**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ157563 Based on observation, interview, and review of facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment for resident rooms on one (1) of six (6) nursing units of the facility observed (2nd floor Unit). The evidence of this deficient practice includes: On 5/23/24 at 10:28 AM, during the initial tour of the 2nd floor Unit, the surveyor observed the following: room [ROOM NUMBER] and room [ROOM NUMBER]- Noticeable odor of wet carpet and urine in room room [ROOM NUMBER]-carpets in room visibly frayed room [ROOM NUMBER]-carpets in room were visibly frayed and stained. room [ROOM NUMBER]- large black stain observed between door and window bed. On 5/28/24 at 12:28 PM, the surveyor observed the following on the 2nd Floor Unit: room [ROOM NUMBER] and room [ROOM NUMBER]-odor of wet carpet and urine remained. room [ROOM NUMBER] and 218- carpets remained frayed and stained. On 5/29/24 at 10:06 AM, during a follow-up tour of the 2nd floor Unit, the surveyor observed the following: room [ROOM NUMBER]- carpet frayed at door entrance, room to hallway transition strip missing, room odor remained. room [ROOM NUMBER]- carpet ripped/frayed, odor remained. room [ROOM NUMBER]- carpet frayed, stained black. room [ROOM NUMBER]- carpet in front of door ripped/frayed. room [ROOM NUMBER]- carpet at entrance of room ripped/frayed, room to hallway transition strip is missing. room [ROOM NUMBER] - carpet by B bed ripped/frayed, room to hallway transition strip missing, carpet near bathroom was stained. room [ROOM NUMBER]- carpet ripped in 2 areas in between the beds. room [ROOM NUMBER]- carpet Stained On 5/29/24 at 10:16 AM, the surveyor interviewed the Director of Maintenance, (DM) who stated that he does environmental rounds such as checking hot water temperatures. The DM further stated that he was just starting to do daily environmental rounds with the housekeeping (HK) department. On that same date and time, the DM stated that he was aware that the carpets in room [ROOM NUMBER] and room [ROOM NUMBER] were wet because the toilet had overflowed into the two carpeted rooms on 5/21/23. The DM stated that when a staff member finds something broken or needing repair, the staff will write it in the Daily Maintenance Log book. When he does his daily rounds, he will check the book and initial next to the room number then he will put in a work order. If it was an emergency repair, the staff will then page him. On 5/29/24 at 12:28 PM, the surveyor reviewed the above carpet and room concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President of Risk Management (VPoRM), and [NAME] President of Clinical Services (VPoCS). The LNHA stated that the maintenance department conducts environmental rounds, and the HK department conducts cleaning rounds. The surveyor requested any documentation of the environmental and HK audits or rounding. A review of the April and May 2024 Daily Maintenance Log binder, located at the 2nd floor Nurses Station, did not reveal any entries regarding the condition of the carpets. On 5/30/24 at 10:42 AM, the surveyor interviewed the Director of Housekeeping (DH) who stated that every day he does environmental rounding of the whole building. He further stated that he does random rooms and checks the carpets, wheelchairs, curtains, blinds, etc. If something was broken or needed repair, he would report it to maintenance. The DH stated that any maintenance repairs observed during the rounds would be told to maintenance verbally and that he did not write it in the maintenance log. The DM further stated that he was aware that the carpets in Rooms 215 and room [ROOM NUMBER] were wet and had an odor because the toilet had overflowed. He stated that the carpets were cleaned with a shampoo machine. The surveyor reviewed the random audits provided by the DH and there was no documentation of the frayed or stained rugs and that the maintenance department was notified. On 5/30/24 at 12:02 PM, the administrator stated that he did environmental rounds with the maintenance dept weekly but was unable to provide any documentation or maintenance audits. A review of the facility's policy Resident Right-Safe/Clean/Comfortable/Homelike Environment dated 5/01/2024, revealed that the facility will provide a safe, clean, comfortable, homelike environment such a manner to acknowledge and respect residents' rights. The resident has a right to a safe, clean, comfortable, and homelike environment. NJAC 8:39-4.1(a) 11, 31.4(a)

Based on observation, interview, and document review, it was determined that the facility failed to ensure the facility policy was followed and a comprehensive person centered care plan was revised to include target behaviors and non-pharmacological interventions for a resident who was administered antipsychotic medications. This deficient practice occurred for one (1) of five (5) residents reviewed for unnecessary medications (Resident #42) and was evidenced by the following: On 5/28/24 at 8:38 AM, the surveyor interviewed the Certified Nursing Aide (CNA) providing care for Resident #42. The CNA stated the resident sometimes refused care, screamed, and threw things like the walker. The surveyor asked if the resident would become physical with the CNA who stated, resident will try. The CNA also stated the resident spoke in a foreign language but could understand English. The surveyor then observed Resident #42 with a winter coat on and was walking toward the door in the room, the CNA stated the resident wanted to go see the spouse. On 5/28/24 at 8:43 AM, the surveyor interviewed Resident #42's Licensed Practical Nurse (LPN) at the medication cart and observed Resident #42 walk by and was dressed in a winter coat. The surveyor asked the LPN about any behaviors the resident had. The LPN stated sometimes complained of pain to the thigh. The surveyor asked if the resident was on psychotropic medication (med) and for what indication, and the LPN stated, yes for depression since the spouse was in the hospital which made the resident sad. The surveyor asked if the resident would leave the unit and the LPN stated the resident went to the other side of the second floor, 2B and wore an elopement monitor on the ankle. On 5/30/24 at 11:39 AM, the surveyor conducted a telephone interview with the Consultant Pharmacist (CP) regarding the monitoring for psychotropic meds. The surveyor asked if the behaviors for the meds should be documented and should be documented as part of the monitoring, and the CP stated yes. A review of Resident #42's electronic Medical Record (eMR) revealed: The admission Record (or face sheet, an admission summary) revealed the resident had diagnoses that included, but were not limited to, major depression disorder and unspecified dementia. The current Med Administration Record (MAR) for May 2024 revealed the following order for Seroquel (Quetiapine Fumarate) Oral Tablet 25 MG (milligram) Give 0.5 tablet by mouth two times a day for depression with psychosis 0.5 tab x 25 mg = 12.5 mg, Start Date-05/15/2024 1700; Monitor for Behaviors every shift-Start Date-04/12/2024; 2300. There were no identified target behaviors related to the depression or psychosis documented in the MAR or quantified. A review of 01/19/2024 06:53 Psychiatry Progress Note revealed: Diagnosis/Impressions: insomnia, depression with psychosis, anxiety, mood d/o [disorder] PLAN: 1. Always consider/implement relevant supportive and non-pharmacologic interventions, including: redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. Treat medical issues including pain, UTI (urinary tract infection), constipation, infection, physical issues, positioning, toileting. Encourage participation in activities, social engagement as tolerated and as possible for psychosocial well being. The current 21-Page Care Plan, including resolved items, and had a Focus for Antidepressant medication, Initiated 8/30/23 and Target Date of 6/07/24 and a Focus for the use of antipsychotic mediation due to behavior disorder, depression with psychosis and mood disorder, Initiated 12/15/23 and Target Date 06/07/24. An Intervention, Date Initiated: 12/15/2023, Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. The above care plan revealed that it was not revised to reflect specific behavioral expressions. There were no non-pharmacologic interventions as indicated in the Psychiatry documentation. On 5/30/24 at 12:17 PM, the [NAME] President of Risk Management (VPoRM) stated to the survey team, after the surveyor's inquiry, the team met and reviewed the psychotropic medications and updated the care plans. The Behavior and Psychoactive Management Program Procedure, dated 05/01/2024 revealed The Facility's behavior Management Program will consist of: 6. Planning and implemented appropriate interventions into the plan of care. 7. Evaluating the effectiveness of Pharmacological and non-pharmacological interventions. The comprehensive Resident Centered Care Plans Policy, Date: 5/1/24 revealed: Intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. Every resident will have an Interdisciplinary Care Plan. The Care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the residents's strengths, limitations and goals. The care plan will be completed, current, realistic, time specific and appropriate to the needs for each resident . NJAC 8:39-11.2(e)2

2.) Surveyor#2 (S#2) reviewed the medical record for Resident #125. Resident #125's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to urinary tract infection, site not specified, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) without lower urinary tract symptoms, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). The most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, dated 3/19/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had an intact cognition. The cMDS also showed that the resident had an indwelling catheter. A review of the Order Summary Report (OSR) for May 2024 reflected a physician's order (PO) dated 4/23/24 for Urinary Catheter Care every shift. The order was plotted in the May 2024 eTAR for day, evening, and night shifts to include the output. The May 2024 eTAR revealed the urinary catheter output was not documented for the following days and shifts: May 2024: 5/02/24 evening and night shifts 5/07/24 evening shift 5/14/24 to 5/16/24 evening shift 5/19/24 evening shift 5/21/24 evening shift 5/23/24 evening shift On 5/24/24 at 10:13 AM, the survey team met with the VPoCS, Licensed Nursing Home Administrator (LNHA), and the DON. S#2 notified the facility management of the above findings and concerns regarding omitted documentation of urine output in the May 2024 eTAR and did not follow the PO. On that same date and time, both the VPoCS and DON stated that they (nurses) should put an output or zero if no output in the eTAR and follow the PO. On 5/28/24 at 8:33 AM, the surveyor observed Resident #125 in their room seated in a wheelchair during breakfast. According to the resident, the Foley catheter was due to bladder and prostate cancer. On 5/29/24 at 12:02 PM, the survey team met with the LNHA, DON, VPoCS, and VP of Risk Management (VPoRM). The surveyor discussed the above concerns. A review of the facility's Infection Control-Indwelling Urinary Catheter Use dated 4/01/24 that was provided by the Infection Preventionist Nurse, included that it is the policy of the facility to ensure the appropriate use of indwelling urinary catheters in accordance with state and federal regulations, and national guidelines. Procedure: #9. Documentation to include urine output and monitoring for signs and symptoms of infection. On 5/30/24 at 11:59 AM, the survey team met with the LNHA, DON, VPoRM, and VPoCS. The DON stated that the nurse failed to put the urine output in the eTAR according to the PO. She further stated that the nurse should follow the order to document the output in the eTAR. NJAC 8:39-27.1(a), 33.2 (c) 5 Complaint NJ #158377 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) document medications and treatments according to physician's orders for one (1) of 32 residents (Resident #18) reviewed for medication and treatment administration, and b.) consistently document catheter urinary output according to the physician's orders for one (1) of three (3) residents reviewed for urinary catheters (Resident #125) according to standards of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 5/21/24 at 9:09 AM, Surveyor #1 observed Resident #18 lying in bed on an air mattress, wearing glasses, and the call bell in reach. Resident #18 was alert and oriented and stated he/she was in the hospital recently and had been at the facility a while. Resident #18 was unable to tell the surveyor of all the previous hospitalizations. Surveyor #1 reviewed a previous readmission record for Resident #18. Resident #18's admission Record (AR, or face sheet, an admission summary) reflected a readmission from the hospital with diagnoses included but were not limited to; Multiple Sclerosis (MS, a disease in which the immune system eats away at the protective covering of nerves), contractures, multiple wounds, skin rash neuromuscular dysfunction of the bladder, elevated blood pressure, and glaucoma (a group of eye conditions that can cause blindness). A review of the facility provided, Physician Orders report from the previous electronic medical record system, included the following: Created 8/25-8/26/2022, 26 orders including medications (meds), treatments, supplements, and tasks. A review of the electronic Medication Administration Record (eMAR) and the electronicTreatment Administration Record (eTAR) both dated September 2022, revealed the following documentation of X Not Addressed on 9/04/2022: Latanoprost eye drop scheduled at 21:00 (9:00 PM) Olopatadine eye drop scheduled at 18:00 (6:00 PM) Polyethylene powder (medication mixed with liquid for constipation) scheduled at 21:00 Tiazanidine (medication for MS) scheduled at 17:00 (5:00 PM) Tecfidera (medication for MS) scheduled at 18:00 Metoprolol (medication for high blood pressure) scheduled at 17:00 Resource Oral Liquid supplement scheduled at 19:00 (7:00 PM) Nystatin Cream wound treatment for the perineum scheduled at 17:00 ProSource liquid supplement scheduled for 16:00 (4:00 PM) Nystatin Cream wound treatment left upper thigh scheduled at 17:00 Nystatin Cream wound treatment groin folds scheduled at 17:00 Urinary catheter care scheduled for 14:00 (2:00 PM) and 22:00 (10:00 PM) Irrigate urinary catheter scheduled for 13:00 (1:00 PM) and 21:00 (9:00 PM) Out of Bed scheduled for 13:00 Turn and Reposition every 2 hours scheduled for 13:00 and 21:00 Wound treatment genital area scheduled for 17:00 Wound treatment both feet and toes opening scheduled for 9:00 AM and 17:00 Wound treatment left ankle scheduled for 9:00 AM and 17:00 Wound treatment a second genital area scheduled for 9:00 AM and 17:00 Wound treatment of the ischium (hip area) scheduled for 9:00 AM and 17:00 Wound treatment left lateral foot middle scheduled for 9:00 AM and 17:00 Wound treatment left lateral foot second area scheduled for 9:00 AM and 17:00 A review of the resident-centered on-going care plan (CP) included but was not limited to; dated 6/02/21: at risk for pain, pressure ulcers, contractures, MS, and sacral wound with interventions including assist with positioning and administer pain medications as ordered. At risk for skin breakdown, limited mobility, incontinent, MS, readmission from hospital with wounds with interventions assist with turning/repositioning, administer supplements, offload heels, wound treatments as ordered. At risk for UTI [Urinary Tract Infection] history of recurrent UTI, use of suprapubic urinary catheter with interventions irrigate catheter per orders, observe for signs and symptoms of infection, change catheter as ordered, catheter care as ordered, and empty urinary drainage bag every shift. A review of the Progress Notes (PN) ranging from 9/02/2022 through 9/07/2022, contained no documentation as to why the meds, treatments, and tasks were marked as not addressed. The PN contained no documentation to the physician or family regarding the meds, treatments, and tasks marked as not addressed. On 5/29/24 at 9:41 AM, during an interview with the surveyor, the Director of Nursing (DON) was questioned if a eMAR or eTAR documented an x, what would that indicate. The DON stated it would mean not given and that there are codes on the bottom [of the eMAR/eTAR] to indicate the documentation. She further explained that if a resident did not receive a med or treatment, the expectation would be to see a PN, call the pharmacy, and call the physician. The DON stated, There should always be a code why med was not given and a PN. On 5/29/24 at 12:03 PM, the survey team met with the facility administration. Surveyor #1 presented the concerns regarding Resident #18. On 5/30/24 at 10:25 AM, the facility [NAME] President of Clinical Services (VPoCS) stated the facility reached out to the nurses working 9/04/22, but it was too long ago, and the nurses could not provide any information. She further stated that if the documentation was noted as not addressed, the staff should have reached out to the physician, but we have nothing else. At that time, the DON acknowledged that the facility was responsible to provide the ordered meds and treatments, but there was no more information the facility could provide. The DON further stated that if a resident was not provided physician ordered meds or treatments, that the resident condition could worsen.

Based on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for one (1) of one (1) employee reviewed for IP. This deficient practice was evidenced by the following: On 5/23/24 at 11:28 AM, the surveyor interviewed the IP who stated that he started as the facility's IP on June 23, 2023. He added that he started the specialized training after he started as the facility's IP. On 5/24/24 at 8:14 AM, the surveyor reviewed the facility provided signed job description for the IP which was dated 6/26/23. The surveyor then reviewed the facility provided specialized training certificate which had a completion date of 7/27/23. The IP did not have the specialized training prior to assumption of the IP role. On 5/24/24 at 9:25 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the VP of Clinical Services (VPoCS) and they confirmed that the date when the IP signed the job description was when he assumed the IP role. On 5/24/24 at 10:13 AM, in the presence of the survey team, the surveyor notified the LNHA, Director of Nursing (DON) and VPoCS the concern that the IP did not have specialized training prior to assuming the role of IP. The VPoCS stated that the IP was in training with the prior IP at first. The surveyor asked the facility administration when the last day of the prior IP was. On 5/24/24 at 11:12 AM, in the presence of the survey team, the VPoCS stated that the prior IP's last day was approximately 7/08/23 and that the IP was only under training with the prior IP for part of the time. The VPoCS confirmed that the IP had assumed the IP role prior to finishing the specialized training. She added that she was going to change the job description. A review of the facility provided IP job description, dated 11/07/2022, included the following: Intent: Facilities will assign an individual meeting the qualifications listed below as the facility IP. In the event the facility cannot recruit and fire an individual that meets the required qualifications, despite good faith efforts to do so, the facility will notify the DOH and request a waiver. The facility may assign/hire an individual with relevant experience and good potential for the IP role. This individual will receive appropriate orientation and training, and be mentored by an experienced IP . If an individual is identified with good potential and relevant experience, the IP assigned will complete the online infection prevention course through the Centers for Disease Control Prevention during the orientation process, if they have not already completed it. N.J.A.C. 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/23/24 at 10:13 AM, S#4 observed Resident #35 sleeping in their wheelchair with his/her head resting on the bedside table with a pillow. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 15 out of 15 indicating intact cognition. A review of the Grievance/Complaint Investigation Report dated 5/24/23 revealed Resident #35 filed a grievance with the Assistant Director of Nursing (ADON). The section referencing to documentation of grievance/complaint, documentation of facility follow up and resolution of grievance/complaint read as followed: -Describe concern briefly using factual terms: (attach resident/family concern form)? The resident reported he/she was removed from the food committee group meeting by the Director of Activities (DA) when she asked to postpone the meeting when other departments could be present. Resident did not appreciate being spoken to in the matter he/she was. -What other action to resolve concern (be specific)? The DA was asked to be mindful of her tone of voice with the residents, as she may come as speaking to loudly and to utilize an approach to gently guide the resident(s) to another aspect or task within the current activity without making them feel interrupted or excluded. -Was the grievance/complaint resolved? Yes, the administrator and ADON informed the resident that the staff member was addressed regarding her approach with the resident. The resident was justified with the resolution. On 5/24/24 at 10:29 AM, S#4 interviewed the Occupational Therapist (OT). The OT stated [he/she] recalled an incident that happened on the second floor of the facility in the activity room/dining area. The OT stated the resident was seated in wheelchair and the DA forcibly pulled the resident away from the table. The OT said it was on camera and the resident filed a complaint. The OT stated that was the last time [he/she] had seen the DA. On 5/28/24 at 11:29 AM, S#4 interviewed Resident #35 who stated the DA was loud and inappropriate in her approach. Resident #35 stated that the DA wanted [him/her] to leave the room and the resident was not ready to. Resident #35 stated, I was pushed against my will, I told her to stop doing it and she kept doing it. The resident stated [he/she] reported it to administration and there were other people present but can not remember who was there. On 5/29/24 at 10:00 AM, S#4 interviewed the LNHA in the presence of the survey team and the LNHA stated the DA was terminated shortly after, and the facility had no other statements to provide. The LNHA stated the facility does not have video footage of the incident and the surveillance was only kept for 24-48 hours. On 5/29/24 at 11:04 AM, the surveyor interviewed the LNHA and stated the DA choose to resign after the incident and the Ombudsman came and did an investigation. The LNHA stated there was nothing to be reported to the DOH. A review of the provided facility policy dated 5/01/24 included the following: Reporting: 2. An alleged violation of abuse, neglect exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: - Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -Twenty-four (24) hours if the alleged violation dies not involve abuse AND has not resulted in serious bodily injury. 5. The Administrator, or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the finding of the investigation within five (5) working days of the occurrence of the incident. NJAC 8:39-9.4 (f) Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report as required to the New Jersey Department of Health (NJDOH) within two hours: a) an allegation of sexual abuse that occurred for two residents by a staff member, b.) an injury of unknown origin, and c.) an allegation of abuse. This deficient practice occurred for four (4) of six (6) residents reviewed for abuse (Residents #35, #42, #85, and #104) and was evidenced by the following: Refer to 610F 1. Surveyor#1 (S#1) reviewed a Reportable Event Record (RER) confirmation sheet that indicated the RER was submitted to the NJDOH by the facility Director of Nursing (DON) on 02/09/24 at 12:34 PM (one day after the incidents were reported). The RER revealed: Today's date: 02/08/24 Date of Event: 02/08/24 Time of Event: 6:30 PM Was this a significant event? Yes. Type of Incident: Staff- to- Resident Abuse. Narrative: Resident #85 stated private part was washed roughly by the nursing assistant who got him/her ready for bed on Saturday evening 02/03/24. Resident #85 stated heard Resident #42, speaking in a foreign language and stated the same thing and that's why he/she reported this issue today 02/08/24. Resident #42, upon interview [untimed] stated that during care a few days ago, a [color] male nursing assistant with curly hair entered the room, took the resident do the bathroom and put his mouth on [genital organ]. The undated Investigation Summary submitted by the facility revealed: Investigation: On 02/08/24, Resident #85 reported to the nurse on duty, that the resident did not like the way the male nursing assistant who provided care on Saturday evening and washed his/her private part. The nurse informed the DON who went to further interview Resident #85. Resident #85 stated that on 02/03/24 the aide was washing his/her private area kind of in a rough manner. Resident #85 stated that on 02/03/24, heard Resident #42 talking in a [foreign language] in the hallway about the same thing. When Resident #85 was asked why did not report the incident sooner, resident stated it had been on resident's mind to report it but he/she did not. Resident #42 explained maybe two nights before, around midnight, a male went into his/her room, led the resident to the bathroom and while in the bathroom, the aide put his mouth on his/her [genital organ]. On 5/28/24 at 01:06 PM, the [NAME] President of Risk Management (VPoRM) provided S#1 with and Abuse Investigation and Reporting Policy. On 5/30/24 at 10:30 AM, the facility met with the survey team and did not provided any additional information regarding the delay in reporting for the allegations of sexual abuse. 2. On 5/23/24 at 9:32 AM, S#2 received information from S#3 that Resident #104 reported to S#3 that he/she was hit by a staff about a year ago. On 5/23/24 at 9:35 AM, during a meeting with the Licensed Nursing Home Administrator (LNHA) and the DON, S#2 discussed the information received by the surveyor regarding Resident #104's allegation that a staff had hit the resident. At that time, the LNHA stated, We will start the investigation right now. At that time, the DON stated, We will report to the state agency and the Ombudsman. According to the admission Record (AR, an admission summary) Resident #104 had diagnoses which included, but were not limited to, dementia and Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/05/24, included the resident had a Brief Interview for Mental Status score of 12 out of 15 which indicated the resident's cognition was moderately impaired. It included that the resident had no signs or symptoms of delirium. The resident's individualized care plan reflected a focus that the resident had an activities of daily living deficit, initiated on 02/28/24 .The interventions included maximum assistance for bathing, showering, bed mobility, dressing eating, personal hygiene. Additionally, the resident required skin inspections for redness, open areas, scratches, cuts, bruises and for changes to be reported to the nurse. A review of Resident #104's skin evaluations revealed the following: -On 3/25/24, right forearm, skin tear was documented without pain -On 4/08/24, left posterior hand, skin tear was documented without pain -On 4/15/24, left posterior hand, skin tear was documented without pain -On 4/22/24, left posterior hand, skin tear was documented without pain -On 4/29/24, left posterior hand, skin tear was documented without pain -On 5/06/24, no skin issues, were documented -On 5/13/24, no skin issues, were documented -On 5/27/24, no skin issues, were documented A review of the facility provided Investigation Summary and Conclusion reflected the Director of Social Services (DSS) interviewed the resident, a resident statement made to the DON and a skin assessment was conducted with no findings. The Witness Statements revealed the following: -Review of the statement from the DSS dated 5/23/24, reflected that the resident reported to the DSS that a short haired [color] male registered nurse banged the resident's knees into the wall in the bathroom. -Review of the statement from the Registered Nurse dated 5/23/24 at 9:45 AM, reflected that the resident stated he/she was hit. The resident was noted to be forgetful, oriented to self and place, no apparent injuries, was able to move all extremities with no difficulties. A fading discoloration noted to bilateral (both) knees. -Review of the statement from the DON dated 5/23/24 reflected that when she had entered the room the full body assessment was in progress. The resident stated to the DON that he/she ran into the wall by a short white [color] while walking in resident's room and the incident occurred in September 1998. The DON's documentation also reflected that the responsible party (RP) of the resident did not believe the incident was true. On 5/29/24 at 12:52 PM, in the presence of the survey team, the [NAME] President of Clinical Services (VPoCS), the VPoRM, the LNHA and the DON, S#2 discussed the concern regarding the facility's abuse investigation process for Resident #104's injury of unknown origin. There was no evidence provided that the facility reported to the State Agency within the two (2) hour time frame upon discovery. On 5/30/24 at 9:41 AM, in the presence of S#2, and the [NAME] President of Clinical Services (VPoCS), the DON stated that the allegation of staff to resident abuse was reported to the State Agency and the Ombudsman. At that time, the DON submitted a copy of the RER that indicated the event was called in on 5/23/24 at 10:00 AM and was reported as a staff to resident abuse. Further review of the RER reflected the resident alleged that the resident was hit by a nurse and could not identify the nurse. The resident stated it might have been a short [color] male. The incident occurred in the bathroom, while in the chair, then while walking and that the incident occurred in 1998. At that time, the DON stated that the allegation was unsubstantiated for the staff to resident abuse since there were no short haired [color] male nurses. At that same time, S#2 asked the DON if there were any other information associated with Resident #104's faded discoloration noted to bilateral knees. The DON stated that the staff to resident abuse was unsubstantiated, while the investigation for the faded bruising continued. The incidents were delineated which was the reason it was not mentioned in the summary and conclusion provided. On 5/30/24 at 12:02 PM, in the presence of the survey team, the VPoCS, the VPoRM, and the LNHA, the DON stated that the resident had narrated three (3) different stories. The DON stated she had unsubstantiated the part of that a man had pushed the resident and was still investigating the bruise on the resident's knees. At that time, the DON provided three additional statements that were related to the bruising investigation. The DON confirmed the investigation for the bruises had not concluded. On 5/31/24 at 9:54 AM, in the presence of the survey team, the surveyor gave the VPoCS, the VPoRM, the LNHA, and the DON an opportunity to submit additional information. No additional information was provided. Complaint #NJ171307 #NJ164582

