Repeat Deficiency Complaint #NJ00174978, and NJ00176742 Based on observation, interview and record review, it was determined that the facility failed to; a) clarify physician's admitting medication orders for 1 of 2 residents admitted for Hospice services (Resident #81); b) ensure a resident received their medications as prescribed by their physician for 1 of 24 residents sampled (Resident #88), in accordance with professional standards of practice. This deficient practice was as follows: 1. On 6/23/25 at 9:03 AM, the surveyor reviewed the closed medical record of discharged Resident #81. A review of the Resident admission Record (an admission summary) reflected the resident was admitted for Hospice respite to the facility with diagnoses which included multiple sclerosis, heart failure, and chronic kidney disease. A review of the Order Summary Report (OSR) with active orders as of 6/22/24 included physician orders (PO) for Farxiga oral tablet 10 mg (milligram) (Dapaglifozin propanediol); give one tablet by mouth for DM and an order for Jardiance 25 mg tablet; give one tablet by mouth one time a day for Diabetes Mellitus. A review of the June 2024 Medication Administration Record (MAR) revealed on 6/18/24, 6/19/24, 6/20/24, 6/21/24 and 6/22/24 at 9:00 AM, Resident #81 received both Jardiance and Farxiga. A review of the Consultant Pharmacist (CP) Comments report dated 6/18/24 revealed a recommendation concurrent use of Farxiga and Jardiance may be considered duplicate therapy. Please document clinical rationale if continuing present therapy. On 6/23/25 at 2:02 PM, the surveyor asked the Director of Nursing (DON) for any evidence the resident's physician had been notified of the potential duplication of therapy using Farxiga and Jardiance together. The DON was unable to provide documentation the orders had been clarified. On 6/24/25 at 1:44 PM, the survey team met with the facility Licensed Nursing Home Administrator and the DON. The DON explained the resident was a Hospice Respite admission and the resident's family would bring in the resident's medication list and medication bottles when he/she was admitted . The nurse would enter the medications into the computer after verifying with the physician and that's when the pharmacist would review the medications for irregularities including duplication of therapy. The surveyor asked for this report and the DON stated it was unavailable. On 6/25/25 at 1:12 PM, via telephone the surveyor interviewed the Regional CP for the facility, she was not the CP who made the recommendation on 6/18/24 to clarify the possible duplication of therapy. The CP was notable to confirm the physician had been contacted regarding the CP recommendations and stated the facility would have those records. When asked if in her professional opinion there was an indication to take Jardiance and Farxiga together she stated not that she was aware of. On 6/25/25 at 1:24 PM, the surveyor attempted to interview the resident's Nurse Practitioner (NP) via telephone. The surveyor left a message but did not receive a return phone call from the NP. On 6/25/25 at 2:25 PM, the DON and the LNHA acknowledged they were unable to locate the pharmacy reconciliation report. The DON further stated there was no documentation the CP recommendations were acted upon. The DON also acknowledged she was unaware of any indication for using both Farxiga and Jardiance together. The DON stated she believed the resident had used their own medications during their stay and that possibly the pharmacy substituted the Jardiance, but confirmed one of the medications should have been discontinued. 2. The surveyor reviewed the closed record for Resident #88. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included acute and chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, and pulmonary fibrosis (chronic lung disease when lung tissue becomes damaged and scarred) A review of the Order Summary Report (OSR) included the following physician's order (PO): Acetazolamide oral tablet 250 mg (milligram); give one tablet by mouth every 12 hours for diuretic, dated 8/25/24. A review of the corresponding September 2024 Medication Administration Record (MAR) revealed on three occasions the nurse documented 9. According to the key 9 indicated other- see nurses note. 9/5/24 6:00 AM 9, 9/5/24 6:00 PM 9, and 9/6/24 6:00 AM 9. A review of the corresponding Progress Notes revealed the following: On 9/5/24 at 6:31 AM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Medication not available, awaiting delivery from pharmacy. On 9/5/24 at 7:04 PM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Awaiting delivery from pharmacy. On 9/5/24 at 11:53 PM, acetazolamide 250 mg not available, a call was made to pharmacy, and I spoke to [redacted], and told me the medication is coming at midnight delivery. On 9/6/24 at 7:08 AM, acetazolamide oral tablet 250 mg give one