**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to protect the residents' right to be free from neglect by not addressing residents' complaints of cold water for bathing and showering. The deficient practice was identified on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 835L Interviews on 11/13/24, with both residents and staff, revealed the facility had no hot water for resident showering and bathing for months, and the facility was aware of the complaints. Temperatures obtained on 11/13/24, in both resident rooms and shower rooms on all the nursing units registered between 66.8 degrees Fahrenheit (F) and 82 degrees F. Interviews with the Maintenance Director (MD) confirmed water temperatures had been cold, that the water temperature should register at least 105 degrees F; residents and their families had complained; and the facility's boiler was underrated for the facility size. The facility's failure to protect all residents from neglect by addressing the residents' complaints of cold water when showered or bathed posed a likelihood of serious harm to the residents' care and ability to achieve their highest practicable level of wellbeing. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/13/24, when the survey team was made aware of the cold water. The facility Administration was notified of the IJ on 11/13/24 at 4:19 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: Reference: STATE OF NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF PUBLIC SAFETY AND OCCUPATIONAL SAFETY AND HEALTH BUREAU OF BOILER AND PRESSURE VESSEL COMPLIANCE included but was not limited to; boilers shall be inspected at 12-month intervals. A review of the facility provided Freedom from Abuse, Neglect and Exploitation policy dated effective October 2022, included: Purpose: To provide a proactive and systematic approach to the protection of the residents' rights and safeguarding residents from harm due to abuse, neglect and or misappropriation of property. This will be accomplished by incorporating the seven components of abuse prevention into the facility's procedural practices . Definitions: g. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. C. Prevention: Administration establishes a close rapport with residents and their representative at the time of admission. During this process, the residents and resident representatives are provided information regarding Resident's Rights, which includes discussion about who to speak to regarding any concerns, incidents, and grievances, without fear or retribution. A review of the facility provided Resident Rights policy, dated effective October 2021, included: Purpose: To inform, recognize, respect and safeguard the individual rights of all residents provided under law. Policy: The resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, as described in the policy consistent with the principles of requirements of Federal, State and Local Laws and Regulation. b. Planning and implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: 5ii. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. d. Respect and Dignity. The resident has a right to be treated with respect and dignity, including: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. e. Self-Determination. The resident has the right to self-determination, including but not limited to the right to: 1. Choose activities, schedules (including sleeping and waking times), health car and providers of health care services consistent with his or her interests, assessments, and plan of care. i. ii. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment in accordance with 483.11(g), including but not limited to receiving treatment and supports for daily living safely. Surveyor #1: On 11/13/24 at 9:28 AM, Resident #43 stated to Surveyor #1 that they had a complaint and asked if it was okay to get washed by staff with cold water. On 11/13/24 at 10:04 AM, on the Birch Unit, Surveyor #1 interviewed a Certified Nurse Aide (CNA #1) about the water temperatures, and CNA #1 stated she was unable to shower residents because the water temperature was too cold and that the facility had been aware of the cold water problem. On 11/13/24 at 11:32 AM, Surveyor #1 interviewed the Housekeeping Director (HD) about the laundry process and the hot water temperatures. The HD stated that they needed to stop using the washing machines at 10:00 AM to preserve the hot water. Surveyor #1 then asked the HD if she had been aware that there was a problem with the hot water and she stated, yes, three months ago, and stated I never in my life worked in such a condition. Surveyor #2: On 11/13/24 at 11:12 AM, Surveyor #2 toured the Dogwood Unit, and in the presence of CNA #2 took the bathroom water temperature for room [ROOM NUMBER] (unoccupied resident room) which registered 68.1 degrees F. At that time, Surveyor #2 asked if that was the hot water knob and CNA #2 confirmed it was and that the facility had not had hot water in a while and they provided cold showers. On 11/13/24 at 11:22 AM, Surveyor #2 interviewed Resident #240, who stated that they could not take a shower, but their bed bath was also cold. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #23, who stated I won't shower with cold water and don't even ask me about washing my hair. It hasn't been pleasant. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #241, who stated they have not been at the facility long, but that the water was cold. Surveyor #3: On 11/13/24 at 11:19 AM, Surveyor #3 entered the Cedar Unit and in the presence of CNA #4, obtained the following water temperatures: Shower #1 the hot water from the sink and shower was 78 degrees F, and in Resident #72 and #74's room the bathroom sink was 78 degrees F. At the time of the observation, Surveyor #3 interviewed CNA #4, who stated that in the morning the water was hot when we gave their baths, it's usually around 10:30 AM and sometimes during the day that it got cold but not all the time. On 11/13/24 at 12:13 PM, Surveyor #3 interviewed Resident #79 about the water temperatures in the room, and the resident stated the water used to be hot but lately it's been cold; I don't take showers when the water was cold. [The facility] fixes it and it got cold again. The resident had reported that the issue had been going on in the last few days. On 11/13/24 at 12:17 PM, Surveyor #3 interviewed Resident #46 in their room who stated, I've been here for 4 ½ years due to a blockage and had surgery for colostomy. I'm a quadriplegic. My major issue was there was no hot water for a year now. My last shower was two months ago, I took two showers that were ice cold. I got a bed bath but it's ice cold. I've told everyone, the nurses, Director of Nursing, Unit Managers, CNAs and Social Worker. Surveyor #4: On 11/13/24 at 11:13 AM, Surveyor #4, in the presence of CNA #5, entered Resident #82's room and tested the hot water in the resident's bathroom which registered at 80 degrees F. CNA #5 stated that residents complained of cold water all the time and CNA #5 stated he worked on all of the units. CNA #5 then accompanied Surveyor #4 to the shower room and held the shower head hose; the water felt cold and registered 69 degrees F. On 11/13/24 at 12:04 PM, Surveyor #4 entered the kitchen and observed the Kitchen Staff employee (KS #1) washing large stainless steel type pans in the three-compartment sink. The surveyor felt the wash water which felt cool and the wash temperature registered 92 degrees F, the sanitizer temperature registered 79 degrees F. Surveyor #4 asked KS #1 if there was hot water and he stated, depends if it was on and hot water was not always on. Surveyor #5: On 11/13/24 at 11:16 AM, Surveyor #5, in the presence of the Maintenance Director (MD), tested the hot water on the Birch Unit bathroom of room [ROOM NUMBER] (unoccupied resident room) which registered 66 degrees F. On 11/13/24 at 11:22 AM, Surveyor #5, in the presence of the MD, tested the hot water on the Birch Unit bathroom of room [ROOM NUMBER] (unoccupied resident room) which registered 66 degrees F. On 11/13/24 at 11:25 AM, Surveyor #5 interviewed the MD about the water temperatures in the boiler room. Surveyor #5 observed and counted that there were 12 boilers. There were six boiler certificates posted that indicated six boilers were inspected in 2023. The MD stated that the boilers observed were only used to heat the resident rooms and not for hot water. The MD stated that there were only six certificates because only six boilers were working. The MD stated that the hot water boiler was recently replaced. Surveyor #5 asked for the annual inspection certificate of the recently replaced hot water boiler and the MD stated that he was not sure if there was one because the boiler was changed prior to MD's date of hire. The MD stated that he believed that the boiler ran well but was undersized for the facility and he believed at one point the facility used to have two bigger boilers in use, telling from the empty space next to the smaller boiler. There were also two boiler venting pipes, one of them did not have a boiler hooked up to it, and the other pipe was connected to the current boiler. The other had the venting pipes reduced in size to accommodate the smaller boiler and appeared as though it was retrofitted per the MD, to accommodate a smaller boiler. Surveyor #5 then noticed old inspection stickers on the boiler and asked the MD if the unit was recently replaced, and why did it have an inspection sticker from January of 2016 on it? The MD stated that he was unsure since the boiler was already installed prior to his employment, and stated that the boiler could have been taken from somewhere else and then was installed at the facility. The MD stated, This was how it was when I got here, I inherited this. At that time the MD explained the facility boilers to Surveyor #5 which included the following: - (1) boiler that provided hot water for the entire building. Kitchen, laundry, and resident areas. - (12) boilers that were used for heating. Only (6) of those boilers were inspected because only (6) of them were working according to the MD, and the MD stated he got that information from the maintenance staff that worked there prior to his date of hire. On 11/13/24 at 12:31 PM, the survey team interviewed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the lack of hot water. The DON stated that she had only been at the facility for two months and had been told by the facility that they were working on it, and some units get it sometimes and some don't. The DON stated she didn't know what was happening, I do not know of anything and that the Executive Director (ED) had been aware of the problem. The ADON stated that she had worked at the facility for 16 years and occasionally the hot water doesn't work, and they (ED/LNHA) don't share with us. The ADON confirmed that residents and their families have complained about the lack of hot water. On 11/13/24 at 12:37 PM, the survey team interviewed the MD regarding the hot water temperature concerns, who stated he had worked at the building for five months. The MD continued that his staff informed him that there was an issue with the hot water. The MD stated the boiler was not fit for the property and the use, and was underrated for the facility size. The MD stated, the boiler only worked to produce enough hot water when the usage was low. The MD stated that the residents told him about the hot water not working and that not having hot water was unacceptable. The MD stated hot water should be available 24-7 (24 hours per day and seven days per week), and occasionally it doesn't work. The MD again confirmed that residents and their families have complained about the lack of hot water, and the ED and LNHA were aware. Surveyor #4 asked the MD if he had ever met the LNHA, and the MD stated, no, never saw him in the building. The MD stated, honest truth, I only spoke to him through her [ED] and stated he cannot call him. Surveyor #4 then asked about the discussion that occurred through the ED. The MD stated that his staff told him that the facility used to have a bigger system, and the MD stated that the hot water temperature needed to be at least 105 F. The MD stated, we only talked to him [the LNHA] through [the ED]. The MD stated about four months ago, he was on a conference phone call that the ED set-up between the ED and the