected a focus area that the resident had an ADL self-care performance deficit related to hospitalization , diagnosis of Syncope, bradycardia and recurrent falls. The goal was for Resident #49 would improve current level of function in ADL,s and mobility. The interventions for the resident CP included that Resident #49 requires assistance by 1 staff with oral care, personal hygiene, and toileting. 2. On 09/08/23 at 8:37 AM, the surveyor observed incontinence rounds in the presence of the Hospice Aide (HA) on the East Unit. The surveyor observed that Resident #50's incontinent brief was wet and yellow stained. The yellow liquid was observed to be covering the front and the back part of the resident's incontinence brief. Two blue pads were also noted on the bed and were also yellow stained. The HA stated that she worked for Hospice Monday through Friday and provided care to Resident #50. The HA added that Resident #50 would be wet every day whenever she received the resident. She reported to work and just started her shift at 8:30 AM and had not yet changed the resident. On 09/15/23 at 8:15 AM, the surveyor observed incontinence rounds in the presence of CNA #1 and the HA on the 2 East Unit for Resident #50. When the HA removed the resident's incontinence brief, the surveyor observed that two long sanitary-type pads were also inside the incontinence brief and were saturated and yellow. The contents of the sanitary-type pads had leaked through the incontinence brief and stained the blue bed pad that was placed on the bed to protect the bed. The surveyor asked CNA #1 to have a supervisor report to the room. The Licensed Nursing Home Administrator (LNHA) was located on the floor and reported to the room. She informed the surveyor that she would call the DON. The HA remained in the room at the bedside with the surveyor. During a second interview with the HA, she stated that she informed both the nurses and the CNAs that Resident #50 needed to be checked for incontinence every 2 hours. On 09/15/23 at 8:30 AM, the DON entered the room where she observed Resident #50 was in bed, two sanitary-type pads soaked with urine, the incontinent brief also saturated with urine and yellow stained. The DON stated that the sanitary-type pads were in place to prevent MASD (Moisture- Associated Skin Damage -a general term for inflammation and erosion of the skin due to prolonged exposure to moisture) and the resident should have had only one pad inside the incontinent brief. On 09/15/23 at 10:30 AM, the facility provided two packages of the sanitary-type pads for review. The surveyors reviewed the package information on the sanitary-type pad. The packages revealed the products were Bladder Pads, Fits Inside Your Own Underwear. The instructions did not correlate with what the facility indicated the intended use was regarding placing the pad inside the incontinent brief. The surveyors requested the facility provide evidenced based guidance regarding using one incontinent product (Bladder Pad) inside of an incontinent brief. On 09/18/23 at 12:00 PM, the surveyor interviewed the UM/RN of the East Unit. She stated that she was not aware that staff were using two adult incontinent brief, and two pads inside the incontinent brief. She further stated that she could not recall if the CNA or the IP alerted her prior to 09/15/23 of the above concerns. The RN/UM further stated that incontinence rounds were to be performed every two hours and as needed for the residents. The surveyor reviewed the medical record for Resident #50. Resident #50 was admitted to the facility with diagnoses which included but were not limited to: Neurocognitive disorder with Lewy Bodies, Parkinson's disease malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care) dated 05/22/23 reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section G of the MDS which addressed Activities of Daily Living (ADL) reflected that Resident #50 required extensive assistance from staff with bed mobility, transfer, personal hygiene, and toileting. A review of the resident's CP with revised date of 09/11/23, reflected a focus area that the resident had an ADL self-care performance and mobility deficit related to hospitalization , shuffling gait due to Parkinson's Disease. The goal of the resident's CP reflected that the resident would be free of complications related to immobility, skin breakdown. The interventions for the residents CP included extensive assist of 1 for dressing, toileting, hygiene. (The Care Plan failed to indicate that Resident #50 required incontinence care every two hours per the HA) When inquired regarding the facility policy for ADLs, the DON stated that the facility did not have a policy for ADL's. On 09/21/23 at 8:05, the surveyor conducted a telephone interview with CNA #3 who cared for Resident #50 on the 11:00 PM-7:00 AM shift on 09/15/23. CNA #3 revealed that Resident #50 required total care, all needs must be anticipated. You have to do everything for [Resident #50], [he/she] is a heavy wetter. She stated she started her last rounds at 4:00 AM and changed the resident around 5:00-5:30 AM. This indicated that approximately four hours had passed since the resident had been provided incontinence care by a staff member, not two hours as was indicated by the HA. CNA #3 further stated that she provided incontinence care as much as she could. CNA #3 stated had 24 residents on her assignment that night. CNA #3 added that she left the facility at 7:15 AM on 09/15/23, and only one CNA reported to the floor for the day shift. She admitted that she put 2 pads inside the brief and stated that she was never informed how many pads could be placed inside the incontinent brief. CNA #3 further added that it was the facility protocol to have the pads inside the adult brief. When asked if she received some in-service education regarding how many pads to use, she stated, No. CNA #3 then stated, The amount of pads being placed in the incontinent brief was never discussed. She acknowledged receipt of in-service education on incontinent care on 09/16/23, only after surveyor inquiry. On 09/20/23 at 12:30 PM, the above concerns were discussed with the facility administrative staff. During an interview with the DON she confirmed that the facility had been using the pads inside the adult brief. The Director of Nursing (DON) stated that the protocol dated back when the facility was managed by the County. The DON added that the residents were care planned for the use of the pads inside the adult brief. When asked about the facility policy for ADLs the DON stated that the facility does not have a policy for ADLs and did not provide any evidenced based guidance regarding utilizing one bladder product inside of another for incontinence care. The facility did not offer any information why residents were not offered more frequent incontinent care. On 09/21/23 the facility provided an in-service policy titled, Maintaining our Resident's Quality of Life which included the following: Quality of Life: to improve or at the very least, maintain the resident's level of function in all aspect of life, safeguarding against lost of ability. Health's Care: ADLs provided are appropriate for the resident's ability- do for them only what they cannot do for themselves. Incontinence Care Residents require timely care when incontinent. A review of the facility's Job Description for Certified Nursing Assistant indicated under Essential Job Functions. Assist residents with bathing, dressing, grooming, dental care, bowel and bladder functions, preparation for medical tests and exams, ear and eye care and positioning in and out of beds, chairs, etc. Performs resident related activities directed throughout the shift including assisting with lifts of residents to wheelchairs/ [recliner], assists residents In transfer activities, assist residents in donning and removing appliances or splints, and guards residents in ambulation. Nursing Care Functions Provide nursing functions as directed by Nurse Manager including daily perineal care, catheter care, turn residents in bed, sponge baths and showers. Resident's Right Functions Maintain resident confidentiality and privacy; treat residents with kindness, dignity, and respect; know and comply with Resident's Rights; and promptly report all resident complaints and incidents to supervisor. The Registered Nurse Supervisor Job Description Provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the nursing personnel in accordance with current State, Federal, and Local standards governing the facility and as may be directed by the Director of Nursing to ensure highest level of quality care in maintained at all times. Administrative Functions Oversees day to day functions of the licensed practical nurses and the nursing assistants. Ensures that all nursing service personnel are giving proper resident care and performing their respective duties in accordance with written policies, procedures, and manuals. Nursing Care Functions Supervise direct care of resident on assigned shift. NJAC 8:39-27.1(a)

Repeat Deficiency Based on observation, interviews, record and review of other pertinent facility documentation, it was determined that the facility failed to: a.) ensure that a cognitively impaired resident admitted with a known history of falls was appropriately supervised and/ or monitored to prevent falls including falls with injury on 08/27/23 when Resident #50 had an unwitnessed fall and sustained front forehead wound and lump measuring 1.5 centimeter x 1.3 and 0.1., and b.) follow fall prevention interventions per the Care Plan, and ensure that assistive devices to alert staff of falls were functional. This deficient practice was identified for 2 of 3 residents reviewed for incident/ accidents (Resident #49 and #50) and was evidenced by the following: On 09/06/23 at 10:22 AM, the surveyor observed Resident #49 in bed, and a strong odor of urine permeated the room. On 09/06/23 at 10:35 AM, while in the hallway of the East Unit, the alarm sounded in room [ROOM NUMBER]. Resident #49 attempted to get out of the bed, blue brief was soaked with urine and bulging from the back. The Certified Nursing Assistant (CNA) emerged from the adjacent bathroom and escorted the resident back to bed. The CNA told the the resident to wait until she could complete care for the other resident that was observed in the bathroom. The CNA informed the surveyor that whenever Resident #49 was wet he/she would try to get out of bed. On 09/06/23 at 12:30 PM, observed Resident #49 in the dayroom with 6 other residents. The residents were unsupervised and there was no staff observed in the dayroom, or at the nursing station at that time. On 09/08/23 at 8:43 AM the surveyor interviewed the CNA who cared for the resident. She stated she was the only CNA on the floor, the other CNA would report to work around 9:00 AM. The CNA further stated that most of the time 2 CNAs would be assigned to the Unit. The Census was 25 and she had 12 residents on her assignment. When inquired regarding the residents observed in the dayroom she stated that the residents who were at risk for falls would be out of the bed first and then placed in the dayroom. She further added that not all residents would be out of bed daily due to staffing issue. When inquired regarding if administrative staff was aware of the concerns with residents care and staffing, she stated, They made the schedule they were aware. On 09/11/23 at 9:39 AM, the surveyor observed Resident #49 sitting in the dayroom with 3 other residents. The residents were unsupervised as there was no staff in present in the day room or at the nursing station. On 09/11/23 at 11:30 AM, the surveyor reviewed Resident #49's medical record. The Admission Face Sheet (an admission summary) reflected that Resident #49 was admitted to the facility with diagnoses which included but were not limited to: syncope (fainting) and collapse, repeated falls, unspecified Dementia. The Admission Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care, reflected that Resident #49 had a BIMS (Brief Interview for Mental Status) of 09/15, indicative of moderate cognitive impairment. The MDS also reflected that Resident #49 required limited assistance of one person physical assist for bed mobility and transfer, and extensive assist for personal hygiene and toileting. A fall risk assessment completed by the facility on 08/11/23 indicated that Resident #49 was a high risk for fall. Resident #49 received a score of 90 on the Morse Fall Scale Morse Fall Scale; Scoring: High Risk 45 and higher. The surveyor reviewed a nurse Progress Note dated 08/11/23 timed 12:45 PM, which reflected that Resident # 49 was found lying on the floor on the right side and was asleep on the floor with feet inside the bathroom and head near the bed. Upon assessment, it was noted to have a circular skin tear to the left forearm measuring 3 centimeters (cm) was identified. A review of the facility's Accident/Incident Report dated 08/11/23 at 12:45 AM, indicated that Resident #49 was found asleep and was lying on the floor. At that time per the Accident report, the resident got out of the bed unassisted, climbed in and out of the bed. Interventions added: Moved to room [ROOM NUMBER]-A. Possible alarm to call bell system. Another entry in the nurse