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) expired supplies were identified and removed from active inventory, b.) maintain a system of medication (med) records that enabled to account the disposition and the prompt identification of potential drug diversion of controlled dangerous substance (narcotics meds, with high potential for abuse and are tracked with detail) within the narcotic box of a med cart, and c.) demonstrate periodic reconciliation of controlled dangerous substances stored within the electronic back-up machine (EBM) was maintained. This deficient practice was identified for three (3) of six (6) medication carts, one (1) of one (1) med room, and one (1) of one (1) EBM, inspected for med storage and labeling. The evidence was as follows: 1.) On [DATE] at 9:57 AM, in the presence of the Registered Nurse (RN), the surveyor began the emergency crash cart inspection located in the dining area of the 6th floor. At that time, the surveyor and the RN observed the following: 1. Two (2) suction connecting tube with male connector (used to evacuate fluid and debris from suction catheter or yankauer suction handle into a vacuum canister) that had an expiration date of [DATE] and [DATE]. 2. One (1) yankauer suction handle (used to remove fluid and debris from a person's airway) had an expiration date of 5/2021. 3. Two (2) nonconductive connecting tubing with two (2) female connector (use to connect suction catheter and yankauer to suction sources to evacuate fluid and debris) that had an expiration date of [DATE]. 4. Two (2) suction catheter kit (used to clear the airway of a person when unable to clear secretions on their own when airway is blocked, and breathing is difficult) that had expiration date of [DATE]. At 10:08 AM, the surveyor and the RN reviewed the Emergency Cart Check (emergency crash cart) accountability log of the 6th floor which reflected the cart was checked and signed daily until [DATE]. At that time, during an interview with the surveyor, the RN stated the 11:00 PM to 7:00 AM nurse was responsible to ensure all items were in date and that the nurse probable missed the expired supplies. At that time, the RN acknowledged that expired supplies should have been removed and replaced. She would remove the identified expired items immediately, replenish the supplies and inform the Director of Nursing (DON) of the concern. On [DATE] at 11:34 AM, in the presence of License Practical Nurse #1 (LPN #1), the surveyor began the emergency cart inspection located in the nurse's station of the 1st floor. At that time, the surveyor and LPN #1 observed the following: 1. One (1) suction connecting tube with male connector that had an expiration date of [DATE]. 2. One (1) yankauer suction handle had an expiration date of 5/2021. 3. One (1) nonconductive connecting tubing with two (2) female connector that had an expiration date of [DATE]. At that time, the surveyor and LPN #1 reviewed the Emergency Cart Check accountability log for the 1st floor which reflected that the cart was checked and signed daily until [DATE]. At that time, during an interview with the surveyor, LPN #1 stated the 11:00 PM to 7:00 AM, nurse was responsible to ensure all items on the emergency cart were up to date. LPN #1 acknowledged no expired items should be in the cart. At that time, LPN #1 stated she would dispose the expired items, replace, and inform the DON of the concern. On [DATE] at 12:43 PM, in the presence of the Infection Preventionist/Registered Nurse (IP/RN), the surveyor observed the following: 1. Two (2) suction connecting tube with male connector that had an expiration date of 10/2019, and [DATE]. 2. Two (2) nonconductive connecting tubing with two (2) female connector that had an expiration date of [DATE]. 3. One (1) suction catheter kit that had expiration date of [DATE]. At 12:48 PM, the IP/RN confirmed the items were expired, will dispose the meds, and inform the DON. 2.) On [DATE] at 10:33 AM, in the presence of LPN #2 the surveyor began the narcotic med inspection, which was stored in a mounted, double locked portion of the med cart (narcotic box). At 10:34 AM the surveyor and LPN #2 observed that Controlled Drug Administration Record (CDAR) for Resident 77's Lorazepam (a narcotic med) was wasted (disposed) five (5) times on [DATE] without a documented time or reason for the disposal. At that time, LPN #2 could not locate the accountability explanation as to the reason why five (5) tablets (tabs) were wasted. The surveyor and LPN #2 did observe the disposition had two nurses' signatures. A review of Resident #77's electronic Med Administration Record (eMAR) for [DATE] did not reflect refusals for the Lorazepam on [DATE]. 3.) On [DATE] at 12:43 PM, the surveyor, LPN #3 and the IP/RN could not locate the narcotic log for the EBM. At that time, during the cycle count conducted by LPN #3 and IP/RN, the surveyor and the staff observed a discrepancy for the Hydromorphone (narcotic med for pain) populated. At that time, the IP/RN did not know how to produce the discrepancy report from the EBM machine. At that same time, the surveyor had not received the transaction log that reflected the date a narcotic med was removed, who removed the narcotic med, for which resident and the electronic log to reflect the shift-to-shift accountability report for the EBM. On [DATE] at 12:52 PM, in the presence of the survey team, the [NAME] President of Clinicals Services (VPoCS), the VP of Risk Management (VPoRM), the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the expired supplies in the emergency carts and the med room, the potential for diversion reflected on the CDAR without documentation of the time disposed and the reason for the disposal for Resident #77's Lorazepam. The missing paper file for the reconciliation of the narcotic meds in the EBM and the inability of the facility to produce the electronic transaction journal that showed the periodic reconciliation of the narcotic meds in the EBM for [DATE]. On [DATE] at 10:29 AM, in the presence of the survey team, the VPoRM, the LNHA and the DON, the VPoCS stated that all the expired supplies have been replenished and acknowledged it should not have been there. At that time, the DON submitted a picture of a text she had received from her staff dated [DATE], informing her that they had wasted/disposed of five (5) tabs of Resident #77's Lorazepam due to poor packaging. No information was presented that the pharmacy was notified, and the Lorazepam that was poorly packaged was not returned to the pharmacy. At 12:02 PM, during the continuation meeting with the survey team, the VPoCS, the VPoRM, and the LNHA, the DON stated that the 11:00 AM to 7:00 PM shift nurses should have performed the narcotic reconciliation for the EBM machine. The DON stated she had received the discrepancy report. The DON admitted that she had not identified prior to surveyor inquiry that the periodic reconciliation of the narcotics for the EBM machine was not occurring. The expectation was that the nurse supervisor counted daily. Furthermore, the DON stated that from that day forward the reconciliation would be signed and counted daily. A review of the provided facility policy Storage of Meds dated [DATE], included the following under Policy Interpretation and Implementation. 4. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals or returned to the dispensing pharmacy or destroyed. A review of the undated facility policy Controlled Substance Accountability included the following: -Have another nurse witness and co-sign the wasting of any dose of controlled drug. The reason for wasting should be documented. -Verify the expiration date of control substances in the back-up [EBM] daily or shift to shift cycle counts. NJAC 8:39-29.4 (g) (k),29.7(c)

2.) According to the manufacturer's specifications for Toprol XL (metoprolol succinate) tablet, Extended Release under section 2.4 titled, Administration: TOPROL-XL tabs are scored and can be divided; however, do not crush or chew the whole or half tab. On 5/24/24 at 8:50 AM, two surveyors observed the Registered Nurse (RN) prepare meds for Resident #88. The meds included a PO for Metoprolol Succinate ER (extended release) 24-hour, 50 mg tab, give 1 tab by mouth one time a day, related to essential primary hypertension (high blood pressure) with an order start date of 10/05/23. At 8:59 AM, the surveyors observed the RN crush the meds, which she poured into a med cup that contained apple sauce, in preparation for administration to Resident #88 that included Metoprolol Succinate ER 50 mg. At that time, the RN stated the resident had special instructions for med administration of crush meds. At that time, the surveyor observed on the eMAR an annotation of crush meds. At 9:01 AM, the RN confirmed she was ready to administer the crushed meds to Resident #88 and proceeded to walk towards the resident who was seated in the dining room. At that time, in the presence of another surveyor, the surveyor, asked to speak with the RN, and walked back together to the med cart parked at the hallway. At 9:02 AM, the surveyor asked the RN, could an extended-release med such as Metoprolol ER for Resident #88 be crushed. The RN stated I am not sure while reviewing the eMAR. At 9:05 AM, the surveyor and the RN reviewed the bingo card for Metoprolol ER, together. The bingo card had an affixed cautionary label that indicated Do not crush. At that time, the RN was unsure of how to proceed with the med administration for Resident #88 and called the Nurse Practitioner (NP) for the resident. At that time, the RN stated she was instructed by the NP to administer the Metoprolol ER whole. At 9:15 AM, the surveyors observed the RN dispose of the crushed meds into a liquid drug disposal system. At 9:16 AM, the surveyors observed the RN prepare the meds for Resident #88 that included a whole tablet of Metoprolol into applesauce. At 9:21 AM, the surveyor asked the RN if the resident had an individualized care plan for the meds to be crushed. The RN was silent and had no response. At 9:32 AM, during a telephonic interview with the surveyors, the NP stated that Metoprolol ER cannot be crushed or dissolved because of loss of efficacy. The surveyor reviewed the medical record for Resident #88. According to Resident #88's admission Record (or face sheet, an admission summary) reflected that that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to syncope (fainting), heart failure (heart can't pump blood well enough to give your body a normal supply) and dysphagia (a swallowing disorder that makes it difficult to use the mouth, lips, and tongue to control food or liquid) and dementia ( loss of cognitive functioning) . A review of Resident #88s most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/15/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #88's cognition was severely impaired. The qMDS revealed the resident did not have a swallowing disorder and while a resident had a mechanically altered diet (change in texture of food or liquid such as pureed food or thickened liquid). A review of the Order Summary Report for May 2024 did not reflect a PO to crush meds. A review of the Care Plan included a focus that the resident had a nutritional problem or potential for nutritional problem related to dementia, initiated on 6/07/23. The interventions included ground texture initiated on 12/27/23. On 5/29/24 at 12:02 PM, in the presence of the survey team, the VPoCS, the VPoRM, the LNHA and the DON, the surveyor discussed the concern regarding the med pass wherein the RN failed to review and adhere to the med cautionary displayed on the bingo card. On 5/30/24 at 12:02 PM, during a follow-up meeting with the survey team, the VPoCS, the VPoRM, and the LNHA, the DON acknowledged that the Metoprolol ER should not have been crushed or dissolved, the physician should have been informed, and the PO should be followed. A review of the provided facility policy dated 5/01/24, included the following: Procedure: E. If it is safe to do so, med tabs may be crushed, or capsules emptied out when a resident has difficulty swallowing or is tub-fed [tube-fed] using the following guideline: a. Long acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought. NJAC 8:39-11.2 (b), 29.2 (d) REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more. During the med observation conducted on 5/24/24, the two (2) surveyors observed five (5) nurses administer meds to six (6) residents. There were 30 opportunities, and three errors were observed which resulted in a med error rate of 10%. This deficient practice was identified for two (2) of six (6) residents (Residents #31 and #88), which was administered by two (2) of five (5) nurses. This deficient practice was evidenced by the following: According to the manufacturer's specifications for Omeprazole included Administration Instructions to take before meals. 1. On 5/24/24 at 8:09 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare meds for Resident #31. The meds included an active physician's order (PO) dated 3/17/23 of the following: Miralax Powder 17 gm/scoop, give 17 gm (gram) by mouth one time a day for constipation and mix with 8 oz (ounces) fluid of choice. The order was plotted in the electronic Med Administration Record (eMAR) for 9 AM. Omeprazole cap (capsule) 20 mg (milligrams) give one cap orally one time a day related to gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining) without esophagitis. The order was plotted in the eMAR for 7:30 AM. On that same date and time, the surveyor observed the LPN pour one (1) cap of Omeprazole 20 mg into a med cup (one ounce) for administration to Resident #31. The LPN did not read the cautionary in the bingo card (also known as blister packs, or bubble packs, are the most commonly used medication packaging in long-term care facilities) to take meds before a meal or as directed by your doctor. The LPN also poured a scoop of Miralax to half a cup of water into a 4 oz plastic cup. At 8:14 AM, inside the resident's room, the LPN confirmed with the surveyor that she was ready to administer the resident's meds. Then, the surveyor stopped the med pass observation in the resident's room and asked the LPN to walk back to the med cart parked outside the resident's room. The surveyor asked the LPN how much water was in the plastic cup and to review the order again. At that same time, the LPN reviewed the eMAR and confirmed that the order for Miralax was 8 oz fluid, and the cup was an 8 oz cup. The LPN stated that the resident would complain if she filled up the cup with water. The surveyor observed the LPN fill the cup with ¾ water, proceeded inside the resident's room, and confirmed to the surveyor that she was ready to administer the meds. At 8:17 AM, the surveyor observed the Director of Activity (DA) inside the room deliver the resident's breakfast tray. The DA and the LPN both repositioned the resident in the bed. The DA set up the breakfast tray. At 8:26 AM, Resident #31 took a bite of food that was served by the DA. The LPN then administered all meds (including Omeprazole) whole with applesauce to the resident and the Miralax. Afterward, the surveyor interviewed the LPN after the nurse signed the eMAR. The LPN informed the surveyor that she used an 8 oz cup of water to mix one scoop of Miralax. The surveyor then asked the LPN to use a clean plastic cup to measure a med cup (one ounce) filled with water to determine how many ounces of the med cup could fill up the plastic cup. The LPN took a med cup and stated that the med cup was a one-ounce cup. The LPN filled up the med cup with water and transferred the water to a plastic cup and it filled the cup halfway. The LPN confirmed that the plastic cup she used for mixing the Miralax was not an 8 oz cup and she was not sure how many ounces it was. At that same time, the LPN stated that she did not follow the PO for Miralax to mix it with 8 oz of fluid. On 5/24/24 at 8:44 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the [NAME] President of Risk Management (VPoRM) that she (DON) will get back to the surveyor to determine how many ounces were the plastic cup that the LPN was used in mixing one scoop of Miralax. On 5/24/24 at 10:11 AM, the DON informed the surveyor that the plastic cup was a four-ounce cup. On 5/24/24 at 11:05 AM, the surveyor interviewed the LPN regarding Omeprazole. The LPN showed the bingo card of Omeprazole and read the cautionary. The LPN stated that the med instruction meant to give the med 30 minutes before a meal. The surveyor then asked the LPN why she administered the med with the meal. The LPN responded that the resident wanted to eat. On 5/29/24 at 12:02 PM, the survey team met with the LNHA, DON, VP of Clinical Services (VPoCS), and VPoRM. The surveyor discussed the above concerns and findings. On 5/30/24 at 8:14 AM, the surveyor called and interviewed the Consultant Pharmacist (CP) in the presence of the two surveyors. The surveyor asked about Omeprazole on when to administer it. The CP informed the surveyor that it should be administered on an empty stomach around 6 AM or at least 30 minutes before meals. The surveyor asked what was the reason that it should be administered on an empty stomach, the CP responded that Omeprazole was a proton pump inhibitor (PPI, are medicines that decrease stomach acid production) and that she usually puts that in her recommendation when she reviews MRR (Medication Record Review) monthly. On that same date and time, the surveyor asked about the Miralax. The CP stated that Miralax should be mixed with 4-6 oz of water/fluids, a minimum of 4 oz. The surveyor then asked if the order was to mix with 8 oz of water what the nurse should do, the CP stated that the nurse should have followed the order. At that same time, the surveyor notified the CP of the above findings and concerns. The CP stated it was wrong to administer Omeprazole with meals, and if the CP was the one doing the med pass observation, it would be a med error. A review of the facility's Med Administration Policy with a date of 5/01/24 that was provided by the VPoRM included that meds are administered as prescribed in accordance with good nursing principles and practices. Meds are administered in accordance with the written orders of the attending physician. On 5/30/24 at 11:59 AM, the survey team met with the LNHA, DON, VPoRM, and VPoCS. The DON informed the surveyor that the new order for Omeprazole was after the surveyor's inquiry. The DON stated that the physician was notified of the concern regarding the Miralax and advised the facility to talk to the CP. The DON further stated that the CP was notified of the physician's information. According to the DON, the CP responded that Miralax should be mixed with 4-8 oz of fluid. At that same time, the VPoCS stated that Omeprazole should be given on an empty stomach.

Based on observation, interview, and review of medical records, it was determined that the facility failed to promptly, within three (3) days, refer Resident #88 for dental services to replace the lost dentures which persisted for nine months, and resulted in a diet texture change to ground due to difficulty chewing. This deficient practice was identified for one (1) of six (6) residents observed during medication (med) administration (Resident #88), and was evidenced by the following: On 5/24/24 at 8:59 AM, the surveyors observed the Registered Nurse (RN) crush the meds, which she poured into a med cup that contained apple sauce, in preparation for administration to Resident #88 that included Metoprolol Succinate ER (extended release, medication for blood pressure) 50 mg (milligrams). At that time, the RN stated the resident had special instructions for med administration of crush meds. At that same time, the surveyor observed on the May 2024 electronic Med Administration Record (eMAR) an annotation of crush meds. The surveyor reviewed the medical record for Resident #88. According to the admission Record (or face sheet, an admission summary) reflected that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to syncope (fainting), heart failure (heart can't pump blood well enough to give your body a normal supply) and dysphagia (a swallowing disorder that makes it difficult to use the mouth, lips, and tongue to control food or liquid) and dementia ( loss of cognitive functioning). The most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/15/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #88's cognition was severely impaired. The qMDS revealed the resident did not have a swallowing disorder and while a resident had a mechanically altered diet (change in texture of food or liquid such as pureed food or thickened liquid). A review of the Care Plan (CP) included a focus that the resident had a nutritional problem or potential for nutritional problem related to dementia, initiated on 6/07/23. The interventions included ground texture initiated on 12/27/23. Further review of the CP under special instructions revealed Crushed Meds. A review of the resident's Dental Consultation dated 8/17/23, revealed that Resident #88 had his/her dentures inserted, and adjustment was made. Resident was to return for adjustment as needed. A review of Progress Notes (PN) for Resident #88 reflected the following: -On 8/17/23 at 10:58 PM, the nurse documented that the resident refused to remove his/her dentures despite the education given by the Certified Nursing Assistant (CNA). The resident slept with the dentures. -On 8/18/23 at 3:53 PM, the nurse documented that the resident was received without dentures. The staff looked through resident's room and belongings and was unable to locate the dentures. All parties were made aware. -On 9/20/23 at 02:04 PM, the Speech Therapist [Speech-language pathologist; SLP] documented that the resident did not have any functional deficits. The resident was on the safest and least restrictive diet. - On 10/27/23 at 7:49 PM, the nurse documented that the [responsible party] requested that the resident not having dentures, found difficulty chewing food. An SLP consult was completed. A new diet order was received: ground with gravy, bread, and thin liquids. The nurse called the [responsible party] who did not answer. A review of the Speech Therapy, SLP Evaluation and Plan of Treatment dated 10/27/23 to 01/17/24, included the following: Current Referral: Reason for Referral/Current Illness: Patient was referred to skilled ST dysphagia evaluation due to recent loss of dentures. Patient presented with mild/moderate dysphagia (difficulty swallowing) characterized by prolonged mastication (chewing), diminished bolus formation (a swallowing abnormality when the tongue doesn't coordinate properly to form a bolus after chewing), and delayed A/P transit anterior (front) hard palate to tongue pressure with cognitive impairment overlay. A review of the SLP Discharge Recommendation dated 12/21/23, included the following recommendations: The diet recommended was minced and moist. The liquid recommended was thin liquids. Restorative and functional maintenance program were not indicated for the resident. A review of the Resident's weight history reflected the following: on 8/02/23, the weight was 129 pounds (lbs.) on 9/05/23, the weight was 133 lbs. on 10/03/23, the weight was 134 lbs. on 10/31/23, the weight was 134 lbs. on 11/01/23, the weight was 135 lbs. on 12/01/23, the weight was 133 lbs. on 12/28/23, the weight was 133 lbs. on 01/18/23, the weight was 134 lbs. on 02/07/24, the weight was 132 lbs. on 3/07/24, the weight was 134 lbs. on 4/05/24, the weight was 135 lbs. on 5/13/24, the weight was 134 lbs. On 5/24/24 at 10:20 AM, during an interview with the surveyor, the SLP confirmed that the referral was due to Resident #88's loss of dentures. The SLP stated that since the resident was unable to chew without the dentures, the resident's diet was changed to ground. At that time, the SLP stated nursing was informed, and the kitchen was informed. At that same time, the Occupational Therapist/ Rehabilitation Director (OT/RD) stated that they had to make sure the resident was safe, and when Resident #88 received his/her new dentures, a re-evaluation can be done. Furthermore, the OT/RD stated that he was part of the interdisciplinary team (a group of health care professionals from complementary fields who work together to treat a patient) and attended the meetings where the resident's recommendations were discussed. On 5/28/24 at 10:39 AM, during an interview with the surveyor, the Director of Social Services (DSS) stated that she had started three (3) months ago. On that same date and time, the DSS explained to the surveyor that all residents, family member or nursing staff were able to report a missing item to her. The DSS stated that after an item was reported to her as lost, she documented the missing item into the Missing Items Report Log (MIRL) and directed the information to the corresponding department; As an example, hearing aids, glasses, and dentures, depending on the insurance we [the facility] would try to replace it. At that time, the surveyor and the DSS reviewed the MIRL and did not find an entry for Resident #88's missing dentures. In addition, the surveyor and the DSS reviewed the Social Services PN from 4/06/23 to 3/21/24, which did not reflect a documentation that the facility had tried to replace Resident #88's dentures or reason for the delay of receiving dental services. On 5/29/24 at 12:52 PM, in the presence of the survey team, the [NAME] President of Clinical Services (VPoCS), the VP of Risk Management (VPoRM), the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the facility's failure to promptly, within three (3) days refer a resident with lost dentures for dental services and whose diet texture was changed to ground due to difficulty chewing food from October 2023. The resident was without dentures from August 18, 2023, nine months to date. On 5/30/23 at 10:29 AM, in the presence of the survey team, the VPoRM, the LNHA and the DON, the VPoCS stated that when the dentures went missing the [responsible party] was informed and the [responsible party] wanted to take the resident to their own dentist but none of that was documented. On that same date and time, the VPoCS stated the other option was for the resident to see the in-house dentist. The option was offered to the [responsible party] who agreed. At that time, the VPoCS stated that their facility policy was three (3) days to follow-up. The VPoCS acknowledged that it should have been done as prior to surveyor inquiry. A review of the provided facility policy, Dental Services dated 5/01/24, included the following under Procedure: 2. The facility will, if necessary or if requested, assist the resident: c. will promptly, within 3 days refer residents with list or damaged dentures for dental services. NJAC 8:39-15.1 (b) (c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate hand hygiene practices during medication (med) administration and dining observation. This deficient practice was identified for two (2) of six (6) staff (one Licensed Practical Nurse and Certified Nursing Aide #1) during med administration, and for two (2) of four (4) staff (CNA#2 and Hospitality Aide) during dining observations according to facility's policy, practice, and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24, included, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. Know how to wash hands with soap and water: Wet hands with water. Apply the manufacturer's recommended amount of product to your hands. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities recommend cleaning hands with soap and water for at least 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times and scrubbing hands and fingers with soap. 1. On 5/24/24 at 8:17 AM, the surveyor observed the Director of Activity (DA) inside the room deliver Resident #31's breakfast tray. The Licensed Practical Nurse (LPN) asked Certified Nursing Aide #1 (CNA#1) who was also inside the room attending to the roommate of the resident to get a box of gloves outside the room. The LPN checked the resident's drawer and nightstand table for gloves and did not find gloves. CNA#1 at that time was wearing a pair of gloves, doffed off (removed) gloves, exit the room without performing hand hygiene. CNA#1 returned to the room with a box of gloves, donned (put on) a new pair of gloves without performing hand hygiene, and assisted the roommate with breakfast. LPN#1 also donned a new pair of gloves without performing hand hygiene after touching the resident's immediate [resident's nightstand table] environment. At that time, the DA and the LPN both repositioned Resident #31 in the bed. The DA set up the breakfast tray. On that same date and time, the surveyor in the presence of the LPN asked CNA#1 about the gloves stored inside the CNA uniform pocket. CNA#1 acknowledged that she was using them (gloves) during the resident's care. The LPN also acknowledged the surveyor's concern regarding CNA#1's hand hygiene and gloves inside the uniform pocket. The LPN stated that the CNA should not store gloves in her uniform pocket for infection control and should perform hand hygiene before and after gloves. At 8:26 AM, Resident #31 took a bite of food, and then the LPN administered all meds. The LPN then performed handwashing for 22 seconds under the stream of running water. The surveyor notified the LPN of the concern regarding scrubbing her hands under a stream of running water and the LPN stated that she did not realize that she was scrubbing her hands under water and that she should have scrubbed her hands outside the water. On 5/24/24 at 8:38 AM, the surveyor interviewed CNA#1 in the 2nd-floor dining area. The CNA informed the surveyor that she was an agency aide. The CNA stated that she should not store gloves inside her uniform pocket. She further stated that she should perform hand hygiene before and after using gloves and other PPE (personal protective equipment). The surveyor then asked the CNA why she stored gloves in her pocket and did not perform hand hygiene when the surveyor observed her in the resident's room above. The CNA responded that she was moving around and there were no gloves inside the room at that time. On 5/24/24 at 8:53 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) in the presence of another surveyor. The surveyor notified the IP/RN of the above findings and concerns regarding CNA#1 and the LPN. The IP/RN stated that regardless of the situation, the CNA and nurse should follow the facility's protocol and policy with hand hygiene and PPE use. 2. On 5/28/24 at 8:44 AM, the surveyor observed the Hospitality Aide (HA) provided hand wipes to all seven residents in the 3rd-floor day room and assisted all residents with their hand hygiene in preparation for breakfast. After the HA collected the used hand wipes, the HA then went to the sink in the day room and performed handwashing. The HA did not wet her hands after turning on the faucet, immediately scrubbed her hands for 26 seconds, then washed off the soap, dried her hands with paper towels, and discarded the used paper towels into the garbage. Afterward, the surveyor interviewed the HA regarding her handwashing. The HA stated the above handwashing as the proper way of performing handwashing according to the education she received from the Director of Nursing (DON). The HA acknowledged and stated that she did not have to wet her hands prior to applying soap and when scrubbing her hands. On that same date at 8:50 AM, the surveyor observed CNA#2 in the 3rd-floor day room assisting the HA. CNA#2 performed handwashing for 8 (eight) seconds. During an interview of the surveyor with CNA#2, CNA#2 stated that handwashing should be at least 20 seconds according to the education and in-service she received from the DON and the previous Assistant Director of Nursing. The surveyor asked the CNA if she scrubbed her hands for 20 seconds and she stated Maybe I did it fast. The surveyor then notified the CNA of the concern that she scrubbed her hands for 8 seconds. The CNA acknowledged that she felt the same way that it was not 20 seconds. On 5/28/24 at 8:55 AM, the surveyor interviewed the IP/RN in the 3rd-floor unit near the day room in the presence of another surveyor. The surveyor notified the IP/RN of the above findings and concerns regarding HA and CNA#2 about handwashing. The IP/RN stated that it was not appropriate what the CNA and the HA performed during handwashing and will re-educate both staff about proper handwashing to wet hands first and it should be done for at least 20 seconds the hand scrubbing. On 5/29/24 at 12:02 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, [NAME] President of Clinical Services (VPoCS), and VP of Risk Management (VPoRM). The surveyor discussed the above concerns regarding hand hygiene. A review of the facility's Handwashing/Hand Hygiene Policy with a review date of 5/01/24 that was provided by the VPoCS included that the facility considers hand hygiene the primary means to prevent the spread of infections. Use an ABHR; or, alternatively, soap and water for the following situations: before and after direct contact with residents; before donning gloves; before moving from a contaminated body site to a clean body site during resident care; after removing PPE; before and after handling food; and before and after assisting a resident with meals. Washing hands: wet hands first with water, then apply an amount of product recommended by the manufacturer to hands, rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers On 5/30/24 at 11:59 AM, the survey team met with the LNHA, DON, VPoRM, and VPoCS. There was no further information provided by the facility management. NJAC 8:39-19.4(a)(1)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was free from alleged abuse. This deficient practice occurred for one (1) of four (4) residents reviewed for abuse (Resident #6) and was evidenced by the following: Refer to 610 F On 5/21/24 at 11:04 AM, Resident #6 stated the following: On 5/06/24 a phlebotomist and a Certified Nursing Assistant (CNA) held both of the residents arms down against the residents will to obtain blood work that the resident did not agree to. As a result the resident sustained bruises to both forearms. Resident #6 then stated that he/she was frustrated and she reported the incident to the facility (RN on duty) on the next day 5/07/24. The resident informed the surveyor that he/she had laboratory (lab) blood work drawn on 5/03/24 and wanted to know why he/she needed to have blood drawn again on 5/06/24. On 5/22/24 at 9:30 AM, the surveyor again interviewed Resident #6, regarding the lab work drawn on 5/06/24. The resident stated that she had lab drawn on 5/03/24 and was not informed of the result. On 5/06/24, the phlebotomist came wanted to draw blood again. The resident refused. When Resident #6 inquired why blood had to be drawn again, the phlebotomist could not provide the rationale for the lab work. Resident #6 stated that he/she she did not agree to the blood being drawn again. The phlebotomist then asked the CNA to hold the resident's arms down for the blood work and the resident was screaming and was frustrated. After the blood work, he/she developed bruises to both forearms. On 5/23/24 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) about the concerns that were reported by Resident #6. The DON stated that she was aware of the issue with the blood drawn on 5/06/24 and an incident report was generated. The DON added that she did not investigate the issue because she knew what happened and confirmed it was not reported to the New Jersey Department of Health (NJDOH) until after surveyor inquiry on 5/23/24. On 5/23/24 at 12:41 PM, the DON provided the Incident/Accident (I/A) Report. According to the I/A Report provided dated 5/07/24 timed 5:00 PM, there was a diagram that indicated bruises on the forearms. A Registered Nurse (RN) documented on 5/07/24, Resident #6 stated on 5/07/24 that the bruise happened when the CNA assisted with lab work on 5/06/24. The Interdisciplinary notes dated 5/08/24 indicated the following: Resident #6 stated that their arm was held tight while lab work was being drawn. The line of the tourniquet could be seen on bilateral arms (2 days later on 5/08/24). Monitor for worsening. Educate technician. A review of the Progress Notes dated 5/07/24 revealed that the resident reported the incident to to the RN on 5/07/24. The Resident Representative visited the resident on 5/11/24, observed the bruises and reported it to the administrative staff. The resident reported the alleged incident to the Licensed Social Worker (LSW) on 5/16/24. The LSW informed the facility and reported the incident to the DON on 5/16/24. There was no investigation of the alleged abuse and it was not reported to the NJDOH until 5/23/24. The facility did not initiate an investigation even after the incident was reported on 5/07/24, 5/11/24 and 5/16/24. The CNA was not asked to provide a statement regarding the incident. The phlebotomist was not contacted and did not have a statement attached to the I/A Report provided dated 5/07/24. There was no documented evidence that the phlebotomist was educated as stated in the Interdisciplinary Notes dated 5/08/24. On 5/23/24 at 01:14 PM, the surveyor interviewed the DON in the presence of the survey team regarding the allegations of abuse made by Resident #6 to the surveyor. The DON stated that she was already aware of the bruises on the bilateral arms. The DON stated that the incident actually took place on 5/06/24. The DON confirmed that an investigation had not yet been started (17 days later). On 5/28/24 at 12:23 PM, the surveyor interviewed the CNA who the resident alleged held their arms down for the blood work. The CNA denied that she held Resident #6's arms down for blood work on 5/06/24. The CNA stated that she requested not to be assigned to Resident #6. There was no evidence that the facility provided regarding the phlebotomist was in-serviced on abuse or had reported the incident to the lab. On 5/28/24 at 02:30 PM, the DON provided the surveyor with the investigation summary and conclusion. A statement from Resident #6 dated 5/23/24 (17 days after the incident occurred) which documented that both the phlebotomist and the CNA held Resident #6's arms down to draw blood. The statement from the phlebotomist was dated 5/24/24 (18 days after the incident) and indicated that the resident was being aggressive and the Phlebotomist asked the CNA to help. An undated statement from the RN indicated that she heard the Resident #6 screaming and she went to the room while the blood work was being drawn. A statement dated 5/24/24 from the CNA, that was already in the room, and documented that she heard the resident asking why he/she had to have blood drawn again. The resident was screaming and she came to calm the resident. Further review of the above information, the facility did not investigate timely or report the incident to the NJDOH as required as revealed by the Long Term Care Reportable Event Summary was completed on 5/23/24 after the surveyor inquiry, 15 days later after the facility was made aware of the incident. On 5/29/24 at 12:41 PM, the surveyor interviewed the LSW. The LSW stated that Resident #6 reported the incident on 5/16/24 and she stated she was not made aware of aware of any prior allegations against staff. A review of the facility's Abuse Investigation and Reporting Policy that was provided by the [NAME] President of Risk Management (VPoRM) included the procedures that should have been followed for an investigation as follows: The Policy Dated: 05/01/24 revealed: Intent: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Procedure: Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. On 5/31/24 at 11:56 AM, the survey team met with Licensed Nursing Home Administrator, DON, [NAME] President of Clinical Services, VPoRM, Administrator In Training, and Infection Preventionist/Registered Nurse. There was no additional information provided by the facility management. NJAC 8:39-4.1(a)(5)

Complaint #NJ171307 Based on interview, record review and review of pertinent documents, it was determined that the facility failed to develop comprehensive policies and consistently implement procedures to prevent and investigate abuse by failing to ensure: a) a system was in place to pre-screen contracted staff timely and provide training on the current facility abuse policies, b) all residents who may have been abused were identified and a documented system was in place to rule out abuse, c) all involved persons, including potential witnesses, were identified, and a documented interview was completed per facility policy, and d) a system was in place to ensure a complete and thorough investigation occurred and was documented. This deficient practice occurred for two (2) of two (2) residents (Resident #42 and #85) who alleged sexual abuse by a contracted certified nurse aide. This deficient practice was evidenced by the following: Refer to 610F On 5/22/24 at 10:40 AM, the Licensed Nursing Home Administrator (LNHA) provided the survey team with the Abuse Prohibition Policy and Procedures that was required as part of the entrance documents provided by the facility. The unsigned document, contained 19 unnumbered pages, included, but was not limited to the following: -Freedom from Abuse, Neglect, and Exploitation Policy/Procedure, dated 6/01/23. Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Procedure: This policy will include: 1. Free from Abuse and Neglect. 2. Free from Misappropriation/Exploitation. 3. Free from Involuntary Seclusion. 4. Right to be Free from Physical Restraints. 5. Right to be Free from Chemical Restraints. 6. Not Employ/Engage Staff with Adverse Actions. 7. Develop/Implement Abuse/Neglect, etc. Policies. 8. Reporting of Reasonable Suspicion of a Crime. 9. Reporting of Alleged Violations. 10. Investigate/Prevent/Correct Alleged Violation. -The next page revealed Subject: Freedom from Abuse, Neglect, Misappropriation, Exploitation with the same Intent. Procedure: 1. The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, or involuntary seclusion. [The remainder of the page was left blank and there was no documented process or procedure]. -Another page revealed the Subject: Freedom from Abuse, Neglect, etc. and had the same Intent. Procedure: 1. The facility will develop and implement written and policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriate of resident property. b. Establish policies and procedures to investigate any such allegations, and c. Include training. [The remainder of the page was left blank and there was no documented process or procedure]. -Another page revealed the Subject: Reporting of Reasonable Suspicion of a Crime and Alleged Violations and had the same Intent. Procedure: . 4. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Have evidence that all alleged violations are thoroughly investigated. b. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. c. Report the results of all investigation to the administrator or his or her designated representative and to other officials in accordance with State Law . 9. The facility Risk Manager or Designee will be responsible for the Form completion when a staff member does not complete one and will also be responsible for the investigation and documentation of final findings. The document did not specify procedures to follow to screen contracted employees, educate contracted employees, identify, and protect other residents that may have been abused when an allegation of abuse was made, and what specific procedures were to be followed to conduct a thorough investigation. A review of a Reportable Event Record (RER) that had been submitted to the Department of Health (DOH) by the facility Director of Nursing (DON) on 02/09/24 at 12:34 PM revealed: Type of Incident: Staff- to- Resident Abuse. Narrative: Resident #85 stated private part was washed roughly by the nursing assistant who got him/her ready for bed on Saturday evening 02/03/24. Resident #85 stated heard Resident #42, speaking in a foreign language and stated the same thing and that's why he/she reported this issue today 02/08/24. Resident #42, upon interview [untimed] stated that during care a few days ago, a [color] male nursing assistant with curly hair entered the room, took the resident do the bathroom and put his mouth on [genital organ]. What interventions were implemented after the incident: Both residents were interviewed and total body assessment were completed immediately. Family and physicians were notified. Police Department was notified. Investigation on going. The undated Investigation Summary submitted by the facility revealed: Investigation: On 02/08/24, Resident #85 reported to the nurse on duty, that he/she did not like the way the male nursing assistant who provided care on Saturday evening and washed his/her private part. The nurse informed the DON who went to further interview Resident #85. Resident #85 stated that on 02/03/24 the aide was washing his/her private area kind of in a rough manner. Resident #85 stated that on 02/03/24, heard Resident #42 talking in a [foreign language] in the hallway about the same thing. DON and a [foreign language] speaking staff interviewed Resident #42. Resident #42 explained maybe two nights before, around midnight, a male went into his/her room, led to the bathroom and while in the bathroom, the aide put his mouth on his/her [genital organ]. Resident #42 stated that he/she told his/her family member (FM). About the incident. The DON placed a call to the FM. The involved Certified Nurse Aide (CNA) was interviewed and denied the accusation. The CNA stated he was assisting Resident #42 to the toilet when the FM arrived at the floor, the CNA left when FM entered the room. Both patients were interviewed by the Police. The roommate of Resident # 85 was present in the room during all interactions and denied seeing or hearing any incidents. Both Residents had complete skin assessment and no injuries noted. Summary/Conclusion: -The Allegation was Unsubstantiated. -According to the staff, Resident #42's FM visited right when the CNA was with Resident #42 and entered the room before the CNA left. -The CNA stated he only assisted the patient at that time before his/her FM visited and that the FM met the CNA in the bathroom with the resident when he was sitting Resident #42 down on the toilet and left the resident in the care of the FM. - All alert and oriented patients on the unit who were cared for by the employee were interviewed and did not report any concerns. Interventions: -Both Resident #42 and #85 were educated on reporting incidents immediately. -FM was educated on reporting incidents regardless of the patients' cognition or description of the incident. -Both patients were assessed, complete body assessment was done with no abnormalities noted. -Both patients were referred for psychology consult for emotional support. -Incident reported to the Ombudsman. -The employee was an agency staff; he was suspended immediately pending the investigation and will not return. On 5/23/24 at 10:30 AM, the surveyor reviewed the electronic Medical Record (eMR) for Resident #85 as follows: The admission Record (AR, or face sheet, an admission summary) revealed diagnoses which included, but were not limited to; type 2 diabetes, Parkinson's Disease and major depressive disorder. A review of the 22-page current Care Plan (CP) with a target date of 7/19/24 and including resolved items, did not reveal a Focus related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. The multi-disciplinary progress notes (PN) from 01/29/24 through 02/26/24 did not show a nurses note or physician documentation related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. A physical, psychosocial or any other type of assessment related to the allegation of sexual abuse was not located in the eMR or paper medical record. The most recent Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated the resident scored a 14/15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact. A review of Resident #42's EMR showed the following: The AR had diagnoses that included, but were not limited to, major depression disorder and unspecified dementia. The current 21-Page CP, including resolved items, and had a target date of 6/07/24, did not show a Focus related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. Reviewed all interdisciplinary PN from 02/02/24 through 02/20/24 which did not reveal a nurses note or physician documentation related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. A physical, psychosocial or any other type of assessment related to the allegation of sexual abuse was not located in the eMR or paper medical record. A review of the most recent Quarterly MDS indicated the resident scored a 9/15 on the BIMS which indicated the resident was moderately cognitively impaired. On 5/28/24 at 9:20 AM, the [NAME] President of Risk Management (VPoRM) provided the surveyor with what he stated was the completed facility investigation and provided the RER. The surveyor then requested all documents from the DON, in the presence of the VPoRM regarding statements and any investigative documents reviewed. The DON pointed to her type-written summary and stated, those were the statements. On 5/28/24 at 10:30 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) what the process was regarding hiring agency staff and educating them on abuse. The LNHA stated, the agency staff had an orientation and was in-serviced by the DON and the process was the same as for a new employee. The process was the same for all new employees and stated was not sure of the process. The surveyor asked if the abuse policy that was provided was the only facility abuse policy and the LNHA stated he will look for any other specific abuse policy. On 5/28/24 at 11:10 AM, the surveyor interviewed the Director of Social Services (DSS) who stated she had been at the facility for three months. She stated she was the Grievance Officer. The surveyor asked what the protocol for abuse was. She stated if she received an allegation of abuse she would inform the LNHA and DON. She stated she interviewed residents and family and would document in the grievance book. At that same time, the surveyor asked the DSS if she had a grievance for abuse from Resident #85 and #42 and she stated, not that she was aware of. The surveyor asked what constituted abuse and the DSS stated if a resident felt they were touched inappropriately, or any signs of bruises that she would interview the resident and anyone involved. The surveyor asked if there was a process for the investigation and she stated she would look for it. On 5/28/24 at 11:32 AM, the survey team met with the LNHA, DON, [NAME] President of Clinical Services (VPoCS) and VPoRM. The surveyor asked if there was anything that was provided as guidance to staff regarding what was supposed to completed when an allegation of abuse occurred. At that time, when asked about the investigation related to Resident #85 and #42, the DON confirmed there were no other individual statements taken from any other residents. The LNHA then confirmed he did not review the investigation as he was not at the facility during that time. A review of the facility provided investigation revealed there were two statements attached, one untimed statement from the accused CNA, dated 02/08/24 and another document with a typed statement, undated and untimed. There were no assessments, interviews from other staff, residents, the FM or any of the alleged documents referenced per the RER, and there were no attached police reports. The education for the CNA that was attached to the facility provided investigation included a copy of an abuse policy from a completely different facility located in another town and did not have the same company name. On 5/28/24 at 01:01 PM, the VPoRM provided a second abuse policy titled, Abuse Investigation and Reporting Policy, dated 5/01/24 which included: Intent: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Procedure: Role of the Administrator 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will suspend immediately any employee who has been accursed of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: The individual conducting the investigation will, as a minimum. -Review the completed documentation forms. -Review the resident's medical record to determine events leading up to the incident. - Interview the person(s) reporting the incident. - Interview the resident. -Interview other residents to who the accused employee provides care or services. - Interview the residents's roommate, family members, and visitors. The following guidelines will be used when conducting interviews: . -Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. On 5/29/24 at 12:52 PM, the above concerns were shared with the LNHA, DON, VPoCS and VPoRM and there was no additional information provided during the exit conference held on 05/31/24 at 11:56 AM. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/24/24 at 10:29 AM, the surveyor interviewed the Occupational Therapist (OT). The OT stated [he/she] recalled an incident that happened on the second floor of the facility in the activity room/dining area. The OT stated the resident was seated in their wheelchair and the Director of Activities (DA) forcibly pulled the resident away from the table. The OT said it was on camera and the resident filed a complaint. The OT stated that was the last time [he/she] had seen the DA. On 5/28/24 at 11:29 AM, the surveyor observed Resident #35 in their room watching television and socializing with her peer. Resident #35 was noted to be in their wheelchair and greeted the surveyor at the door and motioned for the surveyor to come in. The resident stated he/she had been at the facility for eight years. On that same date and time, Resident #35 stated the DA was loud and inappropriate in her approach. Resident #35 stated that the DA wanted him/her to leave the room and the resident was not ready to. Resident #35 stated, I was pushed against my will, I told her to stop doing it and she kept doing it. The resident stated he/she reported it to administration and there were other people present but cannot remember who was there. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 15 out of 15 indicating intact cognition. A review of the Grievance/Complaint Investigation Report dated 5/24/23 revealed Resident #35 filed a grievance with the Assistant Director of Nursing (ADON). The section referencing to documentation of grievance/complaint, documentation of facility follow up and resolution of grievance/complaint read as followed: -Describe concern briefly using factual terms: (attach resident/family concern form)? The resident reported he/she was removed from the food committee group meeting by the DA when she asked to postpone the meeting when other departments could be present. Resident did not appreciate being spoken to in the matter she/he was. -What other action to resolve concern (be specific)? The DA was asked to be mindful of her tone of voice with the residents, as she may come as speaking to loudly and to utilize an approach to gently guide the resident(s) to another aspect or task within the current activity without making them feel interrupted or excluded. -Was the grievance/complaint resolved? Yes, the administrator and ADON informed the resident that the staff member was addressed regarding her approach with the resident. The resident was satisfied with the resolution. A review of the attached paperwork to the Grievance/Complaint Investigation Report revealed a statement dated June 8, 2023 by the ADON. The statement read as followed. Upon the beginning of afternoon rounds, I entered the second-floor day room and noticed the residents enjoying the activity being held. I approached the resident where he/she was noted to be participating. The resident explained there was a situation with the DA, where resident felt the DA was loud. I explained to the resident that the DA tends to be loud in nature at times which he/she understood. I assured the resident I would further be speaking to the DA to address resident's concerns. I further followed up with the DA regarding the resident's concern from the meeting. I addressed the concern of the resident perceiving her being loud, the DA agreed she would come to nursing leadership for further interventions when applicable. I returned to the resident and assured the resident I had resolved the matter with the DA. The resident was pleased with my intervention. On 5/29/24 at 10:00 AM, the surveyor interviewed the LNHA in the presence of the survey team and the LNHA stated the DA was terminated shortly after, and the facility has no other statements to provide. The LNHA stated the facility does not have video footage of the incident and the surveillance was only kept for 24-48 hours. On 5/29/24 at 11:04 AM, the surveyor interviewed the LNHA in the presence of the survey team. The surveyor asked the LNHA the steps the facility would take for a resident that complained about an abuse allegation. The LNHA stated they would send the person accused of abuse home, call the police, notify family, Ombudsman, and DOH. The LNHA further stated after notifying everyone, the facility would start to investigate, speak to the resident and any witnesses, and come to a conclusion. On 5/30/24 at 12:41 PM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA stated Yes I learned and need to get statements moving forward. The LNHA stated we were missing statement, and the facility did not do a thorough investigation. NJAC 8:39-4.1(a)5 2. The surveyor reviewed a Reportable Event Record (RER) that had been submitted to the Department of Health (DOH) by the facility DON on 02/09/24 at 12:34 PM revealed: Today's date: 02/08/24 Date of Event: 02/08/24 Time of Event: 6:30 PM Was this a significant event? Yes. Type of Incident: Staff- to- Resident Abuse. Narrative: Resident #85 stated private part was washed roughly by the nursing assistant who got the resident ready for bed on Saturday evening 02/03/24. Resident #85 stated heard Resident #42, speaking in a foreign language and stated the same thing and that's why he/she reported this issue today 02/08/24. Resident #42, upon interview [untimed] stated that during care a few days ago, a [color] male nursing assistant with curly hair entered the room, took the resident do the bathroom and put his mouth on [genital organ]. 