LNHA (neither was present at the facility). The MD stated he informed the LNHA that the hot water system needed to be replaced sometime soon. The LNHA had no response regarding the MD's concerns, and nothing from the ED either, and he had not heard anything since. On 11/13/24 at 1:11 PM, Surveyor #4 interviewed the HD and asked if she had ever met the LNHA. She stated she had been there for six months and had never met him. The surveyor asked if the washing machine needed to be at a certain temperature to wash clothing and she stated, yes, 130 F. The surveyor asked how would you know, and she stated, I don't. The HD confirmed the facility did all linen and laundry in house. On 11/14/24 at 8:44 AM, the MD came to the conference room to show the survey team a cellular phone picture of a thermometer reading of 113 F. The surveyor asked the MD if the hot water was fixed and the water temperature was now consistent, and the MD confirmed that the hot water temperature was not consistent. On 11/14/24 at 10:14 AM, the LNHA met with the survey team to review the concerns with the lack of hot water and the IJ Situation that was presented to the facility on [DATE] at 4:19 PM. The LNHA stated that he looked at the IJs last night, but it was on his phone and he could not read them. The LNHA then stated I just got the printout this morning, and he now wanted to discuss how the facility was going to respond. The LNHA stated it [the hot water] was on and off these days, and if they [staff] adhered to the schedule they would get hot water, and yesterday they did not adhere to the schedule. The LNHA stated he knew there was an issue with the hot water and we implemented a schedule when they should be using the water and that the [residents] don't remember if they had a shower or not. Surveyor #1: On 11/14/24 at 12:39 PM, Survey #1 interviewed CNA #5, who stated the water was sometimes cold. CNA #5 stated that the resident showers could only be scheduled at 8:00 PM or after because that would be the only way they would have hot water. CNA #5 stated he could not give anyone a shower when they wanted it because of the cold water, and the nurses were aware of the hot water concerns. Surveyor #1 asked how CNA #5 knew the nurses were aware of it, and he stated because we reported it. On 11/14/24 at 12:45 PM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN #1) on the Birch unit, who stated that the concern with the hot water had been reported by staff and the staff had reported that during resident care the water being used was cold, and the water for hand hygiene was cold. LPN #1 stated that Management was already aware, and that they entered documentation regarding the water in the maintenance log. On 11/14/24 at 1:41 PM, Surveyor #1 interviewed a Maintenance Staff employee (MS #1), who stated he was aware of the issue with the hot water and that there was one pipe for the hot water that was smaller. On 11/14/24 at 2:24 PM, Surveyor #1 interviewed the 3:00-11:00 PM CNA (CNA #6), on the Birch unit, who stated they did not document the resident's refusal of a shower; they informed the nurse. On 11/15/24 at 10:55 AM, Surveyor #1 interviewed Resident #36 and Resident #8 in their room, and they both stated they had not received a shower for two months because of cold water. They both stated the DON and ADON were aware of the problem. Surveyor #1 asked how not receiving a shower made them feel and they both stated, very sad, and they do not know what was going on and they cannot shower because of cold water. On 11/14/24 at 2:28 PM, Surveyor #2 interviewed Resident #22, who stated that the showers were terrible. Resident #22 continued that this morning they got all stripped down and the staff used a [mechanical lift name] and went to shower at 9:30 AM and the water was so cold I didn't take one. We came back and I got a bed-bath with cold water. Resident #22 then stated they refused showers often because it was a struggle to get in because of the [mechanical lift] and the water was freezing. Resident #22 stated shower days were on Monday and Thursday but unfortunately they had to wait a week, and the wipes were cold. Resident #22 stated would like to take a warm shower but [expletive redacted]. On 11/14/24 at 12:45 PM, Surveyor #5 obtained water temperatures from room [ROOM NUMBER]'s (unoccupied resident room) sink which registered a hot water temperature of 98.6 degrees F. Surveyor #1: On 11/15/24 at 8:18 AM, Surveyor #1 checked the hot water with MS #1 on the Birch unit and the hot water temperature in the first shower registered 73.9 degrees F, and the sink registered 73.5 degrees F. On 11/15/24 at 8:35 AM, Surveyor #1 checked the hot water with the Maintenance Staff (MS #2) in the Birch unit second shower which registered 63.3 degrees F. On 11/15/24 at 8:37 AM, Surveyor #1 interviewed a Hospice Staff employee (HS #1), who revealed that she did not give showers because the water was cold, so she was only able to give sponge baths. On 11/15/24 at 8:39 AM, Surveyor #1 interviewed CNA #4, who stated she did not give showers because the water was cold. On 11/15/24 at 10:47 AM, Surveyor #1 interviewed MS #2, who revealed that residents could not be showered because of the cold water, and the ADON and DON had been informed. At that time, the shower log for Birch was reviewed and there was no documentation if residents received showers on their scheduled days. Surveyor #3: On 11/15/24 at 8:35 AM, Surveyor #3 observed Resident #46 lying in bed, who stated I've been refusing showers for about two months because it was cold; it made me feel [expletive redacted] because there was no substitute for a shower anymore. On 11/15/24 at 9:33 AM, Surveyor #3 interviewed CNA #5, who stated I gave Resident #46 a complete bed bath the other day. The CNA continued that the resident had not received a shower for some time because the water was cold. The CNA reported for the past three months, all the units had cold water; that the water was usually hot from 8:30 PM to about 7:00 AM. The CNA stated the water temperature was very inconsistent, and the residents wanted a hot shower. On 11/15/24, Surveyor #5 obtained the following hot water temperatures: At 9:59 AM, room [ROOM NUMBER] (unoccupied resident room) - 65.5 degrees F At 10:30 AM, Resident #21 and #47's room - 64 degrees F At 10:47 AM, Resident #2 and #42's room - 67 degrees F An acceptable Removal Plan (RP) was received on 12/4/24 at 12:24 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; a licensed plumber repaired the hot water system; a hot water management system was put in place to verify hot water was available; residents were offered a hot bath or shower two to three times a week; maintenance and nursing staff checked hot water temperatures twice on the day and evening shifts and once during the night shift to ensure acceptable temperatures; if water temperatures were not acceptable, the LNHA was notified to remedy the issue; and nursing staff utilized rinse free wipes for resident care if water was not within acceptable range and the resident requested care. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39- 4.1(a)(3)(5)(12); 5.1 (a); 27.1 (a); 27.2(i); 27.5e; 31.2(e); 31.6 (j), 31.7(h)

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part A Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented including consistently providing hot water for all residents' bathing and care needs. This deficient practice affected all residents who resided on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 600L, F 689L Interviews on 11/13/24, with both residents and staff, revealed that the facility neglected residents' complaints of no hot water for showering and bathing for months, and that the LNHA had not been present at the facility in six months was aware. Temperatures obtained on 11/13/24, in both resident rooms and shower rooms on all three nursing units registered between 66.8 degrees Fahrenheit (F) and 82 degrees F. Interviews with the Maintenance Director (MD) confirmed water temperatures had been cold, that hot water should be at least 105 degrees F; residents' and their families had complained; and the facility's boiler was underrated for the facility size. The facility's failure to ensure the LNHA was present at the facility to implement all facility policies including the residents' rights to hot water for bathing and personal care needs posed a likelihood of serious harm to the residents' care and ability to achieve their highest practicable level of wellbeing. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 11/13/24, when the survey team entered the facility and became aware that the LNHA had not been present at the facility for six months and that the LNHA had neglected the residents' complaints including water temperatures. The facility Administration was notified of the IJ on 11/13/24 at 4:19 PM. The facility submitted and acceptable Removal Plan (RP) on 12/4/24. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. The evidence was as follows: A review of the Administrator Job Description, signed as the Employee and Supervisor on 03/15/24, by the Licensed Nursing Home Administrator (LNHA) revealed: The Administrator is responsible for planning and directing the overall operation of the facility; budgetary development; expense control; supervisory oversight; and ensuring federal and state licensure requirements are met. Job responsibilities: 1. Assists Department Managers in the development and use of facility policies and procedures . 2. Overseeing all department facility operations. 3. Maintaining and meeting federal and state regulations governing nursing facility operations. 4. Plans, submits and reviews financial data and develops budget for operations, revenue and expenses for all departments . 6. Reasonable for facilitating positive resident outcomes and addressing and grievance or concerns in a timely manner following regulatory and organizational policy. 8. Actively participates in facility committees' and community programs. 9. Conducts thorough investigation of occurrences. Participated in and/or conducts Root Cause Analysis (RCA) for precursor/serious safety events. Tracks, analyzes, reports, and oversees plan of correction for occurrences in compliance with organizational policies and procedures. Reports results to the Quality Assurance Performance Improvement (QAPI) Committee. 12. Completes payroll in an accurate and timely manner. 13. Promotes the professional growth and development of all employees. Monitors plans for educational needs of the employees and ensuring compliance for mandatory education as governed by state, federal and accrediting agencies. j) Grievances: 1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances to the facility without discrimination or reprisal. Such grievances include those with respect to care and discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished. 2. The resident has the right to prompt efforts by the facility to resolve grievances in accordance with 483.11 (h). A review of the facility's Resident Rights policy dated effective October 2021, included the resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. The facility must protect and promote rights of each resident, as described in the policy consistent with the principles of requirements of Federal, State and Local Laws and Regulation . On 11/13/24 at 8:10 AM, the survey team entered the facility and the surveyor asked the Receptionist if the LNHA was available. The Receptionist stated, he [the LNHA] worked up north [northern New Jersey]; that he [the LNHA] was the owner and was not in the building. The surveyor then asked the Receptionist if he was expected at the facility, and the Receptionist stated he did not physically work in the facility. The surveyor observed the LNHA's framed New Jersey Department of Health (NJDOH) LNHA license hanging behind the Receptionist on the wall. The Receptionist again stated to the survey team that he works up north, and she did not know where, and informed the survey team that the Executive Director (ED) was in charge. The survey team then observed, affixed to the wall opposite of the reception desk, a plastic holder that contained copies of a document titled: [Facility Name] Below is a list of the Department Heads at Our Facility, Please Feel Free To Call If You Have Any Questions of Concerns Regarding Yourself