**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to initiate an investigation for an allegation of abuse and prevent further potential abuse, after two cognitively intact residents made allegations of abuse. The deficient practice occurred for 2 of 4 residents reviewed for abuse (Resident #109 and Resident 110) and was evidenced by the following:The evidence was as follows:A. On 7/29/25 at 9:01 AM, during the initial tour of the facility, Resident #110 informed the surveyor that Certified Nurse Aides (CNA #1) and (CNA #2) rough handled them during care, they pressed on their incision line, they pushed them and would not stop although they were screaming. Resident #110 stated that they reported the incident to RR #1 who had made the facility aware of what happened on Monday 7/28/25. Resident #110 informed the surveyor, I had a shattered femur, and it hurts. On 7/29/25 at 11:30 AM, the surveyor conducted an interview with the Licensed Practical Nurse Unit Manager (UM #1), on the unit where Resident #110 resided. The surveyor inquired if she had received any resident concerns regarding the care that staff provided. UM #1 confirmed that Resident #110's representative (RR #1) informed her on Monday, 7/28/25, in the morning, that the CNA's assigned to their care were not gentle to Resident #110. When asked to elaborate regarding what does not gentle entail, the UM stated she was informed that the CNAs took three hours to answer the call light, and they were not nice during care. The surveyor inquired to UM #1 if she had interviewed Resident #110 after she had spoken to RR #1. UM #1 stated, No. UM #1 was asked if she documented the interview with RR #1 and she confirmed that she had no documentation, it was verbal. On 7/29/25 at 1:15 PM, the surveyor reviewed the electronic medical record for Resident #110, including the Progress Notes, and there was no documentation regarding the concerns that UM #1 confirmed were reported to her by RR #1, and no documentation regarding a follow-up assessment, or any interaction with Resident #110 after UM #1 spoke with RR #1, and it was reported the staff took three hours to provide care and were not nice to Resident #110. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to, unspecified fracture of the right femur, muscle weakness, other abnormalities of gait and mobility and pain due to internal orthopedic prosthetic devices, implants and grafts.A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 7/29/25, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS, revealed the resident required extensive assistance with activities of daily living and mobility. A review of the individual comprehensive care plan (ICCP) included a Focus area for Activity of Daily Living (ADL), self-care performance deficit related to activity intolerance, limited mobility, limited range of motion, musculoskeletal impairment, dated 7/22/25. The goal included, will improve current level of function in through the review date, Initiated 7/22/25. Interventions included: Use extra caution when doing ADL, Initiated 7/31/25. The resident was totally dependent on two staff for repositioning and turning in bed, Initiated 7/23/25.On 7/30/25 at 9:30 AM, the surveyor, along with UM #1, reviewed the CNA #1 and CNA #2's assignment sheet for 7/26/25, 7/27/25, 7/28/25, for the 3:00 PM -11:00 PM, and 11:00 PM -7:00 AM shift.The assignment sheet confirmed that both CNA #1 and CNA #2 worked over the weekend and provided care to Resident #110. The surveyor then inquired to UM #1 what the current resident census was for the unit and she stated that 18 residents were on the unit, and for the 11:00 PM-7:00 AM shift, there was only one CNA assigned to care for 18 residents.On 7/30/25 at 10:15 AM, the surveyor conducted an interview with the (Social Worker) SW #1 and inquired if there were any grievances that were filed, or any current investigations in progress for the 2 East unit. The LSW stated that she will provide the grievance binder and was not aware of any recent concerns regarding the 2 East Unit. On 7/31/25 at 9:23 AM, the surveyor conducted a second interview with the UM #1 and she again confirmed RR #1 reported the concerns on 7/28/25, during the morning shift. UM #1 then stated, she discussed the concerns with the 11:00 PM- 7:00 AM nursing supervisor, the Social Worker and the Licensed Nursing Home Administrator (LNHA) on 7/29/25. UM #1 stated, at that time, she was not instructed to collect statements or start an investigation. On 07/31/2025 at 10:38 AM, a surveyor, in the presence of the survey team, interviewed the LNHA regarding the abuse policy. The LNHA stated that he was the Compliance Officer and was responsible for all allegations of abuse. The LNHA stated that the Social Worker (SW) was the grievance officer. When asked to differentiate regarding their respective role, the LNHA stated that he was responsible to report all allegations of abuse and the SW was responsible to address grievances. The surveyor asked the LNHA to identify the procedures to identify all type of abuse and how staff were trained to identify abuse and whom to report abuse. The LNHA stated that the facility educated all staff on the abuse policy