Progress Note dated 08/29/23 timed 6:30 PM, revealed that Resident #49 had another unwitnessed fall that occurred in the dayroom. According to the description of Facts and Event, the CNA heard a thud and found Resident #49 sitting on the ground with no apparent injury. Interventions added: 15 minutes monitoring, rehab screen, rule out infection. The CNA's statement revealed that she was at the nursing station and heard the thud and then observed Resident #49 on the floor. The root cause analysis of the event provided by the facility revealed that Resident #49 had poor safety awareness, required assistance with transfer and ambulation. The root cause analysis did not identify /address the lack of supervision as a factor. On 09/11/23 at 09:49 AM, the surveyor observed the Registered Nurse Unit Manager (RN/UM) sitting at the nursing station and was entering information into the computer. During an interview with the RN/UM, she stated that Resident #49 was a high fall risk and that the reason to be in the dayroom. When asked who was monitoring the dayroom, the RN/UM stated she could observed the resident while at the nursing station through the [redacted glass-type] window, but the activity staff should be in shortly. The surveyor observed that the glass window was at knee height and did not provide a full view of the dayroom. The RN/UM further stated that Resident #49 would attempt to ambulate unassisted at times,was not aware of his/her limitation, and needed to be monitored. The surveyor reviewed the following entries in Resident #49's clinical record: On 09/02/23 at 19:52 PM, the Licensed Practical Nurse documented: Resident #49 frequently leaving his/her wheelchair and attempted to ambulate, resident frequently switching seats, undressed in the dayroom. On 09/02/23 at 07:13 AM,the Registered Nurse wrote: Toileting x 8 this shift. Would not call for assistance, would jump out of the bed, unsteady walking to bathroom. Sometimes resident was already incontinent and would remove brief and throw on floor but majority of times would sit on toilet . When interviewed on 09/19/23 at 12:30 PM, in the presence of the team regarding Resident #49's falls, the Director of Nursing (DON) stated that the facility does not have staff dedicated to monitor the dayroom. The DON stated that the residents in the dayroom were being monitored by all staff including the nurse on the medication cart and whomever was in the hallway or at the nursing station. The DON further added that the facility would provide distant supervision for residents in the dayroom. The DON was unable to provide any documentation to support resident monitoring. A review of Resident #49's Care Plan revealed that the line of supervision required for Resident #49, who was identified as a high fall risk since admission, was not addressed. 2. Resident #50 was admitted to the facility with diagnoses which included but were not limited to: Neurocognitive disorder with Lewy Bodies, Parkinson's disease malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care ), dated 05/22/23, reflected that Resident #50 scored 13/15 on the Brief Interview for Mental Status (BIMS). The MDS also reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section 1310 B. Inattention was coded 2. Section G of the MDS which addressed Activities of Daily Living (ADL) reflected that Resident #50 required extensive assistance from staff with bed mobility and transfer. Resident #50 was assessed to be at high risk for fall, Resident #50 received a score of 90 on the Morse Fall Risk dated 06/19/23 and 75 on the fall risk dated 08/27/23. On 09/06/23 at 10:33 AM, the surveyor observed Resident #50 sitting in a high back chair in the dayroom, unsupervised, and not respond to the surveyor's greeting. There was no staff in the dayroom or at the Nursing station. On 09/11/23 at 9:58 AM, the surveyor observed Resident #50 unsupervised, and sitting in the dayroom with 3 other residents. There was no staff observed in the dayroom or at the nursing station. On 09/14/23 at 12:05 PM, the surveyor observed Resident #50 sitting, unsupervised, in the alcove area with 2 other residents. There was no staff present in the hallway. A review of Resident #50's Comprehensive Care Plan for falls initiated on 09/30/21, revealed the following interventions: 1. Urinal within reach initiated 11/22/21. 2. Educate to use call bell for assist initiated 11/22/21. 3. Electronic Pad Alarm on bed initiated 10/13/22. 4. Hip protectors at all times initiated 10/25/22. 5. Sensor Pad to wheelchair initiated 02/04/23. 6. Rehab screen post fall, initiated 02/04/23. 7. Common area when out of bed initiated 06/20/23. 8. Bolster mattress with egress as well as landing matt initiated 08/28/23. On 09/15/23 at 11:15 AM, the surveyor further reviewed the clinical record and noted the following entries: 10/13/22 07:10 AM, the Licensed Practical Nurse documented, (Unwitnessed fall) Resident #50 was found on the floor with an abrasion to the forearm. A review of the Accident/Incident Report revealed that upon assessment, Resident #50 was observed to have redness on left and right knees, a right forearm abrasion measuring 6 centimeters (cm) x 0.4 cm. 02/04/23 5:30 PM, (Unwitnessed fall) Resident #50 was found on the floor in front of the wheelchair in the room. The Director of Nursing documented: Interview of the nurse at the time of the fall, Resident #50 had been at the nurses station. This was just before dinner trays come to the floor. He had appropriate footwear on. No injury was noted by the nurse. The fall was unwitnessed and neuro-checks were implemented .Resident #50 is impulsive and he/she stands without assist. Root Cause analysis: Increase confusion with unpredictable due to Dementia. 06/19/23 4:20 PM, The Licensed Practical Nurse (LPN) documented, While sitting in the dayroom, Resident #50 attempted to get out of wheelchair and fell . Under observation,the LPN wrote, Resident in dayroom on the ground in front of the wheelchair Root Cause Analysis: Poor safety awareness. Overestimates his/her abilities. When inquired who was in the dayroom to monitor the residents, the DON did not provide any information. 08/27/23 11:30 PM, (Unwitnessed fall) The LPN documented that the Certified Nursing Assistant found Resident #50 on the floor in the room. The bed alarm did not sound. The facility was not aware of how long Resident #50 had been on the floor. Root cause analysis: Poor safety awareness and overestimates his/ her abilities to stand related to Dementia and Parkinson. A review of the fall investigation revealed that Resident #50 was found on the floor with a right front forehead wound and lump measuring 1.5 centimeter x 1.3 and 0.1. The root cause analysis revealed that the bed alarm did not sound at time of the fall. Section ( C ) of the Supplemental Fall Information included the following question: Were all of the care planned devices applied prior to the fall was checked? No and indicated that Resident #50 did not have the hipsters implemented (10/25/22) and non skid socks on. Section (D) If an alarm was in place was it sounding? According to the documentation, the bed alarm was in place but did not alert alert the staff of the fall. The surveyors also observed that on 3 occasions, 09/08/23 at 9:01 AM, 09/11/23 at 8:35 AM, 09/15/23 8:15 AM, Resident #50 was in bed, when checked with the CNA Resident #50 did not have the hipsters on (padded brief) implemented since 10/25/22 when Resident was observed to have a bruise of unknown origin to the right hip to minimize fall with injury. On 09/19/23 at 08:36 AM, during an interview with the Hospice CNA (HA), stated that when she cared for Resident #50 in the morning, Resident #50 never had the hip protectors on and she reported the issue to the Unit Manager and the CNAs on the unit. On 09/19/23 at 11:19 AM, the surveyor interviewed the DON, in the presence of the survey team and the Licensed Nursing Home Administrator and the Director of Operations. The surveyor asked who is supposed to supervise the residents who are placed in the dayroom. The DON stated, there is staff that floats in and out of the dayroom. The surveyor asked who the staff is, and the DON stated, CNAs, nurses and activity.The surveyor asked the DON who was monitoring Resident #50 when the resident sustained an unwitnessed fall on 06/19/23. The DON reviewed the investigation and stated, it was an unwitnessed fall. The surveyor asked who was monitoring the dayroom, and the LNHA responded that she had just left the dayroom. A statement dated 06/19/23 revealed that the LNHA left the dayroom and heard an alarm sounding and observed Resident #50 rising from the wheelchair and the alarm sounded and the resident fell to the floor. The surveyor asked the DON who can see what is happening in the dayroom if there is no one assigned to monitor, and you are relying on varied staff who float in and out of the dayroom. The DON stated, we had all the safety interventions in place,and if we thought he/she was a fighter risk we would have had someone in the room. The DON further stated, if their behaviors warrant a closer observation we would have a staff member with them. The facility failed to address supervision as a mitigating factor to prevent further falls. The DON confirmed that Resident #50 is a high risk for falls, as are a lot of residents and the resident has had a few falls. The surveyor asked if interventions added preclude supervision of a resident? The DON stated there was distant supervision, and the surveyor asked how the facility would know that was occurring and it is documented. The DON stated, no. The DON confirmed there is no documentation to confirm that there is any supervision from other staff that are around the unit, or going through the unit. On 09/20/23 at 10:28 AM, during an interview with the RN/UM, she stated that the hipsters were to be always on. She was not aware that the staff had not been compliant with the hipsters. On 09/20/23 at 10:33 AM, the RN/UM looked into the room there was no hipsters. She stated that the Resident had 3 hipsters assigned to him. The RN/UM in the presence of the surveyor searched the room and could not find any hip protectors in the room. There was no hipsters on the unit also. The UM stated that Resident #50 was to have 3 hipsters in the room they could have been soiled and sent to the laundry. On 09/20/23 at 12:30 PM, the surveyor reviewed the CNA's Care Plan initiated 09/22/21 and indicated the following: Hip protectors on at all times. On 09/20/23 at 1:30 PM, the surveyor reviewed the facility policy Titled, Falls and Fall Risk Management The policy indicated that Based on the resident's previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Procedure The Interdisciplinary Care Plan Team will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions ( i.e.; to try one or a few at a time, rather than many at once), # 4 of the procedure indicated the following: If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains irrelevant. The facility indicated on 06/23/23 that Resident #50 had increase confusion with unpredictable behavior due to Dementia. Resident #50 had recurrent falls at the facility when he /she was not being supervised, the facility did not indicate the line of supervision required to prevent falls. On 09/21/23 at 8:30 AM, the surveyor interviewed by phone, the CNA assigned to the 11:00 AM-7:00 PM shift regarding the residents placed in the dayroom. The CNA confirmed prior to leaving the facility at 7:15 AM she would cared for some residents including Resident #49 and placed him/her in the dayroom. When inquired about who was responsible to monitor the residents at risk for falls who were observed early morning in the dayroom. The CNA stated, she could not be at the facility to monitor the dayroom when her shift was over. She stated that she reported to work timely every day when she was assigned to work. The CNA further added, that the administrative staff needed to reinforce the rule and ensure that the 7:00- 3:00 PM shift reported to work on time. On 09/21/23 at 9:39 AM, during a pre-exit conference with the administrative staff which included the LNHA, DON, Regional staff and the Chief Executive Officer (CEO). When the surveyor presented multiple observations where both residents were observed in the dayroom and the alcove unsupervised, she replied, noted. The facility did not provided further information regarding the lack of supervision for the residents who sustained multiple unwitnessed falls, including falls with injury. NJAC 8:39-27.1 (a)