2. Prior to the event, was a plan of care developed that addressed this issue: No. 3. What interventions were implemented after the incident/event? For example, supervision, resident sent to hospital, CNA suspended. Please describe investigative findings/conclusions: -Both residents were interviewed and total body assessment were completed immediately 02/08/24. -Staff identified and was send home immediately. -Family and physicians were notified. -Police Department was notified. Investigation on going. The undated Investigation Summary submitted by the facility revealed: Investigation: On 02/08/24, Resident #85 reported to the nurse on duty, that the resident did not like the way the male nursing assistant who provided care on Saturday evening and washed resident's private part. The nurse informed the DON who went to further interview Resident #85. Resident #85 stated that on 02/03/24 the aide was washing his/her private area kind of in a rough manner. Resident #85 stated that on 02/03/24, heard Resident #42 talking in a [foreign language] in the hallway about the same thing. When Resident #85 was asked why did not report the incident sooner, resident stated it had been on resident's mind to report it but he/she did not. DON and a [foreign language] speaking staff interviewed Resident #42. Resident #42 explained maybe two nights before, around midnight, a male went into resident's room, led him/her to the bathroom and while in the bathroom, the aide put his mouth on his/her [genital organ]. Resident #42 stated that he/she told his/her family member (FM). About the incident who told the resident to let it go and stop talking about it. The DON placed a call to the FM and asked why the FM did not report the incident. I did not know what to make of it, my [parent] is confused and has been upset about [spouse] being in the hospital and I thought that is what was bothering him/her, [parent] is very private and does not want anyone to care for him/her The involved CNA#3 was interviewed and denied the accusation. CNA#3 stated he was assisting Resident #42 to the toilet when the FM arrived at the floor, the CNA left when FM entered the room. Both residents were interviewed by the Police. The roommate of Resident # 85 was present in the room during all interactions and denied seeing or hearing any incidents. Both Residents had complete skin assessment and no injuries noted. Summary/Conclusion: -The Allegation was Unsubstantiated. -According to the staff, Resident #42's FM visited right when CNA#3 was with Resident #42 and entered the room before the CNA left. -CNA#3 stated he only assisted the resident at that time before his/her FM visited and that the FM met the CNA in the bathroom with the resident when he was sitting Resident #42 down on the toilet and left the resident in the care of the FM. - All alert and oriented patients on the unit who were cared for by the employee were interviewed and did not report any concerns. Interventions: -Both Residents #42 and #85 were educated on reporting incidents immediately. -FM was educated on reporting incidents regardless of the residents' cognition or description of the incident. -Both residents were assessed, complete body assessment was done with no abnormalities noted. -Both residents were referred for psychology consult for emotional support. -Incident reported to the Ombudsman. -The employee was an agency staff; he was suspended immediately pending the investigation and will not return. On 5/23/24 at 10:30 AM, the surveyor reviewed the electronic Medical Record (eMR) for both residents to determine compliance with the investigation submitted by the DON. Resident #85's AR revealed diagnoses which included, but were not limited to; type 2 diabetes, Parkinson's Disease and major depressive disorder. A review of the 22-page current CP with a target date of 7/19/24 and including resolved items, did not reveal a Focus related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. A review of the multi-disciplinary PN from 01/29/24 through 02/26/24 did not reveal a nurses note or physician documentation related to the allegation of sexual abuse that occurred on 02/03/24 and was reported on 02/08/24. A physical, psychosocial or any other type of assessment related to the allegation of sexual abuse was not located in the eMR or paper medical record. There was no assessment and complete body assessment completed and documented as per the facility documented interventions. There was no psychology consult for emotional support documented in the medical record and as per the facility documented interventions. The most recent Annual MDS of Resident #85 indicated a BIMS score of 14 out of 15 that showed resident was cognitively intact. On 5/28/24 at 8:20 AM, the surveyor conducted an interview with Resident #85 while the resident was in the room eating breakfast. The surveyor asked the resident about any concerns that occurred with any staff. Resident #85 stated, a CNA touched him/her in the private area inappropriately and stated the CNA did it when he was getting Resident #85 ready for bed. Furthermore, Resident #85 stated the same day a few hours later, the resident overheard Resident #42 stating the same CNA touched Resident #42 touched him/her inappropriately and Resident #85 reported it 1-2 days later. Resident #85 confirmed the police came and interviewed Resident #85. When asked about the roommate being present at the time, Resident #85 stated the curtain was drawn. On 5/28/24 at 8:53 AM, the surveyor requested, from the Licensed Nursing Home Administrator (LNHA) and the [NAME] President of Risk Management (VPoRM) the investigations related to Resident #42 and Resident #85's allegations of abuse and specifically requested the documents in their entirety, including any statements and any documents utilized to complete the investigation and completed because of the investigation. On 5/28/24 at 9:20 AM, the VPoRM provided the surveyor with, what he confirmed, was the completed facility investigation. The surveyor initially reviewed the documents which included one document titled Witness Statement from the accused CNA#3, and a type written undated document. The surveyor again requested all documents from the DON, in the presence of the VPoRM regarding statements and any investigative documents that were reviewed to determine the conclusion of the investigation. The DON pointed to her type-written summary and stated, those were the statements. On 5/28/24 at 9:35 AM the DON, in the presence of the survey team, stated that the two documents provided, one titled Witness Statement and the other untitled document were the only separate statements as part of the investigation. The surveyor asked why the typed statement was not dated and she stated, it was a mistake. The surveyor requested the information when the accused CNA#3 worked and requested the time punch logs. The surveyor asked the DON about any assessments that were completed as alleged and the DON stated, that usually when we do a regular body assessment, we put a note in the [eMR]. At that time, the surveyor notified the DON that there were no documented assessments in the eMR and she did not provide any assessments for any other residents that may have been affected or the alleged victims. The DON stated, if it is not there, then I did not do it. The surveyor asked the DON when the accused CNA#3 provided a statement, and the DON stated he was asked to come in to only fill out a statement and she will look for additional documents related to the investigation. A further review of the facility provided investigation revealed the following documents: -A copy of a police officer's card (there were no police reports included in the investigation). The surveyor requested a copy of the police reports from the VPoRM as the facility confirmed they never requested the reports. - The RER - A handwritten Witness Statement Date of Incident: [Left Blank]; Time of Incident: [Left Blank]; Date and Shift of Witness Involvement: 7-3; Job Title: CNA#3; Please describe what happened in detail: The bed alarm went off for [Resident #42's room] so I went to check since [CNA #4] was with another resident. I took [him/her] to bathroom when [he/she] asked me when I arrived to [his/her] room. The FM came into the bathroom while I was sitting the resident down. I then left and the FM was going to help [Resident #42] afterwards. [Resident #42] then came a couple of hours later exclaiming that I did inappropriate things to [him/her]. I informed nurse and the family when they came back. Signed by CNA#3, Date Completed: 02/08/24. - A type written document, undated and signed by [CNA #4] revealed: I was assigned to Resident #42 for the shift; while I was assisting another patient (also known as resident) next door, the other CNA came to me to tell me that Resident #42 needed help. I asked him to go help the resident as I was busy. When I came out of the other patient's room, I saw the FM of Resident #42 in the hallway and he/she asked me where Resident #42 was and I told FM they took him/her to the bathroom; the FM opened the bathroom door to check on the resident and I saw CNA#3 leaving the room. After a while, the FM left, Resident #42 was saying no good, no good, but when I asked [him/her] what happened [he/she] did not say anything. I helped the nurse take Resident #42 back to their room. The document was signed and undated. There was no documented statement from Resident #42 or the roommate, Resident #85, the FM, nurse, or any other staff or residents who may have been a witness. The Investigation Summary: On 02/08/24, Resident #85 reported to the nurse on duty, that he/she did not like the way the male nursing assistant who provided care on Saturday evening and washed his/her private part. The nurse informed the DON who went to further interview Resident #85. Resident #85 stated that on 02/03/24 CNA#3 approached him/her and asked if the resident was ready to be washed for bed. Resident #85 stated that CNA#3 washed him/her, felt was washing his/her private area kind of in a rough manner. No documented statements from the nurse on duty or the DON were included and no statements were obtained from any other staff or residents cared by CNA#3 . Resident #85 stated that on 02/03/24, heard Resident #42 talking in a [foreign language] in the hallway about the same thing. When Resident #85 was asked why did not report the incident sooner, resident stated it had been on resident's mind to report it but he/she did not. DON and a [foreign language] speaking staff interviewed Resident #42. There was no statement included in the investigation from the DON or foreign speaking staff. Resident #42 explained maybe two nights before, around midnight, a male went into resident's room, a male with a lot of hair, medium built-in stature, led the resident to the bathroom and while in the bathroom, the aide put his mouth on resident's [genital organ]. There were no additional details included in the description as to what was provided to the DOH, and there were no documented statements from Resident #42. When the DON asked Resident #42 what the resident did about it and why the resident did not report it. Resident #42 stated he/she chased CNA#3 out of the bathroom and told the FM who then told him/her to let it go and stop talking about it. There was no additional information added from the DOH submission and no documented statements included. The DON placed a call to the FM. The FM explained that visited Resident #42 multiple times that day and spoke to Resident #42 who then told the FM what happened. The DON placed a call to the FM and asked why the FM did not report the incident. I did not know what to make of it, my [parent] is confused and has been upset about [spouse] being in the hospital and I thought that is what was bothering him/her, [parent] is very private and does not want anyone to care for him/her. DON educated FM to immediately report any incidents. The involved CNA#3 was interviewed and denied the accusation. CNA#3 stated he was assisting Resident #42 to the toilet when the FM arrived at the floor, the CNA left when FM entered the room. The documented Witness Statement from the CNA differs from this account and from CNA #4's documented statement and was not further investigated. CNA #4, the assigned CNA stated that the FM spent some time with Resident #42, then left with no issues. CNA #4 stated that sometime later after the FM left, she saw Resident #42 in the hallway upset saying no good but was redirected back to resident's room. A Nurse on duty stated that the FM visited multiple times during the shift. She stated that nothing was reported to her at that time and the FM left. There was no statement included from the nurse in the investigation. Both residents were interviewed by the police department: Resident #85 reported to the police, in the presence of the DON, that felt as if washed roughly. Resident #85 told the officer that reported the incident because Resident #42 said the same thing in a foreign language. Resident #42 repeated the same thing he told the DON to the officer. The roommate of Resident # 85 was present in the room during all interactions and denied seeing or hearing any incidents. Both Residents had complete skin assessment and no injuries noted. Summary/Conclusion: (Differed from the original that indicated the allegations were unsubstantiated.) The facility could not conclude whether the nursing assistant did put his mouth on Resident #42's genital, or whether CNA#3 roughly washed or fondled Resident #85. According to the staff, the FM visited right when the nursing assistant was with the resident and entered the room before the staff left. CNA#3 stated that he only assisted the patient at that time before the FM visited and that the FM met him/her right when he/she was sitting him/her down on the toilet; and that he left the patient in the care of the FM. The resident's FM stated that Resident #42 did not tell him/her about the incident when visiting and met him/her in the bathroom, until the FM came back later about 8-8:30 PM. All alert and oriented residents on the unit who were care for by the employee were interviewed and did not report any concern with regards to him rendering care. On 5/28/24 at 10:04 AM, the surveyor asked the DON, who was looking through documents in her office, about any additional investigation documents including statements and the DON stated she will continue to look and asked Human Resources for the punch in and out logs for CNA#3. The DON stated, if she did not have anything else she would let the surveyor know. On 5/28/24 at 10:21 AM, the DON stated she cannot locate any other documents. On 5/28/24 at 10:30 AM, the LNHA provided the dates CNA#3 worked at the facility which included the following dates and punch in and out times: 1. 01/28/24- 7:26 AM-3:09 PM 2. 01/28/24- 3:09 PM-10:55 PM 3. 02/03/24- 3:10 PM-10:51 PM 4. 02/04/24- 7:13 AM-3:00 PM 5. 02/04/24-3:00 PM -10 (area x) 6. 02/06/24-8:38 AM-3:11 PM 7. 02/06/24- 3:13 PM-10:41 PM 8. 02/08/24- 8:42 AM-3:02 PM On 5/28/24 at 11:10 AM, the surveyor interviewed the Director of Social Services (DSS) who stated she had been at the facility for three months. She stated she was the Grievance Officer. The surveyor asked what the protocol for abuse was. She stated if she received an allegation of abuse, she would inform the LNHA and DON. She stated she interviewed residents and family and would document in the grievance book. On that same date and time, the surveyor asked the DSS if she had a grievance for abuse from Resident #85 and #42 and she stated, not that she was aware of. The surveyor asked what constituted abuse and she stated if a resident felt they were touched inappropriately, or any signs of bruises that she would interview the resident and anyone involved. The surveyor asked if there was a process for the investigation and she stated she would look for it. On 5/28/24 at 11:20 AM (Resident #85) and 01:01 PM (Resident # 42), the VPoRM provided copies of two police reports which he obtained from the police department. The repots both revealed the DON reported the allegations on 02/09/24 at 9:07 AM. The Investigation Report for Resident #42 detailed a narrative and the officer interviewed the resident (DON not indicated as present for this interview as documented in the summary) and the report documented . the CNA escorted the resident to the bathroom, began to fondle his/her genitals and performed [inappropriate sexual action] on Resident #85 .The narrative for Resident #42 documented . that after the resident heard the account being yelled by Resident #85, he/she informed the staff the he/she was sexually assaulted on 02/03/24 by the same CNA (DON not indicated as present for this interview as documented in the summary) . Resident #42 was escorted to the bathroom by CNA#3, washed genitals, and fondled his/her genitals and then told CNA#3 to stop . On 5/28/24 11:32 AM, the survey team met with the LNHA, DON, [NAME] President of Clinical Services (VPoCS) and VPoRM. The surveyor asked if there was anything that provided guidance to staff regarding what is supposed to be completed in the event of an allegation of abuse. At that time, when asked about the investigation related to Resident #85 and #42, the DON confirmed there were no other individual statements taken from any other residents and the LNHA confirmed he did not review the investigation. On 5/28/24 at 11:35 AM the surveyor, asked the DON where the supporting documents regarding any interviews of any other residents and any other supporting documentation regarding the investigations. The DON stated I included what I had, everyone that was able to tell me, but only the alert and oriented residents could give me a statement and I did not go to the non-alert residents that could not speak. The At that same time, the LNHA stated we go to the oriented person first, and asked staff if they saw something. The LNHA did not explain why there were no documented interviews or assessments completed with other residents and why non-alert residents were not assessed. The DON then stated, she spoke to residents as soon as she found out and it was not documented. On 5/28/24 at 11:50 AM, in the presence of the survey team, the surveyor asked the LNHA about who was responsible to ensure an investigation was completed and he confirmed that he was responsible for the overall process and ensuring the statements were completed. The DON stated, it was just the two CNA's, the one involved and the other one. On 5/28/24 at 12:27 PM, the surveyor interviewed the FM of Resident #42, in the presence of the survey team, regarding the incident. The FM stated the resident told him/her that the nurse did something to me, he put is mouth on [private area]. The FM also stated that other staff, including a nurse, informed the FM what happened with Resident #42 and CNA#3. The FM also stated that Resident #42 informed his/her spouse about what happened. When the surveyor asked the FM if he/she was ever asked to document a statement, the FM responded, never. The FM also remembered speaking with the CNA who told the FM that Resident #42 stated to him, that he did not touched Resident #42. On 5/28/24 at 01:01 PM, the VPoRM provided a second abuse policy stated it included the procedures that should have been followed for the investigation. At that time, the surveyor requested the assignments sheets from the VPoRM for CNA#3 for the days he worked when the allegation occurred. The VPoRM stated, that would need to be researched and the VPoRM confirmed the assignment sheets were not part of the investigation. The policy titled, Abuse Investigation and Reporting Policy, dated 05/01/24 which revealed: Intent: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Procedure: Role of the Administrator 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: The individual conducting the investigation will, as a minimum. -Review the completed documentation forms. -Review the resident's medical record to determine events leading up to the incident. - Interview the person(s) reporting the incident. - Interview the resident. -Interview other residents to who the accused employee provides care or services. - Interview the residents' s roommate, family members, and visitors. The following guidelines will be used when conducting interviews: . -Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. On 5/28/24 at 02:15 PM, the LNHA, upon inquiry by surveyor provided a copy of an invoice from the Staffing Agency that CNA#3 was sent home early and does not indicate the exact time on 02/08/24. On 5/29/24 at 12:52 PM, the above concerns were shared with the LNHA, DON, VPoCS and VPoRM and there was no additional information provided during the exit held conference on 05/31/24 at 11:56 AM. Complaint #NJ164582, NJ169759, and NJ171307 Based on observations, interviews, record review and review of other facility pertinent documents, it was determined the the facility failed to complete and document a thorough investigation: a) to determine the origin for bilateral bruises to a resident's (Resident #6) arms, b) after receiving an allegation of two residents who were sexually abused by a staff member (Resident #42 and Resident #85), and c) an allegation of physical abuse (Resident #35). This deficient practice was identified for four (4) of four (4) residents reviewed for abuse and evidenced by the following: 1. On 5/21/24 at 10:15 AM, the surveyor observed Resident #6 in bed. The resident informed the surveyor that resident had an issue that he/she would like to discuss after breakfast. On that same date at 11:05 AM, the surveyor returned to Resident #6's room. The resident explained to the surveyor that he/she had some bruises to the bilateral arms that the resident obtained during blood drawn. The resident stated that the laboratory (lab) technician had Certified Nursing Assistant #1 (CNA#1) holding the resident's down for blood work on 5/06/24. Resident #6 further stated that he/she attempted to explain that he/she had blood drawn on 5/03/24 and would like to know why blood work had to be drawn again the morning of 5/06/24. Instead of providing the rationale for the blood work, the lab technician ordered the CNA to hold the resident down for the blood work. Furthermore, the resident stated that the Registered Nurse (RN) on duty that day heard them screaming and was mad at them for screaming. The RN did not explain why blood had be drawn this morning again on 5/06/24. Resident #6 stated that he/she was frustrated, upset and all bruised and sore, and the resident reported the incident. Resident #6 further stated that the resident had been on Eliquis (a blood thinner) and never had this issue before. The surveyor reviewed the medical record of Resident #6. The admission Record (AR, or face sheet, an admission summary) indicated that Resident #6 was admitted to the facility with diagnoses which included, but were not limited to chronic kidney disease, difficulty in walking, need for assistance with personal care. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/09/24 revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score 11 out of 15 indicative of moderate cognitive impairment. The MDS of the resident showed that the resident was able to make his/her needs known. The comprehensive Care Plan (CP) with a Focus for potential impairment in skin integrity was initiated on 5/16/24. The CP did not have a Focus which indicated that the resident was combative with care and staff needed to hold the hands down for blood work. A review of the nurses's progress notes (PN) dated 5/07/24 timed 6:35 PM. The RN documented: Noticed bruises on bilateral arms of the resident. Left Arm: 14 centimeter (cm) x 8 cm. Right arm: 9 cm x 6 cm. Dark purplish in color. Not in pain. Mild swelling on right arm. No changes in Range of Motion (ROM). Resident said, It probably happen during lab drawn yesterday referring to 5/06/24 and a CNA was assisting to stabilize the arms. Resident Representative and Nurse Practitioner (NP) made aware. On 5/21/24 at 11:50 AM, the surveyor interviewed the RN who wrote the progress note dated 5/07/24. The nurse confirmed that he noted the bruises,took pictures, measured the bruises and generated the incident report. The RN stated that the incident was reported to the administrative staff. On 5/23/24 at 11:14 AM, during an interview with the CNA involved with the incident, she revealed that Resident#6 gets frustrated [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ162913 Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure there was no delay in addressing laboratory (lab) values in a timely manner for two (2) of two (2) residents (Resident #6 and #109), b.) notify the physician of the the change in condition generated by a [health alert system] for three (3) of three (3) residents (Residents #6, #109, and #330), c.) monitor the skin, specifically the arm of Resident #109, who had a known behavior of scratching, and d.) provide wound care in accordance with professional standards of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/21/24 at 10:04 AM, the surveyor observed Resident #109 seated in the room. The surveyor observed some bruising to the right eyebrow and a non adherent dressing to left upper arm. The resident was unable to participate in an interview. On 5/22/24 at 10:43 AM, the surveyor observed the resident sitting in the room. The electronic Medical Record (eMR) was then reviewed which revealed that the resident had sustained multiple falls at the facility and that Resident #109 was a high fall risk. On 5/23/24 at 8:40 AM, the surveyor observed the resident in bed, and at 9:44 AM, the surveyor observed the resident sitting in a wheelchair in the room and was eating breakfast. The surveyor again reviewed Resident #109's eMR which revealed: The admission Record (AR, or face sheet, an admission summary) reflected that Resident #109 was admitted to the facility with diagnoses which included, but was not limited to; other abnormality of gait and mobility, unspecified Dementia and mood disturbances. The Annual and the Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, respectively dated 02/20/24 and 02/29/24, indicated that Resident #109 scored 01/15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of a Nursing Progress Note (PN) dated 5/20/24 at 01:22 PM, indicated that Resident #109 had a skin tear to right arm with skin breakage with clear drainage and small, reported from scratching. Injury cleaned with saline and bordered gauze dressing applied for protection. On 5/22/24 at 23:07 the nurse documented: Skin issue # 001 Needs Review. Issue type: Bruising . Location right upper arm. #002 Needs review Issue type Laceration. Right upper arm. #003 Needs Review Issue Type: Laceration. Location: Right anterior elbow. Skin is fragile: redness noted to bilateral hands., and full thickness wound to right upper arm. Another entry dated 5/22/24 time 11:39 PM indicated the following: Foul odor and slough noted to wound right upper arm, endorse to night nurse to follow up with wound care nurse. Further review of the medical record revealed there was no documentation regarding the wound to indicate any follow up was completed. A review of the Physician PN did not reflect evidence that the attending Physician was aware of the resident's right upper arm wound having a foul smell. There was no documented evidence that the skin issue was addressed with the Physician. The facility did not alert the Physician of the change in condition regarding the redness on both hands and the full thickness wound to the right upper arm. The area was not measured. The PN of 5/23/24 timed 3:13 PM revealed: [health alert system] (remote patient monitoring device placed within a detectable range of each patient that alerted the staff of any change in condition). Protocol Upon receiving the alert, the resident had to be assessed, vital signs had to be monitored every shift for 3 days, lab work, Comprehensive metabolic profile and and Complete Blood Count (CBC) had to be ordered. Staff were to monitor the lab result and alerted the Physician or the Assistant Physician Nurse (APN) of the result. Resident #109 had another [health alert system] alert on 5/23/24 at 21:50 [9:50 PM]. Laboratory blood drawn on 5/24/24 at 5:53 AM revealed a blood sugar of 61. Normal Range 65-99 mg/dl. The result was forwarded at 3:56 PM. The surveyor reviewed the result on the eMR with the Infection Preventionist/Registered Nurse (IP/RN). Both the surveyor and the IP/RN noted that the result was marked as Not reviewed on 5/29/24. There was no documented evidence that the Physician was notified of the low blood sugar. On 5/29/24 at 10:36 AM, during an interview with the Physician, he revealed that he was not informed of the low blood sugar or any change in condition regarding Resident #109. He acknowledged that he reviewed the lab result today 5/29/24 (5 days later). 2. The surveyor reviewed the medical records of Resident #6 as follows: Resident #6 was admitted to the facility with diagnoses which included, but were not limited to chronic kidney disease, difficulty in walking, need for assistance with personal care. The Quarterly MDS dated [DATE] revealed that Resident #6 had a BIMS score 11 out of 15 indicative of moderate cognitive impairment. On 5/02/24 Resident #6 had a [health alert system] alert. The protocol was for a physical assessment to be done, vital signs and lab work to be completed and report any abnormal lab work to the Physician. Resident #6's blood work was collected on 5/03/24 at 11:47 AM. The result was available the same day at 9:39 PM. A potassium (electrolyte that helps with nerve function, muscle movement heartbeat regulation) level of 2.8 was detected. Normal range 3.4 -5.3 mMOL/Liter (millimoles per liter). The facility did not checked the result or alert the Physician of the [health alert system] alert. The result status was checked and revealed that the blood work had not been reviewed as of 5/29/24 (26 days later). On 5/29/24 at 9:15 AM, the surveyor interviewed the APN regarding the [health alert system] alert of 5/02/24 and the lab result of 5/03/24 with the low potassium level for Resident #6. The APN informed the surveyor that she was not made aware that Resident #6 had blood drawn on 5/03/24. Regarding the potassium level of 2.8, she informed the surveyor that she would have addressed it if she was was made aware. On 5/29/24 at 10:36 AM, the surveyor interviewed the Physician in charge of Resident #6's care. The Physician stated that the [health alert system] alert was a good system that can alert of any change in condition and avoid hospitalization. However, the staff needs to communicate with the physician. The Physician stated that he was not made aware of the [health alert system] alert and the abnormal lab result. The physician stated that his expectations were the facility will either communicate with the physician or the APN any concerns regarding the resident. 