or a Family Member; listed as the administrator was the ED's name and telephone number, which did not correspond with the facility's NJDOH LNHA license on file. On 11/13/24 at 8:15 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who confirmed that the LNHA was the person with the license hanging on the wall, but he was up north [northern New Jersey]. On 11/13/24 at 8:39 AM, the Director of Nursing (DON) greeted the survey team, and when the survey team inquired about the LNHA, and asked if he would be expected at the facility for the survey, the DON stated, he doesn't work here, and she had no idea where he works. The DON stated she was employed by the facility as the DON for two months, and she never met or communicated with the LNHA. The DON continued that the person she reported to, and who hired her was the ED. The DON stated the ED was not available and was not coming to the facility today. The surveyor then inquired if the ED was a LNHA, and the DON stated she was not, and the surveyor then requested a business card for the DON and ED. On 11/13/24 at 9:00 AM, the DON provided a business card for the ED. The card revealed the (ED's name), listed as a registered nurse (RN) with the title Chief Nursing Officer for the [name redacted] Management Company in [town redacted], New Jersey. The surveyor conducted an Internet search for the company location which revealed it was located 96 miles north of the facility. Surveyor #1: On 11/13/24 at 9:28 AM, Resident #43 stated to Surveyor #1 that they had a complaint and asked if it was okay to get washed by staff with cold water. On 11/13/24 at 10:04 AM, on the Birch Unit, Surveyor #1 interviewed a Certified Nurse Aide (CNA #1) about the water temperatures, and CNA #1 who stated she was unable to shower residents because the water temperature was too cold and that the facility had been aware of the cold-water problem. On 11/13/24 at 11:32 AM, Surveyor #1 interviewed the Housekeeping Director (HD) about the laundry process and the hot water temperatures. The HD stated that they needed to stop using the washing machines at 10:00 AM to preserve the hot water. Surveyor #1 then asked the HD if she had been aware that there was a problem with the hot water and she stated, yes, three months ago, and stated I never in my life worked in such a condition. Surveyor #2: On 11/13/24 at 11:12 AM, Surveyor #2 toured the Dogwood Unit, and in the presence of a CNA #2 took the bathroom water temperature for room [ROOM NUMBER] (unoccupied resident room) which registered 68.1 degrees F. At that time, Surveyor #2 asked if that was the hot water knob and CNA #2 confirmed it was and that the facility had not had hot water in a while and they provided cold showers. On 11/13/24 at 11:22 AM, Surveyor #2 interviewed Resident #240, who stated that they could not take a shower, but their bed bath was also cold. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #23, who stated I won't shower with cold water and don't even ask me about washing my hair. It hasn't been pleasant. On 11/13/24 at 11:25 AM, Surveyor #2 interviewed Resident #241, who stated that they had not been at the facility long but that the water was cold. Surveyor #3: On 11/13/24 at 11:19 AM, Surveyor #3 entered the Cedar Unit, in the presence of CNA #4, obtained the following water temperatures: Shower #1 the hot water from the sink and shower was 78 degrees F, and in Resident #72 and #74's room bathroom sink was 78 degrees F. At the time of the observation, Surveyor #3 interviewed CNA #4, who stated this morning the water was hot when we gave their baths, it's usually around 10:30 AM and sometimes during the day that it gets cold but not all the time. On 11/13/24 at 12:13 PM, Surveyor #3 interviewed Resident #79 about the water temperatures in the room and the resident continued, the water used to be hot but lately it's been cold; I don't take showers when the water was cold. [The facility] fixes it and it got cold again. The resident had reported that the issue had been going on in the last few days. On 11/13/24 at 12:17 PM, Surveyor #3 interviewed Resident #46 in their room, who stated I've been here for 4 ½ years due to a blockage and had surgery for colostomy. I'm a quadriplegic. My major issue was there was no hot water for a year now. My last shower was two months ago, I took two showers that were ice cold. I got a bed bath but it's ice cold. I've told everyone, the nurses, Director of Nursing, Unit Managers, CNAs and Social Worker. Surveyor #4: On 11/13/24 at 11:13 AM, Surveyor #4, in the presence of CNA #5, entered Resident #82's room and tested the hot water in the resident's bathroom which registered at 80 degrees F. CNA #5 stated that residents complained of cold water all the time and CNA #5 stated he worked on all of the units. CNA #5 then accompanied Surveyor #4 to the shower room and held the shower head hose; the water felt cold and registered 69 degrees F. On 11/13/24 at 12:04 PM, Surveyor #4 entered the kitchen and observed the Kitchen Staff employee (KS #1) washing large stainless steel type pans in the three-compartment sink. The surveyor felt the wash water which felt cool and the wash temperature registered 92 degrees F, the sanitizer temperature registered 79 degrees F. Surveyor #4 asked KS #1 if there was hot water and he stated, depends if it was on and hot water was not always on. Surveyor #5: On 11/13/24 at 11:16 AM, Surveyor #5, in the presence of the Maintenance Director (MD), tested the hot water on the Birch Unit bathroom in room [ROOM NUMBER] (unoccupied resident room), which registered 66 degrees F. On 11/13/24 at 11:22 AM, Surveyor #5, in the presence of the MD, tested the hot water on the Birch Unit bathroom in room [ROOM NUMBER] (unoccupied resident room), which registered 66 degrees F. On 11/13/24 at 11:25 AM, Surveyor #5 interviewed the MD about the water temperatures in the boiler room. Surveyor #5 observed and counted that there were 12 boilers. There were six boiler certificates posted that indicated six boilers were inspected in 2023. The MD stated that the boilers observed were only used to heat the resident rooms and not for hot water. The MD stated that there were only six certificates