Complaint # NJ 165178 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to: a) provide supervision for resident's who were at risk for falls, who sustained multiple unwitnessed falls, b) consistently provide resident's with assistance to get out of bed, and c) provide appropriate incontinence care. The deficient practice occurred on two of two resident units and was evidenced by the following: Refer to 689E Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. a. On 09/06/23 at 12:30 PM, Surveyor #1 observed Resident #49 in the dayroom with six other residents. The residents were unsupervised and there was no staff observed in the dayroom, or at the nursing station at that time. On 09/08/23 at 8:43 AM, Surveyor #1 toured the East unit and interviewed a Certified Nursing Aide (CNA #1) who stated she was the only CNA for 25 residents and that most of the time there were two CNAs. Surveyor #1 asked CNA #1 if she were able to complete her assigned tasks daily. CNA #1 stated that she usually finished her assignment, but 12:00 PM or 1:00 PM and not all of the residents would be out of bed due to staffing. CNA #1 stated she focused on getting the residents who were at risk for falls out of bed. Surveyor #1 inquired to CNA #1 regarding if the management staff were aware of the staffing concerns. CNA #1 stated that they make the schedule and they know about it. On 09/11/23 at 9:39 AM, Surveyor #1 observed Resident #49 sitting in the dayroom with three other residents. The residents were unsupervised as there was no staff in attendance. A review of the medical record revealed: a fall risk assessment completed by the facility on 08/11/23 indicated that Resident #49 was at a high risk for falls. Resident #49 received a score of 90 on the Morse Fall Scale; Scoring: High Risk 45 and higher. A nurse Progress Note dated 08/11/23, timed 12:45 PM, revealed that Resident # 49 was found lying on the floor with feet inside the bathroom and head was near the bed. Upon assessment, it was noted a circular skin tear to the left forearm measuring three centimeters was identified. Another entry in the nurse Progress Note dated 08/29/23, timed 6:30 PM, revealed that Resident #49 had another unwitnessed fall that occurred in the dayroom. According to the description of Facts and Event, the [CNA] heard a thud and found Resident #49 sitting on the ground with no apparent injury. Interventions added: 15 minutes monitoring, rehabilitation screen, rule out infection. The CNA's statement revealed that she was at the nursing station and heard the thud and then observed Resident #49 on the floor. The root cause analysis of the event provided by the facility revealed that Resident #49 had poor safety awareness, required assistance with transfer and ambulation. b. On 09/06/23 at 10:33 AM, Surveyor #1 observed Resident #50 sitting in a high back chair in the dayroom, unsupervised, and not respond to the surveyor's greeting. There was no staff observed in the dayroom. On 09/11/23 at 9:58 AM, Surveyor #1 observed Resident #50, unsupervised, and sitting in the dayroom with three other residents. There was no staff observed in the dayroom or at the nursing station. On 09/14/23 at 12:05 PM, the surveyor observed Resident #50 sitting, unsupervised, in the alcove area with two other residents. There was no staff present in the hallway. On 09/15/23 at 11:15 AM, the surveyor further reviewed the medical record and noted the following entries: On 10/13/22 at 7:10 AM, Resident #50 was found on the floor with an abrasion to the forearm. On 09/19/23 at 11:19 AM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team along with the Licensed Nursing Home Administrator (LNHA) and Director of Operations. When the facility was interviewed regarding any staff supervision for residients left unnatended in the day room, the DON stated there was distant supervision. The surveyor asked how the facility would know that was occurring and was it documented. The DON stated, no. The DON confirmed there was no documentation to confirm that there was any supervision from other staff that were around the unit, or going through the unit. c. On 09/08/23 at 9:15 AM, Surveyor #2 observed a call bell system blinking at the un-manned nursing station. At that time, the surveyor conducted an interview with a Licensed Practical Nurse (LPN) and a CNA. The LPN stated there were 35 Residents on both the short and long hall, that she had eleven residents and that there were two CNA's for 35 residents. The surveyor asked the CNA and LPN how they managed to get all of the residents out of bed and the LPN stated, sometimes they don't, and the CNA stated sometimes we can't get everyone up, and with the machine [mechanical lift] it is not easy. On 09/11/23 at 8:52 AM, Surveyor #2 was seated at the unoccupied [NAME] nursing desk and observed a blinking call bell unit with a screen that displayed 8 min, 9 min, and 11 min and a red light was observed blinking outside of the door to room [ROOM NUMBER]. Surveyor #2 observed a nurse standing at a medication cart positioned outside of the room and a staff member was observed going into the room at 8:58 AM. On 09/11/23 at 8:56 AM, Surveyor #2 interviewed the LHNA regarding the current staffing level for CNAs. The LNHA confirmed that she was aware of the New Jersey minimum staffing ratios for CNAs and stated staffing was a concern and during the day shift we don't make it. Surveyor #2 asked the LNHA how does she ensure that residents are getting out of bed and provided with the necessary care required due to the staffing concerns. The LNHA stated that the facility prioritized the residents who get out of bed by ensuring that resident's identified as fall risks get out of bed daily. The LNHA shared the CNA recruitment incentives with Surveyor #2 and strategies, including qualified management staff who help. c. On 09/06/23 at 10:22 AM, the Surveyor #1 observed Resident #49 lying in bed and a strong urine odor permeated throughout the room. On 09/06/23 at 10:35 AM, while in the hallway of the East Unit, Surveyor #1 heard an alarm sounding in Resident #49's room. The surveyor observed the Resident attempting to get out of the bed, a blue incontinent brief was observed soaked with urine and was bulging from the back. The CNA was observed emerging from the adjacent bathroom and then escorted the resident back to bed. The CNA told the resident to wait until she could complete care for the other resident that was observed in the bathroom. The CNA informed the surveyor that whenever Resident #49 was wet he/she would try to get out of bed and disrobed. On 09/15/23 at 8:15 AM, Surveyor #1 performed an incontinence tour with CNA #2, and also in the presence of the facility Infection Preventionist Nurse (IPN). Resident #49 was observed wearing two incontinent briefs and was saturated with urine. At that time, CNA #1 stated that wearing two incontinent briefs was not the protocol and Resident #49 should have been wearing one brief. At 9:06 AM, Surveyor #1, in the presence of Surveyor #2 conducted a follow-up interview with CNA #2 regarding the double incontinent briefs. CNA #2 stated staffing was a concern and that it might take all day to complete her assignment, but she would complete it. CNA #2 stated she was trained to only use one incontinent brief and that Resident #49 should have had one incontinent brief on because it was a dignity issue and could affect resident's skin. CNA #2 stated she has observed two briefs on Resident #49 in the past and she always alerted the supervisor who informed her that it would be addressed. CNA #2 stated Resident #49 was suppose to be taken by the staff to use the toilet not be wearing two briefs. CNA #2 stated there were two CNA's at present, and a third CNA was due to start at 11:00 AM and typically she had twelve residents on any given day. A review of the Facility Assessment 2023, Sufficiency Analysis Summary revealed a daily meeting reviews the staffing for the day as well as projected needs over the next several days to ensure appropriate, sufficient staffing. On 09/19/23 at 10:55 AM, Surveyor #2 interviewed the LNHA, in the presence of the survey team and with a Corporate Manager regarding the purpose of the Facility Assessment. The LNHA stated to identify our strength and weaknesses annually or more than annually if something changed. Surveyor #2 inquired as to how the staffing had been completed. The LNHA stated a computer program was used to assist with CNA staffing and what areas of the facility would be short. The LNHA stated she and the DON would be made aware of when staffing would be short and when asked if there were days that were short she stated, yes. When asked if there was a system to monitor call bell response, the LNHA stated no. A reivew of the Promoting/Maintaining Resident Dignity Policy, Effective 09/02/15 was reviewed by Surveyor #2 and revealed the following: It is the practice of this facility to protect and promote resident rights and treat each residnent with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recogniting each resident's individuality. Compliance Guidelines included 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, 4. Respond to requests for assistance in a timely manner. NJAC 8:39- 4.1(a)11; 27.1(a)

Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 2 of 2 sampled residents (Resident # 29 and #50) reviewed for injuries of unknown origin. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #50 was admitted to the facility with diagnoses which included but were not limited to; Neurocognitive disorder with Lewy Bodies (chemical deposits in the brain that can affect thinking), Parkinson's disease, and malignant neoplasm of tonsillar pillar. The Significant Minimum Data Set (MDS) Assessment (an assessment tool used by the facility to prioritize care) dated 05/22/23 reflected that Resident #50 had some difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said. Section 1310 B. Inattention was coded 2. Resident #50 scored 13 out of 15 on the Brief Interview for Mental Status (BIMS). Review of Resident #50's Care Plan (CP) initiated 12/08/22, revealed the following: [Resident #50] had impaired cognitive function related to Neurocognitive Disorder with Lewy Bodies (chemical deposits in the brain that can affect thinking) and is at risk for falls related to Parkinson Disease. According to the Progress Notes dated 10/24/22 timed 10:30 AM, the Certified Nursing Assistant (CNA) reported a bruise to the resident right hip identified during care, measuring 1.5 centimeter (cm) 1.5 cm. The physician and the family were notified. A statement dated 10/23/22 from the CNA who worked the 3:00 PM-11:00 PM shift, revealed that she observed the bruise and reported it to the nurse. The root cause analysis revealed that Resident #50 had a fall on 10/13/22 and was too far back to correlate the fall with the bruise on the resident right hip. The investigation reflected that a sensor pad alarm was then added to alert the staff of Resident #50's attempt to get out of the bed without assistance. On 09/19/23 at 10:30 AM, the surveyor reviewed again the facility Accident/ Incident report dated 10/24/22. The Accident/Incident report indicated that the bruise was found to the right hip. Resident #50 could not explain how he/she got the bruise. Review of the Investigation/Nursing Administration Review, Summary and Follow up /Conclusion to the incident, submitted by the DON on 09/19/23, dated 10/24/22 was left blank. On 09/20/23 at 12:36 PM, the DON stated that the incident was not reported to the NJDOH. Upon inquiry, the DON acknowledged that the injury was unwitnessed and should have been reported to the NJDOH. On 09/20/23 at 1:40 PM, the Administrator confirmed that any injury of unknown origin should be reported to the NJDOH. The Administrator explained that the facility does not have a specific policy for reporting injuries of unknown origin to the NJDOH. On 09/21/23 at 9:18 AM the facility did not provide any further information regarding the above incident. 2. A review of the AR revealed that Resident #29 had diagnoses which included but were not limited to; Dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, and anxiety. A review of the person-centered Care Plan included a focus area dated 01/21/21, dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, physical limitations. Another focus area dated 01/24/21, has activities of daily living (ADL) self-care performance and mobility deficit related to dementia, anxiety, weakness. Interventions included but were not limited to; two staff for all care. Resident requires extensive assist. On 09/19/23, two surveyors reviewed facility provided Resident Accident/Incident Reports for Resident #29. The Reports included but was not limited to the following: Date 09/08/23 at 9:15 AM, the Hospice Aide reported to the Registered Nurse (RN) supervisor on the East unit that Resident #29 had an unwitnessed 5.5 cm x 5.0 cm reddish purple discoloration on the right elbow. Resident #29 was unable to inform the staff what happened. A statement from the Hospice Aide was attached and 3 CNA statements related to their observations on 09/7/23. Dated 01/26/23 at 1:30 PM, a description of events revealed right upper hand bruise purple in color. The resident was unable to inform staff what happened. The bruise measured 2 cm x 1.5 cm. A statement was attached from one of the two CNAs who were providing care to Resident #29 and was signed with a date of 01/24/23 and a time of 6:45 PM. The statement did not document anything about a bruise, but did document that the resident was resistive and screaming rape. There were statements dated 01/25/23 and were related to their observations on 01/25/23. No behaviors were noted from the additional three CNA statements. On 09/19/23 at 11:36 AM, the DON was interviewed in the presence of members of the survey team. The surveyor asked if the unwitnessed incidents of injury of unknown origin, or the allegation of rape were reported to NJDOH? The DON stated she had to do an investigation but did not suspect abuse. We gather the facts first and then call. The DON acknowledged the injuries of unknown origin were unwitnessed and further stated, if it is a significant injury and we suspect abuse, we call right away. [Resident #29] moves around a lot and we figured it was friction and was not significant and did not suspect abuse so we did not call it in. On 09/19/23 at 12:27 PM, the DON and LNHA were interviewed in the presence of members of the survey team. The DON stated the Abuse policy did not include injury of unknown origin. The DON further stated that abuse could be physical, emotional, financial, verbal, sexual, or neglect. The DON stated that the Accident/Incident reports were usually reviewed the day after. When asked about Resident #29's allegation of rape, the DON stated the resident has a history of this in the past and just says these things. The DON stated the resident had a history of an abusive spouse. The DON further stated that she may have known about the allegation of rape but it was the residents normal behavior. The LNHA stated that if a resident made an allegation of rape, she would expect the staff to act on that allegation, complete an assessment and report the allegation. A review of the facility provided, Abuse Identification & Prevention Program dated September 2018, included but was not limited to; G. Reporting. All alleged or suspected incidents of abuse, neglect or mistreatment shall be reported promptly to the NJDOH and Senior Services. 