tablet by mouth every 12 hours for diuretic. Awaiting delivery from pharmacy. On 6/24/25 at 1:44 PM, the survey team met with the facility Licensed Nursing Home Administrator and the Director of Nursing (DON) stated the resident's records were reviewed and the nursing supervisor would enter the medication orders after reviewing them first with the attending physician. If a medication was not available, the nurse should have called the attending physician as to how to proceed. The DON further stated a medication could be considered stat and could be delivered within four hours. The DON reviewed the resident medical record and confirmed the nurse indicated the medication was not available and that the nurse should have documented the physician had been notified. On 6/25/25 at 2:39 PM, the surveyor interviewed the [NAME] President of special clinical projects who acknowledged the physician should have been notified the resident had not received their medication and they should have had medication delivered from the pharmacy stat. A review of the facility's Unavailable Medications policy with an effective date of February 2019, included .The facility must make every effort to ensure the medications are available to meet the needs of each resident .Nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies that are available . NJAC 8:39-11.2(b); 27.1(a)

Complaint #NJ00175069 Based on interviews, medical record reviews, and a review of other pertinent facility documentation, it was determined that the facility failed to revise the comprehensive care plan (CP) interventions for 1 (one) of 18 residents (Resident #83) reviewed for a comprehensive CP. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #83 was admitted with diagnoses that included but were not limited to displaced bimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing disease, and dementia (loss of memory). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) on 6/18/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. Further review of A/MDS, as reflected in Section M - Skin Conditions, revealed that Resident #83 has a pressure reducing device for bed. A review of the June 2024 Order Summary Report (OSR) air mattress monitor for function and placement every shift, with a start date of 6/29/24. A review of the June 2024 Treatment Administration Record (TAR) revealed that the nurses documented that the air mattress was started on 6/29/24. A review of the form [Name Redacted] Wound Care dated 6/18/24 revealed a wound location to the coccyx to the buttock unstageable pressure ulcer (PU) with measurement of 5x7x0.1 with 100% necrotic material. Treatment recommendations include, but are not limited to, a low-air-loss mattress with measures in place for turning and positioning. A review of Resident #83's comprehensive CP review revealed actual skin breakdown related to coccyx PU initiated on 6/12/24. There are no interventions or tasks associated with a pressure-relieving air mattress. On 6/24/25 at 9:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that she would report the skin condition to her supervisor. The supervisor would then call the physician to inform them about the wound and request a treatment order, including an air mattress, and it should be added to the CP. On 6/24/25 at 9:14 AM, the surveyor interviewed the LPN/UM (Unit Manager), who stated that the CP should be updated if there is an additional order from the physician or wound doctor that includes a pressure relieving device. On 6/25/25 at 10:44 AM, the surveyor met with the Clinical Nurse/RN, who stated that the nurses failed to update the CP according to the physician's order. On 6/25/25 at 01:56 PM, the surveyor interviewed the Director of Nursing (DON) regarding the concern above but did not provide further information. A review of the facility policy titled Care Plans, Comprehensive Person-Centered with the revised date of 3/2022 stated under Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. On 6/26/25 at 11:15 AM, the surveyor met with the Licensed Nursing Home Administrator, DON, and Regional Clinical Nurse for the exit conference; no further pertinent information provided. NJAC 8:39-11.2(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ00183311 Based on interview and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident abuse within two hours of being made aware of the allegation. The incident allegedly occurred on 11/23/24 when the Certified Nursing Assistant (CNA) allegedly inappropriately touched a resident during an initial skin evaluation (Resident #90). This deficient practice was identified for 1 of 3 investigations reviewed, and was evidenced by the following: On 6/24/25 at 9:49 AM, the surveyor reviewed the closed medical record for Resident #90 who was discharged from the facility. The surveyor reviewed the medical record for Resident #90. A review of the admission Record