and the facility had written policies to identify all types of abuse, verbal, physical, sexual, and psychosocial abuse. The surveyor asked the LNHA to elaborate on the process that should occur after a resident reports an allegation of abuse, specifically rough handling during care. The LNHA stated that first, the incident would be reported according to the abuse policy. The facility would start an investigation, the facility would identify the staff and notify the Abuse Coordinator which is the LNHA. On 8/1/25 at 9:28 AM, the surveyor requested any accidents, incidents, grievances, or reportable events for Resident #110.On 8/1/25 at 12:30 PM, the LNHA informed the surveyor that he did not have any grievances or Reportable Events (a mandatory reporting document for an allegation of abuse) for Resident #110. On 8/1/25 at 12:45 PM, the surveyor interviewed the LNHA, in the presence of the survey team, and asked who was responsible to oversee all investigations and report all allegations of abuse. The LNHA stated that he was responsible to report all allegations of abuse. The surveyor asked if this allegation was investigated (5 days after the allegation of potential abuse was received by UM #1) and reported, the LNHA stated, No On 8/1/2025 at 12:55 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team regarding the concerns with care reported by Resident #110. The DON stated that if a resident reported any concerns with care, and she stated she would start a grievance, she would inform the Social Worker (SW) and then start an investigation. The DON informed the survey team that the LNHA oversaw the investigations. The DON informed the survey team that she was not aware that Resident #110 documented a statement. On 8/1/25 at 1:15 PM, the surveyor inquired again to the LNHA, in the presence of the survey team, if Resident #110's stated concerns would fall under the abuse category. The LNHA stated that it could be verbal abuse. The LNHA stated when the incident was reported it was not considered as an abuse case. The surveyor inquired to the LNHA what the process was, if there was an allegation of abuse. The LNHA stated that an incident report should have been completed, statements from all staff involved should have been collected and any staff involved should be removed from the assignment pending the investigation. The surveyor then asked the LNHA if the resident provided a statement regarding the incident. The LNHA stated, the resident was not asked to document a statement at that time, but he would have asked the resident to provide a statement. On 8/1/25 at 2:30 PM, the LNHA provided the following documents:-Incident report dated 7/30/25 timed 5:11 PM (two days after the allegation was reported to UM #1). The following was documented: Nursing Description: Resident informed the Assistant Administrator that two of the overnight aides [CNAs] were not gentle while providing care.-A statement dated 7/30/25 from UM #1 indicated the following: [RR #1] advised me on 7/28/25 that Resident #110 indicated that the surgical site is sensitive while being repositioned to provide incontinence care and requested that the staff be careful while providing care. I provided verbal reminders to staff present to be mindful to surgical site while providing care. -A statement from CNA #2 dated 7/31/25 indicated the following: On several nights I took care of Resident #110. There were no concerns brought to my attention while providing care. When changing the resident, the resident stated to be careful with my hip, resident turned with a little assistance, and I gently cleaned them I will be mindful to be extra gentle going forward. -A statement written by the Assistant Administrator dated 7/30/25 at 10:45 AM, revealed the following: I walked into the room to check on Resident #110, and asked how things are going, Resident #110 stated, two nights ago my aide [CNA] was a little rough with me when the aide [CNA] was repositioning them, the aide [CNA] pushed their leg. -A statement from the nurse who worked on 7/28/25 revealed that she was not made aware of any concerns with care regarding Resident #110. -A telephone statement from CNA #1 dated 7/30/25, revealed that CNA #1 provided care to Resident #110 multiple times during the night and was careful not to touch the surgical site. Resident #110 needed a little assistance and denied hearing the resident stay to stop. On 8/1/25 at 3:30 PM, a Grievance Form dated 7/30/25 was provided by the LNHA (2 days after the allegation of rough handling was made by Resident #110) and completed by the Social Worker who documented the following: Resident #110 stated care concerns regarding 2 aides. One was described as CNA #1 (Staff with red hair highlights) and identified CNA #2 by name.On 08/01/2025 at 3:15 PM, RR#3 contacted the surveyor via telephone after the surveyor left a message. The RR #3 stated there were 3 RR's that were responsible for Resident #110 and were routinely at the facility and communicating with Resident #110. RR #3 stated that UM #1 was clearly informed by RR #1 that the staff rough handled Resident #110 and all RR's were in communication about Resident #110's care and RR #1 was not able