2. The Administrator/DON will notify the Department of Health of the alleged abuse, by telephone immediately. Notification will include the details known up to this point in time, and that the investigation has been started. 4. The DON / designee will notify the Department of Health (no later than the third working day from the date of the alleged abuse) that the investigation has been completed. 5. The Administrator / designee will communicate with the Department of Health the results of the investigation including the conclusion that A. they feel no evidence of abuse, neglect or mistreatment, or B. not able to determine, or rule out that abuse, neglect, or mistreatment occurred and their findings are inconclusive, or C. there is strong evidence to support the complaint of abuse, neglect or mistreatment. 6. The DON will ensure all documentation corresponding to the investigation has been completed and available for review by the DOH. 7. The DON / designee will notify the individual who reported the incident whether or not the DOH has been notified of the investigation or that abuse has been ruled out. N.J.A.C. 8:39-9.4 (f)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an injury of unknown origin and an allegation of rape. This deficient practice was identified for 2 of 2 residents (Resident #29 and #50) reviewed for accidents and incidents. The deficient practice was evidenced by the following: 1. According to the medical records, Resident #50 was admitted with diagnoses which included but were not limited to; Parkinson's disease and neurocognitive disorder. A review of the Care Plan (CP) revealed a focus area of impaired cognitive function related to neurocognitive disorder. Another focus area of at risk for falls related to Parkinson's Disease. A review of a facility provided, Resident Accident/Incident Report dated 10/24/22 at 10:30 AM, included but was not limited to; Description and facts of even: bruise found on R [right] hip during A.M. [morning] care. It was documented that the resident reported he/she had no idea it was there. Measurements of the bruise were documented as 1.5 centimeters (cm) x 1.5 cm. Under the section of Injury, there were three areas to be checked off known, unknown, occurred during care. The section was left blank. The resident was noted to have a Brief Interview of Mental Status (BIMS) of 15 at the time which indicated the resident was cognitively intact. Attached to the Accident/Incident Report, was one statement from the Certified Nursing Assistant (CNA) who discovered and reported the bruise. Another attachment provided was Investigation of Past 24 Hours. There were three CNA statements. The CNA who worked the 11 PM to 7 AM shift, dated 10/24/22, documented she had seen the bruise and reported it. The second CNA who worked the 3 PM to 11 PM shift, dated 10/23/22, documented she had not given care to that resident. The third CNA who worked the 7 AM to 3 PM shift, dated 10/24/23, was the CNA who found and reported the bruise. The facility failed to follow their policy and provide statements for a 48 hour look back, a 24 hour post incident statement, or to complete the Accident/Incident Report. The Director of Nursing (DON) documentation included but was not limited to; the resident had a fall 10/13/22, but it was too far out from this discovery to correlate. On 09/20/23 at 12:36 PM, the DON acknowledged that the injury was unwitnessed. On 09/20/23 at 1:40 PM, the Licensed Nursing Home Administrator (LNHA) confirmed that this was an injury of unknown origin. 2. A review of the medical record for Resident #29 revealed diagnoses which included but were not limited to; Dementia with behavioral disturbances, cognitive communication deficit, and anxiety. A review of the Care Plan included a focus area dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitation. Another focus area revealed has activities of daily living self-care performance and mobility deficit related to dementia, anxiety, and weakness. Interventions included 2 staff for care. On 09/19/23, two surveyors reviewed the facility provided, Resident Accident/Incident Report for Resident #29. The report included but was not limited to the following: Dated 01/26/23 at 1:30 PM, Description: R upper hand bruise purple in color. Resident documented as stated, why now nothing happened to my hand? The resident was documented as being non-ambulatory. Under the section of INJURY, there were three areas to choose from known, unknown, occurred during care. The section was left blank. The resident was noted as having a BIMS of 12 out of 15 which indicated mildly impaired cognition. The bruise was measured as 2 cm x 1.5 cm and purple in color. Attached to the Report was a Investigation Witness Statement Form dated 01/24/23 at 6:45 PM. The statement was completed by a CNA and indicated another CNA was present during care of the resident. The statement revealed, After PM [evening] care and [Resident #29] was in bed he/she was screaming rape. Also attached was an Investigation of Unknown Injury 24 Hour Look Back form which indicated the date/time of occurrence as 01/26/23 at 1:30 PM. The form was filled out by three CNAs who reported on the resident from 01/25/23. The facility failed to follow their policy by not obtaining any statement from the second CNA providing care on 01/24/23; obtain statements for a 48 hour look back and 24 hour post incident statements from 01/23/23 and 01/26/23; a witness statement for 01/26/23 the injury of unknown origin; had not completed the Accident/Incident Report; and had not completed either investigation within 3 days. On 09/19/23 at 11:36 AM, the DON was asked about Resident #29 and the injury of unknown origin and the allegation of rape. The DON stated she, had to do an investigation but did not suspect abuse. On 09/19/23 at 12:27 PM, the DON and LNHA were interviewed in the presence of the survey team. The DON stated the facility Abuse policy did not include injury of unknown origin. The DON stated that the Accident/Incident Reports were usually reviewed the day after the incident. The DON further stated that she may have known about the allegation of rape but it was the residents normal behavior. On 09/19/23 at 1:30 PM, the surveyors interviewed the DON and asked when she was first made aware of the allegation that Resident #29 made on 01/24/23. The DON stated the incident report was brought to morning meeting on 01/27/23. The DON stated the nursing unit contacted her via telephone, and she could not recall who she had spoken with on 01/26/23 and that was about a bruise that occurred at 1:30 PM. The DON stated that the nurses knew how to complete an investigation and would also complete a 24- hour look back to obtain statements from all caregivers 24 hours prior to the discovery/when the allegation was made. The DON reviewed the investigation in the presence of the survey team and stated that there was a missing statement from one of the CNA's who was in the room with Resident #29 at the time of the allegation. The DON stated she only received a statement from CNA#1 and not from CNA #2. The DON stated she would have CNA #2 write a statement today, 09/19/23. The DON stated she brought the Incident Report to the morning report meeting held on 01/27/23, and at that time the incident report, and the 24 hours look back had not yet been completed and that nothing else had been provided for the investigation. The DON stated she was not provided CNA #1's statement on 01/27/23 regarding rape and could not recall when she was given that statement. The DON confirmed there were two CNAs in the room with Resident #29 and she just realized that she did not have CNA #2's statement. The DON stated, I know I read it quickly knowing what had happened and stated what happened was that resident was throwing food, digging nails, a horrible scene. The DON stated Resident #29 had a history of an abusive spouse. The DON stated the expectation was to have received all the statements and that it was ultimately my [DON] responsibility. The DON stated that on 01/27/23, the Accident/Incident report had been signed as reviewed but was not complete and stated the LNHA who also signed the report was no longer at the facility. The DON stated that the investigation should have been completed within 24 hours. On 09/19/23 at 2:14 PM, during an interview with the surveyor, the Registered Nurse Unit Manager (RN UM) stated she was responsible to initiate the questions on the back page of the Accident/Investigation report, but that the floor nurse would complete the front-page information. The RN UM stated that she would ask the staff to write statements. The RN UM further stated that Resident #29 has expressed behaviors however, had never made allegations of rape. On 09/19/23 at 3:02 PM, the LPN who cared for Resident #29 on 01/24/23, was interviewed by the survey team. The LPN stated she had cared for Resident #29 and knew the resident had been combative and would also yell at people. The LPN stated the resident required two- staff assistance to provide care. The LPN's progress note was read to the LPN, and the LPN acknowledged she documented the note, and also recalled the documentation regarding the resident yelling rape. The LPN further stated the resident screamed anything, but she had not documented before that the resident had screamed rape. The LPN stated she had not reported that the resident had yelled rape because it had not happened on my watch, and that it was a normal behavior for the resident to yell things for hours. The LPN further stated, I guess looking back that was something I should have reported. I just did not because the resident would say crazy things. The LPN stated, well I guess I wouldn't know if something had happened earlier in the day to Resident #29. A review of the facility provided, Abuse Identification & Prevention Program dated September 2018, included but was not limited to; C. Prevention 4. nursing and social workers identify those residents whose personal histories render them at risk for . becoming a victim of abuse. D. Identification of Signs and Symptoms of Abuse - clues to help identify abuse 1. physical abuse clues: color of bruises red, purple, or black indicate a bruise one day old. Note: Intentional or unintentional abuses necessitate an immediate investigation. During the investigation, the resident must be protected. E. Investigation 3. obtain statements from the caregivers and others directly involved with the resident 48 hours prior and 24 hours after. Interview other residents to determine if they had been abused or mistreated. Ensure the investigation is completed with three working days of the alleged abuse. The DON will maintain an investigative package with the copy of the incident report, all statements obtained and a conclusive summary of finding which indicated why or if and how abuse has been ruled out. NJAC 8:39-4.1(a)5; 9.4(f)