face sheet reflected the resident was admitted to the facility in November of 2024 with diagnoses which included acute cystitis (inflammation of the bladder caused by infection), other specified sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), diabetes and muscle weakness and difficulty in walking. A review of the most recent annual Minimum Data Set (MDS), and assessment tool dated 11/26/24, reflected a brief interview for mental status (BIMS) score of 14 out 15, which indicated an intact cognition and could understand others and make self-understood with clear speech. On 6/24/25 at 9:57 AM, the surveyor reviewed the facility provided Concern Form dated 11/27/24 the concern was reported to Assistant Director of Nursing (ADON) (now current Director of Nursing [DON]) reported by resident's family on day of discharge 11/27/24 was as follows: On 11/27/2024. received a report from patient's family member (redacted) that when the patient was admitted on [DATE] the family member thought they saw the CNA's hand on the residents private part. The family member stated they were in the room and both the nurse, and the CNA went in to do a skin assessment and after they turned the resident on their back this is when the family member thought they saw the incident happen. The family member however did not report this to any staff members. A review of the Nursing Progress notes revealed a resident evaluation dated 11/23/24 at 10:34 PM, which included the resident was oriented to time, place and person. Physical abilities were the resident required the assistance of one person for bed mobility, bathing and dressing. The resident was independent with eating but required total dependence with toileting (assistance of two persons), and transfers. At this time the resident's skin was assessed and revealed redness on the sacrum and a left flank opened blister. A further review of the resident's Progress Notes revealed the following: On 11/24/24 at 4:38 PM, the resident had a social service admission evaluation. There was no documentation the resident or family reported inappropriate touching. On 11/25/24 at 9:36 AM, the resident had an admission follow-up with the Nurse Practitioner (NP). There was no documentation the resident or family reported inappropriate touching. On 11/25/24 at 12:20 PM, the resident was seen by the Physician's Assistant (PA). There was no documentation the resident or family reported inappropriate touching. A review of the facility provided Investigation Report dated 11/27/24 completed by the DON which included a timeline of events. The events were as follows: On 11/27/24 at approximately 10:00 AM, Resident # 90's family met with the ADON and alleged while Resident # 90was having their skin assessed at the time pf admission on [DATE] the resident's family thought they witnessed the CNA place her hand on the resident's private part when turning them in bed. On 11/27/24 at approximately 10:15 AM, the DON and the ADON met Resident # 90 to discuss the allegation made by their family member. Resident # 90 was adamant and stated no one touched me inappropriately. The resident stated they did not know why their family member would say that. On 11/27/24 at approximately 10:30 AM. the DON left voicemails for the nurse and CNA who were accused for statements. On 11/27/24 at 3:00 PM, the DON and the ADON interviewed the CNA who stated she was with the nurse when Resident # 90 was admitted and assisted with turning and positioning the resident so the nurse could check their skin. The CNA denied the allegation of touching the resident's private part and stated her hand was on the resident's back while turning. On 11/27/24 at approximately 3:10 PM, the DON and ADON met with the Registered Nurse (RN) who stated nothing of that sort happened during the skin assessment. In addition, the report included that upon receiving the allegation from the resident's family member, the DON and ADON immediately went to speak with the resident. As per the resident the aide did not touch their private part. The DON reviewed the admission skin assessment dated [DATE] which included a left flank open blister and redness to the sacrum as well as that the resident was alert and oriented X 3 and denied any allegation of inappropriate touching. The investigation conclusion was After a thorough investigation including interviews with the staff and resident, the team has concluded that the allegation of inappropriate touching did not occur and was not substantiated. On 6/24/25 at 1:44 PM, the survey team met with the DON and the Licensed Nursing Home Administrator. The DON stated every staff member was responsible for reporting allegations of abuse, no matter the type of abuse. The LNHA and the DON both confirmed an allegation of sexual abuse should be reported to the NJDOH within two hours of when the allegation was reported. The LNHA stated he reviewed the reportable file from the previous LNHA and confirmed he could not find any additional documentation that this event was reported to the NJDOH as required. The LNHA stated he thought that if the facility could unsubstantiate an allegation before the two hours then the allegation did not have to be reported. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated revised September 2022, included . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours if an allegation that does not involve abuse or result in serious bodily injury . NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ00175069 Based on the interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistently document an actual skin condition of the pressure ulcer (PU, damaged to the skin or underlying tissue) upon admission, b.) provide a necessary treatment and services consistent with professional standards of practice, to promote healing, and prevent worsening of a PU, c.) ensure pressure-relieving interventions according to the physician's order, and d.) consistently complete a weekly skin condition assessment. This deficient practice was identified in 1 (one) of 2 residents (Resident #83) reviewed for pressure ulcers/injuries. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #83 was admitted with diagnoses that included but were not limited to displaced bimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing disease, and dementia (loss of memory). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) on 6/18/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had a moderately impaired cognition. Further review of A/MDS reflected in Section M - Skin Conditions revealed that Resident #83 has unstageable - slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) and/or eschar (a layer of dry, dead tissue that forms over a deep wound): known but not stageable due to coverage of wound bed by slough and/or eschar. A review of the Resident Evaluation assessment dated [DATE] revealed that the resident's Braden score (a tool used to predict risk for developing PU) is 14, which indicated moderate risk for developing pressure ulcers. Furthermore, there is no documentation of the site and description for the coccyx/buttocks PU. A review of the Progress Notes (PN), dated 6/11/24 at 7:53 PM, stated skin evaluation reveals current skin breakdown/skin conditions; refer to the completed evaluation and physicians' orders for type and location. A review of the PN dated 6/12/24 at 1:36 PM stated, second skin check findings include sacrum wound. A review of the June 2024 Order Summary Report (OSR) is as follows: 1. Phytoplex Z-Guard paste (petrolatum zinc oxide) applied to the sacral area topically every shift for a preventative measure for redness, with a start date of 6/11/24. 2. Cleanse the open area on the coccyx to the buttock with Dakin's 0.125% solution. Apply calcium alginate to the wound base, then cover it with a silicone foam dressing twice daily, starting on 6/20/24. 3. Bi-weekly skin observations every evening shift every Tuesday and Friday for 0- no skin breakdown, 1-previously identified wound, and 2-newly identified wounds with a start date on 6/14/24. 4. Braden scale on admission x 3weeks post admission, every evening shift, and every Tuesday for 3 weeks. Complete the Braden Scale in Forms. 5. Air mattress monitor for function and placement every shift, with a start date of 6/29/24. A review of the June 2024 Treatment Administration Record (TAR) stated that Bi-weekly skin observations every evening shift, every Tuesday and Friday, for 0- no skin breakdown, 1-previously identified wound, and 2-newly identified wounds with a start date on 6/14/24. The nurse documented 0 - no skin breakdown on the evening shifts of 6/14/24, 6/18/24, 6/21/24, and 6/25/24. There is no documentation for biweekly observations and Braden scale assessments for the 3 weeks following admission from the hybrid medical record. A review of the form [Name Redacted] Wound Care dated 6/18/24 revealed a wound location to the coccyx to the buttock unstageable PU with measurement of 5x7x0.1 with 100% necrotic material. Treatment recommendations include, but are not limited to, a low-air-loss mattress with measures in place for turning and positioning. A review of Resident #83's comprehensive CP review revealed actual skin breakdown related to coccyx PU initiated on 6/12/24 with a cancelled date on 7/30/24. There are no interventions or tasks associated with a pressure-relieving mattress. On 6/24/25 at 9:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that the process of admitting a new resident they check the skin condition, document it and if there is any pressure injury/wound she will report it to the supervisor then the supervisor will call the physician to inform about the wound to get a treatment order. She will inform the wound consult doctor who comes to the facility every Tuesday. On 