3. On 5/23/24 the surveyor reviewed the closed medical record of Resident #330. Resident # 330 was admitted to the facility with diagnoses which included but were not limited to; muscle wasting, dysphagia (problem with swallowing) and difficulty in walking. The New Jersey Universal Transfer Form dated 02/20/23 reflected that Resident # 330 was admitted with one stage 2 pressure ulcer to the coccyx area measuring 1 centimeter (cm) x 1 cm x 0.2 cm. The admission record 02/14/23 contained an order to provide wound care every shift. Cover with layer of Xeroform, 2 x 2 gauze. Call wound care nurse for any changes in wound characteristics. Wound location: left lower Sacrum/ Coccyx. Wound type: Pressure Ulcer. Stage: Stage 3 or full thickness Cleanse with wound cleanser, apply venelex Change : Every shift. The physician order sheet dated 02/14/23, had an order for Resident #330 to be turned or repositioned every or within two hours of last turned. The surveyor reviewed the PN and noted that staff documented that the resident was being turned and repositioned every 2 hours as ordered and that wound care was being done. The Braden Scale assessment dated [DATE] timed 01:29 AM, revealed that the resident was a high pressure ulcer risk and was constantly moist by perspiration or urine. Resident # 330 received a score of 10 indicative of high risk for pressure ulcer. On 3/02/23 the Health Status Note dated 3/02/23 indicated that Resident #330 was seen by the Wound nurse and the wound treatment was changed from zinc oxide and replaced with Santyl a debrided agent. The electronic Treatment Administration Record (eTAR) was not signed to indicate that the wound care was being done from 3/03/23 to 3/16/23. A skin check was ordered for every evening shift on Wednesday with a start date of 3/15/23. The skin checked was not signed as being done on 3/15/23. The eTAR revealed an order for Santyl external Ointment to apply to inner buttock every shift for pressure ulcer with a start date of 3/16/23. The eTAR was not initialed on 3/16/23, 3/17/23, 3/18/23, 3/21/23 and 3/23/23. The eTAR was left blank. There was no rationale to indicate why the wound care was not documented as completed on those five days. On 3/16/23 timed 23:54 (11:54 PM), a new skin issue was identified. The Physician entered a late entry dated 3/20/23 timed 14:31 (02:31 PM), Resident was seen for Wound Consultation follow up for wound management of open wounds of bilateral gluteal region and erythematous rash with denudements was to sacrum and bilateral gluteal region: -Wound (+) full-thickness of the left gluteal region, 0.6 centimeter (cm) x 3.0 cm.(merged site). Wound base with 50% yellow slough tissue and 50% granular tissue. -Wound (+) full-thickness of the right gluteus/ gluteal region gluteal region 0.5 cm x 1.3 cm. wound base 100% yellow slough tissue. -[plus sign] erythematous rash noted to the sacrum and bilateral gluteal region. denudes site of the left gluteal region measuring 1.5 x 1.0 cm. scant amount of drainage. Plan discussed with primary Physician. If applicable, pressure Ulcer Care, Application of ointment. A PN dated 3/24/23 timed 20:24 [8:24 PM], documented that the Resident Representative (RR) was upset over the worsening of the wound due to incontinence care not being provided in a timely manner. According to the documentation the wound care was not done as ordered. (The eTAR indicated that wound care was not completed on 3/16/23, 3/17/23, 3/18/23, 3/21 and 3/23/23.) On 3/24/23 timed 20:24 the Licensed Practical Nurse (LPN) documented the responsible party (RP) came in very upset c/o [complain of] resident bottom getting worse within a two days period, saying Resident #330 not being changed in a timely manner. Resident sacral wound dressing was changed at 18:00 (6:00 PM). The morning nurse said she got busy and could not do the dressing. An entry dated 3/25/23 timed 20:38 PM (8:38 PM), revealed that the Unit Nurse from the agency arrived to the floor at 7:45 PM and indicated that the RP was upset regarding the care. The nurse went to the 1st floor and observed two Certified Nursing Assistant (CNA) performing wound care to Resident #330's sacral wound. The Unit nurse was not on the floor at that time. The RP went to the Police Department and filed a complaint regarding the care. The RP took the resident home the same day at 8:57 PM. The facility administration was interviewed and did not provide any documentation regarding the above documented concerns. A review of the Certified Nursing Assistant Job Description under specified duties revealed the following Assists the resident in maintaining and improving function, encouraging independence whenever responsible for the Activities of Daily Living, and overall hygiene of the resident: baths, shampoos, shaves, nail care mouth care, foot care and peri-care per facility policy. The job description did not indicate that CNA would perform wound care. A review of the Registered Nurse (RN) Job description indicated the following: As member of the Interdisciplinary team, the RN assumes responsibility and accountability for nursing services delivered to assigned residents of a designated unit for one shift. The RN provides direct care, administers treatments and medication, organize and distribute daily assignments to direct care staff consistent with staff competency and each individual resident's comprehensive resident assessment and plan of care. Supervises direct care staff and makes decisions about resident care needs during shifts concerning scope of clinical competence, consistent with facility policies and procedures. Ensures that Flow of Care is followed. The Director of Nursing (DON) job description indicated that the DON assumes full time administrative and clinical authority for the delivery of nursing services in the facility. Manages employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and state and federal laws and regulations. Develops and implements policies and procedures consistent with current law. In collaboration with the Nursing Home Administrator, allocates department resources in an efficient and economic manner to enable each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being . Makes daily rounds on unit to supervise, observe, examine, interview residents, to evaluate staffing needs, to monitor regulatory compliance, to achieve the care environment and to evaluate staff interactions and clinical skills competency. Review 24 hours reports from every unit daily to ensure timely, effective responses to significant changes in condition, transfers, discharges, use of physical or chemical restraints, unexplained injuries, potential abuse or neglect, medication errors, loss of resident property, any evidence of resident or family dissatisfaction. The DON could not comment on the documentation regarding Resident #330 as she was not employed at the facility when the incident occurred. On 5/30/31 at 01:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), [NAME] President of Clinical Services, and [NAME] President of Risk Management. The administrative staff did not provide any rationale for not informing the Physician of the change in condition for both residents. The DON acknowledged that the nurse should have notified the Physician regarding the laboratory work result. NJAC 8:39-27.1(a)

Complaint #s NJ157563, NJ158377, NJ159018, NJ162913, NJ169759, and NJ173245 Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents' were provided with care to achieve their highest practical wellbeing by failing to a.) provide adequate staff to ensure effective supervision and documentation for residents with multiple falls (Resident #89 and #109) for two (2) of four (4) residents reviewed for falls, and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Refer to F689H 1.) On 5/21/24 at 9:53 AM, Surveyor #1 (S#1) observed Resident #89 in the unit day room in a wheelchair (w/c) eating breakfast. A review of the electronic medical record (eMR) revealed that Resident #89 had: -falls: 02/09/24 and on 3/09/24 (fall with injury). -Resident #89 was documented to have a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. Surveyor #1 reviewed the Incident/Accident (I/A) reports provided by the facility. The reports included but were not limited to the following: Dated 02/09/24, unwitnessed fall with no injury. The investigation did not include all pertinent staff statements, left blank areas that should have been filled out, fall inspection report done asked for footwear wearing of the resident at the time of fall and was left blank. Interventions added: Head to toe assessment. The report did not include a summary or conclusion and was not signed by the Licensed Nursing Home Administrator (LNHA) or Director of Nursing (DON). The facility did not identify the hazards and risks why the resident fell in order to implement interventions to reduce hazards and risk and modify the interventions when necessary when the resident was cognitively impaired. Dated 3/09/24, unwitnessed fall with no injury. Interventions added was left blank. Immediate interventions: Head to toe assessment, call bell within reach, patient educated to call for help. fall inspection report done. List of immediate interventions: head to toe assessment call bell within reach, patient educated to call for help. The report failed to identify the staff who found the resident on the floor. On 5/24/24 at 10:13 AM, in the presence of the survey team, the DON stated that the Certified Nursing Aide (CNA) who wrote the statement on 3/09/24 incident was late and nurse who was administering medications was supposed to take of care of Resident #89. Surveyor #1 then asked the facility management, how the only nurse on that unit, at that time be assigned also perform resident care from 7 AM to 9 AM, and why there was no CNA assigned to the resident instead. The DON stated that the two other CNAs were aware that they would take care of the resident even though they were not assigned. The surveyor also asked who were the two other CNAs and why there were no statements from them. The DON was unable to state the names of the two other CNAs and stated that she had the documentation. The DON was unable to provide the documentation from the two CNAs for 3/09/24 incident. On that same date and time, Surveyor #1 then asked the DON if the fall incidents on 02/09/24 and 3/09/24 were complete investigations. The DON stated, I did not write all the information and I should have went back and wrote in details. On 5/29/24 at 10:15 AM, Surveyor #1 interviewed the [NAME] President of Risk Management (VPoRM) who provided a typewritten Investigation Summary and Conclusion dated 5/24/24 for the two falls: 02/09/24 and 3/09/24. The VPoRM stated in the presence of the survey team that the Investigation Summary and Conclusion were completed after surveyor's inquiry. He stated the team decided to meet on 5/24/24 after surveyor's inquiry, to re-evaluate the two fall incidents of the resident in order to know the root cause and analysis, identify appropriate interventions to prevent further fall because as the surveyor identified and questioned the fall intervention to remind the resident to call for help was not appropriate due to resident's cognitive impairment. He further stated that the facility team acknowledged the surveyor's concern as well as the concern that the investigation had no statements and conclusion and summary for one fall incident. 2.) On 5/21/24 at 10:04 AM, Surveyor #2 observed Resident #109 sitting in their room. The surveyor observed a bruise on the right eyebrow. The resident was unable to be interviewed. On 5/22/24 at 10:43 AM, Surveyor #2 observed Resident #109 sitting in their room. On 5/23/24 at 8:40 AM, Surveyor #2 observed Resident #109 in bed resting. On 5/23/24 at 9:44 AM, Surveyor #2 observed Resident #109 in their room sitting in a w/c eating breakfast. A review of the eMR revealed that Resident #109 had multiple falls as follows: 12/26/23, 02/02/24, 02/20/24 fall with injury, 3/07/24, 4/06/24, 4/13/24, 5/19/24, and 5/25/24 fall with injury. Resident #109 was documented to have a BIMS of 01 out of 15 which indicated severely impaired cognition. A review of the resident-centered on-going care plan included but was not limited to; interventions of educate the resident to ask for assistance, keep resident in supervised area as much as she will allow, ensure appropriate footwear when ambulating, review past falls and attempt to determine the cause, and supervision. On 5/28/24 at 11:08 AM, during an interview with Surveyor #2, the Licensed Practical Nurse (LPN) revealed that the resident was identified for frequent falls. The LPN stated that the staff needed to monitor and keep Resident #109 close to the nursing station, furniture was removed from the room, and to provide frequent toileting. On 5/29/24 at 11:21 AM, Surveyor #2 called the family member (FM) regarding the resident and the falls. The FM stated that the resident was sent to the hospital for repair of resident's shoulder. The shoulder was pretty messed up. The FM further stated that the resident was sent to the operating room, started bleeding, and passed away that morning. 3.) On 5/31/24 at 8:26 AM, S#1 asked LNHA to describe the Facility Assessment (FA) 3.2 and what it meant as stipulated in the FA the following: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Based on resident census and acuities, staffing is assigned to ensure there is sufficient staff to meet the needs of the residents at any time. Position Nurse aides, total number needed or average or range 39, licensed nurses providing direct care total number needed or average or range 19. The LNHA responded that it meant that any given time, the facility was required to have total or average range of 39 CNA and 19 nurses. On that same date and time, the LNHA stated that he was aware of the staffing requirements and the New Jersey (NJ) mandated law. He further stated that he was aware that there were times that the facility was not meeting the requirements and the mandated law. 4.) Review of the NJ Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in CNA staffing as follows: For the 2 weeks of staffing prior to survey from 05/05/2024 to 05/18/2024, the facility was deficient in CNA staffing for residents on 11 of 14 day shifts as follows: -05/05/24 had 13 CNAs for 131 residents on the day shift, required at least 16 CNAs. -05/06/24 had 14 CNAs for 131 residents on the day shift, required at least 16 CNAs. -05/07/24 had 14 CNAs for 131 residents on the day shift, required at least 16 CNAs. -05/08/24 had 14 CNAs for 131 residents on the day shift, required at least 16 CNAs. -05/10/24 had 16 CNAs for 136 residents on the day shift, required at least 17 CNAs. -05/12/24 had 15 CNAs for 132 residents on the day shift, required at least 16 CNAs. -05/13/24 had 15 CNAs for 132 residents on the day shift, required at least 16 CNAs. -05/14/24 had 15 CNAs for 132 residents on the day shift, required at least 16 CNAs. -05/15/24 had 17 CNAs for 143 residents on the day shift, required at least 18 CNAs. -05/16/24 had 16 CNAs for 143 residents on the day shift, required at least 18 CNAs. -05/18/24 had 17 CNAs for 146 residents on the day shift, required at least 18 CNAs. NJAC 8:39-4.1(a), 25.2(b), 27.1(a)

Based on observation, interview, review of medical records, and other facility provided documents, it was determined that the facility administration failed to ensure policies, procedures, and effective systems were implemented to maintain each resident's highest practicable physical, mental, and psychosocial well-being by failing to ensure a.) resident was free from the alleged abuse, b.) a thorough investigation was completed for all alleged abuse and frequent falls with history of falls and fractures, c.) the physician was notified of the change in condition and the results of the blood work in a timely manner, and d.) staffing levels were adequate to meet resident needs. This failure had the potential to affect all 148 residents who currently live in the facility. This deficient practice was evidenced by the following: Refer to: F600F, F607F, F610F, F684F, F689H, and F725F On 5/21/24 at 10:22 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and [NAME] President of Clinical Services (VPoCS). The facility management informed the surveyor that the facility census (total number of residents) was 148. On 5/23/24 at 12:30 PM, the surveyor interviewed the DON about the concerns that were reported by Resident #6. The DON stated that she was aware of the issue with the blood drawn on 5/06/24 and an incident report was generated. The DON added that she did not investigate the issue because she knew what happened and confirmed it was not reported to the New Jersey Department of Health (NJDOH) until after the surveyor's inquiry on 5/23/24. There was no investigation of the alleged abuse and it was not reported to the NJDOH until 5/23/24. The facility did not initiate an investigation even after the incident was reported on 5/07/24, 5/11/24 and 5/16/24. The Certified Nursing Aide (CNA) was not asked to provide a statement regarding the incident. The phlebotomist was not contacted and did not have a statement attached to the Incident/Accident (I/A) Report provided dated 5/07/24. There was no documented evidence that the phlebotomist was educated as stated in the Interdisciplinary Notes dated 5/08/24. On 5/23/24 at 12:50 PM, in the presence of the survey team, the DON provided the I/A report dated 5/07/24 and stated that all she had. The DON added that she knew what had happened, and the resident was alert and able to explain that the bruises were obtained during the blood drawing of Resident #6. The DON stated that she did not have an investigation. There were no other employee statements from the prior three shifts included in the I/A report provided. The I/A report included the CNA statement who worked and reported the bruises on 5/07/24 around 4:00 PM. There were no written statements obtained from the day shift staff involved with Resident #6's care. On 5/28/24 at 10:31 AM, the surveyor interviewed the LNHA regarding I/A. The LNHA was unsure about the facility's policy and procedure with regard to the investigation of incidents. On 5/28/24 at 11:32 AM, the survey team met with the LNHA, DON, VPoCS, and VP of Risk Management (VPoRM). The surveyor asked if there was anything that was provided as guidance to staff regarding what was supposed to be completed when an allegation of abuse occurred. At that time, when asked about the investigation related to Residents #85 and #42, the DON confirmed there were no other individual statements taken from any other residents. The LNHA then confirmed he did not review the investigation as he was not at the facility during that time. A review of the facility provided investigation revealed there were two statements attached, one untimed statement from the accused CNA, dated 02/08/24, and another document with a typed statement, undated and untimed. There were no assessments, interviews from other staff, residents, facility management, or any of the alleged documents referenced per the incident, and there were no attached police reports. The education for the CNA that was attached to the facility-provided investigation included a copy of an abuse policy from a completely different facility located in another town and did not have the same company name. On 5/28/24 at 11:50 AM, in the presence of the survey team, the surveyor asked the LNHA about who was responsible to ensure an investigation was completed and the LNHA confirmed that he was responsible for the overall process and ensuring the statements were completed. On 5/29/24 at 9:15 AM, the surveyor interviewed the Assistant Physician Nurse (APN) in charge of Resident #6's care. The APN revealed that she was not made aware of the laboratory (lab) work being done on 5/03/24 and 5/06/24. The APN was made aware of the bruises on 5/08/24 and spoke with the nurse, who stated that the bruises were obtained during the lab being drawn. On 5/30/24 at 11:59 AM, the survey team met with the LNHA, DON, VPoRM, and the VPoCS. The VPoCS stated that the nurse should have called the doctor at that time. The LNHA stated I know we should have done the whole investigation, and the statements but it was not done. On 5/30/31 at 01:15 PM, the facility management did not provide any rationale for not informing the physician of the change in condition for both residents. The DON acknowledged that the nurse should have notified the physician regarding the lab work result. On 5/31/24 at 8:09 AM, the surveyor interviewed the LNHA regarding the facility's Quality Assurance and Performance Improvement (QAPI). The surveyor discussed the concerns of the surveyors and asked the LNHA what areas in the surveyors identified concerns the facility was not able to identify from the facility's QAPI. The LNHA responded that the facility's investigation process was basically the more detailed documents process with proper outcome, how the facility investigated the incident, and who the facility spoke to. At that same time, the surveyor asked the LNHA were those areas identified as concerns by the surveyors were the facility's process and policy. The LNHA stated, Yes this is our process and policy and should have happened but did not happen. He further stated that he should know those policies and procedures and the I/A that happened. During the follow-up interview of the surveyor with the LNHA on 5/31/24 at 8:26 AM, the LNHA stated that he was aware of the requirement and NJ mandated law. He further stated that there were times when the facility was not meeting the requirements and the mandated law for staffing. The signed LNHA Job Description, dated 6/06/22 revealed: This position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meets residents' needs in accordance with federal, state, and local regulations. Essential Requirements, Duties, and Responsibilities (included and were not limited to): Develop, maintain, and implement operational policies and procedures to meet residents' needs and compliance with federal, state, and local requirements. Determine the personnel requirements of the facility in collaboration with Department Managers and the Human Resource Department and hire or arrange for sufficient staff to provide sound resident care and implement the facility policies and procedures. Establish systems to enforce the facility policies and procedures. Supervise the recruitment, employment, performance, evaluation, promotion, and discharge of all staff in collaboration with the Human Resources Department. Inform appropriate agencies of changes in facility personnel as required. Assume the responsibility of reviewing and evaluating all recommendations of the facility's committee and consultants. Establish systems to ensure compliance with all federal, state, and local regulations. Observe all facility policies and procedures. A review of the facility's Abuse Investigation and Reporting Policy, dated 5/01/24 which revealed: Intent: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Procedure: Role of the Administrator 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. NJAC 8:39- 5.1(a); 25.2(a)(b); 27.1(a); 33.1(d)(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00164594 Based on observations, interviews, and record review, as well as a review of pertinent facility documents on 03/21/24, it was determined that the facility failed to administer the medications in accordance with the acceptable standard of nursing practice and follow the facility policy on Medication Administration and Physician Services in 1 of 6 floors for 5 of 5 sampled residents, (Residents#1, #2, #3, #4, and #5). This deficient practice was evidenced by the following: On 03/21/24 at 10:12 am, the surveyor conducted a medication pass observation on the Nursing Unit with the Registered Nurse (RN #1). The surveyor observed a red color on the Electronic Medication Administration Record (EMAR) screen for Resident #2, #3, #4, and #5. RN#1 stated that the red color on the screen meant that the Residents' medications were due to be given at 9:00 am but were not given yet. The surveyor further observed that RN #1 prepared and administered medications to Resident #2, #3, #4, and #5. 1. According to the admission RECORD (AR), Resident #1 was admitted with diagnoses including but not limited to Diabetes Mellitus type 2, Atrial Fibrillation, Hypertension, Glaucoma, Depression, Heart Failure, and Neuromuscular Dysfunction of Bladder. A review of the Minimum Data Set (MDS), an assessment tool dated 11/17/23, showed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #1 had intact cognition and required assistance with Activity of Daily Living (ADLs). A review of Resident #1's care plan (CP), dated 6/9/23, indicated that Resident #1 had hypertension, hyperlipidemia, atrial fibrillation, and congestive heart failure. The CP had an intervention which included but was not limited to give medication as ordered. A review of Resident #1's Order Summary Report (OSR) revealed an order for the following: On 2/26/23, Glimepiride Tab 2 mg (milligram), give 1 tablet orally two times a day related to type 2 Diabetes Mellitus 30 minutes before breakfast and dinner. On 4/4/23, Metformin HCl (hydrochloride) Oral Tablet Extended Release 24 Hour 500 mg (Metformin HCl), give 2 tablets by mouth two times a day for Type 2 Diabetes Mellitus to be given with food. On 9/24/23, Methenamine Hippurate Tab 1 gm (gram), give 1 tablet orally two times a day for UTI (Urinary Tract Infection) prophylaxis give with meals. On 9/19/23, Simbrinza Suspension 1-0.2%, instill 1 drop in both eyes two times a day for Glaucoma. A review of Resident #1's Medication Administration Report (MAR) for 01/2024 confirmed the abovementioned medications were scheduled and to be administered as follows: Glimepiride Tab 2 mg at 7:30 a.m. and 5:30 p.m. Metformin HCl ER 500 mg at 8:00 a.m. and 5:00 p.m. Methenamine Hippurate Tab 1 gm at 9:00 a.m. and 5:00 p.m. Simbrinza [NAME] 1-0.2% eye drops at 9:00 a.m. and 5:00 p.m. A review of Resident #1's Medication Admin Audit Report (MAAR) indicated that the abovementioned medications were not administered according to the scheduled time. The medications were administered as follows: Glimepiride Tab 2 mg was scheduled to be administered at 7:30 a.m. and 5:30 p.m., however, on the following days the medication was given late. 1/1/24 was administered at 10:59 a.m. 1/2/24 was administered at 10:42 a.m. 1/5/24 was administered at 10:31 a.m. 1/6/24 was administered at 11:29 a.m. and at 8:07 p.m. 1/7/24 was administered at 11:07 a.m. 1/8/24 was administered at 11:28 a.m. and at 7:37 p.m. 1/9/24 was administered at 12:43 p.m. 1/10/24 was administered at 11:32 a.m. 1/11/24 was administered at 11:18 a.m. 1/12/24 was administered at 11:43 a.m. 1/13/24 was administered at 1:11 p.m. 1/14/24 was administered at 11:45 a.m. 1/15/24 was administered at 2:01 p.m. and at 9:09 p.m. 1/16/24 was administered at 10:42 a.m. and at 8:25 p.m. 1/17/24 was administered at 8:02 p.m. 1/18/24 was administered at 11:12 a.m. 1/19/24 was administered at 1:57 p.m. 1/24/24 was administered at 11:35 a.m. 1/25/24 was administered at 8:19 p.m. 1/26/24 was administered at 12:42 p.m. Metformin HCl 500 mg was scheduled to be administered at 8:00 a.m. and 5:00 p.m., however, on the following days the medication was given late. 1/1/24 was administered at 10:59 a.m. 1/2/24 was administered at 10:43 a.m. 1/3/24 was administered at 8:02 p.m. 1/4/24 was administered at 7:10 p.m. 1/6/24 was administered at 11:29 a.m. and at 8:07 p.m. 1/7/24 was administered at 11:07 a.m. 1/8/24 was administered at 11:28 a.m. and at 7:36 p.m. 1/9/24 was administered at 12:43 p.m. 1/10/24 was administered at 11:32 a.m. 1/11/24 was administered at 11:19 a.m. and at 7:20 p.m. 1/12/24 was administered at 11:43 a.m. 1/13/24 was administered at 1:11 p.m. 1/14/24 was administered at 11:45 a.m. 1/15/24 was administered at 2:01 p.m. and at 9:09 p.m. 1/16/24 was administered at 10:42 a.m. and at 8:25 p.m. 1/17/24 was administered at 7:14 p.m. 1/18/24 was administered at 11:13 a.m. 1/19/24 was administered at 1:57 p.m. 1/20/24 was administered at 10:44 a.m. 1/21/24 was administered at 10:56 a.m. 1/22/24 was administered at 10:54 a.m. 1/23/24 was administered at 11:42 a.m. 1/24/24 was administered at 11:35 a.m. and at 7:04 p.m. 1/25/24 was administered at 8:18 p.m. 1/26/24 was administered at 1:56 p.m. Methenamine Hippurate 1 gm was scheduled to be administered at 9:00 a.m. and 5:00 p.m., however, on the following days the medication was given late. 1/1/24 was administered at 11:01 a.m. 1/3/24 was administered at 8:02 p.m. 1/4/24 was administered at 7:10 p.m. 1/6/24 was administered at 11:31 a.m. and at 8:07 p.m. 1/7/24 was administered at 11:08 a.m. 1/8/24 was administered at 11:29 a.m. and at 7:37 p.m. 1/9/24 was administered at 1:06 p.m. 1/10/24 was administered at 11:34 a.m. 1/11/24 was administered at 11:28 a.m. and at 7:20 p.m. 1/12/24 was administered at 11:45 a.m. 1/13/24 was administered at 1:11 p.m. 1/14/24 was administered at 11:45 a.m. 1/15/24 was administered at 2:01 p.m. and at 9:09 p.m. 1/16/24 was administered at 8:25 p.m. 1/17/24 was administered at 7:14 p.m. 1/18/24 was administered at 12:55 p.m. 1/19/24 was administered at 2:02 p.m. 1/23/24 was administered at 11:43 a.m. 1/24/24 was administered at 11:36 a.m. and at 7:04 p.m. 1/25/24 was administered at 8:18 p.m. 1/26/24 was administered at 3:59 p.m. Simbrinza 1-0.2% eye drops was scheduled to be administered at 9:00 a.m. and 5:00 p.m., however, on the following days the medication was given late. 1/1/24 was administered at 11:03 a.m. 1/3/24 was administered at 8:02 p.m. 1/4/24 was administered at 7:10 p.m. 1/6/24 was administered at 11:32 a.m. and at 8:07 p.m. 1/7/24 was administered at 11:09 a.m. and at 7:51 p.m. 1/8/24 was administered at 11:30 a.m. and at 7:37 p.m. 1/9/24 was administered at 1:06 p.m. 1/10/24 was administered at 11:34 a.m. 1/11/24 was administered at 11:29 a.m. and at 7:21 p.m. 1/12/24 was administered at 11:46 a.m. 1/13/24 was administered at 1:11 p.m. 1/14/24 was administered at 11:46 a.m. 1/15/24 was administered at 2:01 p.m. and at 9:09 p.m. 1/16/24 was administered at 8:25 p.m. 1/17/24 was administered at 7:14 p.m. 1/18/24 was administered at 12:55 p.m. 1/19/24 was administered at 2:05 p.m. 1/23/24 was administered at 11:45 a.m. 1/24/24 was administered at 11:37 a.m. and at 7:04 p.m. 1/25/24 was administered at 8:18 p.m. A review of Resident #1's progress notes (PN) from 1/1/24 to 1/26/24, there was no indication in the PN that the Resident's Primary Care Physician (PCP) was notified that the aforementioned medications were not administered according to the scheduled time.Also, there was no documented evidence of harm to the resident from the late administration of medications. 