Based on observation, interview, and record review, it was determined that the facility failed to provide adequate monitoring and supervision to prevent falls with injury, as well as failed to revise, reassess, and reevaluate for appropriate interventions to the care plan (CP) for a resident with a high risk for falls who sustained multiple falls with injuries. This deficient practice was identified for 1 of 4 residents (Resident #35) reviewed for falls, and for 8 out of 10 falls from 5/12/22-7/8/22, which resulted in multiple injuries that included the comminuted fracture of the right mandibular (chin) condyle with a dislocation of the right temporo-mandibular joint requiring hospitalization . This deficient practice was evidenced by the following: On 7/6/22 at 11:26 AM, the surveyor observed Resident#35 sitting in the day room with other residents and there was no staff present. The resident stood up and the surveyor observed the resident wearing a pair of oversized men's pajama pants. The men's pajama pants were loose fitting in the waist and very long in length. On 7/6/22 at 11:30 AM, the surveyor interviewed the Unit Manager Registered Nurse (UMRN) who provided information about the resident and stated that the resident was ambulatory, impulsive, had frequent accidents, and required assistance with Activities of Daily Living (ADLs). The UMRN stated that the resident's clothing were soiled and in the laundry being cleaned. The UMRN added that they had to put something on the resident, so they put men's pajamas on the resident. The UMRN was aware that the men's pajama pants were oversized and was also aware that the resident had a history of falls. The surveyor reviewed Resident#35's hybrid medical records (paper and electronic) that revealed the following: According to the Admission Record, Resident #1 was admitted to the facility with a diagnosis of Alzheimer's Disease, Anxiety Disorder, Obsessive-Compulsive Disorder, Hypertension, Urinary Tract Infection, [CONDITION(S)] [CONDITION(S)] Secondary to Blood Loss (Chronic). The Quarterly Minimum Data Set an assessment tool dated 4/30/22, revealed the facility performed a Brief Interview for Mental Status (BIMS). The BIMS score was 0 out of 15, which indicated that the resident had severe cognitive deficit. The Resident Accident/Incident Reports were obtained from the Director of Nursing (DON) which indicated that the resident had fallen 10 times in three months, May 12, twice on May 28th, twice on June 3rd, June 15th, June 16th, twice on July 4th, and July 8th, 2022. 8 of the 10 falls resulted in injuries. The first fall occurred on 5/12/22 at 8 PM, the resident was found on the floor at the nurse's station naked with blood visible on the resident's chin, the fall was unwitnessed. Interventions that were listed on the Accident/Incident Report included the resident was sent to the Emergency Department (ED), neuro checks were done, 15-minute monitoring for 72 hours post fall was put into place, urinalysis was done to rule out urinary tract infection, & rehabilitation (rehab) screening was done. The second fall occurred on 5/28/22 at 10:20 AM, the resident was found in the alcove with no injury noted, the fall was unwitnessed. Interventions that were listed on the Accident/Incident Report included neuro check, labs/psyche, 15-minute monitoring for 72 hours post fall was put into place, and for the resident to wear dresses instead of pants. However, after this first fall which occurred on 5/28/22, there was no documentation provided by the facility that the interventions were reviewed and updated in the resident's CP. The third fall occurred on 5/28/22 at 1:30 PM, the resident was found in the hallway with dried blood on forehead and face, the fall was unwitnessed. The resident had a laceration to right eyebrow. Interventions that were listed on the Accident/Incident Report included the resident was sent to ED, neuro checks were done, 15-minute monitoring for 72 hours post fall was continued from the 10:20 AM fall, labs/psyche, and notified the family to bring dresses. The fourth fall occurred on 6/3/22 at 2:30 PM, the resident was found on the floor in room 122 with head laying against nightstand, the fall was unwitnessed. There was no injury noted. Interventions that were listed on the Accident/Incident Report neuro checks were done, 15-minute monitoring for 72 hours post fall was put into place, and a note to see second report for the fall at 5:50 PM. However, after this first fall on 6/3/22, there was no documentation provided by the facility that the interventions were reviewed and updated for the appropriateness in the resident's CP. The fifth fall occurred on 6/3/22 at 5:50 PM, the resident was found lying in the long hallway, face down with blood visible from the chin, the fall was unwitnessed. The resident sustained laceration to the chin. Interventions that were listed on the Accident/Incident Report included the resident was sent to ED, resident received six steri-strips to close the wound on the chin, neuro checks,15-minute monitoring for 72 hours post fall was put into place, and to implement medication changes. The sixth fall occurred on 6/15/22 at 9:45 PM, the Certified Nurse Aide (CNA) observed the resident fall in the hallway. The resident sustained a deep laceration on chin. The resident was sent to ED, chin laceration was glued closed at the ED and ED reported a fracture of mandible (chin)-undetermined age. Interventions that were listed on the Accident/Incident Report neuro checks were done, 15-minute monitoring for 72 hours post fall was put into place, call out to psychiatrist for a medication review, offer and assist with periods of rest, monitor nutritious intake, and monitor pain. The seventh fall occurred on 6/16/22 at 6:00 PM, CNA heard a bang in the hallway and found the resident on the floor in the hallway, the fall was unwitnessed. The resident sustained a small laceration to left eye. Interventions that were listed on the Accident/Incident Report included follow up with medication changes, resident had a 1:1 staff shadowing for one night until the resident fell asleep, rehab screening, continue 15-minute monitoring for 72 hours post fall, and monitor nutrition intake. However, after this fall on 6/16/22, there was no documentation provided by the facility that the interventions were reviewed and updated in the resident's CP. The eighth fall occurred on 7/4/22 at 2:50 PM, the CNA witnessed the resident fall face first in the hallway. The resident sustained a bruised right shoulder. Interventions that were listed on the Accident/Incident Report included follow up with psyche medication review and 15-minute monitoring for 72 hours post fall was put into place. However, after this first fall on 7/4/22, there was no documentation provided by the facility that the interventions were reviewed and updated in the resident's CP. The ninth fall occurred on 7/4/22 at 3:10 PM, the CNA witnessed the resident running in hallway and fell to left side. The resident sustained a skin tear on the right elbow. Interventions that were listed on the Accident/Incident Report included treatment to the skin tear site, 15 min monitoring for 72 hours post fall was put into place, frequent redirection, assessment to rule out infection, and medication review. However, after this second fall on 7/4/22, there was no documentation provided by the facility that the interventions were reviewed and updated in the resident's CP. The tenth fall occurred on 7/8/22 at 6:30 PM, the resident was found on hallway floor in pool of blood, the fall was unwitnessed. The resident sustained laceration to the chin. The resident was sent to ED, was admitted with the following diagnosis, a comminuted fracture of the right mandibular (chin) condyle with a dislocation of the right temporomandibular joint and received sutures to the chin. Interventions that were listed on the Accident/Incident Report included the resident was to be placed on 1:1 monitoring to start indefinitely, to be seen by Advanced Practice Nurse (APN) for anticipated medication changes and added chin guard as tolerated. The resident's current Fall care plan reflected an initiation date of 1/24/22 and a revision date of 6/16/22 and revised again on 7/05/22, which indicated that Resident #1 was at risk for fall/injury, had poor safety awareness, anxiety, impulsiveness, behaviors, frequent falls, and an increased risk of injury from falls due to diagnosis of Osteopenia. Interventions that were put into place included 15-minute monitoring after each fall for 72 hours, neuro checks, and ED visits (if there were injuries). There were also testing completed to rule out infection and psych consults completed for medication review. There was no documentation that interventions were reviewed or revised, after the resident had the second falls, which each occurred on 5/28/22 and 6/3/22, nor for the fall which occurred on 6/16/22, and lastly, no documentation for the two falls which occurred on 7/4/22. There was also no documentation on the CP that the Occupational Therapist (OT) was involved in the review and revision of the CP, and that the recommendations that were made by OT were included as updated interventions. The Rehab Screen/Referral forms revealed that the OT made recommendations for the nursing staff to increase the resident's level of supervision during the month of May & June 2022. On 5/13/22, after the 5/12/22 fall, OT recommended that the resident required constant supervision with staff to reduce risk of falls. The CP did not include the OT recommendation completed on 5/13/22, regarding the fall which occurred on 5/12/22. On 6/7/22, after the two falls on 5/28/22 (10:20 AM & 1:30 PM), OT recommended that the resident required constant supervision on unit/redirection for increased safety. The CP did not include the OT recommendations completed on 6/7/22, regarding the two falls on 05/28/22. On 6/7/22, after the two falls on 6/3/22 (2:30 PM & 5:50 PM), OT recommended that the resident required constant supervision/redirection to reduce risk of falls. The CP did not include the OT recommendation completed on 6/7/22, regarding the two falls which occurred on 06/03/22. On 6/21/22, after the 6/15/22 fall, OT recommended that the resident required supervision at all times for increased safety. The CP did not include the OT recommendation completed on 6/21/22, regarding the fall which occurred on 6/15/22. On 6/21/22, after the 6/16/22 fall, OT recommended to nursing staff to supervise resident at all times/provide redirection to reduce risk of falls. The CP did not include the OT recommendation completed on 6/21/22, regarding the fall which occurred on 6/16/22. On 7/7/22 from 10:52 AM to 11:09 AM, the surveyor observed Resident #1 sitting alone in the alcove/hallway. The resident was out of view of the nurse's station, while sitting in the alcove hallway, and there were no staff nearby. On 7/7/22 at 11:10 AM, the surveyor interviewed CNA assigned to the resident who stated the resident sits alone in the alcove/hallway a lot and eventually will come back down the hall. The CNA was unaware of any recent falls, or the 15-minute monitoring for 72 hours post falls. This was the current intervention in place for the resident, due to the two most recent falls that occurred on 7/4/22 at 2:50 PM and 3:10 PM. On 7/7/22 at 11:15 AM, the surveyor interviewed the UMRN who was at the nurse's station working on a computer with the UMRN's back facing the alcove/hallway. The UMRN was aware of the two recent falls on 7/4/22 and was aware of the 15-minute monitoring for 72 hours post fall intervention currently in place but the UMRN was unaware of the resident currently sitting alone in the alcove/hallway. The UMRN stated that the nurses were responsible for completing the 15-minute monitoring for 72 hours post fall not the CNAs. The UMRN added that the CNAs would receive any updates for the resident's care in the Visual/Bedside Kardex Report and stated the Kardex was where the CNA would get the most recent information about the resident's falls or any interventions. The UMRN stated the resident was compulsive and moves around very fast and could benefit from 1:1 but even that was not a sure thing. The UMRN then went down the hallway and escorted the resident into activities. The UMRN came back to the surveyor and added that a chin guard was being ordered for the resident. On 7/7/22 at 11:38 AM, the surveyor interviewed the OT who stated that a rehab assessment was completed after every fall and there was no change in the resident's cognition and functional status. The OT stated several recommendations were made for the nursing staff to increase the resident's level of supervision. During the interview with OT, the Rehabilitation Director (RD) was present and added that if there was a component of balance and strength or limitation of movement then that would be something they would look into, but the resident's issue is a very functional part of their behaviors. The RD agreed with OT that the resident could benefit from an increase in supervision. On 7/11/22 at 10:15 AM, the surveyor interviewed the DON concerning the OT recommendations for increased supervision. The DON stated the recommendations were not presented to the physician or the APN because the wording for constant supervision was incorrectly used. The DON stated the resident received distant monitoring and the staff was aware of the resident's location at all times. The DON was unable to show where the distant monitoring was being documented and at the time of the interview, the DON had not met with OT for clarification or revision of any of the previously made recommendations. On 7/11/22 at 10:28 AM, the surveyor reviewed the resident's Morse Fall Scale (MFS) in the electronic medical record. The MFS was updated after each fall and reflected that as of 5/12/22, the resident's fall risk was elevated from low-risk status to a high risk for falling. The MFS revealed that the facility calculated the resident's total score to be 55. The range for high is 45 and higher. The interventions listed on the Accident/Incident Reports were not consistently documented in the resident's fall care plan. The