6/24/25 at 9:14 AM, the surveyor interviewed the LPN/UM (Unit Manager), who stated that if the resident refused to be seen on the day of admission, she will go and meet the resident for a second skin assessment then document the PU in the Wound Assessment tab including the location, measurement, and the overall condition of the PU. On 6/24/25 at 10:01 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) who stated that there is a documented wound on 6/12/24, second skin check findings include sacrum wound and there is documentation from the wound doctor on 6/18/25 for unstageable PU. On 6/25/25 at 10:44 AM, the surveyor met with the Clinical Nurse/RN, who stated that the nurses failed to document or report the wound, may not have taken the measurement, and did not realize or recognize the need to complete the full assessment. The staff did order a treatment, but there should be an assessment or description of the wound, including the size and the location of the pressure sores. On 6/25/25 at 12:51 PM, the surveyor interviewed LPN#2 over the phone, who stated that she no longer works at the facility and has forgotten the resident, as the incident occurred in 2024. The LPN#2 added that she must have missed the documentation for the PU, and it should be documented, including the measurement and location of the wound. If the resident refused, she would report it to the nurse in charge. On 6/25/25 at 01:56 PM, the surveyor interviewed the Director of Nursing (DON) regarding the concern above and stated that the PU should be documented, including the measurement, and followed the physician's orders accordingly. A review of the facility policy title, Pressure Ulcer/Skin Breakdown-Clinical Protocol with the revised date of April 2018 stated under Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. On 6/26/25 at 11:15 AM, the surveyor met with the Licensed Nursing Home Administrator, DON, and Regional Clinical Nurse for the exit conference; no further pertinent information provided. NJAC 8:39-27.1(a,e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility grievances, and review of facility policy, the facility failed to implement their abuse policy when they did not identify an allegation of employee to resident abuse, failed to report the allegation in a timely manner, and failed to thoroughly investigate the allegation for one (Resident (R)48) of one residents reviewed for abuse allegations of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Reporting and Investigation dated July 2017 indicates that all reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by the facility management. The facility administrator is to suspend immediately all alleged perpetrators. Review of the electronic medical record (EMR) revealed R48 was admitted to the facility on [DATE] and discharged on 11/18/23. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA1 was removed from assignment. The final category or Resolution of Concern indicated CNA1 was removed from assignment. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized a complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over, and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. During an interview with the Director of Nursing (DON) and the Administrator on 11/30/23 at 10:00 AM, the DON said they did not see the report of concern as abuse. The Administrator revealed he was the abuse coordinator and responsible for making reports of abuse to the State Survey Agency (SSA). He confirmed the policy was not implemented as the allegation of abuse was not reported to the SSA in a timely manner, was not fully investigated, and CNA1 continued to work in the facility after the concern was reported on 11/07/23. NJAC 8:39-4.1(a)(5) NJAC 8:39-13.4(c)(i-vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of employee to resident abuse was reported immediately (within two hours) to the state survey agency (SSA) for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Prevention Program edited on 04/04/18 read in pertinent part, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility management. An alleged violation of abuse will be reported immediately but not later than: two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Review of the electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE] and discharged on 11/18/23. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category of a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA was removed from assignment. The final category or Resolution of Concern indicated CNA was removed from assignment. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. Review of the forms titled 7-3 Daily Assignment Sheet (5) dated 11/07/23 provided by the Director of Nursing (DON) revealed CNA1 was assigned to R48 on day shift. On 11/08/23 the 7-3 Daily Assignment Sheet (4) revealed CNA1 was assigned to R48 and then changed to another room on the same unit. Review of the Investigative Report provided by the facility revealed the allegation of employee to resident abuse was not sent to the SSA until 11/30/23, however R48 reported the allegation to staff on 11/07/23. During an interview with the Director of Nursing (DON) and the Administrator on 11/30/23 at 10:00 AM, the DON said they did not see the report of concern as abuse. The Administrator revealed he was the abuse coordinator and responsible for making reports of abuse to the State Survey Agency (SSA). He confirmed R48's allegation of abuse was not reported to the SSA until 11/30/23, 23 days after the allegation was made. During an interview with CNA1 on 11/30/23 at 10:20 AM she revealed she did not work with R48 the morning of the accusation, however, later indicated that she did take her off the bed pan and left room. She also acknowledged that she had worked with her as a CNA the two days prior to the allegation. She also verified that she was reassigned on 11/08/23 or after the allegation, however, was not suspended from the facility. Interview with R48 via phone on 11/30/23 at 12:00 PM confirmed CNA1 was always nasty. She took my legs off the pillow, took the sheets and blankets at my feet, and twisted them hurting my feet and ankle. R48 revealed she was wearing her hospital gown with a tie at the neck and CNA1 pulled the gown down on her neck. R48 revealed she told CNA1 she didn't want her in her room. R48 alleged that CNA1 knocked the phone out of her hand to the floor while she was trying to call for help. She hurt my foot, and it hurts now more than it did before. R48 revealed she did report the incident to facility staff on 11/07/23. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of staff to resident abuse was thoroughly investigated in a timely manner for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents. Findings include: Review of the facility policy titled Abuse Prevention Program edited on 04/04/18 read in pertinent part, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of property, mistreatment and or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility management. Role of the investigator: The individual conducting the investigation will, at a minimum; interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (as medically appropriate); interview the roommate; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. Review of the electronic medical record (EMR) under the Profile tab revealed R48 was admitted to the facility on [DATE] and discharged on 11/18/23. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/23 from the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Review of the facility grievance file provided by the Administrator in a binder labeled Grievances 2023 under the November 2023 tab revealed a Concern Form dated 11/07/23 completed by Licensed Practical Nurse (LPN)2 revealed the category a documentation of concern dated 11/07/23 revealed R48 stated that assigned Certified Nursing Assistant (CNA) 1 was rough with her during care. Assigned CNA had not provided care at that time. On the same form section three titled, Documentation of Facility Follow-up indicated CNA was removed from assignment. The final category or Resolution of Concern indicated CNA was removed from assignment. CNA1's statement indicated on 11/7/23 the nurse notified me and told me that the pt (patient) complained about the care that was given to her. At that time, I haven't given the pt (patient) any type of care. LPN2's statement included On 11/7/23 the Physical Therapist (actually the Occupational Therapist) came to me and brought some concerns regarding care of R48. At the time, the CNA had not provided care as of yet. The resident statement taken by the Occupational Therapist dated 11/08/23 at 12:30 PM indicated, during OT (Occupational Therapy) session in patient's [R48] room, patient verbalized complaint about her CNA working with her. She stated that one time, she pulled the bed sheets over and her legs were inside the sheets, and it hurt her R [right] LE [lower extremity] or right lower extremity [RLE]. Another instance during her care, her hospital gown was still tied in the back around her neck and the CNA pulled it and it hurt her neck. Patient claims the CNA is mean to her and very rough. Review of the forms titled 7-3 Daily Assignment Sheet (5) dated 11/07/23 provided by the Director of Nursing (DON) revealed CNA1 was assigned to R48 on day shift. On 11/08/23 the 7-3 Daily Assignment Sheet (4) describes CNA1 assigned to R48 and then changed to another room on the same unit. Review of the facility Investigation provided by the facility of the Concern reported regarding the allegation of employee to resident abuse on 11/07/23 failed to include interviews with residents on the unit that were being cared for by CNA1 on the day in question and preceding days, and failed to document such