2. According to the AR, Resident #2 was admitted with diagnoses including but not limited to Hypertension, Pain in Knee, Type 2 Diabetes Mellitus, Dementia, and Alzheimer's Disease. A review of the MDS dated [DATE], Resident #2 cognition was impaired and required extensive assistance with ADLs. A review of Resident #2's CP, initiated on 05/25/2023 indicated Resident #2 has hypertension. Interventions included but were not limited to give anti-hypertensive medications as ordered. Resident #2's CP further indicated the following: Resident #2 has Diabetes Mellitus. Interventions included but were not limited to give Diabetes medication as ordered by doctor; Resident #2 has chronic pain related to knee pain, chronic conditions, and limited mobility. Interventions included but were not limited to administer analgesia [pain medication] as per orders. A review of Resident #2's OSR on 3/21/24 revealed an order for the following: On 8/17/21, Acetaminophen tab 500 mg, give 1 tablet orally three times a day related to Pain in Knee. On 2/10/23, Amlodipine 10 mg tab, give 1 tablet orally in the morning for hypertension. On 2/19/23, Clonidine tab 0.1 mg, give 1 tablet orally two times a day related to hypertension. On 2/7/23, Lisinopril tab 200 mg, give 1 tablet orally in the morning related to hypertension. On 2/17/23, metformin tab 500 mg, give 1 tablet orally one time a day for diabetes. A review of Resident #2's MAR for 3/2024 confirmed the abovementioned medications were scheduled and to be administered as follows: Acetaminophen tab 500 mg at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Amlodipine 10 mg tab at 9:00 a.m. Clonidine tab 0.1 mg at 9:00 a.m. and 5:00 p.m. Lisinopril tab 20 mg at 9:00 a.m. Metformin tab 500 mg at 9:00 a.m. A review of Resident #2's MAAR indicated that the abovementioned medications were not administered according to the scheduled time. The medications were administered as follows: Acetaminophen 500 mg tab was scheduled to be administered at 9:00 a.m.,1:00 p.m., and 5:00 p.m., however, on the following days medication was given late. 3/4/24 was administered at 6:08 p.m. 3/5/34 was administered at 6:50 p.m. 3/6/24 was administered at 10:54 a.m. 3/8/24 was administered at 2:14 p.m. 3/10/24 was administered at 11:24 a.m. and at 6:09 p.m. 3/11/24 was administered at 7:33 p.m. 3/12/24 was administered at 7:21 p.m. 3/13/24 was administered at 11:16 a.m. 3/16/24 was administered at 2:03 p.m. 3/18/24 was administered at 3:04 p.m. and at 6:27 p.m. 3/19/24 was administered at 10:05 a.m. and at 6:04 p.m. 3/20/24 was administered at 6:28 p.m. 3/21/24 was administered at 11:01 a.m. Amlodipine 10 mg tab was scheduled to be administered at 9:00 a.m., however, on the following days the morning medication was given late. 3/6/24 was administered at 10:54 a.m. 3/10/24 was administered at 11:24 a.m. 3/13/24 was administered at 11:16 a.m. 3/19/24 was administered at 10:05 a.m. 3/21/24 was administered at 11:01 a.m. Clonidine tab 0.1 mg was scheduled to be given at 9:00 a.m. and 5:00 p.m., however, on the following days the medication was given late. 3/5/24 was administered at 6:50 p.m. 3/6/24 was administered at 10:54 a.m. 3/10/24 was administered at 11:24 a.m. 3/11/24 was administered at 7:33 p.m. 3/12/24 was administered at 7:21 p.m. 3/13/24 was administered at 11:16 a.m. 3/18/24 was administered at 6:27 p.m. 3/20/24 was administered at 6:28 p.m. 3/21/24 was administered at 11:02 a.m. Lisinopril tab 20 mg was scheduled to be given at 9:00 a.m., however, on the following days the morning dose was given late. 3/6/24 was administered at 10:54 a.m. 3/10/24 was administered at 11:24 a.m. 3/13/24 was administered at 11:16 a.m. 3/21/24 was administered at 11:02 a.m. Metformin tab 500 mg was scheduled to be given at 9:00 a.m., however, on the following days the morning dose was given late. 3/6/24 was administered at 10:54 a.m. 3/10/24 was administered at 11:24 a.m. 3/13/24 was administered at 11:16 a.m. 3/21/24 was administered at 11:02 a.m. A review of Resident #2's PN from 3/1/24 to 3/21/24, there was no indication in the PN that the Resident's PCP was notified that the medications were not administered according to the scheduled time. Also, there was no documented evidence of harm to the resident from the late administration of medications. 3. According to the AR, Resident #3 was admitted with diagnoses including but not limited to Hypertension, Encephalopathy, Anemia, Osteoarthritis, Long Term Use of Antibiotics, and Seizure Disorder. A review of the MDS, an assessment tool dated 8/9/23, indicated that Resident #3's cognition was moderately impaired and needed help from staff with ADLs. A review of Resident #3's CP, 3/30/23, indicated that Resident #3 had Seizure Disorder and at risk for constipation related to decrease mobility. The intervention which included but was not limited to give medications as ordered. A review of Resident #3's OSR on 3/21/24 revealed an order for the following: On 1/10/24, Doxycycline Hyclate Oral tablet 100 mg, give 100 mg by mouth every 12 hours for prosthetic knee infection ppx [prophylaxis]. On 1/12/24, Miralax Oral Packet 17 gm, give 17 gm by mouth one time a day for constipation mix with 4-6 ounces of juice. On 9/27/23, Phenobarbital Oral Tablet 30 mg, give 1 tablet by mouth every 12 hours for seizures. A review of Resident #3's MAR for 3/2024 confirmed the abovementioned medications were scheduled and to be administered as follows: Doxycycline Hyclate Oral Tablet 100 mg at 9:00 a.m. and 9:00 p.m. Miralax Oral Packet at 9:00 a.m. Phenobarbital Oral Tablet 30 mg at 9:00 a.m. and 9:00 p.m. A review of Resident #3's MAAR indicated that the abovementioned medications were not administered according to the scheduled time. The medications were administered as follows: Doxycycline Hyclate 100 mg was scheduled to be given at 9:00 a.m. and 9:00 p.m., however, on the following days the morning dose was given late. 3/4/24 was administered at 10:27 a.m. 3/5/24 was administered at 10:22 a.m. 3/6/24 was administered at 11:34 a.m. 3/10/24 was administered at 11:12 a.m. 3/13/24 was administered at 11:04 a.m. 3/16/24 was administered at 10:27 a.m. 3/21/24 was administered at 10:35 a.m. Miralax 17 gm was scheduled to be given at 9:00 a.m., however, on the following days the morning dose was given late. 3/4/24 was administered at 10:27 a.m. 3/5/24 was administered at 10:22 a.m. 3/10/24 was administered at 11:12 a.m. 3/13/24 was administered at 11:04 a.m. 3/16/24 was administered at 10:27 a.m. 3/21/24 was administered at 10:58 a.m. Phenobarbital 30 mg was scheduled to be given at 9:00 a.m. and 9:00 p.m., however, on the following days the morning dose was given late. 3/4/24 was administered at 10:27 a.m. 3/5/24 was administered at 10:22 a.m. 3/10/24 was administered at 11:12 a.m. 3/13/24 was administered at 11:05 a.m. 3/16/24 was administered at 10:28 a.m. 3/21/24 was administered at 10:36 a.m. A review of Resident #3's PN from 3/1/24 to 3/21/24, there was no indication in the PN that the Resident's PCP was notified that the medications were not administered according to the scheduled time. Also, there was no documented evidence of harm to the resident from the late administration of medications. 4. According to the AR, Resident #4 was admitted with diagnoses including but not limited to Dementia, Atrial Fibrillation, Major Depressive Disorder, Metabolic Encephalopathy, and Muscle Weakness. A review of Resident #4's MDS dated [DATE], indicated that Resident #4 had a BIMS score of 03, indicating that Resident #4's cognition was impaired and required total assistance with ADLs. A review of Resident #4's CP, initiated on 8/28/23, indicated that Resident #4 has altered cardiovascular status related to atrial fibrillation. The CP included goal intervention but not limited to the importance of Resident's compliance with treatment. Furthermore, Resident #4's CP indicated Resident has impaired cognitive function or impaired thought processes related to dementia. The CP interventions included but not limited to administer medications as ordered. A review of Resident #4's OSR on 3/21/24 revealed an order for the following: On 12/11/23, Memantine HCL Tablet 5 mg, give 1 tablet by mouth one time a day. On 12/10/23, Diltiazem HCL Oral Tablet, give 300 mg by mouth one time a day. A review of Resident #4's MAR for 3/2024, confirmed the above-mentioned medications were scheduled and administered as follows: Memantine HCL Tablet 5 mg at 9:00 a.m. Diltiazem HCL Oral Tablet 300 mg at 9:00 a.m. A review of Resident #4's MAAR indicated that the above-mentioned medications were not administered according to the scheduled time. The medications were administered as follows: Memantine 5 mg was scheduled to be administered at 9:00 a.m., however, on the following days the medication was given late. 3/1/24 was administered at10:56 a.m. 3/2/24 was administered at 11:16 a.m. 3/4/24 was administered at 10:28 a.m. 3/5/24 was administered at 10:21 a.m. 3/10 24 was administered at 11:20 a.m. 3/11/24 was administered at 10:20 a.m. 3/13/24 was administered at 11:10 a.m. 3/19/24 was administered at 1:05 p.m. 3/20/24 was administered at 10:53 a.m. 3/21/24 was administered at 10:51 a.m. Diltiazem 300 mg was scheduled to be administered at 9:00 a.m., however, on the following days the morning dose given late. 3/1/24 was administered at 10:56 a.m. 3/2/24 was administered at 11:16 a.m. 3/4/24 was administered at 10:28 a.m. 3/5/24 was administered at 10:21 a.m. 3/10 24 was administered at 11:20 a.m. 3/11/24 was administered at 10:20 a.m. 3/13/24 was administered at 11:10 a.m. 3/19/24 was administered at 1:05 p.m. 3/20/24 was administered at 10:53 a.m. 3/21/24 was administered at 10:48 a.m. A review of Resident #4's PN from 3/1/24 to 3/21/24, there was no indication in the PN that the Resident's PCP was notified that the aforementioned medications were not administered according to the scheduled time. Also, there was no documented evidence of harm to the resident from the late administration of the medications. 5. According to the AR, Resident #5 was admitted with diagnoses including but not limited to Hyperglycemia, Acute Kidney Failure, Hypotension, Depressive Disorder, Heart Failure, Localized Edema, Metabolic Encephalopathy, Arthritis, and Anxiety Disorder. A review of Resident #5's MDS dated [DATE], indicated that Resident #5's cognition was moderately impaired and required assistance with ADLs. A review of Resident #5's CP, initiated on 5/4/2023, indicated that Resident #5 had altered in cardiovascular status related to Hypertension, Hypotension, and Hyperlipidemia. The CP included interventions but were not limited to administering medications as ordered. A review of Resident #5's OSR on 3/21/24 revealed an order for the following: On 10/10/21, Artificial Sol Tears, instill 1 drop in both eyes two times a day for dry eyes. On 11/24/19, Aspirin Tab 325 mg EC [enteric coated], give 1 tablet orally in the morning for prophylaxis. On 2/22/23, Bupropion HCL 100 mg Tabs, give 1 tablet orally every 12 hours for depressive disorder. On 1/24/24, Furosemide Tablet 20 mg, give 1 tablet by mouth one time a day for edema. On 2/21/23, Labetalol Tab 100 mg, give 1 tablet orally every 12 hours for HTN [hypertension]. On 4/24/20, Vitamin C Tab 500 mg, give 2 tablets orally one time a day as supplement. A review of Resident #5's MAR for 3/2024, confirmed the medications were scheduled and to be administered as follows: Artificial Sol Tears at 9:00 a.m. and 5:00 p.m. Aspirin Tab 325 mg EC at 9:00 a.m. Bupropion HCL 100 mg at 9:00 a.m. and 9:00 p.m. Furosemide Tablet 20 mg at 9:00 a.m. Labetalol Tab 100 mg at 9:00 a.m. and 9:00 p.m. Vitamin C Tab 500 mg at 9:00 a.m. A review of Resident #5's MAAR indicated that the abovementioned medications were not administered according to the scheduled time. The medications were administered as follows: Artificial Sol Tears was scheduled to be administered at 9:00 a.m. and 5:00 p.m., however, on the following days, the medications were given late. 3/2/24 was administered at 10:37 a.m. 3/5/24 was administered at 6:30 p.m. 3/6/24 was administered at 10:35 a.m. 3/10/24 was administered at 11:26 a.m. 3/11/24 was administered at 6:55 p.m. 3/12/24 was administered at 7:14 p.m. 3/13/24 was administered at 11:21 a.m. 3/21/24 was administered at 10:28 a.m. Aspirin 325 mg was scheduled to be administered at 9:00 a.m., however, on the following days the morning medication was given late. 3/2/24 was administered at 10:37 a.m. 3/6/24 was administered at 10:35 a.m. 3/10/24 was administered at 11:26 a.m. 3/13/24 was administered at 11:21 a.m. 3/21/24 was administered at 10:27 a.m. Bupropion 100 mg was scheduled to be administered at 9:00 a.m. and 9:00 p.m., however, on the following days the morning dose was given late. 3/2/24 was administered at 10:54 a.m. 3/6/24 was administered at 10:35 a.m. 3/10/24 was administered at 11:26 a.m. 3/13/24 was administered at 11:21 a.m. 3/21/24 was administered at 10:28 a.m. Furosemide 20 mg was scheduled to be administered at 9:00 a.m., however, on the following days the morning dose was given late. 3/2/24 was administered at 10:54 a.m. 3/6/24 was administered at 10:35 a.m. 3/10/24 was administered at 11:27 a.m. 3/13/24 was administered at 11:22 a.m. 3/21/24 was administered at 10:28 a.m. Labetalol 100 mg was scheduled to be administered at 9:00 a.m. and 9:00 p.m., however, on the following days the morning dose was given late. 3/2/24 was administered at 10:54 a.m. 3/6/24 was administered at 10:35 a.m. 3/10/24 was administered at 11:27 a.m. 3/12/24 was administered at 11:04 a.m. 3/13/24 was administered at 11:22 a.m. 3/21/24 was administered at 10:28 a.m. Vitamin C 500 mg was scheduled to be administered at 9:00 a.m., however, on the following days morning dose was given late. 3/2/24 was administered at 10:55 a.m. 3/6/24 was administered at 10:36 a.m. 3/10/24 was administered at 11:28 a.m. 3/13/24 was administered at 11:22 a.m. 3/21/24 was administered at 10:28 a.m. A review of Resident #5's PN from 3/1/24 to 3/21/24, there was no indication in the PN that the Resident's PCP was notified that the medications were not administered according to the scheduled time on the aforementioned dates. Also, there was no documented evidence of harm to the resident from the late administration of medications. During an interview with Registered Nurse (RN #1) on 3/21/24 at 1:52 p.m., RN #1 stated that red bars in the EMAR means late medications not given within the hour before and after the medications' scheduled administration time. The RN also stated that if the medications were not administered according to the scheduled time or running late with medications, RN would document that the medications were given late and would call the doctor to notify that the medications were not administered according to the scheduled time. During an interview with the Director of Nursing (DON) on 3/21/24 at 4:35 p.m., the DON stated that the nurses were to administer the medications according to the schedule. DON further stated that if the medications were not administered on scheduled time, the nurse was to notify the doctor and document in the residents' PN. A review of the facility provided document titled, Color indication on EMAR: Red - Documentation overdue, administration window to document has passed . A review of the facility's policy titled Medication Administration, dated on 3/2024, under Procedure .4. Verify the Five rights and check labeling for expiration date prior to administration. e) Right Time . A review of the facility's policy titled Physician Services, dated on 2/2024, under Procedure .8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. NJAC 8:39-29.2 (d)

Complaint# NJ 00164594 Based on observations, interviews, and record review, it was determined that the facility failed to a.) ensure that expired medications were removed from the medication cart, b.) ensure that each medication cabinets and refrigerator (Unit 2B) were locked. This deficient practice was identified for 2 of 2 units and was evidenced by the following: During the medication administration observation with the surveyors on 3/21/24 at 9:46 am, the surveyor observed Registered Nurse (RN #1) went to Unit 2B nurses' station (observed there was no one at the nurse's station) to look for a medication for an unsampled resident. RN #1 was able to open the cabinets without using a key and started looking for the medication. RN #1 then closed the cabinet without locking and stated, I will go to Pyxis [the facility's back up medications storage] to get the unsampled resident's medication, the RN left the unit and the cabinets remained unlocked. The RN went to the medication room and was able to find the unsampled medication and continued to administer medication. At 10:12 a.m., RN #1 pulled a bottle of Aspirin 325 milligram (mg) from Unit 2B's medication cart, the bottle had an expiration date of 2/2024 and a written date of 3/13/24 to indicate when the bottle was opened. Then RN #1 pulled the bottle of Aspirin and went back to Unit 2B's nurse station, for the second time around, RN #1 opened the cabinets without using a key and took a bottle of Aspirin, however she did not find one. The RN then went to Unit 2A nurse station's medication cabinet, opened the unlocked cabinet without using a key. RN took a bottle of unexpired Aspirin and continued to give medication on Unit 2B. From 9:46 am to 10:42 am, Surveyor #2 did not observe any residents wandering around the unit, the surveyor observed Unit 2B medication cabinets were unattended and unlocked. The Director of Nursing (DON) was notified. The DON and the Surveyor observed current and discontinued medications were inside the cabinets. Furthermore, the DON and the Surveyor observed that the fridge at the nurse's station's padlock was unlock. The DON pointed out a signage indicated Don't leave this Fridge unlocked. According to the DON, the cabinets and the fridge must always be locked and only the nurse can open the cabinets. During the interview with the surveyor on 3/21/24 at 1:52 pm, RN #1 stated that the cabinet must be locked at all times. RN #1 further stated that the cabinets were locked in the morning, however, she was unable to explain the reason why the cabinets were unlocked during the medication administration. She stated that the cabinets had to be locked at all times because if anyone takes the medication, they can ingest it and a lot of things can happen, like nausea, vomiting, or worse. The surveyors asked the RN regarding the expired Aspirin. The RN stated that the nurses were to check and remove all expired medications in the cart. The RN stated, I guess I did not check my cart today, otherwise I would've have seen the expired medication. During the interview with the surveyors on 3/21/24 at 4:35 pm, in the presence of Assistant DON, Administrator, Regional Clinical Nurse, Administrator in Training, the DON stated that the nurses had to remove all expired medications from the cart and will do a med error and audit to make sure there was no expired medications in the medication carts. Review of the facility policy titled Medication Storage, dated 2/2024, reflected INTENT: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. PROCEDURE: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .4. Compartments (Including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use . NJAC 8:39-29.4 (g)(h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure life-sustaining treatment wishes were reviewed with the resident or their representative and documented consistently within the medical record. This deficient practice was identified for 1 of 26 residents (Resident #121) reviewed for Advance Directive (AD) planning and was evidenced by the following: On 4/19/22 at 10:57 AM, the surveyor observed Resident #121 seated near the nurse's station with his/her eyes closed. The surveyor reviewed the medical records for Resident #121. A review of the Face Sheet (an admission summary) reflected the resident was admitted to the facility in July of 2020 with diagnoses that included diabetes mellitus, sepsis, and dementia. The record indicated the resident was responsible for him/herself, and the section for Code Status was blank. A review of the electronic Medical Record (eMR) under the resident's profile section, a section to enter the resident's life-sustaining treatment wishes (i.e., full code, do not resuscitate (DNR), do not hospitalize (DNH), do not intubate (DNI)] was blank. The physician's Order Summary Report for April 2022 did not address the resident's life-sustaining treatment wishes. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/8/22, reflected that the resident had long and short-term memory problems and moderately impaired cognition. A review of the resident's hybrid Medical Record and eMR included no documentation that indicated the resident's end-of-life wishes had been discussed with the resident or the resident's family. On 4/19/22 at 12:43 PM, the surveyor interviewed the Registered Nurse (RN) on the Fifth Floor nursing unit, who stated she had reviewed Resident #121's MR and was unable to locate the resident's AD or code status. The RN stated that the Code Status should be listed on the profile screen directly under the resident's room number, but it's not there. On 4/19/22 at 12:54 PM, the surveyor interviewed the Social Worker (SW), who stated that she was responsible for discussing AD with residents and their families upon admission and quarterly during the Interdisciplinary Care Plan meetings (IDCP). The SW stated that she was unable to provide any evidence that AD information had been discussed on admission or during each IDCP meeting. On 4/19/22 at 1:10 PM, the SW provided the surveyor with an Interdisciplinary Care plan note (IDCP) dated 8/5/21 that reflected the SW reviewed the AD forms with Resident #121's son. The SW acknowledged that she had not discussed any AD information and should have reviewed it during the quarterly IDCP meetings. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator, in the presence of the Director of Nursing, Assistant Director of Nursing, Corporate Human Resources/Payroll, and survey team, acknowledged there was no AD. A review of the the facility's Resident Right - Advanced Directive Tracking Program policy dated 2/1/22 included it is the policy of the facility to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or change existing directives. During the admission process, the Social Services Director or designee will discuss with each resident and/or the person accompanying the resident the following: whether they have an advance directive such as a surrogate designation, living will, or durable power of attorney . the resident and or the person accompanying them will be given a copy of the advance directives information, including the forms used by the facility, whether they have completed advance directives or not. The resident or the person accompanying them should sign that they have received this information . Social Services or the appropriate designee should visit the resident and discuss advance directives with them to ensure that he/she has executed the advance directives he/she would want . ensure that the information was given to the resident. Social Services will advise the resident that at any time, he/she may amend, revoke or write a new advance directive, and staff will assist NJAC 8:39-4.1 (a)(2)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physicians order for a psychiatric consultation for a resident receiving an antidepressant medication in accordance with professional standards of nursing practice for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. 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. The deficient practice was evidenced by the following: On 4/28/22 at 9:50 AM, the surveyor observed Resident #9 sitting in their wheelchair in their room. The resident stated that he/she had trouble sleeping at night, so the physician had prescribed a sleep medication to take as needed. The resident stated that the medication was effective. The surveyor reviewed the medical record for Resident #9. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in July of 2021 with diagnoses which included chronic kidney disease, stage 3; Vitamin B 12 deficiency; Vitamin D deficiency; encounter for screening for depression; and persistent mood [affective] disorder, unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/8/22, reflected that the resident had a brief interview for mental status (BIMS) score of 12 out 15, which indicated a moderately impaired cognition. A further review in Section N. Medications, reflected that during a seven day look back period, the resident received an antidepressant daily. A review of the Physicians Orders reflected a physician order (PO) dated 7/27/21 for trazadone HCl 50 milligram (mg) tablet (antidepressant medication); give one tablet by mouth as needed for sleeplessness. A further review of the Physicians Orders reflected a PO dated 12/3/21 for psychiatry consultation. A review of the Physician Consultations did not include a psychiatric consultation. On 4/28/22 at 10:00 AM, the surveyor requested from the Director of Nursing (DON) a copy of all Resident #9's psychiatric consultations and notes. On 4/28/22 at 1:13 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that Resident #9 was being seen by the Psychiatrist today; that the resident had not seen the Psychiatrist since admission at the facility. The LNHA stated that there was a PO in December (2021) for a psychiatric consultation that was never followed through with. On 4/28/22 at 1:25 PM, the surveyor interviewed the DON who stated that there was a PO from December (2021) for Resident #9 for psychiatric consultation, that should have been added to the Psychiatrist's list of residents to visit. The DON stated that she could not speak to why the resident was not seen, but the PO was put into the electronic medical record. The DON stated that the facility was trying to get a new psychiatrist since the current Psychiatrist lived far away and traveling to the facility was difficult. The DON continued that until March, the previous Assistant Director of Nursing (ADON #1) was following up with the Psychiatrist weekly via email to update the list and would look into why the resident was not seen. On 4/29/22 at 10:20 AM, the surveyor re-interviewed the DON who stated that she could only view the PO from December 2021 for the psychiatric consultation and could not access the list to verify if the resident was ever added to the list to be seen and could not speak to why the resident was not seen by the Psychiatrist until surveyor inquiry. On 4/29/22 at 10:29 AM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that she was a per diem nurse but was familiar with Resident #9. The RN stated that the resident had difficulty sleeping and took trazadone as needed which helped them sleep. The RN stated that physician orders were put into the electronic medical record by the nurse who took the order and followed. On 5/2/22 at 10:25 AM, the DON in the presence of the LNHA, current ADON #2, Corporate Human Resource/Payroll, and survey team, acknowledged that the PO for Resident #9's psychiatric consultation should have been followed through. The DON stated that the previous ADON #1 was responsible for putting physician orders into the electronic medical record and following up, but all nurses were responsible. The DON stated that it was a nursing standard of practice to follow a PO. A review of the facility's Physician Services policy dated 2/1/22 included .All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift . NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident who was dependent on staff for assistance with activities of daily living was provided oral care consistent with their needs and preferences. This deficient practice was identified for 1 of 3 residents (Resident #40) reviewed for activities of daily living and was evidenced by the following: On 4/19/22 at 10:48 AM, the surveyor observed Resident #40 in bed with their eyes closed. The resident did not respond to the surveyor. On 4/20/22 at 12:02 PM, the surveyor observed the resident in bed. The surveyor asked the resident about the care they received with their activities of daily living (ADLs). Resident #40 stated that they were assisted with showers, shaving, and bed baths but were never assisted with brushing their teeth or mouth care. The resident further stated that he/she needed assistance with setting up their supplies as it was too challenging to do themselves, and no one had ever assisted them. The surveyor reviewed the medical record for Resident #40. A review of the Face Sheet (an admission summary) reflected the resident was admitted to the facility in September of 2021 with diagnoses that included prostate cancer, muscle weakness, and paranoid schizophrenia. A review of the most recent significant change Minimum Data Set (MDS), an assessment tool dated 2/14/22, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review of the MDS, Section G Functional Status, reflected that the resident required one-person extensive physical assistance for personal hygiene. A review of the resident's individualized care plan (ICP) initiated on 2/28/22 included that the resident received hospice/palliative services related to prostate cancer with metastasis. Interventions included assisting with ADL care as needed; provide routine ADL care desired; and to work cooperatively with hospice staff to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. The care plan did not specifically address oral care. A review of the resident's electronic Certified Nursing Aide (CNA) Care Log, a communication tool used by CNAs with specific resident care needs and preferences, including mouth care, reflected the facility CNA documented that they provided oral care for Resident #40 from 2/9/22 to 4/26/22. On 4/27/22 at 12:45 PM, the surveyor interviewed the resident's CNA, who stated that she had never assisted Resident #40 with their mouth care because she assumed the resident's Hospice Aide did it. The surveyor asked the CNA why she had documented she had assisted Resident #40 with oral care, but the CNA did not respond. On 4/27/22 at 12:50 PM, the surveyor interviewed the resident's Hospice Aide, who stated that she sometimes provided mouth care for Resident #40. The surveyor informed the Hospice Aide that Resident #40 said he/she had never been assisted with mouth care. The Hospice Aide threw up her hands and replied, sometimes I forget. On 4/27/22 at 12:55 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated it was the facility CNA's responsibility to communicate with the Hospice Aide to ensure all ADL care was rendered. On 4/28/22 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON), who stated the CNA was ultimately responsible for providing ADL care. The CNA should have communicated with the Hospice Aide and should not have just assumed oral care was being done by the Hospice Aide. On 4/29/22 at 1:00 PM, the surveyor interviewed Resident #40, who stated that his/her CNA had set them up with all the necessary supplies needed to brush their teeth. The resident smiled and stated, my mouth feels much better. On 4/29/22 at 1:52 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), ADON, and survey team, acknowledged that the facility CNA and Hospice Aide should have communicated with each other to ensure Resident #40 was receiving oral care. A review of the facility's updated CNA Job Description included: maintain a safe homelike environment; assist residents with ADL needs and promote maximal independence .perform all duties as assigned. NJ 8:39-27.1(a)