facility included the same 15-minute monitoring for 72 hours post fall, however the facility failed to properly reassess the interventions that were already put into place nor address the recommendations given by OT on 5/13/22, 6/7/22, or 6/21/22 to increase the resident's level of supervision to prevent further falls and injuries. In addition, there was no documentation that interventions were reviewed or revised after the resident had the second falls, which occurred on 5/28/22 and 6/3/22, nor for the fall which occurred on 6/16/22, and lastly, not for either of the two falls which occurred on 7/4/22. On 7/12/22 at 10:06 AM, the DON and the Administrator discussed the fall incidents regarding Resident #1. The DON provided background information on the resident's behavior and frequent falls. The DON stated they were at their wits end. The DON stated that 1:1 staff supervision or shadowing the resident increased the resident's anxiety, and the resident gets upset. The DON further stated that their team looked at each fall and felt the interventions put into place were all they could do. The Administrator was present during the DON's presentation and was in agreement with the DON's explanation of how difficult the resident was to keep from falling and that the interventions put in place were appropriate. On 7/12/22 at 11:11 AM, the DON provided the surveyor with the Visual/Bedside Kardex Report which provided the CNA with the most up to date information on the resident's care and interventions. The form dated as of 7/12/22, only listed two out of the 10 falls. The fall dated 6/15/22 listed the 15-minute monitoring post falls for 72 hours and the psych medication review. The fall which occurred on 7/8/22, was documented on 7/9/22 and listed the 1:1 monitoring, psyche Nurse Practitioner to review medication management, monitor dietary intake and pain. The chin guard at all times-monitor for increased agitation and tolerance which was included in the Kardex dated 7/11/22. The Kardex did not document the eight other falls which occurred on 5/12/22, the two falls on 5/28/22, the two falls on 6/3/22, the fall on 6/16/22, nor the two falls on 7/4/22. There was no documentation provided by the facility that the CNAs were provided with the most updated interventions. On 7/15/22 at 12:33 PM, the surveyor contacted the DON via telephone to ask for a policy specific to resident falls that would include the 15-minute monitoring for 72 hours post fall. The DON stated the policy for Incident Reporting for Residents and Visitors with a revised date of 7/01/2022, that was given to the surveyor at the facility. In review of the policy, there was nothing noted in the Incident Reporting for Residents and Visitors specific to Falls which identified the 15-minute monitoring to be done 72 hours post fall. This was the only policy provided by the facility to address falls. NJAC 8:39-27.1 (a) (b)

Based on observation, interview, record review, and a review of facility documentation, it was determined that the facility failed to ensure a.) appropriate transmission-based precautions and infection control practices were implemented and practiced by staff providing caring for residents on a unit that contained COVID-19 positive and COVID-19 negative residents, b.) used gowns were continuously worn by staff assigned to provide care for residents that were confirmed positive for COVID-19 and residents that were non-ill, Asymptomatic, c.) staff practiced appropriate hand hygiene to prevent the spread of infection according to the Center for Disease Control and Prevention, d.) staff working at the facility had knowledge of the residents who were pending COVID-19 testing results, and e.) available gowns were easily accessible to nursing and housekeeping staff. This deficient practice was observed during a tour of 3 of 3 operating nursing units (1 East/dementia care unit, 2 West, and 2 East) conducted on [DATE]. The residents identified in the deficient practice included; Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, and Resident #24, 24 residents who were COVID-19 positive, pending COVID testing results, or Asymptomatic out of the 82 residents who resided in the facility on [DATE]. A review of the facility's COVID-19 Summary Report dated [DATE] and timed at 10:00 AM indicated that there was a total of 34 residents on the line list, 20 of the residents had been confirmed COVID-19 positive. Out of the 20 residents that had been confirmed COVID-19 positive, eleven residents resided in the facility on [DATE]. Six residents were pending COVID-19 testing results. A total of six residents had also been hospitalized . A further review of the facility's COVID-19 Summary Report indicated that 14 staff members were included on the line list, and seven of those staff members had tested positive for COVID-19. Surveyor observation and interview revealed that nursing and housekeeping staff were provided one re-usable washable gown and one N-95 respiratory mask at the start of their shift and that gowns were not easily accessible on the units where residents who were confirmed and presumed positive for COVID-19 resided. During the tour on the designated COVID-19 unit (2 East), it was identified that a Certified Nursing Aide (CNA) and a Licensed Practical Nurse (LPN) shared an assignment. This assignment consisted of a mix of confirmed positive COVID-19 residents and Asymptomatic COVID-19 negative residents. The CNA was observed wearing the same yellow gown and not performing appropriate infection control practices while going from COVID-19 positive to COVID-19 negative resident rooms. Further observation and interview revealed that staff were unaware of residents who were pending COVID testing results and were entering the symptomatic (pending results of COVID-19). The staff identified above wore the same washable yellow gown and did not perform appropriate infection control practices between symptomatic (having signs and symptoms ) and non-ill, Asymptomatic residents who resided on that unit (1 West). The interviews conducted with multiple staff members throughout the facility confirmed that staff were continuously wearing the same washable yellow gown while caring for Asymptomatic (non-ill), symptomatic (pending results and COVID-19), and positive COVID-19 residents throughout their shift. The surveyor further observed inappropriate hand hygiene practices by the housekeeping staff on the unit (1 East). Facility provided documentation dated [DATE], identified that 3 out of 20 residents (6.7 %) who were confirmed positive for COVID-19 had expired between [DATE] to [DATE]. The facility's failure to ensure that proper infection control practices were implemented and adhered to resulted in the exposure of a [MEDICAL CONDITION], Covid-19, during an outbreak. It was determined that the provider's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death to residents. The Immediate Jeopardy (IJ) was related to §480.80 Infection Control. The Director of Nursing (DON), Administrator, and Chief Operating Officer were made aware the IJ existed for the residents who resided in the facility on [DATE], at 7:50 PM. The immediacy was removed on [DATE] on 4:45 PM based on an acceptable removal plan that was implemented by the facility and verified during an on-site revisit survey conducted on [DATE]. The evidence was as followed: On [DATE] at 10:00 AM to 10:30 AM, the surveyor conducted the entrance conference with the Director of Nursing (DON) in the presence of the Administrator and Chief Operating Officer. The DON stated that the facility currently had eleven residents that were COVID-19 positive (C19+) and one C19+ resident in the hospital. The DON told the surveyor that all the C19+ residents were located on the long hallway on 2 East. The DON further stated that six residents altogether were pending COVID- 19 testing results, four of the residents resided in the facility, and two of the residents were currently in the hospital. The DON stated that there were three resident deaths related to COVID-19. The DON further stated that fourteen staff members presented with possible signs and symptoms of COVID-19, they were all tested , and seven of them came back positive for [MEDICAL CONDITION]. The surveyor asked the DON what Personal Protective Equipment (PPE) the facility was utilizing. The DON told the surveyor that the facility currently had an adequate amount of PPE (gowns, gloves, N95 masks, surgical masks, and face shields). The DON stated that the facility had 450 washable PPE gowns that were in circulation. She stated that the staff would receive one at the beginning of their shift and return it at the end of their shift to be laundered. The DON stated that the staff received N95 masks, which they would put in a brown paper bag at the end of their shift, and the N95 masks would be used for five to seven days depending upon how frequently the staff member worked. The surveyor asked what the staff would do if they needed more PPE equipment. The DON stated that they could come to her or an Administrator for a replacement. She stated, They know the procedure. If it becomes soiled, ripped, or damaged, it is replaced. On [DATE] at 11:44 AM, the surveyor entered the first-floor locked dementia unit. The surveyor observed the 7:00 AM -3:00 PM Licensed Practical Nurse (LPN)#1 pull her medication cart into Resident #1 and Resident #2's room to make space for staff transporting Resident #3 in his/her bed from the unit. The surveyor observed that Resident #3 was wearing a surgical mask placed over his/her face, and the surgical mask was covering the resident's mouth, leaving the residents nostrils exposed. The surveyor interviewed the staff member transporting Resident #3, who identified himself as the Housekeeping Director (HKD). The surveyor asked the HKD why he was transferring the resident, and the HKD stated that he didn't know why he was told to bring the resident to the second floor. The HKD was observed wearing a yellow washable gown, N95 mask, and gloves. No surgical mask or face shield was observed on the HKD. The surveyor then interviewed the dementia unit ,[DATE] LPN#1, who stated that Resident #3 had a fever of 103.4 degrees Fahrenheit (F) and was suspected of being C19+, so they were transferring the resident to the second floor where the other C19+ residents resided. At 11:57 AM, the surveyor interviewed the dementia unit 7:00 AM -3:00 PM Certified Nursing Aide (CNA) #1, who was observed wearing a yellow washable gown, N95 mask, and face shield. The ,[DATE] CNA #1 stated that the census on the unit was 33 residents, and today they had one nurse and two CNA's working. The ,[DATE] CNA #1 stated that signs and symptoms of COVID-19 were fever, cough, shortness of breath, and diarrhea. The ,[DATE] CNA #1 further stated that when the facility found out a resident who resided on the floor tested positive for COVID-19, the resident would be transferred to the second floor. Then the roommate of the resident who was identified as positive would be placed on transmission-based precautions because the resident was exposed. The surveyor asked the ,[DATE] CNA #1 what PPE she was expected to wear while providing care for the residents on the unit. The ,[DATE] CNA #1 stated that as soon as she entered the facility, her temperature would be taken and was given an N95 mask, a face shield, and a washable yellow gown. The ,[DATE] CNA #1 stated that she was given the N95 mask and washable yellow gowns about seven days ago when another facility affected by COVID-19 residents was on the news. The ,[DATE] CNA #1 stated prior to that she was provided with a blue surgical mask. The ,[DATE] CNA #1 told the surveyor that prior to the implementation of the washable gowns and N95 masks, the staff were entering the resident's rooms on the first-floor dementia unit who had sign and symptom of COVID-19. The ,[DATE] CNA #1 stated that she didn't find out the residents were positive until they were moved to another unit upstairs, but the staff had been taking care of the residents while they were symptomatic without the appropriate PPE. The ,[DATE] CNA #1 stated, We had a lot of people coughing in our faces, and we didn't have the masks. The ,[DATE] CNA #1 stated that she was given one washable yellow gown upon entering the facility, which was worn all day and then handed in at the end of the shift. The ,[DATE] CNA #1 stated that just today, she had gone into a resident's room who was suspected of being C19+ because of a high fever and that resident (Resident #3) was just moved to the second floor. The ,[DATE] CNA #1 stated that after she went into that resident's room, she had then entered other resident rooms that were Asymptomatic of [MEDICAL CONDITION] and still had on the same gown. At 12:12 PM, the surveyor observed the dementia unit ,[DATE] LPN #1 standing outside of a resident's room at her medication cart, not wearing an N95 mask or surgical mask. The surveyor interviewed the dementia unit ,[DATE] LPN #1, who stated that she was so hot, and she couldn't breathe, so she had to take the mask off. The surveyor then observed the ,[DATE] LPN #1 apply the N95 mask. The surveyor asked the dementia unit ,[DATE] LPN #1 when she had first received the N95 mask and gown. The ,[DATE] LPN #1 replied that it was about