to be contacted as they were on vacation. On 8/4/25 at 9:50 AM, the surveyor conducted a telephone interview with CNA #1. CNA #1 informed the surveyor that she had Resident #110 on her assignment on 7/27/25, 7/28/25, and 7/29/25. CNA #1 stated that during the 11:00 PM to 7:00 AM shift, she had 18 residents to provide care for. She stated she went to the room to provide care and Resident #110 was able to assist with turning but was pushing back when trying to provide care. CNA #1 was aware that Resident #110 was in pain, but she continued with care and then informed the nurse that Resident #110 had pain after care was rendered. The surveyor then asked CNA #1 what should have been done if the resident was in pain prior to providing care and she could not answer.B. On 7/29/25 at 9:10 AM, the surveyor observed Resident #109 in their room in bed with the head of the bed elevated. Resident #109 was visibly upset, crying and stated, I am not crazy, I am not crazy. The resident opened their arms toward the surveyor and stated, please help. The surveyor introduced herself and inquired to the resident if she could be of any assistance. The resident replied, Last night referring to July 28, during the 3: 00 PM-11:00 PM shift, the staff called me crazy, I kept screaming for help, they did not change me, they threatened to move me to the crazy room where I could not be heard. They moved me to the room and closed the door. The surveyor asked the resident to activate the tap bell noted on the bedside table. The resident hands were contracted, and the tap bell was not within reach. The surveyor left the room, went to the nursing station and accompanied the UM #1 to the room. In the presence of the surveyor, the resident informed UM #1 that the aide with the red hair called them crazy, refused to change them, and threatened to transfer them to the crazy room where they would not be heard. The resident continued, they transfer me to this room, and closed the door, I continued to scream. I am not crazy.On 7/30/25 at 9:20 AM, the surveyor reviewed the electronic medical record and all Progress Notes for Resident #109 and could not locate any documentation as when the resident was transferred to the current room and the rationale for the transfer. The surveyor then interviewed UM #1 regarding Resident #109. The UM #1 stated that she was made aware of the transfer on 7/28/29, she could not comment on who authorized the transfer. According to the report received, Resident #109 was confused, yelling and screaming, disturbing the unit.On 7/31/25 at 9:40 AM, the surveyor interviewed UM #1 and inquired if Resident #109 had a history of being accusatory toward staff or ever reported any issues with care. UM #1 informed the surveyor that Resident #109 usually was very quiet but at times they would refuse care. The surveyor then asked UM #1 how she addressed the concerns that Resident #109 voiced on 7/29/25. The UM #1 replied, Resident #109 was confused I did not follow up. The surveyor then asked, the UM #1 if a confused resident could have some concerns with the care received and UM #1 did not respond. On 7/31/25 at 10:30 AM, the surveyor conducted an interview with the Social Worker (SW #2) and inquired if she was made aware of any concerns regarding Resident #109. In the presence of the director of the Social Services (SW #1), SW #2 stated that she was not aware of any concerns, nor did she receive any grievance regarding Resident #109. SW #2 further stated that Resident #109 was very credible, she will talk back and added, Resident #109 was awake, alert and oriented.On 8/1/25 at 10:30 AM, the surveyor reviewed Resident #109's medical record. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted with diagnoses which included acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, unspecified cervical region. muscle weakness, malignant neoplasm of upper lobe, pain due to internal orthopedic prosthetic devices, implants, and grafts. A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/31/25, revealed Resident # 109 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated initiated 7/17/25, for Activities of Daily Living (ADL) self-care performance policy related to Activity intolerance, Disease process, fatigue, limited mobility. The Goal included that Resident #109 will improve current level of functioning through the review date. Initiated 7/17/25. Interventions included, Report any change to the nurse. Provide a sponge bath when a full bath or shower cannot be tolerated. Initiated 7/17/25. The resident is totally dependent on one staff for repositioning and turning in bed. Initiated 7/17/25. On 08/4/2025 at 10:42 AM, the surveyor conducted an interview with SW #2, she revealed that she did not talk to the resident specifically about any care concerns as she was informed there were concerns being handled by the LNHA. The SW stated the concerns with Resident #109 were not reported to her. SW #1 stated that she did not have any knowledge of the issue regarding Resident #109.On 8/4/25 at 11:15 AM, following the surveyor's inquiry regarding any concerns or grievances received by Resident #109, SW #2 then visited Resident #109 and informed the survey team