Based on observation and interview, it was determined that the facility failed to a.) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness and b.) separate the hand washing sinks from the food preparation area to prevent splashing and contamination of the clean food preparation area. This deficient practice was evidenced by the following: On 4/19/22 at 9:53 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following: 1. In the food preparation area, the surveyor observed two of two handwashing sinks with no partitions between the hand washing sinks and the food preparation area. Next to one of the hand washing sinks, on the food preparation area, there was a container of clean silverware. The FSD stated that he was not aware of the need for a partition between the sink and the food preparation area. He stated that it could be possible for splashing from hands while washing to contaminate the clean silverware and clean food preparation surface. 2. Above the flat top grill, the surveyor observed half of the metal baffles soiled with a brown grease-like substance. The FSD stated that these baffles should be cleaned. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), Corporate Human Resource/Payroll, and survey team, acknowledged these concerns. A review of the facility's Food and Nutrition Services policy dated 2/1/22, included . store, prepare, distribute and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness the facility will store, prepare, distribute, and serve food in accordance with professional standards for food safety . NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/19/22 at 10:55 AM, the surveyor observed Resident #92 embracing a teddy bear and seated on a mechanical lift pad in a wheelchair in the activity room. On 4/22/22 at 11:51 AM, the surveyor observed Resident #92 seated in a wheelchair in the day room, hugging a teddy bear, listening to music played on the television for a music therapy activity, was frowning and appeared to be upset. The surveyor reviewed the medical record for Resident #92. A review of the Face Sheet reflected that the resident was originally admitted to the facility in May of 2020 and readmission in December of 2021 with diagnoses that included dementia, anxiety, mood disorder, and repeated falls. A review of the most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 3 out of 15, which indicated a severe cognitive impairment. A review of the Physician's Progress Notes from April 2021 through April 2022 reflected that the physician last saw the resident on 8/28/21. The physician had not seen the resident in 2022. On 4/28/22 at 1:17 PM, the surveyor called the resident's physician's office to speak with the physician. The Receptionist answered the telephone and put the surveyor on a brief hold to speak with the physician. The Receptionist informed the surveyor that they spoke with the physician, who stated that they no longer go to that facility and the surveyor would need to speak with the Nurse Practitioner (NP #1). The Receptionist informed the surveyor that she would leave a message for NP #1 to call the surveyor. On 4/29/22 at 10:36 AM, the surveyor interviewed NP #1 via telephone, who stated that she came to the facility twice a month to see residents and saw all the assigned residents at least once a month. NP #1 stated that the physician came if necessary; otherwise, NP #2 was also seeing residents. NP #1 stated that the physician did not have a schedule to go to the facility. On 4/29/22 at 1:28 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that she had only met the physician for this resident a few times in the past year and was unsure if the physician came in during days or times that she was not working. On 5/2/22 at 10:25 AM, the DON, in the presence of the LNHA, ADON, Corporate Human Resource/Payroll, and survey team, stated that she spoke to NP #1 today and told her that the physician must come to the facility and see the residents at least every sixty days. A review of the facility's Physician Services policy dated 2/1/22, included . the residents must be seen by a physician at least once every thirty days for the first ninety days after admission, and at least once every sixty days thereafter; a physician visit is considered timely if it occurs not later than ten days after the visit was required; all required visits will be made by the physician personally; at the option of the physician, required visits in [SNFs] skilled nursing facilities, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance to federal and state law. NJAC 8:39-23.2(d) On 4/22/22 at 11:25 AM, the surveyor observed Resident #109 in the sixth-floor dayroom sitting in a wheelchair. Resident #109 stated he/she was doing good but was going to his/her room to use the bathroom. A review of the Face Sheet reflected that the resident was admitted to the facility in February of 2018 with diagnoses which included dementia, mild protein-calorie malnutrition, gastroesophageal reflux (GERD) disease without esophagitis, and hyperlipidemia. A review of the most recent annual MDS dated [DATE], reflected that the resident had a BIMS score of 4 out of 15, which indicated a severely impaired cognition. The surveyor reviewed the medical record for Resident #109. The Physician's Progress Notes from April 2021 to April 2022, reflected Resident #109 was seen once by his/her primary physician on 12/31/21. A further review of the Physician's Progress Notes reflected the physician's nurse practitioner (NP) completed the other monthly visits. On 4/29 at 1:26 PM, the surveyor interviewed RN #2, who stated that she was a per diem nurse that floated to each floor but was the nurse for the fifth floor that day. She stated the Medical Director came at least three (3) times a week, but for Resident #109, NP #1 conducted the visits. RN #2 further stated she was unsure if Resident #109's Physician came in because the physician could have visited when she was not there. RN #2 confirmed she has always seen NP #1, and that NP #1 came in once or twice a week which would be documented in the electronic medical record. On 4/29/22 at 1:32 PM, the surveyor observed Resident #109 eating his/her lunch in the sixth-floor dayroom. On 4/29/22 at 1:33 PM, the surveyor interviewed RN #1, who stated the Medical Director visited the facility on Monday, Wednesday, and Friday. One physician comes to the facility once a month. As for Resident #109's physician stated she had not seen this year, RN #2 confirmed she had only seen the NP #1 completing the monthly physician visits. Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. b.) Ensure all residents were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was identified for 4 of 4 residents (Resident #4, #9, #92, and #109) reviewed for physician visits and evidenced by the following: On 4/28/22 at 9:50 AM, the surveyor observed Resident #9 sitting in their wheelchair in their room. The resident stated that he/she had trouble sleeping at night, so the physician had prescribed a sleep medication to take as needed. The resident stated that the medication was effective. The surveyor reviewed the medical record for Resident #9. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in July of 2021 with diagnoses that included chronic kidney disease, stage 3; Vitamin B 12 deficiency; Vitamin D deficiency; encounter for screening for depression; and persistent mood [affective] disorder, unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/8/22, reflected that the resident had a brief interview for mental status (BIMS) score of 12 out 15, which indicated a moderately impaired cognition. A review of the Physician Progress Notes reflected the following: 7/28/21 The History and Physical completed by NP #2 7/30/21 Physician Progress Note completed by NP #1 8/06/21 Physician Progress Note completed by NP #1 8/13/21 Physician Progress Note completed by NP #1 8/25/21 Physician Progress Note completed by NP #2 9/01/21 Physician Progress Note completed by NP #2 9/08/21 Physician Progress Note completed by Physician 9/10/21 Physician Progress Note completed by NP #2 9/15/21 Physician Progress Note completed by NP #2 9/29/21 Physician Progress Note completed by NP #2 11/19/21 Physician Progress Note completed by NP #2 12/26/21 Physician Progress Note completed by Physician 2/23/22 Physician Progress Note completed by NP #2 3/07/22 Physician Progress Note completed by NP #1 4/04/22 Physician Progress Note completed by NP #1 There was no documented evidence that the resident was seen at least every thirty days for the first ninety days by the physician. The physician did not see the resident upon admission or in August 2021. The physician saw the resident on 9/8/21. There was no Physician or NP visit for October 2021 or January 2022. The last Physician visit was 12/26/21. There was no evidence of a Physician visit for February or April 2022. On 4/29/22 at 11:22 AM, the surveyor re-interviewed Resident #9, who stated that he/she only knew the physician they saw in the community and were unsure who their physician was at the facility. The resident stated that he/she did not see the physician here. On 4/19/22 at 11:41 AM, the surveyor observed Resident #4 sitting in their wheelchair watching television. The surveyor interviewed the resident, who stated they were happy with the facility and had no concerns. The surveyor reviewed the medical record for Resident #4. A review of the Face Sheet reflected that the resident was admitted to the facility in January of 2019 with diagnoses which included essential (primary) hypertension (high blood pressure); acquired absence of right leg above knee (amputation); other schizophrenia; major depressive disorder; and Alzheimer's disease. A review of the most recent quarterly MDS dated [DATE] reflected a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of the Physician Progress Notes from April 2021 through April 2022 reflected the following: 4/30/21 Physician Progress Note completed by NP #1 5/27/21 Physician Progress Note completed by NP #1 6/25/21 Physician Progress Note completed by NP #1 8/9/21 Physician Progress Note completed by NP #1 9/11/21 Physician Progress Note completed by NP #2 10/15/21 Physician Progress Note completed by NP #2 11/19/21 Physician Progress Note completed by NP #2 12/31/21 Physician Progress Note completed by Physician 2/5/22 Physician Progress Note completed by NP #2 3/21/22 Physician Progress Note completed by NP #1 4/18/22 Physician Progress Note completed by NP #1 There was no evidence of a physician visit for July of 2021 and no evidence that the physician saw the resident at least every sixty days. On 4/29/22 at 1:12 PM, the surveyor observed the resident in their room. The surveyor asked the resident if they knew who their physician was or if they seen their physician. The resident responded that they did not know who their physician was and had not seen their physician.

Based on observation, interview, and record review, it was determined that the facility failed to ensure all medications were administered without error of 5% or more. During the medication pass on 4/21/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 25 opportunities and four (4) errors observed, which calculated a medication administration error rate of 16.0%. The deficient practice was identified for 1 of 2 nurses administering medications to 2 of 4 residents (Resident #131 and #78) and was evidenced by the following: 1. On 4/21/22 at 8:03 AM, the surveyor observed the Licensed Practical Nurse (LPN) during the medication pass administer five (5) medications, including one 10 milliequivalent (meq) tablet of potassium chloride (a medication used to treat and prevent low potassium). The surveyor with the LPN observed Resident #131 sitting in a wheelchair, and the LPN stated that the resident had not had their breakfast yet. The LPN offered Resident #131 a cookie, and the resident refused the cookie. A review of the bingo card (blister pack) for potassium chloride reflected a cautionary to Take with food. (Error#1) The surveyor reviewed the medical records for Resident #131. A review of the resident's current Physician Order Report reflected a physician's order (PO) dated 3/22/22 for potassium chloride 10 meq; give one tablet by mouth daily at 9:00 AM for supplement. A review of the corresponding Medication Administration Record (MAR) reflected the potassium chloride tablet administration time was 9:00 AM. On 4/21/22 at 8:23 AM, the surveyor observed the breakfast truck was delivered to the first floor sub-acute unit. On 4/21/22 at 9:10 AM, the surveyor asked the LPN to review the medication label for the potassium chloride for Resident #131, which revealed a cautionary warning to Take with food. At this time, the LPN acknowledged that she should have administered the potassium chloride with food. On 4/29/22 at 9:46 AM, the surveyor interviewed the Consultant Pharmacist (CP), who stated she conducted drug regimen reviews and medication pass observations with facility nurses monthly. The CP stated that cautionaries were included on the bingo card, such as take with food that the nurses were expected to follow. The CP continued that take with food included two crackers with four ounces of milk, a snack provided by the kitchen, or a meal within ten minutes. The CP stated that if the resident refused food, the nurse would be expected to educate the resident that the medication required to take with food. On 4/29/22 at 10:25 AM, the surveyor interviewed the Director of Nursing (DON), who stated that nurses were expected to follow medication cautionary warnings and that the LPN should have administered the medications with food. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Assistant Director of Nursing (ADON), Corporate Human Resources/Payroll, and survey team, acknowledged that medications with cautionaries to give with food, should be administered with food. 2. On 4/21/22 at 8:23 AM, the surveyor observed the LPN during the medication pass, administer five (5) medications to Resident #78, including one 6.25 mg tablet of carvedilol (a medication to treat high blood pressure); one 10 meq tablet of potassium chloride; and one 100 mg caplet of nitrofurantoin ( a medication used to treat urinary tract infections). The surveyor observed that the above medications had cautionary warnings to Take with food. At the time of administration, the surveyor observed that the resident had no meal tray, and the LPN did not offer food. (Error#2, #3, & #4) The surveyor interviewed the LPN, who confirmed that the resident had not had breakfast yet. The surveyor reviewed the medical record for Resident #78. A review of the current PO Report reflected a PO dated 3/16/22 for carvedilol 6.25 mg, give one tablet twice daily; a PO dated 3/16/22 for potassium chloride 10 meq, give one tablet daily at 8 AM; and a PO dated 4/12/22 for nitrofurantoin 100 mg, give one caplet every 12 hours. A review of the corresponding MAR reflected the following: administer carvedilol 6.25 mg, one tablet by mouth twice daily at 9:00 AM and 5:00 PM administer potassium chloride 10 meq, one tablet by mouth daily at 8:00 AM administer nitrofurantoin 100 mg caplet by mouth every 12 hours at 9:00 AM and 9:00 PM. On 4/21/22 at 8:23 AM, the surveyor observed the breakfast truck was delivered to the first floor sub-acute unit. On 4/21/22 at 9:10 AM, the surveyor asked the LPN to review the medication label for the carvedilol, potassium chloride, and nitrofurantoin, which all revealed cautionary warnings to Take with food. The LPN acknowledged that she should have followed the cautionary warnings and should have administered the medications to Resident #78 with food or with their breakfast trays. On 4/29/22 at 9:46 AM, the surveyor interviewed the CP, who stated she conducted drug regimen reviews and medication pass observations with facility nurses monthly. The CP stated that cautionaries were included on the bingo card, such as take with food that the nurses were expected to follow. The CP continued that take with food included two crackers with four ounces of milk, a snack provided by the kitchen, or a meal within ten minutes. The CP stated that if the resident refused food, the nurse would be expected to educate the resident that the medication required to take with food. On 4/29/22 at 10:25 AM, the surveyor interviewed the DON, who stated that nurses were expected to follow medication cautionary warnings and that the LPN should have administered the medications with food. On 5/2/22 at 10:25 AM, the LNHA, in the presence of the DON, ADON, Corporate Human Resources/Payroll, and survey team, acknowledged that medications with cautionaries to give with food, should be administered with food. A review of the facility's Infection Control - Medication Administration policy dated 2/1/22 included to verify medication name and label, compare it to the physician order or medication administration record (MAR), verify the dosage, and verify the route of administration (i.e., orally, intravenously, or subcutaneously) . NJAC 8:39-29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to provide foods that were maintained at the appropriate temperature. This deficient practice was identified during 2 of 2 observed lunch meal services and was evidenced by the following: 1. On 4/26/22 at 11:34 AM, the surveyor informed the Food Service Director (FSD) that they wanted to observe temperatures taken of both the hot and cold lunch meal items as well as observe the thermometer used calibrated. The FSD informed the surveyor that the cook was the person who took the meal temperatures and instructed the cook to calibrate the thermometer. At this time, the cook informed the surveyor and FSD that she was unaware of how to calibrate a thermometer, that she might have been shown previously but forgot how to, and that she did not calibrate the thermometer prior to taking temperatures. On 4/26/22 at 11:39 AM, the surveyor observed the FSD calibrate the facility's kitchen thermometer to 32 degrees Fahrenheit (F), which the FSD confirmed was the appropriate temperature. On 4/26/22 at 11:51 AM, the surveyor interviewed the cook, who stated that cold foods/drinks needed to be 40 F or below. The surveyor, in the presence of the FSD, observed the cook take the following temperatures: Turkey sandwich 49 F Whole milk 50 F 2% milk 55 F On 4/26/22 at 12:01 PM, the FSD instructed Dietary Aide #1 to remove the milks from the tray line and to put the turkey sandwiches in the freezer to cool. The FSD stated that cold items needed to be served at 40 F or below. 2. On 4/28/22 at 11:03 AM, the surveyor entered the kitchen and observed an opened case of nutritional health shakes unattended on a preparation table. The surveyor observed eleven health shakes were labeled and placed directly on the table. On 4/28/22 at 11:51 AM, the surveyor observed the contracted Consultant Certified Dietary Manager (CDM) calibrate the facility's kitchen thermometer to 32 F. On 4/28/22 at 11:54 AM, the surveyor requested the Consultant CDM take the temperature of one of the health shakes on the table and observed the temperature was 56 F. The Consultant CDM stated that the health shakes were delivered to the facility frozen and then placed in the refrigerator when needed to thaw. The Consultant CDM confirmed that the eleven labeled health shakes were above a safe temperature and needed to be discarded. The Consultant CDM removed a health shake from the box that was still partially frozen and stated that he would put these health shakes in the refrigerator. On 4/28/22 at 11:55 AM, the surveyor interviewed Dietary Aide #2, who stated that he removed the health shakes from the freezer that morning before breakfast around 8:30 AM. Dietary Aide #2 that he was defrosting and labeling the health shakes for tomorrow's supplements after lunch service was finished. On 4/28/22 at 12:09 PM, the surveyor interviewed the FSD, who stated that the health shakes were delivered to the facility frozen, and the case was removed to the refrigerator one at a time as needed. The FSD stated that each health shake was labeled to discard after two weeks from being removed from the freezer. The FSD stated that the health shakes should have remained in the freezer or refrigerator until Dietary Aide #2 was able to label them. The FSD confirmed all cold items should be maintained at 40 F or below. 3. On 4/28/22 at 11:42 AM, the surveyor observed the contracted Consultant CDM calibrate the facility's kitchen thermometer to 32 F. In the presence of the cook, the surveyor observed the Consultant CDM take temperatures for the hot and cold lunch meal items. The surveyor observed the following cold items: Fat free milk 43 F Whole milk 45 F On 4/28/22 at 11:59 AM, the surveyor interviewed the FSD, who stated that cold items needed to be maintained at 40 F or below. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADN), Corporate Human Resources/Payroll, and survey team, acknowledged these concerns. A review of the facility's undated Food Temperatures policy included . the temperature of potentially hazardous cold foods will be no greater than 40 degrees when served to residents. A review of the facility's Food Handling policy dated 2/1/22 included . foods are held at appropriate temperatures while being served. Monitoring of food temperatures using a food thermometer should be performed regularly . NJAC 17.4(a)(2)

Based on observation, interview, and record review, it was determined that the facility failed to ensure standardized recipes were utilized to ensure food was prepared to conserve nutritive value and flavor. This deficient practice was identified for 3 of 3 observed lunch meals prepared and the evidence was as follows: During a standard survey form 4/19/22 through 5/2/22, the survey team received the following food complaints from sampled residents: 1. On 4/19/22 at 10:44 AM, the surveyor interviewed Resident #9 who stated he/she disliked the food here. The resident stated they talked to the Licensed Nursing Home Administrator (LNHA) who informed them that the facility had a new chef. The resident stated he/she ate eggs and wheat soup; that their family brought sandwiches for them because the food was inedible. On 4/28/22 at 9:50 AM, the surveyor observed Resident #9 sitting in their wheelchair in their room. The resident stated everything was good at the facility except the food. The Resident continued that breakfast was okay but not lunch and dinner. The resident stated that he/she spoke with the Food Service Director (FSD) who said that the food would change in May. The resident stated if he/she disliked a food, that they would eat a peanut butter and jelly sandwich and their family brought them food. The resident also stated that they were given salt and pepper shakers to add to the food which helped because the food was bland. 2. On 4/19/22 at 11:19 AM, the surveyor interviewed Resident #3 who stated that the food was terrible that it tasted bad and sometimes was off (hot foods cold and cold foods hot). On 4/22/22 at 11:14 AM, the surveyor re-interviewed Resident #3 who stated that the food had no taste at all. 3. On 4/20/22 at 10:40 AM, the surveyor interviewed Resident #27 who complained that the food was terrible and that the food was cold and not palatable. 