interviews, and failed to interview staff on the unit and document to determine if they were aware of any incidents between CNA1 and R48, or any other residents. Interview with the Director of Nursing (DON) and Administrator on 11/30/23 at 10:00 AM revealed we did not see this as abuse as R48 is unreliable and CNA1 indicated she was not in the room at the time of the allegation. The Administrator confirmed the resident was unreliable, and staff were not in the room. They both confirmed the internal investigation was completed as a Concern and was not thorough and lacked interviews from other residents who had been cared for by CNA1, and failed to interview staff on the unit to determine if they had knowledge of any incidents between CNA1 and R48. There was nothing noted in R48's Care Plan related to her being unreliable. Interview with CNA1 on 11/30/23 at 10:20 AM revealed she did not work with R48 the morning of the accusation, however, later indicated that she did take her off the bed pan that day and left room. She also acknowledged that she had worked with her as a CNA the two days prior to the allegation. She also verified that she was reassigned on 11/08/23 or after the allegation, however, was not suspended from the facility. A further interview with the DON 11/30/23 at 11:00 AM revealed that CNA1 has now been suspended. The DON confirmed R48 did not have a Care Plan related to being unreliable. Interview with R48 via phone call on 11/30/23 at 12:00 PM confirmed CNA1 was always nasty. She took my legs on the pillow, took the sheets and blankets at my feet, and twisted them hurting my feet and ankle. R48 revealed she was wearing her hospital gown with a tie at the neck and CNA1 pulled the gown down on her neck. R48 revealed she told CNA1 she didn't want her in her room. R48 alleged that CNA1 knocked the phone out of her hand to the floor while she was trying to call for help. She hurt my foot, and it hurts now more than it did before. R48 revealed she did report the incident to facility staff on 11/07/23. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f) NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and failed to store food in accordance with the professional standards for food service safety to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 7/29/21 at 10:50 AM, the surveyor toured the kitchen along with Director of Culinary Services (DCS). During the tour, the surveyor observed the following: 1.) The high temperature dishwasher was observed with a temperature of 177 degrees Fahrenheit (F) during the rinse cycle. The surveyor instructed the DCS to run the dishwasher for a second rinse cycle which displayed a temperature of 176 degrees F. The DCS ran the dishwasher for a third rinse cycle that showed a temperature of 177 degrees F. The DCS stated that the temperature should have reached 180 degrees F during the rinse cycle as recommended by the Food and Drug Administration food code. 2.) In the walk-in refrigerator the surveyor observed 26 small milk cartons containing 4 ounces (118 mL) fat free milk in each carton that had expired. The surveyor interviewed the DCS who stated that the milk should have been discarded since it had passed it's expiration date. On 7/29/21 at 11:30 AM, the surveyor discussed the above concern to the Administrator, Assistant Director of Nursing and the Regional Registered Nurse. No further information was presented. NJAC 8:39-17.1(a);17.2(g)

**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 ensure a fast-acting insulin was administered with a breakfast meal in accordance with professional standards of nursing practice and physician orders. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #76). The evidence was as follows: The surveyor reviewed the medical record for Resident #76 on 9/18/19. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/28/19 reflected that Resident #76 was admitted to the facility on [DATE] with a diagnoses which included diabetes mellitus (DM) (a disease that results in too much sugar in the blood). The MDS assessment further reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating fully intact cognition. It further reflected that the resident required an extensive one-person assistance with eating. A review of the resident's individualized, comprehensive care plan initiated on 8/22/19 documented that the resident was dependent on insulin, an injectable medication used to lower blood sugar levels. The goal included that the resident will be free from complications related to his/her disease process. Interventions included, Administer medications per physician orders and Provide diet per physician orders. A review of the electronic Medication Administration Record (eMAR) for September 2019 reflected a physician's order (PO) dated 8/22/19 to administer a fast-acting insulin, NovoLog flex pen. The order specified to inject four (4) units