that she documented a grievance from Resident #109 on 08/4/25. SW #2 provided the survey team with the copy of the Facility Grievance Form which revealed: Resident Name (Resident #109) Date of Concern: 7/28/25. Person reporting the problem: LSW. Department involved: Nursing. Complete Description of the problem: The document revealed: Resident #109, Date of Concern: 7/28/25, Complete Description of the Problem: Resident stated that [they] yelled at the Aide (Certified Nurse Aide) because aide closed the door. Aide then yelled back, If you don't stop, you'll go to crazy room. Resident stated she responded, I'm not crazy. Aide then moved resident from room [ROOM NUMBER] to 211A and closed the door. Resident stated she continued to scream for help. Resident #109 reported when the aide returned, several minutes later, the aide picked up [their] head and stared at [them]. Resident #109 asked What are you doing?, and the Aide did not answer. Resident #109 stated [they] heard another Aide say, cut [them] some slack, [they just lost [their] brother, and then heard the Aide say, good. She described the Aide as a female in her late 40's-50's with short red hair and was heavy set. Resident #109 stated the aides would be mean and ignore [them] when [he/she] was still in room [ROOM NUMBER]. On 08/04/2025 at 2:30 PM, the surveyor interviewed SW #2 and informed SW #2 of the concerns Resident #109 shared with the surveyor, the SW #2 then met with the resident regarding the concerns and documented a grievance that was provided to the LNHA and DON. The document revealed: Resident #109, Date of Concern: 7/28/25, Complete Description of the Problem: Resident stated that [they] yelled at the Aide (Certified Nurse Aide) because aide closed the door. Aide then yelled back, If you don't stop, you'll go to crazy room. Resident stated she responded, I'm not crazy. Aide then moved resident from room [ROOM NUMBER] to 211A and closed the door. Resident stated she continued to scream for help. Resident #109 reported when the aide returned, several minutes later, the aide picked up [their] head and stared at [them]. Resident #109 asked What are you doing?, and the Aide did not answer. Resident #109 stated [they] heard another Aide say, cut [them] some slack, [they just lost [their] brother, and then heard the Aide say, good. She described the Aide as a female in her late 40's-50's with short red hair and was heavy set. Resident #109 stated the aides would be mean and ignore [them] when she was still in room [ROOM NUMBER]. On 08/05/2025 at 9:30 AM, the survey team interviewed SW #1 and SW #2. The surveyor asked SW #1 what her role was with resident abuse and the investigation process when an allegation of abuse was received. SW #1 stated that upon hire, she was informed by the LNHA that he was responsible for all of the abuse investigations, any grievances and any abuse allegations. The surveyor then asked what the documented Grievance for Resident #109 indicated an allegation of? SW #2 stated I would say psychosocial abuse as the staff terrorized Resident #109 when they were holding the resident's face and staring into their eyes. Both SW #1 and #2 confirmed they were not made aware of Resident #109's allegations of abuse.On 08/05/2025 at 12:25 PM, the survey team both SW's about the room change for Resident #109. SW #1 stated, she did not know there was a room change, the room change evaluation should have been completed before the room change had even occurred. SW #1 stated the facility could make a room change for an emergency, however an evaluation still needed to be completed by the social worker to determine appropriateness of the room change and to ensure no abuse had occurred. Both Social Workers explained that Resident #109 was screaming and they needed to find out what was happening at that time and investigate the issue to see what was going on with the resident. On 08/05/2025 1:19 PM, the survey team met with the LNHA and Director of Nursing (DON) and asked what the process for resident room changes was. The LNHA stated if the resident requested a room change, and if the resident was alert and oriented the DON would call the family and let them know. The surveyor asked if there was any documentation for a room change and the LNHA stated it would be documented in the electronic medical record and DON stated, it is documented somewhere. The surveyor asked if there was a policy and the LNHA stated, yes, if it was due to safety, I would move them and let the family know. The LNHA stated the nursing supervisor would make the determination. The DON stated based on the shift-to-shift report from the nursing supervisor, Resident #109 was moved. The surveyor asked if the Social Worker supposed to be involved in the move? The DON stated, they do a form, and the surveyor asked was there any follow-up from nursing or administration to determine if the room change was appropriate? The surveyor asked the DON and LNHA if they are notified of room changes and the DON stated, I wasn't here and they don't need to call her if the resident was disruptive. The surveyor asked if she was aware of Resident #109's statement that the staff threatened the resident they would