a week or a week and a half ago when another facility affected by COVID-19 residents was on the news. The ,[DATE] LPN #1 stated that before that, the nurses working on the unit were given surgical masks to wear and had no gowns. This statement corroborated with the statement made by the dementia unit ,[DATE] CNA #1. The ,[DATE] LPN #1 stated that the facility would give each nurse an N95 mask to be worn for seven days. The ,[DATE] LPN #1 explained that at the end of her shift, she would return the N95 face mask, and it would be stored in a brown paper bag along with the face shields. The ,[DATE] LPN #1 further stated that she would return her washable yellow gown at the end of the day as well and then pick up her designated N95 mask, face shield, and a new gown at the start of her next shift. The ,[DATE] LPN #1 stated that she was not removing the gowns while caring for residents on the first-floor dementia unit and going room to room with the same gown on. The ,[DATE] LPN #1 stated, None of us are, but I can only speak for myself. At 12:21 PM, the surveyor observed the Housekeeper (HK) on the dementia unit enter Resident #5 and Resident #6's room without performing hand hygiene prior to entering the room. The surveyor further observed the HK exit the resident's room without performing hand hygiene and then enter the room of Resident #7. The surveyor observed that the HK was wearing a yellow washable gown and a blue N95 mask. The HK was not observed wearing a surgical mask or a face shield. The HK stated that her responsibility was to collect garbage, wipe down and disinfect areas such as bedrails, keypads, door handles, and the nurse's station three times a day. The HK stated that she never changed her gown throughout the day. The HK stated that she did not go to the second floor, where the C19+ residents were located. The HK could not speak to which residents on the unit were symptomatic or pending test results for [MEDICAL CONDITION]. The HK further stated that she was to use an alcohol-based hand rub before entering the resident's rooms and then wash her hands when she was done cleaning the resident's rooms. On [DATE] at 12:35 PM, the surveyor entered the first-floor unit, which contained rooms 124D-154W. At 12:40 PM, the surveyor interviewed the 7:00 AM - 3:00 PM CNA #2, who stated that she received a mask and face shield in the morning, which she would keep until it got soiled. The ,[DATE] CNA #2 stated that she also received a yellow washable gown every day upon entering the facility, which was tuned in at the end of the day and then laundered. The ,[DATE] CNA #2 stated that she was going room to room wearing the same PPE with residents that were infected, symptomatic, and Asymptomatic. The ,[DATE] CNA #2 stated, We don't have enough. The surveyor asked who said that? How do you know you don't have enough PPE? The ,[DATE] CNA #2 stated that the staff just assumed that because we weren't getting the PPE equipment. The ,[DATE] CNA #2 told the surveyor that for about two weeks now, the staff had been provided with washable gowns and N95 masks, and she was unaware of any event that precipitated the administration of the gowns and N95 masks. The ,[DATE] CNA #2 stated that before the gowns and N95 masks, the staff were wearing surgical masks and gloves while providing care to the residents. The ,[DATE] CNA #2 further stated that the management gave the staff three different N95 masks to choose from, and she chose her mask, based off of comfort and style. The ,[DATE] CNA #2 stated that she would perform hand hygiene before and after entering a resident's room. At 12:50 PM, the surveyor interviewed the ,[DATE] LPN #2, who stated that she was a per diem nurse, and this was only her second day working at the facility the past month. The ,[DATE] LPN #2 stated that when she came to work, she got her temperature taken and was given the same N95 mask and face shield that she had worn yesterday. The ,[DATE] LPN #2 stated that the face shield must be worn when entering the resident's room, and the gown was washable and changed out daily. The ,[DATE] LPN #2 stated the other PPE like the N95 mask and face shield was changed out weekly. The ,[DATE] LPN #2 stated that to her knowledge, there were no C19+ residents who resided on the unit, and as soon as a resident tested positive, they were moved upstairs. The ,[DATE] LPN #2 did not speak of residents on the unit that were pending COVID testing results. On [DATE] at 1:00 PM, the surveyor entered the second floor. The second-floor unit contained two hallways with a nurse's station in the center. One hallway the surveyor was told was where residents that were C19+ resided, and the other hallway was where COVID-19 negative (C19-) residents resided. The surveyor observed C19+ Resident #8 and Resident #9 sitting upright in bed in their room. The surveyor observed a staff member sitting on Resident #9's bed and feeding the resident lunch. The staff member had her face shield up and was observed wearing an N95 mask, gloves, and a washable yellow gown. The surveyor did not observe that the staff member was wearing a surgical mask over her N95 mask. The surveyor further observed that there was no sign on the resident's door indicating that the resident was C19+, and no PPE was attached to the resident's door or located outside of the room in accessible bins. A review of the line listing and the facility census by room number indicated that Resident #8 and Resident #9 were C19+. At 1:01 PM, the surveyor observed C19+ residents, Resident #10 and Resident #11 C19+, in their bedroom. The surveyor observed a stop sign on the door of the resident's room and a PPE bin, which contained no assessable PPE hanging on the resident's door. The surveyor overheard the Resident #10 cough. Both residents observed were not wearing face-masks in the room. A review of the line listing and the facility census by room number indicated that Resident #10 and Resident #11 were C19+. At 1:02 PM, the surveyor observed C19+ Resident #12 lying in bed in his/her room wearing a face mask. There was no stop sign outside of the door, indicating the resident in the room was C19+. The surveyor further observed that the PPE holder attached to the door of the resident's room contained a box of gloves. A review of the line listing and facility census indicated that the Resident #12 was C19+. At 1:03 PM, the surveyor further observed a C19+ Resident #13 in his/her room watching television. The resident was not observed wearing a face- mask. The surveyor observed that there was a stop sign on the door and a PPE holder that contained gloves. A review of the line listing and facility census indicated that Resident #13 was C19+. At 1:05 PM, the surveyor observed a C19+ Resident #14 in his/her room. A stop sign was observed at the door, and the PPE bin hanging on the door contained gloves. A review of the line listing and facility census indicated that Resident #14 was C19+. At 1:10 PM, the surveyor observed the second floor 7:00 AM - 3:00 PM CNA #3 walk into C19+ Resident #15's room. The surveyor observed the ,[DATE] CNA #3 apply a pair of gloves and take the garbage outside of the room. The surveyor did not observe the ,[DATE] CNA #3 perform hand hygiene before entering or exiting Resident #15's room. The surveyor observed the ,[DATE] CNA #3 tie the garbage bag while walking outside of the resident's room wearing the same gloves she applied inside of the room. The surveyor then observed ,[DATE] CNA #3 walk down the hall and opened the door to the soiled utility room to throw away the garbage. The surveyor observed the ,[DATE] CNA #3 remove her soiled gloves upon entering a C19+ Resident #10 and Resident #11's room without performing hand hygiene and without donning a new pair of gloves. The ,[DATE] CNA #3 was observed moving around items on the overbed table of Resident #10. The CNA #3 exited the room without performing hand hygiene and entered C19+ Resident #16's room and washed her hands inside that room for 15 seconds. At 1:14 PM, the surveyor interviewed with the second floor ,[DATE] CNA #3, who stated that the census on the second floor was 22. The ,[DATE] CNA #3 stated that one of the hallways was for the C19+ residents, and the other hallway was for the C19- residents. The surveyor asked the ,[DATE] CNA #3 how many residents resided in the unit who were positive for COVID-19. The ,[DATE] CNA #3 stated that she wasn't quite sure, maybe four to five, because the residents were being moved back and forth. The ,[DATE] CNA #3 stated, So I'm always getting the fresh infected ones. The ,[DATE] CNA #3 stated that the signs and symptoms of [MEDICAL CONDITION] varied from resident to resident. The ,[DATE] CNA #3 stated that some residents would have nausea, vomiting, anorexia (not eating), and some had respiratory symptoms such as coughing. The ,[DATE] CNA #3 explained to the surveyor that in the morning, when she arrived at work, her temperature was taken and then received her mask, face shield, and gown. The ,[DATE] CNA #3 stated that she wore the same gown all day and then, at the end of the day, would remove the gown to be washed by the facility. The ,[DATE] CNA #3 further stated that she would wear the N95 mask until it was soiled and would get a new one every two to three days. The ,[DATE] CNA #3 stated that she received the N95 mask on Monday ([DATE]). The ,[DATE] CNA #3 further stated that she was the only CNA working on the unit and was taking care of the C19+ and C19- residents on the floor. The ,[DATE] CNA #3 stated that she was to wash her hands for 15 seconds before entering and exiting the resident's rooms. At 1:26 PM, the surveyor interviewed the second floor, 7:00 AM - 3:00 PM LPN #3, who stated that she was the full-time nurse working on the unit. The ,[DATE] LPN #3 stated that signs and symptoms of COVID-19 varied from high fever, coughing, shortness of breath, and gastrointestinal (stomach) symptoms. The ,[DATE] LPN #3 stated that she would send the resident who was C19+ to the hospital if the person was not eating and had difficulty breathing. The ,[DATE] LPN #3 stated that it was the third week that she was wearing PPE because, at first, the staff wasn't allowed to because the management stated that the residents weren't infected, and it wasn't necessary. The surveyor asked the ,[DATE] LPN #3 when she was issued the N95 mask. The ,[DATE] LPN #3 stated, Last week, today was the fifth day, so today they gave everyone a new one. The ,[DATE] LPN #3 further stated that today two nurses were working on the unit and one CNA. The ,[DATE] LPN #3 stated that the staff was given one gown at the beginning of their shifts, which they would wear all day. The ,[DATE] LPN #3 stated that the 7:00 AM - 3:00 PM CNA #3 was wearing the same gown while taking care of the C19+ and C19- residents on the unit. The ,[DATE] LPN #3 stated, I don't feel like I'm being safe. I have a family at home, and I don't feel safe. At 1:40 PM, the surveyor observed the second floor ,[DATE] CNA #3 go into C19- rooms on the unit that were indicated as containing residents that were negative and Asymptomatic of [MEDICAL CONDITION]. The surveyor was unable to observe the exact rooms the ,[DATE] CNA #3 entered because the surveyor was standing at a distance. At 1:42 PM, the surveyor interviewed the second floor, 7:00 AM - 3:00 PM LPN #4, who stated that the one hallway is considered C19+, and the other side was considered C19-. The ,[DATE] LPN #4 stated that staffing varied, sometimes there would be two nurses working, but there was always only one nurse and one CNA working the 11:00 PM - 7:00 AM shift on the second floor. The ,[DATE] LPN #4 stated symptoms of COVID-19 varied from resident to resident. She would have some residents with a fever and a cough and some residents that didn't have symptoms. The ,[DATE] LPN #4 stated that she would be very concerned if a C19+ resident were in respiratory distress, and that would initiate her to send the person to the hospital. The ,[DATE] LPN #4 stated that from the first C19+ resident on, the staff was issued N95 masks. The ,[DATE] LPN #4 further stated that she was unsure of the specific time frames as to when the N95 masks were issued. The ,[DATE] LPN #4 stated that the staff was given an N95 mask and face shield for one week or until it became soiled. The ,[DATE] LPN #4 stated that she was given one washable gown at the beginning of her shift, which was handed in at the end of her shift. The ,[DATE] LPN #4 further stated that the staff was going in and out of resident rooms wearing the same gown and N95 mask without putting a surgical mask over the N95 mask. The ,[DATE] LPN #4 confirmed that the ,[DATE] CNA #3 working on the unit was the only CNA working on the second floor during the 7:00 AM - 3:00 PM shift, and was going in and out of all the resident's rooms on the unit. The ,[DATE] LPN #4 stated that staff were supposed to wash their hands for 20 seconds before and after going in and out of resident's rooms. At 1:55 PM, the surveyor interviewed the Staffing Coordinator/Certified Nursing Aide (SC/CNA), who stated that she oversaw the staffing of the building, and it had been challenging since the outbreak of COVID-19. The SC/CNA stated that she was trying her best to keep the staff isolated to working on the same unit. The