4. On 4/20/22 at 10:19 AM, the surveyor observed Resident #19 lying in bed. The resident complained to the surveyor that the food was not good, it had no taste. The surveyor reviewed the Cycle 3 Fall/Winter Menu provided by the facility. The surveyor observed the main lunch meal for 4/26/22 was spaghetti and meatballs with vegetables; 4/27/22 roasted chicken with yellow rice and vegetables; and 4/28/22 teriyaki salmon with white rice and vegetables. The surveyor made the following observations and interviews with the kitchen staff based on the provided menu: On 4/26/22 at 11:42 AM, the surveyor observed the lunch meal food line which contained spaghetti, meatballs in tomato sauce, and mixed vegetables. At this time, the surveyor interviewed the [NAME] who confirmed the lunch meal was spaghetti and meatballs with mixed vegetables and the alternate meal was a turkey sandwich. When asked if the meatballs were a delivered prepared food item, or she made the meatballs from scratch, the [NAME] stated that she made the meatballs. The [NAME] stated that she did not follow a written recipe, that she made the meatballs from how she knew how to. On 4/26/22 at 12:29 PM, the surveyor interviewed the FSD who stated that the facility had a contracted [name redacted] Food Service Company that started in January 2022. On 4/26/22 at 12:35 PM, the FSD stated that the contracted [name redacted] Food Service Company usually sent the facility frozen prepared meatballs, and they did not so there was no recipe for the meatballs. The FSD stated that the [NAME] prepared the meatballs using the Cook's own recipe. On 4/26/22 at 1:22 PM, the surveyor interviewed the facility's Registered Dietitian (RD #1) via telephone who stated that the menus for the meals served were created by an outside food company who their registered dietitian reviewed the menus. RD #1 stated that each meal needed to have a certain amount of nutrients such as protein. RD #1 stated that there should be standardized recipes followed for each menu item to ensure the taste, consistency, and nutrients were the same throughout. On 4/27/22 at 11:30 AM, the surveyor observed the main meal of chicken drumsticks on the steam table for lunch. On 4/28/22 at 11:04 AM, the surveyor observed the [NAME] grinding salmon. At this time, the surveyor interviewed the [NAME] who stated that she was preparing the mechanical ground salmon for the lunch meal. The [NAME] stated that she did not follow a recipe but put garlic and butter on the salmon and cooked it. The [NAME] stated that lunch was teriyaki salmon and that she prepared her own teriyaki sauce that she made herself. At this time, the surveyor interviewed the [NAME] regarding how she prepared yesterday's Roast Chicken meal. The [NAME] stated that the menu indicated rotisserie chicken, but she made baked chicken because they did not have. The [NAME] stated she placed the chicken leg (drumstick) and put [name redacted] no salt added seasoning blend on the chicken and placed in a pan to bake. The [NAME] stated that there were no standard recipes, that she just makes food how she knows how to. The [NAME] added that the facility was switching food companies and would have standard recipes next month. On 4/28/22 at 11:12 AM, the surveyor interviewed the FSD who stated that the facility did not have a standardized recipe for teriyaki salmon. The FSD acknowledged that it was important to have a recipe because certain people cannot have certain things in their diet like salt. On 4/28/22 at 11:13 AM, the surveyor in the presence of the FSD interviewed RD #2 who stated that today was her first day at the facility, but from a nutrition standpoint, it was important to have a standardized recipe to ensure that the same amount of ingredients was in the meal for consistency. RD #2 stated that meal should taste the same every time made regardless of who prepared the meal because they followed a recipe. RD #2 stated that the recipe ensured not only consistency in taste, but that each serving contained the appropriate amount of nutrients needed for each resident for that meal. At this time, the FSD stated that he had received food complaints from residents, and he spoke to those residents to see if they preferred a different food item like a sandwich. The FSD stated that the contracted [name redacted] Food Service Company provided them with standard recipes that they did not use and could not speak to why they did not use. The FSD provided the surveyor with a Baked Chicken recipe and a Teriyaki Fish recipe and confirmed again that there was no meatball recipe. The teriyaki fish was prepared with tilapia according to the recipe, but the FSD stated that the facility was delivered salmon instead. A review of the Baked Chicken recipe included for 100 servings: 25 pounds of chicken drumsticks 2/3 teaspoon ground black pepper 1/2 cup ground paprika 1/3 cup salt At this time, the surveyor informed the FSD that this was not how the [NAME] informed them that the chicken was prepared. The FSD could not speak to it. A review of the Teriyaki Baked Fish recipe included for 100 servings: 100 - 4-ounce tilapia 3-1/10 bunches of sliced green onions 3/8 gallons of cold water 1-1/8 pound granulated sugar 1-1/8 tablespoon salt 1-1/8 tablespoon ground black pepper 12-1/3 ounce chopped garlic 3/8 cup ginger powder 24-5/8 pounds vegetable oil 3/8 pounds corn starch slurry 3/8 gallon soy sauce On 4/28/22 at 11:26 AM, the surveyor re-interviewed the [NAME] regarding how she prepared the teriyaki salmon. The [NAME] stated that she put parsley and butter on the salmon and cooked for twelve minutes. The [NAME] stated for the teriyaki sauce she added a can of crushed pineapple to the blender, added chicken stock, 1/2 cup corn powder, and teriyaki sauce. The [NAME] stated that she used one cup of teriyaki sauce since it was salty and 4-ounces of the chicken base (powder) as the chicken stock. The [NAME] stated that maybe she added 3 ounces of melted butter to each pan. At this time, the surveyor re-interviewed the [NAME] how she prepared the meatballs from the 4/26/22 lunch meal. The [NAME] confirmed she did not follow a recipe but said used twenty-five pounds of ground beef, minced garlic, nine eggs, 3 cups breadcrumbs, 1 cup of parsley. The Cooked stated that the facility did not always have the ingredients needed so they used what they had on hand. On 2/28/22 at 11:30 AM, the surveyor observed the [NAME] prepare chicken gray. The [NAME] used a two-ounce ladle and scooped two heaping portions of flour (not leveled off) and placed it in a pan with a four-ounce scoop of melted butter. The [NAME] then added an unmeasured amount of boiling water to the pan plus one heaping scoop of chicken base powder using a two-ounce ladle that was not leveled off and placed into the pan and mixed to combine. After the [NAME] prepared the gravy, the surveyor observed her immediately prepare mashed potatoes by pouring an unmeasured amount of boiling water into a deep half pan and poured melted margarine into it. The surveyor asked the [NAME] if the melted liquid she used to cook was margarine and not butter as originally stated, the [NAME] confirmed yes. The [NAME] then began to add the powdered potatoes to the water/margarine mixture while whisking. The [NAME] stated that she knew how much potato powder to add by observing the consistency. The surveyor reviewed the five pound twelve ounce can of powdered potatoes that the [NAME] used for the mashed potatoes. The directions for 96 servings were as follows: 2 pounds 14 ounces mashed potato mix 1-1/2 gallons water 2 pints nonfat liquid milk 4 teaspoon salt margarine or butter On 5/2/22 at 10:25 AM, the LNHA in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), Corporate Human Resources/Payroll, and survey team acknowledged that the kitchen was not using standard recipes. A review of the facility's undated Food Preparation policy included that meals will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable and served attractively and at proper temperatures. Recipes: a file of standardized recipes is located in the kitchen. Purpose: standardized recipes give the same result each time they are use; they take the guess work out of food preparation; the exact number of servings to be expected is known; they help make purchasing more accurate . The cook and the Food Service Director are responsible for tasting all prepared food in order to judge the quality of the finished product. A review of the facility's Dietary Services - Food and Drink policy dated 2/1/22 included . food prepared by methods that conserve nutritive value, flavor, and appearance . NJAC 8:39-17.2(a); 17.4(a)(3)

Based on interview and review of facility documents, it was determined that the facility failed to ensure the facility-wide assessment included: a.) competencies for dietary staff and, b.) employee competencies for pureed texture diets. This deficient practice was identified by the following: On 4/19/22 at 10:55 AM, during the entrance conference with the Director of Nursing (DON) and Director of Marketing, the surveyor requested a copy of the Facility Assessment. On 4/27/22 at 9:58 AM, the surveyor reviewed the Facility assessment dated completed 3/29/22. A review of the facility's report for services and care provided for nutrition individualized dietary requirements, liberal diets, specialized diets, IV [intravenous] nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. Consult with speech therapist for upgrade or downgrade of diet. For staff training/education and competencies included training/education and competencies/skill checks are generally provided upon hire, during monthly in-servicing/training, annual in-servicing/training and/or whenever an area is identified, or new areas are identified based on resident diagnoses and/or clinical condition. Trainings and educations are embodied in the facility's Compliance Program General Policies and Procedures. Among the topics, it included: COVID-19; fraud, waste and abuse law; anti-kickback statue; False Claims Act; billing; payments; governance; medical necessity and quality of care; credentialing; physician self-referral statues; investigation and resolution of compliance reports; non-intimidation and non-retaliation for reporting compliance concerns; other risks. Required in-service training for nurse aides must be done to ensure competencies but must be no less that 12 hours per year . For areas of weakness as determined in nurse aides' performance reviews, additional specialized training . Training for specialized care, as needed, like catherization insertion/care, colostomy care. diabetic blood glucose testing, oxygen administration . The assessment did not include employee competencies for dietary staff and employee competencies for pureed texture diets. On 4/28/22 at 12:14 PM, the surveyor re-interviewed the FSD who stated that since he has been at the facility (October 2021), he has not in-serviced his staff or conducted competencies on anything related to the kitchen, food safety, food temperatures, etcetera. The FSD stated that the staff has been in-serviced on infection control. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Assistant Director of Nursing (ADON), Corporate Human Resource/Payroll, and survey team, stated that the facility assessment addressed what the plan was to maintain the services of the facility. The LNHA confirmed that it was specific to the population of the facility. The LNHA acknowledged that the facility did not specifically address pureed texture foods and competencies for dietary staff. The LNHA stated that the contracted [name redacted] Food Service Company was supposed to be conducting competencies with kitchen staff. NJAC 8:39-5.1(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that: a.) their Quality Assurance and Performance Improvement (QAPI) Program was being implemented and b.) a QAPI plan for food concerns was implemented. This deficient practice was identified during the standard survey and was evidenced by the following: A review of the facility's Quality Assurance and Performance Improvement policy dated 2/1/22, included These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA [Quality Assurance and Performance Improvement/Quality Assessment and Assurance] activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of the nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. The policy included that the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. A further review of the policy included that the facility will maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The policy also included that the facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. Further review of the policy included that the governing body and/or executive leadership was responsible and accountable for ensuring that the QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. On 4/28/22 at 9:50 AM, the surveyor interviewed Resident #9 who stated they disliked the food; the food had no taste. The resident continued that he/she had spoken to the Food Service Director (FSD) who informed the resident that the food would change in May. The resident stated that he/she received sandwiches if they did not want the meal offered. On 4/28/22 at 11:13 AM, the surveyor interviewed the FSD who stated that he was aware of residents complaining about the food. The FSD stated that some residents liked certain foods, while others did not. When the resident complained about the food, the FSD stated that he spoke with the resident and offered them other food options like a sandwich. On 4/28/22 at 12:14 PM, the surveyor re-interviewed the FSD who stated that since he has been at the facility (October 2021), he has not in-serviced his staff or conducted competencies on anything related to the kitchen, food safety, food temperatures, etcetera. The FSD stated that the staff has been in-serviced on infection control. A review of the last three quarterly Quality Assurance Performance Improvement meeting held on 10/21/21, 1/4/22, and 4/13/22 all included the FSD had signed in attendance. On 5/2/22 at 10:18 AM, the surveyor interviewed the FSD regarding their participation in the quarterly QAPI meeting, which the FSD replied that he did not attend the QAPI meeting. At this time, the surveyor observed a document on the FSD's desk which reflected QAPI meeting 5/1/22 and informed the FSD that they were questioning their participation in these meeting. The FSD responded that he only participated in a daily morning meeting. When asked if he addressed any kitchen concerns at these meetings, the FSD responded that he addressed staffing, kitchen equipment breaking, and food order shortages. When asked how he addressed the residents' concerns with food, the FSD responded that he walked around and talked to the residents. If it was a concern that he could not fix would let the aide or the Director of Nursing (DON) know. On 5/2/22 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Assistant Director of Nursing (ADON), Corporate Human Resource/Payroll, and survey team stated that he was unaware of the residents complaining about the food. The LNHA stated that the facility had a food committee and Resident Council was focused on food as well. The LNHA stated that if there were any issues related to food, the FSD addressed issues immediately. On 5/2/22 at 10:53 AM, the survey team interviewed the LNHA and DON regarding the facility's QAPI program. The LNHA stated that the FSD was part of the QA committee, but only joined this quarter (April 2022). When asked about the FSD signature of attendance for the October 2021 and January 2022 meetings, the LNHA could not speak. The LNHA stated that in April, the FSD brought the issue of cold food to their attention. The LNHA stated that the number one complaint in all facilities is food. The LNHA stated that the facility contributed food issues to the contracted [name redacted] Food Service Company and their lack of oversight and ordering. The LNHA stated that was why the facility was changing contracted food service companies. On 5/2/22 at 11:48 AM, the LNHA provided the surveyor with a contract for a new contracted [name redacted] Food Service Company. A review of this document revealed a proposal date of 4/7/22 with a contract signed date of 4/26/22 the day the Immediate Jeopardy was called. NJAC 8:39-33.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, family interviews and record review it was determined that the facility failed to allow easy access for family members to have visitation in accordance with state and federal guidelines for 2 of 2 Residents, Resident #57 and Resident #98. This deficient practice was evidenced by the following: 1. On 4/14/21 at 9:15 AM, the surveyor observed Resident #57 in bed, eyes closed with oxygen being delivered via a nasal cannula at the rate of 2 liters. The surveyor reviewed Resident # 57's medical record which reflected that Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to acute respiratory failure, dementia, bilateral contractures of the knees and an unstageable deep tissue injury to the left lateral foot. The surveyor reviewed a skilled nurses note dated 3/31/21 which reflected that the resident's physician recommended hospice care; Resident #57 was admitted to Hospice Care Services on 4/3/21. The surveyor reviewed the Significant Change Minimum Data Set (MDS), an assessment tool dated 4/7/2021 which reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS revealed that Resident #57 was receiving Hospice Care Services. On 4/14/21 at 9:50 AM, during an interview, Resident #57's family member (FM) stated that the facility limited her visits with the resident to 30 minutes once a week. The FM stated that she traveled a long distance to see the resident and requested to visit 2 consecutive days. The FM further stated that her request was always met with resistance. The FM informed the surveyor that the facility receptionist was responsible for scheduling the visits. The FM stated that the facility receptionist informed the them that in order to increase the visitation weekly, they would have to obtain approval from the Licensed Nursing Home Administrator (LNHA). The FM did receive approval for consecutive visits with facility relative on 4/13/21 in the evening and 4/14/21 in the morning On 4/14/21 at 10:15 AM, the surveyor interviewed the Registered Nurse (RN) on Unit 1 who stated that the facility limited the family visits of Resident #57's to 30 minutes. The RN further stated that she had been instructed by the receptionist and LHNA to enforce the 30 minute time limit. On 4/14/21 at 11:40 AM, during an interview, the Director of Nursing (DON) stated that the facility's procedure for visitation was as follows: family members were instructed to call in advance and schedule appointments with the receptionist. All visitors were allowed 30 minute visits per appointments. On 4/14/21 at 11:59 AM, during an interview, the receptionist showed the surveyor the appointment log which had 30 minute time slots. The Receptionist stated that all visits which included Hospice and Compassionate care were limited to 30 minutes once weekly unless there was a special occasion such as a birthday. If there was a special reason to allow more than one 30 minute visit per week the receptionist obtained the approval from the LNHA. She further stated, Families are definitely not allowed to visit daily. The surveyor asked the receptionist if she felt that the Resident #57's family member who traveled a long distance (over 2.5 hours) and stayed in a hotel overnight in order to visit the resident would be considered a special circumstance. The receptionist did not respond to the surveyor's question. The surveyor reviewed the facility's Limited End-of -Life and Compassionate Care Visitation Policy dated 3/2021 which reflected, These visits are not inherently limited and in most cases can happen frequently and for any duration. 2. On 4/20/2021 at 4:15 P.M., the surveyor was approached by a visitor in the facility parking lot. The visitor introduced themselves as the family member (FM2)and POA (Power of Attorney) of Resident #98 and they would like to speak to the surveyor. FM2 wanted to discuss visitation. FM2 informed the surveyor that the facility process for visitation was to call ahead and make an appointment to visit residents in the facility. FM2 informed the surveyor that the facility informed FM2 that visitation hours would accommodate working family members. FM2 stated that recently the facility was not returning calls and FM2 was not able to schedule visitation appointments, which was why FM2 was visiting the facility without an appointment. FM2 further stated that it has become increasingly difficult to make an appointment, especially in the later afternoon hours after work, from 4-5 P.M. and that these hours can rarely be accommodated. FM2 informed the surveyor that communication has decreased with the facility administration approximately since December 2020. FM2 stated that they have attempted to call the facility to make appointments to visit and would had to leave a message. FM2 said that calls have not been returned, so therefore visits with family could not be made. FM2 stated that the facility has not made it easy for families, nor have they been welcoming to family members. FM2 added that they have become so frustrated with attempting to make a visitation appointment, that today they came to the facility, called the facility when they were in the parking lot and said, I am here outside. Please bring my relative out to see me! At this time we concluded our conversation because Resident #98 was brought outside to see FM2. The surveyor observed that Resident #98 was smiling, with arms outstretched when the resident saw FM2. The surveyor reviewed the facility visitation log for the last 4-6 weeks. It was noted the last documented daily appointment time for Resident/Family visits was 3:15 P.M. It was also noted that FM2 and Resident #98 did not have any appointment documented on the visitation logs that were reviewed. The surveyor viewed Resident #98's Record. The record indicated that Resident #98 was admitted to the facility on [DATE] with diagnosis that included but were not limited to, Hypertension, Diabetes, Atrial Fibrillation, and GERD. Review of Resident #98's MDS, had a documented BIMS of 13 which indicates the resident is cognitively intact. The Resident does require staff assistance with ADL's ( activities of daily living) such as walking, dressing, eating, and personal hygiene. The surveyor reviewed CMS Covid-19 QSO 20-39-NH memo dated 9/17/2020, revised 3/10/2021 which reflected: Indoor Visitation Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for: 1. Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; 2. Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or 3. Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. On 4/15/21 at 2:05 PM, the survey team met with the LNHA, DON and Corporate Administrator (CA). The LNHA stated that he had limited visitation in order to do tracking and allow for all families to visit with facility residents. On 4/22/21 at 5:45 PM the survey team met with the LNHA, DON and CA; the facility provided no further information. NJAC 8-39-4.1 (a) (23)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for 4 of 27 residents reviewed, Resident #14, Resident #56, Resident #57, and Resident #96 and was evidenced by the following: 1. On 4/19/21 at 11:20 AM, the surveyor observed Resident #56 in bed with eyes closed. On 4/19/21 at 11:30 AM, the surveyor reviewed the medical record for Resident #56. The resident was admitted to the facility on [DATE] with diagnoses that included but was not limited to Encephalopathy, Dysphagia, Hypothyroidism, and Vascular Dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/5/21 reflected that the resident was not interviewable. The brief interview section for mental status (BIMS) (a test used to get a quick snapshot of how well you are functioning cognitively at the moment) included in the MDS indicated that the Resident #56 had memory problems. The surveyor observed the medical records belonging to Resident #56's on the unit, stored inside of a manila folder that included a face sheet, hospice information, consent for psychoactive medications and a pharmacy consultant sheet. Further review of the medical chart showed that it did not include a copy of the Resident's Practitioner Orders for Life-Sustaining Treatment (POLST) form. A POLST form is a medical order that would indicate to emergency health care professionals how you will and will not be treated during serious, potentially life ending situations. On 4/19/21 at 11:36 AM, the surveyor interviewed the Unit Manager (UM) on the unit who stated that Resident #56's POLST form and other medical information belonging to the resident was kept in the medical records office. The UM informed the surveyor that the resident's POLST was removed in error from the unit when the medical charts were recently converted to medical folders. 2. On 4/19/21 at 11:46 AM, the surveyor observed Resident #14 seated in a wheelchair inside their room eating snacks. The resident was alert. On 4/19/21 at 11:50 AM, the surveyor reviewed the medical record for Resident #14. The resident was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension, Metabolic Encephalopathy, and Atrial Fibrillation. A review of the quarterly MDS dated [DATE] reflected that Resident #14 had a BIMS score of 11 out of 15, indicating moderately impaired cognition. The surveyor observed that Resident #14's medical records were stored inside of a manila folder that included Preadmission Screening and Resident Review (PASRR) form, pharmacy consultant sheet, Interdisciplinary care plan note and Laboratory results. The manila folder did not include a copy of the Resident's POLST form. 3. On 4/19/21 at 12:05 PM, the surveyor observed Resident #96 seated in a wheelchair inside the day/dining room. The resident was alert. On 4/19/21 at 12:15 PM, the surveyor reviewed the medical record for Resident #96. The resident was admitted to the facility on [DATE] with diagnoses that included but not limited to Dementia, History of COVID 19, and Depression. A review of the quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 8 out of 15 indicating moderately impaired. The surveyor observed that the Resident's medical records were on the unit stored inside of a manila folder that included the PASRR form, pharmacy consultant sheet, and Interdisciplinary care plan note. The manila folder did not include a copy of the Resident's POLST form. 4. On 4/14/21 at 9:15 AM, the surveyor observed Resident #57 in their room, in bed, eyes closed, receiving oxygen via nasal cannula at 2 liters. The resident did not acknowledge the surveyor. On 4/19/21 at 12:00 PM, the surveyor reviewed the medical record for Resident #57. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but was not limited to acute respiratory failure, dementia, bilateral contractures of the knees and an unstageable deep tissue injury to the left lateral foot. The surveyor reviewed the Significant Change MDS, dated [DATE] reflected that the resident had a BIMS score of 6 indicating severe cognitive impairment. The surveyor observed that Resident #57's medical records on the unit were placed inside a manila folder which did not include a POLST or an Advance Directives. On 4/21/21 at 2:35 PM, the surveyor requested access to the complete medical records for Resident #56, #14, #96, #57 from the Director of Nursing (DON). The DON stated that the medical records belonging to the residents were stored on the 2nd floor, inside the medical records office. When the surveyors went to the 2nd floor, the DON then stated that it was transferred to the 3rd floor. The staff in charge of the medical records met the surveyor and DON to unlock the door to the office where all the thinned medical charts were found. A review of the facility's policy titled, Electronic Medical Records indicated under Section 9. Certain documentation that needs to be on original documentation/paper will be kept in a small file on the nursing unit. These documents include the POLST, Advance Directives, Ombudsman disclosure, PASRR and any other documents which need to be originals and cannot be scanned into the electronic medical records system. On 4/21/2021 at 5:45 PM, the surveyors met with the Administrator, DON, and Executive Administrator regarding the above concern. The DON stated that the POLST form must be kept on the nurse's unit inside the manila folders. There was no further information provided. NJAC 8:39-35.2 (d)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices. This was identified during 1 of 1 wound treatment observations for Resident # 57. This deficient practice was evidenced by the following: On 4/20/21 at 9:24 AM, the surveyor observed the Registered Nurse (RN) perform a wound treatment for Resident #57's hospital-acquired unstageable pressure ulcer to the left foot; the Hospice Aide assisted the RN with the positioning of the resident during the treatment. The surveyor reviewed the April 2021 Physician Order Summary, which reflected a Physicians' order (PO) to cleanse the left foot wound with Normal Saline, pat dry, apply Betadine, and cover with a border dressing twice daily at 9:00 AM and 5:00 PM. The PO was noted on the April 2021 Electronic Treatment Administration Record. The surveyor observed the RN wash her hands for 20 seconds, clean the overbed table with Hand Sanitizing Disposable Wipes and immediately dried the table with a paper towel. The RN removed her gloves, washed her hands under the stream of running water for 5 seconds and dried her hands with the same paper towel she used to turn off the faucet. The RN placed a plastic trash bag on top of the resident's bed to be used for discarding all contaminated supplies. The RN removed the resident's soiled dressing, placed the contaminated dressing into the plastic garbage bag located on the resident's bed and without changing her gloves or washing her hands cleaned the wound with Saline soaked 4 x 4 gauze pads using a back and forth motion. The RN did not pat the wound dry but used the same back and forth motion to dry the wound. The RN applied the Betadine with a swab stick, discarded it into the trash, removed her gloves and washed her hands under the stream of water for 11 seconds. The RN applied the border gauze to the resident's wound and with the same gloves, reached into her pocket, obtained a marker, initialed, and dated the border gauze by writing directly on the resident. The RN removed her gloves, washed her hands for 9 seconds under the stream of running water and removed the trash from the room. The RN did not disinfect the over bed table after she completed the treatment. On 4/20/21 at 2:55 PM, the surveyor discussed the breaks in technique with the RN who stated that she thought it was appropriate to use disposable hand wipes to clean the over bed table and acknowledged that she should have washed her hands for 20 seconds outside the stream of water. The RN stated that she should have used a clean paper towel to turn off the faucet, removed her gloves and washed her hands after handling the the soiled dressing. The RN stated that she should not have placed the trash bag, used to discard contaminated dressings on Resident #57's bed. The RN stated that she was not aware that it was inappropriate to write directly on a dressing after it was applied onto the resident. The surveyor reviewed the Significant Change Minimum Data Set (MDS), an assessment tool dated 4/7/2021 with a Brief Interview for Mental Status score of 6 which reflected the resident's cognition was severely impaired. The surveyor reviewed the Wound Care Assessment summary dated 4/7/21, which reflected the resident was readmitted to the facility on [DATE] with a Deep Tissue Injury to the Left lateral foot which measured 1 cm x 1 cm. The surveyor reviewed the facility's Handwashing/Hand Hygiene policy and procedure dated 2014 and updated in 2021. The policy's statement reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. Further review reflected that if hands are not visibly soiled use of an alcohol-based hand rub containing 60-95% ethanol or isopropyl for the following situations: a. Before and after direct contact with residents b. Before handling clean or soiled dressings, gauze pads, etc. c. After contact with a resident's intact skin d. After handling used dressings e. After removing gloves Hand Washing Procedure: 1. Vigorously lather hands with soap and rub together, creating friction to all surfaces, for at least 15 seconds under a moderate stream of running water. 2. Rinse hands thoroughly under running water. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. The surveyor reviewed the Wound Care policy dated 1/2021. The policy's statement reflected, The purpose of this policy is to provide guidelines for the care of wounds to promote healing. Further review reflected: 1. Clean overbed table with alcohol/ cover with a barrier. 2. Open supplies/prepare tape with date and initial 3. Wash hands, wear gloves, remove dressing, discard gloves 4. Wash hands 5. Clean wounds from center to outer edge-in circular motion 6. Apply treatment/medication/dressing/date/initial 7. Remove trash, dispose as appropriate 8. Remove gloves 9. Wash hands, apply gloves, clean overbed table with alcohol remove gloves, wash hands and sign Treatment Administration Record On 4/20/21 at 3:30 PM, the survey team discussed the above observations with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Corporate Administrator. The DON stated that the RN should not have used Disposable Hand wipes to disinfect the table, should wash her hands outside of the stream of running water for at least 15 seconds and further acknowledged that the RN should have initialed and dated the dressing before she applied it to the residents wound. NJAC 8-39-19.4 (a)