go to the crazy room. The DON stated she was not aware of Resident #109's statement and provided Resident #109's statement for review. The DON stated there was no documentation in the progress notes regarding the room change that occurred on 7/28/25 at 10:46 PM. On 08/05/25 at 2:22 PM, the survey team interviewed SW #2 regarding the statement obtained from Resident #109 on 8/4/25 and if SW #2 asked Resident #109 anything further about the room change. SW #2 stated that she provided the Grievance to the LNHA and she was informed that the LNHA was handling the investigation as the Abuse Officer, and the LNHA never directed her to participate in the investigation into the abuse or the room change. SW #2 stated she visited the resident for her general room rounds on 7/31/25 and 8/1/25 and did not ask about the incident prior to 8/4/25 when the surveyor brought it to her attention. On 8/5/25 at 3:20 PM, the surveyor in the presence of the survey team conducted a telephone interview with Resident #109's Resident Representative (RR). The surveyor asked the RR if the facility had informed them that Resident #109's room change and they stated, no. The RR stated, Resident #109 told the RR that they put them in the bad [gender redacted] room, the psychiatric room.A review of the facility's Abuse, Neglect, and Exploitation policy provided to the survey team on 7/29/25 at 11:00 AM, dated 9/1/2024, included: to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental abuse. It includes verbal abuse, sexual abuse, physical abuse . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or other but has not been investigated and, if verified, could be an indication of noncompliance with the Federal requirements related to . neglect or abuse . Policy Explanation and Compliance Guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect . Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation . Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. A review of the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, Date Implemented: 9/1/24. Identification: B. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes . verbal abuse, . physical abuse, and mental abuse . iv. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . 5. Alleged Violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yest been investigation . 6. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedures for reporting/response as described below: 7. Protection: The facility will protect residents from harm during an investigation. Procedure for Response and Reporting Allegations of abuse/Neglect/Exploitation: .When reports of abuse/neglect/exploitation occur, the following procedure will be initiated: 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident, b. Remove the accused employee from resident care areas, c. Notify the Administrator or designee, d. Notify the attending physician, resident's family/legal representative, and Medical Director, e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions, f. Document actions taken in the medical record, g. Complete an incident report as indicated, h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result an incident of abuse. 2. The Administered or designee will: a. Notify the appropriate agencies, immediately . b. Obtain statements from direct care staff, c. Suspend the accused employee pending completion of the investigation . f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate if any corrective actions taken, if the allegations were verified. A review of the Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, Date Implemented: 9/1/24. Identification: B. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes . verbal abuse, . physical abuse, and mental abuse . iv. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . 5. Alleged Violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yest been investigation . 6. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedures for reporting/response as described below: 7. Protection: The facility will protect residents from harm during an investigation. Procedure for Response and Reporting Allegations of abuse/Neglect/Exploitation: .When reports of abuse/neglect/exploitation occur, the following procedure will be initiated:1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident, b. Remove the accused employee from resident care areas, c. Notify the Administrator or designee, d. Notify the attending physician, resident's family/legal representative, and Medical Director, e. Monitor and document the resident's condition, including response to medical treatment or nursing interventions, f. Document actions taken in the medical record, g. Complete an incident report as indicated, h. Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result an incident of abuse. 2. The Administered or designee will: a. Notify the appropriate agencies, immediately . b. Obtain statements from direct care staff, c. Suspend the accused employee pending completion of the investigation . f. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate if any corrective actions taken, if the allegations were verified. A review of the UM #1's job description indicated the following: Reports any allegation of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor, /Administrator/Abuse Coordinator. Protects residents from abuse and cooperates with all investigations. NJAC 8:39-4.1(a)(5)(12)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to complete the Comprehensive admission 14-day Assessment in accordance with the Resident Assessment Instrument (RAI) for 10 of 27 residents reviewed for comprehensive admission assessments (Residents #65, #73, #69, #55, and #72, #67, #278, #272, #37, and #22). This deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. 1. According to the Face Sheet, Resident #67 was admitted to the facility on [DATE] with diagnoses including but not limited to: displaced fracture of the left ulna, history of falling and post procedural pain. A review of the Minimum Data Set (MDS) admission Assessment-14 day for Resident #67 revealed an ARD of 06/7/19 with a completion date of 06/8/29 and a submission date of 6/22/19. A review of the medical record on 06/24/19 showed that the MDS for Resident #67 had not been completed or submitted in accordance with RAI manual. During an interview on 06/24/19 at 09:57 AM, the Registered Nurse/MDS Coordinator (RN/MDS) confirmed the 14-day assessment had not been completed on 06/08/19 or submitted on 06/22/19. During an interview on 06/26/19 at 12:30 PM, the MDS Supervisor confirmed the 14-day assessment was completed in the computer 06/25/19 and submitted on 6/26/19. The MDS Coordinator also confirmed the assessment was submitted late. A review of a Submission Validation Report, dated 06/26/19, revealed the admission assessment was submitted on 06/26/19, more than 14 days overdue. 2. According to the Face Sheet, Resident #278 was admitted to the facility on [DATE] with diagnoses including but not limited: Other Orthopedic Aftercare, Displace Fracture of the Upper End of left Humerus, Unspecified Fracture of Upper End of Right Humerus, and Compression Fracture. A review of the MDS admission Assessment-14 day for Resident #278 revealed an ARD of 06/20/19 with a completion date of 06/21/19. A review of the medical record for Resident #278 showed that as of 06/24/19, the MDS had not been completed in accordance with the the RAI manual. During an interview on 06/26/19 at 09:43 AM, the MDS Supervisor confirmed the 14-day assessment had not been completed on 06/21/19 for Resident #278. 3. According to the Face Sheet, Resident #282 was admitted to the facility on [DATE] with diagnoses including but not limited: Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Acute Kidney Failure. A review of the MDS admission Assessment-14 day revealed an ARD of 06/20/19 with a completion date of 06/21/19. A review of the medical record for Resident # 282 showed that as of 06/24/19 the MDS had not been completed in accordance with the RAI manual. During an interview on 06/26/19 at 09:25 AM, the MDS Supervisor confirmed the 14-day assessment had not been completed on 6/21/19 for Resident #282. 4. According to the Face Sheet, Resident #65 was admitted to the facility on [DATE] with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Diastolic Congestive Heart Failure and Muscle Weakness. A review of the MDS admission Assessment-14 day for Resident #65 revealed an ARD of 06/05/19 with a completion date of 06/06/19 and a submission date of 06/20/19. A review of the medical record for Resident #65 showed that as of 06/24/19, the MDS had not been completed or submitted in accordance with the RAI manual. 5. According to the Face Sheet, Resident #73 was admitted to the facility on [DATE] with diagnoses including but not limited to: Fracture of unspecified part of neck of left femur, Chronic Kidney Disease and Parkinson's Disease. A review of the MDS admission Assessment for Resident #73 revealed an ARD of 06/12/19 with a completion date of 06/13/19. A review of the medical record for Resident #73 showed that as of 06/24/19, the MDS had not been completed in accordance with the RAI manual. A review of Resident #73's MDS assessments also revealed a 14-day scheduled assessment with an ARD of 06/14/19 and a completion date of 06/21/19. A review of the medical record showed that as of 06/24/19 neither of the MDS assessments had been completed in accordance with the RAI manual. 6. According to the Face Sheet, Resident #69 was admitted to the facility on [DATE] with diagnoses including but not limited to: Acute Respiratory Failure with Hypoxia (low oxygen blood levels), Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease, Stage 3. A review of the MDS admission Assessment for Resident #69 revealed an ARD of 06/12/19 with a completion date of 06/13/19. A review of the medical record for Resident #69 showed that as of 06/24/19, the MDS had not been completed per the RAI manual. 7. According to the Face Sheet, Resident #55 was admitted to the facility on [DATE] with diagnoses including but not limited to: Dysphagia, Chronic Obstructive Pulmonary Disease and Fracture of unspecified part of neck of unspecified femur. A review of the MDS admission Assessment-14 day for Resident #55 revealed an ARD of 06/12/19 with a completion date of 06/13/19. A review of the medical record for Resident # 55 showed that as of 06/24/19 the MDS had not been completed in accordance with the RAI manual. 