SC/CNA further stated that they had received gowns for the staff to wear three weeks ago. The staff received one gown at the beginning of the shift, one at the end of the shift, and that they were not changing their gowns throughout the day. The SC/CNA stated that if the staff was going from a C19+ room to a C19- room, the staff should be changing their gowns no matter what. At 2:22 PM to 2:41 PM, the surveyor conducted an interview with the Director of Nursing (DON), who stated that the facility was treating all the residents as if they were infected. The DON stated that before the usage of the N95 masks, the staff was utilizing the surgical masks for droplet precautions. The DON stated that on [DATE], she went unit to unit to make sure all the nurses received N95 masks, face shields, and gowns. The surveyor asked the DON how frequently the staff received a new N95 mask. The DON stated that it depended on the mask and if the mask became soiled. The DON stated that it also depended on if the staff worked overtime. For example, depending on how frequently the staff worked, the masks would be changed every three, five, or seven days. The DON did not speak to the placement of a surgical mask over the N95 mask. The DON stated that the staff was provided with the washable yellow gowns on [DATE]. The process for the gowns was that the staff would wear them throughout their shift, and then the gowns would be returned at the end of their shift and washed. The surveyor asked the DON if the CNA working on the second floor today was going room to room wearing the same gown. The DON stated, probably as long as they are not soiled. The DON further stated that the C19+ residents should be wearing a mask in their rooms, and staff should wash their hands for 20 to 30 seconds before entering and exiting a resident's room. At 3:00 PM, the surveyor interviewed the HKD, who stated that the housekeeping staff was to wear gowns, gloves, and a mask while cleaning the resident's rooms. Face shields were not required because the housekeeping staff did not have direct contact with the residents in the room. The HKD stated that he told his staff to clean high touch areas three times a day, such as the elevator buttons, doorknobs, and keypads. The HKD further stated that the housekeeper on the second floor was not cleaning the C19+ rooms and that the nursing staff was responsible for cleaning those resident rooms. A review of the line listing provided by the facility indicated that two of the fourteen staff members that were tested for [MEDICAL CONDITION] worked in the housekeeping department. One of them tested C19+, and the other was pending testing results as of [DATE]. At 3:13 PM, the surveyor interviewed the 3:00 PM - 11:00 PM Registered Nurse/Supervisor (RN/S) who stated that she was helping the staff by taking a medication cart and passing medication during her shift while supervising the building. The RN/S stated that she had never taken a medication cart on the second floor to pass medications because they had a full time 3:00 PM - 11:00 PM nurse on the second floor, who was very good and would take a medication cart for the C19+ residents and another nurse would take a medication cart for the C19- residents. The RN/S stated that on the 11:00 PM - 7:00 AM shift, there was always one nurse and one CNA working on the second floor. The RN/S stated that she received her N95 mask about two weeks ago but could not specify the date. The RN/S further stated, at the beginning of the shift, you get a gown, and then when you leave, you take it off. The RN/S stated that if the gowns were soiled, the staff needed to put on a new gown. The surveyor asked the RN/S what it would take for a gown to be soiled. The RN/S stated that if a resident were to cough or spit on a staff member, the gown would be considered soiled and should be changed. The RN/S further stated that the CNA's were told to change their gowns after they leave a C19+ room, but she was unaware if they followed that protocol. On [DATE] At 4:44 PM, the surveyor re-entered the first-floor unit, which contained rooms 124D-154W. The surveyor observed Resident #17 and Resident #18 seated on their wheelchairs with their overbed tray tables in front of them. The surveyor observed the 3:00 PM - 11:00 PM CNA #4 enter the room wearing a gown, an N95 mask, a face shield, no gloves, and no surgical mask hand out dinner trays to both residents in the room. The surveyor observed ,[DATE] CNA #4 move around items on the residents over bed tables and set up both resident's dinner trays for them. The surveyor then observed the ,[DATE] CNA #4 perform hand hygiene for 20 seconds before exiting the room. A review of the line listing and facility census indicated that Resident #17 and Resident #18 were pending COVID testing results as of [DATE]. A review of Resident #17's Interdisciplinary Notes (IN) dated [DATE] indicated that the resident's physician ordered the nasal swab for COVID-19, and the resident was currently on droplet precautions pending the results. A review of Resident #18's Interdisciplinary Notes (IN) dated [DATE] indicated that the resident's physician ordered the nasal swab for COVID-19 because the resident was observed to be lethargic and the resident was currently on droplet precautions pending the results. At 4:47 PM, the surveyor observed the ,[DATE] CNA #4 enter the room across the hallway and speak to Resident #19 briefly and then exit the room. The ,[DATE] CNA #4 was not observed performing hand hygiene before or after exiting the resident's room. The surveyor then observed the ,[DATE] CNA #4 enter Resident #20's room, move around items on the resident's overbed table, and set up the resident's dinner tray. CNA #4 was observed performing hand hygiene for 20 seconds after exiting the resident's room. CNA #4 was never observed changing her gown after exiting the resident's rooms. A review of the line listing and facility census indicated that Resident #19 was Asymptomatic of [MEDICAL CONDITION] and not including on the line listing. A further review of the line listing and facility census indicated that Resident #20 was pending COVID testing results as of [DATE]. A review lab results dated [DATE] indicated that resident #20 was negative for COVID-19. At 5:08 PM, the surveyor interviewed the ,[DATE] CNA #4, who stated that signs and symptoms of COVID-19 were cough, confusion, weight loss, loss of appetite, diarrhea, and vomiting. The ,[DATE] CNA #4 stated that she had observed this with some of the residents who tested positive for [MEDICAL CONDITION], and then the residents were moved upstairs. The ,[DATE] CNA #4 further stated that she noticed if one resident in the room tested positive, the roommate was likely to test positive as well. The ,[DATE] CNA #4 stated that every day when she came into work, she would get her temperature taken and get a mask and face shield, which were stored in paper bags with her name on it. The ,[DATE] CNA #4 stated that the face shields were sprayed with disinfectant. The ,[DATE] CNA #4 stated, They are telling us that we get one mask and one face shield once a week unless it gets soiled. The ,[DATE] CNA #4 told the surveyor that she returned her gown at the end of her shift and never had to change her gown during her shift unless it got soiled with feces. The ,[DATE] CNA #4 stated that she was unaware of residents on the floor or unit that were pending testing results for COVID. The ,[DATE] CNA #4 stated, (I) don't know who they test day to day. Certain residents are alert and able to tell me if they were swabbed. At 5:16 PM, the surveyor conducted a follow-up interview with the RN/S who stated that Resident #17 and Resident #18 were pending COVID testing because both residents were running a high fever, had a poor appetite, and were lethargic. The RN/S stated that if she were to go into the room to take care of the resident's she would perform hand hygiene, put on gloves, and then perform hand hygiene again for 20 seconds. The RN/S further stated that the resident's pending COVID results were automatically placed on droplet precautions, so it would not be necessary to change the gown you were wearing after leaving the room. The RN/S stated that the nurse leaving

Based on observation, interview and record review, it was determined that the facility failed to follow specific fall prevention interventions for 2 of 7 residents reviewed for falls, Residents #6 and #13. Resident #6, assessed as being at high risk for falls, required the assistance of 2 for transfers and incontinence care. The resident had a fall when left alone during incontinence care and was admitted to the hospital with [REDACTED]. Evidence is as follows: 1. On 9/4/13 at 9:40 a.m. and 10:30 a.m., the surveyor observed Resident #6 who was resting in bed with eyes closed. The surveyor observed that two upper side rails were in the raised position. The surveyor reviewed the medical record on 9/4/13 at 10:35 a.m. The resident was admitted to the facility on [DATE] from home with [DIAGNOSES REDACTED]. On 4/17/12 the Psychiatrist diagnosed the resident with Dementia Alzheimer's type with delusions. The surveyor reviewed the Annual Minimum Data Set (MDS), an assessment tool, dated 3/28/13. The IDC Team determined that the resident required a two person assist for toileting, walking, and for transfers. The resident could not answer the questions in the MDS Brief Interview for Mental Status (BIMS). The IDC team assessed the resident as being severely cognitively impaired with poor long and short term memory with an inability to make decisions. The IDC team documented in the care plan dated 3/28/13 that the resident was at risk for falls based on the [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] completed by the nursing staff documented that the resident was assessed at being at risk for falls. The 3/19/13 Assessment noted that Resident #6 "continues for risk for fall even though score indicates isn't. Antipsychotic use, hx (history) of falls and behavioral issues put (him/her) at risk." The surveyor reviewed the medical record. The resident sustained [REDACTED]. The surveyor reviewed the fall investigations which revealed the following: On 5/27/13 at 10:20 a.m. a Certified Nursing Assistant (CNA) assisted Resident #6 to the bathroom. According to the CNA's statement, the CNA heard another resident's tab alarm ringing and the CNA left Resident #6 alone in the bathroom and went to the door of the room to see where the alarm was sounding, spoke to someone in the hallway to check it and turned to go back to Resident #6. The CNA saw the resident get up from the toilet, try to walk, went to get her and the resident lost their balance and fell . The CNA stated s/he called for the nurse, tried to walk the resident from the bathroom and the resident was limping and holding her groin. The surveyor reviewed the Notice of Major Disciplinary Action (NMDA) provided to the surveyor with the Investigative Report. According to the NMDA the facility determined that no second person was present when the resident was transferred by the CNA out of bed. The facility documented in the NMDA that because of continuing complaints of pain, Resident #6 was transferred to the hospital later that day where the resident was subsequently diagnosed with [REDACTED]. On 9/11/13 at 2:40 p.m., the Administrator and the DON acknowledged that the CNA failed to follow the care plan and did not obtain the assistance of another person when transferring and toileting Resident #6 and that the resident fell and sustained a hip fracture. 2. On 9/5/13 at 11:10 a.m. the surveyor observed Resident #13 in his/her room seated in a wheelchair watching TV. The surveyor conversed with the resident who replied with slow but appropriate responses. The surveyor reviewed the resident's medical record on 9/9/13 at 10:30 a.m. The resident was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. The surveyor reviewed the Annual MDS (Minimum Data Set), a functional assessment tool, dated 2/12/13. The Interdisciplinary (IDC) Team determined that the resident required a one person assist for toileting and for transfers. The IDC team also assessed that the resident was not able to stabilize his/her balance during transfers without staff assistance. The resident's care plan included the IDC team's recommendation for one person assistance for stand/pivot transfers. The surveyor noted a New Jersey Universal Transfer Form (NJUTF) dated 2/9/13 completed by a staff nurse who indicated that the resident had sustained a laceration of the head. A staff nurse made an entry on the Interdisciplinary Note dated 2/9/13 that the resident was standing at the grab bar in the bathroom waiting for the Certified Nursing Assistant (CNA) to get the resident a new pair of pants. The resident thought the wheelchair was directly behind him/her and sat down. S/he missed the chair and struck his/her head on the heating vent. The resident sustained [REDACTED]. The surveyor reviewed the Fall Investigation Report for the fall on 2/9/13. The staff determined that the root cause of the event was that the resident was not seated safely in the chair before the CNA left him/her to get the new pants. The report included an entry by the Director of Nursing that the CNA was counseled. NJAC 8:31-27.1(a)