because only six boilers were working. The MD stated that the hot water boiler was recently replaced. Surveyor #5 asked for the annual inspection certificate of the recently replaced hot water boiler and the MD stated that he was not sure if there was one because the boiler was changed prior to MD's date of hire. The MD stated that he believed that the boiler ran well but was undersized for the facility and he believed at one point the facility used to have two bigger boilers in use, telling from the empty space next to the smaller boiler. There were also two boiler venting pipes, one of them did not have a boiler hooked up to it. The other had the venting pipes reduced in size to accommodate the smaller boiler. Surveyor #5 then noticed old inspection stickers on the boiler and asked the MD if the unit was recently replaced, and why did it have an inspection sticker from January of 2016 on it? The MD stated that he was unsure since the boiler was already installed prior to his employment, and stated that the boiler may have been taken from somewhere else, and then was installed at the facility. The MD stated, This was how it was when I got here, I inherited this. On 11/13/24 at 12:31 PM, the survey team interviewed the DON and ADON regarding the lack of hot water. The DON stated that she had only been at the facility for two months and had been told by the facility that they were working on it, and some units [nursing units] get it sometimes and some don't. The DON stated she didn't know what was happening, I do not know of anything and that the ED had been aware of the problem. The ADON stated that she had worked at the facility for 16 years and occasionally the hot water doesn't work, and they (ED/LNHA) don't share with us. The ADON confirmed that residents and their families had complained about the lack of hot water. On 11/13/24 at 12:37 PM, the survey team interviewed the MD regarding the hot water temperature concerns. The MD stated he had worked at the building for five months and stated that his staff informed him that there was an issue with the hot water. The MD stated the boiler was not fit for the property and the use, and was underrated for the facility size. The MD stated, the boiler only works to produce enough hot water when the usage was low. The MD stated that the residents tell him about the hot water not working and that not having hot water was unacceptable. The MD stated hot water should be available 24-7 (24 hours per day and seven days per week), and occasionally it doesn't work. The MD again confirmed that residents and their families complained about the lack of hot water, and the LNHA and ED were aware. Surveyor #4 asked the MD if he had ever met the LNHA, and the MD stated, no, never saw him in the building. The MD stated, honest truth, I only spoke to him through her [ED] and stated he cannot call him. Surveyor #4 then asked about the discussion that was had through the ED. The MD stated that his staff told him that the facility used to have a bigger system and the MD then stated the hot water temperature needed to be at least 105 degrees F. The MD stated, we only talk to him [the LNHA] through [the ED]. The MD stated about four months ago he was on a conference phone call that the ED set up with her and the LNHA (neither was present at the facility). The MD stated he informed the LNHA that the hot water system needed to be replaced sometime soon. The LNHA had no response regarding the MD's concerns, and nothing from the ED either, and he had not heard anything since. On 11/13/24 at 1:11 PM, Surveyor #4 interviewed the HD and asked if she had ever met the LNHA. She stated she had been there for six months and had never met him. The surveyor asked if the washing machine needed to be at a certain temperature to wash clothing and she stated yes, 130 degrees F. The surveyor asked how would you know, and she stated, I don't. The HD confirmed the facility did all linen and laundry in house. On 11/13/24 at 1:48 PM, Surveyor #4 interviewed the Payroll Staff employee (PS) who provided the LNHA's job description. The LNHA's job description was signed and dated as Employee and Supervisor on 3/15/24. Surveyor #4 asked the PS about the date, and she stated that was when the other LNHA left and he took over. Surveyor #4 asked the PS where the LNHA was since he was not at the facility, and the PS stated he was up north (northern New Jersey) in the corporate office. Surveyor #4 asked when the last time you physically saw the LNHA at the facility and she stated, six months ago. On 11/14/24 at 7:55 AM, the DON informed the survey team that she forwarded the IJ templates to the ED yesterday when they were presented to her. On 11/14/24 at 8:16 AM, the surveyor team observed through the opened door to the conference room, a male who introduced himself as the facility LNHA to the DON, and the LNHA then immediately entered the conference room. Upon entrance, the LNHA introduced himself as the LNHA and stated to the survey team that he had not yet read the IJ templates (provided to the DON more than 12 hours prior). The surveyor informed the LNHA that the IJ templates were sent to the ED per the DON, and then asked the LNHA if the ED was a licensed nursing home administrator? The LNHA confirmed that the ED was not a a licensed nursing home administrator. The surveyor then informed the LNHA of the observation regarding the introduction that he made to the DON, and asked if he had met or interacted with her. The LNHA stated, he spoke with her before. On 11/14/24 at 8:44 AM, the MD came to the conference room to show the survey team a cellular phone picture of a thermometer reading of 113 degrees F. The surveyor asked the MD if the hot water was fixed and the hot water temperature was now consistent, and the MD confirmed that the hot water temperature was not consistent. On 11/14/24 at 10:14 AM, the LNHA met with the survey team to review the concerns with the lack of hot water and the two IJ Situations that were presented to the facility on [DATE] at 4:19 PM. The LNHA stated he looked at the IJs last night, but it was on his phone and he could not read them. The LNHA then stated I just got the printout