8. According to the Face Sheet, Resident #72 was admitted to the facility on [DATE] with diagnoses including but not limited to: Displaced Intertrochanteric Fracture of right Femur, Parkinson's Disease and Muscle Weakness. A review of the MDS admission Assessment-14 day for Resident #72 revealed an ARD of 06/12/19 with a completion date of 06/13/19. A review of the medical record for Resident # 72 showed that as of 06/24/19, the MDS had not been completed in accordance with the RAI manual. 9. According to the Face Sheet, Resident #37 was readmitted to the facility on [DATE] with diagnoses including but not limited to: muscle weakness, heart-valve replacement, cerebral infarct (stroke), and heart failure. A review of the MDS admission Assessment-14 day revealed an ARD of 06/20/19 with a completion date of 06/21/19. A review of the medical record for Resident #37 showed that as of 06/24/19, the MDS had not been completed in accordance with the RAI manual. During an interview on 06/24/19 at 09:27 AM, the RN/MDS stated the Admission/14-day Assessment should have been completed by 06/21/19. The RN/MDS also said that it is was okay that Resident #37's admission assessment was not completed by the Completion Due date because the submission date was scheduled for 07/05/19. The RN/MDS stated that they try to complete the assessments by the completion date but they had too many assessments to do and they try to submit them on time. During an interview on 06/25/19 at 11:14 AM, the MDS Supervisor (MDSS) stated All the data should be collected by the Completion Date. The MDSS stated the comprehensive admission assessment should be completed by the 14th day of a resident's admission to the facility. The MDSS further stated there were some assessments that were currently late. The MDSS reviewed Resident #37's assessment MDS, in the presence of surveyor, and stated it was scheduled to be completed by 06/20/19 but the data still needed to be entered into the system for the 06/08/19 readmission date. During an interview on 06/26/19 at 09:32 AM, the MDSS stated Resident #37 was readmitted on [DATE] and the admission assessment would have been completed by 06/22/19. The MDSS further stated the resident's admission assessment was not inputted into the computer until last night, 06/25/19. The MDSS further stated she collects all the necessary data in her personal writing notes and tries to get the information into the computer as soon as she can. The MDSS also stated she reviews the assessments for accuracy once the data is inputted into the computer and then signs the MDS as completed. The MDSS stated that her personal writing notes are not part of the medical record, it is her personal working sheet. 10. According to the Face Sheet, Resident #22 was admitted to the facility on [DATE] with diagnoses including but not limited to: Cerebral infarction, malignant neoplasm (cancer) of the bronchus and lung and secondary neoplasm of the bone. A review of the MDS admission Assessment-14 day revealed an ARD of 06/22/19 with a completion date of 06/23/19. A review of the medical record for Resident #22 showed that as of 06/24/19 the MDS had not been completed per the RAI manual. During an interview on 06/26/19 at 09:43 AM, the MDSS confirmed that Resident #22's MDS had not been completed and said, This resident is at the bottom of my list. She has been in and out and I know her paper. On 06/26/19 at 10:27 AM, the surveyor reviewed the MDS for Resident #22 and stated the 14-day admission assessment had not yet been completed. During an interview with the MDSS on 06/26/19 at 12:13 PM, the MDSS stated nursing was responsible for sections B, E, G, GG, H, I, J, K, L, N, and P; nursing and social services were responsible for sections A, C, D, and Q; activities was responsible for section F; and nursing and rehab were responsible for section O. The MDSS further stated the coordinator was responsible for reviewing all the sections of the MDS after they were inputted into the computer and then sign off and date as complete in section Z of the assessment. The MDSS stated the assessments were inputted late because they admit a lot of patients, the workflow, computer issues, parts of the MDS changed, and the volume of the MDSs for the current MDS staff. The MDSS further stated the assessment process was very tedious, the residents are short term and sicker. When interviewed in reference to Resident #37, MDSS stated the data was collected but it had not been entered into the computer until 06/25/19. The MDSS further stated she had the data in her notes and that she back-dated the assessments. The MDSS stated the assessments are signed and dated once all the information is inputted into the computer system and reviewed by the MDS coordinator. The MDSS further stated the admission assessments should be completed by the 14th day of admission. A review of a facility policy titled, HMNR MDS Process/Resident Assessment Policy with the revision date of July 2018, indicated the facility would complete comprehensive assessments within the regulatory timeframes for each resident. NJAC 8:39-11.2