subcutaneously (under the skin) with meals for diabetes mellitus. The eMAR noted the insulin was scheduled to be administered at 8:00 AM, 12:00 PM and 5:00 PM. On 9/19/19 at 9:08 AM, the surveyor observed Resident #76 in bed with his/her legs dangling off the edge of the bed. There was a covered breakfast tray on the resident's bedside table positioned against the wall. The breakfast tray had not been touched. The resident stated that he/she did not eat breakfast yet. At that time, the resident's assigned Licensed Practical Nurse (LPN) entered the resident's room. The surveyor observed the LPN assist the resident to sit up on the edge of the bed, and the LPN opened the resident's breakfast meal. The breakfast tray included two mini-muffins, hot oatmeal, and apple juice. The LPN began pouring the hot oatmeal onto the open space on the resident's plate. The LPN stated she was setting up the breakfast meal to speed up the process, so it would be easier for the resident to eat. The resident stated that he/she had some nausea and the LPN encouraged the resident to try and eat because she had administered insulin to the resident that morning. The resident took the first bite of breakfast at 9:10 AM. At 9:12 AM, the surveyor interviewed the LPN who stated that she checked the resident's fasting blood sugar that morning, and the result was 114 (normal fasting glucose range is typically 65-99). The LPN stated that she administered NovoLog insulin this morning, guessing that she administered it around 8:30 AM. The surveyor inquired about how quickly fast-acting NovoLog insulin began to work, and the LPN replied within 15 to 30 minutes, and that it was supposed to be given with the meal so the blood sugar doesn't drop too low. The LPN stated that she gave the insulin when the cart of trays were delivered to the unit. She stated that she did not offer/assist the resident in setting up the breakfast tray until 9:08 AM this morning, because she believed the resident was able to do it independently. She acknowledged that the resident had not eaten food since she administered the insulin. At 9:14 AM, the surveyor interviewed the Registered Nurse (RN) at the desk. The RN stated that NovoLog was a fast-acting insulin and that the resident needed to eat within an hour of giving the insulin. At 9:36 AM, the surveyor interviewed Resident #76 a second time. The surveyor observed that the resident had consumed 100% of the breakfast meal. The resident stated that the nurses check the blood sugar before every meal and that the blood sugars were always above 70. The surveyor inquired if the resident was able to decipher if he/she had a low or high blood sugar based on how he/she felt, and the resident stated that he/she only felt symptoms if the blood sugar was low. The surveyor asked what he/she would feel when it would be low, and the resident stated, I would feel weird. The surveyor asked the resident what he/she meant by weird and the resident replied, I don't know, just weird. The resident denied having any symptoms of low blood sugar while a resident at the facility, adding that the nurses were on top of all that. The surveyor asked if the resident had a preferred time he/she liked to be served breakfast, and the resident denied having a preference. At 9:39 AM, the surveyor interviewed a second LPN (LPN #2), regarding the fast-acting NovoLog insulin. LPN #2 stated that NovoLog worked within 15 minutes of injecting it, and that the resident should have the insulin with a meal. At 9:49 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM stated that NovoLog was a fast-acting insulin that worked within 15 minutes. The RN/UM acknowledged that if the order specified to administer the insulin with a meal, the resident should be set up with the tray and ready to eat at the time the insulin was administered. The surveyor reviewed the Location of Administration Report for September 2019 that accompanied the eMAR for September 2019. The report reflected that the NovoLog insulin was administered to the right lower quadrant of the abdomen on 9/19/19 at 7:51 AM that morning. On 9/23/19 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the LPN had seen the breakfast trays delivered to the unit that morning and she assumed the resident would be eating soon. The DON stated that NovoLog was a fast-acting insulin and worked within 15 minutes of administration. She acknowledged that if the physician order reflected to administer the insulin with a meal, it should have been administered within 15 minutes of the resident eating the meal. She stated that the resident was asymptomatic and that the HBA1C (blood test used to determine blood sugar levels over a period of time) was within a normal range. A review of the manufacturer specifications revised 1/2015 for NovoLog insulin included, NovoLog has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal . NJAC 8:39-29.1; 29.2