this morning, and he now wanted to discuss how the facility was going to respond. The LNHA stated it [the hot water] was on and off these days, and if they [staff] adhered to the schedule they would get hot water, and yesterday they did not adhere to the schedule. The LNHA stated to the survey team, I do not communicate with everyone, I am explaining that I communicate through the ED. The LNHA then stated the ED would not be at the facility. The LNHA provided a business card to the survey team that identified him as the President of the same company as the ED and in the same location (the business card did not identify him as the facility LNHA). The LNHA stated he knew there was an issue with the hot water and we implemented a schedule when they should be using the water and that the [residents] don't remember if they had a shower or not. An acceptable removal plan was received on 12/4/24 at 12:24 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including; a licensed plumber repaired the hot water system; the LNHA was on-site fulltime; the facility maintained a log to track the LNHA at the facility; the Consultant (Consult) LNHA in-serviced the LNHA on facility policies and procedures and the importance of implementing them; a hot water management system was put in place to verify hot water was available; and the LNHA audited daily temperature logs and immediately addressed any temperatures outside parameters. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/5/24. NJAC 8:39-9.2(a)(2) Part B Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) implemented all facility policies and procedures to function in a manner that ensures the resources were available for residents to attain or maintain their highest practicable level by ensuring: a) a system was in place to ensure consistent food and supplements were regularly purchased to coincide with the resident menu and therapeutic needs; b) residents were provided with an operational telephone system; c) a QAPI (Quality Assurance and Performance Improvement) program existed and involved facility staff and the Medical Director; d) waste services were consistently provided to ensure recycling was not stored in the facility due to lack of dumpster space; and e) residents' Personal Needs Account (PNA) funds were protected by having a current surety bond that was in full force and effect. The deficient practice affected all residents who resided on 3 of 3 resident units (Birch, Cedar, and Dogwood) and was evidenced by the following: A review of the Administrator Job Description, signed as the Employee and Supervisor on 03/15/24, by the Licensed Nursing Home Administrator (LNHA) revealed: The Administrator is responsible for planning and directing the overall operation of the facility; budgetary development; expense control; supervisory oversight; and ensuring federal and state licensure requirements are met. Job responsibilities: 1. Assists Department Managers in the development and use of facility policies and procedures . 2. Overseeing all department facility operations. 3. Maintaining and meeting federal and state regulations governing nursing facility operations. 4. Plans, submits and reviews financial data and develops budget for operations, revenue and expenses for all departments . 6. Reasonable for facilitating positive resident outcomes and addressing and grievance or concerns in a timely manner following regulatory and organizational policy. 8. Actively participates in facility committees' and community programs. 9. Conducts thorough investigation of occurrences. Participated in and/or conducts Root Cause Analysis (RCA) for precursor/serious safety events. Tracks, analyzes, reports, and oversees plan of correction for occurrences in compliance with organizational policies and procedures. Reports results to the Quality Assurance Performance Improvement (QAPI) Committee. 12. Completes payroll in an accurate and timely manner. 13. Promotes the professional growth and development of all employees. Monitors plans for educational needs of the employees and ensuring compliance for mandatory education as governed by state, federal and accrediting agencies. j) Grievances: 1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances to the facility without discrimination or reprisal. Such grievances include those with respect to care and discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished. 2. The resident has the right to prompt efforts by the facility to resolve grievances in accordance with 483.11 (h). A) On 11/13/24 at 9:08 AM, upon entrance to the kitchen, the surveyor asked the FSD if there have been any concerns regarding the ability to purchase food. The FSD stated that the representative from the food purveyor sent her a text last week, within one hour of submitting order. The order was submitted 11/05/24, for delivery on 11/06/24, and the text informed her that food order was on hold, and she stated that was the order, that was never delivered last week. When the surveyor asked why that happened, the FSD stated, no one (facility or purveyor) said any reason why and maybe the business office person would know. The FSD stated, it was not the first time it happened and the former FSD told her that happened before. The surveyor asked how the lack of ability to order food was affecting the foods served to the residents, and the FSD stated not fully; that she tried to stock up on items and usually made the main menu items but has had to substitute vegetables. The FSD confirmed that she has had no communication with the LNHA regarding the reason why the food order was canceled. The surveyor requested substitution logs that were provided by the FSD at that time. A review of the substitution log revealed the following: Date: 11/13/24, for lunch revealed original item: green beans and substitute (sub) given asparagus; Reason for Substitution: Vendor did not deliver. Date: 11/13/24, for lunch revealed original item: stuffing and sub given mashed potato; Reason for Substitution: Vendor did not deliver. On 11/13/24 at 3:00 PM, the FSD provided the surveyor a copy of the food order that she stated was the ordered items that were submitted on 11/5/24, and was never delivered. The FSD stated the order would not be saved in the system if it was not delivered, and that was why the order was dated 10/22/24, and she would have to re-enter the entire food order. The food order listed 90 items. The surveyor asked the FSD if she was now able to order food, she stated that she may be able to. On 11/14/24 at 9:28 AM, the surveyor interviewed the FSD regarding if the facility was able to order food. The FSD stated that she was told by the payroll person that she could order food today for tomorrow, and the facility would scan a check to the food vendor after the food order was submitted. On 11/14/24 at 1:12 PM, the surveyor interviewed the Registered Dietitian (RD) regarding her role at the facility. The RD stated she reported to the Executive Director (ED) who was not a LNHA. The RD stated, this was the first time that she saw the LNHA since she had been back at the facility since March 2024. The surveyor asked the RD if she had ever had an issue with getting paid. The RD stated that she heard it had been an issue, but that she was directed by other department heads including the Business Office, to cash her paycheck quickly and deposit the cash into her account and to not directly deposit the paycheck. The surveyor asked the RD if there were problems with the facility being able to order food. The RD stated that she was aware that to order food, the facility had to scan checks first to pre-pay the vendor. The RD stated that there were times they needed to personally go to the grocery store to purchase food items, including not having coffee for the residents and food for a resident who required a gluten free diet and they were unable to get the food. The RD stated, the food order was usually delayed, and the residents were confused at times, because they ordered food and were getting substitutes. The RD stated that they did not have the magic cup [fortified ice cream for extra calories and nutrition] and seven residents received it. On 11/15/24 at 8:52 AM, the surveyor interviewed the FSD regarding the food order, and the FSD stated a new order is supposed to be in today. The surveyor asked if magic cups were available for the residents? The FSD stated, we do not have magic cups because the food order from last week, was not approved and the facility has not had them since lunch yesterday (two meals were missed). On 11/15/24/ at 11:00 AM, the surveyor observed the emergency food storage closet with the FSD, and the 3 Day Menu was posted on the wall. The FSD stated the supply was not full because when the food orders were not able to be ordered, she took food items from the emergency supply and used them for the regular menu which depleted the emergency supply. The FSD stated she did not have enough emergency water also and has not replenished either. On 11/15/24 at 12:21 PM, the surveyor interviewed the Business Office Manager (BOM) regarding why food cannot be delivered at times. The BOM stated there were times that Accounts Payable staff (AP) had to prepay for food before the food would be sent, and stated, we are making payments as the facility was over 60 days on payments for the food vendor. B) On 11/14/24 at 11:06 AM, Surveyor #3 conducted the Resident Council meeting with seven awake and alert residents. During the meeting, seven of seven residents informed the surveyor that the phones had not been working. On 11/20/24 at 8:33 AM, Resident #61 informed Surveyor #3 that their phone had not been working. Resident #61 stated that the maintenance staff could not fix the phone. They informed the nurse and the issue had not been addressed. Resident #61 stated, I feel like a motherless child, I feel horrible. On 11/20/24 at 8:59 AM, Surveyor #3 interviewed the Certified Nursing Aides (CNA #2) regarding the issue with the phone. CNA #2 stated, It makes the residents really upset when the communication system is not working. The residents cannot communicate with their families and they do not have a cell phone. C) On 11/13/24 at 10:27 AM, during the entrance conference that was held with the facility administration, the surveyor requested: the QAPI plan, the QAPI program, the quality assessment and assurance (QAA) committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. On 11/14/24 at 12:28 PM, the surveyor requested from the LNHA the QAPI plan, the QAPI program, the QAA committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. The LNHA stated, I don't know where it is, but I will look for it. On 11/15/24 at 10:36 AM, the surveyor again, requested from the LNHA the QAPI plan, the QAPI program, the QAA committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. On 11/15/24 at 12:38 PM, the surveyor reminded the LNHA that the QAPI documentation was requested on 11/13/24, during entrance conference. The LNHA confirmed that the documentation should have been readily available to the facility administration, but again stated he did not know where it was. The surveyor then stated to the LNHA that he may have additional time to provide the documentation, and the LNHA stated, don't bother, I won't have it. The LNHA stated the Executive Director (ED- not a Licensed Nursing Home Administrator) was in charge of the QAPI binder. On 11/15/24 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team, regarding any involvement she had with QAPI. The DON stated, not here, but was aware of what QAPI was. The DON stated that upon being hired, she requested the QAPI documentation from the ED since that was her supervisor, but was not provided anything. When asked if the facility's Medical Director (MD) was a required attendee of the QAPI meetings, the DON confirmed that the MD was required to attend. On 11/15/24 at 1:37 PM, the surveyor conducted a telephone interview with the acting MD. The MD stated he had been the full-time MD for the facility for seven years. The MD stated that he was involved in monthly QAPI meetings held by the facility until approximately six to nine months ago when the QAPI meetings stopped. The MD stated that the last QAPI meeting he was aware of was held in March 2024. The MD stated that the LNHA was responsible to ensure QAPI meetings were scheduled a[TRUNCATED]